hospital_name,last_updated_on,version,location_name,hospital_address,license_number|NH,type_2_npi,"To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.",attester_name
Wentworth Douglass Hospital,2026-03-27,3.0.0,Wentworth Douglass Hospital,789 Central Ave Dover NH 03820,00010,1033118104,true,Daniel Morash
"description","code|1","code|1|type","code|2","code|2|type","code|3","code|3|type","code|4","code|4|type","modifiers","setting","drug_unit_of_measurement","drug_type_of_measurement","standard_charge|gross","standard_charge|discounted_cash","payer_name","plan_name","standard_charge|negotiated_dollar","standard_charge|negotiated_percentage","standard_charge|negotiated_algorithm","median_amount","10th_percentile","90th_percentile","count","standard_charge|min","standard_charge|max","standard_charge|methodology","additional_generic_notes"
"1 25 Dihydroxy Inc Fraction","PX-30000412","CDM","82652","CPT","0301","RC","","","","both","","","208.00","124.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","145.18","69.8","","140.30","140.30","140.30","1 through 10","25.03","198.67","percent of total billed charges",""
"1 25 Dihydroxy Inc Fraction","PX-30000412","CDM","82652","CPT","0301","RC","","","","outpatient","","","208.00","124.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","151.26","72.72","","146.17","146.17","146.17","1 through 10","35.87","160.99","percent of total billed charges",""
"1 25 Dihydroxy Inc Fraction","PX-30000412","CDM","82652","CPT","0301","RC","","","","outpatient","","","208.00","124.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","130.83","62.9","","126.63","126.63","126.63","1 through 10","35.87","160.99","percent of total billed charges",""
"1 25 Dihydroxy Inc Fraction","PX-30000412","CDM","82652","CPT","0301","RC","","","","outpatient","","","208.00","124.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","160.99","77.4","","155.78","155.78","155.78","1 through 10","35.87","160.99","percent of total billed charges",""
"3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal","PX-48000480","CDM","93319","CPT","0483","RC","","","","outpatient","","","489.00","293.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","70.51","14.42","","68.06","68.06","68.06","1 through 10","56.87","378.49","percent of total billed charges",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2183.00","1309.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","1523.73","69.8","","1470.69","1470.69","1470.69","1 through 10","959.93","6260.06","percent of total billed charges",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2183.00","1309.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","999.12","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","979.64","979.64","979.64","1 through 10","959.93","6260.06","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2183.00","1309.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","6260.06","","Case rate ($6,260.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2217.90","2217.90","2217.90","1 through 10","959.93","6260.06","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2183.00","1309.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","2695.58","","Case rate ($2,695.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2629.86","2107.00","2629.86","1 through 10","959.93","6260.06","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2183.00","1309.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","959.93","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","979.64","883.23","979.64","13","959.93","6260.06","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2183.00","1309.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","5059.95","","Case rate ($5,059.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2258.48","2258.48","2258.48","1 through 10","959.93","6260.06","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2183.00","1309.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1242.13","56.9","","1198.88","1198.88","1198.88","11","959.93","6260.06","percent of total billed charges",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2183.00","1309.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","1008.91","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","995.05","891.54","1009.03","1 through 10","959.93","6260.06","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2183.00","1309.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","960.95","960.95","979.64","1 through 10","959.93","6260.06","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2183.00","1309.80","MEDICARE [2001]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","979.64","979.64","979.64","53","959.93","6260.06","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2183.00","1309.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","967.95","960.05","979.64","1 through 10","959.93","6260.06","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2183.00","1309.80","WELLSENSE NH [1050]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1015.45","1008.05","5137.77","20","959.93","6260.06","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","outpatient","","","2183.00","1309.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","314.79","14.42","","303.83","260.43","303.83","25","253.88","1689.64","percent of total billed charges",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","outpatient","","","2183.00","1309.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","253.88","11.63","","290.13","257.90","290.13","31","253.88","1689.64","percent of total billed charges",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","outpatient","","","2183.00","1309.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1373.11","62.9","","4658.88","1327.41","4658.88","1 through 10","253.88","1689.64","percent of total billed charges",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","outpatient","","","2183.00","1309.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","253.88","11.63","","248.87","248.87","248.87","17","253.88","1689.64","percent of total billed charges",""
"Abdominal Paracentesis W/O Imaging","PX-75000277","CDM","49082","CPT","0361","RC","","","","outpatient","","","5456.00","3273.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","786.76","14.42","","759.21","759.21","759.21","1 through 10","634.53","4222.94","percent of total billed charges",""
"Abdominal Paracentesis W/O Imaging","PX-75000277","CDM","49082","CPT","0361","RC","","","","outpatient","","","5456.00","3273.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","634.53","11.63","","655.51","655.51","655.51","1 through 10","634.53","4222.94","percent of total billed charges",""
"Ablat Endoven Extrem Laser 1st","PX-76001070","CDM","36478","CPT","0761","RC","","","","both","","","12148.00","7288.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","8479.30","69.8","","8181.96","8181.96","8181.96","1 through 10","3222.61","21015.78","percent of total billed charges",""
"Ablat Endoven Extrem Laser 1st","PX-76001070","CDM","36478","CPT","0761","RC","","","","both","","","12148.00","7288.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","3288.38","","APC Price ($3,288.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3230.89","3230.89","3230.89","1 through 10","3222.61","21015.78","other","OPPS APC"
"Ablat Endoven Extrem Laser 1st","PX-76001070","CDM","36478","CPT","0761","RC","","","","outpatient","","","12148.00","7288.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","10409.38","10409.38","10409.38","1 through 10","1412.81","9402.55","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Ablation Atrioventricular Function","PX-48000168","CDM","93650","CPT","0481","RC","","","","both","","","22713.00","13627.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","8086.30","","APC Price ($7,927.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","7928.65","7928.65","7928.65","1 through 10","7769.19","50665.65","other","OPPS APC"
"Ablation Atrioventricular Function","PX-48000168","CDM","93650","CPT","0481","RC","","","","both","","","22713.00","13627.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","7927.74","","APC Price ($7,927.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7136.05","7136.05","7136.05","1 through 10","7769.19","50665.65","other","OPPS APC"
"Ablation Atrioventricular Function","PX-48000168","CDM","93650","CPT","0481","RC","","","","both","","","22713.00","13627.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7927.74","","APC Price ($7,927.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7928.65","7928.65","7928.65","1 through 10","7769.19","50665.65","other","OPPS APC"
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","both","","","5375.00","3225.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","9141.46","","Case rate ($9,141.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8918.60","8918.60","8918.60","1 through 10","3058.38","21229.64","other","OPPS APC"
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","both","","","5375.00","3225.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3058.38","56.9","","14185.74","14185.74","14185.74","1 through 10","3058.38","21229.64","percent of total billed charges",""
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","outpatient","","","5375.00","3225.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4160.25","77.4","","4274.51","4274.51","4274.51","1 through 10","625.11","4160.25","percent of total billed charges",""
"Abortion Induced D&C","PX-72000030","CDM","59840","CPT","0361","RC","","","","outpatient","","","5375.00","3225.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","625.11","11.63","","1713.39","892.48","1713.39","1 through 10","625.11","4160.25","percent of total billed charges",""
"Abortion Induced D&E","PX-72000031","CDM","59841","CPT","0361","RC","","","","both","","","9349.00","5609.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","6525.60","69.8","","16989.03","16989.03","16989.03","1 through 10","3255.41","21229.64","percent of total billed charges",""
"Abortion Induced D&E","PX-72000031","CDM","59841","CPT","0361","RC","","","","both","","","9349.00","5609.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5319.58","56.9","","10088.37","10088.37","10088.37","1 through 10","3255.41","21229.64","percent of total billed charges",""
"Abortion Without D&C","779","MS-DRG","","","","","","","","inpatient","","","7214.54","4328.72","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","6703.98","","Case rate ($6,840.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,348.24, add-ons for qualifying new technology services are included. If operating cost exceeds $10,266.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,272.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $5,928.55 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,903.37 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $467.38. The transfer capital threshold is the transfer adjustment factor * $467.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5918.98","5918.98","5918.98","1 through 10","3975","31969.48","other","Inpatient DRG"
"ACETABULAR AUGMENT 20X54 56MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118713","CDM","C1776","HCPCS","0278","RC","","","","both","","","6062.50","3637.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","705.07","5153.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ACETABULAR AUGMENT 20X54 56MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118713","CDM","C1776","HCPCS","0278","RC","","","","both","","","6062.50","3637.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3449.56","56.9","","2911.53","1863.86","5209.05","65","705.07","5153.13","percent of total billed charges",""
"ACETABULAR AUGMENT 20X54 56MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118713","CDM","C1776","HCPCS","0278","RC","","","","both","","","6062.50","3637.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","705.07","11.63","","400.94","400.94","400.94","1 through 10","705.07","5153.13","percent of total billed charges",""
"ACETABULAR AUGMENT 20X54 56MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118713","CDM","C1776","HCPCS","0278","RC","","","","both","","","6062.50","3637.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4692.38","77.4","","5214.50","5214.50","16415.28","1 through 10","705.07","5153.13","percent of total billed charges",""
"ACETABULAR AUGMENT 20X54 56MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118713","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","705.07","11.63","","400.94","400.94","400.94","1 through 10","705.07","4692.38","percent of total billed charges",""
"ACETABULAR AUGMENT 20X54 56MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118713","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2650.53","43.72","","1543.33","1543.33","1671.61","1 through 10","705.07","4692.38","percent of total billed charges",""
"ACETABULAR AUGMENT 20X54 56MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118713","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4408.65","72.72","","3700.21","2382.07","6427.18","53","705.07","4692.38","percent of total billed charges",""
"ACETABULAR AUGMENT 20X54 56MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118713","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4408.65","72.72","","12685.80","12685.80","12685.80","1 through 10","705.07","4692.38","percent of total billed charges",""
"ACETABULAR AUGMENT 20X54 56MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118713","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3813.31","62.9","","3408.87","2784.05","9859.40","46","705.07","4692.38","percent of total billed charges",""
"ACETABULAR AUGMENT 20X54 56MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118713","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4692.38","77.4","","5214.50","5214.50","16415.28","1 through 10","705.07","4692.38","percent of total billed charges",""
"ACETABULAR INSERT 28MM 0DEG SIZE D TRIDENT POLYETHYLENE","SUP-ITM-10016790","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.50","2280.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","442","3230.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ACETABULAR INSERT 28MM 0DEG SIZE D TRIDENT POLYETHYLENE","SUP-ITM-10016790","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.50","2280.30","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2162.48","56.9","","2911.53","1863.86","5209.05","65","442","3230.43","percent of total billed charges",""
"ACETABULAR INSERT 28MM 0DEG SIZE D TRIDENT POLYETHYLENE","SUP-ITM-10016790","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.50","2280.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","442.00","11.63","","400.94","400.94","400.94","1 through 10","442","3230.43","percent of total billed charges",""
"ACETABULAR INSERT 28MM 0DEG SIZE D TRIDENT POLYETHYLENE","SUP-ITM-10016790","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.50","2280.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2941.59","77.4","","5214.50","5214.50","16415.28","1 through 10","442","3230.43","percent of total billed charges",""
"ACETABULAR INSERT 28MM 0DEG SIZE D TRIDENT POLYETHYLENE","SUP-ITM-10016790","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.50","2280.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","442.00","11.63","","400.94","400.94","400.94","1 through 10","442","2941.59","percent of total billed charges",""
"ACETABULAR INSERT 28MM 0DEG SIZE D TRIDENT POLYETHYLENE","SUP-ITM-10016790","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.50","2280.30","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1661.58","43.72","","1543.33","1543.33","1671.61","1 through 10","442","2941.59","percent of total billed charges",""
"ACETABULAR INSERT 28MM 0DEG SIZE D TRIDENT POLYETHYLENE","SUP-ITM-10016790","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.50","2280.30","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2763.72","72.72","","3700.21","2382.07","6427.18","53","442","2941.59","percent of total billed charges",""
"ACETABULAR INSERT 28MM 0DEG SIZE D TRIDENT POLYETHYLENE","SUP-ITM-10016790","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.50","2280.30","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2763.72","72.72","","12685.80","12685.80","12685.80","1 through 10","442","2941.59","percent of total billed charges",""
"ACETABULAR INSERT 28MM 0DEG SIZE D TRIDENT POLYETHYLENE","SUP-ITM-10016790","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.50","2280.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2390.51","62.9","","3408.87","2784.05","9859.40","46","442","2941.59","percent of total billed charges",""
"ACETABULAR INSERT 28MM 0DEG SIZE D TRIDENT POLYETHYLENE","SUP-ITM-10016790","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.50","2280.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2941.59","77.4","","5214.50","5214.50","16415.28","1 through 10","442","2941.59","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.50","2280.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","442","3230.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.50","2280.30","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2162.48","56.9","","2911.53","1863.86","5209.05","65","442","3230.43","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.50","2280.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","442.00","11.63","","400.94","400.94","400.94","1 through 10","442","3230.43","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.50","2280.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2941.59","77.4","","5214.50","5214.50","16415.28","1 through 10","442","3230.43","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.50","2280.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","442.00","11.63","","400.94","400.94","400.94","1 through 10","442","2941.59","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.50","2280.30","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1661.58","43.72","","1543.33","1543.33","1671.61","1 through 10","442","2941.59","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.50","2280.30","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2763.72","72.72","","3700.21","2382.07","6427.18","53","442","2941.59","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.50","2280.30","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2763.72","72.72","","12685.80","12685.80","12685.80","1 through 10","442","2941.59","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.50","2280.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2390.51","62.9","","3408.87","2784.05","9859.40","46","442","2941.59","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.50","2280.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2941.59","77.4","","5214.50","5214.50","16415.28","1 through 10","442","2941.59","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","both","","","5293.06","3175.84","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","615.58","4499.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","both","","","5293.06","3175.84","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3011.75","56.9","","2911.53","1863.86","5209.05","65","615.58","4499.1","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","both","","","5293.06","3175.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","615.58","11.63","","400.94","400.94","400.94","1 through 10","615.58","4499.1","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","both","","","5293.06","3175.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4096.83","77.4","","5214.50","5214.50","16415.28","1 through 10","615.58","4499.1","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5293.06","3175.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","615.58","11.63","","400.94","400.94","400.94","1 through 10","615.58","4096.83","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5293.06","3175.84","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2314.13","43.72","","1543.33","1543.33","1671.61","1 through 10","615.58","4096.83","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5293.06","3175.84","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3849.11","72.72","","3700.21","2382.07","6427.18","53","615.58","4096.83","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5293.06","3175.84","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3849.11","72.72","","12685.80","12685.80","12685.80","1 through 10","615.58","4096.83","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5293.06","3175.84","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3329.33","62.9","","3408.87","2784.05","9859.40","46","615.58","4096.83","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5293.06","3175.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4096.83","77.4","","5214.50","5214.50","16415.28","1 through 10","615.58","4096.83","percent of total billed charges",""
"ACETABULAR LINER 28X47MM BI-MENTUM PFRK POLYETHYLENE","SUP-ITM-10282664","CDM","C1776","HCPCS","0278","RC","","","","both","","","5044.30","3026.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","586.65","4287.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ACETABULAR LINER 28X47MM BI-MENTUM PFRK POLYETHYLENE","SUP-ITM-10282664","CDM","C1776","HCPCS","0278","RC","","","","both","","","5044.30","3026.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2870.21","56.9","","2911.53","1863.86","5209.05","65","586.65","4287.66","percent of total billed charges",""
"ACETABULAR LINER 28X47MM BI-MENTUM PFRK POLYETHYLENE","SUP-ITM-10282664","CDM","C1776","HCPCS","0278","RC","","","","both","","","5044.30","3026.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","586.65","11.63","","400.94","400.94","400.94","1 through 10","586.65","4287.66","percent of total billed charges",""
"ACETABULAR LINER 28X47MM BI-MENTUM PFRK POLYETHYLENE","SUP-ITM-10282664","CDM","C1776","HCPCS","0278","RC","","","","both","","","5044.30","3026.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3904.29","77.4","","5214.50","5214.50","16415.28","1 through 10","586.65","4287.66","percent of total billed charges",""
"ACETABULAR LINER 28X47MM BI-MENTUM PFRK POLYETHYLENE","SUP-ITM-10282664","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5044.30","3026.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","586.65","11.63","","400.94","400.94","400.94","1 through 10","586.65","3904.29","percent of total billed charges",""
"ACETABULAR LINER 28X47MM BI-MENTUM PFRK POLYETHYLENE","SUP-ITM-10282664","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5044.30","3026.58","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2205.37","43.72","","1543.33","1543.33","1671.61","1 through 10","586.65","3904.29","percent of total billed charges",""
"ACETABULAR LINER 28X47MM BI-MENTUM PFRK POLYETHYLENE","SUP-ITM-10282664","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5044.30","3026.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3668.21","72.72","","3700.21","2382.07","6427.18","53","586.65","3904.29","percent of total billed charges",""
"ACETABULAR LINER 28X47MM BI-MENTUM PFRK POLYETHYLENE","SUP-ITM-10282664","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5044.30","3026.58","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3668.21","72.72","","12685.80","12685.80","12685.80","1 through 10","586.65","3904.29","percent of total billed charges",""
"ACETABULAR LINER 28X47MM BI-MENTUM PFRK POLYETHYLENE","SUP-ITM-10282664","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5044.30","3026.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3172.86","62.9","","3408.87","2784.05","9859.40","46","586.65","3904.29","percent of total billed charges",""
"ACETABULAR LINER 28X47MM BI-MENTUM PFRK POLYETHYLENE","SUP-ITM-10282664","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5044.30","3026.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3904.29","77.4","","5214.50","5214.50","16415.28","1 through 10","586.65","3904.29","percent of total billed charges",""
"ACETABULAR LINER 28X49MM BI MENTUM ALTRX","SUP-ITM-10307545","CDM","C1776","HCPCS","0278","RC","","","","both","","","5044.30","3026.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","586.65","4287.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ACETABULAR LINER 28X49MM BI MENTUM ALTRX","SUP-ITM-10307545","CDM","C1776","HCPCS","0278","RC","","","","both","","","5044.30","3026.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2870.21","56.9","","2911.53","1863.86","5209.05","65","586.65","4287.66","percent of total billed charges",""
"ACETABULAR LINER 28X49MM BI MENTUM ALTRX","SUP-ITM-10307545","CDM","C1776","HCPCS","0278","RC","","","","both","","","5044.30","3026.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","586.65","11.63","","400.94","400.94","400.94","1 through 10","586.65","4287.66","percent of total billed charges",""
"ACETABULAR LINER 28X49MM BI MENTUM ALTRX","SUP-ITM-10307545","CDM","C1776","HCPCS","0278","RC","","","","both","","","5044.30","3026.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3904.29","77.4","","5214.50","5214.50","16415.28","1 through 10","586.65","4287.66","percent of total billed charges",""
"ACETABULAR LINER 28X49MM BI MENTUM ALTRX","SUP-ITM-10307545","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5044.30","3026.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","586.65","11.63","","400.94","400.94","400.94","1 through 10","586.65","3904.29","percent of total billed charges",""
"ACETABULAR LINER 28X49MM BI MENTUM ALTRX","SUP-ITM-10307545","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5044.30","3026.58","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2205.37","43.72","","1543.33","1543.33","1671.61","1 through 10","586.65","3904.29","percent of total billed charges",""
"ACETABULAR LINER 28X49MM BI MENTUM ALTRX","SUP-ITM-10307545","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5044.30","3026.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3668.21","72.72","","3700.21","2382.07","6427.18","53","586.65","3904.29","percent of total billed charges",""
"ACETABULAR LINER 28X49MM BI MENTUM ALTRX","SUP-ITM-10307545","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5044.30","3026.58","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3668.21","72.72","","12685.80","12685.80","12685.80","1 through 10","586.65","3904.29","percent of total billed charges",""
"ACETABULAR LINER 28X49MM BI MENTUM ALTRX","SUP-ITM-10307545","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5044.30","3026.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3172.86","62.9","","3408.87","2784.05","9859.40","46","586.65","3904.29","percent of total billed charges",""
"ACETABULAR LINER 28X49MM BI MENTUM ALTRX","SUP-ITM-10307545","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5044.30","3026.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3904.29","77.4","","5214.50","5214.50","16415.28","1 through 10","586.65","3904.29","percent of total billed charges",""
"ACETABULAR LINER 32X56MM NEUTRAL PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042881","CDM","C1776","HCPCS","0278","RC","","","","both","","","2411.59","1446.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","280.47","2049.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ACETABULAR LINER 32X56MM NEUTRAL PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042881","CDM","C1776","HCPCS","0278","RC","","","","both","","","2411.59","1446.95","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1372.19","56.9","","2911.53","1863.86","5209.05","65","280.47","2049.85","percent of total billed charges",""
"ACETABULAR LINER 32X56MM NEUTRAL PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042881","CDM","C1776","HCPCS","0278","RC","","","","both","","","2411.59","1446.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","280.47","11.63","","400.94","400.94","400.94","1 through 10","280.47","2049.85","percent of total billed charges",""
"ACETABULAR LINER 32X56MM NEUTRAL PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042881","CDM","C1776","HCPCS","0278","RC","","","","both","","","2411.59","1446.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1866.57","77.4","","5214.50","5214.50","16415.28","1 through 10","280.47","2049.85","percent of total billed charges",""
"ACETABULAR LINER 32X56MM NEUTRAL PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042881","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2411.59","1446.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","280.47","11.63","","400.94","400.94","400.94","1 through 10","280.47","1866.57","percent of total billed charges",""
"ACETABULAR LINER 32X56MM NEUTRAL PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042881","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2411.59","1446.95","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1054.35","43.72","","1543.33","1543.33","1671.61","1 through 10","280.47","1866.57","percent of total billed charges",""
"ACETABULAR LINER 32X56MM NEUTRAL PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042881","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2411.59","1446.95","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1753.71","72.72","","3700.21","2382.07","6427.18","53","280.47","1866.57","percent of total billed charges",""
"ACETABULAR LINER 32X56MM NEUTRAL PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042881","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2411.59","1446.95","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1753.71","72.72","","12685.80","12685.80","12685.80","1 through 10","280.47","1866.57","percent of total billed charges",""
"ACETABULAR LINER 32X56MM NEUTRAL PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042881","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2411.59","1446.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1516.89","62.9","","3408.87","2784.05","9859.40","46","280.47","1866.57","percent of total billed charges",""
"ACETABULAR LINER 32X56MM NEUTRAL PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042881","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2411.59","1446.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1866.57","77.4","","5214.50","5214.50","16415.28","1 through 10","280.47","1866.57","percent of total billed charges",""
"ACETABULAR LINER 36X58MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10020409","CDM","C1776","HCPCS","0278","RC","","","","both","","","5293.06","3175.84","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","615.58","4499.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ACETABULAR LINER 36X58MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10020409","CDM","C1776","HCPCS","0278","RC","","","","both","","","5293.06","3175.84","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3011.75","56.9","","2911.53","1863.86","5209.05","65","615.58","4499.1","percent of total billed charges",""
"ACETABULAR LINER 36X58MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10020409","CDM","C1776","HCPCS","0278","RC","","","","both","","","5293.06","3175.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","615.58","11.63","","400.94","400.94","400.94","1 through 10","615.58","4499.1","percent of total billed charges",""
"ACETABULAR LINER 36X58MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10020409","CDM","C1776","HCPCS","0278","RC","","","","both","","","5293.06","3175.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4096.83","77.4","","5214.50","5214.50","16415.28","1 through 10","615.58","4499.1","percent of total billed charges",""
"ACETABULAR LINER 36X58MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10020409","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5293.06","3175.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","615.58","11.63","","400.94","400.94","400.94","1 through 10","615.58","4096.83","percent of total billed charges",""
"ACETABULAR LINER 36X58MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10020409","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5293.06","3175.84","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2314.13","43.72","","1543.33","1543.33","1671.61","1 through 10","615.58","4096.83","percent of total billed charges",""
"ACETABULAR LINER 36X58MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10020409","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5293.06","3175.84","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3849.11","72.72","","3700.21","2382.07","6427.18","53","615.58","4096.83","percent of total billed charges",""
"ACETABULAR LINER 36X58MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10020409","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5293.06","3175.84","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3849.11","72.72","","12685.80","12685.80","12685.80","1 through 10","615.58","4096.83","percent of total billed charges",""
"ACETABULAR LINER 36X58MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10020409","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5293.06","3175.84","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3329.33","62.9","","3408.87","2784.05","9859.40","46","615.58","4096.83","percent of total billed charges",""
"ACETABULAR LINER 36X58MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10020409","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5293.06","3175.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4096.83","77.4","","5214.50","5214.50","16415.28","1 through 10","615.58","4096.83","percent of total billed charges",""
"ACETABULAR LINER 42MM SIZE E SHE MODULE DUAL MOBILITY TITANIUM NONCEMENTED","SUP-ITM-10090958","CDM","C1776","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","562.54","4111.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ACETABULAR LINER 42MM SIZE E SHE MODULE DUAL MOBILITY TITANIUM NONCEMENTED","SUP-ITM-10090958","CDM","C1776","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2752.25","56.9","","2911.53","1863.86","5209.05","65","562.54","4111.45","percent of total billed charges",""
"ACETABULAR LINER 42MM SIZE E SHE MODULE DUAL MOBILITY TITANIUM NONCEMENTED","SUP-ITM-10090958","CDM","C1776","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","562.54","11.63","","400.94","400.94","400.94","1 through 10","562.54","4111.45","percent of total billed charges",""
"ACETABULAR LINER 42MM SIZE E SHE MODULE DUAL MOBILITY TITANIUM NONCEMENTED","SUP-ITM-10090958","CDM","C1776","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3743.84","77.4","","5214.50","5214.50","16415.28","1 through 10","562.54","4111.45","percent of total billed charges",""
"ACETABULAR LINER 42MM SIZE E SHE MODULE DUAL MOBILITY TITANIUM NONCEMENTED","SUP-ITM-10090958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","562.54","11.63","","400.94","400.94","400.94","1 through 10","562.54","3743.84","percent of total billed charges",""
"ACETABULAR LINER 42MM SIZE E SHE MODULE DUAL MOBILITY TITANIUM NONCEMENTED","SUP-ITM-10090958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2114.74","43.72","","1543.33","1543.33","1671.61","1 through 10","562.54","3743.84","percent of total billed charges",""
"ACETABULAR LINER 42MM SIZE E SHE MODULE DUAL MOBILITY TITANIUM NONCEMENTED","SUP-ITM-10090958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3517.47","72.72","","3700.21","2382.07","6427.18","53","562.54","3743.84","percent of total billed charges",""
"ACETABULAR LINER 42MM SIZE E SHE MODULE DUAL MOBILITY TITANIUM NONCEMENTED","SUP-ITM-10090958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3517.47","72.72","","12685.80","12685.80","12685.80","1 through 10","562.54","3743.84","percent of total billed charges",""
"ACETABULAR LINER 42MM SIZE E SHE MODULE DUAL MOBILITY TITANIUM NONCEMENTED","SUP-ITM-10090958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3042.47","62.9","","3408.87","2784.05","9859.40","46","562.54","3743.84","percent of total billed charges",""
"ACETABULAR LINER 42MM SIZE E SHE MODULE DUAL MOBILITY TITANIUM NONCEMENTED","SUP-ITM-10090958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3743.84","77.4","","5214.50","5214.50","16415.28","1 through 10","562.54","3743.84","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE CERAMAX POROCOAT SECTOR","SUP-ITM-10007280","CDM","C1776","HCPCS","0278","RC","","","","both","","","4498.41","2699.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","523.17","3823.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ACETABULAR SHELL 54MM PINNACLE CERAMAX POROCOAT SECTOR","SUP-ITM-10007280","CDM","C1776","HCPCS","0278","RC","","","","both","","","4498.41","2699.05","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2559.60","56.9","","2911.53","1863.86","5209.05","65","523.17","3823.65","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE CERAMAX POROCOAT SECTOR","SUP-ITM-10007280","CDM","C1776","HCPCS","0278","RC","","","","both","","","4498.41","2699.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","523.17","11.63","","400.94","400.94","400.94","1 through 10","523.17","3823.65","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE CERAMAX POROCOAT SECTOR","SUP-ITM-10007280","CDM","C1776","HCPCS","0278","RC","","","","both","","","4498.41","2699.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3481.77","77.4","","5214.50","5214.50","16415.28","1 through 10","523.17","3823.65","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE CERAMAX POROCOAT SECTOR","SUP-ITM-10007280","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4498.41","2699.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","523.17","11.63","","400.94","400.94","400.94","1 through 10","523.17","3481.77","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE CERAMAX POROCOAT SECTOR","SUP-ITM-10007280","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4498.41","2699.05","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1966.70","43.72","","1543.33","1543.33","1671.61","1 through 10","523.17","3481.77","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE CERAMAX POROCOAT SECTOR","SUP-ITM-10007280","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4498.41","2699.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3271.24","72.72","","3700.21","2382.07","6427.18","53","523.17","3481.77","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE CERAMAX POROCOAT SECTOR","SUP-ITM-10007280","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4498.41","2699.05","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3271.24","72.72","","12685.80","12685.80","12685.80","1 through 10","523.17","3481.77","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE CERAMAX POROCOAT SECTOR","SUP-ITM-10007280","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4498.41","2699.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2829.50","62.9","","3408.87","2784.05","9859.40","46","523.17","3481.77","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE CERAMAX POROCOAT SECTOR","SUP-ITM-10007280","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4498.41","2699.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3481.77","77.4","","5214.50","5214.50","16415.28","1 through 10","523.17","3481.77","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","both","","","7740.60","4644.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","900.23","6579.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","both","","","7740.60","4644.36","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4404.40","56.9","","2911.53","1863.86","5209.05","65","900.23","6579.51","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","both","","","7740.60","4644.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","900.23","11.63","","400.94","400.94","400.94","1 through 10","900.23","6579.51","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","both","","","7740.60","4644.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5991.22","77.4","","5214.50","5214.50","16415.28","1 through 10","900.23","6579.51","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7740.60","4644.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","900.23","11.63","","400.94","400.94","400.94","1 through 10","900.23","5991.22","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7740.60","4644.36","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3384.19","43.72","","1543.33","1543.33","1671.61","1 through 10","900.23","5991.22","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7740.60","4644.36","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5628.96","72.72","","3700.21","2382.07","6427.18","53","900.23","5991.22","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7740.60","4644.36","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5628.96","72.72","","12685.80","12685.80","12685.80","1 through 10","900.23","5991.22","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7740.60","4644.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4868.84","62.9","","3408.87","2784.05","9859.40","46","900.23","5991.22","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7740.60","4644.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5991.22","77.4","","5214.50","5214.50","16415.28","1 through 10","900.23","5991.22","percent of total billed charges",""
"ACETABULAR SHELL 54MM REDAPT MODULAR","SUP-ITM-10280268","CDM","C1776","HCPCS","0278","RC","","","","both","","","5335.00","3201.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","620.46","4534.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ACETABULAR SHELL 54MM REDAPT MODULAR","SUP-ITM-10280268","CDM","C1776","HCPCS","0278","RC","","","","both","","","5335.00","3201.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3035.62","56.9","","2911.53","1863.86","5209.05","65","620.46","4534.75","percent of total billed charges",""
"ACETABULAR SHELL 54MM REDAPT MODULAR","SUP-ITM-10280268","CDM","C1776","HCPCS","0278","RC","","","","both","","","5335.00","3201.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","620.46","11.63","","400.94","400.94","400.94","1 through 10","620.46","4534.75","percent of total billed charges",""
"ACETABULAR SHELL 54MM REDAPT MODULAR","SUP-ITM-10280268","CDM","C1776","HCPCS","0278","RC","","","","both","","","5335.00","3201.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4129.29","77.4","","5214.50","5214.50","16415.28","1 through 10","620.46","4534.75","percent of total billed charges",""
"ACETABULAR SHELL 54MM REDAPT MODULAR","SUP-ITM-10280268","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5335.00","3201.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","620.46","11.63","","400.94","400.94","400.94","1 through 10","620.46","4129.29","percent of total billed charges",""
"ACETABULAR SHELL 54MM REDAPT MODULAR","SUP-ITM-10280268","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5335.00","3201.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2332.46","43.72","","1543.33","1543.33","1671.61","1 through 10","620.46","4129.29","percent of total billed charges",""
"ACETABULAR SHELL 54MM REDAPT MODULAR","SUP-ITM-10280268","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5335.00","3201.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3879.61","72.72","","3700.21","2382.07","6427.18","53","620.46","4129.29","percent of total billed charges",""
"ACETABULAR SHELL 54MM REDAPT MODULAR","SUP-ITM-10280268","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5335.00","3201.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3879.61","72.72","","12685.80","12685.80","12685.80","1 through 10","620.46","4129.29","percent of total billed charges",""
"ACETABULAR SHELL 54MM REDAPT MODULAR","SUP-ITM-10280268","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5335.00","3201.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3355.72","62.9","","3408.87","2784.05","9859.40","46","620.46","4129.29","percent of total billed charges",""
"ACETABULAR SHELL 54MM REDAPT MODULAR","SUP-ITM-10280268","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5335.00","3201.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4129.29","77.4","","5214.50","5214.50","16415.28","1 through 10","620.46","4129.29","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","564.06","4122.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2759.65","56.9","","2911.53","1863.86","5209.05","65","564.06","4122.5","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.06","11.63","","400.94","400.94","400.94","1 through 10","564.06","4122.5","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3753.90","77.4","","5214.50","5214.50","16415.28","1 through 10","564.06","4122.5","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.06","11.63","","400.94","400.94","400.94","1 through 10","564.06","3753.9","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2120.42","43.72","","1543.33","1543.33","1671.61","1 through 10","564.06","3753.9","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3526.92","72.72","","3700.21","2382.07","6427.18","53","564.06","3753.9","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3526.92","72.72","","12685.80","12685.80","12685.80","1 through 10","564.06","3753.9","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3050.65","62.9","","3408.87","2784.05","9859.40","46","564.06","3753.9","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3753.90","77.4","","5214.50","5214.50","16415.28","1 through 10","564.06","3753.9","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","6219.00","3731.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","723.27","5286.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","6219.00","3731.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3538.61","56.9","","2911.53","1863.86","5209.05","65","723.27","5286.15","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","6219.00","3731.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","723.27","11.63","","400.94","400.94","400.94","1 through 10","723.27","5286.15","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","6219.00","3731.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4813.51","77.4","","5214.50","5214.50","16415.28","1 through 10","723.27","5286.15","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","723.27","11.63","","400.94","400.94","400.94","1 through 10","723.27","4813.51","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2718.95","43.72","","1543.33","1543.33","1671.61","1 through 10","723.27","4813.51","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4522.46","72.72","","3700.21","2382.07","6427.18","53","723.27","4813.51","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4522.46","72.72","","12685.80","12685.80","12685.80","1 through 10","723.27","4813.51","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3911.75","62.9","","3408.87","2784.05","9859.40","46","723.27","4813.51","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4813.51","77.4","","5214.50","5214.50","16415.28","1 through 10","723.27","4813.51","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","5601.75","3361.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","651.48","4761.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","5601.75","3361.05","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3187.40","56.9","","2911.53","1863.86","5209.05","65","651.48","4761.49","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","5601.75","3361.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","651.48","11.63","","400.94","400.94","400.94","1 through 10","651.48","4761.49","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","5601.75","3361.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4335.75","77.4","","5214.50","5214.50","16415.28","1 through 10","651.48","4761.49","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5601.75","3361.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","651.48","11.63","","400.94","400.94","400.94","1 through 10","651.48","4335.75","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5601.75","3361.05","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2449.09","43.72","","1543.33","1543.33","1671.61","1 through 10","651.48","4335.75","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5601.75","3361.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4073.59","72.72","","3700.21","2382.07","6427.18","53","651.48","4335.75","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5601.75","3361.05","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4073.59","72.72","","12685.80","12685.80","12685.80","1 through 10","651.48","4335.75","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5601.75","3361.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3523.50","62.9","","3408.87","2784.05","9859.40","46","651.48","4335.75","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5601.75","3361.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4335.75","77.4","","5214.50","5214.50","16415.28","1 through 10","651.48","4335.75","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","562.54","4111.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2752.25","56.9","","2911.53","1863.86","5209.05","65","562.54","4111.45","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","562.54","11.63","","400.94","400.94","400.94","1 through 10","562.54","4111.45","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3743.84","77.4","","5214.50","5214.50","16415.28","1 through 10","562.54","4111.45","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","562.54","11.63","","400.94","400.94","400.94","1 through 10","562.54","3743.84","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2114.74","43.72","","1543.33","1543.33","1671.61","1 through 10","562.54","3743.84","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3517.47","72.72","","3700.21","2382.07","6427.18","53","562.54","3743.84","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3517.47","72.72","","12685.80","12685.80","12685.80","1 through 10","562.54","3743.84","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3042.47","62.9","","3408.87","2784.05","9859.40","46","562.54","3743.84","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3743.84","77.4","","5214.50","5214.50","16415.28","1 through 10","562.54","3743.84","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","691.00","414.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","80.36","587.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","691.00","414.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","393.18","56.9","","2911.53","1863.86","5209.05","65","80.36","587.35","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","691.00","414.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","80.36","11.63","","400.94","400.94","400.94","1 through 10","80.36","587.35","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","691.00","414.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","534.83","77.4","","5214.50","5214.50","16415.28","1 through 10","80.36","587.35","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","80.36","11.63","","400.94","400.94","400.94","1 through 10","80.36","534.83","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","302.11","43.72","","1543.33","1543.33","1671.61","1 through 10","80.36","534.83","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","502.50","72.72","","3700.21","2382.07","6427.18","53","80.36","534.83","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","502.50","72.72","","12685.80","12685.80","12685.80","1 through 10","80.36","534.83","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","434.64","62.9","","3408.87","2784.05","9859.40","46","80.36","534.83","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","534.83","77.4","","5214.50","5214.50","16415.28","1 through 10","80.36","534.83","percent of total billed charges",""
"Acetone/Ketones Serum Qn","PX-30000275","CDM","82010","CPT","0300","RC","","","","inpatient","","","116.00","69.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","89.16","76.86","","70.56","70.56","70.56","1 through 10","76.79","89.16","percent of total billed charges",""
"Acetone/Ketones Serum Qn","PX-30000275","CDM","82010","CPT","0301","RC","","","","outpatient","","","116.00","69.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","72.96","62.9","","70.56","70.56","70.56","1 through 10","9.79","89.78","percent of total billed charges",""
"Acetone/Ketones Serum Qn","PX-30000275","CDM","82010","CPT","0301","RC","","","","outpatient","","","116.00","69.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","89.78","77.4","","86.80","81.45","86.80","1 through 10","9.79","89.78","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","both","","","199.00","119.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","113.23","56.9","","109.25","109.25","109.25","1 through 10","11.96","169.15","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","outpatient","","","199.00","119.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","87.00","43.72","","83.94","83.94","83.94","1 through 10","23.14","154.03","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","outpatient","","","199.00","119.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","144.71","72.72","","139.62","139.62","139.62","1 through 10","23.14","154.03","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","outpatient","","","199.00","119.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","144.71","72.72","","139.62","139.62","139.62","1 through 10","23.14","154.03","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","outpatient","","","199.00","119.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","125.17","62.9","","120.96","120.96","120.96","1 through 10","23.14","154.03","percent of total billed charges",""
"Acetylcholine Receptor Blocking Antibody","PX-30003821","CDM","86042","CPT","0302","RC","","","","both","","","65.00","39.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","36.99","56.9","","35.85","35.85","35.85","1 through 10","11.96","55.25","percent of total billed charges",""
"Acetylcholine Receptor Blocking Antibody","PX-30003821","CDM","86042","CPT","0302","RC","","","","outpatient","","","65.00","39.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","47.27","72.72","","45.81","45.81","45.81","1 through 10","7.56","50.31","percent of total billed charges",""
"Acetylcholine Receptor Modulating Antibody","PX-30003822","CDM","86043","CPT","0302","RC","","","","outpatient","","","130.00","78.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","15.12","11.63","","10.63","10.63","10.63","1 through 10","15.12","100.62","percent of total billed charges",""
"Acetylcholine Receptor Modulating Antibody","PX-30003822","CDM","86043","CPT","0302","RC","","","","outpatient","","","130.00","78.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","56.84","43.72","","55.09","55.09","55.09","1 through 10","15.12","100.62","percent of total billed charges",""
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","both","","","11227.00","6736.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","3542.81","","Case rate ($3,542.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3456.41","3456.41","3456.41","1 through 10","543.26","9542.95","other","OPPS APC"
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","both","","","11227.00","6736.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1525.53","","Case rate ($1,525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2793.76","2793.76","2793.76","1 through 10","543.26","9542.95","other","OPPS APC"
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","both","","","11227.00","6736.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","543.26","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","543.32","522.23","554.41","1 through 10","543.26","9542.95","other","OPPS APC"
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","both","","","11227.00","6736.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","2863.62","","Case rate ($2,863.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2793.76","2793.76","2793.76","1 through 10","543.26","9542.95","other","OPPS APC"
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","both","","","11227.00","6736.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6388.16","56.9","","6164.55","6164.54","6164.55","1 through 10","543.26","9542.95","percent of total billed charges",""
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","both","","","11227.00","6736.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","554.35","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","522.23","522.23","522.23","1 through 10","543.26","9542.95","other","OPPS APC"
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","both","","","11227.00","6736.20","MEDICARE [2001]","HB WDH MEDICARE","554.35","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","554.41","522.23","554.41","1 through 10","543.26","9542.95","other","OPPS APC"
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","both","","","11227.00","6736.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","554.35","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","545.54","522.23","554.41","1 through 10","543.26","9542.95","other","OPPS APC"
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","both","","","11227.00","6736.20","WELLPOINT [1015]","HB WDH ANTHEM PPO","2863.62","","Case rate ($2,863.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2793.76","2657.47","2793.76","1 through 10","543.26","9542.95","other","OPPS APC"
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","outpatient","","","11227.00","6736.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1305.70","11.63","","1491.84","1491.84","1491.84","1 through 10","1305.7","8689.7","percent of total billed charges",""
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","outpatient","","","11227.00","6736.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8164.27","72.72","","7878.48","7878.48","7878.48","1 through 10","1305.7","8689.7","percent of total billed charges",""
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","outpatient","","","11227.00","6736.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7061.78","62.9","","6825.42","6825.42","6825.42","1 through 10","1305.7","8689.7","percent of total billed charges",""
"ACID REFLUX TEST MUCOSAL pH ELEC","PX-75000315","CDM","91035","CPT","0750","RC","","","","outpatient","","","11227.00","6736.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1305.70","11.63","","1279.67","1279.67","1279.67","1 through 10","1305.7","8689.7","percent of total billed charges",""
"Acid Reflux Test Nasal Intluminal","PX-75000316","CDM","91037","CPT","0750","RC","","","","both","","","3512.00","2107.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2079.19","","Case rate ($2,079.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2028.48","2028.48","2028.48","1 through 10","318.83","2985.2","other","OPPS APC"
"Acid Reflux Test Nasal Intluminal","PX-75000316","CDM","91037","CPT","0750","RC","","","","both","","","3512.00","2107.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","895.30","","Case rate ($895.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","873.47","856.04","3389.00","1 through 10","318.83","2985.2","other","OPPS APC"
"Acid Reflux Test Nasal Intluminal","PX-75000316","CDM","91037","CPT","0750","RC","","","","both","","","3512.00","2107.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1998.33","56.9","","1928.34","1928.33","1928.34","1 through 10","318.83","2985.2","percent of total billed charges",""
"Acid Reflux Test Nasal Intluminal","PX-75000316","CDM","91037","CPT","0750","RC","","","","both","","","3512.00","2107.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","335.10","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","328.44","328.44","328.44","1 through 10","318.83","2985.2","other","OPPS APC"
"Acid Reflux Test Nasal Intluminal","PX-75000316","CDM","91037","CPT","0750","RC","","","","both","","","3512.00","2107.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","325.38","325.38","325.38","1 through 10","318.83","2985.2","other","OPPS APC"
"Acid Reflux Test Nasal Intluminal","PX-75000316","CDM","91037","CPT","0750","RC","","","","both","","","3512.00","2107.20","MEDICARE [2001]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","325.38","305.82","325.38","1 through 10","318.83","2985.2","other","OPPS APC"
"Acid Reflux Test Nasal Intluminal","PX-75000316","CDM","91037","CPT","0750","RC","","","","both","","","3512.00","2107.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","318.88","318.88","318.88","1 through 10","318.83","2985.2","other","OPPS APC"
"Acid Reflux Test Nasal Intluminal","PX-75000316","CDM","91037","CPT","0750","RC","","","","outpatient","","","3512.00","2107.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","506.43","14.42","","488.69","488.69","488.69","1 through 10","408.45","2718.29","percent of total billed charges",""
"Acid Reflux Test Nasal Intluminal","PX-75000316","CDM","91037","CPT","0750","RC","","","","outpatient","","","3512.00","2107.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2553.93","72.72","","2464.48","2464.48","5689.17","1 through 10","408.45","2718.29","percent of total billed charges",""
"Acid Reflux Test Nasal Intluminal","PX-75000316","CDM","91037","CPT","0750","RC","","","","outpatient","","","3512.00","2107.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2553.93","72.72","","2464.48","2464.48","2464.48","1 through 10","408.45","2718.29","percent of total billed charges",""
"Acid Reflux Test Nasal Intluminal","PX-75000316","CDM","91037","CPT","0750","RC","","","","outpatient","","","3512.00","2107.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2209.05","62.9","","2135.07","2135.07","2135.07","1 through 10","408.45","2718.29","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","both","","","132.00","79.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","92.14","69.8","","89.34","89.34","89.34","1 through 10","7.83","112.2","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","outpatient","","","132.00","79.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","95.99","72.72","","93.08","93.08","93.08","1 through 10","15.35","102.17","percent of total billed charges",""
"Activated Protein C Resistance","PX-30001077","CDM","85307","CPT","0305","RC","","","","outpatient","","","83.00","49.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","52.21","62.9","","50.40","50.40","50.40","1 through 10","13.31","64.24","percent of total billed charges",""
"Activated Protein C Resistance","PX-30001077","CDM","85307","CPT","0305","RC","","","","outpatient","","","83.00","49.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","60.36","72.72","","58.18","58.18","58.18","1 through 10","13.31","64.24","percent of total billed charges",""
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","","","","inpatient","","","68043.12","40825.87","MEDICARE [2001]","HB WDH MEDICARE","7744.72","","Case rate ($7,744.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,182.55, add-ons for qualifying new technology services are included. If operating cost exceeds $11,100.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,338.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,766.43 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,737.69 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.43. The transfer capital threshold is the transfer adjustment factor * $533.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7696.80","7696.80","7696.80","1 through 10","3975","36487.7","other","Inpatient DRG"
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","","","","inpatient","","","44553.25","26731.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","13153.03","","Case rate ($13,421.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,422.13, add-ons for qualifying new technology services are included. If operating cost exceeds $16,340.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,753.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $12,028.34 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,977.26 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $948.26. The transfer capital threshold is the transfer adjustment factor * $948.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12341.86","12341.86","12341.86","1 through 10","3975","34657.92","other","Inpatient DRG"
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","","","","inpatient","","","44553.25","26731.95","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","13421.46","","Case rate ($13,421.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,422.13, add-ons for qualifying new technology services are included. If operating cost exceeds $16,340.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,753.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $12,028.34 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,977.26 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $948.26. The transfer capital threshold is the transfer adjustment factor * $948.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7309.61","7309.61","7309.61","1 through 10","3975","34657.92","other","Inpatient DRG"
"Acute And Subacute Endocarditis With McC","288","MS-DRG","","","","","","","","inpatient","","","45626.75","27376.05","MEDICARE [2001]","HB WDH MEDICARE","21018.57","","Case rate ($21,018.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $19,434.17, add-ons for qualifying new technology services are included. If operating cost exceeds $23,352.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,308.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $19,070.30 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $18,989.31 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,503.41. The transfer capital threshold is the transfer adjustment factor * $1,503.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17199.48","17199.48","17199.48","1 through 10","3975","102835.87","other","Inpatient DRG"
"Acute Hepatitis Panel","PX-30000176","CDM","80074","CPT","0301","RC","","","","both","","","676.00","405.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","471.85","69.8","","456.49","411.37","456.49","11","30.96","574.6","percent of total billed charges",""
"Acute Hepatitis Panel","PX-30000176","CDM","80074","CPT","0301","RC","","","","outpatient","","","676.00","405.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","424.39","62.78","","410.58","410.58","410.58","1 through 10","43.47","523.22","percent of total billed charges",""
"Acute Hepatitis Panel","PX-30000176","CDM","80074","CPT","0301","RC","","","","outpatient","","","676.00","405.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","295.55","43.72","","285.93","285.93","285.93","1 through 10","43.47","523.22","percent of total billed charges",""
"Acute Hepatitis Panel","PX-30000176","CDM","80074","CPT","0301","RC","","","","outpatient","","","676.00","405.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","491.59","72.72","","475.59","475.59","1426.77","18","43.47","523.22","percent of total billed charges",""
"Acute Hepatitis Panel","PX-30000176","CDM","80074","CPT","0301","RC","","","","outpatient","","","676.00","405.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","359.77","53.22","","697.30","697.30","697.30","1 through 10","43.47","523.22","percent of total billed charges",""
"Acute Hepatitis Panel","PX-30000176","CDM","80074","CPT","0301","RC","","","","outpatient","","","676.00","405.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","425.20","62.9","","412.02","412.02","1581.56","24","43.47","523.22","percent of total billed charges",""
"Acute Hepatitis Panel","PX-30000176","CDM","80074","CPT","0301","RC","","","","outpatient","","","676.00","405.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","523.22","77.4","","506.85","486.55","506.85","1 through 10","43.47","523.22","percent of total billed charges",""
"Acute Leukemia With Cc","835","MS-DRG","","","","","","","","inpatient","","","49212.91","29527.75","MEDICARE [2001]","HB WDH MEDICARE","16302.03","","Case rate ($16,302.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,080.85, add-ons for qualifying new technology services are included. If operating cost exceeds $18,999.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,963.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,698.41 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,635.98 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.75. The transfer capital threshold is the transfer adjustment factor * $1,158.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","0.05","1 through 10","3975","42351.33","other","Inpatient DRG"
"Acute Leukemia With McC","834","MS-DRG","","","","","","","","inpatient","","","31363.53","18818.12","MEDICARE [2001]","HB WDH MEDICARE","42181.48","","Case rate ($42,181.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $38,967.30, add-ons for qualifying new technology services are included. If operating cost exceeds $42,885.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,854.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.6. The base transfer operating payment is the transfer adjustment factor * $38,686.73 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $38,522.43 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,049.88. The transfer capital threshold is the transfer adjustment factor * $3,049.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9319.94","9319.94","9319.94","1 through 10","3975","111470.22","other","Inpatient DRG"
"Acute Major Eye Infections With Cc/McC","121","MS-DRG","","","","","","","","inpatient","","","20055.39","12033.23","MEDICARE [2001]","HB WDH MEDICARE","9288.78","","Case rate ($9,288.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,607.70, add-ons for qualifying new technology services are included. If operating cost exceeds $12,525.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,451.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $8,197.65 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,162.83 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $646.26. The transfer capital threshold is the transfer adjustment factor * $646.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","0.05","1 through 10","3975","44205.52","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","","","","inpatient","","","44007.70","26404.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","13752.38","","Fee schedule rate ($13,752.38). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","50276.80","50276.80","50276.80","1 through 10","3975","34925.89","case rate",""
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","","","","inpatient","","","44007.70","26404.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","7283.62","","Case rate ($7,432.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,894.16, add-ons for qualifying new technology services are included. If operating cost exceeds $10,812.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,315.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,476.80 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,449.29 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.60. The transfer capital threshold is the transfer adjustment factor * $510.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7400.27","7400.27","7400.27","1 through 10","3975","34925.89","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","","","","inpatient","","","44007.70","26404.62","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","7655.24","","Case rate ($7,432.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,894.16, add-ons for qualifying new technology services are included. If operating cost exceeds $10,812.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,315.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,476.80 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,449.29 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.60. The transfer capital threshold is the transfer adjustment factor * $510.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","5818.40","5818.40","5818.40","1 through 10","3975","34925.89","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","","","","inpatient","","","44007.70","26404.62","MARTIN'S POINT [160007]","HB WDH MEDICARE","7432.27","","Case rate ($7,432.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,894.16, add-ons for qualifying new technology services are included. If operating cost exceeds $10,812.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,315.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,476.80 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,449.29 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.60. The transfer capital threshold is the transfer adjustment factor * $510.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9331.95","9331.95","9331.95","1 through 10","3975","34925.89","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","","","","inpatient","","","44007.70","26404.62","MEDICARE [2001]","HB WDH MEDICARE","7432.27","","Case rate ($7,432.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,894.16, add-ons for qualifying new technology services are included. If operating cost exceeds $10,812.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,315.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,476.80 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,449.29 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.60. The transfer capital threshold is the transfer adjustment factor * $510.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7400.27","640.62","7418.40","14","3975","34925.89","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","","","","inpatient","","","44007.70","26404.62","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7432.27","","Case rate ($7,432.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,894.16, add-ons for qualifying new technology services are included. If operating cost exceeds $10,812.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,315.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,476.80 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,449.29 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.60. The transfer capital threshold is the transfer adjustment factor * $510.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7315.04","7307.64","7418.40","1 through 10","3975","34925.89","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","46263.49","27758.09","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","12892.72","","Case rate ($12,639.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,700.78, add-ons for qualifying new technology services are included. If operating cost exceeds $15,618.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,696.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $11,303.92 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,255.91 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.15. The transfer capital threshold is the transfer adjustment factor * $891.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","12830.03","12830.03","12862.35","1 through 10","3975","60955.96","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","46263.49","27758.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","12387.12","","Case rate ($12,639.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,700.78, add-ons for qualifying new technology services are included. If operating cost exceeds $15,618.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,696.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $11,303.92 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,255.91 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.15. The transfer capital threshold is the transfer adjustment factor * $891.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12606.68","12605.10","34014.51","1 through 10","3975","60955.96","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","46263.49","27758.09","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","13019.12","","Case rate ($12,639.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,700.78, add-ons for qualifying new technology services are included. If operating cost exceeds $15,618.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,696.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $11,303.92 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,255.91 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.15. The transfer capital threshold is the transfer adjustment factor * $891.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11847.82","11847.82","11847.82","1 through 10","3975","60955.96","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","46263.49","27758.09","MARTIN'S POINT [160007]","HB WDH MEDICARE","12639.92","","Case rate ($12,639.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,700.78, add-ons for qualifying new technology services are included. If operating cost exceeds $15,618.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,696.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $11,303.92 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,255.91 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.15. The transfer capital threshold is the transfer adjustment factor * $891.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12635.10","12621.08","15542.39","1 through 10","3975","60955.96","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","46263.49","27758.09","MEDICARE [2001]","HB WDH MEDICARE","12639.92","","Case rate ($12,639.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,700.78, add-ons for qualifying new technology services are included. If operating cost exceeds $15,618.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,696.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $11,303.92 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,255.91 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.15. The transfer capital threshold is the transfer adjustment factor * $891.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12830.08","968.83","12863.20","38","3975","60955.96","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","46263.49","27758.09","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","12639.92","","Case rate ($12,639.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,700.78, add-ons for qualifying new technology services are included. If operating cost exceeds $15,618.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,696.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $11,303.92 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,255.91 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.15. The transfer capital threshold is the transfer adjustment factor * $891.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12611.08","6379.92","12659.34","12","3975","60955.96","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive Without Cc/McC","282","MS-DRG","","","","","","","","inpatient","","","38521.84","23113.10","MEDICARE [2001]","HB WDH MEDICARE","5942.19","","Case rate ($5,942.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,518.84, add-ons for qualifying new technology services are included. If operating cost exceeds $9,437.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,206.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,095.61 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,073.97 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $401.71. The transfer capital threshold is the transfer adjustment factor * $401.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5916.07","5916.07","5930.33","1 through 10","3975","16163","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive Without Cc/McC","282","MS-DRG","","","","","","","","inpatient","","","38521.84","23113.10","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","5942.19","","Case rate ($5,942.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,518.84, add-ons for qualifying new technology services are included. If operating cost exceeds $9,437.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,206.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,095.61 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,073.97 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $401.71. The transfer capital threshold is the transfer adjustment factor * $401.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5797.75","5797.75","5797.75","1 through 10","3975","16163","other","Inpatient DRG"
"Acute Myocardial Infarction, Expired With McC","283","MS-DRG","","","","","","","","inpatient","","","100506.66","60304.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","15193.70","","Case rate ($15,503.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,344.08, add-ons for qualifying new technology services are included. If operating cost exceeds $18,262.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,905.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,958.48 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,899.20 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,100.42. The transfer capital threshold is the transfer adjustment factor * $1,100.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14897.38","14897.38","14897.38","1 through 10","4637","75270.6","other","Inpatient DRG"
"Acute Myocardial Infarction, Expired With McC","283","MS-DRG","","","","","","","","inpatient","","","100506.66","60304.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","15503.78","","Case rate ($15,503.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,344.08, add-ons for qualifying new technology services are included. If operating cost exceeds $18,262.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,905.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,958.48 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,899.20 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,100.42. The transfer capital threshold is the transfer adjustment factor * $1,100.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14947.88","14947.88","14947.88","1 through 10","4637","75270.6","other","Inpatient DRG"
"Acute Myocardial Infarction, Expired With McC","283","MS-DRG","","","","","","","","inpatient","","","100506.66","60304.00","MEDICARE [2001]","HB WDH MEDICARE","15503.78","","Case rate ($15,503.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,344.08, add-ons for qualifying new technology services are included. If operating cost exceeds $18,262.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,905.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,958.48 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,899.20 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,100.42. The transfer capital threshold is the transfer adjustment factor * $1,100.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15237.82","15237.82","15237.82","1 through 10","4637","75270.6","other","Inpatient DRG"
"Acute Myocardial Infarction, Expired With McC","283","MS-DRG","","","","","","","","inpatient","","","100506.66","60304.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","15503.78","","Case rate ($15,503.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,344.08, add-ons for qualifying new technology services are included. If operating cost exceeds $18,262.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,905.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,958.48 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,899.20 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,100.42. The transfer capital threshold is the transfer adjustment factor * $1,100.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14972.57","14972.57","14972.57","1 through 10","4637","75270.6","other","Inpatient DRG"
"Adalimumab Qn","PX-30003603","CDM","80299","CPT","0301","RC","","","","both","","","146.00","87.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","101.91","69.8","","69.80","62.90","69.80","1 through 10","12.12","124.1","percent of total billed charges",""
"Adalimumab Qn","PX-30003603","CDM","80299","CPT","0301","RC","","","","outpatient","","","146.00","87.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","63.83","43.72","","43.72","43.72","43.72","1 through 10","12.76","113","percent of total billed charges",""
"Adalimumab Qn","PX-30003603","CDM","80299","CPT","0301","RC","","","","outpatient","","","146.00","87.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","106.17","72.72","","72.72","72.72","72.72","1 through 10","12.76","113","percent of total billed charges",""
"Adalimumab Qn","PX-30003603","CDM","80299","CPT","0301","RC","","","","outpatient","","","146.00","87.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","106.17","72.72","","190.53","190.53","190.53","1 through 10","12.76","113","percent of total billed charges",""
"Adalimumab Qn","PX-30003603","CDM","80299","CPT","0301","RC","","","","outpatient","","","146.00","87.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","77.70","53.22","","53.31","53.31","53.31","1 through 10","12.76","113","percent of total billed charges",""
"Adalimumab Qn","PX-30003603","CDM","80299","CPT","0301","RC","","","","outpatient","","","146.00","87.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","91.83","62.9","","63.00","63.00","189.00","13","12.76","113","percent of total billed charges",""
"Adamts 13 Antibody","PX-30002779","CDM","83520","CPT","0301","RC","","","","both","","","200.00","120.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","139.60","69.8","","134.71","14.76","134.71","17","11.23","170","percent of total billed charges",""
"Adamts 13 Antibody","PX-30002779","CDM","83520","CPT","0301","RC","","","","inpatient","","","200.00","120.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","153.72","76.86","","121.59","121.59","121.59","1 through 10","132.4","153.72","percent of total billed charges",""
"Adamts 13 Antibody","PX-30002779","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","145.44","72.72","","140.35","140.35","140.35","16","12.06","154.8","percent of total billed charges",""
"Adamts 13 Antibody","PX-30002779","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","145.44","72.72","","140.35","140.35","140.35","1 through 10","12.06","154.8","percent of total billed charges",""
"Adamts 13 Antibody","PX-30002779","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","106.44","53.22","","102.89","102.89","102.89","1 through 10","12.06","154.8","percent of total billed charges",""
"Adamts 13 Antibody","PX-30002779","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","125.80","62.9","","243.18","121.59","364.77","19","12.06","154.8","percent of total billed charges",""
"Adamts 13 Antibody","PX-30002779","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","154.80","77.4","","149.58","138.91","149.58","12","12.06","154.8","percent of total billed charges",""
"ADAPTER CONNECTION 1X8 1.3MM 15CM PRECISION M8 POLYURETHANE SILICONE INLINE CONNECTOR","SUP-ITM-10191376","CDM","C1883","HCPCS","0278","RC","","","","outpatient","","","4664.25","2798.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2933.81","62.9","","4897.47","4897.47","4897.47","1 through 10","542.45","3610.13","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","4636.61","2781.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","539.24","3941.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","4636.61","2781.97","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2638.23","56.9","","2911.53","1863.86","5209.05","65","539.24","3941.12","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","4636.61","2781.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","539.24","11.63","","400.94","400.94","400.94","1 through 10","539.24","3941.12","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","4636.61","2781.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3588.74","77.4","","5214.50","5214.50","16415.28","1 through 10","539.24","3941.12","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4636.61","2781.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","539.24","11.63","","400.94","400.94","400.94","1 through 10","539.24","3588.74","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4636.61","2781.97","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2027.13","43.72","","1543.33","1543.33","1671.61","1 through 10","539.24","3588.74","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4636.61","2781.97","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3371.74","72.72","","3700.21","2382.07","6427.18","53","539.24","3588.74","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4636.61","2781.97","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3371.74","72.72","","12685.80","12685.80","12685.80","1 through 10","539.24","3588.74","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4636.61","2781.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2916.43","62.9","","3408.87","2784.05","9859.40","46","539.24","3588.74","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4636.61","2781.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3588.74","77.4","","5214.50","5214.50","16415.28","1 through 10","539.24","3588.74","percent of total billed charges",""
"ADAPTER PRECISION 15CM S8","SUP-ITM-10191378","CDM","C1883","HCPCS","0278","RC","","","","outpatient","","","4664.25","2798.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2933.81","62.9","","4897.47","4897.47","4897.47","1 through 10","542.45","3610.13","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","812.62","487.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","94.51","690.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","812.62","487.57","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","462.38","56.9","","2911.53","1863.86","5209.05","65","94.51","690.73","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","812.62","487.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","94.51","11.63","","400.94","400.94","400.94","1 through 10","94.51","690.73","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","812.62","487.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","628.97","77.4","","5214.50","5214.50","16415.28","1 through 10","94.51","690.73","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","812.62","487.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","94.51","11.63","","400.94","400.94","400.94","1 through 10","94.51","628.97","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","812.62","487.57","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","355.28","43.72","","1543.33","1543.33","1671.61","1 through 10","94.51","628.97","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","812.62","487.57","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","590.94","72.72","","3700.21","2382.07","6427.18","53","94.51","628.97","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","812.62","487.57","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","590.94","72.72","","12685.80","12685.80","12685.80","1 through 10","94.51","628.97","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","812.62","487.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","511.14","62.9","","3408.87","2784.05","9859.40","46","94.51","628.97","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","812.62","487.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","628.97","77.4","","5214.50","5214.50","16415.28","1 through 10","94.51","628.97","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","1623.85","974.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","188.85","1380.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","1623.85","974.31","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","923.97","56.9","","2911.53","1863.86","5209.05","65","188.85","1380.27","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","1623.85","974.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","188.85","11.63","","400.94","400.94","400.94","1 through 10","188.85","1380.27","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","1623.85","974.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1256.86","77.4","","5214.50","5214.50","16415.28","1 through 10","188.85","1380.27","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1623.85","974.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","188.85","11.63","","400.94","400.94","400.94","1 through 10","188.85","1256.86","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1623.85","974.31","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","709.95","43.72","","1543.33","1543.33","1671.61","1 through 10","188.85","1256.86","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1623.85","974.31","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1180.86","72.72","","3700.21","2382.07","6427.18","53","188.85","1256.86","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1623.85","974.31","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1180.86","72.72","","12685.80","12685.80","12685.80","1 through 10","188.85","1256.86","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1623.85","974.31","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1021.40","62.9","","3408.87","2784.05","9859.40","46","188.85","1256.86","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1623.85","974.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1256.86","77.4","","5214.50","5214.50","16415.28","1 through 10","188.85","1256.86","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","outpatient","","","230.00","138.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","100.56","43.72","","97.06","97.06","97.06","1 through 10","51.91","178.02","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","outpatient","","","230.00","138.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","167.26","72.72","","161.44","161.44","484.32","15","51.91","178.02","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","outpatient","","","230.00","138.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","122.41","53.22","","118.35","118.35","118.35","1 through 10","51.91","178.02","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","outpatient","","","230.00","138.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","144.67","62.9","","139.86","139.86","419.58","44","51.91","178.02","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","outpatient","","","230.00","138.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","178.02","77.4","","172.05","172.05","172.05","1 through 10","51.91","178.02","percent of total billed charges",""
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","48.00","28.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","33.50","69.8","","32.11","32.11","32.11","1 through 10","20.5","308.05","percent of total billed charges",""
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","48.00","28.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","49.17","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","46.28","42.59","48.21","1 through 10","20.5","308.05","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","48.00","28.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","132.65","","Case rate ($132.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","129.41","129.41","129.41","1 through 10","20.5","308.05","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","48.00","28.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","47.24","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","47.25","47.25","47.25","1 through 10","20.5","308.05","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","48.00","28.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","248.99","","Case rate ($248.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","129.41","129.41","129.41","1 through 10","20.5","308.05","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","outpatient","","","48.00","28.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","5.58","11.63","","11.62","5.92","11.62","1 through 10","5.58","37.15","percent of total billed charges",""
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","outpatient","","","48.00","28.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","34.91","72.72","","33.45","33.45","33.45","1 through 10","5.58","37.15","percent of total billed charges",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","both","","","208.00","124.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","145.18","69.8","","126.43","126.43","140.30","1 through 10","25.1","198.67","percent of total billed charges",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","outpatient","","","208.00","124.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","130.83","62.9","","126.63","126.63","126.63","1 through 10","35.99","160.99","percent of total billed charges",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","outpatient","","","208.00","124.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","160.99","77.4","","155.78","155.78","155.78","1 through 10","35.99","160.99","percent of total billed charges",""
"Aerosol Neb/Mdi/Ippb Demo/Eval","PX-46000007","CDM","94664","CPT","0410","RC","","","","both","","","194.00","116.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","135.41","69.8","","130.53","130.53","130.53","1 through 10","110.39","1358.06","percent of total billed charges",""
"Aerosol Neb/Mdi/Ippb Demo/Eval","PX-46000007","CDM","94664","CPT","0410","RC","","","","both","","","194.00","116.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","212.49","","APC Price ($212.49). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","212.52","208.91","212.52","1 through 10","110.39","1358.06","other","OPPS APC"
"Aerosol Neb/Mdi/Ippb Demo/Eval","PX-46000007","CDM","94664","CPT","0410","RC","","","","both","","","194.00","116.40","MEDICARE [2001]","HB WDH MEDICARE","212.49","","APC Price ($212.49). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","425.04","212.52","425.04","1 through 10","110.39","1358.06","other","OPPS APC"
"Aerosol Neb/Mdi/Ippb Demo/Eval","PX-46000007","CDM","94664","CPT","0410","RC","","","","both","","","194.00","116.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","212.49","","APC Price ($212.49). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.00","187.00","187.00","1 through 10","110.39","1358.06","other","OPPS APC"
"Aerosol Neb/Mdi/Ippb Demo/Eval","PX-46000007","CDM","94664","CPT","0410","RC","","","","both","","","194.00","116.40","WELLSENSE NH [1050]","HB WDH MEDICARE","212.49","","APC Price ($212.49). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","223.15","223.15","223.15","1 through 10","110.39","1358.06","other","OPPS APC"
"Aerosol Neb/Mdi/Ippb Demo/Eval","PX-46000007","CDM","94664","CPT","0410","RC","","","","outpatient","","","194.00","116.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","150.16","77.4","","144.92","144.92","144.93","1 through 10","22.56","150.16","percent of total billed charges",""
"Aerosol Neb/Mdi/Ippb Demo/Eval","PX-46000007","CDM","94664","CPT","0410","RC","","","","outpatient","","","194.00","116.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","22.56","11.63","","22.08","22.08","22.08","1 through 10","22.56","150.16","percent of total billed charges",""
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","","","","inpatient","","","38716.77","23230.06","MEDICARE [2001]","HB WDH MEDICARE","9005.98","","Case rate ($9,005.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,346.68, add-ons for qualifying new technology services are included. If operating cost exceeds $12,264.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,430.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $7,935.50 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,901.80 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $625.60. The transfer capital threshold is the transfer adjustment factor * $625.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9036.92","7429.43","9059.30","1 through 10","3975","42791.91","other","Inpatient DRG"
"Aftercare, Musculoskeletal System And Connective Tissue With McC","559","MS-DRG","","","","","","","","inpatient","","","22877.44","13726.46","MEDICARE [2001]","HB WDH MEDICARE","14622.65","","Case rate ($14,622.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,530.81, add-ons for qualifying new technology services are included. If operating cost exceeds $17,448.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,841.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $13,141.75 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,085.94 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,036.03. The transfer capital threshold is the transfer adjustment factor * $1,036.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","957.19","957.19","957.19","1 through 10","3975","70866.39","other","Inpatient DRG"
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/McC","561","MS-DRG","","","","","","","","inpatient","","","18245.08","10947.05","MEDICARE [2001]","HB WDH MEDICARE","6556.46","","Case rate ($6,556.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,085.80, add-ons for qualifying new technology services are included. If operating cost exceeds $10,003.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,251.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,665.00 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,640.94 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $446.60. The transfer capital threshold is the transfer adjustment factor * $446.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6614.03","6614.03","6614.03","1 through 10","3975","30548.28","other","Inpatient DRG"
"Albumin Qn Urine or Other Source","PX-30000282","CDM","82042","CPT","0301","RC","","","","both","","","91.00","54.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","63.52","69.8","","61.42","61.42","61.42","1 through 10","5.06","77.35","percent of total billed charges",""
"Albumin Qn Urine or Other Source","PX-30000282","CDM","82042","CPT","0301","RC","","","","outpatient","","","91.00","54.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","57.24","62.9","","211.88","55.44","211.88","1 through 10","6.2","70.43","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","both","","","70.00","42.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","48.86","69.8","","47.46","5.64","47.46","33","3.22","59.5","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","outpatient","","","70.00","42.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","43.95","62.78","","42.69","42.69","42.69","1 through 10","4.61","54.18","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","outpatient","","","70.00","42.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","30.60","43.72","","29.73","29.73","29.73","1 through 10","4.61","54.18","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","outpatient","","","70.00","42.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","50.90","72.72","","49.45","49.45","49.45","42","4.61","54.18","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","outpatient","","","70.00","42.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","37.25","53.22","","36.25","36.25","36.25","1 through 10","4.61","54.18","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","outpatient","","","70.00","42.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","44.03","62.9","","42.84","42.84","42.84","67","4.61","54.18","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","outpatient","","","70.00","42.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","54.18","77.4","","52.70","49.45","52.70","23","4.61","54.18","percent of total billed charges",""
"Alcohol (Quantitative Alcohols)","PX-30002837","CDM","80320","CPT","0301","RC","","","","both","","","1315.00","789.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","917.87","69.8","","887.86","887.86","887.86","1 through 10","74.38","1117.75","percent of total billed charges",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC","896","MS-DRG","","","","","","","","inpatient","","","39061.92","23437.15","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","13986.11","","Case rate ($13,711.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,690.17, add-ons for qualifying new technology services are included. If operating cost exceeds $16,608.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,774.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,297.53 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,245.30 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $969.48. The transfer capital threshold is the transfer adjustment factor * $969.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","7101.43","7101.43","7101.43","1 through 10","3975","66313.97","other","Inpatient DRG"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC","896","MS-DRG","","","","","","","","inpatient","","","39061.92","23437.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","66313.97","","Fee schedule rate ($66,313.97). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","52012.42","52012.42","52012.42","1 through 10","3975","66313.97","case rate",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC","896","MS-DRG","","","","","","","","inpatient","","","39061.92","23437.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","52815.94","","Fee schedule rate ($52,815.94). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","52581.85","52581.85","52581.85","1 through 10","3975","66313.97","case rate",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC","896","MS-DRG","","","","","","","","inpatient","","","39061.92","23437.15","MEDICARE [2001]","HB WDH MEDICARE","13711.87","","Case rate ($13,711.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,690.17, add-ons for qualifying new technology services are included. If operating cost exceeds $16,608.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,774.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,297.53 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,245.30 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $969.48. The transfer capital threshold is the transfer adjustment factor * $969.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13916.93","1005.40","13916.93","1 through 10","3975","66313.97","other","Inpatient DRG"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC","896","MS-DRG","","","","","","","","inpatient","","","39061.92","23437.15","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","13711.87","","Case rate ($13,711.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,690.17, add-ons for qualifying new technology services are included. If operating cost exceeds $16,608.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,774.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,297.53 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,245.30 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $969.48. The transfer capital threshold is the transfer adjustment factor * $969.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13642.79","13620.09","13881.92","1 through 10","3975","66313.97","other","Inpatient DRG"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","25440.14","15264.08","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","13209.23","","Fee schedule rate ($13,209.23). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","12878.29","12878.29","12878.29","1 through 10","3975","33546.49","case rate",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","25440.14","15264.08","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","7013.17","","Case rate ($7,156.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,639.44, add-ons for qualifying new technology services are included. If operating cost exceeds $10,557.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,295.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,221.00 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,194.58 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $490.43. The transfer capital threshold is the transfer adjustment factor * $490.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7101.48","7101.48","7118.82","1 through 10","3975","33546.49","other","Inpatient DRG"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","25440.14","15264.08","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","7370.99","","Case rate ($7,156.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,639.44, add-ons for qualifying new technology services are included. If operating cost exceeds $10,557.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,295.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,221.00 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,194.58 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $490.43. The transfer capital threshold is the transfer adjustment factor * $490.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","6716.67","6716.67","6716.67","1 through 10","3975","33546.49","other","Inpatient DRG"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","25440.14","15264.08","MEDICARE [2001]","HB WDH MEDICARE","7156.30","","Case rate ($7,156.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,639.44, add-ons for qualifying new technology services are included. If operating cost exceeds $10,557.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,295.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,221.00 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,194.58 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $490.43. The transfer capital threshold is the transfer adjustment factor * $490.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7118.82","7101.48","7119.29","1 through 10","3975","33546.49","other","Inpatient DRG"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","25440.14","15264.08","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7156.30","","Case rate ($7,156.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,639.44, add-ons for qualifying new technology services are included. If operating cost exceeds $10,557.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,295.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,221.00 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,194.58 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $490.43. The transfer capital threshold is the transfer adjustment factor * $490.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7000.45","7000.45","7000.45","1 through 10","3975","33546.49","other","Inpatient DRG"
"Aldolase","PX-30000288","CDM","82085","CPT","0301","RC","","","","both","","","52.00","31.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","36.30","69.8","","34.90","34.90","34.90","1 through 10","6.31","49.65","percent of total billed charges",""
"Aldolase","PX-30000288","CDM","82085","CPT","0301","RC","","","","outpatient","","","52.00","31.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","37.81","72.72","","36.36","36.36","36.36","1 through 10","9.05","40.25","percent of total billed charges",""
"Aldolase","PX-30000288","CDM","82085","CPT","0301","RC","","","","outpatient","","","52.00","31.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","32.71","62.9","","31.50","31.50","31.50","1 through 10","9.05","40.25","percent of total billed charges",""
"Aldolase","PX-30000288","CDM","82085","CPT","0301","RC","","","","outpatient","","","52.00","31.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","40.25","77.4","","38.75","38.75","38.75","1 through 10","9.05","40.25","percent of total billed charges",""
"Aldosterone","PX-30000289","CDM","82088","CPT","0301","RC","","","","both","","","221.00","132.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","154.26","69.8","","149.37","134.61","149.37","1 through 10","26.49","210.71","percent of total billed charges",""
"Aldosterone","PX-30000289","CDM","82088","CPT","0301","RC","","","","outpatient","","","221.00","132.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","160.71","72.72","","155.62","155.62","299.18","1 through 10","37.97","171.05","percent of total billed charges",""
"Aldosterone","PX-30000289","CDM","82088","CPT","0301","RC","","","","outpatient","","","221.00","132.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","139.01","62.9","","134.82","134.82","134.82","1 through 10","37.97","171.05","percent of total billed charges",""
"Aldosterone","PX-30000289","CDM","82088","CPT","0301","RC","","","","outpatient","","","221.00","132.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","171.05","77.4","","165.85","165.85","165.85","1 through 10","37.97","171.05","percent of total billed charges",""
"Allergen Spec Ige Recombinant/Purified Compnt Ea","PX-30003473","CDM","86008","CPT","0302","RC","","","","outpatient","","","254.00","152.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","29.54","11.63","","246.00","246.00","246.00","1 through 10","29.54","196.6","percent of total billed charges",""
"Allergen Spec Ige Recombinant/Purified Compnt Ea","PX-30003473","CDM","86008","CPT","0302","RC","","","","outpatient","","","254.00","152.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","184.71","72.72","","178.89","178.89","1024.25","1 through 10","29.54","196.6","percent of total billed charges",""
"Allergen Spec Ige Recombinant/Purified Compnt Ea","PX-30003473","CDM","86008","CPT","0302","RC","","","","outpatient","","","254.00","152.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","159.77","62.9","","309.96","154.98","309.96","1 through 10","29.54","196.6","percent of total billed charges",""
"Allergen Spec Ige Recombinant/Purified Compnt Ea","PX-30003473","CDM","86008","CPT","0302","RC","","","","outpatient","","","254.00","152.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","196.60","77.4","","381.30","381.30","381.30","1 through 10","29.54","196.6","percent of total billed charges",""
"Allergen Spec Ige Recombinant/Purified Compnt Ea","PX-30003473","CDM","86008","CPT","0302","RC","","","","outpatient","","","254.00","152.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","29.54","11.63","","10.98","10.98","10.98","1 through 10","29.54","196.6","percent of total billed charges",""
"Allergen Specific Ige Quan/Semiquan Ea Allergen","PX-30001851","CDM","86003","CPT","0302","RC","","","","both","","","71.00","42.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","49.56","69.8","","48.16","5.95","48.16","156","3.39","60.35","percent of total billed charges",""
"Allergen Specific Ige Quan/Semiquan Ea Allergen","PX-30001851","CDM","86003","CPT","0302","RC","","","","outpatient","","","71.00","42.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","31.04","43.72","","452.50","452.50","452.50","1 through 10","4.86","54.95","percent of total billed charges",""
"Allergen Specific Ige Quan/Semiquan Ea Allergen","PX-30001851","CDM","86003","CPT","0302","RC","","","","outpatient","","","71.00","42.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","51.63","72.72","","50.18","50.18","150.54","97","4.86","54.95","percent of total billed charges",""
"Allergen Specific Ige Quan/Semiquan Ea Allergen","PX-30001851","CDM","86003","CPT","0302","RC","","","","outpatient","","","71.00","42.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","37.79","53.22","","36.78","36.78","36.78","29","4.86","54.95","percent of total billed charges",""
"Allergen Specific Ige Quan/Semiquan Ea Allergen","PX-30001851","CDM","86003","CPT","0302","RC","","","","outpatient","","","71.00","42.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","44.66","62.9","","43.47","43.47","43.47","235","4.86","54.95","percent of total billed charges",""
"Allergen Specific Ige Quan/Semiquan Ea Allergen","PX-30001851","CDM","86003","CPT","0302","RC","","","","outpatient","","","71.00","42.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","54.95","77.4","","53.48","49.60","53.48","109","4.86","54.95","percent of total billed charges",""
"Allergic Reactions With McC","915","MS-DRG","","","","","","","","inpatient","","","83929.53","50357.72","MEDICARE [2001]","HB WDH MEDICARE","13657.14","","Case rate ($13,657.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,639.65, add-ons for qualifying new technology services are included. If operating cost exceeds $16,557.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,770.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $12,246.79 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,194.78 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $965.48. The transfer capital threshold is the transfer adjustment factor * $965.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13592.39","13592.39","13592.39","1 through 10","3975","66040.37","other","Inpatient DRG"
"Allergic Reactions With McC","915","MS-DRG","","","","","","","","inpatient","","","83929.53","50357.72","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","13657.14","","Case rate ($13,657.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,639.65, add-ons for qualifying new technology services are included. If operating cost exceeds $16,557.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,770.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $12,246.79 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,194.78 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $965.48. The transfer capital threshold is the transfer adjustment factor * $965.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13360.05","13360.05","13360.05","1 through 10","3975","66040.37","other","Inpatient DRG"
"Allergic Reactions Without McC","916","MS-DRG","","","","","","","","inpatient","","","22758.53","13655.12","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","5400.16","","Case rate ($5,510.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,120.27, add-ons for qualifying new technology services are included. If operating cost exceeds $9,038.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,175.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,695.34 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,675.40 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $370.16. The transfer capital threshold is the transfer adjustment factor * $370.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5346.67","5346.67","5346.67","1 through 10","3975","25319.47","other","Inpatient DRG"
"ALLOGRAFT BONE 10MM OSTEOCHONDRAL TISSUE FRESH PLUG","SUP-ITM-10278727","CDM","C1889","HCPCS","0278","RC","","","","both","","","12094.69","7256.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","1406.61","10280.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ALLOGRAFT BONE 10MM OSTEOCHONDRAL TISSUE FRESH PLUG","SUP-ITM-10278727","CDM","C1889","HCPCS","0278","RC","","","","both","","","12094.69","7256.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","1406.61","10280.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ALLOGRAFT BONE 10MM OSTEOCHONDRAL TISSUE FRESH PLUG","SUP-ITM-10278727","CDM","C1889","HCPCS","0278","RC","","","","both","","","12094.69","7256.81","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6881.88","56.9","","0.63","0.63","0.63","1 through 10","1406.61","10280.49","percent of total billed charges",""
"ALLOGRAFT BONE 10MM OSTEOCHONDRAL TISSUE FRESH PLUG","SUP-ITM-10278727","CDM","C1889","HCPCS","0278","RC","","","","both","","","12094.69","7256.81","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1744.05","14.42","","317.14","317.14","317.14","1 through 10","1406.61","10280.49","percent of total billed charges",""
"ALLOGRAFT BONE 10MM OSTEOCHONDRAL TISSUE FRESH PLUG","SUP-ITM-10278727","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12094.69","7256.81","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1744.05","14.42","","317.14","317.14","317.14","1 through 10","1406.61","9361.29","percent of total billed charges",""
"ALLOGRAFT BONE 10MM OSTEOCHONDRAL TISSUE FRESH PLUG","SUP-ITM-10278727","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12094.69","7256.81","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","7593.05","62.78","","1125.09","1125.09","1125.09","1 through 10","1406.61","9361.29","percent of total billed charges",""
"ALLOGRAFT BONE 10MM OSTEOCHONDRAL TISSUE FRESH PLUG","SUP-ITM-10278727","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12094.69","7256.81","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8795.26","72.72","","4732.50","1617.43","14180.40","1 through 10","1406.61","9361.29","percent of total billed charges",""
"ALLOGRAFT BONE 10MM OSTEOCHONDRAL TISSUE FRESH PLUG","SUP-ITM-10278727","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","12094.69","7256.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7607.56","62.9","","3896.20","3341.38","3896.20","1 through 10","1406.61","9361.29","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","both","","","92.00","55.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","64.22","69.8","","62.12","55.98","62.12","15","10.9","87.29","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","outpatient","","","92.00","55.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","40.22","43.72","","38.91","38.91","38.91","1 through 10","15.64","71.21","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","outpatient","","","92.00","55.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","66.90","72.72","","64.72","64.72","64.72","21","15.64","71.21","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","outpatient","","","92.00","55.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","48.96","53.22","","47.45","47.45","47.45","1 through 10","15.64","71.21","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","outpatient","","","92.00","55.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","57.87","62.9","","56.07","56.07","56.07","21","15.64","71.21","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","outpatient","","","92.00","55.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","71.21","77.4","","68.98","64.72","68.98","1 through 10","15.64","71.21","percent of total billed charges",""
"Alpha-1 Antitrypsin Phenotype","PX-30000292","CDM","82104","CPT","0301","RC","","","","both","","","79.00","47.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","55.14","69.8","","16.48","16.48","16.48","1 through 10","9.4","75.25","percent of total billed charges",""
"Alpha-1 Antitrypsin Phenotype","PX-30000292","CDM","82104","CPT","0301","RC","","","","outpatient","","","79.00","47.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","34.54","43.72","","33.23","33.23","33.23","1 through 10","13.48","61.15","percent of total billed charges",""
"Alpha-1 Antitrypsin Phenotype","PX-30000292","CDM","82104","CPT","0301","RC","","","","outpatient","","","79.00","47.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","57.45","72.72","","55.27","55.27","55.27","1 through 10","13.48","61.15","percent of total billed charges",""
"Alpha-1 Antitrypsin Phenotype","PX-30000292","CDM","82104","CPT","0301","RC","","","","outpatient","","","79.00","47.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","49.69","62.9","","47.88","47.88","47.88","1 through 10","13.48","61.15","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","both","","","72.00","43.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","50.26","69.8","","48.86","15.32","48.86","1 through 10","8.74","69.25","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","outpatient","","","72.00","43.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","31.48","43.72","","30.60","30.60","30.60","1 through 10","12.52","55.73","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","outpatient","","","72.00","43.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","52.36","72.72","","50.90","50.90","50.90","17","12.52","55.73","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","outpatient","","","72.00","43.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","45.29","62.9","","44.10","44.10","169.00","24","12.52","55.73","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","outpatient","","","72.00","43.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","55.73","77.4","","54.25","12.41","54.25","1 through 10","12.52","55.73","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","both","","","74.00","44.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","51.65","69.8","","50.26","45.29","50.26","54","3.45","62.9","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","both","","","74.00","44.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","62.90","85","","27.09","7.42","27.09","1 through 10","3.45","62.9","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","outpatient","","","74.00","44.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","46.46","62.78","","45.20","45.20","45.20","1 through 10","4.94","57.28","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","outpatient","","","74.00","44.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","32.35","43.72","","31.48","31.48","60.54","1 through 10","4.94","57.28","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","outpatient","","","74.00","44.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","53.81","72.72","","52.36","52.36","52.36","96","4.94","57.28","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","outpatient","","","74.00","44.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","53.81","72.72","","52.36","52.36","52.36","1 through 10","4.94","57.28","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","outpatient","","","74.00","44.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","39.38","53.22","","38.38","38.38","38.38","1 through 10","4.94","57.28","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","outpatient","","","74.00","44.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","46.55","62.9","","45.36","45.36","45.36","86","4.94","57.28","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","outpatient","","","74.00","44.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","57.28","77.4","","55.80","55.80","55.80","32","4.94","57.28","percent of total billed charges",""
"Ambulatory Bp Analysis W/Report","PX-48000031","CDM","93788","CPT","0480","RC","","","","outpatient","","","673.00","403.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","97.05","14.42","","93.59","93.59","93.59","1 through 10","78.27","520.9","percent of total billed charges",""
"Ambulatory Bp Analysis W/Report","PX-48000031","CDM","93788","CPT","0480","RC","","","","outpatient","","","673.00","403.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","78.27","11.63","","76.65","76.65","76.65","1 through 10","78.27","520.9","percent of total billed charges",""
"Ambulatory Bp Analysis W/Report","PX-48000031","CDM","93788","CPT","0480","RC","","","","outpatient","","","673.00","403.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","489.41","72.72","","653.08","653.08","653.08","1 through 10","78.27","520.9","percent of total billed charges",""
"Ambulatory Bp Recording Only","PX-48000030","CDM","93786","CPT","0480","RC","","","","both","","","294.00","176.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","860.68","","Case rate ($860.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","809.02","809.02","809.02","1 through 10","167.29","860.68","other","OPPS APC"
"Ambulatory Bp Recording Only","PX-48000030","CDM","93786","CPT","0480","RC","","","","both","","","294.00","176.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","370.61","","Case rate ($370.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","348.37","348.37","348.37","1 through 10","167.29","860.68","other","OPPS APC"
"Ambulatory Bp Recording Only","PX-48000030","CDM","93786","CPT","0480","RC","","","","both","","","294.00","176.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","695.68","","Case rate ($695.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","653.92","653.92","653.92","1 through 10","167.29","860.68","other","OPPS APC"
"Ambulatory Bp Recording Only","PX-48000030","CDM","93786","CPT","0480","RC","","","","outpatient","","","294.00","176.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","42.39","14.42","","40.95","40.95","40.95","1 through 10","34.19","227.56","percent of total billed charges",""
"Ambulatory Bp Recording Only","PX-48000030","CDM","93786","CPT","0480","RC","","","","outpatient","","","294.00","176.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","34.19","11.63","","33.55","33.55","33.55","1 through 10","34.19","227.56","percent of total billed charges",""
"Ammonia","PX-30000305","CDM","82140","CPT","0301","RC","","","","both","","","207.00","124.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","144.49","69.8","","139.60","139.60","139.60","1 through 10","9.47","175.95","percent of total billed charges",""
"Ammonia","PX-30000305","CDM","82140","CPT","0301","RC","","","","outpatient","","","207.00","124.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","90.50","43.72","","262.32","262.32","262.32","1 through 10","13.58","160.22","percent of total billed charges",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","","","","inpatient","","","87628.58","52577.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","42651.69","","Fee schedule rate ($42,651.69). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","42512.09","42512.09","42512.09","1 through 10","3975","108319.29","case rate",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","","","","inpatient","","","87628.58","52577.15","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","22779.09","","Case rate ($22,115.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $20,446.73, add-ons for qualifying new technology services are included. If operating cost exceeds $24,364.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,388.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $20,087.16 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $20,001.86 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,583.58. The transfer capital threshold is the transfer adjustment factor * $1,583.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","21704.50","21704.50","21704.50","1 through 10","3975","108319.29","other","Inpatient DRG"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","","","","inpatient","","","87628.58","52577.15","MEDICARE [2001]","HB WDH MEDICARE","22115.62","","Case rate ($22,115.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $20,446.73, add-ons for qualifying new technology services are included. If operating cost exceeds $24,364.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,388.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $20,087.16 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $20,001.86 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,583.58. The transfer capital threshold is the transfer adjustment factor * $1,583.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22476.22","22476.22","22476.22","1 through 10","3975","108319.29","other","Inpatient DRG"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","","","","inpatient","","","87628.58","52577.15","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","22115.62","","Case rate ($22,115.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $20,446.73, add-ons for qualifying new technology services are included. If operating cost exceeds $24,364.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,388.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $20,087.16 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $20,001.86 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,583.58. The transfer capital threshold is the transfer adjustment factor * $1,583.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22010.10","22010.10","22418.97","1 through 10","3975","108319.29","other","Inpatient DRG"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With McC","239","MS-DRG","","","","","","","","inpatient","","","124494.07","74696.44","MEDICARE [2001]","HB WDH MEDICARE","37861.77","","Case rate ($37,861.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $34,980.26, add-ons for qualifying new technology services are included. If operating cost exceeds $38,898.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,539.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 11.1. The base transfer operating payment is the transfer adjustment factor * $34,682.69 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $34,535.39 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,734.22. The transfer capital threshold is the transfer adjustment factor * $2,734.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","38552.68","38552.68","38552.68","1 through 10","3975","187025.09","other","Inpatient DRG"
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","","","","inpatient","","","91279.72","54767.83","MEDICARE [2001]","HB WDH MEDICARE","17745.73","","Case rate ($17,745.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $16,413.38, add-ons for qualifying new technology services are included. If operating cost exceeds $20,331.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,069.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $16,036.61 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,968.51 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,264.25. The transfer capital threshold is the transfer adjustment factor * $1,264.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16722.83","16722.83","16722.83","1 through 10","3975","86476.83","other","Inpatient DRG"
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/McC","476","MS-DRG","","","","","","","","inpatient","","","43132.59","25879.55","MEDICARE [2001]","HB WDH MEDICARE","9417.26","","Case rate ($9,417.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,726.29, add-ons for qualifying new technology services are included. If operating cost exceeds $12,644.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,460.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $8,316.74 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,281.42 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $655.65. The transfer capital threshold is the transfer adjustment factor * $655.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9243.89","9243.89","9243.89","1 through 10","3975","44847.72","other","Inpatient DRG"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","","","","inpatient","","","52123.86","31274.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","56605.15","","Fee schedule rate ($56,605.15). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","67615.80","67615.80","67615.80","1 through 10","3975","71071.59","case rate",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","","","","inpatient","","","52123.86","31274.32","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","15103.61","","Case rate ($14,663.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,568.70, add-ons for qualifying new technology services are included. If operating cost exceeds $17,486.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,844.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $13,179.80 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,123.83 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,039.03. The transfer capital threshold is the transfer adjustment factor * $1,039.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11831.86","11831.86","11831.86","1 through 10","3975","71071.59","other","Inpatient DRG"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","","","","inpatient","","","52123.86","31274.32","MARTIN'S POINT [160007]","HB WDH MEDICARE","14663.70","","Case rate ($14,663.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,568.70, add-ons for qualifying new technology services are included. If operating cost exceeds $17,486.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,844.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $13,179.80 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,123.83 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,039.03. The transfer capital threshold is the transfer adjustment factor * $1,039.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14802.59","14802.59","14802.59","1 through 10","3975","71071.59","other","Inpatient DRG"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","","","","inpatient","","","52123.86","31274.32","MEDICARE [2001]","HB WDH MEDICARE","14663.70","","Case rate ($14,663.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,568.70, add-ons for qualifying new technology services are included. If operating cost exceeds $17,486.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,844.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $13,179.80 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,123.83 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,039.03. The transfer capital threshold is the transfer adjustment factor * $1,039.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15019.78","0.05","15058.77","12","3975","71071.59","other","Inpatient DRG"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","","","","inpatient","","","52123.86","31274.32","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","14663.70","","Case rate ($14,663.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,568.70, add-ons for qualifying new technology services are included. If operating cost exceeds $17,486.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,844.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $13,179.80 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,123.83 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,039.03. The transfer capital threshold is the transfer adjustment factor * $1,039.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14758.89","13020.03","19256.34","1 through 10","3975","71071.59","other","Inpatient DRG"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With McC","616","MS-DRG","","","","","","","","inpatient","","","106797.04","64078.22","MEDICARE [2001]","HB WDH MEDICARE","26957.60","","Case rate ($26,957.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $24,915.83, add-ons for qualifying new technology services are included. If operating cost exceeds $28,834.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,742.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $24,575.33 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $24,470.96 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,937.40. The transfer capital threshold is the transfer adjustment factor * $1,937.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","29608.37","29608.37","29608.37","1 through 10","3975","132521.55","other","Inpatient DRG"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With McC","616","MS-DRG","","","","","","","","inpatient","","","106797.04","64078.22","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","26957.60","","Case rate ($26,957.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $24,915.83, add-ons for qualifying new technology services are included. If operating cost exceeds $28,834.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,742.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $24,575.33 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $24,470.96 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,937.40. The transfer capital threshold is the transfer adjustment factor * $1,937.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","29132.16","29132.16","29132.16","1 through 10","3975","132521.55","other","Inpatient DRG"
"Amylase","PX-30000309","CDM","82150","CPT","0301","RC","","","","both","","","93.00","55.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","64.91","69.8","","62.82","56.61","62.82","1 through 10","4.21","79.05","percent of total billed charges",""
"Amylase","PX-30000309","CDM","82150","CPT","0301","RC","","","","outpatient","","","93.00","55.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","49.49","53.22","","47.98","47.98","47.98","1 through 10","6.04","71.98","percent of total billed charges",""
"Amylase","PX-30000309","CDM","82150","CPT","0301","RC","","","","outpatient","","","93.00","55.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","58.50","62.9","","56.70","56.70","216.92","27","6.04","71.98","percent of total billed charges",""
"Amylase","PX-30000309","CDM","82150","CPT","0301","RC","","","","outpatient","","","93.00","55.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","71.98","77.4","","69.75","69.75","69.75","24","6.04","71.98","percent of total billed charges",""
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","","","","inpatient","","","29080.92","17448.55","MEDICARE [2001]","HB WDH MEDICARE","10394.94","","Case rate ($10,394.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,628.67, add-ons for qualifying new technology services are included. If operating cost exceeds $13,546.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,532.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,222.97 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,183.80 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $727.10. The transfer capital threshold is the transfer adjustment factor * $727.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","0.05","1 through 10","3975","49734.53","other","Inpatient DRG"
"Analy Gene Cftr Common Variants","PX-30000208","CDM","81220","CPT","0301","RC","","","","outpatient","","","2435.00","1461.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1531.62","62.9","","1483.65","1483.65","1483.65","1 through 10","327.56","1884.69","percent of total billed charges",""
"Analy Gene Cyp2c19 Common Variants","PX-30000213","CDM","81225","CPT","0310","RC","","","","both","","","1286.00","771.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","897.63","69.8","","1687.12","1687.12","1687.12","1 through 10","189.38","1217.54","percent of total billed charges",""
"Analy Gene Cyp2c19 Common Variants","PX-30000213","CDM","81225","CPT","0310","RC","","","","outpatient","","","1286.00","771.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","149.56","11.63","","1244.00","1244.00","1244.00","1 through 10","149.56","995.36","percent of total billed charges",""
"Analy Gene Serpina1 Common Variants","PX-30000266","CDM","81332","CPT","0310","RC","","","","outpatient","","","290.00","174.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","33.73","11.63","","26.71","26.71","26.71","1 through 10","33.73","224.46","percent of total billed charges",""
"Analysis Gene F2 20210g>a Variant","PX-30000218","CDM","81240","CPT","0310","RC","","","","both","","","286.00","171.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","199.63","69.8","","193.35","193.35","193.35","1 through 10","42.7","273.92","percent of total billed charges",""
"Analysis Gene F2 20210g>a Variant","PX-30000218","CDM","81240","CPT","0310","RC","","","","outpatient","","","286.00","171.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","41.24","14.42","","277.00","277.00","277.00","1 through 10","33.26","221.36","percent of total billed charges",""
"Analysis Gene F2 20210g>a Variant","PX-30000218","CDM","81240","CPT","0310","RC","","","","outpatient","","","286.00","171.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","33.26","11.63","","277.00","40.20","277.00","1 through 10","33.26","221.36","percent of total billed charges",""
"Analysis Gene F2 20210g>a Variant","PX-30000218","CDM","81240","CPT","0310","RC","","","","outpatient","","","286.00","171.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","207.98","72.72","","201.43","201.43","201.43","1 through 10","33.26","221.36","percent of total billed charges",""
"Analysis Gene F2 20210g>a Variant","PX-30000218","CDM","81240","CPT","0310","RC","","","","outpatient","","","286.00","171.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","207.98","72.72","","201.43","201.43","201.43","1 through 10","33.26","221.36","percent of total billed charges",""
"Analysis Gene F2 20210g>a Variant","PX-30000218","CDM","81240","CPT","0310","RC","","","","outpatient","","","286.00","171.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","179.89","62.9","","174.51","174.51","174.51","1 through 10","33.26","221.36","percent of total billed charges",""
"Analysis Gene F2 20210g>a Variant","PX-30000218","CDM","81240","CPT","0310","RC","","","","outpatient","","","286.00","171.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","221.36","77.4","","214.67","214.67","214.67","1 through 10","33.26","221.36","percent of total billed charges",""
"Analysis Gene F2 20210g>a Variant","PX-30000218","CDM","81240","CPT","0310","RC","","","","outpatient","","","286.00","171.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","33.26","11.63","","120.60","40.20","120.60","13","33.26","221.36","percent of total billed charges",""
"Analysis Gene F5 Leiden Variant","PX-30000219","CDM","81241","CPT","0310","RC","","","","outpatient","","","331.00","198.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","47.73","14.42","","320.00","320.00","320.00","1 through 10","38.5","256.19","percent of total billed charges",""
"Analysis Gene F5 Leiden Variant","PX-30000219","CDM","81241","CPT","0310","RC","","","","outpatient","","","331.00","198.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","38.50","11.63","","320.00","44.90","320.00","1 through 10","38.5","256.19","percent of total billed charges",""
"Analysis Gene F5 Leiden Variant","PX-30000219","CDM","81241","CPT","0310","RC","","","","outpatient","","","331.00","198.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","240.70","72.72","","232.70","232.70","434.13","1 through 10","38.5","256.19","percent of total billed charges",""
"Analysis Gene F5 Leiden Variant","PX-30000219","CDM","81241","CPT","0310","RC","","","","outpatient","","","331.00","198.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","240.70","72.72","","232.70","232.70","232.70","1 through 10","38.5","256.19","percent of total billed charges",""
"Analysis Gene F5 Leiden Variant","PX-30000219","CDM","81241","CPT","0310","RC","","","","outpatient","","","331.00","198.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","208.20","62.9","","201.60","201.60","201.60","1 through 10","38.5","256.19","percent of total billed charges",""
"Analysis Gene F5 Leiden Variant","PX-30000219","CDM","81241","CPT","0310","RC","","","","outpatient","","","331.00","198.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","256.19","77.4","","248.00","248.00","248.00","1 through 10","38.5","256.19","percent of total billed charges",""
"Analysis Gene F5 Leiden Variant","PX-30000219","CDM","81241","CPT","0310","RC","","","","outpatient","","","331.00","198.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","38.50","11.63","","134.70","44.90","134.70","13","38.5","256.19","percent of total billed charges",""
"Analysis Gene Hfe Common Variants","PX-30000227","CDM","81256","CPT","0310","RC","","","","both","","","354.00","212.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","247.09","69.8","","238.72","215.12","238.72","1 through 10","42.48","337.13","percent of total billed charges",""
"Analysis Gene Hfe Common Variants","PX-30000227","CDM","81256","CPT","0310","RC","","","","outpatient","","","354.00","212.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","51.05","14.42","","342.00","342.00","342.00","1 through 10","41.17","274","percent of total billed charges",""
"Analysis Gene Hfe Common Variants","PX-30000227","CDM","81256","CPT","0310","RC","","","","outpatient","","","354.00","212.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","41.17","11.63","","342.00","40.00","342.00","1 through 10","41.17","274","percent of total billed charges",""
"Analysis Gene Hfe Common Variants","PX-30000227","CDM","81256","CPT","0310","RC","","","","outpatient","","","354.00","212.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","257.43","72.72","","248.70","248.70","248.70","1 through 10","41.17","274","percent of total billed charges",""
"Analysis Gene Hfe Common Variants","PX-30000227","CDM","81256","CPT","0310","RC","","","","outpatient","","","354.00","212.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","188.40","53.22","","182.32","182.32","182.32","1 through 10","41.17","274","percent of total billed charges",""
"Analysis Gene Hfe Common Variants","PX-30000227","CDM","81256","CPT","0310","RC","","","","outpatient","","","354.00","212.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","222.67","62.9","","215.46","215.46","215.46","1 through 10","41.17","274","percent of total billed charges",""
"Analysis Gene Hfe Common Variants","PX-30000227","CDM","81256","CPT","0310","RC","","","","outpatient","","","354.00","212.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","41.17","11.63","","40.00","40.00","104.58","1 through 10","41.17","274","percent of total billed charges",""
"Analysis Gene Jak2 V617f Variant","PX-30000238","CDM","81270","CPT","0301","RC","","","","both","","","495.00","297.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","345.51","69.8","","334.34","334.34","334.34","1 through 10","59.58","472.59","percent of total billed charges",""
"Analysis Gene Jak2 V617f Variant","PX-30000238","CDM","81270","CPT","0301","RC","","","","outpatient","","","495.00","297.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","71.38","14.42","","479.00","479.00","479.00","1 through 10","57.57","383.13","percent of total billed charges",""
"Analysis Gene Jak2 V617f Variant","PX-30000238","CDM","81270","CPT","0301","RC","","","","outpatient","","","495.00","297.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","57.57","11.63","","479.00","479.00","479.00","1 through 10","57.57","383.13","percent of total billed charges",""
"Analysis Gene Jak2 V617f Variant","PX-30000238","CDM","81270","CPT","0301","RC","","","","outpatient","","","495.00","297.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","359.96","72.72","","348.33","348.33","348.33","1 through 10","57.57","383.13","percent of total billed charges",""
"Analysis Gene Jak2 V617f Variant","PX-30000238","CDM","81270","CPT","0301","RC","","","","outpatient","","","495.00","297.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","263.44","53.22","","766.05","766.05","766.05","1 through 10","57.57","383.13","percent of total billed charges",""
"Analysis Gene Jak2 V617f Variant","PX-30000238","CDM","81270","CPT","0301","RC","","","","outpatient","","","495.00","297.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","311.36","62.9","","905.31","289.45","905.31","1 through 10","57.57","383.13","percent of total billed charges",""
"Analysis Gene Jak2 V617f Variant","PX-30000238","CDM","81270","CPT","0301","RC","","","","outpatient","","","495.00","297.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","57.57","11.63","","168.30","168.30","168.30","1 through 10","57.57","383.13","percent of total billed charges",""
"Analysis Neurostim Smp W/Progam","PX-92000004","CDM","95971","CPT","0920","RC","","","","both","","","1879.00","1127.40","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","97.82","","APC Price ($95.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","95.91","95.91","95.91","1 through 10","93.98","1597.15","other","OPPS APC"
"Analysis Neurostim Smp W/Progam","PX-92000004","CDM","95971","CPT","0920","RC","","","","both","","","1879.00","1127.40","MEDICARE [2001]","HB WDH MEDICARE","95.90","","APC Price ($95.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","95.91","95.91","95.91","1 through 10","93.98","1597.15","other","OPPS APC"
"Analysis Pump Pain W/Program","PX-76001484","CDM","62368","CPT","0761","RC","","","","both","","","2058.00","1234.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","313.33","","APC Price ($313.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","291.03","291.03","291.03","1 through 10","307.07","2002.5","other","OPPS APC"
"Analysis Pump Pain W/Program","PX-76001484","CDM","62368","CPT","0761","RC","","","","outpatient","","","2058.00","1234.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","239.35","11.63","","234.58","234.58","234.58","1 through 10","239.35","1592.89","percent of total billed charges",""
"Analysis Trans Bcr/Abl1 Major Bp","PX-30000196","CDM","81206","CPT","0310","RC","","","","both","","","885.00","531.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","617.73","69.8","","597.49","597.49","597.49","1 through 10","106.57","845.81","percent of total billed charges",""
"Analysis Trans Bcr/Abl1 Major Bp","PX-30000196","CDM","81206","CPT","0310","RC","","","","outpatient","","","885.00","531.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","127.62","14.42","","856.00","856.00","856.00","1 through 10","102.93","684.99","percent of total billed charges",""
"Analysis Trans Bcr/Abl1 Major Bp","PX-30000196","CDM","81206","CPT","0310","RC","","","","outpatient","","","885.00","531.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","102.93","11.63","","100.35","100.35","100.35","1 through 10","102.93","684.99","percent of total billed charges",""
"Analysis Trans Bcr/Abl1 Major Bp","PX-30000196","CDM","81206","CPT","0310","RC","","","","outpatient","","","885.00","531.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","643.57","72.72","","622.48","622.48","622.48","1 through 10","102.93","684.99","percent of total billed charges",""
"Analysis Trans Bcr/Abl1 Major Bp","PX-30000196","CDM","81206","CPT","0310","RC","","","","outpatient","","","885.00","531.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","556.67","62.9","","539.28","517.72","1617.84","1 through 10","102.93","684.99","percent of total billed charges",""
"Analysis Trans Bcr/Abl1 Minor Bp","PX-30000197","CDM","81207","CPT","0310","RC","","","","outpatient","","","1666.00","999.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","240.24","14.42","","1611.00","1611.00","1611.00","1 through 10","193.76","1289.48","percent of total billed charges",""
"Analysis Trans Bcr/Abl1 Minor Bp","PX-30000197","CDM","81207","CPT","0310","RC","","","","outpatient","","","1666.00","999.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1211.52","72.72","","1171.52","1171.52","1171.52","1 through 10","193.76","1289.48","percent of total billed charges",""
"Analysis Trans Bcr/Abl1 Minor Bp","PX-30000197","CDM","81207","CPT","0310","RC","","","","outpatient","","","1666.00","999.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1047.91","62.9","","1014.93","1014.93","1014.93","1 through 10","193.76","1289.48","percent of total billed charges",""
"Analysis Trans Bcr/Abl1 Other Bp","PX-30000198","CDM","81208","CPT","0310","RC","","","","outpatient","","","947.00","568.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","136.56","14.42","","916.00","916.00","916.00","1 through 10","110.14","732.98","percent of total billed charges",""
"Analysis Trans Bcr/Abl1 Other Bp","PX-30000198","CDM","81208","CPT","0310","RC","","","","outpatient","","","947.00","568.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","688.66","72.72","","666.12","666.12","666.12","1 through 10","110.14","732.98","percent of total billed charges",""
"Analysis Trans Bcr/Abl1 Other Bp","PX-30000198","CDM","81208","CPT","0310","RC","","","","outpatient","","","947.00","568.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","595.66","62.9","","577.08","577.08","577.08","1 through 10","110.14","732.98","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","482.18","3524.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","482.18","3524.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2359.07","56.9","","812.12","238.65","1587.46","163","482.18","3524.1","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","482.18","11.63","","112.68","112.68","146.99","38","482.18","3524.1","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3209.00","77.4","","303.98","303.98","5854.79","1 through 10","482.18","3524.1","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","482.18","11.63","","112.68","112.68","146.99","38","482.18","3209","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2602.86","62.78","","780.86","208.94","10480.28","15","482.18","3209","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1812.63","43.72","","179.76","179.76","179.76","1 through 10","482.18","3209","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3014.97","72.72","","2355.45","298.99","3965.19","155","482.18","3209","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3014.97","72.72","","3643.09","3643.09","3643.09","1 through 10","482.18","3209","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2206.50","53.22","","554.28","554.28","554.28","16","482.18","3209","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2607.83","62.9","","619.64","173.09","2370.64","150","482.18","3209","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3209.00","77.4","","303.98","303.98","5854.79","1 through 10","482.18","3209","percent of total billed charges",""
"ANCHOR BONE 6.5MM OMEGA PEEK KNOTLESS PK/5EA","SUP-ITM-10297101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3420.45","2052.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","397.8","2907.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR BONE 6.5MM OMEGA PEEK KNOTLESS PK/5EA","SUP-ITM-10297101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3420.45","2052.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","397.8","2907.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR BONE 6.5MM OMEGA PEEK KNOTLESS PK/5EA","SUP-ITM-10297101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3420.45","2052.27","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1946.24","56.9","","812.12","238.65","1587.46","163","397.8","2907.38","percent of total billed charges",""
"ANCHOR BONE 6.5MM OMEGA PEEK KNOTLESS PK/5EA","SUP-ITM-10297101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3420.45","2052.27","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","397.80","11.63","","112.68","112.68","146.99","38","397.8","2907.38","percent of total billed charges",""
"ANCHOR BONE 6.5MM OMEGA PEEK KNOTLESS PK/5EA","SUP-ITM-10297101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3420.45","2052.27","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2647.43","77.4","","303.98","303.98","5854.79","1 through 10","397.8","2907.38","percent of total billed charges",""
"ANCHOR BONE 6.5MM OMEGA PEEK KNOTLESS PK/5EA","SUP-ITM-10297101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3420.45","2052.27","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","397.80","11.63","","112.68","112.68","146.99","38","397.8","2647.43","percent of total billed charges",""
"ANCHOR BONE 6.5MM OMEGA PEEK KNOTLESS PK/5EA","SUP-ITM-10297101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3420.45","2052.27","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2147.36","62.78","","780.86","208.94","10480.28","15","397.8","2647.43","percent of total billed charges",""
"ANCHOR BONE 6.5MM OMEGA PEEK KNOTLESS PK/5EA","SUP-ITM-10297101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3420.45","2052.27","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1495.42","43.72","","179.76","179.76","179.76","1 through 10","397.8","2647.43","percent of total billed charges",""
"ANCHOR BONE 6.5MM OMEGA PEEK KNOTLESS PK/5EA","SUP-ITM-10297101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3420.45","2052.27","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2487.35","72.72","","2355.45","298.99","3965.19","155","397.8","2647.43","percent of total billed charges",""
"ANCHOR BONE 6.5MM OMEGA PEEK KNOTLESS PK/5EA","SUP-ITM-10297101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3420.45","2052.27","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2487.35","72.72","","3643.09","3643.09","3643.09","1 through 10","397.8","2647.43","percent of total billed charges",""
"ANCHOR BONE 6.5MM OMEGA PEEK KNOTLESS PK/5EA","SUP-ITM-10297101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3420.45","2052.27","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1820.36","53.22","","554.28","554.28","554.28","16","397.8","2647.43","percent of total billed charges",""
"ANCHOR BONE 6.5MM OMEGA PEEK KNOTLESS PK/5EA","SUP-ITM-10297101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3420.45","2052.27","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2151.46","62.9","","619.64","173.09","2370.64","150","397.8","2647.43","percent of total billed charges",""
"ANCHOR BONE 6.5MM OMEGA PEEK KNOTLESS PK/5EA","SUP-ITM-10297101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3420.45","2052.27","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2647.43","77.4","","303.98","303.98","5854.79","1 through 10","397.8","2647.43","percent of total billed charges",""
"ANCHOR PEEK INTRALINE 6.5MM","SUP-ITM-10092353","CDM","C1713","HCPCS","0278","RC","","","","both","","","1994.50","1196.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","231.96","1695.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR PEEK INTRALINE 6.5MM","SUP-ITM-10092353","CDM","C1713","HCPCS","0278","RC","","","","both","","","1994.50","1196.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","231.96","1695.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR PEEK INTRALINE 6.5MM","SUP-ITM-10092353","CDM","C1713","HCPCS","0278","RC","","","","both","","","1994.50","1196.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1134.87","56.9","","812.12","238.65","1587.46","163","231.96","1695.33","percent of total billed charges",""
"ANCHOR PEEK INTRALINE 6.5MM","SUP-ITM-10092353","CDM","C1713","HCPCS","0278","RC","","","","both","","","1994.50","1196.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","231.96","11.63","","112.68","112.68","146.99","38","231.96","1695.33","percent of total billed charges",""
"ANCHOR PEEK INTRALINE 6.5MM","SUP-ITM-10092353","CDM","C1713","HCPCS","0278","RC","","","","both","","","1994.50","1196.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1543.74","77.4","","303.98","303.98","5854.79","1 through 10","231.96","1695.33","percent of total billed charges",""
"ANCHOR PEEK INTRALINE 6.5MM","SUP-ITM-10092353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1994.50","1196.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","231.96","11.63","","112.68","112.68","146.99","38","231.96","1543.74","percent of total billed charges",""
"ANCHOR PEEK INTRALINE 6.5MM","SUP-ITM-10092353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1994.50","1196.70","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1252.15","62.78","","780.86","208.94","10480.28","15","231.96","1543.74","percent of total billed charges",""
"ANCHOR PEEK INTRALINE 6.5MM","SUP-ITM-10092353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1994.50","1196.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","872.00","43.72","","179.76","179.76","179.76","1 through 10","231.96","1543.74","percent of total billed charges",""
"ANCHOR PEEK INTRALINE 6.5MM","SUP-ITM-10092353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1994.50","1196.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1450.40","72.72","","2355.45","298.99","3965.19","155","231.96","1543.74","percent of total billed charges",""
"ANCHOR PEEK INTRALINE 6.5MM","SUP-ITM-10092353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1994.50","1196.70","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1450.40","72.72","","3643.09","3643.09","3643.09","1 through 10","231.96","1543.74","percent of total billed charges",""
"ANCHOR PEEK INTRALINE 6.5MM","SUP-ITM-10092353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1994.50","1196.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1061.47","53.22","","554.28","554.28","554.28","16","231.96","1543.74","percent of total billed charges",""
"ANCHOR PEEK INTRALINE 6.5MM","SUP-ITM-10092353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1994.50","1196.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1254.54","62.9","","619.64","173.09","2370.64","150","231.96","1543.74","percent of total billed charges",""
"ANCHOR PEEK INTRALINE 6.5MM","SUP-ITM-10092353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1994.50","1196.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1543.74","77.4","","303.98","303.98","5854.79","1 through 10","231.96","1543.74","percent of total billed charges",""
"ANCHOR PUSHLOCK 3.5MX19.5MM PEEK SELF PUNCHING BX/5EA","SUP-ITM-10319756","CDM","C1713","HCPCS","0278","RC","","","","both","","","2936.75","1762.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","341.54","2496.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR PUSHLOCK 3.5MX19.5MM PEEK SELF PUNCHING BX/5EA","SUP-ITM-10319756","CDM","C1713","HCPCS","0278","RC","","","","both","","","2936.75","1762.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","341.54","2496.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR PUSHLOCK 3.5MX19.5MM PEEK SELF PUNCHING BX/5EA","SUP-ITM-10319756","CDM","C1713","HCPCS","0278","RC","","","","both","","","2936.75","1762.05","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1671.01","56.9","","812.12","238.65","1587.46","163","341.54","2496.24","percent of total billed charges",""
"ANCHOR PUSHLOCK 3.5MX19.5MM PEEK SELF PUNCHING BX/5EA","SUP-ITM-10319756","CDM","C1713","HCPCS","0278","RC","","","","both","","","2936.75","1762.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","341.54","11.63","","112.68","112.68","146.99","38","341.54","2496.24","percent of total billed charges",""
"ANCHOR PUSHLOCK 3.5MX19.5MM PEEK SELF PUNCHING BX/5EA","SUP-ITM-10319756","CDM","C1713","HCPCS","0278","RC","","","","both","","","2936.75","1762.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2273.04","77.4","","303.98","303.98","5854.79","1 through 10","341.54","2496.24","percent of total billed charges",""
"ANCHOR PUSHLOCK 3.5MX19.5MM PEEK SELF PUNCHING BX/5EA","SUP-ITM-10319756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","341.54","11.63","","112.68","112.68","146.99","38","341.54","2273.04","percent of total billed charges",""
"ANCHOR PUSHLOCK 3.5MX19.5MM PEEK SELF PUNCHING BX/5EA","SUP-ITM-10319756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1843.69","62.78","","780.86","208.94","10480.28","15","341.54","2273.04","percent of total billed charges",""
"ANCHOR PUSHLOCK 3.5MX19.5MM PEEK SELF PUNCHING BX/5EA","SUP-ITM-10319756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1283.95","43.72","","179.76","179.76","179.76","1 through 10","341.54","2273.04","percent of total billed charges",""
"ANCHOR PUSHLOCK 3.5MX19.5MM PEEK SELF PUNCHING BX/5EA","SUP-ITM-10319756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2135.60","72.72","","2355.45","298.99","3965.19","155","341.54","2273.04","percent of total billed charges",""
"ANCHOR PUSHLOCK 3.5MX19.5MM PEEK SELF PUNCHING BX/5EA","SUP-ITM-10319756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2135.60","72.72","","3643.09","3643.09","3643.09","1 through 10","341.54","2273.04","percent of total billed charges",""
"ANCHOR PUSHLOCK 3.5MX19.5MM PEEK SELF PUNCHING BX/5EA","SUP-ITM-10319756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1562.94","53.22","","554.28","554.28","554.28","16","341.54","2273.04","percent of total billed charges",""
"ANCHOR PUSHLOCK 3.5MX19.5MM PEEK SELF PUNCHING BX/5EA","SUP-ITM-10319756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1847.22","62.9","","619.64","173.09","2370.64","150","341.54","2273.04","percent of total billed charges",""
"ANCHOR PUSHLOCK 3.5MX19.5MM PEEK SELF PUNCHING BX/5EA","SUP-ITM-10319756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2273.04","77.4","","303.98","303.98","5854.79","1 through 10","341.54","2273.04","percent of total billed charges",""
"ANCHOR QUATTRO 4.5MM LINK SP KNOTLESS METAL TIP","SUP-ITM-10230126","CDM","C1713","HCPCS","0278","RC","","","","both","","","3238.37","1943.02","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","376.62","2752.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR QUATTRO 4.5MM LINK SP KNOTLESS METAL TIP","SUP-ITM-10230126","CDM","C1713","HCPCS","0278","RC","","","","both","","","3238.37","1943.02","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","376.62","2752.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR QUATTRO 4.5MM LINK SP KNOTLESS METAL TIP","SUP-ITM-10230126","CDM","C1713","HCPCS","0278","RC","","","","both","","","3238.37","1943.02","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1842.63","56.9","","812.12","238.65","1587.46","163","376.62","2752.61","percent of total billed charges",""
"ANCHOR QUATTRO 4.5MM LINK SP KNOTLESS METAL TIP","SUP-ITM-10230126","CDM","C1713","HCPCS","0278","RC","","","","both","","","3238.37","1943.02","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","376.62","11.63","","112.68","112.68","146.99","38","376.62","2752.61","percent of total billed charges",""
"ANCHOR QUATTRO 4.5MM LINK SP KNOTLESS METAL TIP","SUP-ITM-10230126","CDM","C1713","HCPCS","0278","RC","","","","both","","","3238.37","1943.02","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2506.50","77.4","","303.98","303.98","5854.79","1 through 10","376.62","2752.61","percent of total billed charges",""
"ANCHOR QUATTRO 4.5MM LINK SP KNOTLESS METAL TIP","SUP-ITM-10230126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3238.37","1943.02","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","376.62","11.63","","112.68","112.68","146.99","38","376.62","2506.5","percent of total billed charges",""
"ANCHOR QUATTRO 4.5MM LINK SP KNOTLESS METAL TIP","SUP-ITM-10230126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3238.37","1943.02","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2033.05","62.78","","780.86","208.94","10480.28","15","376.62","2506.5","percent of total billed charges",""
"ANCHOR QUATTRO 4.5MM LINK SP KNOTLESS METAL TIP","SUP-ITM-10230126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3238.37","1943.02","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1415.82","43.72","","179.76","179.76","179.76","1 through 10","376.62","2506.5","percent of total billed charges",""
"ANCHOR QUATTRO 4.5MM LINK SP KNOTLESS METAL TIP","SUP-ITM-10230126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3238.37","1943.02","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2354.94","72.72","","2355.45","298.99","3965.19","155","376.62","2506.5","percent of total billed charges",""
"ANCHOR QUATTRO 4.5MM LINK SP KNOTLESS METAL TIP","SUP-ITM-10230126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3238.37","1943.02","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2354.94","72.72","","3643.09","3643.09","3643.09","1 through 10","376.62","2506.5","percent of total billed charges",""
"ANCHOR QUATTRO 4.5MM LINK SP KNOTLESS METAL TIP","SUP-ITM-10230126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3238.37","1943.02","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1723.46","53.22","","554.28","554.28","554.28","16","376.62","2506.5","percent of total billed charges",""
"ANCHOR QUATTRO 4.5MM LINK SP KNOTLESS METAL TIP","SUP-ITM-10230126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3238.37","1943.02","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2036.93","62.9","","619.64","173.09","2370.64","150","376.62","2506.5","percent of total billed charges",""
"ANCHOR QUATTRO 4.5MM LINK SP KNOTLESS METAL TIP","SUP-ITM-10230126","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3238.37","1943.02","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2506.50","77.4","","303.98","303.98","5854.79","1 through 10","376.62","2506.5","percent of total billed charges",""
"ANCHOR SURGICAL CLICKX MRI SAFE","SUP-ITM-10174952","CDM","C1883","HCPCS","0278","RC","","","","outpatient","","","2591.25","1554.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1629.90","62.9","","4897.47","4897.47","4897.47","1 through 10","301.36","2005.63","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","both","","","4269.34","2561.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","496.52","3628.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","both","","","4269.34","2561.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","496.52","3628.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","both","","","4269.34","2561.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2429.25","56.9","","812.12","238.65","1587.46","163","496.52","3628.94","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","both","","","4269.34","2561.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","496.52","11.63","","112.68","112.68","146.99","38","496.52","3628.94","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","both","","","4269.34","2561.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3304.47","77.4","","303.98","303.98","5854.79","1 through 10","496.52","3628.94","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4269.34","2561.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","496.52","11.63","","112.68","112.68","146.99","38","496.52","3304.47","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4269.34","2561.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2680.29","62.78","","780.86","208.94","10480.28","15","496.52","3304.47","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4269.34","2561.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1866.56","43.72","","179.76","179.76","179.76","1 through 10","496.52","3304.47","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4269.34","2561.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3104.66","72.72","","2355.45","298.99","3965.19","155","496.52","3304.47","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4269.34","2561.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3104.66","72.72","","3643.09","3643.09","3643.09","1 through 10","496.52","3304.47","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4269.34","2561.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2272.14","53.22","","554.28","554.28","554.28","16","496.52","3304.47","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4269.34","2561.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2685.41","62.9","","619.64","173.09","2370.64","150","496.52","3304.47","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM 1.2M XBRAID NANOTACK STAINLESS STEEL STERILE DISPOSABLE","SUP-ITM-10216597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4269.34","2561.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3304.47","77.4","","303.98","303.98","5854.79","1 through 10","496.52","3304.47","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3101.07","1860.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","360.65","2635.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3101.07","1860.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","360.65","2635.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3101.07","1860.64","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1764.51","56.9","","812.12","238.65","1587.46","163","360.65","2635.91","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3101.07","1860.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","360.65","11.63","","112.68","112.68","146.99","38","360.65","2635.91","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3101.07","1860.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2400.23","77.4","","303.98","303.98","5854.79","1 through 10","360.65","2635.91","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3101.07","1860.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","360.65","11.63","","112.68","112.68","146.99","38","360.65","2400.23","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3101.07","1860.64","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1946.85","62.78","","780.86","208.94","10480.28","15","360.65","2400.23","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3101.07","1860.64","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1355.79","43.72","","179.76","179.76","179.76","1 through 10","360.65","2400.23","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3101.07","1860.64","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2255.10","72.72","","2355.45","298.99","3965.19","155","360.65","2400.23","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3101.07","1860.64","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2255.10","72.72","","3643.09","3643.09","3643.09","1 through 10","360.65","2400.23","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3101.07","1860.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1650.39","53.22","","554.28","554.28","554.28","16","360.65","2400.23","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3101.07","1860.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1950.57","62.9","","619.64","173.09","2370.64","150","360.65","2400.23","percent of total billed charges",""
"ANCHOR SUTURE 1.4MM ARTHROSCOPY NANOTACK PLUS FLEXIBLE INSERTER","SUP-ITM-10190887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3101.07","1860.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2400.23","77.4","","303.98","303.98","5854.79","1 through 10","360.65","2400.23","percent of total billed charges",""
"ANCHOR SUTURE 1.8 FIBERTAK KNOTLESS PRO BX/5EA","SUP-ITM-10266980","CDM","C1713","HCPCS","0278","RC","","","","both","","","2902.20","1741.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","337.53","2466.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 1.8 FIBERTAK KNOTLESS PRO BX/5EA","SUP-ITM-10266980","CDM","C1713","HCPCS","0278","RC","","","","both","","","2902.20","1741.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","337.53","2466.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 1.8 FIBERTAK KNOTLESS PRO BX/5EA","SUP-ITM-10266980","CDM","C1713","HCPCS","0278","RC","","","","both","","","2902.20","1741.32","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1651.35","56.9","","812.12","238.65","1587.46","163","337.53","2466.87","percent of total billed charges",""
"ANCHOR SUTURE 1.8 FIBERTAK KNOTLESS PRO BX/5EA","SUP-ITM-10266980","CDM","C1713","HCPCS","0278","RC","","","","both","","","2902.20","1741.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","337.53","11.63","","112.68","112.68","146.99","38","337.53","2466.87","percent of total billed charges",""
"ANCHOR SUTURE 1.8 FIBERTAK KNOTLESS PRO BX/5EA","SUP-ITM-10266980","CDM","C1713","HCPCS","0278","RC","","","","both","","","2902.20","1741.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2246.30","77.4","","303.98","303.98","5854.79","1 through 10","337.53","2466.87","percent of total billed charges",""
"ANCHOR SUTURE 1.8 FIBERTAK KNOTLESS PRO BX/5EA","SUP-ITM-10266980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2902.20","1741.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","337.53","11.63","","112.68","112.68","146.99","38","337.53","2246.3","percent of total billed charges",""
"ANCHOR SUTURE 1.8 FIBERTAK KNOTLESS PRO BX/5EA","SUP-ITM-10266980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2902.20","1741.32","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1822.00","62.78","","780.86","208.94","10480.28","15","337.53","2246.3","percent of total billed charges",""
"ANCHOR SUTURE 1.8 FIBERTAK KNOTLESS PRO BX/5EA","SUP-ITM-10266980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2902.20","1741.32","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1268.84","43.72","","179.76","179.76","179.76","1 through 10","337.53","2246.3","percent of total billed charges",""
"ANCHOR SUTURE 1.8 FIBERTAK KNOTLESS PRO BX/5EA","SUP-ITM-10266980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2902.20","1741.32","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2110.48","72.72","","2355.45","298.99","3965.19","155","337.53","2246.3","percent of total billed charges",""
"ANCHOR SUTURE 1.8 FIBERTAK KNOTLESS PRO BX/5EA","SUP-ITM-10266980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2902.20","1741.32","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2110.48","72.72","","3643.09","3643.09","3643.09","1 through 10","337.53","2246.3","percent of total billed charges",""
"ANCHOR SUTURE 1.8 FIBERTAK KNOTLESS PRO BX/5EA","SUP-ITM-10266980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2902.20","1741.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1544.55","53.22","","554.28","554.28","554.28","16","337.53","2246.3","percent of total billed charges",""
"ANCHOR SUTURE 1.8 FIBERTAK KNOTLESS PRO BX/5EA","SUP-ITM-10266980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2902.20","1741.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1825.48","62.9","","619.64","173.09","2370.64","150","337.53","2246.3","percent of total billed charges",""
"ANCHOR SUTURE 1.8 FIBERTAK KNOTLESS PRO BX/5EA","SUP-ITM-10266980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2902.20","1741.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2246.30","77.4","","303.98","303.98","5854.79","1 through 10","337.53","2246.3","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.40","1824.24","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","353.6","2584.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.40","1824.24","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","353.6","2584.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.40","1824.24","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1729.99","56.9","","812.12","238.65","1587.46","163","353.6","2584.34","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.40","1824.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","353.60","11.63","","112.68","112.68","146.99","38","353.6","2584.34","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.40","1824.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2353.27","77.4","","303.98","303.98","5854.79","1 through 10","353.6","2584.34","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3040.40","1824.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","353.60","11.63","","112.68","112.68","146.99","38","353.6","2353.27","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3040.40","1824.24","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1908.76","62.78","","780.86","208.94","10480.28","15","353.6","2353.27","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3040.40","1824.24","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1329.26","43.72","","179.76","179.76","179.76","1 through 10","353.6","2353.27","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3040.40","1824.24","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2210.98","72.72","","2355.45","298.99","3965.19","155","353.6","2353.27","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3040.40","1824.24","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2210.98","72.72","","3643.09","3643.09","3643.09","1 through 10","353.6","2353.27","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3040.40","1824.24","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1618.10","53.22","","554.28","554.28","554.28","16","353.6","2353.27","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3040.40","1824.24","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1912.41","62.9","","619.64","173.09","2370.64","150","353.6","2353.27","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3040.40","1824.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2353.27","77.4","","303.98","303.98","5854.79","1 through 10","353.6","2353.27","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","both","","","3247.70","1948.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","377.71","2760.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","both","","","3247.70","1948.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","377.71","2760.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","both","","","3247.70","1948.62","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1847.94","56.9","","812.12","238.65","1587.46","163","377.71","2760.55","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","both","","","3247.70","1948.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","377.71","11.63","","112.68","112.68","146.99","38","377.71","2760.55","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","both","","","3247.70","1948.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2513.72","77.4","","303.98","303.98","5854.79","1 through 10","377.71","2760.55","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3247.70","1948.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","377.71","11.63","","112.68","112.68","146.99","38","377.71","2513.72","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3247.70","1948.62","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2038.91","62.78","","780.86","208.94","10480.28","15","377.71","2513.72","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3247.70","1948.62","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1419.89","43.72","","179.76","179.76","179.76","1 through 10","377.71","2513.72","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3247.70","1948.62","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2361.73","72.72","","2355.45","298.99","3965.19","155","377.71","2513.72","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3247.70","1948.62","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2361.73","72.72","","3643.09","3643.09","3643.09","1 through 10","377.71","2513.72","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3247.70","1948.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1728.43","53.22","","554.28","554.28","554.28","16","377.71","2513.72","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3247.70","1948.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2042.80","62.9","","619.64","173.09","2370.64","150","377.71","2513.72","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3247.70","1948.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2513.72","77.4","","303.98","303.98","5854.79","1 through 10","377.71","2513.72","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","321.45","2349.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","321.45","2349.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1572.72","56.9","","812.12","238.65","1587.46","163","321.45","2349.4","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.45","11.63","","112.68","112.68","146.99","38","321.45","2349.4","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2139.34","77.4","","303.98","303.98","5854.79","1 through 10","321.45","2349.4","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.45","11.63","","112.68","112.68","146.99","38","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1735.24","62.78","","780.86","208.94","10480.28","15","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1208.42","43.72","","179.76","179.76","179.76","1 through 10","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2009.98","72.72","","2355.45","298.99","3965.19","155","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2009.98","72.72","","3643.09","3643.09","3643.09","1 through 10","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1471.00","53.22","","554.28","554.28","554.28","16","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1738.56","62.9","","619.64","173.09","2370.64","150","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2139.34","77.4","","303.98","303.98","5854.79","1 through 10","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE 2 5.5X16MM ARTHROSCOPY CORKSCREW FIBERWIRE LF FULL THREAD II TITANIUM ABSORBABLE STERILE DISPOSABLE BX/5EA","SUP-ITM-10015262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1589.30","953.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","184.84","1350.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 2 5.5X16MM ARTHROSCOPY CORKSCREW FIBERWIRE LF FULL THREAD II TITANIUM ABSORBABLE STERILE DISPOSABLE BX/5EA","SUP-ITM-10015262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1589.30","953.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","184.84","1350.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 2 5.5X16MM ARTHROSCOPY CORKSCREW FIBERWIRE LF FULL THREAD II TITANIUM ABSORBABLE STERILE DISPOSABLE BX/5EA","SUP-ITM-10015262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1589.30","953.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","904.31","56.9","","812.12","238.65","1587.46","163","184.84","1350.91","percent of total billed charges",""
"ANCHOR SUTURE 2 5.5X16MM ARTHROSCOPY CORKSCREW FIBERWIRE LF FULL THREAD II TITANIUM ABSORBABLE STERILE DISPOSABLE BX/5EA","SUP-ITM-10015262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1589.30","953.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","184.84","11.63","","112.68","112.68","146.99","38","184.84","1350.91","percent of total billed charges",""
"ANCHOR SUTURE 2 5.5X16MM ARTHROSCOPY CORKSCREW FIBERWIRE LF FULL THREAD II TITANIUM ABSORBABLE STERILE DISPOSABLE BX/5EA","SUP-ITM-10015262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1589.30","953.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1230.12","77.4","","303.98","303.98","5854.79","1 through 10","184.84","1350.91","percent of total billed charges",""
"ANCHOR SUTURE 2 5.5X16MM ARTHROSCOPY CORKSCREW FIBERWIRE LF FULL THREAD II TITANIUM ABSORBABLE STERILE DISPOSABLE BX/5EA","SUP-ITM-10015262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1589.30","953.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","184.84","11.63","","112.68","112.68","146.99","38","184.84","1230.12","percent of total billed charges",""
"ANCHOR SUTURE 2 5.5X16MM ARTHROSCOPY CORKSCREW FIBERWIRE LF FULL THREAD II TITANIUM ABSORBABLE STERILE DISPOSABLE BX/5EA","SUP-ITM-10015262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1589.30","953.58","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","997.76","62.78","","780.86","208.94","10480.28","15","184.84","1230.12","percent of total billed charges",""
"ANCHOR SUTURE 2 5.5X16MM ARTHROSCOPY CORKSCREW FIBERWIRE LF FULL THREAD II TITANIUM ABSORBABLE STERILE DISPOSABLE BX/5EA","SUP-ITM-10015262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1589.30","953.58","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","694.84","43.72","","179.76","179.76","179.76","1 through 10","184.84","1230.12","percent of total billed charges",""
"ANCHOR SUTURE 2 5.5X16MM ARTHROSCOPY CORKSCREW FIBERWIRE LF FULL THREAD II TITANIUM ABSORBABLE STERILE DISPOSABLE BX/5EA","SUP-ITM-10015262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1589.30","953.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1155.74","72.72","","2355.45","298.99","3965.19","155","184.84","1230.12","percent of total billed charges",""
"ANCHOR SUTURE 2 5.5X16MM ARTHROSCOPY CORKSCREW FIBERWIRE LF FULL THREAD II TITANIUM ABSORBABLE STERILE DISPOSABLE BX/5EA","SUP-ITM-10015262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1589.30","953.58","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1155.74","72.72","","3643.09","3643.09","3643.09","1 through 10","184.84","1230.12","percent of total billed charges",""
"ANCHOR SUTURE 2 5.5X16MM ARTHROSCOPY CORKSCREW FIBERWIRE LF FULL THREAD II TITANIUM ABSORBABLE STERILE DISPOSABLE BX/5EA","SUP-ITM-10015262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1589.30","953.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","845.83","53.22","","554.28","554.28","554.28","16","184.84","1230.12","percent of total billed charges",""
"ANCHOR SUTURE 2 5.5X16MM ARTHROSCOPY CORKSCREW FIBERWIRE LF FULL THREAD II TITANIUM ABSORBABLE STERILE DISPOSABLE BX/5EA","SUP-ITM-10015262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1589.30","953.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","999.67","62.9","","619.64","173.09","2370.64","150","184.84","1230.12","percent of total billed charges",""
"ANCHOR SUTURE 2 5.5X16MM ARTHROSCOPY CORKSCREW FIBERWIRE LF FULL THREAD II TITANIUM ABSORBABLE STERILE DISPOSABLE BX/5EA","SUP-ITM-10015262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1589.30","953.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1230.12","77.4","","303.98","303.98","5854.79","1 through 10","184.84","1230.12","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM3 STRAND 1.2 XBRAID TAPE ICONIX SPD PK/5EA","SUP-ITM-10267012","CDM","C1713","HCPCS","0278","RC","","","","both","","","3109.50","1865.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","361.63","2643.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 2.3MM3 STRAND 1.2 XBRAID TAPE ICONIX SPD PK/5EA","SUP-ITM-10267012","CDM","C1713","HCPCS","0278","RC","","","","both","","","3109.50","1865.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","361.63","2643.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 2.3MM3 STRAND 1.2 XBRAID TAPE ICONIX SPD PK/5EA","SUP-ITM-10267012","CDM","C1713","HCPCS","0278","RC","","","","both","","","3109.50","1865.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1769.31","56.9","","812.12","238.65","1587.46","163","361.63","2643.08","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM3 STRAND 1.2 XBRAID TAPE ICONIX SPD PK/5EA","SUP-ITM-10267012","CDM","C1713","HCPCS","0278","RC","","","","both","","","3109.50","1865.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","361.63","11.63","","112.68","112.68","146.99","38","361.63","2643.08","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM3 STRAND 1.2 XBRAID TAPE ICONIX SPD PK/5EA","SUP-ITM-10267012","CDM","C1713","HCPCS","0278","RC","","","","both","","","3109.50","1865.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2406.75","77.4","","303.98","303.98","5854.79","1 through 10","361.63","2643.08","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM3 STRAND 1.2 XBRAID TAPE ICONIX SPD PK/5EA","SUP-ITM-10267012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","361.63","11.63","","112.68","112.68","146.99","38","361.63","2406.75","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM3 STRAND 1.2 XBRAID TAPE ICONIX SPD PK/5EA","SUP-ITM-10267012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1952.14","62.78","","780.86","208.94","10480.28","15","361.63","2406.75","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM3 STRAND 1.2 XBRAID TAPE ICONIX SPD PK/5EA","SUP-ITM-10267012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1359.47","43.72","","179.76","179.76","179.76","1 through 10","361.63","2406.75","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM3 STRAND 1.2 XBRAID TAPE ICONIX SPD PK/5EA","SUP-ITM-10267012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2261.23","72.72","","2355.45","298.99","3965.19","155","361.63","2406.75","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM3 STRAND 1.2 XBRAID TAPE ICONIX SPD PK/5EA","SUP-ITM-10267012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2261.23","72.72","","3643.09","3643.09","3643.09","1 through 10","361.63","2406.75","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM3 STRAND 1.2 XBRAID TAPE ICONIX SPD PK/5EA","SUP-ITM-10267012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1654.88","53.22","","554.28","554.28","554.28","16","361.63","2406.75","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM3 STRAND 1.2 XBRAID TAPE ICONIX SPD PK/5EA","SUP-ITM-10267012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1955.88","62.9","","619.64","173.09","2370.64","150","361.63","2406.75","percent of total billed charges",""
"ANCHOR SUTURE 2.3MM3 STRAND 1.2 XBRAID TAPE ICONIX SPD PK/5EA","SUP-ITM-10267012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2406.75","77.4","","303.98","303.98","5854.79","1 through 10","361.63","2406.75","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","both","","","3662.30","2197.38","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","425.93","3112.96","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","both","","","3662.30","2197.38","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","425.93","3112.96","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","both","","","3662.30","2197.38","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2083.85","56.9","","812.12","238.65","1587.46","163","425.93","3112.96","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","both","","","3662.30","2197.38","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","425.93","11.63","","112.68","112.68","146.99","38","425.93","3112.96","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","both","","","3662.30","2197.38","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2834.62","77.4","","303.98","303.98","5854.79","1 through 10","425.93","3112.96","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3662.30","2197.38","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","425.93","11.63","","112.68","112.68","146.99","38","425.93","2834.62","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3662.30","2197.38","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2299.19","62.78","","780.86","208.94","10480.28","15","425.93","2834.62","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3662.30","2197.38","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1601.16","43.72","","179.76","179.76","179.76","1 through 10","425.93","2834.62","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3662.30","2197.38","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2663.22","72.72","","2355.45","298.99","3965.19","155","425.93","2834.62","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3662.30","2197.38","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2663.22","72.72","","3643.09","3643.09","3643.09","1 through 10","425.93","2834.62","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3662.30","2197.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1949.08","53.22","","554.28","554.28","554.28","16","425.93","2834.62","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3662.30","2197.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2303.59","62.9","","619.64","173.09","2370.64","150","425.93","2834.62","percent of total billed charges",""
"ANCHOR SUTURE 2.6MM SOFT KNOTLESS FIBERTAK SEPUNCHING 1.7MM TIGERTAPE LOOP BLACK/BLUE NUMBER 2 BLUE/BLACK BX/5EA","SUP-ITM-10318070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3662.30","2197.38","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2834.62","77.4","","303.98","303.98","5854.79","1 through 10","425.93","2834.62","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM ARTHROSCOPY QUATTRO LINK KNOTLESS","SUP-ITM-10216297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2498.17","1498.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","290.54","2123.44","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 2.9MM ARTHROSCOPY QUATTRO LINK KNOTLESS","SUP-ITM-10216297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2498.17","1498.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","290.54","2123.44","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 2.9MM ARTHROSCOPY QUATTRO LINK KNOTLESS","SUP-ITM-10216297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2498.17","1498.90","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1421.46","56.9","","812.12","238.65","1587.46","163","290.54","2123.44","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM ARTHROSCOPY QUATTRO LINK KNOTLESS","SUP-ITM-10216297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2498.17","1498.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","290.54","11.63","","112.68","112.68","146.99","38","290.54","2123.44","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM ARTHROSCOPY QUATTRO LINK KNOTLESS","SUP-ITM-10216297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2498.17","1498.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1933.58","77.4","","303.98","303.98","5854.79","1 through 10","290.54","2123.44","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM ARTHROSCOPY QUATTRO LINK KNOTLESS","SUP-ITM-10216297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2498.17","1498.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","290.54","11.63","","112.68","112.68","146.99","38","290.54","1933.58","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM ARTHROSCOPY QUATTRO LINK KNOTLESS","SUP-ITM-10216297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2498.17","1498.90","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1568.35","62.78","","780.86","208.94","10480.28","15","290.54","1933.58","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM ARTHROSCOPY QUATTRO LINK KNOTLESS","SUP-ITM-10216297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2498.17","1498.90","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1092.20","43.72","","179.76","179.76","179.76","1 through 10","290.54","1933.58","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM ARTHROSCOPY QUATTRO LINK KNOTLESS","SUP-ITM-10216297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2498.17","1498.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1816.67","72.72","","2355.45","298.99","3965.19","155","290.54","1933.58","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM ARTHROSCOPY QUATTRO LINK KNOTLESS","SUP-ITM-10216297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2498.17","1498.90","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1816.67","72.72","","3643.09","3643.09","3643.09","1 through 10","290.54","1933.58","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM ARTHROSCOPY QUATTRO LINK KNOTLESS","SUP-ITM-10216297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2498.17","1498.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1329.53","53.22","","554.28","554.28","554.28","16","290.54","1933.58","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM ARTHROSCOPY QUATTRO LINK KNOTLESS","SUP-ITM-10216297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2498.17","1498.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1571.35","62.9","","619.64","173.09","2370.64","150","290.54","1933.58","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM ARTHROSCOPY QUATTRO LINK KNOTLESS","SUP-ITM-10216297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2498.17","1498.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1933.58","77.4","","303.98","303.98","5854.79","1 through 10","290.54","1933.58","percent of total billed charges",""
"ANCHOR SUTURE 2.9X12.5MM PUSHLOCK BIOCOMPOSITE SWIVELOCK VENTED BX/5EA","SUP-ITM-10318067","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","321.45","2349.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 2.9X12.5MM PUSHLOCK BIOCOMPOSITE SWIVELOCK VENTED BX/5EA","SUP-ITM-10318067","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","321.45","2349.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 2.9X12.5MM PUSHLOCK BIOCOMPOSITE SWIVELOCK VENTED BX/5EA","SUP-ITM-10318067","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1572.72","56.9","","812.12","238.65","1587.46","163","321.45","2349.4","percent of total billed charges",""
"ANCHOR SUTURE 2.9X12.5MM PUSHLOCK BIOCOMPOSITE SWIVELOCK VENTED BX/5EA","SUP-ITM-10318067","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.45","11.63","","112.68","112.68","146.99","38","321.45","2349.4","percent of total billed charges",""
"ANCHOR SUTURE 2.9X12.5MM PUSHLOCK BIOCOMPOSITE SWIVELOCK VENTED BX/5EA","SUP-ITM-10318067","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2139.34","77.4","","303.98","303.98","5854.79","1 through 10","321.45","2349.4","percent of total billed charges",""
"ANCHOR SUTURE 2.9X12.5MM PUSHLOCK BIOCOMPOSITE SWIVELOCK VENTED BX/5EA","SUP-ITM-10318067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.45","11.63","","112.68","112.68","146.99","38","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE 2.9X12.5MM PUSHLOCK BIOCOMPOSITE SWIVELOCK VENTED BX/5EA","SUP-ITM-10318067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1735.24","62.78","","780.86","208.94","10480.28","15","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE 2.9X12.5MM PUSHLOCK BIOCOMPOSITE SWIVELOCK VENTED BX/5EA","SUP-ITM-10318067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1208.42","43.72","","179.76","179.76","179.76","1 through 10","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE 2.9X12.5MM PUSHLOCK BIOCOMPOSITE SWIVELOCK VENTED BX/5EA","SUP-ITM-10318067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2009.98","72.72","","2355.45","298.99","3965.19","155","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE 2.9X12.5MM PUSHLOCK BIOCOMPOSITE SWIVELOCK VENTED BX/5EA","SUP-ITM-10318067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2009.98","72.72","","3643.09","3643.09","3643.09","1 through 10","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE 2.9X12.5MM PUSHLOCK BIOCOMPOSITE SWIVELOCK VENTED BX/5EA","SUP-ITM-10318067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1471.00","53.22","","554.28","554.28","554.28","16","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE 2.9X12.5MM PUSHLOCK BIOCOMPOSITE SWIVELOCK VENTED BX/5EA","SUP-ITM-10318067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1738.56","62.9","","619.64","173.09","2370.64","150","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE 2.9X12.5MM PUSHLOCK BIOCOMPOSITE SWIVELOCK VENTED BX/5EA","SUP-ITM-10318067","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2139.34","77.4","","303.98","303.98","5854.79","1 through 10","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE 25MM LOOP KNOTILUS SOFT TISSUE NONRESORBABLE BX/5EA","SUP-ITM-10267760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.55","1085.13","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","210.33","1537.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 25MM LOOP KNOTILUS SOFT TISSUE NONRESORBABLE BX/5EA","SUP-ITM-10267760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.55","1085.13","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","210.33","1537.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 25MM LOOP KNOTILUS SOFT TISSUE NONRESORBABLE BX/5EA","SUP-ITM-10267760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.55","1085.13","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1029.06","56.9","","812.12","238.65","1587.46","163","210.33","1537.27","percent of total billed charges",""
"ANCHOR SUTURE 25MM LOOP KNOTILUS SOFT TISSUE NONRESORBABLE BX/5EA","SUP-ITM-10267760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.55","1085.13","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","210.33","11.63","","112.68","112.68","146.99","38","210.33","1537.27","percent of total billed charges",""
"ANCHOR SUTURE 25MM LOOP KNOTILUS SOFT TISSUE NONRESORBABLE BX/5EA","SUP-ITM-10267760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.55","1085.13","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1399.82","77.4","","303.98","303.98","5854.79","1 through 10","210.33","1537.27","percent of total billed charges",""
"ANCHOR SUTURE 25MM LOOP KNOTILUS SOFT TISSUE NONRESORBABLE BX/5EA","SUP-ITM-10267760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1808.55","1085.13","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","210.33","11.63","","112.68","112.68","146.99","38","210.33","1399.82","percent of total billed charges",""
"ANCHOR SUTURE 25MM LOOP KNOTILUS SOFT TISSUE NONRESORBABLE BX/5EA","SUP-ITM-10267760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1808.55","1085.13","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1135.41","62.78","","780.86","208.94","10480.28","15","210.33","1399.82","percent of total billed charges",""
"ANCHOR SUTURE 25MM LOOP KNOTILUS SOFT TISSUE NONRESORBABLE BX/5EA","SUP-ITM-10267760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1808.55","1085.13","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","790.70","43.72","","179.76","179.76","179.76","1 through 10","210.33","1399.82","percent of total billed charges",""
"ANCHOR SUTURE 25MM LOOP KNOTILUS SOFT TISSUE NONRESORBABLE BX/5EA","SUP-ITM-10267760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1808.55","1085.13","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1315.18","72.72","","2355.45","298.99","3965.19","155","210.33","1399.82","percent of total billed charges",""
"ANCHOR SUTURE 25MM LOOP KNOTILUS SOFT TISSUE NONRESORBABLE BX/5EA","SUP-ITM-10267760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1808.55","1085.13","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1315.18","72.72","","3643.09","3643.09","3643.09","1 through 10","210.33","1399.82","percent of total billed charges",""
"ANCHOR SUTURE 25MM LOOP KNOTILUS SOFT TISSUE NONRESORBABLE BX/5EA","SUP-ITM-10267760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1808.55","1085.13","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","962.51","53.22","","554.28","554.28","554.28","16","210.33","1399.82","percent of total billed charges",""
"ANCHOR SUTURE 25MM LOOP KNOTILUS SOFT TISSUE NONRESORBABLE BX/5EA","SUP-ITM-10267760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1808.55","1085.13","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1137.58","62.9","","619.64","173.09","2370.64","150","210.33","1399.82","percent of total billed charges",""
"ANCHOR SUTURE 25MM LOOP KNOTILUS SOFT TISSUE NONRESORBABLE BX/5EA","SUP-ITM-10267760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1808.55","1085.13","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1399.82","77.4","","303.98","303.98","5854.79","1 through 10","210.33","1399.82","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","241.09","1762.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","241.09","1762.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1179.54","56.9","","812.12","238.65","1587.46","163","241.09","1762.05","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","241.09","11.63","","112.68","112.68","146.99","38","241.09","1762.05","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1604.50","77.4","","303.98","303.98","5854.79","1 through 10","241.09","1762.05","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","241.09","11.63","","112.68","112.68","146.99","38","241.09","1604.5","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1301.43","62.78","","780.86","208.94","10480.28","15","241.09","1604.5","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","906.32","43.72","","179.76","179.76","179.76","1 through 10","241.09","1604.5","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1507.49","72.72","","2355.45","298.99","3965.19","155","241.09","1604.5","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1507.49","72.72","","3643.09","3643.09","3643.09","1 through 10","241.09","1604.5","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1103.25","53.22","","554.28","554.28","554.28","16","241.09","1604.5","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1303.92","62.9","","619.64","173.09","2370.64","150","241.09","1604.5","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1604.50","77.4","","303.98","303.98","5854.79","1 through 10","241.09","1604.5","percent of total billed charges",""
"ANCHOR SUTURE 4 0 1.3MM SIZE ARTHROSCOPY ETHIBOND QUICK PLUS MICRO NEEDLE C1 DRILL BIT","SUP-ITM-10012187","CDM","C1713","HCPCS","0278","RC","","","","both","","","2038.45","1223.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","237.07","1732.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 4 0 1.3MM SIZE ARTHROSCOPY ETHIBOND QUICK PLUS MICRO NEEDLE C1 DRILL BIT","SUP-ITM-10012187","CDM","C1713","HCPCS","0278","RC","","","","both","","","2038.45","1223.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","237.07","1732.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 4 0 1.3MM SIZE ARTHROSCOPY ETHIBOND QUICK PLUS MICRO NEEDLE C1 DRILL BIT","SUP-ITM-10012187","CDM","C1713","HCPCS","0278","RC","","","","both","","","2038.45","1223.07","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1159.88","56.9","","812.12","238.65","1587.46","163","237.07","1732.68","percent of total billed charges",""
"ANCHOR SUTURE 4 0 1.3MM SIZE ARTHROSCOPY ETHIBOND QUICK PLUS MICRO NEEDLE C1 DRILL BIT","SUP-ITM-10012187","CDM","C1713","HCPCS","0278","RC","","","","both","","","2038.45","1223.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","237.07","11.63","","112.68","112.68","146.99","38","237.07","1732.68","percent of total billed charges",""
"ANCHOR SUTURE 4 0 1.3MM SIZE ARTHROSCOPY ETHIBOND QUICK PLUS MICRO NEEDLE C1 DRILL BIT","SUP-ITM-10012187","CDM","C1713","HCPCS","0278","RC","","","","both","","","2038.45","1223.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1577.76","77.4","","303.98","303.98","5854.79","1 through 10","237.07","1732.68","percent of total billed charges",""
"ANCHOR SUTURE 4 0 1.3MM SIZE ARTHROSCOPY ETHIBOND QUICK PLUS MICRO NEEDLE C1 DRILL BIT","SUP-ITM-10012187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2038.45","1223.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","237.07","11.63","","112.68","112.68","146.99","38","237.07","1577.76","percent of total billed charges",""
"ANCHOR SUTURE 4 0 1.3MM SIZE ARTHROSCOPY ETHIBOND QUICK PLUS MICRO NEEDLE C1 DRILL BIT","SUP-ITM-10012187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2038.45","1223.07","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1279.74","62.78","","780.86","208.94","10480.28","15","237.07","1577.76","percent of total billed charges",""
"ANCHOR SUTURE 4 0 1.3MM SIZE ARTHROSCOPY ETHIBOND QUICK PLUS MICRO NEEDLE C1 DRILL BIT","SUP-ITM-10012187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2038.45","1223.07","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","891.21","43.72","","179.76","179.76","179.76","1 through 10","237.07","1577.76","percent of total billed charges",""
"ANCHOR SUTURE 4 0 1.3MM SIZE ARTHROSCOPY ETHIBOND QUICK PLUS MICRO NEEDLE C1 DRILL BIT","SUP-ITM-10012187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2038.45","1223.07","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1482.36","72.72","","2355.45","298.99","3965.19","155","237.07","1577.76","percent of total billed charges",""
"ANCHOR SUTURE 4 0 1.3MM SIZE ARTHROSCOPY ETHIBOND QUICK PLUS MICRO NEEDLE C1 DRILL BIT","SUP-ITM-10012187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2038.45","1223.07","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1482.36","72.72","","3643.09","3643.09","3643.09","1 through 10","237.07","1577.76","percent of total billed charges",""
"ANCHOR SUTURE 4 0 1.3MM SIZE ARTHROSCOPY ETHIBOND QUICK PLUS MICRO NEEDLE C1 DRILL BIT","SUP-ITM-10012187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2038.45","1223.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1084.86","53.22","","554.28","554.28","554.28","16","237.07","1577.76","percent of total billed charges",""
"ANCHOR SUTURE 4 0 1.3MM SIZE ARTHROSCOPY ETHIBOND QUICK PLUS MICRO NEEDLE C1 DRILL BIT","SUP-ITM-10012187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2038.45","1223.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1282.19","62.9","","619.64","173.09","2370.64","150","237.07","1577.76","percent of total billed charges",""
"ANCHOR SUTURE 4 0 1.3MM SIZE ARTHROSCOPY ETHIBOND QUICK PLUS MICRO NEEDLE C1 DRILL BIT","SUP-ITM-10012187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2038.45","1223.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1577.76","77.4","","303.98","303.98","5854.79","1 through 10","237.07","1577.76","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY REELX STT PEEK SS CORE KNOTLESS SHAPR TIP EXPANDABLE BX/5EA","SUP-ITM-10146504","CDM","C1713","HCPCS","0278","RC","","","","both","","","2245.75","1347.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","261.18","1908.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 4.5MM ARTHROSCOPY REELX STT PEEK SS CORE KNOTLESS SHAPR TIP EXPANDABLE BX/5EA","SUP-ITM-10146504","CDM","C1713","HCPCS","0278","RC","","","","both","","","2245.75","1347.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","261.18","1908.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 4.5MM ARTHROSCOPY REELX STT PEEK SS CORE KNOTLESS SHAPR TIP EXPANDABLE BX/5EA","SUP-ITM-10146504","CDM","C1713","HCPCS","0278","RC","","","","both","","","2245.75","1347.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1277.83","56.9","","812.12","238.65","1587.46","163","261.18","1908.89","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY REELX STT PEEK SS CORE KNOTLESS SHAPR TIP EXPANDABLE BX/5EA","SUP-ITM-10146504","CDM","C1713","HCPCS","0278","RC","","","","both","","","2245.75","1347.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","261.18","11.63","","112.68","112.68","146.99","38","261.18","1908.89","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY REELX STT PEEK SS CORE KNOTLESS SHAPR TIP EXPANDABLE BX/5EA","SUP-ITM-10146504","CDM","C1713","HCPCS","0278","RC","","","","both","","","2245.75","1347.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1738.21","77.4","","303.98","303.98","5854.79","1 through 10","261.18","1908.89","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY REELX STT PEEK SS CORE KNOTLESS SHAPR TIP EXPANDABLE BX/5EA","SUP-ITM-10146504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2245.75","1347.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","261.18","11.63","","112.68","112.68","146.99","38","261.18","1738.21","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY REELX STT PEEK SS CORE KNOTLESS SHAPR TIP EXPANDABLE BX/5EA","SUP-ITM-10146504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2245.75","1347.45","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1409.88","62.78","","780.86","208.94","10480.28","15","261.18","1738.21","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY REELX STT PEEK SS CORE KNOTLESS SHAPR TIP EXPANDABLE BX/5EA","SUP-ITM-10146504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2245.75","1347.45","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","981.84","43.72","","179.76","179.76","179.76","1 through 10","261.18","1738.21","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY REELX STT PEEK SS CORE KNOTLESS SHAPR TIP EXPANDABLE BX/5EA","SUP-ITM-10146504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2245.75","1347.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1633.11","72.72","","2355.45","298.99","3965.19","155","261.18","1738.21","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY REELX STT PEEK SS CORE KNOTLESS SHAPR TIP EXPANDABLE BX/5EA","SUP-ITM-10146504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2245.75","1347.45","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1633.11","72.72","","3643.09","3643.09","3643.09","1 through 10","261.18","1738.21","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY REELX STT PEEK SS CORE KNOTLESS SHAPR TIP EXPANDABLE BX/5EA","SUP-ITM-10146504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2245.75","1347.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1195.19","53.22","","554.28","554.28","554.28","16","261.18","1738.21","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY REELX STT PEEK SS CORE KNOTLESS SHAPR TIP EXPANDABLE BX/5EA","SUP-ITM-10146504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2245.75","1347.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1412.58","62.9","","619.64","173.09","2370.64","150","261.18","1738.21","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM ARTHROSCOPY REELX STT PEEK SS CORE KNOTLESS SHAPR TIP EXPANDABLE BX/5EA","SUP-ITM-10146504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2245.75","1347.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1738.21","77.4","","303.98","303.98","5854.79","1 through 10","261.18","1738.21","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM QUATTRO LANT LINK KNOTLESS","SUP-ITM-10216296","CDM","C1713","HCPCS","0278","RC","","","","both","","","2914.57","1748.74","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","338.96","2477.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 4.5MM QUATTRO LANT LINK KNOTLESS","SUP-ITM-10216296","CDM","C1713","HCPCS","0278","RC","","","","both","","","2914.57","1748.74","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","338.96","2477.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 4.5MM QUATTRO LANT LINK KNOTLESS","SUP-ITM-10216296","CDM","C1713","HCPCS","0278","RC","","","","both","","","2914.57","1748.74","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1658.39","56.9","","812.12","238.65","1587.46","163","338.96","2477.38","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM QUATTRO LANT LINK KNOTLESS","SUP-ITM-10216296","CDM","C1713","HCPCS","0278","RC","","","","both","","","2914.57","1748.74","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","338.96","11.63","","112.68","112.68","146.99","38","338.96","2477.38","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM QUATTRO LANT LINK KNOTLESS","SUP-ITM-10216296","CDM","C1713","HCPCS","0278","RC","","","","both","","","2914.57","1748.74","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2255.88","77.4","","303.98","303.98","5854.79","1 through 10","338.96","2477.38","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM QUATTRO LANT LINK KNOTLESS","SUP-ITM-10216296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2914.57","1748.74","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","338.96","11.63","","112.68","112.68","146.99","38","338.96","2255.88","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM QUATTRO LANT LINK KNOTLESS","SUP-ITM-10216296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2914.57","1748.74","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1829.77","62.78","","780.86","208.94","10480.28","15","338.96","2255.88","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM QUATTRO LANT LINK KNOTLESS","SUP-ITM-10216296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2914.57","1748.74","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1274.25","43.72","","179.76","179.76","179.76","1 through 10","338.96","2255.88","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM QUATTRO LANT LINK KNOTLESS","SUP-ITM-10216296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2914.57","1748.74","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2119.48","72.72","","2355.45","298.99","3965.19","155","338.96","2255.88","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM QUATTRO LANT LINK KNOTLESS","SUP-ITM-10216296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2914.57","1748.74","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2119.48","72.72","","3643.09","3643.09","3643.09","1 through 10","338.96","2255.88","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM QUATTRO LANT LINK KNOTLESS","SUP-ITM-10216296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2914.57","1748.74","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1551.13","53.22","","554.28","554.28","554.28","16","338.96","2255.88","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM QUATTRO LANT LINK KNOTLESS","SUP-ITM-10216296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2914.57","1748.74","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1833.26","62.9","","619.64","173.09","2370.64","150","338.96","2255.88","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM QUATTRO LANT LINK KNOTLESS","SUP-ITM-10216296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2914.57","1748.74","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2255.88","77.4","","303.98","303.98","5854.79","1 through 10","338.96","2255.88","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","642.91","4698.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","642.91","4698.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3145.43","56.9","","812.12","238.65","1587.46","163","642.91","4698.8","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","642.91","11.63","","112.68","112.68","146.99","38","642.91","4698.8","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4278.67","77.4","","303.98","303.98","5854.79","1 through 10","642.91","4698.8","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","642.91","11.63","","112.68","112.68","146.99","38","642.91","4278.67","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3470.48","62.78","","780.86","208.94","10480.28","15","642.91","4278.67","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2416.84","43.72","","179.76","179.76","179.76","1 through 10","642.91","4278.67","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4019.96","72.72","","2355.45","298.99","3965.19","155","642.91","4278.67","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4019.96","72.72","","3643.09","3643.09","3643.09","1 through 10","642.91","4278.67","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2942.00","53.22","","554.28","554.28","554.28","16","642.91","4278.67","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3477.11","62.9","","619.64","173.09","2370.64","150","642.91","4278.67","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4278.67","77.4","","303.98","303.98","5854.79","1 through 10","642.91","4278.67","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PEEK ALPHAVENT 3 STRANDS 1.4MM XBRAID TT SUTURE TAPE","SUP-ITM-10321180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2349.40","1409.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","273.24","1996.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 4.75MM PEEK ALPHAVENT 3 STRANDS 1.4MM XBRAID TT SUTURE TAPE","SUP-ITM-10321180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2349.40","1409.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","273.24","1996.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 4.75MM PEEK ALPHAVENT 3 STRANDS 1.4MM XBRAID TT SUTURE TAPE","SUP-ITM-10321180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2349.40","1409.64","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1336.81","56.9","","812.12","238.65","1587.46","163","273.24","1996.99","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PEEK ALPHAVENT 3 STRANDS 1.4MM XBRAID TT SUTURE TAPE","SUP-ITM-10321180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2349.40","1409.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","273.24","11.63","","112.68","112.68","146.99","38","273.24","1996.99","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PEEK ALPHAVENT 3 STRANDS 1.4MM XBRAID TT SUTURE TAPE","SUP-ITM-10321180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2349.40","1409.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1818.44","77.4","","303.98","303.98","5854.79","1 through 10","273.24","1996.99","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PEEK ALPHAVENT 3 STRANDS 1.4MM XBRAID TT SUTURE TAPE","SUP-ITM-10321180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2349.40","1409.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","273.24","11.63","","112.68","112.68","146.99","38","273.24","1818.44","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PEEK ALPHAVENT 3 STRANDS 1.4MM XBRAID TT SUTURE TAPE","SUP-ITM-10321180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2349.40","1409.64","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1474.95","62.78","","780.86","208.94","10480.28","15","273.24","1818.44","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PEEK ALPHAVENT 3 STRANDS 1.4MM XBRAID TT SUTURE TAPE","SUP-ITM-10321180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2349.40","1409.64","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1027.16","43.72","","179.76","179.76","179.76","1 through 10","273.24","1818.44","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PEEK ALPHAVENT 3 STRANDS 1.4MM XBRAID TT SUTURE TAPE","SUP-ITM-10321180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2349.40","1409.64","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1708.48","72.72","","2355.45","298.99","3965.19","155","273.24","1818.44","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PEEK ALPHAVENT 3 STRANDS 1.4MM XBRAID TT SUTURE TAPE","SUP-ITM-10321180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2349.40","1409.64","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1708.48","72.72","","3643.09","3643.09","3643.09","1 through 10","273.24","1818.44","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PEEK ALPHAVENT 3 STRANDS 1.4MM XBRAID TT SUTURE TAPE","SUP-ITM-10321180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2349.40","1409.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1250.35","53.22","","554.28","554.28","554.28","16","273.24","1818.44","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PEEK ALPHAVENT 3 STRANDS 1.4MM XBRAID TT SUTURE TAPE","SUP-ITM-10321180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2349.40","1409.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1477.77","62.9","","619.64","173.09","2370.64","150","273.24","1818.44","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PEEK ALPHAVENT 3 STRANDS 1.4MM XBRAID TT SUTURE TAPE","SUP-ITM-10321180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2349.40","1409.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1818.44","77.4","","303.98","303.98","5854.79","1 through 10","273.24","1818.44","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","both","","","3178.60","1907.16","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","369.67","2701.81","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","both","","","3178.60","1907.16","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","369.67","2701.81","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","both","","","3178.60","1907.16","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1808.62","56.9","","812.12","238.65","1587.46","163","369.67","2701.81","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","both","","","3178.60","1907.16","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","369.67","11.63","","112.68","112.68","146.99","38","369.67","2701.81","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","both","","","3178.60","1907.16","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2460.24","77.4","","303.98","303.98","5854.79","1 through 10","369.67","2701.81","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3178.60","1907.16","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","369.67","11.63","","112.68","112.68","146.99","38","369.67","2460.24","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3178.60","1907.16","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1995.53","62.78","","780.86","208.94","10480.28","15","369.67","2460.24","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3178.60","1907.16","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1389.68","43.72","","179.76","179.76","179.76","1 through 10","369.67","2460.24","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3178.60","1907.16","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2311.48","72.72","","2355.45","298.99","3965.19","155","369.67","2460.24","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3178.60","1907.16","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2311.48","72.72","","3643.09","3643.09","3643.09","1 through 10","369.67","2460.24","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3178.60","1907.16","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1691.65","53.22","","554.28","554.28","554.28","16","369.67","2460.24","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3178.60","1907.16","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1999.34","62.9","","619.64","173.09","2370.64","150","369.67","2460.24","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3178.60","1907.16","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2460.24","77.4","","303.98","303.98","5854.79","1 through 10","369.67","2460.24","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","8439.00","5063.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","981.46","7173.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","8439.00","5063.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","981.46","7173.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","8439.00","5063.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4801.79","56.9","","812.12","238.65","1587.46","163","981.46","7173.15","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","8439.00","5063.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","981.46","11.63","","112.68","112.68","146.99","38","981.46","7173.15","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","8439.00","5063.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6531.79","77.4","","303.98","303.98","5854.79","1 through 10","981.46","7173.15","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8439.00","5063.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","981.46","11.63","","112.68","112.68","146.99","38","981.46","6531.79","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8439.00","5063.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5298.00","62.78","","780.86","208.94","10480.28","15","981.46","6531.79","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8439.00","5063.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3689.53","43.72","","179.76","179.76","179.76","1 through 10","981.46","6531.79","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8439.00","5063.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6136.84","72.72","","2355.45","298.99","3965.19","155","981.46","6531.79","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8439.00","5063.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6136.84","72.72","","3643.09","3643.09","3643.09","1 through 10","981.46","6531.79","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8439.00","5063.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4491.24","53.22","","554.28","554.28","554.28","16","981.46","6531.79","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8439.00","5063.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5308.13","62.9","","619.64","173.09","2370.64","150","981.46","6531.79","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8439.00","5063.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6531.79","77.4","","303.98","303.98","5854.79","1 through 10","981.46","6531.79","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE FORCE FIBER","SUP-ITM-10092352","CDM","C1713","HCPCS","0278","RC","","","","both","","","1987.39","1192.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","231.13","1689.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE FORCE FIBER","SUP-ITM-10092352","CDM","C1713","HCPCS","0278","RC","","","","both","","","1987.39","1192.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","231.13","1689.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE FORCE FIBER","SUP-ITM-10092352","CDM","C1713","HCPCS","0278","RC","","","","both","","","1987.39","1192.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1130.82","56.9","","812.12","238.65","1587.46","163","231.13","1689.28","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE FORCE FIBER","SUP-ITM-10092352","CDM","C1713","HCPCS","0278","RC","","","","both","","","1987.39","1192.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","231.13","11.63","","112.68","112.68","146.99","38","231.13","1689.28","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE FORCE FIBER","SUP-ITM-10092352","CDM","C1713","HCPCS","0278","RC","","","","both","","","1987.39","1192.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1538.24","77.4","","303.98","303.98","5854.79","1 through 10","231.13","1689.28","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE FORCE FIBER","SUP-ITM-10092352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1987.39","1192.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","231.13","11.63","","112.68","112.68","146.99","38","231.13","1538.24","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE FORCE FIBER","SUP-ITM-10092352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1987.39","1192.43","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1247.68","62.78","","780.86","208.94","10480.28","15","231.13","1538.24","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE FORCE FIBER","SUP-ITM-10092352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1987.39","1192.43","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","868.89","43.72","","179.76","179.76","179.76","1 through 10","231.13","1538.24","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE FORCE FIBER","SUP-ITM-10092352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1987.39","1192.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1445.23","72.72","","2355.45","298.99","3965.19","155","231.13","1538.24","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE FORCE FIBER","SUP-ITM-10092352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1987.39","1192.43","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1445.23","72.72","","3643.09","3643.09","3643.09","1 through 10","231.13","1538.24","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE FORCE FIBER","SUP-ITM-10092352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1987.39","1192.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1057.69","53.22","","554.28","554.28","554.28","16","231.13","1538.24","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE FORCE FIBER","SUP-ITM-10092352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1987.39","1192.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1250.07","62.9","","619.64","173.09","2370.64","150","231.13","1538.24","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE FORCE FIBER","SUP-ITM-10092352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1987.39","1192.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1538.24","77.4","","303.98","303.98","5854.79","1 through 10","231.13","1538.24","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE TITANIUM FORCE FIBER","SUP-ITM-10092355","CDM","C1713","HCPCS","0278","RC","","","","both","","","1948.69","1169.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","226.63","1656.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE TITANIUM FORCE FIBER","SUP-ITM-10092355","CDM","C1713","HCPCS","0278","RC","","","","both","","","1948.69","1169.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","226.63","1656.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE TITANIUM FORCE FIBER","SUP-ITM-10092355","CDM","C1713","HCPCS","0278","RC","","","","both","","","1948.69","1169.21","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1108.80","56.9","","812.12","238.65","1587.46","163","226.63","1656.39","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE TITANIUM FORCE FIBER","SUP-ITM-10092355","CDM","C1713","HCPCS","0278","RC","","","","both","","","1948.69","1169.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","226.63","11.63","","112.68","112.68","146.99","38","226.63","1656.39","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE TITANIUM FORCE FIBER","SUP-ITM-10092355","CDM","C1713","HCPCS","0278","RC","","","","both","","","1948.69","1169.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1508.29","77.4","","303.98","303.98","5854.79","1 through 10","226.63","1656.39","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE TITANIUM FORCE FIBER","SUP-ITM-10092355","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1948.69","1169.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","226.63","11.63","","112.68","112.68","146.99","38","226.63","1508.29","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE TITANIUM FORCE FIBER","SUP-ITM-10092355","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1948.69","1169.21","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1223.39","62.78","","780.86","208.94","10480.28","15","226.63","1508.29","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE TITANIUM FORCE FIBER","SUP-ITM-10092355","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1948.69","1169.21","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","851.97","43.72","","179.76","179.76","179.76","1 through 10","226.63","1508.29","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE TITANIUM FORCE FIBER","SUP-ITM-10092355","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1948.69","1169.21","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1417.09","72.72","","2355.45","298.99","3965.19","155","226.63","1508.29","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE TITANIUM FORCE FIBER","SUP-ITM-10092355","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1948.69","1169.21","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1417.09","72.72","","3643.09","3643.09","3643.09","1 through 10","226.63","1508.29","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE TITANIUM FORCE FIBER","SUP-ITM-10092355","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1948.69","1169.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1037.09","53.22","","554.28","554.28","554.28","16","226.63","1508.29","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE TITANIUM FORCE FIBER","SUP-ITM-10092355","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1948.69","1169.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1225.73","62.9","","619.64","173.09","2370.64","150","226.63","1508.29","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM SIZE 2 INTRALINE TITANIUM FORCE FIBER","SUP-ITM-10092355","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1948.69","1169.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1508.29","77.4","","303.98","303.98","5854.79","1 through 10","226.63","1508.29","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM POLYETHER ETHER KETONE ZIP BX/5EA","SUP-ITM-10033418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1866.39","1119.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","217.06","1586.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 6.5MM POLYETHER ETHER KETONE ZIP BX/5EA","SUP-ITM-10033418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1866.39","1119.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","217.06","1586.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 6.5MM POLYETHER ETHER KETONE ZIP BX/5EA","SUP-ITM-10033418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1866.39","1119.83","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1061.98","56.9","","812.12","238.65","1587.46","163","217.06","1586.43","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM POLYETHER ETHER KETONE ZIP BX/5EA","SUP-ITM-10033418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1866.39","1119.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","217.06","11.63","","112.68","112.68","146.99","38","217.06","1586.43","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM POLYETHER ETHER KETONE ZIP BX/5EA","SUP-ITM-10033418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1866.39","1119.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1444.59","77.4","","303.98","303.98","5854.79","1 through 10","217.06","1586.43","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM POLYETHER ETHER KETONE ZIP BX/5EA","SUP-ITM-10033418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1866.39","1119.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","217.06","11.63","","112.68","112.68","146.99","38","217.06","1444.59","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM POLYETHER ETHER KETONE ZIP BX/5EA","SUP-ITM-10033418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1866.39","1119.83","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1171.72","62.78","","780.86","208.94","10480.28","15","217.06","1444.59","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM POLYETHER ETHER KETONE ZIP BX/5EA","SUP-ITM-10033418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1866.39","1119.83","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","815.99","43.72","","179.76","179.76","179.76","1 through 10","217.06","1444.59","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM POLYETHER ETHER KETONE ZIP BX/5EA","SUP-ITM-10033418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1866.39","1119.83","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1357.24","72.72","","2355.45","298.99","3965.19","155","217.06","1444.59","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM POLYETHER ETHER KETONE ZIP BX/5EA","SUP-ITM-10033418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1866.39","1119.83","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1357.24","72.72","","3643.09","3643.09","3643.09","1 through 10","217.06","1444.59","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM POLYETHER ETHER KETONE ZIP BX/5EA","SUP-ITM-10033418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1866.39","1119.83","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","993.29","53.22","","554.28","554.28","554.28","16","217.06","1444.59","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM POLYETHER ETHER KETONE ZIP BX/5EA","SUP-ITM-10033418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1866.39","1119.83","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1173.96","62.9","","619.64","173.09","2370.64","150","217.06","1444.59","percent of total billed charges",""
"ANCHOR SUTURE 6.5MM POLYETHER ETHER KETONE ZIP BX/5EA","SUP-ITM-10033418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1866.39","1119.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1444.59","77.4","","303.98","303.98","5854.79","1 through 10","217.06","1444.59","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","both","","","2798.55","1679.13","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","325.47","2378.77","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","both","","","2798.55","1679.13","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","325.47","2378.77","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","both","","","2798.55","1679.13","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1592.37","56.9","","812.12","238.65","1587.46","163","325.47","2378.77","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","both","","","2798.55","1679.13","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","325.47","11.63","","112.68","112.68","146.99","38","325.47","2378.77","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","both","","","2798.55","1679.13","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2166.08","77.4","","303.98","303.98","5854.79","1 through 10","325.47","2378.77","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2798.55","1679.13","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","325.47","11.63","","112.68","112.68","146.99","38","325.47","2166.08","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2798.55","1679.13","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1756.93","62.78","","780.86","208.94","10480.28","15","325.47","2166.08","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2798.55","1679.13","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1223.53","43.72","","179.76","179.76","179.76","1 through 10","325.47","2166.08","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2798.55","1679.13","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2035.11","72.72","","2355.45","298.99","3965.19","155","325.47","2166.08","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2798.55","1679.13","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2035.11","72.72","","3643.09","3643.09","3643.09","1 through 10","325.47","2166.08","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2798.55","1679.13","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1489.39","53.22","","554.28","554.28","554.28","16","325.47","2166.08","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2798.55","1679.13","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1760.29","62.9","","619.64","173.09","2370.64","150","325.47","2166.08","percent of total billed charges",""
"ANCHOR SUTURE 7X19.5MM PEEK FORKED EYELET SWIVELOCK BX/5EA","SUP-ITM-10318087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2798.55","1679.13","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2166.08","77.4","","303.98","303.98","5854.79","1 through 10","325.47","2166.08","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","321.45","2349.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","321.45","2349.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1572.72","56.9","","812.12","238.65","1587.46","163","321.45","2349.4","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.45","11.63","","112.68","112.68","146.99","38","321.45","2349.4","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2139.34","77.4","","303.98","303.98","5854.79","1 through 10","321.45","2349.4","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.45","11.63","","112.68","112.68","146.99","38","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1735.24","62.78","","780.86","208.94","10480.28","15","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1208.42","43.72","","179.76","179.76","179.76","1 through 10","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2009.98","72.72","","2355.45","298.99","3965.19","155","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2009.98","72.72","","3643.09","3643.09","3643.09","1 through 10","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1471.00","53.22","","554.28","554.28","554.28","16","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1738.56","62.9","","619.64","173.09","2370.64","150","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE PROCINCH RT REVERSE TENSIONING","SUP-ITM-10158814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2139.34","77.4","","303.98","303.98","5854.79","1 through 10","321.45","2139.34","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP LENGTH36IN ARTHROSCOPY QUICK ETHIBOND BX/5EA","SUP-ITM-10014618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1547.84","928.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","180.01","1315.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE SIZE 2 0 NEEDLECP LENGTH36IN ARTHROSCOPY QUICK ETHIBOND BX/5EA","SUP-ITM-10014618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1547.84","928.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","180.01","1315.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE SIZE 2 0 NEEDLECP LENGTH36IN ARTHROSCOPY QUICK ETHIBOND BX/5EA","SUP-ITM-10014618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1547.84","928.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","880.72","56.9","","812.12","238.65","1587.46","163","180.01","1315.66","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP LENGTH36IN ARTHROSCOPY QUICK ETHIBOND BX/5EA","SUP-ITM-10014618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1547.84","928.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","180.01","11.63","","112.68","112.68","146.99","38","180.01","1315.66","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP LENGTH36IN ARTHROSCOPY QUICK ETHIBOND BX/5EA","SUP-ITM-10014618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1547.84","928.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1198.03","77.4","","303.98","303.98","5854.79","1 through 10","180.01","1315.66","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP LENGTH36IN ARTHROSCOPY QUICK ETHIBOND BX/5EA","SUP-ITM-10014618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1547.84","928.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","180.01","11.63","","112.68","112.68","146.99","38","180.01","1198.03","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP LENGTH36IN ARTHROSCOPY QUICK ETHIBOND BX/5EA","SUP-ITM-10014618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1547.84","928.70","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","971.73","62.78","","780.86","208.94","10480.28","15","180.01","1198.03","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP LENGTH36IN ARTHROSCOPY QUICK ETHIBOND BX/5EA","SUP-ITM-10014618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1547.84","928.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","676.72","43.72","","179.76","179.76","179.76","1 through 10","180.01","1198.03","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP LENGTH36IN ARTHROSCOPY QUICK ETHIBOND BX/5EA","SUP-ITM-10014618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1547.84","928.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1125.59","72.72","","2355.45","298.99","3965.19","155","180.01","1198.03","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP LENGTH36IN ARTHROSCOPY QUICK ETHIBOND BX/5EA","SUP-ITM-10014618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1547.84","928.70","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1125.59","72.72","","3643.09","3643.09","3643.09","1 through 10","180.01","1198.03","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP LENGTH36IN ARTHROSCOPY QUICK ETHIBOND BX/5EA","SUP-ITM-10014618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1547.84","928.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","823.76","53.22","","554.28","554.28","554.28","16","180.01","1198.03","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP LENGTH36IN ARTHROSCOPY QUICK ETHIBOND BX/5EA","SUP-ITM-10014618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1547.84","928.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","973.59","62.9","","619.64","173.09","2370.64","150","180.01","1198.03","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP LENGTH36IN ARTHROSCOPY QUICK ETHIBOND BX/5EA","SUP-ITM-10014618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1547.84","928.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1198.03","77.4","","303.98","303.98","5854.79","1 through 10","180.01","1198.03","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","both","","","1292.17","775.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","150.28","1098.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","both","","","1292.17","775.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","150.28","1098.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","both","","","1292.17","775.30","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","735.24","56.9","","812.12","238.65","1587.46","163","150.28","1098.34","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","both","","","1292.17","775.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","150.28","11.63","","112.68","112.68","146.99","38","150.28","1098.34","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","both","","","1292.17","775.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1000.14","77.4","","303.98","303.98","5854.79","1 through 10","150.28","1098.34","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1292.17","775.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","150.28","11.63","","112.68","112.68","146.99","38","150.28","1000.14","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1292.17","775.30","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","811.22","62.78","","780.86","208.94","10480.28","15","150.28","1000.14","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1292.17","775.30","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","564.94","43.72","","179.76","179.76","179.76","1 through 10","150.28","1000.14","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1292.17","775.30","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","939.67","72.72","","2355.45","298.99","3965.19","155","150.28","1000.14","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1292.17","775.30","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","939.67","72.72","","3643.09","3643.09","3643.09","1 through 10","150.28","1000.14","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1292.17","775.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","687.69","53.22","","554.28","554.28","554.28","16","150.28","1000.14","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1292.17","775.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","812.77","62.9","","619.64","173.09","2370.64","150","150.28","1000.14","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH36IN ARTHROSCOPY GII QUICK PLUS","SUP-ITM-10005974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1292.17","775.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1000.14","77.4","","303.98","303.98","5854.79","1 through 10","150.28","1000.14","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","1437.28","862.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","167.16","1221.69","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","1437.28","862.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","167.16","1221.69","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","1437.28","862.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","817.81","56.9","","812.12","238.65","1587.46","163","167.16","1221.69","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","1437.28","862.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","167.16","11.63","","112.68","112.68","146.99","38","167.16","1221.69","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","1437.28","862.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1112.45","77.4","","303.98","303.98","5854.79","1 through 10","167.16","1221.69","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1437.28","862.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","167.16","11.63","","112.68","112.68","146.99","38","167.16","1112.45","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1437.28","862.37","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","902.32","62.78","","780.86","208.94","10480.28","15","167.16","1112.45","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1437.28","862.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","628.38","43.72","","179.76","179.76","179.76","1 through 10","167.16","1112.45","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1437.28","862.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1045.19","72.72","","2355.45","298.99","3965.19","155","167.16","1112.45","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1437.28","862.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1045.19","72.72","","3643.09","3643.09","3643.09","1 through 10","167.16","1112.45","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1437.28","862.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","764.92","53.22","","554.28","554.28","554.28","16","167.16","1112.45","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1437.28","862.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","904.05","62.9","","619.64","173.09","2370.64","150","167.16","1112.45","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1437.28","862.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1112.45","77.4","","303.98","303.98","5854.79","1 through 10","167.16","1112.45","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","2487.60","1492.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","289.31","2114.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","2487.60","1492.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","289.31","2114.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","2487.60","1492.56","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1415.44","56.9","","812.12","238.65","1587.46","163","289.31","2114.46","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","2487.60","1492.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","289.31","11.63","","112.68","112.68","146.99","38","289.31","2114.46","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","2487.60","1492.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1925.40","77.4","","303.98","303.98","5854.79","1 through 10","289.31","2114.46","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2487.60","1492.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","289.31","11.63","","112.68","112.68","146.99","38","289.31","1925.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2487.60","1492.56","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1561.72","62.78","","780.86","208.94","10480.28","15","289.31","1925.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2487.60","1492.56","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1087.58","43.72","","179.76","179.76","179.76","1 through 10","289.31","1925.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2487.60","1492.56","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1808.98","72.72","","2355.45","298.99","3965.19","155","289.31","1925.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2487.60","1492.56","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1808.98","72.72","","3643.09","3643.09","3643.09","1 through 10","289.31","1925.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2487.60","1492.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1323.90","53.22","","554.28","554.28","554.28","16","289.31","1925.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2487.60","1492.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1564.70","62.9","","619.64","173.09","2370.64","150","289.31","1925.4","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2487.60","1492.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1925.40","77.4","","303.98","303.98","5854.79","1 through 10","289.31","1925.4","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 1.4MM ICONIX INTELLIBRAID FORCE FIBER 1 STRAND BX/5EA","SUP-ITM-10318004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2891.28","1734.77","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","336.26","2457.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE SZ 2-0 1.4MM ICONIX INTELLIBRAID FORCE FIBER 1 STRAND BX/5EA","SUP-ITM-10318004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2891.28","1734.77","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","336.26","2457.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE SZ 2-0 1.4MM ICONIX INTELLIBRAID FORCE FIBER 1 STRAND BX/5EA","SUP-ITM-10318004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2891.28","1734.77","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1645.14","56.9","","812.12","238.65","1587.46","163","336.26","2457.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 1.4MM ICONIX INTELLIBRAID FORCE FIBER 1 STRAND BX/5EA","SUP-ITM-10318004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2891.28","1734.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","336.26","11.63","","112.68","112.68","146.99","38","336.26","2457.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 1.4MM ICONIX INTELLIBRAID FORCE FIBER 1 STRAND BX/5EA","SUP-ITM-10318004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2891.28","1734.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2237.85","77.4","","303.98","303.98","5854.79","1 through 10","336.26","2457.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 1.4MM ICONIX INTELLIBRAID FORCE FIBER 1 STRAND BX/5EA","SUP-ITM-10318004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2891.28","1734.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","336.26","11.63","","112.68","112.68","146.99","38","336.26","2237.85","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 1.4MM ICONIX INTELLIBRAID FORCE FIBER 1 STRAND BX/5EA","SUP-ITM-10318004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2891.28","1734.77","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1815.15","62.78","","780.86","208.94","10480.28","15","336.26","2237.85","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 1.4MM ICONIX INTELLIBRAID FORCE FIBER 1 STRAND BX/5EA","SUP-ITM-10318004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2891.28","1734.77","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1264.07","43.72","","179.76","179.76","179.76","1 through 10","336.26","2237.85","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 1.4MM ICONIX INTELLIBRAID FORCE FIBER 1 STRAND BX/5EA","SUP-ITM-10318004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2891.28","1734.77","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2102.54","72.72","","2355.45","298.99","3965.19","155","336.26","2237.85","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 1.4MM ICONIX INTELLIBRAID FORCE FIBER 1 STRAND BX/5EA","SUP-ITM-10318004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2891.28","1734.77","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2102.54","72.72","","3643.09","3643.09","3643.09","1 through 10","336.26","2237.85","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 1.4MM ICONIX INTELLIBRAID FORCE FIBER 1 STRAND BX/5EA","SUP-ITM-10318004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2891.28","1734.77","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1538.74","53.22","","554.28","554.28","554.28","16","336.26","2237.85","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 1.4MM ICONIX INTELLIBRAID FORCE FIBER 1 STRAND BX/5EA","SUP-ITM-10318004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2891.28","1734.77","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1818.62","62.9","","619.64","173.09","2370.64","150","336.26","2237.85","percent of total billed charges",""
"ANCHOR SUTURE SZ 2-0 1.4MM ICONIX INTELLIBRAID FORCE FIBER 1 STRAND BX/5EA","SUP-ITM-10318004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2891.28","1734.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2237.85","77.4","","303.98","303.98","5854.79","1 through 10","336.26","2237.85","percent of total billed charges",""
"ANCHOR SUTURE SZ 3 2.3MM ICONIX INTELLIBRAID FORCE FIBER 3 STRAND PK/5EA","SUP-ITM-10306212","CDM","C1713","HCPCS","0278","RC","","","","both","","","2891.28","1734.77","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","336.26","2457.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE SZ 3 2.3MM ICONIX INTELLIBRAID FORCE FIBER 3 STRAND PK/5EA","SUP-ITM-10306212","CDM","C1713","HCPCS","0278","RC","","","","both","","","2891.28","1734.77","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","336.26","2457.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANCHOR SUTURE SZ 3 2.3MM ICONIX INTELLIBRAID FORCE FIBER 3 STRAND PK/5EA","SUP-ITM-10306212","CDM","C1713","HCPCS","0278","RC","","","","both","","","2891.28","1734.77","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1645.14","56.9","","812.12","238.65","1587.46","163","336.26","2457.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 3 2.3MM ICONIX INTELLIBRAID FORCE FIBER 3 STRAND PK/5EA","SUP-ITM-10306212","CDM","C1713","HCPCS","0278","RC","","","","both","","","2891.28","1734.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","336.26","11.63","","112.68","112.68","146.99","38","336.26","2457.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 3 2.3MM ICONIX INTELLIBRAID FORCE FIBER 3 STRAND PK/5EA","SUP-ITM-10306212","CDM","C1713","HCPCS","0278","RC","","","","both","","","2891.28","1734.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2237.85","77.4","","303.98","303.98","5854.79","1 through 10","336.26","2457.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 3 2.3MM ICONIX INTELLIBRAID FORCE FIBER 3 STRAND PK/5EA","SUP-ITM-10306212","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2891.28","1734.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","336.26","11.63","","112.68","112.68","146.99","38","336.26","2237.85","percent of total billed charges",""
"ANCHOR SUTURE SZ 3 2.3MM ICONIX INTELLIBRAID FORCE FIBER 3 STRAND PK/5EA","SUP-ITM-10306212","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2891.28","1734.77","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1815.15","62.78","","780.86","208.94","10480.28","15","336.26","2237.85","percent of total billed charges",""
"ANCHOR SUTURE SZ 3 2.3MM ICONIX INTELLIBRAID FORCE FIBER 3 STRAND PK/5EA","SUP-ITM-10306212","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2891.28","1734.77","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1264.07","43.72","","179.76","179.76","179.76","1 through 10","336.26","2237.85","percent of total billed charges",""
"ANCHOR SUTURE SZ 3 2.3MM ICONIX INTELLIBRAID FORCE FIBER 3 STRAND PK/5EA","SUP-ITM-10306212","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2891.28","1734.77","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2102.54","72.72","","2355.45","298.99","3965.19","155","336.26","2237.85","percent of total billed charges",""
"ANCHOR SUTURE SZ 3 2.3MM ICONIX INTELLIBRAID FORCE FIBER 3 STRAND PK/5EA","SUP-ITM-10306212","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2891.28","1734.77","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2102.54","72.72","","3643.09","3643.09","3643.09","1 through 10","336.26","2237.85","percent of total billed charges",""
"ANCHOR SUTURE SZ 3 2.3MM ICONIX INTELLIBRAID FORCE FIBER 3 STRAND PK/5EA","SUP-ITM-10306212","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2891.28","1734.77","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1538.74","53.22","","554.28","554.28","554.28","16","336.26","2237.85","percent of total billed charges",""
"ANCHOR SUTURE SZ 3 2.3MM ICONIX INTELLIBRAID FORCE FIBER 3 STRAND PK/5EA","SUP-ITM-10306212","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2891.28","1734.77","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1818.62","62.9","","619.64","173.09","2370.64","150","336.26","2237.85","percent of total billed charges",""
"ANCHOR SUTURE SZ 3 2.3MM ICONIX INTELLIBRAID FORCE FIBER 3 STRAND PK/5EA","SUP-ITM-10306212","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2891.28","1734.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2237.85","77.4","","303.98","303.98","5854.79","1 through 10","336.26","2237.85","percent of total billed charges",""
"Androstenedione","PX-30000312","CDM","82157","CPT","0301","RC","","","","both","","","157.00","94.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","109.59","69.8","","95.61","95.61","95.61","1 through 10","19.03","150.5","percent of total billed charges",""
"Androstenedione","PX-30000312","CDM","82157","CPT","0301","RC","","","","outpatient","","","157.00","94.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","114.17","72.72","","110.53","110.53","110.53","1 through 10","27.27","121.52","percent of total billed charges",""
"Androstenedione","PX-30000312","CDM","82157","CPT","0301","RC","","","","outpatient","","","157.00","94.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","98.75","62.9","","287.28","95.76","287.28","1 through 10","27.27","121.52","percent of total billed charges",""
"Androstenedione","PX-30000312","CDM","82157","CPT","0301","RC","","","","outpatient","","","157.00","94.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","121.52","77.4","","117.80","117.80","117.80","1 through 10","27.27","121.52","percent of total billed charges",""
"Angina Pectoris","311","MS-DRG","","","","","","","","inpatient","","","28173.13","16903.88","MEDICARE [2001]","HB WDH MEDICARE","5781.02","","Case rate ($5,781.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,370.08, add-ons for qualifying new technology services are included. If operating cost exceeds $9,288.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,194.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,946.21 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,925.21 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $389.94. The transfer capital threshold is the transfer adjustment factor * $389.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5727.94","5727.94","5727.94","1 through 10","3975","26672.27","other","Inpatient DRG"
"Angiotensin I Enzyme (Ace)","PX-30000315","CDM","82164","CPT","0301","RC","","","","both","","","79.00","47.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","55.14","69.8","","47.80","47.80","47.80","1 through 10","9.49","75.25","percent of total billed charges",""
"Angiotensin I Enzyme (Ace)","PX-30000315","CDM","82164","CPT","0301","RC","","","","outpatient","","","79.00","47.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","57.45","72.72","","55.27","55.27","55.27","1 through 10","13.61","61.15","percent of total billed charges",""
"Angiotensin I Enzyme (Ace)","PX-30000315","CDM","82164","CPT","0301","RC","","","","outpatient","","","79.00","47.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","49.69","62.9","","179.76","47.88","179.76","1 through 10","13.61","61.15","percent of total billed charges",""
"Angiotensin I Enzyme (Ace)","PX-30000315","CDM","82164","CPT","0301","RC","","","","outpatient","","","79.00","47.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","61.15","77.4","","58.90","58.90","58.90","1 through 10","13.61","61.15","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 12 H BONE VA LCP STAINLESS DISTAL TIBIA LEFT ANTEROMEDIAL","SUP-ITM-10124997","CDM","C1713","HCPCS","0278","RC","","","","both","","","7778.92","4667.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","904.69","6612.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANKLE PLATE 2.7 TO 3.5MM 12 H BONE VA LCP STAINLESS DISTAL TIBIA LEFT ANTEROMEDIAL","SUP-ITM-10124997","CDM","C1713","HCPCS","0278","RC","","","","both","","","7778.92","4667.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","904.69","6612.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANKLE PLATE 2.7 TO 3.5MM 12 H BONE VA LCP STAINLESS DISTAL TIBIA LEFT ANTEROMEDIAL","SUP-ITM-10124997","CDM","C1713","HCPCS","0278","RC","","","","both","","","7778.92","4667.35","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4426.21","56.9","","812.12","238.65","1587.46","163","904.69","6612.08","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 12 H BONE VA LCP STAINLESS DISTAL TIBIA LEFT ANTEROMEDIAL","SUP-ITM-10124997","CDM","C1713","HCPCS","0278","RC","","","","both","","","7778.92","4667.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","904.69","11.63","","112.68","112.68","146.99","38","904.69","6612.08","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 12 H BONE VA LCP STAINLESS DISTAL TIBIA LEFT ANTEROMEDIAL","SUP-ITM-10124997","CDM","C1713","HCPCS","0278","RC","","","","both","","","7778.92","4667.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6020.88","77.4","","303.98","303.98","5854.79","1 through 10","904.69","6612.08","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 12 H BONE VA LCP STAINLESS DISTAL TIBIA LEFT ANTEROMEDIAL","SUP-ITM-10124997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7778.92","4667.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","904.69","11.63","","112.68","112.68","146.99","38","904.69","6020.88","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 12 H BONE VA LCP STAINLESS DISTAL TIBIA LEFT ANTEROMEDIAL","SUP-ITM-10124997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7778.92","4667.35","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4883.61","62.78","","780.86","208.94","10480.28","15","904.69","6020.88","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 12 H BONE VA LCP STAINLESS DISTAL TIBIA LEFT ANTEROMEDIAL","SUP-ITM-10124997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7778.92","4667.35","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3400.94","43.72","","179.76","179.76","179.76","1 through 10","904.69","6020.88","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 12 H BONE VA LCP STAINLESS DISTAL TIBIA LEFT ANTEROMEDIAL","SUP-ITM-10124997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7778.92","4667.35","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5656.83","72.72","","2355.45","298.99","3965.19","155","904.69","6020.88","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 12 H BONE VA LCP STAINLESS DISTAL TIBIA LEFT ANTEROMEDIAL","SUP-ITM-10124997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7778.92","4667.35","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5656.83","72.72","","3643.09","3643.09","3643.09","1 through 10","904.69","6020.88","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 12 H BONE VA LCP STAINLESS DISTAL TIBIA LEFT ANTEROMEDIAL","SUP-ITM-10124997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7778.92","4667.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4139.94","53.22","","554.28","554.28","554.28","16","904.69","6020.88","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 12 H BONE VA LCP STAINLESS DISTAL TIBIA LEFT ANTEROMEDIAL","SUP-ITM-10124997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7778.92","4667.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4892.94","62.9","","619.64","173.09","2370.64","150","904.69","6020.88","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 12 H BONE VA LCP STAINLESS DISTAL TIBIA LEFT ANTEROMEDIAL","SUP-ITM-10124997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7778.92","4667.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6020.88","77.4","","303.98","303.98","5854.79","1 through 10","904.69","6020.88","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS DISTAL LEFT ANTEROMEDIAL","SUP-ITM-10124994","CDM","C1713","HCPCS","0278","RC","","","","both","","","7261.71","4357.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","844.54","6172.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANKLE PLATE 2.7 TO 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS DISTAL LEFT ANTEROMEDIAL","SUP-ITM-10124994","CDM","C1713","HCPCS","0278","RC","","","","both","","","7261.71","4357.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","844.54","6172.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANKLE PLATE 2.7 TO 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS DISTAL LEFT ANTEROMEDIAL","SUP-ITM-10124994","CDM","C1713","HCPCS","0278","RC","","","","both","","","7261.71","4357.03","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4131.91","56.9","","812.12","238.65","1587.46","163","844.54","6172.45","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS DISTAL LEFT ANTEROMEDIAL","SUP-ITM-10124994","CDM","C1713","HCPCS","0278","RC","","","","both","","","7261.71","4357.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","844.54","11.63","","112.68","112.68","146.99","38","844.54","6172.45","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS DISTAL LEFT ANTEROMEDIAL","SUP-ITM-10124994","CDM","C1713","HCPCS","0278","RC","","","","both","","","7261.71","4357.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5620.56","77.4","","303.98","303.98","5854.79","1 through 10","844.54","6172.45","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS DISTAL LEFT ANTEROMEDIAL","SUP-ITM-10124994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7261.71","4357.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","844.54","11.63","","112.68","112.68","146.99","38","844.54","5620.56","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS DISTAL LEFT ANTEROMEDIAL","SUP-ITM-10124994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7261.71","4357.03","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4558.90","62.78","","780.86","208.94","10480.28","15","844.54","5620.56","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS DISTAL LEFT ANTEROMEDIAL","SUP-ITM-10124994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7261.71","4357.03","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3174.82","43.72","","179.76","179.76","179.76","1 through 10","844.54","5620.56","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS DISTAL LEFT ANTEROMEDIAL","SUP-ITM-10124994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7261.71","4357.03","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5280.72","72.72","","2355.45","298.99","3965.19","155","844.54","5620.56","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS DISTAL LEFT ANTEROMEDIAL","SUP-ITM-10124994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7261.71","4357.03","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5280.72","72.72","","3643.09","3643.09","3643.09","1 through 10","844.54","5620.56","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS DISTAL LEFT ANTEROMEDIAL","SUP-ITM-10124994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7261.71","4357.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3864.68","53.22","","554.28","554.28","554.28","16","844.54","5620.56","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS DISTAL LEFT ANTEROMEDIAL","SUP-ITM-10124994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7261.71","4357.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4567.62","62.9","","619.64","173.09","2370.64","150","844.54","5620.56","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS DISTAL LEFT ANTEROMEDIAL","SUP-ITM-10124994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7261.71","4357.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5620.56","77.4","","303.98","303.98","5854.79","1 through 10","844.54","5620.56","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 8 H BONE VA LCP STAINLESS DISTAL TIBIA RIGHT ANTEROMEDIAL","SUP-ITM-10124947","CDM","C1713","HCPCS","0278","RC","","","","both","","","7405.61","4443.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","861.27","6294.77","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANKLE PLATE 2.7 TO 3.5MM 8 H BONE VA LCP STAINLESS DISTAL TIBIA RIGHT ANTEROMEDIAL","SUP-ITM-10124947","CDM","C1713","HCPCS","0278","RC","","","","both","","","7405.61","4443.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","861.27","6294.77","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANKLE PLATE 2.7 TO 3.5MM 8 H BONE VA LCP STAINLESS DISTAL TIBIA RIGHT ANTEROMEDIAL","SUP-ITM-10124947","CDM","C1713","HCPCS","0278","RC","","","","both","","","7405.61","4443.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4213.79","56.9","","812.12","238.65","1587.46","163","861.27","6294.77","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 8 H BONE VA LCP STAINLESS DISTAL TIBIA RIGHT ANTEROMEDIAL","SUP-ITM-10124947","CDM","C1713","HCPCS","0278","RC","","","","both","","","7405.61","4443.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","861.27","11.63","","112.68","112.68","146.99","38","861.27","6294.77","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 8 H BONE VA LCP STAINLESS DISTAL TIBIA RIGHT ANTEROMEDIAL","SUP-ITM-10124947","CDM","C1713","HCPCS","0278","RC","","","","both","","","7405.61","4443.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5731.94","77.4","","303.98","303.98","5854.79","1 through 10","861.27","6294.77","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 8 H BONE VA LCP STAINLESS DISTAL TIBIA RIGHT ANTEROMEDIAL","SUP-ITM-10124947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7405.61","4443.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","861.27","11.63","","112.68","112.68","146.99","38","861.27","5731.94","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 8 H BONE VA LCP STAINLESS DISTAL TIBIA RIGHT ANTEROMEDIAL","SUP-ITM-10124947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7405.61","4443.37","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4649.24","62.78","","780.86","208.94","10480.28","15","861.27","5731.94","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 8 H BONE VA LCP STAINLESS DISTAL TIBIA RIGHT ANTEROMEDIAL","SUP-ITM-10124947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7405.61","4443.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3237.73","43.72","","179.76","179.76","179.76","1 through 10","861.27","5731.94","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 8 H BONE VA LCP STAINLESS DISTAL TIBIA RIGHT ANTEROMEDIAL","SUP-ITM-10124947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7405.61","4443.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5385.36","72.72","","2355.45","298.99","3965.19","155","861.27","5731.94","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 8 H BONE VA LCP STAINLESS DISTAL TIBIA RIGHT ANTEROMEDIAL","SUP-ITM-10124947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7405.61","4443.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5385.36","72.72","","3643.09","3643.09","3643.09","1 through 10","861.27","5731.94","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 8 H BONE VA LCP STAINLESS DISTAL TIBIA RIGHT ANTEROMEDIAL","SUP-ITM-10124947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7405.61","4443.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3941.27","53.22","","554.28","554.28","554.28","16","861.27","5731.94","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 8 H BONE VA LCP STAINLESS DISTAL TIBIA RIGHT ANTEROMEDIAL","SUP-ITM-10124947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7405.61","4443.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4658.13","62.9","","619.64","173.09","2370.64","150","861.27","5731.94","percent of total billed charges",""
"ANKLE PLATE 2.7 TO 3.5MM 8 H BONE VA LCP STAINLESS DISTAL TIBIA RIGHT ANTEROMEDIAL","SUP-ITM-10124947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7405.61","4443.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5731.94","77.4","","303.98","303.98","5854.79","1 through 10","861.27","5731.94","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","both","","","11514.00","6908.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1339.08","9786.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","both","","","11514.00","6908.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1339.08","9786.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","both","","","11514.00","6908.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6551.47","56.9","","812.12","238.65","1587.46","163","1339.08","9786.9","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","both","","","11514.00","6908.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1339.08","11.63","","112.68","112.68","146.99","38","1339.08","9786.9","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","both","","","11514.00","6908.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8911.84","77.4","","303.98","303.98","5854.79","1 through 10","1339.08","9786.9","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11514.00","6908.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1339.08","11.63","","112.68","112.68","146.99","38","1339.08","8911.84","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11514.00","6908.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","7228.49","62.78","","780.86","208.94","10480.28","15","1339.08","8911.84","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11514.00","6908.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","5033.92","43.72","","179.76","179.76","179.76","1 through 10","1339.08","8911.84","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11514.00","6908.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8372.98","72.72","","2355.45","298.99","3965.19","155","1339.08","8911.84","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11514.00","6908.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","8372.98","72.72","","3643.09","3643.09","3643.09","1 through 10","1339.08","8911.84","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11514.00","6908.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","6127.75","53.22","","554.28","554.28","554.28","16","1339.08","8911.84","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11514.00","6908.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7242.31","62.9","","619.64","173.09","2370.64","150","1339.08","8911.84","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11514.00","6908.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8911.84","77.4","","303.98","303.98","5854.79","1 through 10","1339.08","8911.84","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT RIGHT","SUP-ITM-10270054","CDM","C1713","HCPCS","0278","RC","","","","both","","","11514.00","6908.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1339.08","9786.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT RIGHT","SUP-ITM-10270054","CDM","C1713","HCPCS","0278","RC","","","","both","","","11514.00","6908.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1339.08","9786.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT RIGHT","SUP-ITM-10270054","CDM","C1713","HCPCS","0278","RC","","","","both","","","11514.00","6908.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6551.47","56.9","","812.12","238.65","1587.46","163","1339.08","9786.9","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT RIGHT","SUP-ITM-10270054","CDM","C1713","HCPCS","0278","RC","","","","both","","","11514.00","6908.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1339.08","11.63","","112.68","112.68","146.99","38","1339.08","9786.9","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT RIGHT","SUP-ITM-10270054","CDM","C1713","HCPCS","0278","RC","","","","both","","","11514.00","6908.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8911.84","77.4","","303.98","303.98","5854.79","1 through 10","1339.08","9786.9","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT RIGHT","SUP-ITM-10270054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11514.00","6908.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1339.08","11.63","","112.68","112.68","146.99","38","1339.08","8911.84","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT RIGHT","SUP-ITM-10270054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11514.00","6908.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","7228.49","62.78","","780.86","208.94","10480.28","15","1339.08","8911.84","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT RIGHT","SUP-ITM-10270054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11514.00","6908.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","5033.92","43.72","","179.76","179.76","179.76","1 through 10","1339.08","8911.84","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT RIGHT","SUP-ITM-10270054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11514.00","6908.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8372.98","72.72","","2355.45","298.99","3965.19","155","1339.08","8911.84","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT RIGHT","SUP-ITM-10270054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11514.00","6908.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","8372.98","72.72","","3643.09","3643.09","3643.09","1 through 10","1339.08","8911.84","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT RIGHT","SUP-ITM-10270054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11514.00","6908.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","6127.75","53.22","","554.28","554.28","554.28","16","1339.08","8911.84","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT RIGHT","SUP-ITM-10270054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11514.00","6908.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7242.31","62.9","","619.64","173.09","2370.64","150","1339.08","8911.84","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT RIGHT","SUP-ITM-10270054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11514.00","6908.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8911.84","77.4","","303.98","303.98","5854.79","1 through 10","1339.08","8911.84","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION LATERAL TT","SUP-ITM-10270059","CDM","C1713","HCPCS","0278","RC","","","","both","","","10306.25","6183.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1198.62","8760.31","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANKLE PLATE 4-HOLE FUSION LATERAL TT","SUP-ITM-10270059","CDM","C1713","HCPCS","0278","RC","","","","both","","","10306.25","6183.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1198.62","8760.31","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANKLE PLATE 4-HOLE FUSION LATERAL TT","SUP-ITM-10270059","CDM","C1713","HCPCS","0278","RC","","","","both","","","10306.25","6183.75","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5864.26","56.9","","812.12","238.65","1587.46","163","1198.62","8760.31","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION LATERAL TT","SUP-ITM-10270059","CDM","C1713","HCPCS","0278","RC","","","","both","","","10306.25","6183.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1198.62","11.63","","112.68","112.68","146.99","38","1198.62","8760.31","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION LATERAL TT","SUP-ITM-10270059","CDM","C1713","HCPCS","0278","RC","","","","both","","","10306.25","6183.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7977.04","77.4","","303.98","303.98","5854.79","1 through 10","1198.62","8760.31","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION LATERAL TT","SUP-ITM-10270059","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10306.25","6183.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1198.62","11.63","","112.68","112.68","146.99","38","1198.62","7977.04","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION LATERAL TT","SUP-ITM-10270059","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10306.25","6183.75","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6470.26","62.78","","780.86","208.94","10480.28","15","1198.62","7977.04","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION LATERAL TT","SUP-ITM-10270059","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10306.25","6183.75","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4505.89","43.72","","179.76","179.76","179.76","1 through 10","1198.62","7977.04","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION LATERAL TT","SUP-ITM-10270059","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10306.25","6183.75","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7494.71","72.72","","2355.45","298.99","3965.19","155","1198.62","7977.04","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION LATERAL TT","SUP-ITM-10270059","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10306.25","6183.75","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7494.71","72.72","","3643.09","3643.09","3643.09","1 through 10","1198.62","7977.04","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION LATERAL TT","SUP-ITM-10270059","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10306.25","6183.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","5484.99","53.22","","554.28","554.28","554.28","16","1198.62","7977.04","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION LATERAL TT","SUP-ITM-10270059","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10306.25","6183.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6482.63","62.9","","619.64","173.09","2370.64","150","1198.62","7977.04","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION LATERAL TT","SUP-ITM-10270059","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10306.25","6183.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7977.04","77.4","","303.98","303.98","5854.79","1 through 10","1198.62","7977.04","percent of total billed charges",""
"ANKLE PLATE 98MM 5 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076942","CDM","C1713","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","562.54","4111.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANKLE PLATE 98MM 5 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076942","CDM","C1713","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","562.54","4111.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANKLE PLATE 98MM 5 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076942","CDM","C1713","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2752.25","56.9","","812.12","238.65","1587.46","163","562.54","4111.45","percent of total billed charges",""
"ANKLE PLATE 98MM 5 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076942","CDM","C1713","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","562.54","11.63","","112.68","112.68","146.99","38","562.54","4111.45","percent of total billed charges",""
"ANKLE PLATE 98MM 5 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076942","CDM","C1713","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3743.84","77.4","","303.98","303.98","5854.79","1 through 10","562.54","4111.45","percent of total billed charges",""
"ANKLE PLATE 98MM 5 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076942","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","562.54","11.63","","112.68","112.68","146.99","38","562.54","3743.84","percent of total billed charges",""
"ANKLE PLATE 98MM 5 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076942","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3036.67","62.78","","780.86","208.94","10480.28","15","562.54","3743.84","percent of total billed charges",""
"ANKLE PLATE 98MM 5 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076942","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2114.74","43.72","","179.76","179.76","179.76","1 through 10","562.54","3743.84","percent of total billed charges",""
"ANKLE PLATE 98MM 5 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076942","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3517.47","72.72","","2355.45","298.99","3965.19","155","562.54","3743.84","percent of total billed charges",""
"ANKLE PLATE 98MM 5 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076942","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3517.47","72.72","","3643.09","3643.09","3643.09","1 through 10","562.54","3743.84","percent of total billed charges",""
"ANKLE PLATE 98MM 5 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076942","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2574.25","53.22","","554.28","554.28","554.28","16","562.54","3743.84","percent of total billed charges",""
"ANKLE PLATE 98MM 5 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076942","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3042.47","62.9","","619.64","173.09","2370.64","150","562.54","3743.84","percent of total billed charges",""
"ANKLE PLATE 98MM 5 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076942","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3743.84","77.4","","303.98","303.98","5854.79","1 through 10","562.54","3743.84","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","5786.05","3471.63","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","672.92","4918.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","5786.05","3471.63","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","672.92","4918.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","5786.05","3471.63","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3292.26","56.9","","812.12","238.65","1587.46","163","672.92","4918.14","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","5786.05","3471.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","672.92","11.63","","112.68","112.68","146.99","38","672.92","4918.14","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","5786.05","3471.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4478.40","77.4","","303.98","303.98","5854.79","1 through 10","672.92","4918.14","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5786.05","3471.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","672.92","11.63","","112.68","112.68","146.99","38","672.92","4478.4","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5786.05","3471.63","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3632.48","62.78","","780.86","208.94","10480.28","15","672.92","4478.4","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5786.05","3471.63","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2529.66","43.72","","179.76","179.76","179.76","1 through 10","672.92","4478.4","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5786.05","3471.63","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4207.62","72.72","","2355.45","298.99","3965.19","155","672.92","4478.4","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5786.05","3471.63","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4207.62","72.72","","3643.09","3643.09","3643.09","1 through 10","672.92","4478.4","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5786.05","3471.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3079.34","53.22","","554.28","554.28","554.28","16","672.92","4478.4","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5786.05","3471.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3639.43","62.9","","619.64","173.09","2370.64","150","672.92","4478.4","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5786.05","3471.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4478.40","77.4","","303.98","303.98","5854.79","1 through 10","672.92","4478.4","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","both","","","200.00","120.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","139.60","69.8","","134.71","14.76","134.71","17","11.23","170","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","inpatient","","","200.00","120.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","153.72","76.86","","121.59","121.59","121.59","1 through 10","132.4","153.72","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","145.44","72.72","","140.35","140.35","140.35","16","12.06","154.8","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","145.44","72.72","","140.35","140.35","140.35","1 through 10","12.06","154.8","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","106.44","53.22","","102.89","102.89","102.89","1 through 10","12.06","154.8","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","125.80","62.9","","243.18","121.59","364.77","19","12.06","154.8","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","154.80","77.4","","149.58","138.91","149.58","12","12.06","154.8","percent of total billed charges",""
"Anti-Phosphatidylserine Antibody","PX-30000793","CDM","86148","CPT","0302","RC","","","","outpatient","","","220.00","132.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","138.38","62.9","","134.19","134.19","134.19","1 through 10","12.81","170.28","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","both","","","139.00","83.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","97.02","69.8","","93.53","93.53","93.53","1 through 10","7.83","118.15","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","both","","","139.00","83.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","79.09","56.9","","76.25","76.25","228.75","1 through 10","7.83","118.15","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","139.00","83.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","20.04","14.42","","10.73","10.73","10.73","1 through 10","16.17","107.59","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","139.00","83.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16.17","11.63","","10.63","10.63","10.63","1 through 10","16.17","107.59","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","139.00","83.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","101.08","72.72","","97.44","97.44","97.44","14","16.17","107.59","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","139.00","83.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","107.59","77.4","","103.85","103.85","103.85","1 through 10","16.17","107.59","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","139.00","83.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16.17","11.63","","18.99","10.63","18.99","1 through 10","16.17","107.59","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0300","RC","","","","inpatient","","","65.00","39.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","49.96","76.86","","39.69","39.69","39.69","1 through 10","43.03","49.96","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","both","","","65.00","39.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","45.37","69.8","","43.97","39.63","43.97","46","7.86","61.69","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","both","","","65.00","39.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","55.25","85","","53.55","53.55","53.55","1 through 10","7.86","61.69","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","outpatient","","","65.00","39.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","40.81","62.78","","39.55","39.55","39.55","1 through 10","11.26","50.31","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","outpatient","","","65.00","39.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","28.42","43.72","","27.54","27.54","27.54","1 through 10","11.26","50.31","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","outpatient","","","65.00","39.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","47.27","72.72","","45.81","45.81","45.81","72","11.26","50.31","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","outpatient","","","65.00","39.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","47.27","72.72","","45.81","45.81","45.81","1 through 10","11.26","50.31","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","outpatient","","","65.00","39.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","34.59","53.22","","33.59","33.59","33.59","1 through 10","11.26","50.31","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","outpatient","","","65.00","39.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","40.89","62.9","","39.69","39.69","119.07","113","11.26","50.31","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","outpatient","","","65.00","39.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","50.31","77.4","","48.83","48.83","48.83","37","11.26","50.31","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","both","","","60.00","36.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","41.88","69.8","","40.48","36.48","40.48","37","7.25","57.21","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","both","","","60.00","36.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","51.00","85","","49.30","49.30","49.30","1 through 10","7.25","57.21","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","outpatient","","","60.00","36.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","26.23","43.72","","50.72","25.36","50.72","1 through 10","10.4","46.44","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","outpatient","","","60.00","36.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","43.63","72.72","","42.18","42.18","42.18","33","10.4","46.44","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","outpatient","","","60.00","36.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","31.93","53.22","","30.92","30.92","30.92","1 through 10","10.4","46.44","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","outpatient","","","60.00","36.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","37.74","62.9","","36.54","36.54","136.72","64","10.4","46.44","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Titer","PX-30000784","CDM","86039","CPT","0302","RC","","","","outpatient","","","60.00","36.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","46.44","77.4","","44.95","44.95","44.95","16","10.4","46.44","percent of total billed charges",""
"Antistreptolysin O Titer","PX-30000785","CDM","86060","CPT","0302","RC","","","","both","","","39.00","23.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","27.22","69.8","","26.52","26.52","26.52","1 through 10","4.75","37.61","percent of total billed charges",""
"Antistreptolysin O Titer","PX-30000785","CDM","86060","CPT","0302","RC","","","","outpatient","","","39.00","23.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","24.53","62.9","","23.94","23.94","23.94","1 through 10","6.92","30.19","percent of total billed charges",""
"Antistreptolysin O Titer","PX-30000785","CDM","86060","CPT","0302","RC","","","","outpatient","","","39.00","23.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","30.19","77.4","","29.45","29.45","29.45","1 through 10","6.92","30.19","percent of total billed charges",""
"Antithrombin III Activity","PX-30001071","CDM","85300","CPT","0305","RC","","","","both","","","69.00","41.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","48.16","69.8","","46.77","46.77","46.77","1 through 10","7.7","61.69","percent of total billed charges",""
"Antithrombin III Activity","PX-30001071","CDM","85300","CPT","0305","RC","","","","outpatient","","","69.00","41.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","50.18","72.72","","48.72","48.72","48.72","1 through 10","11.06","53.41","percent of total billed charges",""
"Antithrombin III Activity","PX-30001071","CDM","85300","CPT","0305","RC","","","","outpatient","","","69.00","41.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","43.40","62.9","","42.21","42.21","42.21","1 through 10","11.06","53.41","percent of total billed charges",""
"Antithrombin III Activity","PX-30001071","CDM","85300","CPT","0305","RC","","","","outpatient","","","69.00","41.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","53.41","77.4","","51.93","51.93","51.93","1 through 10","11.06","53.41","percent of total billed charges",""
"Antithrombin III Antigen","PX-30001072","CDM","85301","CPT","0305","RC","","","","both","","","65.00","39.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","45.37","69.8","","43.97","43.97","43.97","1 through 10","7.03","55.69","percent of total billed charges",""
"Antithrombin III Antigen","PX-30001072","CDM","85301","CPT","0305","RC","","","","outpatient","","","65.00","39.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","47.27","72.72","","91.62","45.81","91.62","1 through 10","10.08","50.31","percent of total billed charges",""
"Antithrombin III Antigen","PX-30001072","CDM","85301","CPT","0305","RC","","","","outpatient","","","65.00","39.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","40.89","62.9","","39.69","39.69","39.69","1 through 10","10.08","50.31","percent of total billed charges",""
"Antithrombin III Antigen","PX-30001072","CDM","85301","CPT","0305","RC","","","","outpatient","","","65.00","39.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","50.31","77.4","","48.82","48.82","48.82","1 through 10","10.08","50.31","percent of total billed charges",""
"Aortic And Heart Assist Procedures Except Pulsation Balloon With McC","268","MS-DRG","","","","","","","","inpatient","","","167803.65","100682.19","MARTIN'S POINT [160007]","HB WDH MEDICARE","52733.66","","Case rate ($52,733.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $48,706.85, add-ons for qualifying new technology services are included. If operating cost exceeds $52,625.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $51,625.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $48,467.82 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $48,261.98 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,820.97. The transfer capital threshold is the transfer adjustment factor * $3,820.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Includes an additional $800 of payment.","63818.54","63818.54","63818.54","1 through 10","3975","261360.89","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Aortic And Heart Assist Procedures Except Pulsation Balloon With McC","268","MS-DRG","","","","","","","","inpatient","","","167803.65","100682.19","MEDICARE [2001]","HB WDH MEDICARE","52733.66","","Case rate ($52,733.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $48,706.85, add-ons for qualifying new technology services are included. If operating cost exceeds $52,625.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $51,625.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $48,467.82 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $48,261.98 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,820.97. The transfer capital threshold is the transfer adjustment factor * $3,820.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Includes an additional $800 of payment.","50886.65","50886.65","50886.65","1 through 10","3975","261360.89","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Aortic And Heart Assist Procedures Except Pulsation Balloon With McC","268","MS-DRG","","","","","","","","inpatient","","","167803.65","100682.19","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","52733.66","","Case rate ($52,733.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $48,706.85, add-ons for qualifying new technology services are included. If operating cost exceeds $52,625.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $51,625.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. The base transfer operating payment is the transfer adjustment factor * $48,467.82 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $48,261.98 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,820.97. The transfer capital threshold is the transfer adjustment factor * $3,820.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Includes an additional $800 of payment.","38540.36","38540.36","38540.36","1 through 10","3975","261360.89","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC","269","MS-DRG","","","","","","","","inpatient","","","130764.08","78458.45","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","33202.50","","Case rate ($32,551.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $30,078.91, add-ons for qualifying new technology services are included. If operating cost exceeds $33,997.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,151.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $29,760.43 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $29,634.04 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,346.17. The transfer capital threshold is the transfer adjustment factor * $2,346.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.","31839.54","31839.54","31839.54","1 through 10","3975","160482.02","other","Inpatient DRG"
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC","269","MS-DRG","","","","","","","","inpatient","","","130764.08","78458.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","160482.02","","Fee schedule rate ($160,482.02). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","148567.64","148567.64","148567.64","1 through 10","3975","160482.02","case rate",""
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC","269","MS-DRG","","","","","","","","inpatient","","","130764.08","78458.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","31900.44","","Case rate ($32,551.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $30,078.91, add-ons for qualifying new technology services are included. If operating cost exceeds $33,997.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,151.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $29,760.43 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $29,634.04 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,346.17. The transfer capital threshold is the transfer adjustment factor * $2,346.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","31236.32","31236.32","31236.32","1 through 10","3975","160482.02","other","Inpatient DRG"
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC","269","MS-DRG","","","","","","","","inpatient","","","130764.08","78458.45","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","33528.01","","Case rate ($32,551.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $30,078.91, add-ons for qualifying new technology services are included. If operating cost exceeds $33,997.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,151.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $29,760.43 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $29,634.04 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,346.17. The transfer capital threshold is the transfer adjustment factor * $2,346.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","220742.13","220742.13","220742.13","1 through 10","3975","160482.02","other","Inpatient DRG"
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC","269","MS-DRG","","","","","","","","inpatient","","","130764.08","78458.45","MARTIN'S POINT [160007]","HB WDH MEDICARE","32551.47","","Case rate ($32,551.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $30,078.91, add-ons for qualifying new technology services are included. If operating cost exceeds $33,997.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,151.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $29,760.43 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $29,634.04 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,346.17. The transfer capital threshold is the transfer adjustment factor * $2,346.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","53883.35","53883.35","53883.35","1 through 10","3975","160482.02","other","Inpatient DRG"
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC","269","MS-DRG","","","","","","","","inpatient","","","130764.08","78458.45","MEDICARE [2001]","HB WDH MEDICARE","32551.47","","Case rate ($32,551.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $30,078.91, add-ons for qualifying new technology services are included. If operating cost exceeds $33,997.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,151.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $29,760.43 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $29,634.04 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,346.17. The transfer capital threshold is the transfer adjustment factor * $2,346.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","31839.59","31921.39","55661.57","1 through 10","3975","160482.02","other","Inpatient DRG"
"Apligraf 44 Sq Cm Tier1","PX-27001040","CDM","Q4101","HCPCS","0636","RC","","","","outpatient","","","186.00","111.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","26.82","14.42","","22.99","22.99","22.99","176","21.63","143.96","percent of total billed charges",""
"Apolipoprotein","PX-30000316","CDM","82172","CPT","0301","RC","","","","both","","","94.00","56.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","65.61","69.8","","63.52","63.52","63.52","1 through 10","13.71","88.81","percent of total billed charges",""
"Apolipoprotein","PX-30000316","CDM","82172","CPT","0301","RC","","","","outpatient","","","94.00","56.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","68.36","72.72","","66.18","66.18","91.00","1 through 10","18.57","72.76","percent of total billed charges",""
"Apolipoprotein","PX-30000316","CDM","82172","CPT","0301","RC","","","","outpatient","","","94.00","56.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","59.13","62.9","","57.33","57.33","57.33","11","18.57","72.76","percent of total billed charges",""
"Apolipoprotein","PX-30000316","CDM","82172","CPT","0301","RC","","","","outpatient","","","94.00","56.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","72.76","77.4","","70.53","70.53","70.53","1 through 10","18.57","72.76","percent of total billed charges",""
"Appendix Procedures With Cc","398","MS-DRG","","","","","","","","inpatient","","","59267.54","35560.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","45809.53","","Fee schedule rate ($45,809.53). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","22089.58","22089.58","22089.58","1 through 10","3975","57516.95","case rate",""
"Appendix Procedures With Cc","398","MS-DRG","","","","","","","","inpatient","","","59267.54","35560.52","MARTIN'S POINT [160007]","HB WDH MEDICARE","11951.92","","Case rate ($11,951.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,065.75, add-ons for qualifying new technology services are included. If operating cost exceeds $14,983.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,645.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $10,666.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,620.88 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $840.87. The transfer capital threshold is the transfer adjustment factor * $840.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11707.13","11707.13","11707.13","1 through 10","3975","57516.95","other","Inpatient DRG"
"Appendix Procedures With Cc","398","MS-DRG","","","","","","","","inpatient","","","59267.54","35560.52","MEDICARE [2001]","HB WDH MEDICARE","11951.92","","Case rate ($11,951.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,065.75, add-ons for qualifying new technology services are included. If operating cost exceeds $14,983.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,645.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $10,666.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,620.88 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $840.87. The transfer capital threshold is the transfer adjustment factor * $840.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","0.05","1 through 10","3975","57516.95","other","Inpatient DRG"
"Appendix Procedures With Cc","398","MS-DRG","","","","","","","","inpatient","","","59267.54","35560.52","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","11951.92","","Case rate ($11,951.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,065.75, add-ons for qualifying new technology services are included. If operating cost exceeds $14,983.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,645.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $10,666.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,620.88 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $840.87. The transfer capital threshold is the transfer adjustment factor * $840.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11678.64","11678.64","11892.48","1 through 10","3975","57516.95","other","Inpatient DRG"
"Appendix Procedures With McC","397","MS-DRG","","","","","","","","inpatient","","","76864.15","46118.49","MEDICARE [2001]","HB WDH MEDICARE","18651.94","","Case rate ($18,651.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $17,249.79, add-ons for qualifying new technology services are included. If operating cost exceeds $21,167.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,135.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,876.60 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $16,804.93 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,330.47. The transfer capital threshold is the transfer adjustment factor * $1,330.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","0.05","1 through 10","3975","91006.44","other","Inpatient DRG"
"Appendix Procedures Without Cc/McC","399","MS-DRG","","","","","","","","inpatient","","","49288.85","29573.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","43498.71","","Fee schedule rate ($43,498.71). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","41662.94","41662.94","41662.94","1 through 10","3975","43498.71","case rate",""
"Appendix Procedures Without Cc/McC","399","MS-DRG","","","","","","","","inpatient","","","49288.85","29573.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","17128.01","","Fee schedule rate ($17,128.01). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","16405.15","16405.15","16405.15","1 through 10","3975","43498.71","case rate",""
"Appendix Procedures Without Cc/McC","399","MS-DRG","","","","","","","","inpatient","","","49288.85","29573.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","34644.67","","Fee schedule rate ($34,644.67). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","24368.14","24368.14","24368.14","1 through 10","3975","43498.71","case rate",""
"Appendix Procedures Without Cc/McC","399","MS-DRG","","","","","","","","inpatient","","","49288.85","29573.31","MARTIN'S POINT [160007]","HB WDH MEDICARE","9147.37","","Case rate ($9,147.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,477.18, add-ons for qualifying new technology services are included. If operating cost exceeds $12,395.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,440.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,066.58 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,032.32 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.93. The transfer capital threshold is the transfer adjustment factor * $635.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8782.65","8782.65","8782.65","1 through 10","3975","43498.71","other","Inpatient DRG"
"Appendix Procedures Without Cc/McC","399","MS-DRG","","","","","","","","inpatient","","","49288.85","29573.31","MEDICARE [2001]","HB WDH MEDICARE","9147.37","","Case rate ($9,147.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,477.18, add-ons for qualifying new technology services are included. If operating cost exceeds $12,395.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,440.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,066.58 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,032.32 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.93. The transfer capital threshold is the transfer adjustment factor * $635.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","0.05","1 through 10","3975","43498.71","other","Inpatient DRG"
"Appendix Procedures Without Cc/McC","399","MS-DRG","","","","","","","","inpatient","","","49288.85","29573.31","TRICARE [160005]","HB WDH MEDICARE","9147.37","","Case rate ($9,147.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,477.18, add-ons for qualifying new technology services are included. If operating cost exceeds $12,395.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,440.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,066.58 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,032.32 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $635.93. The transfer capital threshold is the transfer adjustment factor * $635.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11193.73","11193.73","11193.73","1 through 10","3975","43498.71","other","Inpatient DRG"
"Appl of Capsaicin Patch 1 or More","PX-76002971","CDM","17999","CPT","0761","RC","","","","both","","","1379.00","827.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1326.74","","Case rate ($1,326.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1331.00","1164.96","1331.00","1 through 10","203.44","1326.74","other","OPPS APC"
"Appl of Capsaicin Patch 1 or More","PX-76002971","CDM","17999","CPT","0761","RC","","","","both","","","1379.00","827.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","571.29","","Case rate ($571.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","501.64","501.64","501.64","1 through 10","203.44","1326.74","other","OPPS APC"
"Appl of Capsaicin Patch 1 or More","PX-76002971","CDM","17999","CPT","0761","RC","","","","both","","","1379.00","827.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","207.59","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.62","207.62","207.62","1 through 10","203.44","1326.74","other","OPPS APC"
"Appl of Capsaicin Patch 1 or More","PX-76002971","CDM","17999","CPT","0761","RC","","","","both","","","1379.00","827.40","MEDICARE [2001]","HB WDH MEDICARE","207.59","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.62","207.62","622.86","16","203.44","1326.74","other","OPPS APC"
"Appl of Capsaicin Patch 1 or More","PX-76002971","CDM","17999","CPT","0761","RC","","","","both","","","1379.00","827.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","207.59","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.62","207.62","207.62","1 through 10","203.44","1326.74","other","OPPS APC"
"Appl of Capsaicin Patch 1 or More","PX-76002971","CDM","17999","CPT","0761","RC","","","","outpatient","","","1379.00","827.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","1331.00","1331.00","1331.00","1 through 10","733.9","1067.35","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Appl of Capsaicin Patch 1 or More","PX-76002971","CDM","17999","CPT","0761","RC","","","","outpatient","","","1379.00","827.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","18129.82","18129.82","18129.82","1 through 10","733.9","1067.35","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Appl of Capsaicin Patch 1 or More","PX-76002971","CDM","17999","CPT","0761","RC","","","","outpatient","","","1379.00","827.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","867.39","62.9","","838.53","838.53","838.53","1 through 10","733.9","1067.35","percent of total billed charges",""
"Appl on-Body Injector for Timed Sc Inj - 96377","PX-26000022","CDM","96377","CPT","0260","RC","","","","both","","","277.00","166.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","193.35","69.8","","186.37","186.37","186.37","1 through 10","47.24","248.99","percent of total billed charges",""
"Appl Splint Forarm/Arm Shrt Static","PX-76000699","CDM","29125","CPT","0510","RC","","","","both","","","395.00","237.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","275.71","69.8","","181.48","181.48","181.48","1 through 10","41.55","860.68","percent of total billed charges",""
"Appl Splint Forarm/Arm Shrt Static","PX-76000699","CDM","29125","CPT","0510","RC","","","","both","","","395.00","237.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","335.75","85","","39.49","39.49","39.49","1 through 10","41.55","860.68","percent of total billed charges",""
"Appl Splint Forarm/Arm Shrt Static","PX-76000699","CDM","29125","CPT","0510","RC","","","","outpatient","","","395.00","237.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","248.46","62.9","","163.80","163.80","163.80","1 through 10","45.94","305.73","percent of total billed charges",""
"Appl Splint Forarm/Arm Shrt Static","PX-76000699","CDM","29125","CPT","0510","RC","","","","outpatient","","","395.00","237.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","305.73","77.4","","201.50","201.50","201.50","1 through 10","45.94","305.73","percent of total billed charges",""
"Appl Splint Leg Long","PX-76000719","CDM","29505","CPT","0510","RC","","","","both","","","492.00","295.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","343.42","69.8","","225.45","225.45","225.45","1 through 10","53.25","1053.58","percent of total billed charges",""
"Appl Splint Leg Long","PX-76000719","CDM","29505","CPT","0510","RC","","","","both","","","492.00","295.20","TRICARE [160005]","HB WDH MEDICARE","164.85","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","115.15","115.15","115.15","1 through 10","53.25","1053.58","other","OPPS APC"
"Appl Splint Leg Long","PX-76000719","CDM","29505","CPT","0510","RC","","","","both","","","492.00","295.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","164.85","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","164.87","164.87","164.87","1 through 10","53.25","1053.58","other","OPPS APC"
"Appl Splint Leg Short","PX-76000720","CDM","29515","CPT","0510","RC","","","","both","","","481.00","288.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","335.74","69.8","","220.57","220.57","220.57","1 through 10","52.06","1053.58","percent of total billed charges",""
"Appl Splint Leg Short","PX-76000720","CDM","29515","CPT","0510","RC","","","","both","","","481.00","288.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","164.85","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","164.87","164.87","164.87","1 through 10","52.06","1053.58","other","OPPS APC"
"Appl Splint Leg Short","PX-76000720","CDM","29515","CPT","0510","RC","","","","outpatient","","","481.00","288.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","302.55","62.9","","199.08","199.08","199.08","1 through 10","55.94","372.29","percent of total billed charges",""
"Appl Splint Leg Short","PX-76000720","CDM","29515","CPT","0510","RC","","","","outpatient","","","481.00","288.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","372.29","77.4","","244.90","244.90","244.90","1 through 10","55.94","372.29","percent of total billed charges",""
"Apply Cast Leg Rigid Total Contact","PX-76000717","CDM","29445","CPT","0510","RC","","","","both","","","1041.00","624.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","277.47","","APC Price ($277.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","277.50","277.50","277.50","1 through 10","271.92","1773.28","other","OPPS APC"
"Apply Cast Leg Rigid Total Contact","PX-76000717","CDM","29445","CPT","0510","RC","","","","both","","","1041.00","624.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","277.47","","APC Price ($277.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","271.95","257.49","273.06","11","271.92","1773.28","other","OPPS APC"
"Apply Multlay Comprs Bl Knee","PX-76000726","CDM","29581","CPT","0761","RC","","","","both","","","450.00","270.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","314.10","69.8","","435.55","302.93","435.55","21","161.56","1053.58","percent of total billed charges",""
"Apply Multlay Comprs Bl Knee","PX-76000726","CDM","29581","CPT","0761","RC","","","","both","","","450.00","270.00","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","168.15","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","164.87","164.87","164.87","1 through 10","161.56","1053.58","other","OPPS APC"
"Apply Multlay Comprs Bl Knee","PX-76000726","CDM","29581","CPT","0761","RC","","","","both","","","450.00","270.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","161.56","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","163.57","163.57","163.57","1 through 10","161.56","1053.58","other","OPPS APC"
"Apply Multlay Comprs Bl Knee","PX-76000726","CDM","29581","CPT","0761","RC","","","","both","","","450.00","270.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","851.60","","Case rate ($851.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","434.00","434.00","434.00","1 through 10","161.56","1053.58","other","OPPS APC"
"Apply Multlay Comprs Bl Knee","PX-76000726","CDM","29581","CPT","0761","RC","","","","both","","","450.00","270.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","256.05","56.9","","246.95","246.95","246.95","13","161.56","1053.58","percent of total billed charges",""
"Apply Multlay Comprs Bl Knee","PX-76000726","CDM","29581","CPT","0761","RC","","","","both","","","450.00","270.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","164.85","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","162.47","151.26","162.47","41","161.56","1053.58","other","OPPS APC"
"Apply Multlay Comprs Bl Knee","PX-76000726","CDM","29581","CPT","0761","RC","","","","both","","","450.00","270.00","MEDICARE [2001]","HB WDH MEDICARE","164.85","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","164.87","153.53","164.87","229","161.56","1053.58","other","OPPS APC"
"Apply Multlay Comprs Bl Knee","PX-76000726","CDM","29581","CPT","0761","RC","","","","both","","","450.00","270.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","164.85","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","164.87","162.24","243.36","62","161.56","1053.58","other","OPPS APC"
"Apply Multlay Comprs Bl Knee","PX-76000726","CDM","29581","CPT","0761","RC","","","","outpatient","","","450.00","270.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","283.05","62.9","","273.42","273.42","273.42","1 through 10","52.34","348.3","percent of total billed charges",""
"Apply Multlay Comprs Bl Knee|BILATERAL PROCEDURE","PX-76000726","CDM","29581","CPT","0761","RC","","","50","both","","","450.00","270.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","161.56","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","243.36","243.36","243.36","1 through 10","161.56","169.8","other","OPPS APC"
"Apply Multlay Comprs Bl Knee|BILATERAL PROCEDURE","PX-76000726","CDM","29581","CPT","0761","RC","","","50","both","","","450.00","270.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","169.80","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","250.64","232.47","250.64","1 through 10","161.56","169.8","other","OPPS APC"
"Apply Multlay Comprs Bl Knee|BILATERAL PROCEDURE","PX-76000726","CDM","29581","CPT","0761","RC","","","50","both","","","450.00","270.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","164.85","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","226.49","226.49","243.26","1 through 10","161.56","169.8","other","OPPS APC"
"Apply Multlay Comprs Bl Knee|BILATERAL PROCEDURE","PX-76000726","CDM","29581","CPT","0761","RC","","","50","both","","","450.00","270.00","MEDICARE [2001]","HB WDH MEDICARE","164.85","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","247.31","247.31","247.31","79","161.56","169.8","other","OPPS APC"
"Apply Multlay Comprs Bl Knee|BILATERAL PROCEDURE","PX-76000726","CDM","29581","CPT","0761","RC","","","50","both","","","450.00","270.00","WELLSENSE NH [1050]","HB WDH MEDICARE","164.85","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1957.47","254.49","1975.36","34","161.56","169.8","other","OPPS APC"
"Apply Splint Arm Long","PX-76000698","CDM","29105","CPT","0510","RC","","","","both","","","479.00","287.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","164.85","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","151.26","151.26","151.26","1 through 10","44.02","1053.58","other","OPPS APC"
"Apply Splint Arm Long","PX-76000698","CDM","29105","CPT","0510","RC","","","","outpatient","","","479.00","287.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","301.29","62.9","","198.45","198.45","198.45","1 through 10","55.71","370.75","percent of total billed charges",""
"Apply Splint Arm Long","PX-76000698","CDM","29105","CPT","0510","RC","","","","outpatient","","","479.00","287.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","370.75","77.4","","244.13","244.13","244.13","1 through 10","55.71","370.75","percent of total billed charges",""
"Apply Splint Finger Static","PX-76000701","CDM","29130","CPT","0510","RC","","","","both","","","288.00","172.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","201.02","69.8","","133.32","133.32","133.32","1 through 10","31.02","860.68","percent of total billed charges",""
"Apply Splint Finger Static","PX-76000701","CDM","29130","CPT","0510","RC","","","","outpatient","","","288.00","172.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","181.15","62.9","","120.33","120.33","120.33","1 through 10","33.49","222.91","percent of total billed charges",""
"Apply Splint Finger Static","PX-76000701","CDM","29130","CPT","0510","RC","","","","outpatient","","","288.00","172.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","222.91","77.4","","148.03","148.03","148.03","1 through 10","33.49","222.91","percent of total billed charges",""
"Aquaporin-4 Antibody Cell-Based Imfluor Assay Ea","PX-30003765","CDM","86052","CPT","0302","RC","","","","both","","","139.00","83.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","79.09","56.9","","76.25","76.25","76.25","1 through 10","7.83","118.15","percent of total billed charges",""
"Arsenic","PX-30000317","CDM","82175","CPT","0301","RC","","","","outpatient","","","102.00","61.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","64.16","62.9","","62.37","62.37","62.37","1 through 10","17.68","78.95","percent of total billed charges",""
"Arsenic","PX-30000317","CDM","82175","CPT","0301","RC","","","","outpatient","","","102.00","61.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","78.95","77.4","","76.73","76.73","76.73","1 through 10","17.68","78.95","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","both","","","1897.00","1138.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1971.01","","Case rate ($1,971.01). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1922.94","1875.89","1922.94","1 through 10","39.39","1971.01","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","both","","","1897.00","1138.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1079.39","56.9","","3125.52","331.68","3125.52","1 through 10","39.39","1971.01","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","both","","","1897.00","1138.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","317.65","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","317.69","311.59","317.69","1 through 10","39.39","1971.01","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","both","","","1897.00","1138.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","303.17","303.17","303.17","1 through 10","39.39","1971.01","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","both","","","1897.00","1138.20","MEDICARE [2001]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","308.44","308.44","308.44","1 through 10","39.39","1971.01","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","both","","","1897.00","1138.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","302.28","154.22","302.28","1 through 10","39.39","1971.01","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","outpatient","","","1897.00","1138.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","273.55","14.42","","264.03","264.03","264.03","1 through 10","220.62","1468.28","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","outpatient","","","1897.00","1138.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","220.62","11.63","","648.81","462.43","648.81","1 through 10","220.62","1468.28","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US","PX-76002075","CDM","20605","CPT","0761","RC","","","","outpatient","","","1897.00","1138.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","1331.50","1331.50","1331.50","1 through 10","220.62","1468.28","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Arthrocentesis Aspir&/Inj Interm Jt/Burs W/US","PX-76002076","CDM","20606","CPT","0761","RC","","","","outpatient","","","686.00","411.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","431.49","62.9","","417.06","417.06","417.06","1 through 10","79.78","530.96","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","2529.00","1517.40","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","314.57","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","308.44","308.44","308.44","1 through 10","302.23","2149.65","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","2529.00","1517.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1439.00","56.9","","236.78","236.78","236.78","1 through 10","302.23","2149.65","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","2529.00","1517.40","MEDICARE [2001]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","616.88","308.44","925.32","1 through 10","302.23","2149.65","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","2529.00","1517.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","308.44","302.28","308.44","11","302.23","2149.65","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","outpatient","","","2529.00","1517.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3548.74","3548.74","3548.74","1 through 10","294.12","1957.45","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","outpatient","","","2529.00","1517.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1590.74","62.9","","1537.20","1537.20","1537.20","1 through 10","294.12","1957.45","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","both","","","2529.00","1517.40","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","314.57","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","462.66","462.66","462.66","1 through 10","302.23","317.65","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","both","","","2529.00","1517.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","302.23","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","454.21","425.21","454.21","1 through 10","302.23","317.65","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","both","","","2529.00","1517.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","317.65","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","476.54","476.54","476.54","1 through 10","302.23","317.65","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","both","","","2529.00","1517.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","454.31","454.31","454.31","1 through 10","302.23","317.65","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","both","","","2529.00","1517.40","MEDICARE [2001]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","462.66","462.66","925.32","17","302.23","317.65","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","both","","","2529.00","1517.40","WELLSENSE NH [1050]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","478.02","478.02","478.02","1 through 10","302.23","317.65","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","both","","","3061.00","1836.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","2136.58","69.8","","2061.89","2061.89","2061.89","1 through 10","302.23","2601.85","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","both","","","3061.00","1836.60","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","314.57","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","308.44","308.44","308.44","1 through 10","302.23","2601.85","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","both","","","3061.00","1836.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","848.71","","Case rate ($848.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","726.99","726.99","726.99","1 through 10","302.23","2601.85","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","both","","","3061.00","1836.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","302.23","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","302.27","282.81","303.27","1 through 10","302.23","2601.85","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","both","","","3061.00","1836.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1593.15","","Case rate ($1,593.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","569.92","569.92","569.92","1 through 10","302.23","2601.85","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","both","","","3061.00","1836.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1741.71","56.9","","1680.83","1680.83","1680.83","1 through 10","302.23","2601.85","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","both","","","3061.00","1836.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","303.17","302.27","308.44","1 through 10","302.23","2601.85","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","both","","","3061.00","1836.60","MEDICARE [2001]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","308.44","308.44","1156.65","44","302.23","2601.85","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","both","","","3061.00","1836.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","308.44","303.51","461.31","21","302.23","2601.85","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","outpatient","","","3061.00","1836.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1925.37","62.9","","1861.02","1861.02","3722.04","1 through 10","355.99","2369.21","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US|BILATERAL PROCEDURE","PX-76002078","CDM","20611","CPT","0761","RC","","","50","both","","","3061.00","1836.60","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","314.57","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","462.66","462.66","462.66","1 through 10","302.23","317.65","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US|BILATERAL PROCEDURE","PX-76002078","CDM","20611","CPT","0761","RC","","","50","both","","","3061.00","1836.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","302.23","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","425.21","86.57","454.41","1 through 10","302.23","317.65","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US|BILATERAL PROCEDURE","PX-76002078","CDM","20611","CPT","0761","RC","","","50","both","","","3061.00","1836.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","462.66","462.66","462.66","1 through 10","302.23","317.65","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US|BILATERAL PROCEDURE","PX-76002078","CDM","20611","CPT","0761","RC","","","50","both","","","3061.00","1836.60","MEDICARE [2001]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","462.66","432.88","462.66","18","302.23","317.65","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US|BILATERAL PROCEDURE","PX-76002078","CDM","20611","CPT","0761","RC","","","50","both","","","3061.00","1836.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","462.66","462.66","462.66","1 through 10","302.23","317.65","other","OPPS APC"
"Arup, Hemochromatosis (Hfe) 3 Mutations, 0055656","PX-31001429","CDM","81256","CPT","0310","RC","","","","both","","","354.00","212.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","247.09","69.8","","238.72","215.12","238.72","1 through 10","42.48","337.13","percent of total billed charges",""
"Arup, Hemochromatosis (Hfe) 3 Mutations, 0055656","PX-31001429","CDM","81256","CPT","0310","RC","","","","outpatient","","","354.00","212.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","51.05","14.42","","342.00","342.00","342.00","1 through 10","41.17","274","percent of total billed charges",""
"Arup, Hemochromatosis (Hfe) 3 Mutations, 0055656","PX-31001429","CDM","81256","CPT","0310","RC","","","","outpatient","","","354.00","212.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","41.17","11.63","","342.00","40.00","342.00","1 through 10","41.17","274","percent of total billed charges",""
"Arup, Hemochromatosis (Hfe) 3 Mutations, 0055656","PX-31001429","CDM","81256","CPT","0310","RC","","","","outpatient","","","354.00","212.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","257.43","72.72","","248.70","248.70","248.70","1 through 10","41.17","274","percent of total billed charges",""
"Arup, Hemochromatosis (Hfe) 3 Mutations, 0055656","PX-31001429","CDM","81256","CPT","0310","RC","","","","outpatient","","","354.00","212.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","188.40","53.22","","182.32","182.32","182.32","1 through 10","41.17","274","percent of total billed charges",""
"Arup, Hemochromatosis (Hfe) 3 Mutations, 0055656","PX-31001429","CDM","81256","CPT","0310","RC","","","","outpatient","","","354.00","212.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","222.67","62.9","","215.46","215.46","215.46","1 through 10","41.17","274","percent of total billed charges",""
"Arup, Hemochromatosis (Hfe) 3 Mutations, 0055656","PX-31001429","CDM","81256","CPT","0310","RC","","","","outpatient","","","354.00","212.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","41.17","11.63","","40.00","40.00","104.58","1 through 10","41.17","274","percent of total billed charges",""
"Aspergillus Agent Enzyme Infect Ant","PX-30001231","CDM","87305","CPT","0300","RC","","","","inpatient","","","173.00","103.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","132.97","76.86","","105.21","105.21","105.21","1 through 10","114.53","132.97","percent of total billed charges",""
"Aspergillus Agent Enzyme Infect Ant","PX-30001231","CDM","87305","CPT","0306","RC","","","","outpatient","","","173.00","103.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","125.81","72.72","","121.44","121.44","121.44","1 through 10","8.69","133.9","percent of total billed charges",""
"Aspergillus Antibody","PX-30000881","CDM","86606","CPT","0302","RC","","","","both","","","81.00","48.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","56.54","69.8","","54.44","54.44","54.44","11","9.78","78.25","percent of total billed charges",""
"Aspergillus Antibody","PX-30000881","CDM","86606","CPT","0302","RC","","","","outpatient","","","81.00","48.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","58.90","72.72","","56.72","56.72","56.72","1 through 10","17.68","62.69","percent of total billed charges",""
"Aspergillus Antibody","PX-30000881","CDM","86606","CPT","0302","RC","","","","outpatient","","","81.00","48.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","50.95","62.9","","94.59","94.59","94.59","1 through 10","17.68","62.69","percent of total billed charges",""
"Aspergillus Antibody","PX-30000881","CDM","86606","CPT","0302","RC","","","","outpatient","","","81.00","48.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","62.69","77.4","","302.25","302.25","302.25","1 through 10","17.68","62.69","percent of total billed charges",""
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","both","","","1171.00","702.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2667.66","","Case rate ($2,667.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2602.60","2602.60","2602.60","1 through 10","409.06","2667.66","other","OPPS APC"
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","both","","","1171.00","702.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","666.30","56.9","","642.97","642.97","642.97","1 through 10","409.06","2667.66","percent of total billed charges",""
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","both","","","1171.00","702.60","MEDICARE [2001]","HB WDH MEDICARE","417.41","","APC Price ($417.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1252.38","417.46","1252.38","1 through 10","409.06","2667.66","other","OPPS APC"
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","outpatient","","","1171.00","702.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","821.74","821.74","821.74","1 through 10","136.19","906.35","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","outpatient","","","1171.00","702.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","736.56","62.9","","711.90","711.90","711.90","1 through 10","136.19","906.35","percent of total billed charges",""
"Aspiration Bladder/Insert Suprapub","PX-76001844","CDM","51102","CPT","0761","RC","","","","both","","","10745.00","6447.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","13677.84","","Case rate ($13,677.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11324.97","11324.97","11324.97","1 through 10","2097.4","13677.84","other","OPPS APC"
"Aspiration Bladder/Insert Suprapub","PX-76001844","CDM","51102","CPT","0761","RC","","","","both","","","10745.00","6447.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","5889.66","","Case rate ($5,889.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5746.08","5746.08","5746.08","1 through 10","2097.4","13677.84","other","OPPS APC"
"Aspiration Bladder/Insert Suprapub","PX-76001844","CDM","51102","CPT","0761","RC","","","","both","","","10745.00","6447.00","MEDICARE [2001]","HB WDH MEDICARE","2140.20","","APC Price ($2,140.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2140.45","1984.56","2140.45","1 through 10","2097.4","13677.84","other","OPPS APC"
"Aspiration Bladder/Insert Suprapub","PX-76001844","CDM","51102","CPT","0761","RC","","","","both","","","10745.00","6447.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","2140.20","","APC Price ($2,140.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2140.45","2100.09","2140.45","1 through 10","2097.4","13677.84","other","OPPS APC"
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","both","","","4425.00","2655.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2517.83","56.9","","2429.63","2429.63","2429.63","1 through 10","720.38","4697.85","percent of total billed charges",""
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","both","","","4425.00","2655.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","735.08","","APC Price ($735.08). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","721.37","721.37","721.37","1 through 10","720.38","4697.85","other","OPPS APC"
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","outpatient","","","4425.00","2655.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","514.63","11.63","","522.65","522.65","522.65","1 through 10","514.63","3424.95","percent of total billed charges",""
"Assay Lipoprotein Pla2","PX-30000554","CDM","83698","CPT","0301","RC","","","","outpatient","","","533.00","319.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","335.26","62.9","","324.45","324.45","324.45","1 through 10","41.14","412.54","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","both","","","135.00","81.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","94.23","69.8","","91.44","82.40","91.44","17","25.1","114.75","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","both","","","135.00","81.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","76.82","56.9","","74.54","74.54","74.54","22","25.1","114.75","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","both","","","135.00","81.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","114.75","85","","85.03","85.03","85.03","1 through 10","25.1","114.75","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","135.00","81.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","19.47","14.42","","34.41","34.41","34.41","1 through 10","15.7","104.49","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","135.00","81.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","15.70","11.63","","34.08","23.63","34.08","1 through 10","15.7","104.49","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","135.00","81.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","98.17","72.72","","95.26","95.26","95.26","15","15.7","104.49","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","135.00","81.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","71.85","53.22","","69.84","69.84","69.84","1 through 10","15.7","104.49","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","135.00","81.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","84.92","62.9","","82.53","82.53","82.53","31","15.7","104.49","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","135.00","81.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","104.49","77.4","","101.53","97.78","101.53","19","15.7","104.49","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","135.00","81.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","15.70","11.63","","34.08","34.08","34.08","1 through 10","15.7","104.49","percent of total billed charges",""
"Assay of Interleukin-6 (Il-6)","PX-30003760","CDM","83529","CPT","0301","RC","","","","both","","","200.00","120.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","113.80","56.9","","109.82","109.82","109.82","1 through 10","11.23","170","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","both","","","69.00","41.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","48.16","69.8","","46.77","46.77","46.77","1 through 10","9.31","66.21","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","outpatient","","","69.00","41.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","30.17","43.72","","29.29","29.29","29.29","1 through 10","11.77","53.41","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","outpatient","","","69.00","41.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","50.18","72.72","","48.72","48.72","67.00","32","11.77","53.41","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","outpatient","","","69.00","41.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","36.72","53.22","","35.72","35.72","35.72","1 through 10","11.77","53.41","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","outpatient","","","69.00","41.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","43.40","62.9","","42.21","42.21","42.21","53","11.77","53.41","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","outpatient","","","69.00","41.40","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","50.18","72.72","","67.00","67.00","67.00","1 through 10","11.77","53.41","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","outpatient","","","69.00","41.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","53.41","77.4","","51.93","51.93","51.93","1 through 10","11.77","53.41","percent of total billed charges",""
"Assay of Sirolimus","PX-30000035","CDM","80195","CPT","0301","RC","","","","outpatient","","","86.00","51.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","62.54","72.72","","60.36","60.36","60.36","1 through 10","6.52","66.56","percent of total billed charges",""
"Assay of Sirolimus","PX-30000035","CDM","80195","CPT","0301","RC","","","","outpatient","","","86.00","51.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","54.09","62.9","","52.29","52.29","156.87","23","6.52","66.56","percent of total billed charges",""
"Assay of Sirolimus","PX-30000035","CDM","80195","CPT","0301","RC","","","","outpatient","","","86.00","51.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","66.56","77.4","","64.33","64.33","64.33","1 through 10","6.52","66.56","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","both","","","152.00","91.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","106.10","69.8","","102.61","31.85","102.61","60","18.16","144.46","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","both","","","152.00","91.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","129.20","85","","25.15","25.15","25.15","1 through 10","18.16","144.46","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","outpatient","","","152.00","91.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","95.43","62.78","","92.29","92.29","92.29","1 through 10","26.03","117.65","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","outpatient","","","152.00","91.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","66.45","43.72","","64.27","64.27","64.27","1 through 10","26.03","117.65","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","outpatient","","","152.00","91.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","110.53","72.72","","106.90","106.90","106.90","62","26.03","117.65","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","outpatient","","","152.00","91.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","110.53","72.72","","106.90","106.90","106.90","1 through 10","26.03","117.65","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","outpatient","","","152.00","91.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","80.89","53.22","","78.37","78.37","78.37","1 through 10","26.03","117.65","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","outpatient","","","152.00","91.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","95.61","62.9","","92.61","92.61","92.61","101","26.03","117.65","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","outpatient","","","152.00","91.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","117.65","77.4","","113.93","113.93","113.93","43","26.03","117.65","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","outpatient","","","152.00","91.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","110.53","72.72","","106.90","106.90","106.90","1 through 10","26.03","117.65","percent of total billed charges",""
"Assay Thiopurine S-Methyltransferase","PX-30003803","CDM","84433","CPT","0301","RC","","","","both","","","247.00","148.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","172.41","69.8","","166.82","166.82","166.82","1 through 10","14.41","209.95","percent of total billed charges",""
"Assay Thiopurine S-Methyltransferase","PX-30003803","CDM","84433","CPT","0301","RC","","","","outpatient","","","247.00","148.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","179.62","72.72","","173.80","173.80","173.80","1 through 10","28.73","191.18","percent of total billed charges",""
"Assay Thiopurine S-Methyltransferase","PX-30003803","CDM","84433","CPT","0301","RC","","","","outpatient","","","247.00","148.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","155.36","62.9","","150.57","150.57","150.57","1 through 10","28.73","191.18","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","both","","","73.00","43.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","50.95","69.8","","49.56","44.66","49.56","36","3.37","62.05","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","both","","","73.00","43.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","62.05","85","","7.25","7.25","7.25","1 through 10","3.37","62.05","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","outpatient","","","73.00","43.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","45.83","62.78","","44.57","44.57","44.57","1 through 10","4.82","56.5","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","outpatient","","","73.00","43.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","31.92","43.72","","31.04","31.04","59.66","1 through 10","4.82","56.5","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","outpatient","","","73.00","43.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","53.09","72.72","","51.63","51.63","51.63","61","4.82","56.5","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","outpatient","","","73.00","43.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","53.09","72.72","","51.63","51.63","51.63","1 through 10","4.82","56.5","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","outpatient","","","73.00","43.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","38.85","53.22","","37.85","37.85","37.85","1 through 10","4.82","56.5","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","outpatient","","","73.00","43.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","45.92","62.9","","44.73","44.73","44.73","45","4.82","56.5","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","outpatient","","","73.00","43.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","56.50","77.4","","55.03","55.03","55.03","18","4.82","56.5","percent of total billed charges",""
"Atherosclerosis Without McC","303","MS-DRG","","","","","","","","inpatient","","","22572.18","13543.31","MEDICARE [2001]","HB WDH MEDICARE","5562.82","","Case rate ($5,562.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,168.69, add-ons for qualifying new technology services are included. If operating cost exceeds $9,086.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,179.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,743.97 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,723.82 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.99. The transfer capital threshold is the transfer adjustment factor * $373.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5531.63","5531.63","5531.63","1 through 10","3975","25581.67","other","Inpatient DRG"
"Atherosclerosis Without McC","303","MS-DRG","","","","","","","","inpatient","","","22572.18","13543.31","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","5562.82","","Case rate ($5,562.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,168.69, add-ons for qualifying new technology services are included. If operating cost exceeds $9,086.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,179.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,743.97 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,723.82 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $373.99. The transfer capital threshold is the transfer adjustment factor * $373.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5436.80","5436.80","5436.80","1 through 10","3975","25581.67","other","Inpatient DRG"
"ATTRAX PUTTY 10CC US","SUP-ITM-10252406","CDM","C1713","HCPCS","0278","RC","","","","both","","","7275.00","4365.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","846.08","6183.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ATTRAX PUTTY 10CC US","SUP-ITM-10252406","CDM","C1713","HCPCS","0278","RC","","","","both","","","7275.00","4365.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","846.08","6183.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ATTRAX PUTTY 10CC US","SUP-ITM-10252406","CDM","C1713","HCPCS","0278","RC","","","","both","","","7275.00","4365.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4139.48","56.9","","812.12","238.65","1587.46","163","846.08","6183.75","percent of total billed charges",""
"ATTRAX PUTTY 10CC US","SUP-ITM-10252406","CDM","C1713","HCPCS","0278","RC","","","","both","","","7275.00","4365.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","846.08","11.63","","112.68","112.68","146.99","38","846.08","6183.75","percent of total billed charges",""
"ATTRAX PUTTY 10CC US","SUP-ITM-10252406","CDM","C1713","HCPCS","0278","RC","","","","both","","","7275.00","4365.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5630.85","77.4","","303.98","303.98","5854.79","1 through 10","846.08","6183.75","percent of total billed charges",""
"ATTRAX PUTTY 10CC US","SUP-ITM-10252406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","846.08","11.63","","112.68","112.68","146.99","38","846.08","5630.85","percent of total billed charges",""
"ATTRAX PUTTY 10CC US","SUP-ITM-10252406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4567.25","62.78","","780.86","208.94","10480.28","15","846.08","5630.85","percent of total billed charges",""
"ATTRAX PUTTY 10CC US","SUP-ITM-10252406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3180.63","43.72","","179.76","179.76","179.76","1 through 10","846.08","5630.85","percent of total billed charges",""
"ATTRAX PUTTY 10CC US","SUP-ITM-10252406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5290.38","72.72","","2355.45","298.99","3965.19","155","846.08","5630.85","percent of total billed charges",""
"ATTRAX PUTTY 10CC US","SUP-ITM-10252406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5290.38","72.72","","3643.09","3643.09","3643.09","1 through 10","846.08","5630.85","percent of total billed charges",""
"ATTRAX PUTTY 10CC US","SUP-ITM-10252406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3871.76","53.22","","554.28","554.28","554.28","16","846.08","5630.85","percent of total billed charges",""
"ATTRAX PUTTY 10CC US","SUP-ITM-10252406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4575.98","62.9","","619.64","173.09","2370.64","150","846.08","5630.85","percent of total billed charges",""
"ATTRAX PUTTY 10CC US","SUP-ITM-10252406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5630.85","77.4","","303.98","303.98","5854.79","1 through 10","846.08","5630.85","percent of total billed charges",""
"ATTRAX PUTTY 5CC US","SUP-ITM-10252408","CDM","C1713","HCPCS","0278","RC","","","","both","","","5182.50","3109.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","602.72","4405.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ATTRAX PUTTY 5CC US","SUP-ITM-10252408","CDM","C1713","HCPCS","0278","RC","","","","both","","","5182.50","3109.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","602.72","4405.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ATTRAX PUTTY 5CC US","SUP-ITM-10252408","CDM","C1713","HCPCS","0278","RC","","","","both","","","5182.50","3109.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2948.84","56.9","","812.12","238.65","1587.46","163","602.72","4405.13","percent of total billed charges",""
"ATTRAX PUTTY 5CC US","SUP-ITM-10252408","CDM","C1713","HCPCS","0278","RC","","","","both","","","5182.50","3109.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","602.72","11.63","","112.68","112.68","146.99","38","602.72","4405.13","percent of total billed charges",""
"ATTRAX PUTTY 5CC US","SUP-ITM-10252408","CDM","C1713","HCPCS","0278","RC","","","","both","","","5182.50","3109.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4011.26","77.4","","303.98","303.98","5854.79","1 through 10","602.72","4405.13","percent of total billed charges",""
"ATTRAX PUTTY 5CC US","SUP-ITM-10252408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5182.50","3109.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","602.72","11.63","","112.68","112.68","146.99","38","602.72","4011.26","percent of total billed charges",""
"ATTRAX PUTTY 5CC US","SUP-ITM-10252408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5182.50","3109.50","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3253.57","62.78","","780.86","208.94","10480.28","15","602.72","4011.26","percent of total billed charges",""
"ATTRAX PUTTY 5CC US","SUP-ITM-10252408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5182.50","3109.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2265.79","43.72","","179.76","179.76","179.76","1 through 10","602.72","4011.26","percent of total billed charges",""
"ATTRAX PUTTY 5CC US","SUP-ITM-10252408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5182.50","3109.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3768.71","72.72","","2355.45","298.99","3965.19","155","602.72","4011.26","percent of total billed charges",""
"ATTRAX PUTTY 5CC US","SUP-ITM-10252408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5182.50","3109.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3768.71","72.72","","3643.09","3643.09","3643.09","1 through 10","602.72","4011.26","percent of total billed charges",""
"ATTRAX PUTTY 5CC US","SUP-ITM-10252408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5182.50","3109.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2758.13","53.22","","554.28","554.28","554.28","16","602.72","4011.26","percent of total billed charges",""
"ATTRAX PUTTY 5CC US","SUP-ITM-10252408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5182.50","3109.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3259.79","62.9","","619.64","173.09","2370.64","150","602.72","4011.26","percent of total billed charges",""
"ATTRAX PUTTY 5CC US","SUP-ITM-10252408","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5182.50","3109.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4011.26","77.4","","303.98","303.98","5854.79","1 through 10","602.72","4011.26","percent of total billed charges",""
"Avulsion Nail Plate Single","PX-76000089","CDM","11730","CPT","0761","RC","","","","both","","","567.00","340.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","322.62","56.9","","445.63","445.63","445.63","1 through 10","57.26","1326.74","percent of total billed charges",""
"Avulsion Nail Plate Single","PX-76000089","CDM","11730","CPT","0761","RC","","","","outpatient","","","567.00","340.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","356.64","62.9","","452.78","235.62","452.78","1 through 10","65.94","438.86","percent of total billed charges",""
"Avulsion Nail Plate Single","PX-76000089","CDM","11730","CPT","0761","RC","","","","outpatient","","","567.00","340.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","438.86","77.4","","289.85","289.85","289.85","1 through 10","65.94","438.86","percent of total billed charges",""
"B Cells Total","PX-30000849","CDM","86355","CPT","0302","RC","","","","both","","","263.00","157.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","183.57","69.8","","177.29","159.77","177.29","1 through 10","24.52","223.55","percent of total billed charges",""
"B Cells Total","PX-30000849","CDM","86355","CPT","0302","RC","","","","outpatient","","","263.00","157.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","191.25","72.72","","184.71","184.71","554.13","15","10.68","203.56","percent of total billed charges",""
"B Cells Total","PX-30000849","CDM","86355","CPT","0302","RC","","","","outpatient","","","263.00","157.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","139.97","53.22","","135.41","135.41","135.41","1 through 10","10.68","203.56","percent of total billed charges",""
"B Cells Total","PX-30000849","CDM","86355","CPT","0302","RC","","","","outpatient","","","263.00","157.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","165.43","62.9","","160.02","160.02","160.02","1 through 10","10.68","203.56","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","both","","","188.00","112.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","131.22","69.8","","127.04","114.48","508.14","20","22.81","180.59","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","118.03","62.78","","114.26","114.26","114.26","1 through 10","24.28","145.51","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","82.19","43.72","","79.57","79.57","79.57","1 through 10","24.28","145.51","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","529.40","79","24.28","145.51","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","118.25","62.9","","114.66","114.66","114.66","231","24.28","145.51","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","145.51","77.4","","141.05","141.05","564.20","57","24.28","145.51","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","","","","inpatient","","","102731.58","61638.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","15338.24","","Case rate ($15,651.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,480.21, add-ons for qualifying new technology services are included. If operating cost exceeds $18,398.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,916.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,095.19 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,035.33 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,111.20. The transfer capital threshold is the transfer adjustment factor * $1,111.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15064.69","15064.69","15064.69","1 through 10","14284.69","76007.8","other","Inpatient DRG"
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","","","","inpatient","","","102731.58","61638.95","TRICARE [160005]","HB WDH MEDICARE","15651.27","","Case rate ($15,651.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,480.21, add-ons for qualifying new technology services are included. If operating cost exceeds $18,398.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,916.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,095.19 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,035.33 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,111.20. The transfer capital threshold is the transfer adjustment factor * $1,111.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10782.92","10782.92","10782.92","1 through 10","14284.69","76007.8","other","Inpatient DRG"
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","","","","inpatient","","","102731.58","61638.95","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","15651.27","","Case rate ($15,651.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,480.21, add-ons for qualifying new technology services are included. If operating cost exceeds $18,398.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,916.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,095.19 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,035.33 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,111.20. The transfer capital threshold is the transfer adjustment factor * $1,111.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15062.40","15062.40","15097.28","1 through 10","14284.69","76007.8","other","Inpatient DRG"
"Back And Neck Procedures Except Spinal Fusion With McC Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","","","","inpatient","","","141856.27","85113.76","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","28857.44","","Case rate ($28,857.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $26,669.37, add-ons for qualifying new technology services are included. If operating cost exceeds $30,587.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,881.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $26,336.35 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $26,224.50 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,076.23. The transfer capital threshold is the transfer adjustment factor * $2,076.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27010.27","27010.27","27010.27","1 through 10","23789","142017.77","other","Inpatient DRG"
"Back And Neck Procedures Except Spinal Fusion Without Cc/McC","520","MS-DRG","","","","","","","","inpatient","","","38498.77","23099.26","MEDICARE [2001]","HB WDH MEDICARE","11802.14","","Case rate ($11,802.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,927.51, add-ons for qualifying new technology services are included. If operating cost exceeds $14,845.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,634.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $10,527.35 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,482.64 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $829.93. The transfer capital threshold is the transfer adjustment factor * $829.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","0.05","1 through 10","10668.88","56768.35","other","Inpatient DRG"
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/McC","096","MS-DRG","","","","","","","","inpatient","","","75814.50","45488.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","78060.21","","Fee schedule rate ($78,060.21). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","70782.36","70782.36","70782.36","1 through 10","3975","98009.86","case rate",""
"BALLOON HERCULES 12MM 5.5CM 240 .035IN GUIDEWIRE 3 STAGE ENDOSCOPIC GASTROINTESTINAL OBLONG FILL WATER","SUP-ITM-10073889","CDM","C1726","HCPCS","0272","RC","","","","both","","","1810.42","1086.25","AETNA [1001]","HB WDH AETNA COMMERCIAL","1263.67","69.8","","166.96","137.81","825.49","1 through 10","210.55","1538.86","percent of total billed charges",""
"BALLOON HERCULES 12MM 5.5CM 240 .035IN GUIDEWIRE 3 STAGE ENDOSCOPIC GASTROINTESTINAL OBLONG FILL WATER","SUP-ITM-10073889","CDM","C1726","HCPCS","0272","RC","","","","both","","","1810.42","1086.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1716.86","1716.86","1716.86","1 through 10","210.55","1538.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BALLOON HERCULES 12MM 5.5CM 240 .035IN GUIDEWIRE 3 STAGE ENDOSCOPIC GASTROINTESTINAL OBLONG FILL WATER","SUP-ITM-10073889","CDM","C1726","HCPCS","0272","RC","","","","both","","","1810.42","1086.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","4281.09","1182.65","4281.09","1 through 10","210.55","1538.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BALLOON HERCULES 12MM 5.5CM 240 .035IN GUIDEWIRE 3 STAGE ENDOSCOPIC GASTROINTESTINAL OBLONG FILL WATER","SUP-ITM-10073889","CDM","C1726","HCPCS","0272","RC","","","","both","","","1810.42","1086.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","210.55","11.63","","262.01","27.19","426.66","1 through 10","210.55","1538.86","percent of total billed charges",""
"BALLOON HERCULES 12MM 5.5CM 240 .035IN GUIDEWIRE 3 STAGE ENDOSCOPIC GASTROINTESTINAL OBLONG FILL WATER","SUP-ITM-10073889","CDM","C1726","HCPCS","0272","RC","","","","both","","","1810.42","1086.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1401.27","77.4","","1411.46","916.55","1411.46","1 through 10","210.55","1538.86","percent of total billed charges",""
"BALLOON HERCULES 12MM 5.5CM 240 .035IN GUIDEWIRE 3 STAGE ENDOSCOPIC GASTROINTESTINAL OBLONG FILL WATER","SUP-ITM-10073889","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1810.42","1086.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","210.55","11.63","","262.01","27.19","426.66","1 through 10","210.55","1401.27","percent of total billed charges",""
"BALLOON HERCULES 12MM 5.5CM 240 .035IN GUIDEWIRE 3 STAGE ENDOSCOPIC GASTROINTESTINAL OBLONG FILL WATER","SUP-ITM-10073889","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1810.42","1086.25","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","791.52","43.72","","517.05","517.05","517.05","1 through 10","210.55","1401.27","percent of total billed charges",""
"BALLOON HERCULES 12MM 5.5CM 240 .035IN GUIDEWIRE 3 STAGE ENDOSCOPIC GASTROINTESTINAL OBLONG FILL WATER","SUP-ITM-10073889","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1810.42","1086.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1316.54","72.72","","1556.61","860.02","1914.17","1 through 10","210.55","1401.27","percent of total billed charges",""
"BALLOON HERCULES 12MM 5.5CM 240 .035IN GUIDEWIRE 3 STAGE ENDOSCOPIC GASTROINTESTINAL OBLONG FILL WATER","SUP-ITM-10073889","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1810.42","1086.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1138.75","62.9","","1348.55","745.07","1348.55","19","210.55","1401.27","percent of total billed charges",""
"BALLOON HERCULES 12MM 5.5CM 240 .035IN GUIDEWIRE 3 STAGE ENDOSCOPIC GASTROINTESTINAL OBLONG FILL WATER","SUP-ITM-10073889","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1810.42","1086.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1401.27","77.4","","1411.46","916.55","1411.46","1 through 10","210.55","1401.27","percent of total billed charges",""
"BALLOON HERCULES 12MM 5.5CM 240 .035IN GUIDEWIRE 3 STAGE ENDOSCOPIC GASTROINTESTINAL OBLONG FILL WATER","SUP-ITM-10073889","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1810.42","1086.25","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","1316.54","72.72","","860.02","860.02","860.02","1 through 10","210.55","1401.27","percent of total billed charges",""
"Bartonella Antibody","PX-30000885","CDM","86611","CPT","0302","RC","","","","outpatient","","","71.00","42.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","44.66","62.9","","43.47","43.47","43.47","1 through 10","9.1","54.95","percent of total billed charges",""
"Bartonella Pcr,B","PX-30003035","CDM","87801","CPT","0306","RC","","","","both","","","808.00","484.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","563.98","69.8","","545.14","491.25","545.14","15","45.63","686.8","percent of total billed charges",""
"Bartonella Pcr,B","PX-30003035","CDM","87801","CPT","0306","RC","","","","both","","","808.00","484.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","686.80","85","","545.14","545.14","545.14","1 through 10","45.63","686.8","percent of total billed charges",""
"Bartonella Pcr,B","PX-30003035","CDM","87801","CPT","0306","RC","","","","outpatient","","","808.00","484.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","507.26","62.78","","1470.93","490.31","1470.93","1 through 10","31.21","625.39","percent of total billed charges",""
"Bartonella Pcr,B","PX-30003035","CDM","87801","CPT","0306","RC","","","","outpatient","","","808.00","484.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","353.26","43.72","","341.45","341.45","341.45","1 through 10","31.21","625.39","percent of total billed charges",""
"Bartonella Pcr,B","PX-30003035","CDM","87801","CPT","0306","RC","","","","outpatient","","","808.00","484.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","587.58","72.72","","567.94","567.94","567.94","40","31.21","625.39","percent of total billed charges",""
"Bartonella Pcr,B","PX-30003035","CDM","87801","CPT","0306","RC","","","","outpatient","","","808.00","484.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","587.58","72.72","","567.94","567.94","1135.88","1 through 10","31.21","625.39","percent of total billed charges",""
"Bartonella Pcr,B","PX-30003035","CDM","87801","CPT","0306","RC","","","","outpatient","","","808.00","484.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","430.02","53.22","","416.35","416.35","416.35","1 through 10","31.21","625.39","percent of total billed charges",""
"Bartonella Pcr,B","PX-30003035","CDM","87801","CPT","0306","RC","","","","outpatient","","","808.00","484.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","508.23","62.9","","492.03","492.03","1476.09","66","31.21","625.39","percent of total billed charges",""
"Bartonella Pcr,B","PX-30003035","CDM","87801","CPT","0306","RC","","","","outpatient","","","808.00","484.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","625.39","77.4","","605.28","605.28","605.28","14","31.21","625.39","percent of total billed charges",""
"Bartonella Pcr,B","PX-30003035","CDM","87801","CPT","0306","RC","","","","outpatient","","","808.00","484.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","587.58","72.72","","567.94","567.94","567.94","1 through 10","31.21","625.39","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","8730.00","5238.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1015.3","7420.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","8730.00","5238.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4967.37","56.9","","2911.53","1863.86","5209.05","65","1015.3","7420.5","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","8730.00","5238.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1015.30","11.63","","400.94","400.94","400.94","1 through 10","1015.3","7420.5","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","8730.00","5238.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6757.02","77.4","","5214.50","5214.50","16415.28","1 through 10","1015.3","7420.5","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8730.00","5238.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1015.30","11.63","","400.94","400.94","400.94","1 through 10","1015.3","6757.02","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8730.00","5238.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3816.76","43.72","","1543.33","1543.33","1671.61","1 through 10","1015.3","6757.02","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8730.00","5238.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6348.46","72.72","","3700.21","2382.07","6427.18","53","1015.3","6757.02","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8730.00","5238.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6348.46","72.72","","12685.80","12685.80","12685.80","1 through 10","1015.3","6757.02","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8730.00","5238.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5491.17","62.9","","3408.87","2784.05","9859.40","46","1015.3","6757.02","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8730.00","5238.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6757.02","77.4","","5214.50","5214.50","16415.28","1 through 10","1015.3","6757.02","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","both","","","6697.85","4018.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","778.96","5693.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","both","","","6697.85","4018.71","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3811.08","56.9","","2911.53","1863.86","5209.05","65","778.96","5693.17","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","both","","","6697.85","4018.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","778.96","11.63","","400.94","400.94","400.94","1 through 10","778.96","5693.17","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","both","","","6697.85","4018.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5184.14","77.4","","5214.50","5214.50","16415.28","1 through 10","778.96","5693.17","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6697.85","4018.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","778.96","11.63","","400.94","400.94","400.94","1 through 10","778.96","5184.14","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6697.85","4018.71","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2928.30","43.72","","1543.33","1543.33","1671.61","1 through 10","778.96","5184.14","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6697.85","4018.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4870.68","72.72","","3700.21","2382.07","6427.18","53","778.96","5184.14","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6697.85","4018.71","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4870.68","72.72","","12685.80","12685.80","12685.80","1 through 10","778.96","5184.14","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6697.85","4018.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4212.95","62.9","","3408.87","2784.05","9859.40","46","778.96","5184.14","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6697.85","4018.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5184.14","77.4","","5214.50","5214.50","16415.28","1 through 10","778.96","5184.14","percent of total billed charges",""
"BASEPLATE SHOULDER 36MMX29MM AEQUALIS REVERSED CENTERED","SUP-ITM-10286750","CDM","C1776","HCPCS","0278","RC","","","","both","","","13784.48","8270.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1603.14","11716.81","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BASEPLATE SHOULDER 36MMX29MM AEQUALIS REVERSED CENTERED","SUP-ITM-10286750","CDM","C1776","HCPCS","0278","RC","","","","both","","","13784.48","8270.69","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7843.37","56.9","","2911.53","1863.86","5209.05","65","1603.14","11716.81","percent of total billed charges",""
"BASEPLATE SHOULDER 36MMX29MM AEQUALIS REVERSED CENTERED","SUP-ITM-10286750","CDM","C1776","HCPCS","0278","RC","","","","both","","","13784.48","8270.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1603.14","11.63","","400.94","400.94","400.94","1 through 10","1603.14","11716.81","percent of total billed charges",""
"BASEPLATE SHOULDER 36MMX29MM AEQUALIS REVERSED CENTERED","SUP-ITM-10286750","CDM","C1776","HCPCS","0278","RC","","","","both","","","13784.48","8270.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10669.19","77.4","","5214.50","5214.50","16415.28","1 through 10","1603.14","11716.81","percent of total billed charges",""
"BASEPLATE SHOULDER 36MMX29MM AEQUALIS REVERSED CENTERED","SUP-ITM-10286750","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13784.48","8270.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1603.14","11.63","","400.94","400.94","400.94","1 through 10","1603.14","10669.19","percent of total billed charges",""
"BASEPLATE SHOULDER 36MMX29MM AEQUALIS REVERSED CENTERED","SUP-ITM-10286750","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13784.48","8270.69","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","6026.57","43.72","","1543.33","1543.33","1671.61","1 through 10","1603.14","10669.19","percent of total billed charges",""
"BASEPLATE SHOULDER 36MMX29MM AEQUALIS REVERSED CENTERED","SUP-ITM-10286750","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13784.48","8270.69","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10024.07","72.72","","3700.21","2382.07","6427.18","53","1603.14","10669.19","percent of total billed charges",""
"BASEPLATE SHOULDER 36MMX29MM AEQUALIS REVERSED CENTERED","SUP-ITM-10286750","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13784.48","8270.69","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","10024.07","72.72","","12685.80","12685.80","12685.80","1 through 10","1603.14","10669.19","percent of total billed charges",""
"BASEPLATE SHOULDER 36MMX29MM AEQUALIS REVERSED CENTERED","SUP-ITM-10286750","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13784.48","8270.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8670.44","62.9","","3408.87","2784.05","9859.40","46","1603.14","10669.19","percent of total billed charges",""
"BASEPLATE SHOULDER 36MMX29MM AEQUALIS REVERSED CENTERED","SUP-ITM-10286750","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13784.48","8270.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10669.19","77.4","","5214.50","5214.50","16415.28","1 through 10","1603.14","10669.19","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0300","RC","","","","inpatient","","","120.00","72.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","92.23","76.86","","73.08","73.08","140.00","15","79.44","92.23","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","120.00","72.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","83.76","69.8","","80.97","72.96","80.97","412","5.5","102","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","120.00","72.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","83.76","69.8","","80.97","77.95","80.97","1 through 10","5.5","102","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","120.00","72.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","102.00","85","","20.57","11.84","98.60","1 through 10","5.5","102","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","120.00","72.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","75.34","62.78","","72.82","72.82","218.46","25","7.88","92.88","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","120.00","72.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","52.46","43.72","","50.72","50.72","152.16","44","7.88","92.88","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","120.00","72.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","87.26","72.72","","84.36","84.36","84.36","723","7.88","92.88","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","120.00","72.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","87.26","72.72","","84.36","84.36","253.08","21","7.88","92.88","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","120.00","72.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","63.86","53.22","","61.84","61.84","123.68","39","7.88","92.88","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","120.00","72.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","75.48","62.9","","73.08","73.08","270.92","902","7.88","92.88","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","120.00","72.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","92.88","77.4","","89.90","89.90","179.80","267","7.88","92.88","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","120.00","72.00","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","87.26","72.72","","168.72","84.36","337.44","11","7.88","92.88","percent of total billed charges",""
"Basic Metabolic Panel Calcium Ioniz","PX-30000006","CDM","80047","CPT","0301","RC","","","","both","","","157.00","94.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","109.59","69.8","","106.10","106.10","106.10","29","13.73","133.45","percent of total billed charges",""
"Basic Metabolic Panel Calcium Ioniz","PX-30000006","CDM","80047","CPT","0301","RC","","","","both","","","157.00","94.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","109.59","69.8","","129.20","129.20","129.20","1 through 10","13.73","133.45","percent of total billed charges",""
"Basic Metabolic Panel Calcium Ioniz","PX-30000006","CDM","80047","CPT","0301","RC","","","","outpatient","","","157.00","94.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","98.56","62.78","","95.43","95.43","286.29","1 through 10","7.88","121.52","percent of total billed charges",""
"Basic Metabolic Panel Calcium Ioniz","PX-30000006","CDM","80047","CPT","0301","RC","","","","outpatient","","","157.00","94.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","114.17","72.72","","110.53","110.53","110.53","44","7.88","121.52","percent of total billed charges",""
"Basic Metabolic Panel Calcium Ioniz","PX-30000006","CDM","80047","CPT","0301","RC","","","","outpatient","","","157.00","94.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","114.17","72.72","","110.53","110.53","110.53","1 through 10","7.88","121.52","percent of total billed charges",""
"Basic Metabolic Panel Calcium Ioniz","PX-30000006","CDM","80047","CPT","0301","RC","","","","outpatient","","","157.00","94.20","INTERNATIONAL COMMERCIAL [140001]","HB WDH UNITED HMO / PPO / INDEM","121.52","77.4","","117.80","117.80","117.80","1 through 10","7.88","121.52","percent of total billed charges",""
"Basic Metabolic Panel Calcium Ioniz","PX-30000006","CDM","80047","CPT","0301","RC","","","","outpatient","","","157.00","94.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","83.56","53.22","","243.09","243.09","243.09","1 through 10","7.88","121.52","percent of total billed charges",""
"Basic Metabolic Panel Calcium Ioniz","PX-30000006","CDM","80047","CPT","0301","RC","","","","outpatient","","","157.00","94.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","98.75","62.9","","95.76","95.76","287.28","47","7.88","121.52","percent of total billed charges",""
"Basic Metabolic Panel Calcium Ioniz","PX-30000006","CDM","80047","CPT","0301","RC","","","","outpatient","","","157.00","94.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","121.52","77.4","","117.80","117.80","117.80","29","7.88","121.52","percent of total billed charges",""
"Basivertebral Nerve Destruction Lumbar Two Bodies","PX-76002685","CDM","64628","CPT","0761","RC","","","","outpatient","","","75695.00","45417.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","8803.33","11.63","","2703.73","2703.73","2703.73","1 through 10","8803.33","55045.4","percent of total billed charges",""
"Behavral Qualit Analys Voice","PX-44000061","CDM","92524","CPT","0444","RC","","","","both","","","649.00","389.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","453.00","69.8","","436.95","393.75","436.95","1 through 10","107.61","551.65","percent of total billed charges",""
"Behavral Qualit Analys Voice","PX-44000061","CDM","92524","CPT","0444","RC","","","","both","","","649.00","389.40","TRICARE [160005]","HB WDH MEDICARE","107.61","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($107.61). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($85.36). Each line will be capped at the line billed amount.","108.04","108.04","108.04","1 through 10","107.61","551.65","fee schedule",""
"Behavral Qualit Analys Voice","PX-44000061","CDM","92524","CPT","0444","RC","","","","both","","","649.00","389.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","107.61","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($107.61). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($85.36). Each line will be capped at the line billed amount.","108.54","105.46","108.54","1 through 10","107.61","551.65","fee schedule",""
"Behavral Qualit Analys Voice","PX-44000061","CDM","92524","CPT","0444","RC","","","","outpatient","","","649.00","389.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","408.22","62.9","","394.38","394.38","394.38","1 through 10","75.48","502.33","percent of total billed charges",""
"Behavral Qualit Analys Voice","PX-44000061","CDM","92524","CPT","0444","RC","","","","outpatient","","","649.00","389.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","75.48","11.63","","73.94","73.94","73.94","1 through 10","75.48","502.33","percent of total billed charges",""
"Benign Prostatic Hypertrophy With McC","725","MS-DRG","","","","","","","","inpatient","","","22726.50","13635.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","17509.56","","Fee schedule rate ($17,509.56). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","15783.12","15783.12","15783.12","1 through 10","3975","44467.72","case rate",""
"Benign Prostatic Hypertrophy With McC","725","MS-DRG","","","","","","","","inpatient","","","22726.50","13635.90","MEDICARE [2001]","HB WDH MEDICARE","9341.25","","Case rate ($9,341.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,656.13, add-ons for qualifying new technology services are included. If operating cost exceeds $12,574.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,455.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,246.27 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,211.25 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $650.10. The transfer capital threshold is the transfer adjustment factor * $650.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9971.81","9971.81","9971.81","1 through 10","3975","44467.72","other","Inpatient DRG"
"Benign Prostatic Hypertrophy Without McC","726","MS-DRG","","","","","","","","inpatient","","","16339.48","9803.69","WELLSENSE NH [1050]","HB WDH MEDICARE","5933.81","","Case rate ($5,933.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,511.11, add-ons for qualifying new technology services are included. If operating cost exceeds $9,429.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,206.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $5,087.86 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,066.25 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $401.10. The transfer capital threshold is the transfer adjustment factor * $401.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6286.55","6286.55","6286.55","1 through 10","3975","27436.07","other","Inpatient DRG"
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","both","","","136.00","81.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","94.93","69.8","","92.14","83.03","276.41","1 through 10","16.54","130.94","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","outpatient","","","136.00","81.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","59.46","43.72","","173.13","173.13","173.13","1 through 10","12.81","105.26","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","outpatient","","","136.00","81.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","98.90","72.72","","95.99","95.99","95.99","22","12.81","105.26","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","outpatient","","","136.00","81.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","98.90","72.72","","95.99","95.99","95.99","1 through 10","12.81","105.26","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","outpatient","","","136.00","81.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","85.54","62.9","","83.16","83.16","83.16","32","12.81","105.26","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","outpatient","","","136.00","81.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","105.26","77.4","","102.30","102.30","306.90","1 through 10","12.81","105.26","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","outpatient","","","136.00","81.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","98.90","72.72","","95.99","95.99","95.99","1 through 10","12.81","105.26","percent of total billed charges",""
"Beta-2 Microglobulin","PX-30000321","CDM","82232","CPT","0301","RC","","","","both","","","86.00","51.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","60.03","69.8","","57.93","57.93","57.93","1 through 10","10.52","82.77","percent of total billed charges",""
"Beta-2 Microglobulin","PX-30000321","CDM","82232","CPT","0301","RC","","","","outpatient","","","86.00","51.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","62.54","72.72","","60.36","60.36","120.72","1 through 10","15.07","66.56","percent of total billed charges",""
"Beta-2 Microglobulin","PX-30000321","CDM","82232","CPT","0301","RC","","","","outpatient","","","86.00","51.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","54.09","62.9","","156.87","52.29","156.87","1 through 10","15.07","66.56","percent of total billed charges",""
"Beta-2 Microglobulin","PX-30000321","CDM","82232","CPT","0301","RC","","","","outpatient","","","86.00","51.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","66.56","77.4","","64.33","64.32","64.33","15","15.07","66.56","percent of total billed charges",""
"Beta-Amyloid 1-40 (Abeta 40)","PX-30003837","CDM","82233","CPT","0301","RC","","","","outpatient","","","1106.00","663.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","128.63","11.63","","267.50","267.50","267.50","1 through 10","128.63","856.04","percent of total billed charges",""
"Beta-Amyloid 1-42 (Abeta 42)","PX-30003838","CDM","82234","CPT","0301","RC","","","","outpatient","","","1106.00","663.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","128.63","11.63","","267.50","267.50","267.50","1 through 10","128.63","856.04","percent of total billed charges",""
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without McC","462","MS-DRG","","","","","","","","inpatient","","","97639.50","58583.70","MEDICARE [2001]","HB WDH MEDICARE","20667.34","","Case rate ($20,667.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $19,109.99, add-ons for qualifying new technology services are included. If operating cost exceeds $23,028.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,282.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $18,744.73 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $18,665.12 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,477.75. The transfer capital threshold is the transfer adjustment factor * $1,477.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","22110.06","22110.06","22110.06","1 through 10","18996.74","101080.27","other","Inpatient DRG"
"Bile Acids","PX-30000322","CDM","82239","CPT","0301","RC","","","","both","","","94.00","56.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","65.61","69.8","","63.52","63.52","63.52","1 through 10","11.13","88.81","percent of total billed charges",""
"Bile Acids","PX-30000322","CDM","82239","CPT","0301","RC","","","","outpatient","","","94.00","56.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","68.36","72.72","","66.18","66.18","66.18","1 through 10","15.96","72.76","percent of total billed charges",""
"Bile Acids","PX-30000322","CDM","82239","CPT","0301","RC","","","","outpatient","","","94.00","56.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","59.13","62.9","","57.33","57.33","57.33","1 through 10","15.96","72.76","percent of total billed charges",""
"Bile Acids","PX-30000322","CDM","82239","CPT","0301","RC","","","","outpatient","","","94.00","56.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","72.76","77.4","","70.53","66.18","70.53","1 through 10","15.96","72.76","percent of total billed charges",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/McC","410","MS-DRG","","","","","","","","inpatient","","","52591.81","31555.09","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","12515.26","","Case rate ($12,515.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,585.70, add-ons for qualifying new technology services are included. If operating cost exceeds $15,503.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,687.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $11,188.35 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,140.83 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $882.04. The transfer capital threshold is the transfer adjustment factor * $882.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11943.51","11943.51","11943.51","1 through 10","3975","60332.76","other","Inpatient DRG"
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","72.00","43.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","50.26","69.8","","48.16","43.40","48.16","39","3.26","61.2","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","72.00","43.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","61.20","85","","412.00","412.00","412.00","1 through 10","3.26","61.2","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","outpatient","","","72.00","43.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","45.20","62.78","","43.32","43.32","43.32","1 through 10","4.51","55.73","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","outpatient","","","72.00","43.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","52.36","72.72","","50.18","50.18","100.36","48","4.51","55.73","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","outpatient","","","72.00","43.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","52.36","72.72","","50.18","50.18","50.18","1 through 10","4.51","55.73","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","outpatient","","","72.00","43.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","38.32","53.22","","36.78","36.78","36.78","1 through 10","4.51","55.73","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","outpatient","","","72.00","43.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","45.29","62.9","","43.47","43.47","43.47","46","4.51","55.73","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","outpatient","","","72.00","43.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","55.73","77.4","","53.48","53.48","53.48","48","4.51","55.73","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","both","","","71.00","42.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","49.56","69.8","","43.40","43.40","48.16","12","3.26","60.35","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","outpatient","","","71.00","42.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","51.63","72.72","","50.18","50.18","100.36","23","4.51","54.95","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","outpatient","","","71.00","42.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","44.66","62.9","","43.47","43.47","43.47","1 through 10","4.51","54.95","percent of total billed charges",""
"Bilirubin Total","PX-30000324","CDM","82247","CPT","0301","RC","","","","outpatient","","","71.00","42.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","54.95","77.4","","53.48","53.48","53.48","1 through 10","4.51","54.95","percent of total billed charges",""
"Biopsies Of Musculoskeletal System And Connective Tissue With McC","477","MS-DRG","","","","","","","","inpatient","","","99695.13","59817.08","MEDICARE [2001]","HB WDH MEDICARE","26708.25","","Case rate ($26,708.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $24,685.68, add-ons for qualifying new technology services are included. If operating cost exceeds $28,603.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,724.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $24,344.19 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $24,240.80 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,919.18. The transfer capital threshold is the transfer adjustment factor * $1,919.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26461.58","26461.58","26461.58","1 through 10","3975","131275.15","other","Inpatient DRG"
"Biopsies Of Musculoskeletal System And Connective Tissue With McC","477","MS-DRG","","","","","","","","inpatient","","","99695.13","59817.08","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","26708.25","","Case rate ($26,708.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $24,685.68, add-ons for qualifying new technology services are included. If operating cost exceeds $28,603.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,724.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 8.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $24,344.19 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $24,240.80 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,919.18. The transfer capital threshold is the transfer adjustment factor * $1,919.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1245.72","1245.72","25969.95","1 through 10","3975","131275.15","other","Inpatient DRG"
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","both","","","4194.00","2516.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1658.91","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2878.03","2878.03","2878.03","1 through 10","1658.91","10818.29","other","OPPS APC"
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","both","","","4194.00","2516.40","MEDICARE [2001]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1692.96","1579.69","1692.96","1 through 10","1658.91","10818.29","other","OPPS APC"
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","both","","","4194.00","2516.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2938.59","2938.59","2938.59","1 through 10","1658.91","10818.29","other","OPPS APC"
"Biopsy Bone Trocar/Needle Deep","PX-76000277","CDM","20225","CPT","0761","RC","","","","outpatient","","","4194.00","2516.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2638.03","62.9","","2549.61","2549.61","2549.61","1 through 10","487.76","3246.16","percent of total billed charges",""
"Biopsy Bone Trocar/Needle Superfic","PX-76000276","CDM","20220","CPT","0761","RC","","","","both","","","2838.00","1702.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","8744.32","","Case rate ($8,744.32). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4544.78","4544.78","4544.78","1 through 10","1614.82","10818.29","other","OPPS APC"
"Biopsy Bone Trocar/Needle Superfic","PX-76000276","CDM","20220","CPT","0761","RC","","","","both","","","2838.00","1702.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1692.96","1692.96","1692.96","1 through 10","1614.82","10818.29","other","OPPS APC"
"Biopsy Bone Trocar/Needle Superfic","PX-76000276","CDM","20220","CPT","0761","RC","","","","both","","","2838.00","1702.80","MEDICARE [2001]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1692.96","1692.96","1692.96","1 through 10","1614.82","10818.29","other","OPPS APC"
"Biopsy Bone Trocar/Needle Superfic","PX-76000276","CDM","20220","CPT","0761","RC","","","","both","","","2838.00","1702.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1659.11","1548.10","1659.11","1 through 10","1614.82","10818.29","other","OPPS APC"
"Biopsy Bone Trocar/Needle Superfic","PX-76000276","CDM","20220","CPT","0761","RC","","","","outpatient","","","2838.00","1702.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","409.24","14.42","","394.96","394.96","394.96","1 through 10","330.06","2196.61","percent of total billed charges",""
"Biopsy Bone Trocar/Needle Superfic","PX-76000276","CDM","20220","CPT","0761","RC","","","","outpatient","","","2838.00","1702.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2196.61","77.4","","2122.73","2122.73","2122.73","1 through 10","330.06","2196.61","percent of total billed charges",""
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","605.00","363.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","422.29","69.8","","407.63","407.63","407.63","1 through 10","205.97","1343.24","percent of total billed charges",""
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","605.00","363.00","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","214.38","","APC Price ($210.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","210.20","185.66","210.20","1 through 10","205.97","1343.24","other","OPPS APC"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","605.00","363.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","578.40","","Case rate ($578.40). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","564.30","564.30","564.30","1 through 10","205.97","1343.24","other","OPPS APC"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","605.00","363.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","205.97","","APC Price ($210.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","190.27","190.27","190.27","1 through 10","205.97","1343.24","other","OPPS APC"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","605.00","363.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","216.48","","APC Price ($210.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","216.51","216.51","216.51","1 through 10","205.97","1343.24","other","OPPS APC"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","605.00","363.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","210.17","","APC Price ($210.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","210.20","210.20","210.20","1 through 10","205.97","1343.24","other","OPPS APC"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","605.00","363.00","MEDICARE [2001]","HB WDH MEDICARE","210.17","","APC Price ($210.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","210.20","210.20","210.20","1 through 10","205.97","1343.24","other","OPPS APC"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","both","","","605.00","363.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","210.17","","APC Price ($210.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","210.20","194.15","210.20","1 through 10","205.97","1343.24","other","OPPS APC"
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","605.00","363.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","380.55","62.9","","4760.28","4760.28","4760.28","1 through 10","70.36","468.27","percent of total billed charges",""
"Biopsy Gland Salivary Needle","PX-75000057","CDM","42400","CPT","0761","RC","","","","both","","","3760.00","2256.00","MEDICARE [2001]","HB WDH MEDICARE","735.08","","APC Price ($735.08). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","735.17","735.17","735.17","1 through 10","720.38","4697.85","other","OPPS APC"
"Biopsy Lesion Vulva/ Perineum Add","PX-76001336","CDM","56606","CPT","0761","RC","","","","both","","","490.00","294.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","473.00","473.00","473.00","1 through 10","278.81","416.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","both","","","2051.00","1230.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","1431.60","69.8","","1381.34","1381.34","1381.34","1 through 10","891.52","5813.95","percent of total billed charges",""
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","both","","","2051.00","1230.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","891.52","","APC Price ($909.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","892.62","892.52","892.62","1 through 10","891.52","5813.95","other","OPPS APC"
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","both","","","2051.00","1230.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","4699.36","","Case rate ($4,699.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2452.00","2452.00","2452.00","1 through 10","891.52","5813.95","other","OPPS APC"
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","both","","","2051.00","1230.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1167.02","56.9","","1126.05","1126.05","1126.05","1 through 10","891.52","5813.95","percent of total billed charges",""
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","both","","","2051.00","1230.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","909.71","","APC Price ($909.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","909.82","909.82","909.82","1 through 10","891.52","5813.95","other","OPPS APC"
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","both","","","2051.00","1230.60","MEDICARE [2001]","HB WDH MEDICARE","909.71","","APC Price ($909.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","909.82","909.82","909.82","1 through 10","891.52","5813.95","other","OPPS APC"
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","both","","","2051.00","1230.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","909.71","","APC Price ($909.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","899.53","895.27","899.53","1 through 10","891.52","5813.95","other","OPPS APC"
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","outpatient","","","2051.00","1230.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1290.08","62.9","","3740.31","1246.77","3740.31","1 through 10","238.53","1587.47","percent of total billed charges",""
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","4881.00","2928.60","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","1726.62","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","1692.96","1692.96","1692.96","1 through 10","1658.91","10818.29","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","4881.00","2928.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","10818.29","","Case rate ($10,818.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5187.21","5187.21","5187.21","1 through 10","1658.91","10818.29","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","4881.00","2928.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","4658.35","","Case rate ($4,658.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4544.78","4544.78","4544.78","1 through 10","1658.91","10818.29","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","4881.00","2928.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1658.91","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1692.96","1557.57","2878.03","1 through 10","1658.91","10818.29","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","4881.00","2928.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","8744.32","","Case rate ($8,744.32). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5572.03","5572.03","5572.03","1 through 10","1658.91","10818.29","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","4881.00","2928.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2777.29","56.9","","2679.99","2679.99","2679.99","1 through 10","1658.91","10818.29","percent of total billed charges",""
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","4881.00","2928.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","1743.54","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1727.29","1711.37","1727.29","1 through 10","1658.91","10818.29","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","4881.00","2928.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1692.96","1664.60","1692.96","1 through 10","1658.91","10818.29","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","4881.00","2928.60","MEDICARE [2001]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1692.96","1692.96","5078.88","30","1658.91","10818.29","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","4881.00","2928.60","TRICARE [160005]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1692.96","1692.96","1692.96","1 through 10","1658.91","10818.29","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","4881.00","2928.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1667.11","1659.11","1692.96","1 through 10","1658.91","10818.29","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","outpatient","","","4881.00","2928.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","703.84","14.42","","679.18","582.16","679.18","1 through 10","567.66","3777.89","percent of total billed charges",""
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","outpatient","","","4881.00","2928.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","567.66","11.63","","1189.53","648.57","1189.53","1 through 10","567.66","3777.89","percent of total billed charges",""
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","outpatient","","","4881.00","2928.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3425.11","3425.11","3425.11","1 through 10","567.66","3777.89","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","outpatient","","","4881.00","2928.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3070.15","62.9","","2967.30","2967.30","2967.30","1 through 10","567.66","3777.89","percent of total billed charges",""
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","outpatient","","","4881.00","2928.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","567.66","11.63","","12067.52","556.33","12067.52","1 through 10","567.66","3777.89","percent of total billed charges",""
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","1104.00","662.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","770.59","69.8","","743.37","743.37","743.37","1 through 10","628.18","10818.29","percent of total billed charges",""
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","1104.00","662.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","10818.29","","Case rate ($10,818.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1897.66","1897.66","1897.66","1 through 10","628.18","10818.29","other","OPPS APC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","1104.00","662.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","4658.35","","Case rate ($4,658.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2748.97","2743.74","4544.78","1 through 10","628.18","10818.29","other","OPPS APC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","1104.00","662.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1666.60","1666.60","1666.60","1 through 10","628.18","10818.29","other","OPPS APC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","1104.00","662.40","MEDICARE [2001]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1692.96","1692.96","1692.96","11","628.18","10818.29","other","OPPS APC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","1104.00","662.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1663.37","1663.37","1692.96","1 through 10","628.18","10818.29","other","OPPS APC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","1104.00","662.40","WELLSENSE NH [1050]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1749.26","1749.26","1749.26","1 through 10","628.18","10818.29","other","OPPS APC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","outpatient","","","1104.00","662.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","128.40","11.63","","130.36","130.36","130.36","1 through 10","128.4","854.5","percent of total billed charges",""
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","outpatient","","","1104.00","662.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","774.47","774.47","774.47","1 through 10","128.4","854.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Biopsy Mucosa Vaginal Extensive","PX-76001347","CDM","57105","CPT","0761","RC","","","","outpatient","","","1137.00","682.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","797.74","797.74","797.74","1 through 10","132.23","880.04","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Biopsy Mucosa Vaginal Smp","PX-76001346","CDM","57100","CPT","0761","RC","","","","both","","","575.00","345.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","327.18","56.9","","315.80","315.79","315.80","1 through 10","327.18","5813.95","percent of total billed charges",""
"Biopsy Mucosa Vaginal Smp","PX-76001346","CDM","57100","CPT","0761","RC","","","","both","","","575.00","345.00","MEDICARE [2001]","HB WDH MEDICARE","909.71","","APC Price ($909.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2274.55","909.82","2274.55","1 through 10","327.18","5813.95","other","OPPS APC"
"Biopsy Mucosa Vaginal Smp","PX-76001346","CDM","57100","CPT","0761","RC","","","","both","","","575.00","345.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","909.71","","APC Price ($909.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","445.82","445.82","445.82","1 through 10","327.18","5813.95","other","OPPS APC"
"Biopsy Mucosa Vaginal Smp","PX-76001346","CDM","57100","CPT","0761","RC","","","","both","","","575.00","345.00","WELLSENSE NH [1050]","HB WDH MEDICARE","909.71","","APC Price ($909.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","943.50","943.50","943.50","1 through 10","327.18","5813.95","other","OPPS APC"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2331.00","1398.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","1627.04","69.8","","1569.80","1569.80","1569.80","1 through 10","1326.34","10818.29","percent of total billed charges",""
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2331.00","1398.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","10818.29","","Case rate ($10,818.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2718.00","2718.00","2718.00","1 through 10","1326.34","10818.29","other","OPPS APC"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2331.00","1398.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1658.91","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1659.10","1659.10","1659.10","1 through 10","1326.34","10818.29","other","OPPS APC"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2331.00","1398.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1326.34","56.9","","1279.68","1279.68","1279.68","1 through 10","1326.34","10818.29","percent of total billed charges",""
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2331.00","1398.60","MEDICARE [2001]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1692.96","1692.96","1692.96","1 through 10","1326.34","10818.29","other","OPPS APC"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2331.00","1398.60","TRICARE [160005]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3385.92","3385.92","3385.92","1 through 10","1326.34","10818.29","other","OPPS APC"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2331.00","1398.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1692.96","1665.88","1692.96","1 through 10","1326.34","10818.29","other","OPPS APC"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","outpatient","","","2331.00","1398.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","336.13","14.42","","324.31","324.31","324.31","1 through 10","271.1","1804.19","percent of total billed charges",""
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","outpatient","","","2331.00","1398.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","271.10","11.63","","309.69","309.69","309.69","1 through 10","271.1","1804.19","percent of total billed charges",""
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","outpatient","","","2331.00","1398.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","271.10","11.63","","265.64","265.64","265.64","1 through 10","271.1","1804.19","percent of total billed charges",""
"Biopsy Renal Needle Perc","PX-76001222","CDM","50200","CPT","0761","RC","","","","both","","","5048.00","3028.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1679.82","1659.11","1679.82","1 through 10","1658.91","10818.29","other","OPPS APC"
"Biopsy Thyroid Needle Perc","PX-76001412","CDM","60100","CPT","0761","RC","","","","outpatient","","","4224.00","2534.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2656.90","62.9","","2567.88","2567.88","2567.88","1 through 10","491.25","3269.38","percent of total billed charges",""
"Biopsy/Exc Cervix Local","PX-76001368","CDM","57500","CPT","0761","RC","","","","both","","","644.00","386.40","MEDICARE [2001]","HB WDH MEDICARE","909.71","","APC Price ($909.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","909.82","909.82","909.82","1 through 10","366.44","5813.95","other","OPPS APC"
"Biopsy/Exc Node Lymph Ndle Super","PX-76001206","CDM","38505","CPT","0761","RC","","","","both","","","3560.00","2136.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","2484.88","69.8","","2397.63","973.36","2397.63","1 through 10","1658.91","10818.29","percent of total billed charges",""
"Biopsy/Exc Node Lymph Ndle Super","PX-76001206","CDM","38505","CPT","0761","RC","","","","both","","","3560.00","2136.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","3026.00","85","","4361.36","4361.36","4361.36","1 through 10","1658.91","10818.29","percent of total billed charges",""
"Biopsy/Exc Node Lymph Ndle Super","PX-76001206","CDM","38505","CPT","0761","RC","","","","both","","","3560.00","2136.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1667.01","1554.42","1667.01","1 through 10","1658.91","10818.29","other","OPPS APC"
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","outpatient","","","230.00","138.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","100.56","43.72","","97.06","97.06","97.06","1 through 10","51.91","178.02","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","outpatient","","","230.00","138.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","167.26","72.72","","161.44","161.44","484.32","15","51.91","178.02","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","outpatient","","","230.00","138.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","122.41","53.22","","118.35","118.35","118.35","1 through 10","51.91","178.02","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","outpatient","","","230.00","138.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","144.67","62.9","","139.86","139.86","419.58","44","51.91","178.02","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","outpatient","","","230.00","138.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","178.02","77.4","","172.05","172.05","172.05","1 through 10","51.91","178.02","percent of total billed charges",""
"Bk Virus, Molecular Detection, Pcr, Plasma","PX-31001117","CDM","87798","CPT","0306","RC","","","","both","","","188.00","112.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","131.22","69.8","","127.04","114.48","508.14","20","22.81","180.59","percent of total billed charges",""
"Bk Virus, Molecular Detection, Pcr, Plasma","PX-31001117","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","118.03","62.78","","114.26","114.26","114.26","1 through 10","24.28","145.51","percent of total billed charges",""
"Bk Virus, Molecular Detection, Pcr, Plasma","PX-31001117","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","82.19","43.72","","79.57","79.57","79.57","1 through 10","24.28","145.51","percent of total billed charges",""
"Bk Virus, Molecular Detection, Pcr, Plasma","PX-31001117","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","529.40","79","24.28","145.51","percent of total billed charges",""
"Bk Virus, Molecular Detection, Pcr, Plasma","PX-31001117","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Bk Virus, Molecular Detection, Pcr, Plasma","PX-31001117","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","118.25","62.9","","114.66","114.66","114.66","231","24.28","145.51","percent of total billed charges",""
"Bk Virus, Molecular Detection, Pcr, Plasma","PX-31001117","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","145.51","77.4","","141.05","141.05","564.20","57","24.28","145.51","percent of total billed charges",""
"Bk Virus, Molecular Detection, Pcr, Plasma","PX-31001117","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"BLADE BONE 10.35X130MM HELICAL TFN ADVANCED","SUP-ITM-10164400","CDM","C1713","HCPCS","0278","RC","","","","both","","","3193.32","1915.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","371.38","2714.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BLADE BONE 10.35X130MM HELICAL TFN ADVANCED","SUP-ITM-10164400","CDM","C1713","HCPCS","0278","RC","","","","both","","","3193.32","1915.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","371.38","2714.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BLADE BONE 10.35X130MM HELICAL TFN ADVANCED","SUP-ITM-10164400","CDM","C1713","HCPCS","0278","RC","","","","both","","","3193.32","1915.99","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1817.00","56.9","","812.12","238.65","1587.46","163","371.38","2714.32","percent of total billed charges",""
"BLADE BONE 10.35X130MM HELICAL TFN ADVANCED","SUP-ITM-10164400","CDM","C1713","HCPCS","0278","RC","","","","both","","","3193.32","1915.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","371.38","11.63","","112.68","112.68","146.99","38","371.38","2714.32","percent of total billed charges",""
"BLADE BONE 10.35X130MM HELICAL TFN ADVANCED","SUP-ITM-10164400","CDM","C1713","HCPCS","0278","RC","","","","both","","","3193.32","1915.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2471.63","77.4","","303.98","303.98","5854.79","1 through 10","371.38","2714.32","percent of total billed charges",""
"BLADE BONE 10.35X130MM HELICAL TFN ADVANCED","SUP-ITM-10164400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3193.32","1915.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","371.38","11.63","","112.68","112.68","146.99","38","371.38","2471.63","percent of total billed charges",""
"BLADE BONE 10.35X130MM HELICAL TFN ADVANCED","SUP-ITM-10164400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3193.32","1915.99","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2004.77","62.78","","780.86","208.94","10480.28","15","371.38","2471.63","percent of total billed charges",""
"BLADE BONE 10.35X130MM HELICAL TFN ADVANCED","SUP-ITM-10164400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3193.32","1915.99","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1396.12","43.72","","179.76","179.76","179.76","1 through 10","371.38","2471.63","percent of total billed charges",""
"BLADE BONE 10.35X130MM HELICAL TFN ADVANCED","SUP-ITM-10164400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3193.32","1915.99","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2322.18","72.72","","2355.45","298.99","3965.19","155","371.38","2471.63","percent of total billed charges",""
"BLADE BONE 10.35X130MM HELICAL TFN ADVANCED","SUP-ITM-10164400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3193.32","1915.99","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2322.18","72.72","","3643.09","3643.09","3643.09","1 through 10","371.38","2471.63","percent of total billed charges",""
"BLADE BONE 10.35X130MM HELICAL TFN ADVANCED","SUP-ITM-10164400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3193.32","1915.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1699.48","53.22","","554.28","554.28","554.28","16","371.38","2471.63","percent of total billed charges",""
"BLADE BONE 10.35X130MM HELICAL TFN ADVANCED","SUP-ITM-10164400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3193.32","1915.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2008.60","62.9","","619.64","173.09","2370.64","150","371.38","2471.63","percent of total billed charges",""
"BLADE BONE 10.35X130MM HELICAL TFN ADVANCED","SUP-ITM-10164400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3193.32","1915.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2471.63","77.4","","303.98","303.98","5854.79","1 through 10","371.38","2471.63","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3512.91","2107.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","408.55","2985.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3512.91","2107.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","408.55","2985.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3512.91","2107.75","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1998.85","56.9","","812.12","238.65","1587.46","163","408.55","2985.97","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3512.91","2107.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","408.55","11.63","","112.68","112.68","146.99","38","408.55","2985.97","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3512.91","2107.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2718.99","77.4","","303.98","303.98","5854.79","1 through 10","408.55","2985.97","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3512.91","2107.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","408.55","11.63","","112.68","112.68","146.99","38","408.55","2718.99","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3512.91","2107.75","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2205.40","62.78","","780.86","208.94","10480.28","15","408.55","2718.99","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3512.91","2107.75","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1535.84","43.72","","179.76","179.76","179.76","1 through 10","408.55","2718.99","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3512.91","2107.75","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2554.59","72.72","","2355.45","298.99","3965.19","155","408.55","2718.99","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3512.91","2107.75","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2554.59","72.72","","3643.09","3643.09","3643.09","1 through 10","408.55","2718.99","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3512.91","2107.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1869.57","53.22","","554.28","554.28","554.28","16","408.55","2718.99","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3512.91","2107.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2209.62","62.9","","619.64","173.09","2370.64","150","408.55","2718.99","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3512.91","2107.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2718.99","77.4","","303.98","303.98","5854.79","1 through 10","408.55","2718.99","percent of total billed charges",""
"BLADE BONE 65MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020766","CDM","C1713","HCPCS","0278","RC","","","","both","","","2702.43","1621.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","314.29","2297.07","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BLADE BONE 65MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020766","CDM","C1713","HCPCS","0278","RC","","","","both","","","2702.43","1621.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","314.29","2297.07","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BLADE BONE 65MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020766","CDM","C1713","HCPCS","0278","RC","","","","both","","","2702.43","1621.46","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1537.68","56.9","","812.12","238.65","1587.46","163","314.29","2297.07","percent of total billed charges",""
"BLADE BONE 65MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020766","CDM","C1713","HCPCS","0278","RC","","","","both","","","2702.43","1621.46","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","314.29","11.63","","112.68","112.68","146.99","38","314.29","2297.07","percent of total billed charges",""
"BLADE BONE 65MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020766","CDM","C1713","HCPCS","0278","RC","","","","both","","","2702.43","1621.46","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2091.68","77.4","","303.98","303.98","5854.79","1 through 10","314.29","2297.07","percent of total billed charges",""
"BLADE BONE 65MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2702.43","1621.46","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","314.29","11.63","","112.68","112.68","146.99","38","314.29","2091.68","percent of total billed charges",""
"BLADE BONE 65MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2702.43","1621.46","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1696.59","62.78","","780.86","208.94","10480.28","15","314.29","2091.68","percent of total billed charges",""
"BLADE BONE 65MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2702.43","1621.46","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1181.50","43.72","","179.76","179.76","179.76","1 through 10","314.29","2091.68","percent of total billed charges",""
"BLADE BONE 65MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2702.43","1621.46","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1965.21","72.72","","2355.45","298.99","3965.19","155","314.29","2091.68","percent of total billed charges",""
"BLADE BONE 65MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2702.43","1621.46","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1965.21","72.72","","3643.09","3643.09","3643.09","1 through 10","314.29","2091.68","percent of total billed charges",""
"BLADE BONE 65MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2702.43","1621.46","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1438.23","53.22","","554.28","554.28","554.28","16","314.29","2091.68","percent of total billed charges",""
"BLADE BONE 65MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2702.43","1621.46","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1699.83","62.9","","619.64","173.09","2370.64","150","314.29","2091.68","percent of total billed charges",""
"BLADE BONE 65MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2702.43","1621.46","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2091.68","77.4","","303.98","303.98","5854.79","1 through 10","314.29","2091.68","percent of total billed charges",""
"BLADE BONE 80MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020769","CDM","C1713","HCPCS","0278","RC","","","","both","","","2702.43","1621.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","314.29","2297.07","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BLADE BONE 80MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020769","CDM","C1713","HCPCS","0278","RC","","","","both","","","2702.43","1621.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","314.29","2297.07","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BLADE BONE 80MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020769","CDM","C1713","HCPCS","0278","RC","","","","both","","","2702.43","1621.46","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1537.68","56.9","","812.12","238.65","1587.46","163","314.29","2297.07","percent of total billed charges",""
"BLADE BONE 80MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020769","CDM","C1713","HCPCS","0278","RC","","","","both","","","2702.43","1621.46","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","314.29","11.63","","112.68","112.68","146.99","38","314.29","2297.07","percent of total billed charges",""
"BLADE BONE 80MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020769","CDM","C1713","HCPCS","0278","RC","","","","both","","","2702.43","1621.46","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2091.68","77.4","","303.98","303.98","5854.79","1 through 10","314.29","2297.07","percent of total billed charges",""
"BLADE BONE 80MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2702.43","1621.46","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","314.29","11.63","","112.68","112.68","146.99","38","314.29","2091.68","percent of total billed charges",""
"BLADE BONE 80MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2702.43","1621.46","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1696.59","62.78","","780.86","208.94","10480.28","15","314.29","2091.68","percent of total billed charges",""
"BLADE BONE 80MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2702.43","1621.46","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1181.50","43.72","","179.76","179.76","179.76","1 through 10","314.29","2091.68","percent of total billed charges",""
"BLADE BONE 80MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2702.43","1621.46","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1965.21","72.72","","2355.45","298.99","3965.19","155","314.29","2091.68","percent of total billed charges",""
"BLADE BONE 80MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2702.43","1621.46","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1965.21","72.72","","3643.09","3643.09","3643.09","1 through 10","314.29","2091.68","percent of total billed charges",""
"BLADE BONE 80MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2702.43","1621.46","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1438.23","53.22","","554.28","554.28","554.28","16","314.29","2091.68","percent of total billed charges",""
"BLADE BONE 80MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2702.43","1621.46","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1699.83","62.9","","619.64","173.09","2370.64","150","314.29","2091.68","percent of total billed charges",""
"BLADE BONE 80MM SPIRAL NAIL RETROGRADE FEMORAL TITANIUM","SUP-ITM-10020769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2702.43","1621.46","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2091.68","77.4","","303.98","303.98","5854.79","1 through 10","314.29","2091.68","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","3193.32","1915.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","371.38","2714.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","3193.32","1915.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","371.38","2714.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","3193.32","1915.99","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1817.00","56.9","","812.12","238.65","1587.46","163","371.38","2714.32","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","3193.32","1915.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","371.38","11.63","","112.68","112.68","146.99","38","371.38","2714.32","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","3193.32","1915.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2471.63","77.4","","303.98","303.98","5854.79","1 through 10","371.38","2714.32","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3193.32","1915.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","371.38","11.63","","112.68","112.68","146.99","38","371.38","2471.63","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3193.32","1915.99","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2004.77","62.78","","780.86","208.94","10480.28","15","371.38","2471.63","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3193.32","1915.99","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1396.12","43.72","","179.76","179.76","179.76","1 through 10","371.38","2471.63","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3193.32","1915.99","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2322.18","72.72","","2355.45","298.99","3965.19","155","371.38","2471.63","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3193.32","1915.99","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2322.18","72.72","","3643.09","3643.09","3643.09","1 through 10","371.38","2471.63","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3193.32","1915.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1699.48","53.22","","554.28","554.28","554.28","16","371.38","2471.63","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3193.32","1915.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2008.60","62.9","","619.64","173.09","2370.64","150","371.38","2471.63","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3193.32","1915.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2471.63","77.4","","303.98","303.98","5854.79","1 through 10","371.38","2471.63","percent of total billed charges",""
"BLADE HYSTEROSCOPY 2.9MM TRUCLEAR MORCELLATOR INCISOR PLUS","SUP-ITM-10113777","CDM","C1782","HCPCS","0272","RC","","","","both","","","3938.70","2363.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","458.07","11.63","","482.10","482.10","482.10","1 through 10","458.07","3347.9","percent of total billed charges",""
"BLADE HYSTEROSCOPY 2.9MM TRUCLEAR MORCELLATOR INCISOR PLUS","SUP-ITM-10113777","CDM","C1782","HCPCS","0272","RC","","","","outpatient","","","3938.70","2363.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","458.07","11.63","","482.10","482.10","482.10","1 through 10","458.07","3048.55","percent of total billed charges",""
"BLADE HYSTEROSCOPY 2.9MM TRUCLEAR MORCELLATOR INCISOR PLUS","SUP-ITM-10113777","CDM","C1782","HCPCS","0272","RC","","","","outpatient","","","3938.70","2363.22","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2477.44","62.9","","3074.95","3074.95","3074.95","1 through 10","458.07","3048.55","percent of total billed charges",""
"BLADE HYSTEROSCOPY 4MM TRUCLEAR MORCELLATOR ROTARY","SUP-ITM-10023173","CDM","C1782","HCPCS","0272","RC","","","","both","","","3074.95","1844.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","357.62","11.63","","482.10","482.10","482.10","1 through 10","357.62","2613.71","percent of total billed charges",""
"BLADE HYSTEROSCOPY 4MM TRUCLEAR MORCELLATOR ROTARY","SUP-ITM-10023173","CDM","C1782","HCPCS","0272","RC","","","","outpatient","","","3074.95","1844.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","357.62","11.63","","482.10","482.10","482.10","1 through 10","357.62","2380.01","percent of total billed charges",""
"BLADE HYSTEROSCOPY 4MM TRUCLEAR MORCELLATOR ROTARY","SUP-ITM-10023173","CDM","C1782","HCPCS","0272","RC","","","","outpatient","","","3074.95","1844.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1934.14","62.9","","3074.95","3074.95","3074.95","1 through 10","357.62","2380.01","percent of total billed charges",""
"BLADE RECIPROCATING 4MM MORCELLATOR TRUCLEAR ULTRA HYSTEROSCOPIC","SUP-ITM-10113776","CDM","C1782","HCPCS","0272","RC","","","","both","","","5182.50","3109.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","602.72","11.63","","482.10","482.10","482.10","1 through 10","602.72","4405.13","percent of total billed charges",""
"BLADE RECIPROCATING 4MM MORCELLATOR TRUCLEAR ULTRA HYSTEROSCOPIC","SUP-ITM-10113776","CDM","C1782","HCPCS","0272","RC","","","","outpatient","","","5182.50","3109.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","602.72","11.63","","482.10","482.10","482.10","1 through 10","602.72","4011.26","percent of total billed charges",""
"BLADE RECIPROCATING 4MM MORCELLATOR TRUCLEAR ULTRA HYSTEROSCOPIC","SUP-ITM-10113776","CDM","C1782","HCPCS","0272","RC","","","","outpatient","","","5182.50","3109.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3259.79","62.9","","3074.95","3074.95","3074.95","1 through 10","602.72","4011.26","percent of total billed charges",""
"BLADE SURGICAL 95MM HELICAL TFN ADVANCED TI","SUP-ITM-10163873","CDM","C1713","HCPCS","0278","RC","","","","both","","","3512.91","2107.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","408.55","2985.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BLADE SURGICAL 95MM HELICAL TFN ADVANCED TI","SUP-ITM-10163873","CDM","C1713","HCPCS","0278","RC","","","","both","","","3512.91","2107.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","408.55","2985.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BLADE SURGICAL 95MM HELICAL TFN ADVANCED TI","SUP-ITM-10163873","CDM","C1713","HCPCS","0278","RC","","","","both","","","3512.91","2107.75","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1998.85","56.9","","812.12","238.65","1587.46","163","408.55","2985.97","percent of total billed charges",""
"BLADE SURGICAL 95MM HELICAL TFN ADVANCED TI","SUP-ITM-10163873","CDM","C1713","HCPCS","0278","RC","","","","both","","","3512.91","2107.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","408.55","11.63","","112.68","112.68","146.99","38","408.55","2985.97","percent of total billed charges",""
"BLADE SURGICAL 95MM HELICAL TFN ADVANCED TI","SUP-ITM-10163873","CDM","C1713","HCPCS","0278","RC","","","","both","","","3512.91","2107.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2718.99","77.4","","303.98","303.98","5854.79","1 through 10","408.55","2985.97","percent of total billed charges",""
"BLADE SURGICAL 95MM HELICAL TFN ADVANCED TI","SUP-ITM-10163873","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3512.91","2107.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","408.55","11.63","","112.68","112.68","146.99","38","408.55","2718.99","percent of total billed charges",""
"BLADE SURGICAL 95MM HELICAL TFN ADVANCED TI","SUP-ITM-10163873","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3512.91","2107.75","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2205.40","62.78","","780.86","208.94","10480.28","15","408.55","2718.99","percent of total billed charges",""
"BLADE SURGICAL 95MM HELICAL TFN ADVANCED TI","SUP-ITM-10163873","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3512.91","2107.75","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1535.84","43.72","","179.76","179.76","179.76","1 through 10","408.55","2718.99","percent of total billed charges",""
"BLADE SURGICAL 95MM HELICAL TFN ADVANCED TI","SUP-ITM-10163873","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3512.91","2107.75","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2554.59","72.72","","2355.45","298.99","3965.19","155","408.55","2718.99","percent of total billed charges",""
"BLADE SURGICAL 95MM HELICAL TFN ADVANCED TI","SUP-ITM-10163873","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3512.91","2107.75","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2554.59","72.72","","3643.09","3643.09","3643.09","1 through 10","408.55","2718.99","percent of total billed charges",""
"BLADE SURGICAL 95MM HELICAL TFN ADVANCED TI","SUP-ITM-10163873","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3512.91","2107.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1869.57","53.22","","554.28","554.28","554.28","16","408.55","2718.99","percent of total billed charges",""
"BLADE SURGICAL 95MM HELICAL TFN ADVANCED TI","SUP-ITM-10163873","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3512.91","2107.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2209.62","62.9","","619.64","173.09","2370.64","150","408.55","2718.99","percent of total billed charges",""
"BLADE SURGICAL 95MM HELICAL TFN ADVANCED TI","SUP-ITM-10163873","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3512.91","2107.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2718.99","77.4","","303.98","303.98","5854.79","1 through 10","408.55","2718.99","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0300","RC","","","","inpatient","","","117.00","70.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","89.93","76.86","","71.19","71.19","136.20","14","77.45","89.93","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","117.00","70.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","81.67","69.8","","78.87","71.08","78.87","947","5.05","99.45","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","117.00","70.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","81.67","69.8","","78.87","10.02","78.87","1 through 10","5.05","99.45","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","117.00","70.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","99.45","85","","83.74","13.91","113.00","26","5.05","99.45","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","117.00","70.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","73.45","62.78","","70.94","70.94","70.94","51","7.24","90.56","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","117.00","70.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","51.15","43.72","","49.40","49.40","49.40","115","7.24","90.56","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","117.00","70.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","85.08","72.72","","82.17","82.17","164.34","1745","7.24","90.56","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","117.00","70.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","85.08","72.72","","82.17","82.17","164.34","51","7.24","90.56","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","117.00","70.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","62.27","53.22","","60.24","60.24","120.48","78","7.24","90.56","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","117.00","70.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","73.59","62.9","","71.19","71.19","213.57","1687","7.24","90.56","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","117.00","70.20","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","85.08","72.72","","87.58","87.58","87.58","1 through 10","7.24","90.56","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","117.00","70.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","90.56","77.4","","87.58","87.57","87.58","653","7.24","90.56","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","117.00","70.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","85.08","72.72","","82.17","82.17","164.34","16","7.24","90.56","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0300","RC","","","","inpatient","","","98.00","58.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","75.32","76.86","","59.85","59.85","59.85","1 through 10","64.88","75.32","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","98.00","58.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","68.40","69.8","","66.31","59.76","66.31","501","4.21","83.3","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","98.00","58.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","68.40","69.8","","66.31","66.31","66.31","1 through 10","4.21","83.3","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","98.00","58.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","83.30","85","","68.00","13.19","135.44","17","4.21","83.3","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","98.00","58.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","61.52","62.78","","59.64","59.64","59.64","27","6.03","75.85","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","98.00","58.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","42.85","43.72","","41.53","41.53","124.59","40","6.03","75.85","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","98.00","58.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","71.27","72.72","","69.08","69.08","138.16","862","6.03","75.85","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","98.00","58.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","71.27","72.72","","69.08","69.08","69.08","29","6.03","75.85","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","98.00","58.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","52.16","53.22","","50.64","50.64","94.26","40","6.03","75.85","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","98.00","58.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","61.64","62.9","","59.85","59.85","179.55","1038","6.03","75.85","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","98.00","58.80","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","71.27","72.72","","73.62","69.08","73.63","1 through 10","6.03","75.85","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","98.00","58.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","75.85","77.4","","73.63","73.61","73.63","341","6.03","75.85","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","98.00","58.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","71.27","72.72","","69.08","69.08","276.32","1 through 10","6.03","75.85","percent of total billed charges",""
"Blood Count Hematocrit (Hct)","PX-30001035","CDM","85014","CPT","0305","RC","","","","both","","","35.00","21.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","24.43","69.8","","23.73","21.39","23.73","12","1.54","29.75","percent of total billed charges",""
"Blood Count Hematocrit (Hct)","PX-30001035","CDM","85014","CPT","0305","RC","","","","outpatient","","","35.00","21.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","15.30","43.72","","14.86","14.86","14.86","1 through 10","2.19","27.09","percent of total billed charges",""
"Blood Count Hematocrit (Hct)","PX-30001035","CDM","85014","CPT","0305","RC","","","","outpatient","","","35.00","21.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","25.45","72.72","","24.72","24.72","24.72","18","2.19","27.09","percent of total billed charges",""
"Blood Count Hematocrit (Hct)","PX-30001035","CDM","85014","CPT","0305","RC","","","","outpatient","","","35.00","21.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","25.45","72.72","","49.44","49.44","49.44","1 through 10","2.19","27.09","percent of total billed charges",""
"Blood Count Hematocrit (Hct)","PX-30001035","CDM","85014","CPT","0305","RC","","","","outpatient","","","35.00","21.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","22.02","62.9","","21.42","21.42","21.42","19","2.19","27.09","percent of total billed charges",""
"Blood Count Hematocrit (Hct)","PX-30001035","CDM","85014","CPT","0305","RC","","","","outpatient","","","35.00","21.00","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","25.45","72.72","","26.35","26.35","26.35","1 through 10","2.19","27.09","percent of total billed charges",""
"Blood Count Hematocrit (Hct)","PX-30001035","CDM","85014","CPT","0305","RC","","","","outpatient","","","35.00","21.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","27.09","77.4","","26.35","26.35","26.35","14","2.19","27.09","percent of total billed charges",""
"Blood Count Hematocrit (Hct)","PX-30001035","CDM","85014","CPT","0305","RC","","","","outpatient","","","35.00","21.00","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","25.45","72.72","","24.73","24.73","24.73","1 through 10","2.19","27.09","percent of total billed charges",""
"Blood Count Hemoglobin (Hgb)","PX-30001036","CDM","85018","CPT","0305","RC","","","","both","","","35.00","21.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","24.43","69.8","","23.73","21.39","23.73","12","1.54","29.75","percent of total billed charges",""
"Blood Count Hemoglobin (Hgb)","PX-30001036","CDM","85018","CPT","0305","RC","","","","outpatient","","","35.00","21.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","15.30","43.72","","14.86","14.86","14.86","1 through 10","2.19","27.09","percent of total billed charges",""
"Blood Count Hemoglobin (Hgb)","PX-30001036","CDM","85018","CPT","0305","RC","","","","outpatient","","","35.00","21.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","25.45","72.72","","24.72","24.72","96.71","17","2.19","27.09","percent of total billed charges",""
"Blood Count Hemoglobin (Hgb)","PX-30001036","CDM","85018","CPT","0305","RC","","","","outpatient","","","35.00","21.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","25.45","72.72","","49.44","49.44","49.44","1 through 10","2.19","27.09","percent of total billed charges",""
"Blood Count Hemoglobin (Hgb)","PX-30001036","CDM","85018","CPT","0305","RC","","","","outpatient","","","35.00","21.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","22.02","62.9","","21.42","21.42","21.42","18","2.19","27.09","percent of total billed charges",""
"Blood Count Hemoglobin (Hgb)","PX-30001036","CDM","85018","CPT","0305","RC","","","","outpatient","","","35.00","21.00","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","25.45","72.72","","26.35","26.35","26.35","1 through 10","2.19","27.09","percent of total billed charges",""
"Blood Count Hemoglobin (Hgb)","PX-30001036","CDM","85018","CPT","0305","RC","","","","outpatient","","","35.00","21.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","27.09","77.4","","26.35","26.35","26.35","1 through 10","2.19","27.09","percent of total billed charges",""
"Blood Count Hemoglobin (Hgb)","PX-30001036","CDM","85018","CPT","0305","RC","","","","outpatient","","","35.00","21.00","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","25.45","72.72","","24.73","24.73","24.73","1 through 10","2.19","27.09","percent of total billed charges",""
"Blood Count Leukocyte (Wbc) Auto","PX-30001044","CDM","85048","CPT","0305","RC","","","","both","","","37.00","22.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","25.83","69.8","","25.13","25.13","50.26","23","1.65","31.45","percent of total billed charges",""
"Blood Count Leukocyte (Wbc) Auto","PX-30001044","CDM","85048","CPT","0305","RC","","","","both","","","37.00","22.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","25.83","69.8","","30.60","30.60","30.60","1 through 10","1.65","31.45","percent of total billed charges",""
"Blood Count Leukocyte (Wbc) Auto","PX-30001044","CDM","85048","CPT","0305","RC","","","","outpatient","","","37.00","22.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","23.23","62.78","","67.80","22.60","67.80","1 through 10","1.99","28.64","percent of total billed charges",""
"Blood Count Leukocyte (Wbc) Auto","PX-30001044","CDM","85048","CPT","0305","RC","","","","outpatient","","","37.00","22.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","26.91","72.72","","26.18","26.18","26.18","31","1.99","28.64","percent of total billed charges",""
"Blood Count Leukocyte (Wbc) Auto","PX-30001044","CDM","85048","CPT","0305","RC","","","","outpatient","","","37.00","22.20","INTERNATIONAL COMMERCIAL [140001]","HB WDH UNITED HMO / PPO / INDEM","28.64","77.4","","27.90","27.90","27.90","1 through 10","1.99","28.64","percent of total billed charges",""
"Blood Count Leukocyte (Wbc) Auto","PX-30001044","CDM","85048","CPT","0305","RC","","","","outpatient","","","37.00","22.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","19.69","53.22","","57.57","57.57","57.57","1 through 10","1.99","28.64","percent of total billed charges",""
"Blood Count Leukocyte (Wbc) Auto","PX-30001044","CDM","85048","CPT","0305","RC","","","","outpatient","","","37.00","22.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","23.27","62.9","","22.68","22.68","68.04","30","1.99","28.64","percent of total billed charges",""
"Blood Count Leukocyte (Wbc) Auto","PX-30001044","CDM","85048","CPT","0305","RC","","","","outpatient","","","37.00","22.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","28.64","77.4","","27.90","27.90","27.90","23","1.99","28.64","percent of total billed charges",""
"Blood Count Manual Diff Buffy Coat","PX-30001033","CDM","85009","CPT","0305","RC","","","","both","","","62.00","37.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","43.28","69.8","","41.88","41.88","41.88","1 through 10","3.3","52.7","percent of total billed charges",""
"Blood Count Manual Diff Buffy Coat","PX-30001033","CDM","85009","CPT","0305","RC","","","","outpatient","","","62.00","37.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","45.09","72.72","","43.63","43.63","43.63","1 through 10","4.46","47.99","percent of total billed charges",""
"Blood Count Manual Diff Buffy Coat","PX-30001033","CDM","85009","CPT","0305","RC","","","","outpatient","","","62.00","37.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","39.00","62.9","","37.80","37.80","37.80","1 through 10","4.46","47.99","percent of total billed charges",""
"Blood Count Manual Diff Buffy Coat","PX-30001033","CDM","85009","CPT","0305","RC","","","","outpatient","","","62.00","37.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","47.99","77.4","","46.50","46.50","46.50","1 through 10","4.46","47.99","percent of total billed charges",""
"Blood Count Platelet Auto","PX-30001045","CDM","85049","CPT","0305","RC","","","","both","","","68.00","40.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","47.46","69.8","","46.07","46.07","46.07","1 through 10","2.91","57.8","percent of total billed charges",""
"Blood Count Platelet Auto","PX-30001045","CDM","85049","CPT","0305","RC","","","","both","","","68.00","40.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","57.80","85","","94.12","94.12","94.12","1 through 10","2.91","57.8","percent of total billed charges",""
"Blood Count Platelet Auto","PX-30001045","CDM","85049","CPT","0305","RC","","","","outpatient","","","68.00","40.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","49.45","72.72","","48.00","48.00","48.00","1 through 10","4.16","52.63","percent of total billed charges",""
"Blood Count Platelet Auto","PX-30001045","CDM","85049","CPT","0305","RC","","","","outpatient","","","68.00","40.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","42.77","62.9","","41.58","41.58","41.58","1 through 10","4.16","52.63","percent of total billed charges",""
"Blood Count Platelet Auto","PX-30001045","CDM","85049","CPT","0305","RC","","","","outpatient","","","68.00","40.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","52.63","77.4","","51.15","51.15","51.15","1 through 10","4.16","52.63","percent of total billed charges",""
"Blood Count Reticulocytes Automated","PX-30001043","CDM","85046","CPT","0305","RC","","","","both","","","83.00","49.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","57.93","69.8","","55.84","50.32","55.84","19","3.62","70.55","percent of total billed charges",""
"Blood Count Reticulocytes Automated","PX-30001043","CDM","85046","CPT","0305","RC","","","","outpatient","","","83.00","49.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","36.29","43.72","","34.98","34.98","34.98","1 through 10","3.69","64.24","percent of total billed charges",""
"Blood Count Reticulocytes Automated","PX-30001043","CDM","85046","CPT","0305","RC","","","","outpatient","","","83.00","49.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","60.36","72.72","","58.18","58.18","58.18","29","3.69","64.24","percent of total billed charges",""
"Blood Count Reticulocytes Automated","PX-30001043","CDM","85046","CPT","0305","RC","","","","outpatient","","","83.00","49.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","44.17","53.22","","42.65","42.65","42.65","1 through 10","3.69","64.24","percent of total billed charges",""
"Blood Count Reticulocytes Automated","PX-30001043","CDM","85046","CPT","0305","RC","","","","outpatient","","","83.00","49.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","52.21","62.9","","50.40","50.40","97.12","29","3.69","64.24","percent of total billed charges",""
"Blood Count Reticulocytes Automated","PX-30001043","CDM","85046","CPT","0305","RC","","","","outpatient","","","83.00","49.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","64.24","77.4","","62.00","62.00","62.00","1 through 10","3.69","64.24","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0300","RC","","","","inpatient","","","308.00","184.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","236.73","76.86","","187.74","187.74","187.74","1 through 10","203.9","236.73","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","both","","","308.00","184.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","214.98","69.8","","208.00","53.86","208.00","1 through 10","16.95","261.8","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","outpatient","","","308.00","184.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","193.36","62.78","","187.09","187.09","187.09","1 through 10","23.18","238.39","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","outpatient","","","308.00","184.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","134.66","43.72","","390.87","130.29","390.87","1 through 10","23.18","238.39","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","outpatient","","","308.00","184.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","223.98","72.72","","433.42","216.71","433.42","1 through 10","23.18","238.39","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","outpatient","","","308.00","184.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","193.73","62.9","","187.74","187.74","375.48","13","23.18","238.39","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","outpatient","","","308.00","184.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","238.39","77.4","","230.95","216.71","230.95","1 through 10","23.18","238.39","percent of total billed charges",""
"Blood Product Irradiation","PX-30000094","CDM","86945","CPT","0302","RC","","","","both","","","135.00","81.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","262.09","","Case rate ($262.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","12.38","12.38","26.32","1 through 10","40.19","262.09","other","OPPS APC"
"Blood Product Irradiation","PX-30000094","CDM","86945","CPT","0302","RC","","","","both","","","135.00","81.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","112.85","","Case rate ($112.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","12.38","12.38","12.38","1 through 10","40.19","262.09","other","OPPS APC"
"Blood Product Irradiation","PX-30000094","CDM","86945","CPT","0302","RC","","","","both","","","135.00","81.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","40.19","","APC Price ($41.01). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","152.32","152.32","152.32","1 through 10","40.19","262.09","other","OPPS APC"
"Blood Product Irradiation","PX-30000094","CDM","86945","CPT","0302","RC","","","","both","","","135.00","81.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","211.84","","Case rate ($211.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","12.38","12.38","12.38","1 through 10","40.19","262.09","other","OPPS APC"
"Blood Product Irradiation","PX-30000094","CDM","86945","CPT","0302","RC","","","","outpatient","","","135.00","81.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","59.02","43.72","","113.68","56.84","113.68","1 through 10","4.37","104.49","percent of total billed charges",""
"Blood Smear W/Manual Diff Wbc","PX-30001031","CDM","85007","CPT","0305","RC","","","","outpatient","","","47.00","28.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","29.56","62.9","","54.24","54.24","54.24","1 through 10","1.9","36.38","percent of total billed charges",""
"Blood Type Antigen Donor Reagent Serum Each","PX-30000077","CDM","86902","CPT","0302","RC","","","","both","","","617.00","370.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","430.67","69.8","","415.31","415.31","415.31","1 through 10","27.08","2401.82","percent of total billed charges",""
"Blood Type Antigen Donor Reagent Serum Each","PX-30000077","CDM","86902","CPT","0302","RC","","","","both","","","617.00","370.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","368.30","","APC Price ($375.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6.35","6.35","1196.35","1 through 10","27.08","2401.82","other","OPPS APC"
"Blood Type Antigen Donor Reagent Serum Each","PX-30000077","CDM","86902","CPT","0302","RC","","","","both","","","617.00","370.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1941.37","","Case rate ($1,941.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4.13","4.13","4.13","1 through 10","27.08","2401.82","other","OPPS APC"
"Blood Type Antigen Donor Reagent Serum Each","PX-30000077","CDM","86902","CPT","0302","RC","","","","both","","","617.00","370.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","375.82","","APC Price ($375.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.64","62.64","62.64","12","27.08","2401.82","other","OPPS APC"
"Blood Typing RBC Antigens Oth/Thn Abo/Rh D Each","PX-30000079","CDM","86905","CPT","0302","RC","","","","both","","","62.00","37.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","43.28","69.8","","41.88","41.88","41.88","1 through 10","19.56","2401.82","percent of total billed charges",""
"Blood Typing RBC Antigens Oth/Thn Abo/Rh D Each","PX-30000079","CDM","86905","CPT","0302","RC","","","","both","","","62.00","37.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","368.30","","APC Price ($375.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3.83","3.75","3.83","1 through 10","19.56","2401.82","other","OPPS APC"
"Blood Typing RBC Antigens Oth/Thn Abo/Rh D Each","PX-30000079","CDM","86905","CPT","0302","RC","","","","both","","","62.00","37.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1941.37","","Case rate ($1,941.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2.49","2.49","2.49","1 through 10","19.56","2401.82","other","OPPS APC"
"Blood Typing RBC Antigens Oth/Thn Abo/Rh D Each","PX-30000079","CDM","86905","CPT","0302","RC","","","","both","","","62.00","37.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","375.82","","APC Price ($375.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","40.94","40.94","40.94","1 through 10","19.56","2401.82","other","OPPS APC"
"Blood Typing RBC Antigens Oth/Thn Abo/Rh D Each","PX-30000079","CDM","86905","CPT","0302","RC","","","","both","","","62.00","37.20","MEDICARE [2001]","HB WDH MEDICARE","375.82","","APC Price ($375.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","31.32","31.32","31.32","12","19.56","2401.82","other","OPPS APC"
"Blood Typing RBC Antigens Oth/Thn Abo/Rh D Each","PX-30000079","CDM","86905","CPT","0302","RC","","","","both","","","62.00","37.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","375.82","","APC Price ($375.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","73.67","73.67","73.67","1 through 10","19.56","2401.82","other","OPPS APC"
"Blood Typing RBC Antigens Oth/Thn Abo/Rh D Each","PX-30000079","CDM","86905","CPT","0302","RC","","","","outpatient","","","62.00","37.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","45.09","72.72","","436.32","436.32","436.32","1 through 10","3.24","47.99","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0300","RC","","","","inpatient","","","49.00","29.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","37.66","76.86","","29.61","29.61","29.61","1 through 10","32.44","37.66","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","49.00","29.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","34.20","69.8","","32.81","29.56","32.81","106","15.04","860.68","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","49.00","29.40","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","137.36","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","134.69","62.23","134.69","1 through 10","15.04","860.68","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","49.00","29.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","860.68","","Case rate ($860.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1.94","1.94","1.94","119","15.04","860.68","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","49.00","29.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","370.61","","Case rate ($370.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1.94","1.94","1.94","249","15.04","860.68","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","49.00","29.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","131.98","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2.99","2.99","4.07","110","15.04","860.68","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","49.00","29.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","695.68","","Case rate ($695.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1.94","1.94","1.94","270","15.04","860.68","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","49.00","29.40","CHAMPVA [160001]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","47.00","47.00","47.00","1 through 10","15.04","860.68","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","49.00","29.40","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","34.20","69.8","","32.81","32.81","32.81","1 through 10","15.04","860.68","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","49.00","29.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","138.71","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","136.90","136.90","136.90","1 through 10","15.04","860.68","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","49.00","29.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","134.69","132.00","134.69","32","15.04","860.68","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","49.00","29.40","MEDICARE [2001]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","134.69","124.46","373.38","24","15.04","860.68","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","49.00","29.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","41.65","85","","32.81","32.81","32.81","1 through 10","15.04","860.68","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","49.00","29.40","TRICARE [160005]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","134.69","134.69","134.69","54","15.04","860.68","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","49.00","29.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","132.00","121.98","134.69","28","15.04","860.68","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","49.00","29.40","WELLPOINT [1015]","HB WDH ANTHEM PPO","695.68","","Case rate ($695.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6.15","6.15","6.15","1 through 10","15.04","860.68","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","49.00","29.40","WELLSENSE NH [1050]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","138.79","138.79","138.79","1 through 10","15.04","860.68","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","outpatient","","","49.00","29.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","30.76","62.78","","29.51","29.51","88.53","1 through 10","2.77","37.93","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","outpatient","","","49.00","29.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","21.42","43.72","","20.55","20.55","41.10","12","2.77","37.93","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","outpatient","","","49.00","29.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","35.63","72.72","","34.18","34.18","34.18","132","2.77","37.93","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","outpatient","","","49.00","29.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","35.63","72.72","","34.18","34.18","34.18","1 through 10","2.77","37.93","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","outpatient","","","49.00","29.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","26.08","53.22","","25.06","25.06","25.06","1 through 10","2.77","37.93","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","outpatient","","","49.00","29.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","30.82","62.9","","29.61","29.61","29.61","150","2.77","37.93","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","outpatient","","","49.00","29.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","37.93","77.4","","36.43","36.43","36.43","73","2.77","37.93","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","outpatient","","","49.00","29.40","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","35.63","72.72","","34.18","34.18","34.18","1 through 10","2.77","37.93","percent of total billed charges",""
"Blood Typing Serologic Rh Phenotyping Complete","PX-30000081","CDM","86906","CPT","0302","RC","","","","both","","","443.00","265.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","211.84","","Case rate ($211.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5.04","5.04","5.04","1 through 10","40.19","376.55","other","OPPS APC"
"BODY HUMERAL SZ 9 132.5DEG NECK ANGLE PROXIMAL AEQUALIS FLEX REVIVE","SUP-ITM-10275024","CDM","C1776","HCPCS","0278","RC","","","","both","","","15618.64","9371.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1816.45","13275.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BODY HUMERAL SZ 9 132.5DEG NECK ANGLE PROXIMAL AEQUALIS FLEX REVIVE","SUP-ITM-10275024","CDM","C1776","HCPCS","0278","RC","","","","both","","","15618.64","9371.18","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","8887.01","56.9","","2911.53","1863.86","5209.05","65","1816.45","13275.84","percent of total billed charges",""
"BODY HUMERAL SZ 9 132.5DEG NECK ANGLE PROXIMAL AEQUALIS FLEX REVIVE","SUP-ITM-10275024","CDM","C1776","HCPCS","0278","RC","","","","both","","","15618.64","9371.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1816.45","11.63","","400.94","400.94","400.94","1 through 10","1816.45","13275.84","percent of total billed charges",""
"BODY HUMERAL SZ 9 132.5DEG NECK ANGLE PROXIMAL AEQUALIS FLEX REVIVE","SUP-ITM-10275024","CDM","C1776","HCPCS","0278","RC","","","","both","","","15618.64","9371.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12088.83","77.4","","5214.50","5214.50","16415.28","1 through 10","1816.45","13275.84","percent of total billed charges",""
"BODY HUMERAL SZ 9 132.5DEG NECK ANGLE PROXIMAL AEQUALIS FLEX REVIVE","SUP-ITM-10275024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15618.64","9371.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1816.45","11.63","","400.94","400.94","400.94","1 through 10","1816.45","12088.83","percent of total billed charges",""
"BODY HUMERAL SZ 9 132.5DEG NECK ANGLE PROXIMAL AEQUALIS FLEX REVIVE","SUP-ITM-10275024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15618.64","9371.18","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","6828.47","43.72","","1543.33","1543.33","1671.61","1 through 10","1816.45","12088.83","percent of total billed charges",""
"BODY HUMERAL SZ 9 132.5DEG NECK ANGLE PROXIMAL AEQUALIS FLEX REVIVE","SUP-ITM-10275024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15618.64","9371.18","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","11357.88","72.72","","3700.21","2382.07","6427.18","53","1816.45","12088.83","percent of total billed charges",""
"BODY HUMERAL SZ 9 132.5DEG NECK ANGLE PROXIMAL AEQUALIS FLEX REVIVE","SUP-ITM-10275024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15618.64","9371.18","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","11357.88","72.72","","12685.80","12685.80","12685.80","1 through 10","1816.45","12088.83","percent of total billed charges",""
"BODY HUMERAL SZ 9 132.5DEG NECK ANGLE PROXIMAL AEQUALIS FLEX REVIVE","SUP-ITM-10275024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15618.64","9371.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","9824.12","62.9","","3408.87","2784.05","9859.40","46","1816.45","12088.83","percent of total billed charges",""
"BODY HUMERAL SZ 9 132.5DEG NECK ANGLE PROXIMAL AEQUALIS FLEX REVIVE","SUP-ITM-10275024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15618.64","9371.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12088.83","77.4","","5214.50","5214.50","16415.28","1 through 10","1816.45","12088.83","percent of total billed charges",""
"BODY PTC PROXIMAL 13MM AEQUALIS FLEX REVIVE STANDARD","SUP-ITM-10269635","CDM","C1776","HCPCS","0278","RC","","","","both","","","15618.64","9371.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1816.45","13275.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BODY PTC PROXIMAL 13MM AEQUALIS FLEX REVIVE STANDARD","SUP-ITM-10269635","CDM","C1776","HCPCS","0278","RC","","","","both","","","15618.64","9371.18","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","8887.01","56.9","","2911.53","1863.86","5209.05","65","1816.45","13275.84","percent of total billed charges",""
"BODY PTC PROXIMAL 13MM AEQUALIS FLEX REVIVE STANDARD","SUP-ITM-10269635","CDM","C1776","HCPCS","0278","RC","","","","both","","","15618.64","9371.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1816.45","11.63","","400.94","400.94","400.94","1 through 10","1816.45","13275.84","percent of total billed charges",""
"BODY PTC PROXIMAL 13MM AEQUALIS FLEX REVIVE STANDARD","SUP-ITM-10269635","CDM","C1776","HCPCS","0278","RC","","","","both","","","15618.64","9371.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12088.83","77.4","","5214.50","5214.50","16415.28","1 through 10","1816.45","13275.84","percent of total billed charges",""
"BODY PTC PROXIMAL 13MM AEQUALIS FLEX REVIVE STANDARD","SUP-ITM-10269635","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15618.64","9371.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1816.45","11.63","","400.94","400.94","400.94","1 through 10","1816.45","12088.83","percent of total billed charges",""
"BODY PTC PROXIMAL 13MM AEQUALIS FLEX REVIVE STANDARD","SUP-ITM-10269635","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15618.64","9371.18","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","6828.47","43.72","","1543.33","1543.33","1671.61","1 through 10","1816.45","12088.83","percent of total billed charges",""
"BODY PTC PROXIMAL 13MM AEQUALIS FLEX REVIVE STANDARD","SUP-ITM-10269635","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15618.64","9371.18","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","11357.88","72.72","","3700.21","2382.07","6427.18","53","1816.45","12088.83","percent of total billed charges",""
"BODY PTC PROXIMAL 13MM AEQUALIS FLEX REVIVE STANDARD","SUP-ITM-10269635","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15618.64","9371.18","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","11357.88","72.72","","12685.80","12685.80","12685.80","1 through 10","1816.45","12088.83","percent of total billed charges",""
"BODY PTC PROXIMAL 13MM AEQUALIS FLEX REVIVE STANDARD","SUP-ITM-10269635","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15618.64","9371.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","9824.12","62.9","","3408.87","2784.05","9859.40","46","1816.45","12088.83","percent of total billed charges",""
"BODY PTC PROXIMAL 13MM AEQUALIS FLEX REVIVE STANDARD","SUP-ITM-10269635","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15618.64","9371.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12088.83","77.4","","5214.50","5214.50","16415.28","1 through 10","1816.45","12088.83","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","both","","","2097.74","1258.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","243.97","1783.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","both","","","2097.74","1258.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","243.97","1783.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","both","","","2097.74","1258.64","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1193.61","56.9","","812.12","238.65","1587.46","163","243.97","1783.08","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","both","","","2097.74","1258.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","243.97","11.63","","112.68","112.68","146.99","38","243.97","1783.08","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","both","","","2097.74","1258.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1623.65","77.4","","303.98","303.98","5854.79","1 through 10","243.97","1783.08","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2097.74","1258.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","243.97","11.63","","112.68","112.68","146.99","38","243.97","1623.65","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2097.74","1258.64","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1316.96","62.78","","780.86","208.94","10480.28","15","243.97","1623.65","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2097.74","1258.64","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","917.13","43.72","","179.76","179.76","179.76","1 through 10","243.97","1623.65","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2097.74","1258.64","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1525.48","72.72","","2355.45","298.99","3965.19","155","243.97","1623.65","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2097.74","1258.64","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1525.48","72.72","","3643.09","3643.09","3643.09","1 through 10","243.97","1623.65","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2097.74","1258.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1116.42","53.22","","554.28","554.28","554.28","16","243.97","1623.65","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2097.74","1258.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1319.48","62.9","","619.64","173.09","2370.64","150","243.97","1623.65","percent of total billed charges",""
"BOLT BONE 10X85MM FEMORAL NECK SYSTEM GOLD TI","SUP-ITM-10296784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2097.74","1258.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1623.65","77.4","","303.98","303.98","5854.79","1 through 10","243.97","1623.65","percent of total billed charges",""
"BOLT BONE 6.5X130MM MIDFOOT FUSION","SUP-ITM-10096818","CDM","C1776","HCPCS","0278","RC","","","","both","","","3108.95","1865.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","361.57","2642.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BOLT BONE 6.5X130MM MIDFOOT FUSION","SUP-ITM-10096818","CDM","C1776","HCPCS","0278","RC","","","","both","","","3108.95","1865.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1768.99","56.9","","2911.53","1863.86","5209.05","65","361.57","2642.61","percent of total billed charges",""
"BOLT BONE 6.5X130MM MIDFOOT FUSION","SUP-ITM-10096818","CDM","C1776","HCPCS","0278","RC","","","","both","","","3108.95","1865.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","361.57","11.63","","400.94","400.94","400.94","1 through 10","361.57","2642.61","percent of total billed charges",""
"BOLT BONE 6.5X130MM MIDFOOT FUSION","SUP-ITM-10096818","CDM","C1776","HCPCS","0278","RC","","","","both","","","3108.95","1865.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2406.33","77.4","","5214.50","5214.50","16415.28","1 through 10","361.57","2642.61","percent of total billed charges",""
"BOLT BONE 6.5X130MM MIDFOOT FUSION","SUP-ITM-10096818","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3108.95","1865.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","361.57","11.63","","400.94","400.94","400.94","1 through 10","361.57","2406.33","percent of total billed charges",""
"BOLT BONE 6.5X130MM MIDFOOT FUSION","SUP-ITM-10096818","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3108.95","1865.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1359.23","43.72","","1543.33","1543.33","1671.61","1 through 10","361.57","2406.33","percent of total billed charges",""
"BOLT BONE 6.5X130MM MIDFOOT FUSION","SUP-ITM-10096818","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3108.95","1865.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2260.83","72.72","","3700.21","2382.07","6427.18","53","361.57","2406.33","percent of total billed charges",""
"BOLT BONE 6.5X130MM MIDFOOT FUSION","SUP-ITM-10096818","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3108.95","1865.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2260.83","72.72","","12685.80","12685.80","12685.80","1 through 10","361.57","2406.33","percent of total billed charges",""
"BOLT BONE 6.5X130MM MIDFOOT FUSION","SUP-ITM-10096818","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3108.95","1865.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1955.53","62.9","","3408.87","2784.05","9859.40","46","361.57","2406.33","percent of total billed charges",""
"BOLT BONE 6.5X130MM MIDFOOT FUSION","SUP-ITM-10096818","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3108.95","1865.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2406.33","77.4","","5214.50","5214.50","16415.28","1 through 10","361.57","2406.33","percent of total billed charges",""
"BOLT BONE 6.5X145MM MIDFOOT FUSION","SUP-ITM-10095071","CDM","C1713","HCPCS","0278","RC","","","","both","","","2812.37","1687.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","327.08","2390.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BOLT BONE 6.5X145MM MIDFOOT FUSION","SUP-ITM-10095071","CDM","C1713","HCPCS","0278","RC","","","","both","","","2812.37","1687.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","327.08","2390.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BOLT BONE 6.5X145MM MIDFOOT FUSION","SUP-ITM-10095071","CDM","C1713","HCPCS","0278","RC","","","","both","","","2812.37","1687.42","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1600.24","56.9","","812.12","238.65","1587.46","163","327.08","2390.51","percent of total billed charges",""
"BOLT BONE 6.5X145MM MIDFOOT FUSION","SUP-ITM-10095071","CDM","C1713","HCPCS","0278","RC","","","","both","","","2812.37","1687.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","327.08","11.63","","112.68","112.68","146.99","38","327.08","2390.51","percent of total billed charges",""
"BOLT BONE 6.5X145MM MIDFOOT FUSION","SUP-ITM-10095071","CDM","C1713","HCPCS","0278","RC","","","","both","","","2812.37","1687.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2176.77","77.4","","303.98","303.98","5854.79","1 through 10","327.08","2390.51","percent of total billed charges",""
"BOLT BONE 6.5X145MM MIDFOOT FUSION","SUP-ITM-10095071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2812.37","1687.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","327.08","11.63","","112.68","112.68","146.99","38","327.08","2176.77","percent of total billed charges",""
"BOLT BONE 6.5X145MM MIDFOOT FUSION","SUP-ITM-10095071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2812.37","1687.42","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1765.61","62.78","","780.86","208.94","10480.28","15","327.08","2176.77","percent of total billed charges",""
"BOLT BONE 6.5X145MM MIDFOOT FUSION","SUP-ITM-10095071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2812.37","1687.42","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1229.57","43.72","","179.76","179.76","179.76","1 through 10","327.08","2176.77","percent of total billed charges",""
"BOLT BONE 6.5X145MM MIDFOOT FUSION","SUP-ITM-10095071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2812.37","1687.42","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2045.16","72.72","","2355.45","298.99","3965.19","155","327.08","2176.77","percent of total billed charges",""
"BOLT BONE 6.5X145MM MIDFOOT FUSION","SUP-ITM-10095071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2812.37","1687.42","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2045.16","72.72","","3643.09","3643.09","3643.09","1 through 10","327.08","2176.77","percent of total billed charges",""
"BOLT BONE 6.5X145MM MIDFOOT FUSION","SUP-ITM-10095071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2812.37","1687.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1496.74","53.22","","554.28","554.28","554.28","16","327.08","2176.77","percent of total billed charges",""
"BOLT BONE 6.5X145MM MIDFOOT FUSION","SUP-ITM-10095071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2812.37","1687.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1768.98","62.9","","619.64","173.09","2370.64","150","327.08","2176.77","percent of total billed charges",""
"BOLT BONE 6.5X145MM MIDFOOT FUSION","SUP-ITM-10095071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2812.37","1687.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2176.77","77.4","","303.98","303.98","5854.79","1 through 10","327.08","2176.77","percent of total billed charges",""
"BOLT BONE 90MM FEMORAL NECK SYSTEM","SUP-ITM-10297536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2097.74","1258.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","243.97","1783.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BOLT BONE 90MM FEMORAL NECK SYSTEM","SUP-ITM-10297536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2097.74","1258.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","243.97","1783.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BOLT BONE 90MM FEMORAL NECK SYSTEM","SUP-ITM-10297536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2097.74","1258.64","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1193.61","56.9","","812.12","238.65","1587.46","163","243.97","1783.08","percent of total billed charges",""
"BOLT BONE 90MM FEMORAL NECK SYSTEM","SUP-ITM-10297536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2097.74","1258.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","243.97","11.63","","112.68","112.68","146.99","38","243.97","1783.08","percent of total billed charges",""
"BOLT BONE 90MM FEMORAL NECK SYSTEM","SUP-ITM-10297536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2097.74","1258.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1623.65","77.4","","303.98","303.98","5854.79","1 through 10","243.97","1783.08","percent of total billed charges",""
"BOLT BONE 90MM FEMORAL NECK SYSTEM","SUP-ITM-10297536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2097.74","1258.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","243.97","11.63","","112.68","112.68","146.99","38","243.97","1623.65","percent of total billed charges",""
"BOLT BONE 90MM FEMORAL NECK SYSTEM","SUP-ITM-10297536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2097.74","1258.64","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1316.96","62.78","","780.86","208.94","10480.28","15","243.97","1623.65","percent of total billed charges",""
"BOLT BONE 90MM FEMORAL NECK SYSTEM","SUP-ITM-10297536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2097.74","1258.64","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","917.13","43.72","","179.76","179.76","179.76","1 through 10","243.97","1623.65","percent of total billed charges",""
"BOLT BONE 90MM FEMORAL NECK SYSTEM","SUP-ITM-10297536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2097.74","1258.64","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1525.48","72.72","","2355.45","298.99","3965.19","155","243.97","1623.65","percent of total billed charges",""
"BOLT BONE 90MM FEMORAL NECK SYSTEM","SUP-ITM-10297536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2097.74","1258.64","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1525.48","72.72","","3643.09","3643.09","3643.09","1 through 10","243.97","1623.65","percent of total billed charges",""
"BOLT BONE 90MM FEMORAL NECK SYSTEM","SUP-ITM-10297536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2097.74","1258.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1116.42","53.22","","554.28","554.28","554.28","16","243.97","1623.65","percent of total billed charges",""
"BOLT BONE 90MM FEMORAL NECK SYSTEM","SUP-ITM-10297536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2097.74","1258.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1319.48","62.9","","619.64","173.09","2370.64","150","243.97","1623.65","percent of total billed charges",""
"BOLT BONE 90MM FEMORAL NECK SYSTEM","SUP-ITM-10297536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2097.74","1258.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1623.65","77.4","","303.98","303.98","5854.79","1 through 10","243.97","1623.65","percent of total billed charges",""
"Bone Diseases And Arthropathies With McC","553","MS-DRG","","","","","","","","inpatient","","","50975.25","30585.15","MEDICARE [2001]","HB WDH MEDICARE","10299.90","","Case rate ($10,299.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,540.96, add-ons for qualifying new technology services are included. If operating cost exceeds $13,459.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,525.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,134.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,096.09 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $720.15. The transfer capital threshold is the transfer adjustment factor * $720.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5264.32","5264.32","5264.32","1 through 10","4637","26320.85","other","Inpatient DRG"
"Bone Diseases And Arthropathies With McC","553","MS-DRG","","","","","","","","inpatient","","","50975.25","30585.15","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","10299.90","","Case rate ($10,299.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,540.96, add-ons for qualifying new technology services are included. If operating cost exceeds $13,459.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,525.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $9,134.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,096.09 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $720.15. The transfer capital threshold is the transfer adjustment factor * $720.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10324.95","10324.95","10324.95","1 through 10","4637","26320.85","other","Inpatient DRG"
"Bone Diseases And Arthropathies Without McC","554","MS-DRG","","","","","","","","inpatient","","","18374.66","11024.80","MEDICARE [2001]","HB WDH MEDICARE","6755.65","","Case rate ($6,755.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,269.65, add-ons for qualifying new technology services are included. If operating cost exceeds $10,187.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,266.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,849.62 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,824.78 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $461.16. The transfer capital threshold is the transfer adjustment factor * $461.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6742.30","6742.30","6742.30","1 through 10","3975","31543.88","other","Inpatient DRG"
"Bone Marrow Asp","PX-76001195","CDM","38220","CPT","0761","RC","","","","both","","","4814.00","2888.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1667.01","1667.01","1667.01","1 through 10","1658.91","10818.29","other","OPPS APC"
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.29","3624.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","702.49","5134.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.29","3624.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","702.49","5134.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.29","3624.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3436.93","56.9","","812.12","238.65","1587.46","163","702.49","5134.25","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.29","3624.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","702.49","11.63","","112.68","112.68","146.99","38","702.49","5134.25","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.29","3624.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4675.18","77.4","","303.98","303.98","5854.79","1 through 10","702.49","5134.25","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","702.49","11.63","","112.68","112.68","146.99","38","702.49","4675.18","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3792.09","62.78","","780.86","208.94","10480.28","15","702.49","4675.18","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2640.81","43.72","","179.76","179.76","179.76","1 through 10","702.49","4675.18","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4392.50","72.72","","2355.45","298.99","3965.19","155","702.49","4675.18","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4392.50","72.72","","3643.09","3643.09","3643.09","1 through 10","702.49","4675.18","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3214.64","53.22","","554.28","554.28","554.28","16","702.49","4675.18","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3799.34","62.9","","619.64","173.09","2370.64","150","702.49","4675.18","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK LEFT","SUP-ITM-10164072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4675.18","77.4","","303.98","303.98","5854.79","1 through 10","702.49","4675.18","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.29","3624.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","702.49","5134.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.29","3624.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","702.49","5134.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.29","3624.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3436.93","56.9","","812.12","238.65","1587.46","163","702.49","5134.25","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.29","3624.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","702.49","11.63","","112.68","112.68","146.99","38","702.49","5134.25","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.29","3624.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4675.18","77.4","","303.98","303.98","5854.79","1 through 10","702.49","5134.25","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","702.49","11.63","","112.68","112.68","146.99","38","702.49","4675.18","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3792.09","62.78","","780.86","208.94","10480.28","15","702.49","4675.18","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2640.81","43.72","","179.76","179.76","179.76","1 through 10","702.49","4675.18","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4392.50","72.72","","2355.45","298.99","3965.19","155","702.49","4675.18","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4392.50","72.72","","3643.09","3643.09","3643.09","1 through 10","702.49","4675.18","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3214.64","53.22","","554.28","554.28","554.28","16","702.49","4675.18","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3799.34","62.9","","619.64","173.09","2370.64","150","702.49","4675.18","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4675.18","77.4","","303.98","303.98","5854.79","1 through 10","702.49","4675.18","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","both","","","1413.86","848.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","164.43","1201.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","both","","","1413.86","848.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","164.43","1201.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","both","","","1413.86","848.32","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","804.49","56.9","","812.12","238.65","1587.46","163","164.43","1201.78","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","both","","","1413.86","848.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","164.43","11.63","","112.68","112.68","146.99","38","164.43","1201.78","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","both","","","1413.86","848.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1094.33","77.4","","303.98","303.98","5854.79","1 through 10","164.43","1201.78","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1413.86","848.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","164.43","11.63","","112.68","112.68","146.99","38","164.43","1094.33","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1413.86","848.32","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","887.62","62.78","","780.86","208.94","10480.28","15","164.43","1094.33","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1413.86","848.32","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","618.14","43.72","","179.76","179.76","179.76","1 through 10","164.43","1094.33","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1413.86","848.32","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1028.16","72.72","","2355.45","298.99","3965.19","155","164.43","1094.33","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1413.86","848.32","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1028.16","72.72","","3643.09","3643.09","3643.09","1 through 10","164.43","1094.33","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1413.86","848.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","752.46","53.22","","554.28","554.28","554.28","16","164.43","1094.33","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1413.86","848.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","889.32","62.9","","619.64","173.09","2370.64","150","164.43","1094.33","percent of total billed charges",""
"BONE NAIL 2MMX440 FEMORAL TI ELASTIC GREEN","SUP-ITM-10040838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1413.86","848.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1094.33","77.4","","303.98","303.98","5854.79","1 through 10","164.43","1094.33","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","both","","","1605.61","963.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","186.73","1364.77","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","both","","","1605.61","963.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","186.73","1364.77","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","both","","","1605.61","963.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","913.59","56.9","","812.12","238.65","1587.46","163","186.73","1364.77","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","both","","","1605.61","963.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","186.73","11.63","","112.68","112.68","146.99","38","186.73","1364.77","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","both","","","1605.61","963.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1242.74","77.4","","303.98","303.98","5854.79","1 through 10","186.73","1364.77","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1605.61","963.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","186.73","11.63","","112.68","112.68","146.99","38","186.73","1242.74","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1605.61","963.37","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1008.00","62.78","","780.86","208.94","10480.28","15","186.73","1242.74","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1605.61","963.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","701.97","43.72","","179.76","179.76","179.76","1 through 10","186.73","1242.74","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1605.61","963.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1167.60","72.72","","2355.45","298.99","3965.19","155","186.73","1242.74","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1605.61","963.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1167.60","72.72","","3643.09","3643.09","3643.09","1 through 10","186.73","1242.74","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1605.61","963.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","854.51","53.22","","554.28","554.28","554.28","16","186.73","1242.74","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1605.61","963.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1009.93","62.9","","619.64","173.09","2370.64","150","186.73","1242.74","percent of total billed charges",""
"BONE NAIL 3MMX440 FEMORAL TI INTRAMEDULLARY ELASTIC","SUP-ITM-10040839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1605.61","963.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1242.74","77.4","","303.98","303.98","5854.79","1 through 10","186.73","1242.74","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","1521.24","912.74","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","176.92","1293.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","1521.24","912.74","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","176.92","1293.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","1521.24","912.74","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","865.59","56.9","","812.12","238.65","1587.46","163","176.92","1293.05","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","1521.24","912.74","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","176.92","11.63","","112.68","112.68","146.99","38","176.92","1293.05","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","1521.24","912.74","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1177.44","77.4","","303.98","303.98","5854.79","1 through 10","176.92","1293.05","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1521.24","912.74","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","176.92","11.63","","112.68","112.68","146.99","38","176.92","1177.44","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1521.24","912.74","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","955.03","62.78","","780.86","208.94","10480.28","15","176.92","1177.44","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1521.24","912.74","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","665.09","43.72","","179.76","179.76","179.76","1 through 10","176.92","1177.44","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1521.24","912.74","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1106.25","72.72","","2355.45","298.99","3965.19","155","176.92","1177.44","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1521.24","912.74","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1106.25","72.72","","3643.09","3643.09","3643.09","1 through 10","176.92","1177.44","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1521.24","912.74","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","809.60","53.22","","554.28","554.28","554.28","16","176.92","1177.44","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1521.24","912.74","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","956.86","62.9","","619.64","173.09","2370.64","150","176.92","1177.44","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1521.24","912.74","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1177.44","77.4","","303.98","303.98","5854.79","1 through 10","176.92","1177.44","percent of total billed charges",""
"BONE NAIL 7MMX230 HUMERAL EX TI","SUP-ITM-10036593","CDM","C1713","HCPCS","0278","RC","","","","both","","","5943.38","3566.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","691.22","5051.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 7MMX230 HUMERAL EX TI","SUP-ITM-10036593","CDM","C1713","HCPCS","0278","RC","","","","both","","","5943.38","3566.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","691.22","5051.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 7MMX230 HUMERAL EX TI","SUP-ITM-10036593","CDM","C1713","HCPCS","0278","RC","","","","both","","","5943.38","3566.03","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3381.78","56.9","","812.12","238.65","1587.46","163","691.22","5051.87","percent of total billed charges",""
"BONE NAIL 7MMX230 HUMERAL EX TI","SUP-ITM-10036593","CDM","C1713","HCPCS","0278","RC","","","","both","","","5943.38","3566.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","691.22","11.63","","112.68","112.68","146.99","38","691.22","5051.87","percent of total billed charges",""
"BONE NAIL 7MMX230 HUMERAL EX TI","SUP-ITM-10036593","CDM","C1713","HCPCS","0278","RC","","","","both","","","5943.38","3566.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4600.18","77.4","","303.98","303.98","5854.79","1 through 10","691.22","5051.87","percent of total billed charges",""
"BONE NAIL 7MMX230 HUMERAL EX TI","SUP-ITM-10036593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5943.38","3566.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","691.22","11.63","","112.68","112.68","146.99","38","691.22","4600.18","percent of total billed charges",""
"BONE NAIL 7MMX230 HUMERAL EX TI","SUP-ITM-10036593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5943.38","3566.03","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3731.25","62.78","","780.86","208.94","10480.28","15","691.22","4600.18","percent of total billed charges",""
"BONE NAIL 7MMX230 HUMERAL EX TI","SUP-ITM-10036593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5943.38","3566.03","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2598.45","43.72","","179.76","179.76","179.76","1 through 10","691.22","4600.18","percent of total billed charges",""
"BONE NAIL 7MMX230 HUMERAL EX TI","SUP-ITM-10036593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5943.38","3566.03","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4322.03","72.72","","2355.45","298.99","3965.19","155","691.22","4600.18","percent of total billed charges",""
"BONE NAIL 7MMX230 HUMERAL EX TI","SUP-ITM-10036593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5943.38","3566.03","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4322.03","72.72","","3643.09","3643.09","3643.09","1 through 10","691.22","4600.18","percent of total billed charges",""
"BONE NAIL 7MMX230 HUMERAL EX TI","SUP-ITM-10036593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5943.38","3566.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3163.07","53.22","","554.28","554.28","554.28","16","691.22","4600.18","percent of total billed charges",""
"BONE NAIL 7MMX230 HUMERAL EX TI","SUP-ITM-10036593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5943.38","3566.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3738.39","62.9","","619.64","173.09","2370.64","150","691.22","4600.18","percent of total billed charges",""
"BONE NAIL 7MMX230 HUMERAL EX TI","SUP-ITM-10036593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5943.38","3566.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4600.18","77.4","","303.98","303.98","5854.79","1 through 10","691.22","4600.18","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","both","","","6917.80","4150.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","804.54","5880.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","both","","","6917.80","4150.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","804.54","5880.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","both","","","6917.80","4150.68","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3936.23","56.9","","812.12","238.65","1587.46","163","804.54","5880.13","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","both","","","6917.80","4150.68","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","804.54","11.63","","112.68","112.68","146.99","38","804.54","5880.13","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","both","","","6917.80","4150.68","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5354.38","77.4","","303.98","303.98","5854.79","1 through 10","804.54","5880.13","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6917.80","4150.68","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","804.54","11.63","","112.68","112.68","146.99","38","804.54","5354.38","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6917.80","4150.68","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4342.99","62.78","","780.86","208.94","10480.28","15","804.54","5354.38","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6917.80","4150.68","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3024.46","43.72","","179.76","179.76","179.76","1 through 10","804.54","5354.38","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6917.80","4150.68","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5030.62","72.72","","2355.45","298.99","3965.19","155","804.54","5354.38","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6917.80","4150.68","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5030.62","72.72","","3643.09","3643.09","3643.09","1 through 10","804.54","5354.38","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6917.80","4150.68","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3681.65","53.22","","554.28","554.28","554.28","16","804.54","5354.38","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6917.80","4150.68","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4351.30","62.9","","619.64","173.09","2370.64","150","804.54","5354.38","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6917.80","4150.68","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5354.38","77.4","","303.98","303.98","5854.79","1 through 10","804.54","5354.38","percent of total billed charges",""
"BONE NAIL 8X315MM TIBIAL CANNULATED EX TI","SUP-ITM-10018747","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","629.23","4598.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 8X315MM TIBIAL CANNULATED EX TI","SUP-ITM-10018747","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","629.23","4598.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 8X315MM TIBIAL CANNULATED EX TI","SUP-ITM-10018747","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3078.53","56.9","","812.12","238.65","1587.46","163","629.23","4598.86","percent of total billed charges",""
"BONE NAIL 8X315MM TIBIAL CANNULATED EX TI","SUP-ITM-10018747","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","629.23","11.63","","112.68","112.68","146.99","38","629.23","4598.86","percent of total billed charges",""
"BONE NAIL 8X315MM TIBIAL CANNULATED EX TI","SUP-ITM-10018747","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4187.67","77.4","","303.98","303.98","5854.79","1 through 10","629.23","4598.86","percent of total billed charges",""
"BONE NAIL 8X315MM TIBIAL CANNULATED EX TI","SUP-ITM-10018747","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","629.23","11.63","","112.68","112.68","146.99","38","629.23","4187.67","percent of total billed charges",""
"BONE NAIL 8X315MM TIBIAL CANNULATED EX TI","SUP-ITM-10018747","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3396.66","62.78","","780.86","208.94","10480.28","15","629.23","4187.67","percent of total billed charges",""
"BONE NAIL 8X315MM TIBIAL CANNULATED EX TI","SUP-ITM-10018747","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2365.44","43.72","","179.76","179.76","179.76","1 through 10","629.23","4187.67","percent of total billed charges",""
"BONE NAIL 8X315MM TIBIAL CANNULATED EX TI","SUP-ITM-10018747","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3934.46","72.72","","2355.45","298.99","3965.19","155","629.23","4187.67","percent of total billed charges",""
"BONE NAIL 8X315MM TIBIAL CANNULATED EX TI","SUP-ITM-10018747","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3934.46","72.72","","3643.09","3643.09","3643.09","1 through 10","629.23","4187.67","percent of total billed charges",""
"BONE NAIL 8X315MM TIBIAL CANNULATED EX TI","SUP-ITM-10018747","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2879.43","53.22","","554.28","554.28","554.28","16","629.23","4187.67","percent of total billed charges",""
"BONE NAIL 8X315MM TIBIAL CANNULATED EX TI","SUP-ITM-10018747","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3403.15","62.9","","619.64","173.09","2370.64","150","629.23","4187.67","percent of total billed charges",""
"BONE NAIL 8X315MM TIBIAL CANNULATED EX TI","SUP-ITM-10018747","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4187.67","77.4","","303.98","303.98","5854.79","1 through 10","629.23","4187.67","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","629.23","4598.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","629.23","4598.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3078.53","56.9","","812.12","238.65","1587.46","163","629.23","4598.86","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","629.23","11.63","","112.68","112.68","146.99","38","629.23","4598.86","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4187.67","77.4","","303.98","303.98","5854.79","1 through 10","629.23","4598.86","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","629.23","11.63","","112.68","112.68","146.99","38","629.23","4187.67","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3396.66","62.78","","780.86","208.94","10480.28","15","629.23","4187.67","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2365.44","43.72","","179.76","179.76","179.76","1 through 10","629.23","4187.67","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3934.46","72.72","","2355.45","298.99","3965.19","155","629.23","4187.67","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3934.46","72.72","","3643.09","3643.09","3643.09","1 through 10","629.23","4187.67","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2879.43","53.22","","554.28","554.28","554.28","16","629.23","4187.67","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3403.15","62.9","","619.64","173.09","2370.64","150","629.23","4187.67","percent of total billed charges",""
"BONE NAIL 8X330MM TIBIAL CANNULATED EX TI EA","SUP-ITM-10018748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4187.67","77.4","","303.98","303.98","5854.79","1 through 10","629.23","4187.67","percent of total billed charges",""
"BONE NAIL 8X405MM TIBIAL EX TI CANNULATED EXPERT ROUND CROSS SECTION","SUP-ITM-10018753","CDM","C1713","HCPCS","0278","RC","","","","both","","","5575.51","3345.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","648.43","4739.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 8X405MM TIBIAL EX TI CANNULATED EXPERT ROUND CROSS SECTION","SUP-ITM-10018753","CDM","C1713","HCPCS","0278","RC","","","","both","","","5575.51","3345.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","648.43","4739.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 8X405MM TIBIAL EX TI CANNULATED EXPERT ROUND CROSS SECTION","SUP-ITM-10018753","CDM","C1713","HCPCS","0278","RC","","","","both","","","5575.51","3345.31","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3172.47","56.9","","812.12","238.65","1587.46","163","648.43","4739.18","percent of total billed charges",""
"BONE NAIL 8X405MM TIBIAL EX TI CANNULATED EXPERT ROUND CROSS SECTION","SUP-ITM-10018753","CDM","C1713","HCPCS","0278","RC","","","","both","","","5575.51","3345.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","648.43","11.63","","112.68","112.68","146.99","38","648.43","4739.18","percent of total billed charges",""
"BONE NAIL 8X405MM TIBIAL EX TI CANNULATED EXPERT ROUND CROSS SECTION","SUP-ITM-10018753","CDM","C1713","HCPCS","0278","RC","","","","both","","","5575.51","3345.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4315.44","77.4","","303.98","303.98","5854.79","1 through 10","648.43","4739.18","percent of total billed charges",""
"BONE NAIL 8X405MM TIBIAL EX TI CANNULATED EXPERT ROUND CROSS SECTION","SUP-ITM-10018753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5575.51","3345.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","648.43","11.63","","112.68","112.68","146.99","38","648.43","4315.44","percent of total billed charges",""
"BONE NAIL 8X405MM TIBIAL EX TI CANNULATED EXPERT ROUND CROSS SECTION","SUP-ITM-10018753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5575.51","3345.31","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3500.31","62.78","","780.86","208.94","10480.28","15","648.43","4315.44","percent of total billed charges",""
"BONE NAIL 8X405MM TIBIAL EX TI CANNULATED EXPERT ROUND CROSS SECTION","SUP-ITM-10018753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5575.51","3345.31","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2437.61","43.72","","179.76","179.76","179.76","1 through 10","648.43","4315.44","percent of total billed charges",""
"BONE NAIL 8X405MM TIBIAL EX TI CANNULATED EXPERT ROUND CROSS SECTION","SUP-ITM-10018753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5575.51","3345.31","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4054.51","72.72","","2355.45","298.99","3965.19","155","648.43","4315.44","percent of total billed charges",""
"BONE NAIL 8X405MM TIBIAL EX TI CANNULATED EXPERT ROUND CROSS SECTION","SUP-ITM-10018753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5575.51","3345.31","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4054.51","72.72","","3643.09","3643.09","3643.09","1 through 10","648.43","4315.44","percent of total billed charges",""
"BONE NAIL 8X405MM TIBIAL EX TI CANNULATED EXPERT ROUND CROSS SECTION","SUP-ITM-10018753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5575.51","3345.31","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2967.29","53.22","","554.28","554.28","554.28","16","648.43","4315.44","percent of total billed charges",""
"BONE NAIL 8X405MM TIBIAL EX TI CANNULATED EXPERT ROUND CROSS SECTION","SUP-ITM-10018753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5575.51","3345.31","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3507.00","62.9","","619.64","173.09","2370.64","150","648.43","4315.44","percent of total billed charges",""
"BONE NAIL 8X405MM TIBIAL EX TI CANNULATED EXPERT ROUND CROSS SECTION","SUP-ITM-10018753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5575.51","3345.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4315.44","77.4","","303.98","303.98","5854.79","1 through 10","648.43","4315.44","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","6917.80","4150.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","804.54","5880.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","6917.80","4150.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","804.54","5880.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","6917.80","4150.68","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3936.23","56.9","","812.12","238.65","1587.46","163","804.54","5880.13","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","6917.80","4150.68","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","804.54","11.63","","112.68","112.68","146.99","38","804.54","5880.13","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","6917.80","4150.68","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5354.38","77.4","","303.98","303.98","5854.79","1 through 10","804.54","5880.13","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6917.80","4150.68","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","804.54","11.63","","112.68","112.68","146.99","38","804.54","5354.38","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6917.80","4150.68","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4342.99","62.78","","780.86","208.94","10480.28","15","804.54","5354.38","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6917.80","4150.68","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3024.46","43.72","","179.76","179.76","179.76","1 through 10","804.54","5354.38","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6917.80","4150.68","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5030.62","72.72","","2355.45","298.99","3965.19","155","804.54","5354.38","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6917.80","4150.68","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5030.62","72.72","","3643.09","3643.09","3643.09","1 through 10","804.54","5354.38","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6917.80","4150.68","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3681.65","53.22","","554.28","554.28","554.28","16","804.54","5354.38","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6917.80","4150.68","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4351.30","62.9","","619.64","173.09","2370.64","150","804.54","5354.38","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6917.80","4150.68","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5354.38","77.4","","303.98","303.98","5854.79","1 through 10","804.54","5354.38","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","5769.32","3461.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","670.97","4903.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","5769.32","3461.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","670.97","4903.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","5769.32","3461.59","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3282.74","56.9","","812.12","238.65","1587.46","163","670.97","4903.92","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","5769.32","3461.59","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","670.97","11.63","","112.68","112.68","146.99","38","670.97","4903.92","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","5769.32","3461.59","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4465.45","77.4","","303.98","303.98","5854.79","1 through 10","670.97","4903.92","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5769.32","3461.59","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","670.97","11.63","","112.68","112.68","146.99","38","670.97","4465.45","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5769.32","3461.59","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3621.98","62.78","","780.86","208.94","10480.28","15","670.97","4465.45","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5769.32","3461.59","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2522.35","43.72","","179.76","179.76","179.76","1 through 10","670.97","4465.45","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5769.32","3461.59","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4195.45","72.72","","2355.45","298.99","3965.19","155","670.97","4465.45","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5769.32","3461.59","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4195.45","72.72","","3643.09","3643.09","3643.09","1 through 10","670.97","4465.45","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5769.32","3461.59","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3070.43","53.22","","554.28","554.28","554.28","16","670.97","4465.45","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5769.32","3461.59","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3628.90","62.9","","619.64","173.09","2370.64","150","670.97","4465.45","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5769.32","3461.59","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4465.45","77.4","","303.98","303.98","5854.79","1 through 10","670.97","4465.45","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.71","368.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","71.49","522.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.71","368.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","71.49","522.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.71","368.83","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","349.77","56.9","","812.12","238.65","1587.46","163","71.49","522.5","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.71","368.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.49","11.63","","112.68","112.68","146.99","38","71.49","522.5","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.71","368.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","475.79","77.4","","303.98","303.98","5854.79","1 through 10","71.49","522.5","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.71","368.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.49","11.63","","112.68","112.68","146.99","38","71.49","475.79","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.71","368.83","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","385.91","62.78","","780.86","208.94","10480.28","15","71.49","475.79","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.71","368.83","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","268.75","43.72","","179.76","179.76","179.76","1 through 10","71.49","475.79","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.71","368.83","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","447.02","72.72","","2355.45","298.99","3965.19","155","71.49","475.79","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.71","368.83","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","447.02","72.72","","3643.09","3643.09","3643.09","1 through 10","71.49","475.79","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.71","368.83","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","327.15","53.22","","554.28","554.28","554.28","16","71.49","475.79","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.71","368.83","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","386.65","62.9","","619.64","173.09","2370.64","150","71.49","475.79","percent of total billed charges",""
"BONE PIN 250X5MM STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10020708","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.71","368.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","475.79","77.4","","303.98","303.98","5854.79","1 through 10","71.49","475.79","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.97","553.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","107.34","784.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.97","553.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","107.34","784.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.97","553.78","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","525.17","56.9","","812.12","238.65","1587.46","163","107.34","784.52","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.97","553.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","107.34","11.63","","112.68","112.68","146.99","38","107.34","784.52","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.97","553.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","714.38","77.4","","303.98","303.98","5854.79","1 through 10","107.34","784.52","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","922.97","553.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","107.34","11.63","","112.68","112.68","146.99","38","107.34","714.38","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","922.97","553.78","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","579.44","62.78","","780.86","208.94","10480.28","15","107.34","714.38","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","922.97","553.78","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","403.52","43.72","","179.76","179.76","179.76","1 through 10","107.34","714.38","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","922.97","553.78","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","671.18","72.72","","2355.45","298.99","3965.19","155","107.34","714.38","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","922.97","553.78","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","671.18","72.72","","3643.09","3643.09","3643.09","1 through 10","107.34","714.38","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","922.97","553.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","491.20","53.22","","554.28","554.28","554.28","16","107.34","714.38","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","922.97","553.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","580.55","62.9","","619.64","173.09","2370.64","150","107.34","714.38","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","922.97","553.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","714.38","77.4","","303.98","303.98","5854.79","1 through 10","107.34","714.38","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.97","553.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","107.34","784.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.97","553.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","107.34","784.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.97","553.78","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","525.17","56.9","","812.12","238.65","1587.46","163","107.34","784.52","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.97","553.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","107.34","11.63","","112.68","112.68","146.99","38","107.34","784.52","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.97","553.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","714.38","77.4","","303.98","303.98","5854.79","1 through 10","107.34","784.52","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","922.97","553.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","107.34","11.63","","112.68","112.68","146.99","38","107.34","714.38","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","922.97","553.78","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","579.44","62.78","","780.86","208.94","10480.28","15","107.34","714.38","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","922.97","553.78","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","403.52","43.72","","179.76","179.76","179.76","1 through 10","107.34","714.38","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","922.97","553.78","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","671.18","72.72","","2355.45","298.99","3965.19","155","107.34","714.38","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","922.97","553.78","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","671.18","72.72","","3643.09","3643.09","3643.09","1 through 10","107.34","714.38","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","922.97","553.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","491.20","53.22","","554.28","554.28","554.28","16","107.34","714.38","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","922.97","553.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","580.55","62.9","","619.64","173.09","2370.64","150","107.34","714.38","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","922.97","553.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","714.38","77.4","","303.98","303.98","5854.79","1 through 10","107.34","714.38","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.59","330.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","64.03","468","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.59","330.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","64.03","468","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.59","330.35","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","313.29","56.9","","812.12","238.65","1587.46","163","64.03","468","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.59","330.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","64.03","11.63","","112.68","112.68","146.99","38","64.03","468","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.59","330.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","426.16","77.4","","303.98","303.98","5854.79","1 through 10","64.03","468","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","550.59","330.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","64.03","11.63","","112.68","112.68","146.99","38","64.03","426.16","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","550.59","330.35","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","345.66","62.78","","780.86","208.94","10480.28","15","64.03","426.16","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","550.59","330.35","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","240.72","43.72","","179.76","179.76","179.76","1 through 10","64.03","426.16","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","550.59","330.35","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","400.39","72.72","","2355.45","298.99","3965.19","155","64.03","426.16","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","550.59","330.35","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","400.39","72.72","","3643.09","3643.09","3643.09","1 through 10","64.03","426.16","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","550.59","330.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","293.02","53.22","","554.28","554.28","554.28","16","64.03","426.16","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","550.59","330.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","346.32","62.9","","619.64","173.09","2370.64","150","64.03","426.16","percent of total billed charges",""
"BONE PIN 4MMX200 STEINMANN STAINLESS CENTRAL THREAD","SUP-ITM-10006102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","550.59","330.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","426.16","77.4","","303.98","303.98","5854.79","1 through 10","64.03","426.16","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","2070.93","1242.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","240.85","1760.29","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","2070.93","1242.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","240.85","1760.29","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","2070.93","1242.56","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1178.36","56.9","","812.12","238.65","1587.46","163","240.85","1760.29","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","2070.93","1242.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","240.85","11.63","","112.68","112.68","146.99","38","240.85","1760.29","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","2070.93","1242.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1602.90","77.4","","303.98","303.98","5854.79","1 through 10","240.85","1760.29","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2070.93","1242.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","240.85","11.63","","112.68","112.68","146.99","38","240.85","1602.9","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2070.93","1242.56","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1300.13","62.78","","780.86","208.94","10480.28","15","240.85","1602.9","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2070.93","1242.56","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","905.41","43.72","","179.76","179.76","179.76","1 through 10","240.85","1602.9","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2070.93","1242.56","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1505.98","72.72","","2355.45","298.99","3965.19","155","240.85","1602.9","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2070.93","1242.56","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1505.98","72.72","","3643.09","3643.09","3643.09","1 through 10","240.85","1602.9","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2070.93","1242.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1102.15","53.22","","554.28","554.28","554.28","16","240.85","1602.9","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2070.93","1242.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1302.61","62.9","","619.64","173.09","2370.64","150","240.85","1602.9","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2070.93","1242.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1602.90","77.4","","303.98","303.98","5854.79","1 through 10","240.85","1602.9","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE HEAD 7 VARIABLE ANGLE LOCKING HAND STAINLESS T SHAPE","SUP-ITM-10164625","CDM","C1713","HCPCS","0278","RC","","","","both","","","2380.29","1428.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","276.83","2023.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 1.5X1MM 3 HOLE HEAD 7 VARIABLE ANGLE LOCKING HAND STAINLESS T SHAPE","SUP-ITM-10164625","CDM","C1713","HCPCS","0278","RC","","","","both","","","2380.29","1428.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","276.83","2023.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 1.5X1MM 3 HOLE HEAD 7 VARIABLE ANGLE LOCKING HAND STAINLESS T SHAPE","SUP-ITM-10164625","CDM","C1713","HCPCS","0278","RC","","","","both","","","2380.29","1428.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1354.39","56.9","","812.12","238.65","1587.46","163","276.83","2023.25","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE HEAD 7 VARIABLE ANGLE LOCKING HAND STAINLESS T SHAPE","SUP-ITM-10164625","CDM","C1713","HCPCS","0278","RC","","","","both","","","2380.29","1428.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","276.83","11.63","","112.68","112.68","146.99","38","276.83","2023.25","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE HEAD 7 VARIABLE ANGLE LOCKING HAND STAINLESS T SHAPE","SUP-ITM-10164625","CDM","C1713","HCPCS","0278","RC","","","","both","","","2380.29","1428.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1842.34","77.4","","303.98","303.98","5854.79","1 through 10","276.83","2023.25","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE HEAD 7 VARIABLE ANGLE LOCKING HAND STAINLESS T SHAPE","SUP-ITM-10164625","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2380.29","1428.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","276.83","11.63","","112.68","112.68","146.99","38","276.83","1842.34","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE HEAD 7 VARIABLE ANGLE LOCKING HAND STAINLESS T SHAPE","SUP-ITM-10164625","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2380.29","1428.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1494.35","62.78","","780.86","208.94","10480.28","15","276.83","1842.34","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE HEAD 7 VARIABLE ANGLE LOCKING HAND STAINLESS T SHAPE","SUP-ITM-10164625","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2380.29","1428.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1040.66","43.72","","179.76","179.76","179.76","1 through 10","276.83","1842.34","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE HEAD 7 VARIABLE ANGLE LOCKING HAND STAINLESS T SHAPE","SUP-ITM-10164625","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2380.29","1428.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1730.95","72.72","","2355.45","298.99","3965.19","155","276.83","1842.34","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE HEAD 7 VARIABLE ANGLE LOCKING HAND STAINLESS T SHAPE","SUP-ITM-10164625","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2380.29","1428.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1730.95","72.72","","3643.09","3643.09","3643.09","1 through 10","276.83","1842.34","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE HEAD 7 VARIABLE ANGLE LOCKING HAND STAINLESS T SHAPE","SUP-ITM-10164625","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2380.29","1428.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1266.79","53.22","","554.28","554.28","554.28","16","276.83","1842.34","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE HEAD 7 VARIABLE ANGLE LOCKING HAND STAINLESS T SHAPE","SUP-ITM-10164625","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2380.29","1428.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1497.20","62.9","","619.64","173.09","2370.64","150","276.83","1842.34","percent of total billed charges",""
"BONE PLATE 1.5X1MM 3 HOLE HEAD 7 VARIABLE ANGLE LOCKING HAND STAINLESS T SHAPE","SUP-ITM-10164625","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2380.29","1428.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1842.34","77.4","","303.98","303.98","5854.79","1 through 10","276.83","1842.34","percent of total billed charges",""
"BONE PLATE 1.7MM 16 HOLE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT","SUP-ITM-10143751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6044.04","3626.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","702.92","5137.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 1.7MM 16 HOLE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT","SUP-ITM-10143751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6044.04","3626.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","702.92","5137.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 1.7MM 16 HOLE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT","SUP-ITM-10143751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6044.04","3626.42","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3439.06","56.9","","812.12","238.65","1587.46","163","702.92","5137.43","percent of total billed charges",""
"BONE PLATE 1.7MM 16 HOLE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT","SUP-ITM-10143751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6044.04","3626.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","702.92","11.63","","112.68","112.68","146.99","38","702.92","5137.43","percent of total billed charges",""
"BONE PLATE 1.7MM 16 HOLE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT","SUP-ITM-10143751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6044.04","3626.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4678.09","77.4","","303.98","303.98","5854.79","1 through 10","702.92","5137.43","percent of total billed charges",""
"BONE PLATE 1.7MM 16 HOLE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT","SUP-ITM-10143751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6044.04","3626.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","702.92","11.63","","112.68","112.68","146.99","38","702.92","4678.09","percent of total billed charges",""
"BONE PLATE 1.7MM 16 HOLE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT","SUP-ITM-10143751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6044.04","3626.42","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3794.45","62.78","","780.86","208.94","10480.28","15","702.92","4678.09","percent of total billed charges",""
"BONE PLATE 1.7MM 16 HOLE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT","SUP-ITM-10143751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6044.04","3626.42","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2642.45","43.72","","179.76","179.76","179.76","1 through 10","702.92","4678.09","percent of total billed charges",""
"BONE PLATE 1.7MM 16 HOLE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT","SUP-ITM-10143751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6044.04","3626.42","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4395.23","72.72","","2355.45","298.99","3965.19","155","702.92","4678.09","percent of total billed charges",""
"BONE PLATE 1.7MM 16 HOLE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT","SUP-ITM-10143751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6044.04","3626.42","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4395.23","72.72","","3643.09","3643.09","3643.09","1 through 10","702.92","4678.09","percent of total billed charges",""
"BONE PLATE 1.7MM 16 HOLE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT","SUP-ITM-10143751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6044.04","3626.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3216.64","53.22","","554.28","554.28","554.28","16","702.92","4678.09","percent of total billed charges",""
"BONE PLATE 1.7MM 16 HOLE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT","SUP-ITM-10143751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6044.04","3626.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3801.70","62.9","","619.64","173.09","2370.64","150","702.92","4678.09","percent of total billed charges",""
"BONE PLATE 1.7MM 16 HOLE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT","SUP-ITM-10143751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6044.04","3626.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4678.09","77.4","","303.98","303.98","5854.79","1 through 10","702.92","4678.09","percent of total billed charges",""
"BONE PLATE 122MM 8 HOLE CLAVICLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LT REPROCESSED","SUP-ITM-10144652","CDM","C1713","HCPCS","0278","RC","","","","both","","","9746.17","5847.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1133.48","8284.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 122MM 8 HOLE CLAVICLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LT REPROCESSED","SUP-ITM-10144652","CDM","C1713","HCPCS","0278","RC","","","","both","","","9746.17","5847.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1133.48","8284.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 122MM 8 HOLE CLAVICLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LT REPROCESSED","SUP-ITM-10144652","CDM","C1713","HCPCS","0278","RC","","","","both","","","9746.17","5847.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5545.57","56.9","","812.12","238.65","1587.46","163","1133.48","8284.24","percent of total billed charges",""
"BONE PLATE 122MM 8 HOLE CLAVICLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LT REPROCESSED","SUP-ITM-10144652","CDM","C1713","HCPCS","0278","RC","","","","both","","","9746.17","5847.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1133.48","11.63","","112.68","112.68","146.99","38","1133.48","8284.24","percent of total billed charges",""
"BONE PLATE 122MM 8 HOLE CLAVICLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LT REPROCESSED","SUP-ITM-10144652","CDM","C1713","HCPCS","0278","RC","","","","both","","","9746.17","5847.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7543.54","77.4","","303.98","303.98","5854.79","1 through 10","1133.48","8284.24","percent of total billed charges",""
"BONE PLATE 122MM 8 HOLE CLAVICLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LT REPROCESSED","SUP-ITM-10144652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9746.17","5847.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1133.48","11.63","","112.68","112.68","146.99","38","1133.48","7543.54","percent of total billed charges",""
"BONE PLATE 122MM 8 HOLE CLAVICLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LT REPROCESSED","SUP-ITM-10144652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9746.17","5847.70","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6118.65","62.78","","780.86","208.94","10480.28","15","1133.48","7543.54","percent of total billed charges",""
"BONE PLATE 122MM 8 HOLE CLAVICLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LT REPROCESSED","SUP-ITM-10144652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9746.17","5847.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4261.03","43.72","","179.76","179.76","179.76","1 through 10","1133.48","7543.54","percent of total billed charges",""
"BONE PLATE 122MM 8 HOLE CLAVICLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LT REPROCESSED","SUP-ITM-10144652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9746.17","5847.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7087.41","72.72","","2355.45","298.99","3965.19","155","1133.48","7543.54","percent of total billed charges",""
"BONE PLATE 122MM 8 HOLE CLAVICLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LT REPROCESSED","SUP-ITM-10144652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9746.17","5847.70","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7087.41","72.72","","3643.09","3643.09","3643.09","1 through 10","1133.48","7543.54","percent of total billed charges",""
"BONE PLATE 122MM 8 HOLE CLAVICLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LT REPROCESSED","SUP-ITM-10144652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9746.17","5847.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","5186.91","53.22","","554.28","554.28","554.28","16","1133.48","7543.54","percent of total billed charges",""
"BONE PLATE 122MM 8 HOLE CLAVICLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LT REPROCESSED","SUP-ITM-10144652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9746.17","5847.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6130.34","62.9","","619.64","173.09","2370.64","150","1133.48","7543.54","percent of total billed charges",""
"BONE PLATE 122MM 8 HOLE CLAVICLE VARIAX TITANIUM BRIDGE LOCKING DECREASED CURVATURE SUPERIOR MIDSHAFT LT REPROCESSED","SUP-ITM-10144652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9746.17","5847.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7543.54","77.4","","303.98","303.98","5854.79","1 through 10","1133.48","7543.54","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","both","","","5248.91","3149.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","610.45","4461.57","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","both","","","5248.91","3149.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","610.45","4461.57","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","both","","","5248.91","3149.35","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2986.63","56.9","","812.12","238.65","1587.46","163","610.45","4461.57","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","both","","","5248.91","3149.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","610.45","11.63","","112.68","112.68","146.99","38","610.45","4461.57","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","both","","","5248.91","3149.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4062.66","77.4","","303.98","303.98","5854.79","1 through 10","610.45","4461.57","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5248.91","3149.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","610.45","11.63","","112.68","112.68","146.99","38","610.45","4062.66","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5248.91","3149.35","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3295.27","62.78","","780.86","208.94","10480.28","15","610.45","4062.66","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5248.91","3149.35","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2294.82","43.72","","179.76","179.76","179.76","1 through 10","610.45","4062.66","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5248.91","3149.35","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3817.01","72.72","","2355.45","298.99","3965.19","155","610.45","4062.66","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5248.91","3149.35","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3817.01","72.72","","3643.09","3643.09","3643.09","1 through 10","610.45","4062.66","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5248.91","3149.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2793.47","53.22","","554.28","554.28","554.28","16","610.45","4062.66","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5248.91","3149.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3301.56","62.9","","619.64","173.09","2370.64","150","610.45","4062.66","percent of total billed charges",""
"BONE PLATE 2.4 2.7X27MM SM 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGEL SHAPE","SUP-ITM-10091802","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5248.91","3149.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4062.66","77.4","","303.98","303.98","5854.79","1 through 10","610.45","4062.66","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","both","","","5399.75","3239.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","627.99","4589.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","both","","","5399.75","3239.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","627.99","4589.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","both","","","5399.75","3239.85","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3072.46","56.9","","812.12","238.65","1587.46","163","627.99","4589.79","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","both","","","5399.75","3239.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","627.99","11.63","","112.68","112.68","146.99","38","627.99","4589.79","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","both","","","5399.75","3239.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4179.41","77.4","","303.98","303.98","5854.79","1 through 10","627.99","4589.79","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5399.75","3239.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","627.99","11.63","","112.68","112.68","146.99","38","627.99","4179.41","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5399.75","3239.85","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3389.96","62.78","","780.86","208.94","10480.28","15","627.99","4179.41","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5399.75","3239.85","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2360.77","43.72","","179.76","179.76","179.76","1 through 10","627.99","4179.41","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5399.75","3239.85","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3926.70","72.72","","2355.45","298.99","3965.19","155","627.99","4179.41","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5399.75","3239.85","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3926.70","72.72","","3643.09","3643.09","3643.09","1 through 10","627.99","4179.41","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5399.75","3239.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2873.75","53.22","","554.28","554.28","554.28","16","627.99","4179.41","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5399.75","3239.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3396.44","62.9","","619.64","173.09","2370.64","150","627.99","4179.41","percent of total billed charges",""
"BONE PLATE 2.4 2.7X35MM LG 4 HOLE FOREFOOT LCP STAINLESS LOCKING VARIABLE ANGLE SHAPE","SUP-ITM-10095281","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5399.75","3239.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4179.41","77.4","","303.98","303.98","5854.79","1 through 10","627.99","4179.41","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","both","","","4497.24","2698.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","523.03","3822.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","both","","","4497.24","2698.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","523.03","3822.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","both","","","4497.24","2698.34","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2558.93","56.9","","812.12","238.65","1587.46","163","523.03","3822.65","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","both","","","4497.24","2698.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","523.03","11.63","","112.68","112.68","146.99","38","523.03","3822.65","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","both","","","4497.24","2698.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3480.86","77.4","","303.98","303.98","5854.79","1 through 10","523.03","3822.65","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4497.24","2698.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","523.03","11.63","","112.68","112.68","146.99","38","523.03","3480.86","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4497.24","2698.34","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2823.37","62.78","","780.86","208.94","10480.28","15","523.03","3480.86","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4497.24","2698.34","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1966.19","43.72","","179.76","179.76","179.76","1 through 10","523.03","3480.86","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4497.24","2698.34","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3270.39","72.72","","2355.45","298.99","3965.19","155","523.03","3480.86","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4497.24","2698.34","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3270.39","72.72","","3643.09","3643.09","3643.09","1 through 10","523.03","3480.86","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4497.24","2698.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2393.43","53.22","","554.28","554.28","554.28","16","523.03","3480.86","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4497.24","2698.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2828.76","62.9","","619.64","173.09","2370.64","150","523.03","3480.86","percent of total billed charges",""
"BONE PLATE 2.4 2.7X40MM 4 HOLE FOOT STAINLESS LOCKING VARIABLE ANGLE STRAIGHT","SUP-ITM-10091982","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4497.24","2698.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3480.86","77.4","","303.98","303.98","5854.79","1 through 10","523.03","3480.86","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","both","","","5496.91","3298.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","639.29","4672.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","both","","","5496.91","3298.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","639.29","4672.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","both","","","5496.91","3298.15","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3127.74","56.9","","812.12","238.65","1587.46","163","639.29","4672.37","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","both","","","5496.91","3298.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","639.29","11.63","","112.68","112.68","146.99","38","639.29","4672.37","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","both","","","5496.91","3298.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4254.61","77.4","","303.98","303.98","5854.79","1 through 10","639.29","4672.37","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5496.91","3298.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","639.29","11.63","","112.68","112.68","146.99","38","639.29","4254.61","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5496.91","3298.15","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3450.96","62.78","","780.86","208.94","10480.28","15","639.29","4254.61","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5496.91","3298.15","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2403.25","43.72","","179.76","179.76","179.76","1 through 10","639.29","4254.61","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5496.91","3298.15","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3997.35","72.72","","2355.45","298.99","3965.19","155","639.29","4254.61","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5496.91","3298.15","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3997.35","72.72","","3643.09","3643.09","3643.09","1 through 10","639.29","4254.61","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5496.91","3298.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2925.46","53.22","","554.28","554.28","554.28","16","639.29","4254.61","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5496.91","3298.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3457.56","62.9","","619.64","173.09","2370.64","150","639.29","4254.61","percent of total billed charges",""
"BONE PLATE 2.4 2.7X48MM LONG FUSION/VA LCP FIRST TMT","SUP-ITM-10082534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5496.91","3298.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4254.61","77.4","","303.98","303.98","5854.79","1 through 10","639.29","4254.61","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","both","","","4868.48","2921.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","566.2","4138.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","both","","","4868.48","2921.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","566.2","4138.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","both","","","4868.48","2921.09","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2770.17","56.9","","812.12","238.65","1587.46","163","566.2","4138.21","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","both","","","4868.48","2921.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","566.20","11.63","","112.68","112.68","146.99","38","566.2","4138.21","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","both","","","4868.48","2921.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3768.20","77.4","","303.98","303.98","5854.79","1 through 10","566.2","4138.21","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4868.48","2921.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","566.20","11.63","","112.68","112.68","146.99","38","566.2","3768.2","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4868.48","2921.09","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3056.43","62.78","","780.86","208.94","10480.28","15","566.2","3768.2","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4868.48","2921.09","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2128.50","43.72","","179.76","179.76","179.76","1 through 10","566.2","3768.2","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4868.48","2921.09","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3540.36","72.72","","2355.45","298.99","3965.19","155","566.2","3768.2","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4868.48","2921.09","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3540.36","72.72","","3643.09","3643.09","3643.09","1 through 10","566.2","3768.2","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4868.48","2921.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2591.01","53.22","","554.28","554.28","554.28","16","566.2","3768.2","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4868.48","2921.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3062.27","62.9","","619.64","173.09","2370.64","150","566.2","3768.2","percent of total billed charges",""
"BONE PLATE 2.4 2.7X53MM 0.0DEG FOOT VA LCP STAINLESS REVISION FIRST MTP FUSION RIGHT","SUP-ITM-10091995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4868.48","2921.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3768.20","77.4","","303.98","303.98","5854.79","1 through 10","566.2","3768.2","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","both","","","4888.41","2933.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","568.52","4155.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","both","","","4888.41","2933.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","568.52","4155.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","both","","","4888.41","2933.05","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2781.51","56.9","","812.12","238.65","1587.46","163","568.52","4155.15","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","both","","","4888.41","2933.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","568.52","11.63","","112.68","112.68","146.99","38","568.52","4155.15","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","both","","","4888.41","2933.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3783.63","77.4","","303.98","303.98","5854.79","1 through 10","568.52","4155.15","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4888.41","2933.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","568.52","11.63","","112.68","112.68","146.99","38","568.52","3783.63","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4888.41","2933.05","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3068.94","62.78","","780.86","208.94","10480.28","15","568.52","3783.63","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4888.41","2933.05","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2137.21","43.72","","179.76","179.76","179.76","1 through 10","568.52","3783.63","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4888.41","2933.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3554.85","72.72","","2355.45","298.99","3965.19","155","568.52","3783.63","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4888.41","2933.05","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3554.85","72.72","","3643.09","3643.09","3643.09","1 through 10","568.52","3783.63","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4888.41","2933.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2601.61","53.22","","554.28","554.28","554.28","16","568.52","3783.63","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4888.41","2933.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3074.81","62.9","","619.64","173.09","2370.64","150","568.52","3783.63","percent of total billed charges",""
"BONE PLATE 2.4-2.7X37MM SHORT FOOT VA LCP SS L FUSION RIGHT","SUP-ITM-10091980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4888.41","2933.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3783.63","77.4","","303.98","303.98","5854.79","1 through 10","568.52","3783.63","percent of total billed charges",""
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.330","SUP-ITM-10096096","CDM","C1713","HCPCS","0278","RC","","","","both","","","3975.67","2385.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","462.37","3379.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.330","SUP-ITM-10096096","CDM","C1713","HCPCS","0278","RC","","","","both","","","3975.67","2385.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","462.37","3379.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.330","SUP-ITM-10096096","CDM","C1713","HCPCS","0278","RC","","","","both","","","3975.67","2385.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2262.16","56.9","","812.12","238.65","1587.46","163","462.37","3379.32","percent of total billed charges",""
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.330","SUP-ITM-10096096","CDM","C1713","HCPCS","0278","RC","","","","both","","","3975.67","2385.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","462.37","11.63","","112.68","112.68","146.99","38","462.37","3379.32","percent of total billed charges",""
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.330","SUP-ITM-10096096","CDM","C1713","HCPCS","0278","RC","","","","both","","","3975.67","2385.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3077.17","77.4","","303.98","303.98","5854.79","1 through 10","462.37","3379.32","percent of total billed charges",""
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.330","SUP-ITM-10096096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3975.67","2385.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","462.37","11.63","","112.68","112.68","146.99","38","462.37","3077.17","percent of total billed charges",""
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.330","SUP-ITM-10096096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3975.67","2385.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2495.93","62.78","","780.86","208.94","10480.28","15","462.37","3077.17","percent of total billed charges",""
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.330","SUP-ITM-10096096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3975.67","2385.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1738.16","43.72","","179.76","179.76","179.76","1 through 10","462.37","3077.17","percent of total billed charges",""
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.330","SUP-ITM-10096096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3975.67","2385.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2891.11","72.72","","2355.45","298.99","3965.19","155","462.37","3077.17","percent of total billed charges",""
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.330","SUP-ITM-10096096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3975.67","2385.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2891.11","72.72","","3643.09","3643.09","3643.09","1 through 10","462.37","3077.17","percent of total billed charges",""
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.330","SUP-ITM-10096096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3975.67","2385.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2115.85","53.22","","554.28","554.28","554.28","16","462.37","3077.17","percent of total billed charges",""
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.330","SUP-ITM-10096096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3975.67","2385.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2500.70","62.9","","619.64","173.09","2370.64","150","462.37","3077.17","percent of total billed charges",""
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.330","SUP-ITM-10096096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3975.67","2385.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3077.17","77.4","","303.98","303.98","5854.79","1 through 10","462.37","3077.17","percent of total billed charges",""
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.350","SUP-ITM-10096097","CDM","C1713","HCPCS","0278","RC","","","","both","","","4144.41","2486.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","481.99","3522.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.350","SUP-ITM-10096097","CDM","C1713","HCPCS","0278","RC","","","","both","","","4144.41","2486.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","481.99","3522.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.350","SUP-ITM-10096097","CDM","C1713","HCPCS","0278","RC","","","","both","","","4144.41","2486.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2358.17","56.9","","812.12","238.65","1587.46","163","481.99","3522.75","percent of total billed charges",""
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.350","SUP-ITM-10096097","CDM","C1713","HCPCS","0278","RC","","","","both","","","4144.41","2486.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","481.99","11.63","","112.68","112.68","146.99","38","481.99","3522.75","percent of total billed charges",""
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.350","SUP-ITM-10096097","CDM","C1713","HCPCS","0278","RC","","","","both","","","4144.41","2486.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3207.77","77.4","","303.98","303.98","5854.79","1 through 10","481.99","3522.75","percent of total billed charges",""
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.350","SUP-ITM-10096097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4144.41","2486.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","481.99","11.63","","112.68","112.68","146.99","38","481.99","3207.77","percent of total billed charges",""
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.350","SUP-ITM-10096097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4144.41","2486.65","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2601.86","62.78","","780.86","208.94","10480.28","15","481.99","3207.77","percent of total billed charges",""
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.350","SUP-ITM-10096097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4144.41","2486.65","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1811.94","43.72","","179.76","179.76","179.76","1 through 10","481.99","3207.77","percent of total billed charges",""
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.350","SUP-ITM-10096097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4144.41","2486.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3013.81","72.72","","2355.45","298.99","3965.19","155","481.99","3207.77","percent of total billed charges",""
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.350","SUP-ITM-10096097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4144.41","2486.65","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3013.81","72.72","","3643.09","3643.09","3643.09","1 through 10","481.99","3207.77","percent of total billed charges",""
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.350","SUP-ITM-10096097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4144.41","2486.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2205.66","53.22","","554.28","554.28","554.28","16","481.99","3207.77","percent of total billed charges",""
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.350","SUP-ITM-10096097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4144.41","2486.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2606.83","62.9","","619.64","173.09","2370.64","150","481.99","3207.77","percent of total billed charges",""
"BONE PLATE 2.4MM /3 H 3H TI VA LCP DORSAL DISTAL RAD T 04.115.350","SUP-ITM-10096097","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4144.41","2486.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3207.77","77.4","","303.98","303.98","5854.79","1 through 10","481.99","3207.77","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","both","","","6176.67","3706.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","718.35","5250.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","both","","","6176.67","3706.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","718.35","5250.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","both","","","6176.67","3706.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3514.53","56.9","","812.12","238.65","1587.46","163","718.35","5250.17","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","both","","","6176.67","3706.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","718.35","11.63","","112.68","112.68","146.99","38","718.35","5250.17","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","both","","","6176.67","3706.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4780.74","77.4","","303.98","303.98","5854.79","1 through 10","718.35","5250.17","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6176.67","3706.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","718.35","11.63","","112.68","112.68","146.99","38","718.35","4780.74","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6176.67","3706.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3877.71","62.78","","780.86","208.94","10480.28","15","718.35","4780.74","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6176.67","3706.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2700.44","43.72","","179.76","179.76","179.76","1 through 10","718.35","4780.74","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6176.67","3706.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4491.67","72.72","","2355.45","298.99","3965.19","155","718.35","4780.74","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6176.67","3706.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4491.67","72.72","","3643.09","3643.09","3643.09","1 through 10","718.35","4780.74","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6176.67","3706.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3287.22","53.22","","554.28","554.28","554.28","16","718.35","4780.74","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6176.67","3706.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3885.13","62.9","","619.64","173.09","2370.64","150","718.35","4780.74","percent of total billed charges",""
"BONE PLATE 2.4MM 2.7 5X12 HOLE VA LCP SS MESH LOCKING","SUP-ITM-10095288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6176.67","3706.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4780.74","77.4","","303.98","303.98","5854.79","1 through 10","718.35","4780.74","percent of total billed charges",""
"BONE PLATE 2.4MM 2H 90DEG L DISTAL RAD TI VA LCP DRSL +/+/2 H SHAFT","SUP-ITM-10096090","CDM","C1713","HCPCS","0278","RC","","","","both","","","4047.26","2428.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","470.7","3440.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4MM 2H 90DEG L DISTAL RAD TI VA LCP DRSL +/+/2 H SHAFT","SUP-ITM-10096090","CDM","C1713","HCPCS","0278","RC","","","","both","","","4047.26","2428.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","470.7","3440.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4MM 2H 90DEG L DISTAL RAD TI VA LCP DRSL +/+/2 H SHAFT","SUP-ITM-10096090","CDM","C1713","HCPCS","0278","RC","","","","both","","","4047.26","2428.36","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2302.89","56.9","","812.12","238.65","1587.46","163","470.7","3440.17","percent of total billed charges",""
"BONE PLATE 2.4MM 2H 90DEG L DISTAL RAD TI VA LCP DRSL +/+/2 H SHAFT","SUP-ITM-10096090","CDM","C1713","HCPCS","0278","RC","","","","both","","","4047.26","2428.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","470.70","11.63","","112.68","112.68","146.99","38","470.7","3440.17","percent of total billed charges",""
"BONE PLATE 2.4MM 2H 90DEG L DISTAL RAD TI VA LCP DRSL +/+/2 H SHAFT","SUP-ITM-10096090","CDM","C1713","HCPCS","0278","RC","","","","both","","","4047.26","2428.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3132.58","77.4","","303.98","303.98","5854.79","1 through 10","470.7","3440.17","percent of total billed charges",""
"BONE PLATE 2.4MM 2H 90DEG L DISTAL RAD TI VA LCP DRSL +/+/2 H SHAFT","SUP-ITM-10096090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4047.26","2428.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","470.70","11.63","","112.68","112.68","146.99","38","470.7","3132.58","percent of total billed charges",""
"BONE PLATE 2.4MM 2H 90DEG L DISTAL RAD TI VA LCP DRSL +/+/2 H SHAFT","SUP-ITM-10096090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4047.26","2428.36","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2540.87","62.78","","780.86","208.94","10480.28","15","470.7","3132.58","percent of total billed charges",""
"BONE PLATE 2.4MM 2H 90DEG L DISTAL RAD TI VA LCP DRSL +/+/2 H SHAFT","SUP-ITM-10096090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4047.26","2428.36","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1769.46","43.72","","179.76","179.76","179.76","1 through 10","470.7","3132.58","percent of total billed charges",""
"BONE PLATE 2.4MM 2H 90DEG L DISTAL RAD TI VA LCP DRSL +/+/2 H SHAFT","SUP-ITM-10096090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4047.26","2428.36","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2943.17","72.72","","2355.45","298.99","3965.19","155","470.7","3132.58","percent of total billed charges",""
"BONE PLATE 2.4MM 2H 90DEG L DISTAL RAD TI VA LCP DRSL +/+/2 H SHAFT","SUP-ITM-10096090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4047.26","2428.36","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2943.17","72.72","","3643.09","3643.09","3643.09","1 through 10","470.7","3132.58","percent of total billed charges",""
"BONE PLATE 2.4MM 2H 90DEG L DISTAL RAD TI VA LCP DRSL +/+/2 H SHAFT","SUP-ITM-10096090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4047.26","2428.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2153.95","53.22","","554.28","554.28","554.28","16","470.7","3132.58","percent of total billed charges",""
"BONE PLATE 2.4MM 2H 90DEG L DISTAL RAD TI VA LCP DRSL +/+/2 H SHAFT","SUP-ITM-10096090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4047.26","2428.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2545.73","62.9","","619.64","173.09","2370.64","150","470.7","3132.58","percent of total billed charges",""
"BONE PLATE 2.4MM 2H 90DEG L DISTAL RAD TI VA LCP DRSL +/+/2 H SHAFT","SUP-ITM-10096090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4047.26","2428.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3132.58","77.4","","303.98","303.98","5854.79","1 through 10","470.7","3132.58","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3497.57","2098.54","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","406.77","2972.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3497.57","2098.54","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","406.77","2972.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3497.57","2098.54","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1990.12","56.9","","812.12","238.65","1587.46","163","406.77","2972.93","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3497.57","2098.54","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","406.77","11.63","","112.68","112.68","146.99","38","406.77","2972.93","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3497.57","2098.54","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2707.12","77.4","","303.98","303.98","5854.79","1 through 10","406.77","2972.93","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3497.57","2098.54","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","406.77","11.63","","112.68","112.68","146.99","38","406.77","2707.12","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3497.57","2098.54","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2195.77","62.78","","780.86","208.94","10480.28","15","406.77","2707.12","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3497.57","2098.54","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1529.14","43.72","","179.76","179.76","179.76","1 through 10","406.77","2707.12","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3497.57","2098.54","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2543.43","72.72","","2355.45","298.99","3965.19","155","406.77","2707.12","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3497.57","2098.54","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2543.43","72.72","","3643.09","3643.09","3643.09","1 through 10","406.77","2707.12","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3497.57","2098.54","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1861.41","53.22","","554.28","554.28","554.28","16","406.77","2707.12","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3497.57","2098.54","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2199.97","62.9","","619.64","173.09","2370.64","150","406.77","2707.12","percent of total billed charges",""
"BONE PLATE 2.4MM 3XDISTAL 41 HOLE 20DEG ARM VA LCP STAINLESS L SHAPE DORSAL RADIUS MINUS","SUP-ITM-10090910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3497.57","2098.54","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2707.12","77.4","","303.98","303.98","5854.79","1 through 10","406.77","2707.12","percent of total billed charges",""
"BONE PLATE 2.4MM 5 HOLE HEAD 3 VOLAR VA LCP TI COMPRESSION EXTRA ARTICULAR DISTAL RADIUS RIGHT","SUP-ITM-10095925","CDM","C1713","HCPCS","0278","RC","","","","both","","","4506.43","2703.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","524.1","3830.47","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4MM 5 HOLE HEAD 3 VOLAR VA LCP TI COMPRESSION EXTRA ARTICULAR DISTAL RADIUS RIGHT","SUP-ITM-10095925","CDM","C1713","HCPCS","0278","RC","","","","both","","","4506.43","2703.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","524.1","3830.47","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4MM 5 HOLE HEAD 3 VOLAR VA LCP TI COMPRESSION EXTRA ARTICULAR DISTAL RADIUS RIGHT","SUP-ITM-10095925","CDM","C1713","HCPCS","0278","RC","","","","both","","","4506.43","2703.86","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2564.16","56.9","","812.12","238.65","1587.46","163","524.1","3830.47","percent of total billed charges",""
"BONE PLATE 2.4MM 5 HOLE HEAD 3 VOLAR VA LCP TI COMPRESSION EXTRA ARTICULAR DISTAL RADIUS RIGHT","SUP-ITM-10095925","CDM","C1713","HCPCS","0278","RC","","","","both","","","4506.43","2703.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","524.10","11.63","","112.68","112.68","146.99","38","524.1","3830.47","percent of total billed charges",""
"BONE PLATE 2.4MM 5 HOLE HEAD 3 VOLAR VA LCP TI COMPRESSION EXTRA ARTICULAR DISTAL RADIUS RIGHT","SUP-ITM-10095925","CDM","C1713","HCPCS","0278","RC","","","","both","","","4506.43","2703.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3487.98","77.4","","303.98","303.98","5854.79","1 through 10","524.1","3830.47","percent of total billed charges",""
"BONE PLATE 2.4MM 5 HOLE HEAD 3 VOLAR VA LCP TI COMPRESSION EXTRA ARTICULAR DISTAL RADIUS RIGHT","SUP-ITM-10095925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4506.43","2703.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","524.10","11.63","","112.68","112.68","146.99","38","524.1","3487.98","percent of total billed charges",""
"BONE PLATE 2.4MM 5 HOLE HEAD 3 VOLAR VA LCP TI COMPRESSION EXTRA ARTICULAR DISTAL RADIUS RIGHT","SUP-ITM-10095925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4506.43","2703.86","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2829.14","62.78","","780.86","208.94","10480.28","15","524.1","3487.98","percent of total billed charges",""
"BONE PLATE 2.4MM 5 HOLE HEAD 3 VOLAR VA LCP TI COMPRESSION EXTRA ARTICULAR DISTAL RADIUS RIGHT","SUP-ITM-10095925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4506.43","2703.86","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1970.21","43.72","","179.76","179.76","179.76","1 through 10","524.1","3487.98","percent of total billed charges",""
"BONE PLATE 2.4MM 5 HOLE HEAD 3 VOLAR VA LCP TI COMPRESSION EXTRA ARTICULAR DISTAL RADIUS RIGHT","SUP-ITM-10095925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4506.43","2703.86","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3277.08","72.72","","2355.45","298.99","3965.19","155","524.1","3487.98","percent of total billed charges",""
"BONE PLATE 2.4MM 5 HOLE HEAD 3 VOLAR VA LCP TI COMPRESSION EXTRA ARTICULAR DISTAL RADIUS RIGHT","SUP-ITM-10095925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4506.43","2703.86","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3277.08","72.72","","3643.09","3643.09","3643.09","1 through 10","524.1","3487.98","percent of total billed charges",""
"BONE PLATE 2.4MM 5 HOLE HEAD 3 VOLAR VA LCP TI COMPRESSION EXTRA ARTICULAR DISTAL RADIUS RIGHT","SUP-ITM-10095925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4506.43","2703.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2398.32","53.22","","554.28","554.28","554.28","16","524.1","3487.98","percent of total billed charges",""
"BONE PLATE 2.4MM 5 HOLE HEAD 3 VOLAR VA LCP TI COMPRESSION EXTRA ARTICULAR DISTAL RADIUS RIGHT","SUP-ITM-10095925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4506.43","2703.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2834.54","62.9","","619.64","173.09","2370.64","150","524.1","3487.98","percent of total billed charges",""
"BONE PLATE 2.4MM 5 HOLE HEAD 3 VOLAR VA LCP TI COMPRESSION EXTRA ARTICULAR DISTAL RADIUS RIGHT","SUP-ITM-10095925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4506.43","2703.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3487.98","77.4","","303.98","303.98","5854.79","1 through 10","524.1","3487.98","percent of total billed charges",""
"BONE PLATE 2.4MM 6 HOLE 5 VA LCP TI VARIABLE ANGLE RIGHT RIM","SUP-ITM-10096108","CDM","C1713","HCPCS","0278","RC","","","","both","","","4645.52","2787.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","540.27","3948.69","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4MM 6 HOLE 5 VA LCP TI VARIABLE ANGLE RIGHT RIM","SUP-ITM-10096108","CDM","C1713","HCPCS","0278","RC","","","","both","","","4645.52","2787.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","540.27","3948.69","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4MM 6 HOLE 5 VA LCP TI VARIABLE ANGLE RIGHT RIM","SUP-ITM-10096108","CDM","C1713","HCPCS","0278","RC","","","","both","","","4645.52","2787.31","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2643.30","56.9","","812.12","238.65","1587.46","163","540.27","3948.69","percent of total billed charges",""
"BONE PLATE 2.4MM 6 HOLE 5 VA LCP TI VARIABLE ANGLE RIGHT RIM","SUP-ITM-10096108","CDM","C1713","HCPCS","0278","RC","","","","both","","","4645.52","2787.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","540.27","11.63","","112.68","112.68","146.99","38","540.27","3948.69","percent of total billed charges",""
"BONE PLATE 2.4MM 6 HOLE 5 VA LCP TI VARIABLE ANGLE RIGHT RIM","SUP-ITM-10096108","CDM","C1713","HCPCS","0278","RC","","","","both","","","4645.52","2787.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3595.63","77.4","","303.98","303.98","5854.79","1 through 10","540.27","3948.69","percent of total billed charges",""
"BONE PLATE 2.4MM 6 HOLE 5 VA LCP TI VARIABLE ANGLE RIGHT RIM","SUP-ITM-10096108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4645.52","2787.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","540.27","11.63","","112.68","112.68","146.99","38","540.27","3595.63","percent of total billed charges",""
"BONE PLATE 2.4MM 6 HOLE 5 VA LCP TI VARIABLE ANGLE RIGHT RIM","SUP-ITM-10096108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4645.52","2787.31","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2916.46","62.78","","780.86","208.94","10480.28","15","540.27","3595.63","percent of total billed charges",""
"BONE PLATE 2.4MM 6 HOLE 5 VA LCP TI VARIABLE ANGLE RIGHT RIM","SUP-ITM-10096108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4645.52","2787.31","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2031.02","43.72","","179.76","179.76","179.76","1 through 10","540.27","3595.63","percent of total billed charges",""
"BONE PLATE 2.4MM 6 HOLE 5 VA LCP TI VARIABLE ANGLE RIGHT RIM","SUP-ITM-10096108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4645.52","2787.31","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3378.22","72.72","","2355.45","298.99","3965.19","155","540.27","3595.63","percent of total billed charges",""
"BONE PLATE 2.4MM 6 HOLE 5 VA LCP TI VARIABLE ANGLE RIGHT RIM","SUP-ITM-10096108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4645.52","2787.31","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3378.22","72.72","","3643.09","3643.09","3643.09","1 through 10","540.27","3595.63","percent of total billed charges",""
"BONE PLATE 2.4MM 6 HOLE 5 VA LCP TI VARIABLE ANGLE RIGHT RIM","SUP-ITM-10096108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4645.52","2787.31","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2472.35","53.22","","554.28","554.28","554.28","16","540.27","3595.63","percent of total billed charges",""
"BONE PLATE 2.4MM 6 HOLE 5 VA LCP TI VARIABLE ANGLE RIGHT RIM","SUP-ITM-10096108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4645.52","2787.31","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2922.03","62.9","","619.64","173.09","2370.64","150","540.27","3595.63","percent of total billed charges",""
"BONE PLATE 2.4MM 6 HOLE 5 VA LCP TI VARIABLE ANGLE RIGHT RIM","SUP-ITM-10096108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4645.52","2787.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3595.63","77.4","","303.98","303.98","5854.79","1 through 10","540.27","3595.63","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","both","","","3776.25","2265.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","439.18","3209.81","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","both","","","3776.25","2265.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","439.18","3209.81","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","both","","","3776.25","2265.75","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2148.69","56.9","","812.12","238.65","1587.46","163","439.18","3209.81","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","both","","","3776.25","2265.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","439.18","11.63","","112.68","112.68","146.99","38","439.18","3209.81","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","both","","","3776.25","2265.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2922.82","77.4","","303.98","303.98","5854.79","1 through 10","439.18","3209.81","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3776.25","2265.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","439.18","11.63","","112.68","112.68","146.99","38","439.18","2922.82","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3776.25","2265.75","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2370.73","62.78","","780.86","208.94","10480.28","15","439.18","2922.82","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3776.25","2265.75","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1650.98","43.72","","179.76","179.76","179.76","1 through 10","439.18","2922.82","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3776.25","2265.75","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2746.09","72.72","","2355.45","298.99","3965.19","155","439.18","2922.82","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3776.25","2265.75","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2746.09","72.72","","3643.09","3643.09","3643.09","1 through 10","439.18","2922.82","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3776.25","2265.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2009.72","53.22","","554.28","554.28","554.28","16","439.18","2922.82","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3776.25","2265.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2375.26","62.9","","619.64","173.09","2370.64","150","439.18","2922.82","percent of total billed charges",""
"BONE PLATE 2.4MM/5 H 5H TI VA LCP DRSL DISTAL RAD/RADIAL COLUMN/SHAFT","SUP-ITM-10096102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3776.25","2265.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2922.82","77.4","","303.98","303.98","5854.79","1 through 10","439.18","2922.82","percent of total billed charges",""
"BONE PLATE 2.4MMX47 7 HOLE 2 VA LCP TI COMPRESSION RIGHT","SUP-ITM-10095975","CDM","C1713","HCPCS","0278","RC","","","","both","","","4092.93","2455.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","476.01","3478.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4MMX47 7 HOLE 2 VA LCP TI COMPRESSION RIGHT","SUP-ITM-10095975","CDM","C1713","HCPCS","0278","RC","","","","both","","","4092.93","2455.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","476.01","3478.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4MMX47 7 HOLE 2 VA LCP TI COMPRESSION RIGHT","SUP-ITM-10095975","CDM","C1713","HCPCS","0278","RC","","","","both","","","4092.93","2455.76","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2328.88","56.9","","812.12","238.65","1587.46","163","476.01","3478.99","percent of total billed charges",""
"BONE PLATE 2.4MMX47 7 HOLE 2 VA LCP TI COMPRESSION RIGHT","SUP-ITM-10095975","CDM","C1713","HCPCS","0278","RC","","","","both","","","4092.93","2455.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","476.01","11.63","","112.68","112.68","146.99","38","476.01","3478.99","percent of total billed charges",""
"BONE PLATE 2.4MMX47 7 HOLE 2 VA LCP TI COMPRESSION RIGHT","SUP-ITM-10095975","CDM","C1713","HCPCS","0278","RC","","","","both","","","4092.93","2455.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3167.93","77.4","","303.98","303.98","5854.79","1 through 10","476.01","3478.99","percent of total billed charges",""
"BONE PLATE 2.4MMX47 7 HOLE 2 VA LCP TI COMPRESSION RIGHT","SUP-ITM-10095975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4092.93","2455.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","476.01","11.63","","112.68","112.68","146.99","38","476.01","3167.93","percent of total billed charges",""
"BONE PLATE 2.4MMX47 7 HOLE 2 VA LCP TI COMPRESSION RIGHT","SUP-ITM-10095975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4092.93","2455.76","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2569.54","62.78","","780.86","208.94","10480.28","15","476.01","3167.93","percent of total billed charges",""
"BONE PLATE 2.4MMX47 7 HOLE 2 VA LCP TI COMPRESSION RIGHT","SUP-ITM-10095975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4092.93","2455.76","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1789.43","43.72","","179.76","179.76","179.76","1 through 10","476.01","3167.93","percent of total billed charges",""
"BONE PLATE 2.4MMX47 7 HOLE 2 VA LCP TI COMPRESSION RIGHT","SUP-ITM-10095975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4092.93","2455.76","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2976.38","72.72","","2355.45","298.99","3965.19","155","476.01","3167.93","percent of total billed charges",""
"BONE PLATE 2.4MMX47 7 HOLE 2 VA LCP TI COMPRESSION RIGHT","SUP-ITM-10095975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4092.93","2455.76","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2976.38","72.72","","3643.09","3643.09","3643.09","1 through 10","476.01","3167.93","percent of total billed charges",""
"BONE PLATE 2.4MMX47 7 HOLE 2 VA LCP TI COMPRESSION RIGHT","SUP-ITM-10095975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4092.93","2455.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2178.26","53.22","","554.28","554.28","554.28","16","476.01","3167.93","percent of total billed charges",""
"BONE PLATE 2.4MMX47 7 HOLE 2 VA LCP TI COMPRESSION RIGHT","SUP-ITM-10095975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4092.93","2455.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2574.45","62.9","","619.64","173.09","2370.64","150","476.01","3167.93","percent of total billed charges",""
"BONE PLATE 2.4MMX47 7 HOLE 2 VA LCP TI COMPRESSION RIGHT","SUP-ITM-10095975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4092.93","2455.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3167.93","77.4","","303.98","303.98","5854.79","1 through 10","476.01","3167.93","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","both","","","4947.21","2968.33","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","575.36","4205.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","both","","","4947.21","2968.33","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","575.36","4205.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","both","","","4947.21","2968.33","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2814.96","56.9","","812.12","238.65","1587.46","163","575.36","4205.13","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","both","","","4947.21","2968.33","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","575.36","11.63","","112.68","112.68","146.99","38","575.36","4205.13","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","both","","","4947.21","2968.33","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3829.14","77.4","","303.98","303.98","5854.79","1 through 10","575.36","4205.13","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4947.21","2968.33","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","575.36","11.63","","112.68","112.68","146.99","38","575.36","3829.14","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4947.21","2968.33","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3105.86","62.78","","780.86","208.94","10480.28","15","575.36","3829.14","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4947.21","2968.33","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2162.92","43.72","","179.76","179.76","179.76","1 through 10","575.36","3829.14","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4947.21","2968.33","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3597.61","72.72","","2355.45","298.99","3965.19","155","575.36","3829.14","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4947.21","2968.33","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3597.61","72.72","","3643.09","3643.09","3643.09","1 through 10","575.36","3829.14","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4947.21","2968.33","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2632.91","53.22","","554.28","554.28","554.28","16","575.36","3829.14","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4947.21","2968.33","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3111.80","62.9","","619.64","173.09","2370.64","150","575.36","3829.14","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM 4 HOLE VA LCP TITANIUM LOCKING STRAIGHT FUSION","SUP-ITM-10096303","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4947.21","2968.33","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3829.14","77.4","","303.98","303.98","5854.79","1 through 10","575.36","3829.14","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","both","","","5228.45","3137.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","608.07","4444.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","both","","","5228.45","3137.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","608.07","4444.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","both","","","5228.45","3137.07","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2974.99","56.9","","812.12","238.65","1587.46","163","608.07","4444.18","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","both","","","5228.45","3137.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","608.07","11.63","","112.68","112.68","146.99","38","608.07","4444.18","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","both","","","5228.45","3137.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4046.82","77.4","","303.98","303.98","5854.79","1 through 10","608.07","4444.18","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5228.45","3137.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","608.07","11.63","","112.68","112.68","146.99","38","608.07","4046.82","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5228.45","3137.07","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3282.42","62.78","","780.86","208.94","10480.28","15","608.07","4046.82","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5228.45","3137.07","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2285.88","43.72","","179.76","179.76","179.76","1 through 10","608.07","4046.82","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5228.45","3137.07","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3802.13","72.72","","2355.45","298.99","3965.19","155","608.07","4046.82","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5228.45","3137.07","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3802.13","72.72","","3643.09","3643.09","3643.09","1 through 10","608.07","4046.82","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5228.45","3137.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2782.58","53.22","","554.28","554.28","554.28","16","608.07","4046.82","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5228.45","3137.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3288.70","62.9","","619.64","173.09","2370.64","150","608.07","4046.82","percent of total billed charges",""
"BONE PLATE 2.4X2.7MM SHORT VA LCP TITANIUM CLOVERLEAF FUSION","SUP-ITM-10096290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5228.45","3137.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4046.82","77.4","","303.98","303.98","5854.79","1 through 10","608.07","4046.82","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","both","","","3617.73","2170.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","420.74","3075.07","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","both","","","3617.73","2170.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","420.74","3075.07","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","both","","","3617.73","2170.64","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2058.49","56.9","","812.12","238.65","1587.46","163","420.74","3075.07","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","both","","","3617.73","2170.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","420.74","11.63","","112.68","112.68","146.99","38","420.74","3075.07","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","both","","","3617.73","2170.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2800.12","77.4","","303.98","303.98","5854.79","1 through 10","420.74","3075.07","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3617.73","2170.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","420.74","11.63","","112.68","112.68","146.99","38","420.74","2800.12","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3617.73","2170.64","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2271.21","62.78","","780.86","208.94","10480.28","15","420.74","2800.12","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3617.73","2170.64","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1581.67","43.72","","179.76","179.76","179.76","1 through 10","420.74","2800.12","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3617.73","2170.64","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2630.81","72.72","","2355.45","298.99","3965.19","155","420.74","2800.12","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3617.73","2170.64","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2630.81","72.72","","3643.09","3643.09","3643.09","1 through 10","420.74","2800.12","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3617.73","2170.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1925.36","53.22","","554.28","554.28","554.28","16","420.74","2800.12","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3617.73","2170.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2275.55","62.9","","619.64","173.09","2370.64","150","420.74","2800.12","percent of total billed charges",""
"BONE PLATE 2.4X37MM 3 HOLE HEAD LCP STAINLESS DORSAL DISTAL RADIUS T SHAPE","SUP-ITM-10095136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3617.73","2170.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2800.12","77.4","","303.98","303.98","5854.79","1 through 10","420.74","2800.12","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10006089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3543.59","2126.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","412.12","3012.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4X54MM 2 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10006089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3543.59","2126.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","412.12","3012.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4X54MM 2 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10006089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3543.59","2126.15","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2016.30","56.9","","812.12","238.65","1587.46","163","412.12","3012.05","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10006089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3543.59","2126.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","412.12","11.63","","112.68","112.68","146.99","38","412.12","3012.05","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10006089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3543.59","2126.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2742.74","77.4","","303.98","303.98","5854.79","1 through 10","412.12","3012.05","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10006089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3543.59","2126.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","412.12","11.63","","112.68","112.68","146.99","38","412.12","2742.74","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10006089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3543.59","2126.15","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2224.67","62.78","","780.86","208.94","10480.28","15","412.12","2742.74","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10006089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3543.59","2126.15","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1549.26","43.72","","179.76","179.76","179.76","1 through 10","412.12","2742.74","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10006089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3543.59","2126.15","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2576.90","72.72","","2355.45","298.99","3965.19","155","412.12","2742.74","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10006089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3543.59","2126.15","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2576.90","72.72","","3643.09","3643.09","3643.09","1 through 10","412.12","2742.74","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10006089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3543.59","2126.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1885.90","53.22","","554.28","554.28","554.28","16","412.12","2742.74","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10006089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3543.59","2126.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2228.92","62.9","","619.64","173.09","2370.64","150","412.12","2742.74","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HD 8 SHAFT T SHAPE MODULAR HAND TITANIUM","SUP-ITM-10006089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3543.59","2126.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2742.74","77.4","","303.98","303.98","5854.79","1 through 10","412.12","2742.74","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095144","CDM","C1713","HCPCS","0278","RC","","","","both","","","4223.67","2534.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","491.21","3590.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4X57MM 6 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095144","CDM","C1713","HCPCS","0278","RC","","","","both","","","4223.67","2534.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","491.21","3590.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4X57MM 6 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095144","CDM","C1713","HCPCS","0278","RC","","","","both","","","4223.67","2534.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2403.27","56.9","","812.12","238.65","1587.46","163","491.21","3590.12","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095144","CDM","C1713","HCPCS","0278","RC","","","","both","","","4223.67","2534.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","491.21","11.63","","112.68","112.68","146.99","38","491.21","3590.12","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095144","CDM","C1713","HCPCS","0278","RC","","","","both","","","4223.67","2534.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3269.12","77.4","","303.98","303.98","5854.79","1 through 10","491.21","3590.12","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4223.67","2534.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","491.21","11.63","","112.68","112.68","146.99","38","491.21","3269.12","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4223.67","2534.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2651.62","62.78","","780.86","208.94","10480.28","15","491.21","3269.12","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4223.67","2534.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1846.59","43.72","","179.76","179.76","179.76","1 through 10","491.21","3269.12","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4223.67","2534.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3071.45","72.72","","2355.45","298.99","3965.19","155","491.21","3269.12","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4223.67","2534.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3071.45","72.72","","3643.09","3643.09","3643.09","1 through 10","491.21","3269.12","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4223.67","2534.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2247.84","53.22","","554.28","554.28","554.28","16","491.21","3269.12","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4223.67","2534.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2656.69","62.9","","619.64","173.09","2370.64","150","491.21","3269.12","percent of total billed charges",""
"BONE PLATE 2.4X57MM 6 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4223.67","2534.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3269.12","77.4","","303.98","303.98","5854.79","1 through 10","491.21","3269.12","percent of total billed charges",""
"BONE PLATE 2.4X57MM 7 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095146","CDM","C1713","HCPCS","0278","RC","","","","both","","","4223.67","2534.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","491.21","3590.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4X57MM 7 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095146","CDM","C1713","HCPCS","0278","RC","","","","both","","","4223.67","2534.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","491.21","3590.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4X57MM 7 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095146","CDM","C1713","HCPCS","0278","RC","","","","both","","","4223.67","2534.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2403.27","56.9","","812.12","238.65","1587.46","163","491.21","3590.12","percent of total billed charges",""
"BONE PLATE 2.4X57MM 7 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095146","CDM","C1713","HCPCS","0278","RC","","","","both","","","4223.67","2534.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","491.21","11.63","","112.68","112.68","146.99","38","491.21","3590.12","percent of total billed charges",""
"BONE PLATE 2.4X57MM 7 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095146","CDM","C1713","HCPCS","0278","RC","","","","both","","","4223.67","2534.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3269.12","77.4","","303.98","303.98","5854.79","1 through 10","491.21","3590.12","percent of total billed charges",""
"BONE PLATE 2.4X57MM 7 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095146","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4223.67","2534.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","491.21","11.63","","112.68","112.68","146.99","38","491.21","3269.12","percent of total billed charges",""
"BONE PLATE 2.4X57MM 7 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095146","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4223.67","2534.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2651.62","62.78","","780.86","208.94","10480.28","15","491.21","3269.12","percent of total billed charges",""
"BONE PLATE 2.4X57MM 7 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095146","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4223.67","2534.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1846.59","43.72","","179.76","179.76","179.76","1 through 10","491.21","3269.12","percent of total billed charges",""
"BONE PLATE 2.4X57MM 7 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095146","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4223.67","2534.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3071.45","72.72","","2355.45","298.99","3965.19","155","491.21","3269.12","percent of total billed charges",""
"BONE PLATE 2.4X57MM 7 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095146","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4223.67","2534.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3071.45","72.72","","3643.09","3643.09","3643.09","1 through 10","491.21","3269.12","percent of total billed charges",""
"BONE PLATE 2.4X57MM 7 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095146","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4223.67","2534.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2247.84","53.22","","554.28","554.28","554.28","16","491.21","3269.12","percent of total billed charges",""
"BONE PLATE 2.4X57MM 7 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095146","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4223.67","2534.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2656.69","62.9","","619.64","173.09","2370.64","150","491.21","3269.12","percent of total billed charges",""
"BONE PLATE 2.4X57MM 7 HOLE 5 LCP STAINLESS RIM RIGHT","SUP-ITM-10095146","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4223.67","2534.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3269.12","77.4","","303.98","303.98","5854.79","1 through 10","491.21","3269.12","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","3569.15","2141.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","415.09","3033.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","3569.15","2141.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","415.09","3033.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","3569.15","2141.49","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2030.85","56.9","","812.12","238.65","1587.46","163","415.09","3033.78","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","3569.15","2141.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","415.09","11.63","","112.68","112.68","146.99","38","415.09","3033.78","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","3569.15","2141.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2762.52","77.4","","303.98","303.98","5854.79","1 through 10","415.09","3033.78","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3569.15","2141.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","415.09","11.63","","112.68","112.68","146.99","38","415.09","2762.52","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3569.15","2141.49","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2240.71","62.78","","780.86","208.94","10480.28","15","415.09","2762.52","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3569.15","2141.49","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1560.43","43.72","","179.76","179.76","179.76","1 through 10","415.09","2762.52","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3569.15","2141.49","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2595.49","72.72","","2355.45","298.99","3965.19","155","415.09","2762.52","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3569.15","2141.49","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2595.49","72.72","","3643.09","3643.09","3643.09","1 through 10","415.09","2762.52","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3569.15","2141.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1899.50","53.22","","554.28","554.28","554.28","16","415.09","2762.52","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3569.15","2141.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2245.00","62.9","","619.64","173.09","2370.64","150","415.09","2762.52","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3569.15","2141.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2762.52","77.4","","303.98","303.98","5854.79","1 through 10","415.09","2762.52","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.90","2499.54","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","484.49","3541.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.90","2499.54","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","484.49","3541.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.90","2499.54","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2370.40","56.9","","812.12","238.65","1587.46","163","484.49","3541.02","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.90","2499.54","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","484.49","11.63","","112.68","112.68","146.99","38","484.49","3541.02","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.90","2499.54","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3224.41","77.4","","303.98","303.98","5854.79","1 through 10","484.49","3541.02","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4165.90","2499.54","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","484.49","11.63","","112.68","112.68","146.99","38","484.49","3224.41","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4165.90","2499.54","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2615.35","62.78","","780.86","208.94","10480.28","15","484.49","3224.41","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4165.90","2499.54","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1821.33","43.72","","179.76","179.76","179.76","1 through 10","484.49","3224.41","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4165.90","2499.54","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3029.44","72.72","","2355.45","298.99","3965.19","155","484.49","3224.41","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4165.90","2499.54","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3029.44","72.72","","3643.09","3643.09","3643.09","1 through 10","484.49","3224.41","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4165.90","2499.54","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2217.09","53.22","","554.28","554.28","554.28","16","484.49","3224.41","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4165.90","2499.54","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2620.35","62.9","","619.64","173.09","2370.64","150","484.49","3224.41","percent of total billed charges",""
"BONE PLATE 2.4X77MM 7 HOLE HEAD LCP STAINLESS 2 COLUMN 5 DISTAL VOLAR LEFT","SUP-ITM-10080033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4165.90","2499.54","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3224.41","77.4","","303.98","303.98","5854.79","1 through 10","484.49","3224.41","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.24","1359.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","263.45","1925.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.24","1359.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","263.45","1925.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.24","1359.14","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1288.92","56.9","","812.12","238.65","1587.46","163","263.45","1925.45","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.24","1359.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","263.45","11.63","","112.68","112.68","146.99","38","263.45","1925.45","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.24","1359.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1753.30","77.4","","303.98","303.98","5854.79","1 through 10","263.45","1925.45","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.24","1359.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","263.45","11.63","","112.68","112.68","146.99","38","263.45","1753.3","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.24","1359.14","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1422.12","62.78","","780.86","208.94","10480.28","15","263.45","1753.3","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.24","1359.14","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","990.36","43.72","","179.76","179.76","179.76","1 through 10","263.45","1753.3","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.24","1359.14","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1647.28","72.72","","2355.45","298.99","3965.19","155","263.45","1753.3","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.24","1359.14","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1647.28","72.72","","3643.09","3643.09","3643.09","1 through 10","263.45","1753.3","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.24","1359.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1205.56","53.22","","554.28","554.28","554.28","16","263.45","1753.3","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.24","1359.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1424.84","62.9","","619.64","173.09","2370.64","150","263.45","1753.3","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.24","1359.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1753.30","77.4","","303.98","303.98","5854.79","1 through 10","263.45","1753.3","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","both","","","1968.66","1181.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","228.96","1673.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","both","","","1968.66","1181.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","228.96","1673.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","both","","","1968.66","1181.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1120.17","56.9","","812.12","238.65","1587.46","163","228.96","1673.36","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","both","","","1968.66","1181.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","228.96","11.63","","112.68","112.68","146.99","38","228.96","1673.36","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","both","","","1968.66","1181.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1523.74","77.4","","303.98","303.98","5854.79","1 through 10","228.96","1673.36","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","228.96","11.63","","112.68","112.68","146.99","38","228.96","1523.74","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1235.92","62.78","","780.86","208.94","10480.28","15","228.96","1523.74","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","860.70","43.72","","179.76","179.76","179.76","1 through 10","228.96","1523.74","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1431.61","72.72","","2355.45","298.99","3965.19","155","228.96","1523.74","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1431.61","72.72","","3643.09","3643.09","3643.09","1 through 10","228.96","1523.74","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1047.72","53.22","","554.28","554.28","554.28","16","228.96","1523.74","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1238.29","62.9","","619.64","173.09","2370.64","150","228.96","1523.74","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE 4 LCP STAINLESS LEFT L SHAPE","SUP-ITM-10038152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1523.74","77.4","","303.98","303.98","5854.79","1 through 10","228.96","1523.74","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 105 4 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10130298","CDM","C1713","HCPCS","0278","RC","","","","both","","","8100.18","4860.11","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","942.05","6885.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.7MM 3.5 105 4 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10130298","CDM","C1713","HCPCS","0278","RC","","","","both","","","8100.18","4860.11","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","942.05","6885.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.7MM 3.5 105 4 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10130298","CDM","C1713","HCPCS","0278","RC","","","","both","","","8100.18","4860.11","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4609.00","56.9","","812.12","238.65","1587.46","163","942.05","6885.15","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 105 4 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10130298","CDM","C1713","HCPCS","0278","RC","","","","both","","","8100.18","4860.11","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","942.05","11.63","","112.68","112.68","146.99","38","942.05","6885.15","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 105 4 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10130298","CDM","C1713","HCPCS","0278","RC","","","","both","","","8100.18","4860.11","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6269.54","77.4","","303.98","303.98","5854.79","1 through 10","942.05","6885.15","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 105 4 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10130298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8100.18","4860.11","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","942.05","11.63","","112.68","112.68","146.99","38","942.05","6269.54","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 105 4 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10130298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8100.18","4860.11","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5085.29","62.78","","780.86","208.94","10480.28","15","942.05","6269.54","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 105 4 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10130298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8100.18","4860.11","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3541.40","43.72","","179.76","179.76","179.76","1 through 10","942.05","6269.54","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 105 4 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10130298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8100.18","4860.11","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5890.45","72.72","","2355.45","298.99","3965.19","155","942.05","6269.54","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 105 4 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10130298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8100.18","4860.11","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5890.45","72.72","","3643.09","3643.09","3643.09","1 through 10","942.05","6269.54","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 105 4 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10130298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8100.18","4860.11","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4310.92","53.22","","554.28","554.28","554.28","16","942.05","6269.54","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 105 4 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10130298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8100.18","4860.11","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5095.01","62.9","","619.64","173.09","2370.64","150","942.05","6269.54","percent of total billed charges",""
"BONE PLATE 2.7MM 3.5 105 4 HOLE VARIAX TITANIUM LOCKING DISTAL POSTERIOR LATERAL LEFT","SUP-ITM-10130298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8100.18","4860.11","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6269.54","77.4","","303.98","303.98","5854.79","1 through 10","942.05","6269.54","percent of total billed charges",""
"BONE PLATE 2.7MM 4 HOLE HEAD SHAFT LCP SS OBLIQUE RT L SHAPE","SUP-ITM-10038149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1968.66","1181.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","228.96","1673.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.7MM 4 HOLE HEAD SHAFT LCP SS OBLIQUE RT L SHAPE","SUP-ITM-10038149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1968.66","1181.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","228.96","1673.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.7MM 4 HOLE HEAD SHAFT LCP SS OBLIQUE RT L SHAPE","SUP-ITM-10038149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1968.66","1181.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1120.17","56.9","","812.12","238.65","1587.46","163","228.96","1673.36","percent of total billed charges",""
"BONE PLATE 2.7MM 4 HOLE HEAD SHAFT LCP SS OBLIQUE RT L SHAPE","SUP-ITM-10038149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1968.66","1181.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","228.96","11.63","","112.68","112.68","146.99","38","228.96","1673.36","percent of total billed charges",""
"BONE PLATE 2.7MM 4 HOLE HEAD SHAFT LCP SS OBLIQUE RT L SHAPE","SUP-ITM-10038149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1968.66","1181.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1523.74","77.4","","303.98","303.98","5854.79","1 through 10","228.96","1673.36","percent of total billed charges",""
"BONE PLATE 2.7MM 4 HOLE HEAD SHAFT LCP SS OBLIQUE RT L SHAPE","SUP-ITM-10038149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","228.96","11.63","","112.68","112.68","146.99","38","228.96","1523.74","percent of total billed charges",""
"BONE PLATE 2.7MM 4 HOLE HEAD SHAFT LCP SS OBLIQUE RT L SHAPE","SUP-ITM-10038149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1235.92","62.78","","780.86","208.94","10480.28","15","228.96","1523.74","percent of total billed charges",""
"BONE PLATE 2.7MM 4 HOLE HEAD SHAFT LCP SS OBLIQUE RT L SHAPE","SUP-ITM-10038149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","860.70","43.72","","179.76","179.76","179.76","1 through 10","228.96","1523.74","percent of total billed charges",""
"BONE PLATE 2.7MM 4 HOLE HEAD SHAFT LCP SS OBLIQUE RT L SHAPE","SUP-ITM-10038149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1431.61","72.72","","2355.45","298.99","3965.19","155","228.96","1523.74","percent of total billed charges",""
"BONE PLATE 2.7MM 4 HOLE HEAD SHAFT LCP SS OBLIQUE RT L SHAPE","SUP-ITM-10038149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1431.61","72.72","","3643.09","3643.09","3643.09","1 through 10","228.96","1523.74","percent of total billed charges",""
"BONE PLATE 2.7MM 4 HOLE HEAD SHAFT LCP SS OBLIQUE RT L SHAPE","SUP-ITM-10038149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1047.72","53.22","","554.28","554.28","554.28","16","228.96","1523.74","percent of total billed charges",""
"BONE PLATE 2.7MM 4 HOLE HEAD SHAFT LCP SS OBLIQUE RT L SHAPE","SUP-ITM-10038149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1238.29","62.9","","619.64","173.09","2370.64","150","228.96","1523.74","percent of total billed charges",""
"BONE PLATE 2.7MM 4 HOLE HEAD SHAFT LCP SS OBLIQUE RT L SHAPE","SUP-ITM-10038149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1523.74","77.4","","303.98","303.98","5854.79","1 through 10","228.96","1523.74","percent of total billed charges",""
"BONE PLATE 2.7MM 58 SM LOCKING VA CALCANEAL LEFT","SUP-ITM-10164581","CDM","C1713","HCPCS","0278","RC","","","","both","","","4778.47","2867.08","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","555.74","4061.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.7MM 58 SM LOCKING VA CALCANEAL LEFT","SUP-ITM-10164581","CDM","C1713","HCPCS","0278","RC","","","","both","","","4778.47","2867.08","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","555.74","4061.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.7MM 58 SM LOCKING VA CALCANEAL LEFT","SUP-ITM-10164581","CDM","C1713","HCPCS","0278","RC","","","","both","","","4778.47","2867.08","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2718.95","56.9","","812.12","238.65","1587.46","163","555.74","4061.7","percent of total billed charges",""
"BONE PLATE 2.7MM 58 SM LOCKING VA CALCANEAL LEFT","SUP-ITM-10164581","CDM","C1713","HCPCS","0278","RC","","","","both","","","4778.47","2867.08","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","555.74","11.63","","112.68","112.68","146.99","38","555.74","4061.7","percent of total billed charges",""
"BONE PLATE 2.7MM 58 SM LOCKING VA CALCANEAL LEFT","SUP-ITM-10164581","CDM","C1713","HCPCS","0278","RC","","","","both","","","4778.47","2867.08","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3698.54","77.4","","303.98","303.98","5854.79","1 through 10","555.74","4061.7","percent of total billed charges",""
"BONE PLATE 2.7MM 58 SM LOCKING VA CALCANEAL LEFT","SUP-ITM-10164581","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4778.47","2867.08","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","555.74","11.63","","112.68","112.68","146.99","38","555.74","3698.54","percent of total billed charges",""
"BONE PLATE 2.7MM 58 SM LOCKING VA CALCANEAL LEFT","SUP-ITM-10164581","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4778.47","2867.08","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2999.92","62.78","","780.86","208.94","10480.28","15","555.74","3698.54","percent of total billed charges",""
"BONE PLATE 2.7MM 58 SM LOCKING VA CALCANEAL LEFT","SUP-ITM-10164581","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4778.47","2867.08","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2089.15","43.72","","179.76","179.76","179.76","1 through 10","555.74","3698.54","percent of total billed charges",""
"BONE PLATE 2.7MM 58 SM LOCKING VA CALCANEAL LEFT","SUP-ITM-10164581","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4778.47","2867.08","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3474.90","72.72","","2355.45","298.99","3965.19","155","555.74","3698.54","percent of total billed charges",""
"BONE PLATE 2.7MM 58 SM LOCKING VA CALCANEAL LEFT","SUP-ITM-10164581","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4778.47","2867.08","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3474.90","72.72","","3643.09","3643.09","3643.09","1 through 10","555.74","3698.54","percent of total billed charges",""
"BONE PLATE 2.7MM 58 SM LOCKING VA CALCANEAL LEFT","SUP-ITM-10164581","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4778.47","2867.08","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2543.10","53.22","","554.28","554.28","554.28","16","555.74","3698.54","percent of total billed charges",""
"BONE PLATE 2.7MM 58 SM LOCKING VA CALCANEAL LEFT","SUP-ITM-10164581","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4778.47","2867.08","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3005.66","62.9","","619.64","173.09","2370.64","150","555.74","3698.54","percent of total billed charges",""
"BONE PLATE 2.7MM 58 SM LOCKING VA CALCANEAL LEFT","SUP-ITM-10164581","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4778.47","2867.08","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3698.54","77.4","","303.98","303.98","5854.79","1 through 10","555.74","3698.54","percent of total billed charges",""
"BONE PLATE 2.7MM 70 LG TI VA LOCKING CALCANEAL RIGHT PERI OP ORTHO IMPLANTS TRAUMA","SUP-ITM-10164293","CDM","C1713","HCPCS","0278","RC","","","","both","","","5330.72","3198.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","619.96","4531.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.7MM 70 LG TI VA LOCKING CALCANEAL RIGHT PERI OP ORTHO IMPLANTS TRAUMA","SUP-ITM-10164293","CDM","C1713","HCPCS","0278","RC","","","","both","","","5330.72","3198.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","619.96","4531.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.7MM 70 LG TI VA LOCKING CALCANEAL RIGHT PERI OP ORTHO IMPLANTS TRAUMA","SUP-ITM-10164293","CDM","C1713","HCPCS","0278","RC","","","","both","","","5330.72","3198.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3033.18","56.9","","812.12","238.65","1587.46","163","619.96","4531.11","percent of total billed charges",""
"BONE PLATE 2.7MM 70 LG TI VA LOCKING CALCANEAL RIGHT PERI OP ORTHO IMPLANTS TRAUMA","SUP-ITM-10164293","CDM","C1713","HCPCS","0278","RC","","","","both","","","5330.72","3198.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","619.96","11.63","","112.68","112.68","146.99","38","619.96","4531.11","percent of total billed charges",""
"BONE PLATE 2.7MM 70 LG TI VA LOCKING CALCANEAL RIGHT PERI OP ORTHO IMPLANTS TRAUMA","SUP-ITM-10164293","CDM","C1713","HCPCS","0278","RC","","","","both","","","5330.72","3198.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4125.98","77.4","","303.98","303.98","5854.79","1 through 10","619.96","4531.11","percent of total billed charges",""
"BONE PLATE 2.7MM 70 LG TI VA LOCKING CALCANEAL RIGHT PERI OP ORTHO IMPLANTS TRAUMA","SUP-ITM-10164293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5330.72","3198.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","619.96","11.63","","112.68","112.68","146.99","38","619.96","4125.98","percent of total billed charges",""
"BONE PLATE 2.7MM 70 LG TI VA LOCKING CALCANEAL RIGHT PERI OP ORTHO IMPLANTS TRAUMA","SUP-ITM-10164293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5330.72","3198.43","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3346.63","62.78","","780.86","208.94","10480.28","15","619.96","4125.98","percent of total billed charges",""
"BONE PLATE 2.7MM 70 LG TI VA LOCKING CALCANEAL RIGHT PERI OP ORTHO IMPLANTS TRAUMA","SUP-ITM-10164293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5330.72","3198.43","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2330.59","43.72","","179.76","179.76","179.76","1 through 10","619.96","4125.98","percent of total billed charges",""
"BONE PLATE 2.7MM 70 LG TI VA LOCKING CALCANEAL RIGHT PERI OP ORTHO IMPLANTS TRAUMA","SUP-ITM-10164293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5330.72","3198.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3876.50","72.72","","2355.45","298.99","3965.19","155","619.96","4125.98","percent of total billed charges",""
"BONE PLATE 2.7MM 70 LG TI VA LOCKING CALCANEAL RIGHT PERI OP ORTHO IMPLANTS TRAUMA","SUP-ITM-10164293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5330.72","3198.43","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3876.50","72.72","","3643.09","3643.09","3643.09","1 through 10","619.96","4125.98","percent of total billed charges",""
"BONE PLATE 2.7MM 70 LG TI VA LOCKING CALCANEAL RIGHT PERI OP ORTHO IMPLANTS TRAUMA","SUP-ITM-10164293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5330.72","3198.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2837.01","53.22","","554.28","554.28","554.28","16","619.96","4125.98","percent of total billed charges",""
"BONE PLATE 2.7MM 70 LG TI VA LOCKING CALCANEAL RIGHT PERI OP ORTHO IMPLANTS TRAUMA","SUP-ITM-10164293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5330.72","3198.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3353.02","62.9","","619.64","173.09","2370.64","150","619.96","4125.98","percent of total billed charges",""
"BONE PLATE 2.7MM 70 LG TI VA LOCKING CALCANEAL RIGHT PERI OP ORTHO IMPLANTS TRAUMA","SUP-ITM-10164293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5330.72","3198.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4125.98","77.4","","303.98","303.98","5854.79","1 through 10","619.96","4125.98","percent of total billed charges",""
"BONE PLATE 2.7MM DISTAL FIBULA TI VA LCP LATERAL 7 HOLE RIGHT","SUP-ITM-10286751","CDM","C1713","HCPCS","0278","RC","","","","both","","","4658.31","2794.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","541.76","3959.56","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.7MM DISTAL FIBULA TI VA LCP LATERAL 7 HOLE RIGHT","SUP-ITM-10286751","CDM","C1713","HCPCS","0278","RC","","","","both","","","4658.31","2794.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","541.76","3959.56","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.7MM DISTAL FIBULA TI VA LCP LATERAL 7 HOLE RIGHT","SUP-ITM-10286751","CDM","C1713","HCPCS","0278","RC","","","","both","","","4658.31","2794.99","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2650.58","56.9","","812.12","238.65","1587.46","163","541.76","3959.56","percent of total billed charges",""
"BONE PLATE 2.7MM DISTAL FIBULA TI VA LCP LATERAL 7 HOLE RIGHT","SUP-ITM-10286751","CDM","C1713","HCPCS","0278","RC","","","","both","","","4658.31","2794.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","541.76","11.63","","112.68","112.68","146.99","38","541.76","3959.56","percent of total billed charges",""
"BONE PLATE 2.7MM DISTAL FIBULA TI VA LCP LATERAL 7 HOLE RIGHT","SUP-ITM-10286751","CDM","C1713","HCPCS","0278","RC","","","","both","","","4658.31","2794.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3605.53","77.4","","303.98","303.98","5854.79","1 through 10","541.76","3959.56","percent of total billed charges",""
"BONE PLATE 2.7MM DISTAL FIBULA TI VA LCP LATERAL 7 HOLE RIGHT","SUP-ITM-10286751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4658.31","2794.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","541.76","11.63","","112.68","112.68","146.99","38","541.76","3605.53","percent of total billed charges",""
"BONE PLATE 2.7MM DISTAL FIBULA TI VA LCP LATERAL 7 HOLE RIGHT","SUP-ITM-10286751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4658.31","2794.99","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2924.49","62.78","","780.86","208.94","10480.28","15","541.76","3605.53","percent of total billed charges",""
"BONE PLATE 2.7MM DISTAL FIBULA TI VA LCP LATERAL 7 HOLE RIGHT","SUP-ITM-10286751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4658.31","2794.99","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2036.61","43.72","","179.76","179.76","179.76","1 through 10","541.76","3605.53","percent of total billed charges",""
"BONE PLATE 2.7MM DISTAL FIBULA TI VA LCP LATERAL 7 HOLE RIGHT","SUP-ITM-10286751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4658.31","2794.99","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3387.52","72.72","","2355.45","298.99","3965.19","155","541.76","3605.53","percent of total billed charges",""
"BONE PLATE 2.7MM DISTAL FIBULA TI VA LCP LATERAL 7 HOLE RIGHT","SUP-ITM-10286751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4658.31","2794.99","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3387.52","72.72","","3643.09","3643.09","3643.09","1 through 10","541.76","3605.53","percent of total billed charges",""
"BONE PLATE 2.7MM DISTAL FIBULA TI VA LCP LATERAL 7 HOLE RIGHT","SUP-ITM-10286751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4658.31","2794.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2479.15","53.22","","554.28","554.28","554.28","16","541.76","3605.53","percent of total billed charges",""
"BONE PLATE 2.7MM DISTAL FIBULA TI VA LCP LATERAL 7 HOLE RIGHT","SUP-ITM-10286751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4658.31","2794.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2930.08","62.9","","619.64","173.09","2370.64","150","541.76","3605.53","percent of total billed charges",""
"BONE PLATE 2.7MM DISTAL FIBULA TI VA LCP LATERAL 7 HOLE RIGHT","SUP-ITM-10286751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4658.31","2794.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3605.53","77.4","","303.98","303.98","5854.79","1 through 10","541.76","3605.53","percent of total billed charges",""
"BONE PLATE 2.7MM SM 6 HOLE PATELLA VA LOCKING STAINLESS ANTERIOR","SUP-ITM-10294352","CDM","C1776","HCPCS","0278","RC","","","","both","","","8692.36","5215.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1010.92","7388.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.7MM SM 6 HOLE PATELLA VA LOCKING STAINLESS ANTERIOR","SUP-ITM-10294352","CDM","C1776","HCPCS","0278","RC","","","","both","","","8692.36","5215.42","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4945.95","56.9","","2911.53","1863.86","5209.05","65","1010.92","7388.51","percent of total billed charges",""
"BONE PLATE 2.7MM SM 6 HOLE PATELLA VA LOCKING STAINLESS ANTERIOR","SUP-ITM-10294352","CDM","C1776","HCPCS","0278","RC","","","","both","","","8692.36","5215.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1010.92","11.63","","400.94","400.94","400.94","1 through 10","1010.92","7388.51","percent of total billed charges",""
"BONE PLATE 2.7MM SM 6 HOLE PATELLA VA LOCKING STAINLESS ANTERIOR","SUP-ITM-10294352","CDM","C1776","HCPCS","0278","RC","","","","both","","","8692.36","5215.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6727.89","77.4","","5214.50","5214.50","16415.28","1 through 10","1010.92","7388.51","percent of total billed charges",""
"BONE PLATE 2.7MM SM 6 HOLE PATELLA VA LOCKING STAINLESS ANTERIOR","SUP-ITM-10294352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8692.36","5215.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1010.92","11.63","","400.94","400.94","400.94","1 through 10","1010.92","6727.89","percent of total billed charges",""
"BONE PLATE 2.7MM SM 6 HOLE PATELLA VA LOCKING STAINLESS ANTERIOR","SUP-ITM-10294352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8692.36","5215.42","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3800.30","43.72","","1543.33","1543.33","1671.61","1 through 10","1010.92","6727.89","percent of total billed charges",""
"BONE PLATE 2.7MM SM 6 HOLE PATELLA VA LOCKING STAINLESS ANTERIOR","SUP-ITM-10294352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8692.36","5215.42","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6321.08","72.72","","3700.21","2382.07","6427.18","53","1010.92","6727.89","percent of total billed charges",""
"BONE PLATE 2.7MM SM 6 HOLE PATELLA VA LOCKING STAINLESS ANTERIOR","SUP-ITM-10294352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8692.36","5215.42","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6321.08","72.72","","12685.80","12685.80","12685.80","1 through 10","1010.92","6727.89","percent of total billed charges",""
"BONE PLATE 2.7MM SM 6 HOLE PATELLA VA LOCKING STAINLESS ANTERIOR","SUP-ITM-10294352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8692.36","5215.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5467.49","62.9","","3408.87","2784.05","9859.40","46","1010.92","6727.89","percent of total billed charges",""
"BONE PLATE 2.7MM SM 6 HOLE PATELLA VA LOCKING STAINLESS ANTERIOR","SUP-ITM-10294352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8692.36","5215.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6727.89","77.4","","5214.50","5214.50","16415.28","1 through 10","1010.92","6727.89","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","3180.53","1908.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","369.9","2703.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","3180.53","1908.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","369.9","2703.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","3180.53","1908.32","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1809.72","56.9","","812.12","238.65","1587.46","163","369.9","2703.45","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","3180.53","1908.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","369.90","11.63","","112.68","112.68","146.99","38","369.9","2703.45","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","3180.53","1908.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2461.73","77.4","","303.98","303.98","5854.79","1 through 10","369.9","2703.45","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3180.53","1908.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","369.90","11.63","","112.68","112.68","146.99","38","369.9","2461.73","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3180.53","1908.32","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1996.74","62.78","","780.86","208.94","10480.28","15","369.9","2461.73","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3180.53","1908.32","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1390.53","43.72","","179.76","179.76","179.76","1 through 10","369.9","2461.73","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3180.53","1908.32","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2312.88","72.72","","2355.45","298.99","3965.19","155","369.9","2461.73","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3180.53","1908.32","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2312.88","72.72","","3643.09","3643.09","3643.09","1 through 10","369.9","2461.73","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3180.53","1908.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1692.68","53.22","","554.28","554.28","554.28","16","369.9","2461.73","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3180.53","1908.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2000.55","62.9","","619.64","173.09","2370.64","150","369.9","2461.73","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3180.53","1908.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2461.73","77.4","","303.98","303.98","5854.79","1 through 10","369.9","2461.73","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","2053.03","1231.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","238.77","1745.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","2053.03","1231.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","238.77","1745.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","2053.03","1231.82","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1168.17","56.9","","812.12","238.65","1587.46","163","238.77","1745.08","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","2053.03","1231.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","238.77","11.63","","112.68","112.68","146.99","38","238.77","1745.08","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","2053.03","1231.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1589.05","77.4","","303.98","303.98","5854.79","1 through 10","238.77","1745.08","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2053.03","1231.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","238.77","11.63","","112.68","112.68","146.99","38","238.77","1589.05","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2053.03","1231.82","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1288.89","62.78","","780.86","208.94","10480.28","15","238.77","1589.05","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2053.03","1231.82","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","897.58","43.72","","179.76","179.76","179.76","1 through 10","238.77","1589.05","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2053.03","1231.82","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1492.96","72.72","","2355.45","298.99","3965.19","155","238.77","1589.05","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2053.03","1231.82","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1492.96","72.72","","3643.09","3643.09","3643.09","1 through 10","238.77","1589.05","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2053.03","1231.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1092.62","53.22","","554.28","554.28","554.28","16","238.77","1589.05","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2053.03","1231.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1291.36","62.9","","619.64","173.09","2370.64","150","238.77","1589.05","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2053.03","1231.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1589.05","77.4","","303.98","303.98","5854.79","1 through 10","238.77","1589.05","percent of total billed charges",""
"BONE PLATE 200MM 10 HOLE CLOVERLEAF THIN BLADE SS","SUP-ITM-10038030","CDM","C1713","HCPCS","0278","RC","","","","both","","","6182.05","3709.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","718.97","5254.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 200MM 10 HOLE CLOVERLEAF THIN BLADE SS","SUP-ITM-10038030","CDM","C1713","HCPCS","0278","RC","","","","both","","","6182.05","3709.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","718.97","5254.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 200MM 10 HOLE CLOVERLEAF THIN BLADE SS","SUP-ITM-10038030","CDM","C1713","HCPCS","0278","RC","","","","both","","","6182.05","3709.23","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3517.59","56.9","","812.12","238.65","1587.46","163","718.97","5254.74","percent of total billed charges",""
"BONE PLATE 200MM 10 HOLE CLOVERLEAF THIN BLADE SS","SUP-ITM-10038030","CDM","C1713","HCPCS","0278","RC","","","","both","","","6182.05","3709.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","718.97","11.63","","112.68","112.68","146.99","38","718.97","5254.74","percent of total billed charges",""
"BONE PLATE 200MM 10 HOLE CLOVERLEAF THIN BLADE SS","SUP-ITM-10038030","CDM","C1713","HCPCS","0278","RC","","","","both","","","6182.05","3709.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4784.91","77.4","","303.98","303.98","5854.79","1 through 10","718.97","5254.74","percent of total billed charges",""
"BONE PLATE 200MM 10 HOLE CLOVERLEAF THIN BLADE SS","SUP-ITM-10038030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6182.05","3709.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","718.97","11.63","","112.68","112.68","146.99","38","718.97","4784.91","percent of total billed charges",""
"BONE PLATE 200MM 10 HOLE CLOVERLEAF THIN BLADE SS","SUP-ITM-10038030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6182.05","3709.23","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3881.09","62.78","","780.86","208.94","10480.28","15","718.97","4784.91","percent of total billed charges",""
"BONE PLATE 200MM 10 HOLE CLOVERLEAF THIN BLADE SS","SUP-ITM-10038030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6182.05","3709.23","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2702.79","43.72","","179.76","179.76","179.76","1 through 10","718.97","4784.91","percent of total billed charges",""
"BONE PLATE 200MM 10 HOLE CLOVERLEAF THIN BLADE SS","SUP-ITM-10038030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6182.05","3709.23","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4495.59","72.72","","2355.45","298.99","3965.19","155","718.97","4784.91","percent of total billed charges",""
"BONE PLATE 200MM 10 HOLE CLOVERLEAF THIN BLADE SS","SUP-ITM-10038030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6182.05","3709.23","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4495.59","72.72","","3643.09","3643.09","3643.09","1 through 10","718.97","4784.91","percent of total billed charges",""
"BONE PLATE 200MM 10 HOLE CLOVERLEAF THIN BLADE SS","SUP-ITM-10038030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6182.05","3709.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3290.09","53.22","","554.28","554.28","554.28","16","718.97","4784.91","percent of total billed charges",""
"BONE PLATE 200MM 10 HOLE CLOVERLEAF THIN BLADE SS","SUP-ITM-10038030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6182.05","3709.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3888.51","62.9","","619.64","173.09","2370.64","150","718.97","4784.91","percent of total billed charges",""
"BONE PLATE 200MM 10 HOLE CLOVERLEAF THIN BLADE SS","SUP-ITM-10038030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6182.05","3709.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4784.91","77.4","","303.98","303.98","5854.79","1 through 10","718.97","4784.91","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","both","","","2421.19","1452.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","281.58","2058.01","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","both","","","2421.19","1452.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","281.58","2058.01","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","both","","","2421.19","1452.71","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1377.66","56.9","","812.12","238.65","1587.46","163","281.58","2058.01","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","both","","","2421.19","1452.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","281.58","11.63","","112.68","112.68","146.99","38","281.58","2058.01","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","both","","","2421.19","1452.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1874.00","77.4","","303.98","303.98","5854.79","1 through 10","281.58","2058.01","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2421.19","1452.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","281.58","11.63","","112.68","112.68","146.99","38","281.58","1874","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2421.19","1452.71","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1520.02","62.78","","780.86","208.94","10480.28","15","281.58","1874","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2421.19","1452.71","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1058.54","43.72","","179.76","179.76","179.76","1 through 10","281.58","1874","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2421.19","1452.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1760.69","72.72","","2355.45","298.99","3965.19","155","281.58","1874","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2421.19","1452.71","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1760.69","72.72","","3643.09","3643.09","3643.09","1 through 10","281.58","1874","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2421.19","1452.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1288.56","53.22","","554.28","554.28","554.28","16","281.58","1874","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2421.19","1452.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1522.93","62.9","","619.64","173.09","2370.64","150","281.58","1874","percent of total billed charges",""
"BONE PLATE 29X1.5MM 6 HOLE TI STRAIGHT","SUP-ITM-10005538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2421.19","1452.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1874.00","77.4","","303.98","303.98","5854.79","1 through 10","281.58","1874","percent of total billed charges",""
"BONE PLATE 2HOLE FEMORAL NECK SYSTEM TI","SUP-ITM-10297516","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.02","2545.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","493.46","3606.57","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2HOLE FEMORAL NECK SYSTEM TI","SUP-ITM-10297516","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.02","2545.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","493.46","3606.57","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2HOLE FEMORAL NECK SYSTEM TI","SUP-ITM-10297516","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.02","2545.81","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2414.28","56.9","","812.12","238.65","1587.46","163","493.46","3606.57","percent of total billed charges",""
"BONE PLATE 2HOLE FEMORAL NECK SYSTEM TI","SUP-ITM-10297516","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.02","2545.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","493.46","11.63","","112.68","112.68","146.99","38","493.46","3606.57","percent of total billed charges",""
"BONE PLATE 2HOLE FEMORAL NECK SYSTEM TI","SUP-ITM-10297516","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.02","2545.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3284.10","77.4","","303.98","303.98","5854.79","1 through 10","493.46","3606.57","percent of total billed charges",""
"BONE PLATE 2HOLE FEMORAL NECK SYSTEM TI","SUP-ITM-10297516","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4243.02","2545.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","493.46","11.63","","112.68","112.68","146.99","38","493.46","3284.1","percent of total billed charges",""
"BONE PLATE 2HOLE FEMORAL NECK SYSTEM TI","SUP-ITM-10297516","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4243.02","2545.81","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2663.77","62.78","","780.86","208.94","10480.28","15","493.46","3284.1","percent of total billed charges",""
"BONE PLATE 2HOLE FEMORAL NECK SYSTEM TI","SUP-ITM-10297516","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4243.02","2545.81","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1855.05","43.72","","179.76","179.76","179.76","1 through 10","493.46","3284.1","percent of total billed charges",""
"BONE PLATE 2HOLE FEMORAL NECK SYSTEM TI","SUP-ITM-10297516","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4243.02","2545.81","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3085.52","72.72","","2355.45","298.99","3965.19","155","493.46","3284.1","percent of total billed charges",""
"BONE PLATE 2HOLE FEMORAL NECK SYSTEM TI","SUP-ITM-10297516","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4243.02","2545.81","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3085.52","72.72","","3643.09","3643.09","3643.09","1 through 10","493.46","3284.1","percent of total billed charges",""
"BONE PLATE 2HOLE FEMORAL NECK SYSTEM TI","SUP-ITM-10297516","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4243.02","2545.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2258.14","53.22","","554.28","554.28","554.28","16","493.46","3284.1","percent of total billed charges",""
"BONE PLATE 2HOLE FEMORAL NECK SYSTEM TI","SUP-ITM-10297516","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4243.02","2545.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2668.86","62.9","","619.64","173.09","2370.64","150","493.46","3284.1","percent of total billed charges",""
"BONE PLATE 2HOLE FEMORAL NECK SYSTEM TI","SUP-ITM-10297516","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4243.02","2545.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3284.10","77.4","","303.98","303.98","5854.79","1 through 10","493.46","3284.1","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.98","1757.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","340.76","2490.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.98","1757.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","340.76","2490.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.98","1757.99","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1667.16","56.9","","812.12","238.65","1587.46","163","340.76","2490.48","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.98","1757.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","340.76","11.63","","112.68","112.68","146.99","38","340.76","2490.48","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","2929.98","1757.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2267.80","77.4","","303.98","303.98","5854.79","1 through 10","340.76","2490.48","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.98","1757.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","340.76","11.63","","112.68","112.68","146.99","38","340.76","2267.8","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.98","1757.99","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1839.44","62.78","","780.86","208.94","10480.28","15","340.76","2267.8","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.98","1757.99","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1280.99","43.72","","179.76","179.76","179.76","1 through 10","340.76","2267.8","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.98","1757.99","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2130.68","72.72","","2355.45","298.99","3965.19","155","340.76","2267.8","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.98","1757.99","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2130.68","72.72","","3643.09","3643.09","3643.09","1 through 10","340.76","2267.8","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.98","1757.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1559.34","53.22","","554.28","554.28","554.28","16","340.76","2267.8","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.98","1757.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1842.96","62.9","","619.64","173.09","2370.64","150","340.76","2267.8","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2929.98","1757.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2267.80","77.4","","303.98","303.98","5854.79","1 through 10","340.76","2267.8","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","2147.63","1288.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","249.77","1825.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","2147.63","1288.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","249.77","1825.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","2147.63","1288.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1222.00","56.9","","812.12","238.65","1587.46","163","249.77","1825.49","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","2147.63","1288.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","249.77","11.63","","112.68","112.68","146.99","38","249.77","1825.49","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","2147.63","1288.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1662.27","77.4","","303.98","303.98","5854.79","1 through 10","249.77","1825.49","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2147.63","1288.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","249.77","11.63","","112.68","112.68","146.99","38","249.77","1662.27","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2147.63","1288.58","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1348.28","62.78","","780.86","208.94","10480.28","15","249.77","1662.27","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2147.63","1288.58","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","938.94","43.72","","179.76","179.76","179.76","1 through 10","249.77","1662.27","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2147.63","1288.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1561.76","72.72","","2355.45","298.99","3965.19","155","249.77","1662.27","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2147.63","1288.58","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1561.76","72.72","","3643.09","3643.09","3643.09","1 through 10","249.77","1662.27","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2147.63","1288.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1142.97","53.22","","554.28","554.28","554.28","16","249.77","1662.27","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2147.63","1288.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1350.86","62.9","","619.64","173.09","2370.64","150","249.77","1662.27","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2147.63","1288.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1662.27","77.4","","303.98","303.98","5854.79","1 through 10","249.77","1662.27","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","both","","","2738.23","1642.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","318.46","2327.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","both","","","2738.23","1642.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","318.46","2327.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","both","","","2738.23","1642.94","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1558.05","56.9","","812.12","238.65","1587.46","163","318.46","2327.5","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","both","","","2738.23","1642.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","318.46","11.63","","112.68","112.68","146.99","38","318.46","2327.5","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","both","","","2738.23","1642.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2119.39","77.4","","303.98","303.98","5854.79","1 through 10","318.46","2327.5","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2738.23","1642.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","318.46","11.63","","112.68","112.68","146.99","38","318.46","2119.39","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2738.23","1642.94","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1719.06","62.78","","780.86","208.94","10480.28","15","318.46","2119.39","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2738.23","1642.94","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1197.15","43.72","","179.76","179.76","179.76","1 through 10","318.46","2119.39","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2738.23","1642.94","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1991.24","72.72","","2355.45","298.99","3965.19","155","318.46","2119.39","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2738.23","1642.94","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1991.24","72.72","","3643.09","3643.09","3643.09","1 through 10","318.46","2119.39","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2738.23","1642.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1457.29","53.22","","554.28","554.28","554.28","16","318.46","2119.39","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2738.23","1642.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1722.35","62.9","","619.64","173.09","2370.64","150","318.46","2119.39","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2738.23","1642.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2119.39","77.4","","303.98","303.98","5854.79","1 through 10","318.46","2119.39","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.70","194.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","37.76","276","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.70","194.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","37.76","276","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.70","194.82","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","184.75","56.9","","812.12","238.65","1587.46","163","37.76","276","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.70","194.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","37.76","11.63","","112.68","112.68","146.99","38","37.76","276","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.70","194.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","251.32","77.4","","303.98","303.98","5854.79","1 through 10","37.76","276","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","324.70","194.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","37.76","11.63","","112.68","112.68","146.99","38","37.76","251.32","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","324.70","194.82","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","203.85","62.78","","780.86","208.94","10480.28","15","37.76","251.32","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","324.70","194.82","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","141.96","43.72","","179.76","179.76","179.76","1 through 10","37.76","251.32","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","324.70","194.82","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","236.12","72.72","","2355.45","298.99","3965.19","155","37.76","251.32","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","324.70","194.82","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","236.12","72.72","","3643.09","3643.09","3643.09","1 through 10","37.76","251.32","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","324.70","194.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","172.81","53.22","","554.28","554.28","554.28","16","37.76","251.32","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","324.70","194.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","204.24","62.9","","619.64","173.09","2370.64","150","37.76","251.32","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","324.70","194.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","251.32","77.4","","303.98","303.98","5854.79","1 through 10","37.76","251.32","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2134.84","1280.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","248.28","1814.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2134.84","1280.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","248.28","1814.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2134.84","1280.90","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1214.72","56.9","","812.12","238.65","1587.46","163","248.28","1814.61","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2134.84","1280.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","248.28","11.63","","112.68","112.68","146.99","38","248.28","1814.61","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","2134.84","1280.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1652.37","77.4","","303.98","303.98","5854.79","1 through 10","248.28","1814.61","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2134.84","1280.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","248.28","11.63","","112.68","112.68","146.99","38","248.28","1652.37","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2134.84","1280.90","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1340.25","62.78","","780.86","208.94","10480.28","15","248.28","1652.37","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2134.84","1280.90","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","933.35","43.72","","179.76","179.76","179.76","1 through 10","248.28","1652.37","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2134.84","1280.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1552.46","72.72","","2355.45","298.99","3965.19","155","248.28","1652.37","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2134.84","1280.90","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1552.46","72.72","","3643.09","3643.09","3643.09","1 through 10","248.28","1652.37","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2134.84","1280.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1136.16","53.22","","554.28","554.28","554.28","16","248.28","1652.37","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2134.84","1280.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1342.81","62.9","","619.64","173.09","2370.64","150","248.28","1652.37","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2134.84","1280.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1652.37","77.4","","303.98","303.98","5854.79","1 through 10","248.28","1652.37","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1216.99","730.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","141.54","1034.44","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1216.99","730.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","141.54","1034.44","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1216.99","730.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","692.47","56.9","","812.12","238.65","1587.46","163","141.54","1034.44","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1216.99","730.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","141.54","11.63","","112.68","112.68","146.99","38","141.54","1034.44","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1216.99","730.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","941.95","77.4","","303.98","303.98","5854.79","1 through 10","141.54","1034.44","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1216.99","730.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","141.54","11.63","","112.68","112.68","146.99","38","141.54","941.95","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1216.99","730.19","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","764.03","62.78","","780.86","208.94","10480.28","15","141.54","941.95","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1216.99","730.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","532.07","43.72","","179.76","179.76","179.76","1 through 10","141.54","941.95","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1216.99","730.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","885.00","72.72","","2355.45","298.99","3965.19","155","141.54","941.95","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1216.99","730.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","885.00","72.72","","3643.09","3643.09","3643.09","1 through 10","141.54","941.95","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1216.99","730.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","647.68","53.22","","554.28","554.28","554.28","16","141.54","941.95","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1216.99","730.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","765.49","62.9","","619.64","173.09","2370.64","150","141.54","941.95","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1216.99","730.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","941.95","77.4","","303.98","303.98","5854.79","1 through 10","141.54","941.95","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","both","","","4816.82","2890.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","560.2","4094.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","both","","","4816.82","2890.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","560.2","4094.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","both","","","4816.82","2890.09","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2740.77","56.9","","812.12","238.65","1587.46","163","560.2","4094.3","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","both","","","4816.82","2890.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","560.20","11.63","","112.68","112.68","146.99","38","560.2","4094.3","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","both","","","4816.82","2890.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3728.22","77.4","","303.98","303.98","5854.79","1 through 10","560.2","4094.3","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4816.82","2890.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","560.20","11.63","","112.68","112.68","146.99","38","560.2","3728.22","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4816.82","2890.09","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3024.00","62.78","","780.86","208.94","10480.28","15","560.2","3728.22","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4816.82","2890.09","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2105.91","43.72","","179.76","179.76","179.76","1 through 10","560.2","3728.22","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4816.82","2890.09","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3502.79","72.72","","2355.45","298.99","3965.19","155","560.2","3728.22","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4816.82","2890.09","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3502.79","72.72","","3643.09","3643.09","3643.09","1 through 10","560.2","3728.22","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4816.82","2890.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2563.51","53.22","","554.28","554.28","554.28","16","560.2","3728.22","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4816.82","2890.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3029.78","62.9","","619.64","173.09","2370.64","150","560.2","3728.22","percent of total billed charges",""
"BONE PLATE 3.5MM 280 20HOLE LCP RECONSTRUCTION SYN","SUP-ITM-10011603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4816.82","2890.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3728.22","77.4","","303.98","303.98","5854.79","1 through 10","560.2","3728.22","percent of total billed charges",""
"BONE PLATE 3.5MM 4 HOLE HEAD 9 SHAFT T SHAPE RIGHT ANGLE SS","SUP-ITM-10037972","CDM","C1713","HCPCS","0278","RC","","","","both","","","3313.48","1988.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","385.36","2816.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MM 4 HOLE HEAD 9 SHAFT T SHAPE RIGHT ANGLE SS","SUP-ITM-10037972","CDM","C1713","HCPCS","0278","RC","","","","both","","","3313.48","1988.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","385.36","2816.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MM 4 HOLE HEAD 9 SHAFT T SHAPE RIGHT ANGLE SS","SUP-ITM-10037972","CDM","C1713","HCPCS","0278","RC","","","","both","","","3313.48","1988.09","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1885.37","56.9","","812.12","238.65","1587.46","163","385.36","2816.46","percent of total billed charges",""
"BONE PLATE 3.5MM 4 HOLE HEAD 9 SHAFT T SHAPE RIGHT ANGLE SS","SUP-ITM-10037972","CDM","C1713","HCPCS","0278","RC","","","","both","","","3313.48","1988.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","385.36","11.63","","112.68","112.68","146.99","38","385.36","2816.46","percent of total billed charges",""
"BONE PLATE 3.5MM 4 HOLE HEAD 9 SHAFT T SHAPE RIGHT ANGLE SS","SUP-ITM-10037972","CDM","C1713","HCPCS","0278","RC","","","","both","","","3313.48","1988.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2564.63","77.4","","303.98","303.98","5854.79","1 through 10","385.36","2816.46","percent of total billed charges",""
"BONE PLATE 3.5MM 4 HOLE HEAD 9 SHAFT T SHAPE RIGHT ANGLE SS","SUP-ITM-10037972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3313.48","1988.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","385.36","11.63","","112.68","112.68","146.99","38","385.36","2564.63","percent of total billed charges",""
"BONE PLATE 3.5MM 4 HOLE HEAD 9 SHAFT T SHAPE RIGHT ANGLE SS","SUP-ITM-10037972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3313.48","1988.09","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2080.20","62.78","","780.86","208.94","10480.28","15","385.36","2564.63","percent of total billed charges",""
"BONE PLATE 3.5MM 4 HOLE HEAD 9 SHAFT T SHAPE RIGHT ANGLE SS","SUP-ITM-10037972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3313.48","1988.09","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1448.65","43.72","","179.76","179.76","179.76","1 through 10","385.36","2564.63","percent of total billed charges",""
"BONE PLATE 3.5MM 4 HOLE HEAD 9 SHAFT T SHAPE RIGHT ANGLE SS","SUP-ITM-10037972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3313.48","1988.09","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2409.56","72.72","","2355.45","298.99","3965.19","155","385.36","2564.63","percent of total billed charges",""
"BONE PLATE 3.5MM 4 HOLE HEAD 9 SHAFT T SHAPE RIGHT ANGLE SS","SUP-ITM-10037972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3313.48","1988.09","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2409.56","72.72","","3643.09","3643.09","3643.09","1 through 10","385.36","2564.63","percent of total billed charges",""
"BONE PLATE 3.5MM 4 HOLE HEAD 9 SHAFT T SHAPE RIGHT ANGLE SS","SUP-ITM-10037972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3313.48","1988.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1763.43","53.22","","554.28","554.28","554.28","16","385.36","2564.63","percent of total billed charges",""
"BONE PLATE 3.5MM 4 HOLE HEAD 9 SHAFT T SHAPE RIGHT ANGLE SS","SUP-ITM-10037972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3313.48","1988.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2084.18","62.9","","619.64","173.09","2370.64","150","385.36","2564.63","percent of total billed charges",""
"BONE PLATE 3.5MM 4 HOLE HEAD 9 SHAFT T SHAPE RIGHT ANGLE SS","SUP-ITM-10037972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3313.48","1988.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2564.63","77.4","","303.98","303.98","5854.79","1 through 10","385.36","2564.63","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.22","1033.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","200.41","1464.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.22","1033.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","200.41","1464.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.22","1033.93","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","980.51","56.9","","812.12","238.65","1587.46","163","200.41","1464.74","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.22","1033.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","200.41","11.63","","112.68","112.68","146.99","38","200.41","1464.74","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.22","1033.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1333.77","77.4","","303.98","303.98","5854.79","1 through 10","200.41","1464.74","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1723.22","1033.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","200.41","11.63","","112.68","112.68","146.99","38","200.41","1333.77","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1723.22","1033.93","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1081.84","62.78","","780.86","208.94","10480.28","15","200.41","1333.77","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1723.22","1033.93","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","753.39","43.72","","179.76","179.76","179.76","1 through 10","200.41","1333.77","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1723.22","1033.93","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1253.13","72.72","","2355.45","298.99","3965.19","155","200.41","1333.77","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1723.22","1033.93","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1253.13","72.72","","3643.09","3643.09","3643.09","1 through 10","200.41","1333.77","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1723.22","1033.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","917.10","53.22","","554.28","554.28","554.28","16","200.41","1333.77","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1723.22","1033.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1083.91","62.9","","619.64","173.09","2370.64","150","200.41","1333.77","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1723.22","1033.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1333.77","77.4","","303.98","303.98","5854.79","1 through 10","200.41","1333.77","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","both","","","7296.15","4377.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","848.54","6201.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","both","","","7296.15","4377.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","848.54","6201.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","both","","","7296.15","4377.69","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4151.51","56.9","","812.12","238.65","1587.46","163","848.54","6201.73","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","both","","","7296.15","4377.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","848.54","11.63","","112.68","112.68","146.99","38","848.54","6201.73","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","both","","","7296.15","4377.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5647.22","77.4","","303.98","303.98","5854.79","1 through 10","848.54","6201.73","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7296.15","4377.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","848.54","11.63","","112.68","112.68","146.99","38","848.54","5647.22","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7296.15","4377.69","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4580.52","62.78","","780.86","208.94","10480.28","15","848.54","5647.22","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7296.15","4377.69","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3189.88","43.72","","179.76","179.76","179.76","1 through 10","848.54","5647.22","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7296.15","4377.69","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5305.76","72.72","","2355.45","298.99","3965.19","155","848.54","5647.22","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7296.15","4377.69","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5305.76","72.72","","3643.09","3643.09","3643.09","1 through 10","848.54","5647.22","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7296.15","4377.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3883.01","53.22","","554.28","554.28","554.28","16","848.54","5647.22","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7296.15","4377.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4589.28","62.9","","619.64","173.09","2370.64","150","848.54","5647.22","percent of total billed charges",""
"BONE PLATE 3.5MM SM RING ATTACHMENT VA-LOCKING PPFX GREATER TROCHANTER SS LEFT","SUP-ITM-10297807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7296.15","4377.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5647.22","77.4","","303.98","303.98","5854.79","1 through 10","848.54","5647.22","percent of total billed charges",""
"BONE PLATE 3.5MMX100 4 HOLE HEAD 8 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037971","CDM","C1713","HCPCS","0278","RC","","","","both","","","3096.16","1857.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","360.08","2631.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MMX100 4 HOLE HEAD 8 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037971","CDM","C1713","HCPCS","0278","RC","","","","both","","","3096.16","1857.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","360.08","2631.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MMX100 4 HOLE HEAD 8 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037971","CDM","C1713","HCPCS","0278","RC","","","","both","","","3096.16","1857.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1761.72","56.9","","812.12","238.65","1587.46","163","360.08","2631.74","percent of total billed charges",""
"BONE PLATE 3.5MMX100 4 HOLE HEAD 8 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037971","CDM","C1713","HCPCS","0278","RC","","","","both","","","3096.16","1857.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","360.08","11.63","","112.68","112.68","146.99","38","360.08","2631.74","percent of total billed charges",""
"BONE PLATE 3.5MMX100 4 HOLE HEAD 8 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037971","CDM","C1713","HCPCS","0278","RC","","","","both","","","3096.16","1857.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2396.43","77.4","","303.98","303.98","5854.79","1 through 10","360.08","2631.74","percent of total billed charges",""
"BONE PLATE 3.5MMX100 4 HOLE HEAD 8 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3096.16","1857.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","360.08","11.63","","112.68","112.68","146.99","38","360.08","2396.43","percent of total billed charges",""
"BONE PLATE 3.5MMX100 4 HOLE HEAD 8 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3096.16","1857.70","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1943.77","62.78","","780.86","208.94","10480.28","15","360.08","2396.43","percent of total billed charges",""
"BONE PLATE 3.5MMX100 4 HOLE HEAD 8 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3096.16","1857.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1353.64","43.72","","179.76","179.76","179.76","1 through 10","360.08","2396.43","percent of total billed charges",""
"BONE PLATE 3.5MMX100 4 HOLE HEAD 8 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3096.16","1857.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2251.53","72.72","","2355.45","298.99","3965.19","155","360.08","2396.43","percent of total billed charges",""
"BONE PLATE 3.5MMX100 4 HOLE HEAD 8 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3096.16","1857.70","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2251.53","72.72","","3643.09","3643.09","3643.09","1 through 10","360.08","2396.43","percent of total billed charges",""
"BONE PLATE 3.5MMX100 4 HOLE HEAD 8 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3096.16","1857.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1647.78","53.22","","554.28","554.28","554.28","16","360.08","2396.43","percent of total billed charges",""
"BONE PLATE 3.5MMX100 4 HOLE HEAD 8 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3096.16","1857.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1947.48","62.9","","619.64","173.09","2370.64","150","360.08","2396.43","percent of total billed charges",""
"BONE PLATE 3.5MMX100 4 HOLE HEAD 8 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3096.16","1857.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2396.43","77.4","","303.98","303.98","5854.79","1 through 10","360.08","2396.43","percent of total billed charges",""
"BONE PLATE 3.5MMX107 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10037952","CDM","C1713","HCPCS","0278","RC","","","","both","","","2257.57","1354.54","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","262.56","1918.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MMX107 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10037952","CDM","C1713","HCPCS","0278","RC","","","","both","","","2257.57","1354.54","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","262.56","1918.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MMX107 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10037952","CDM","C1713","HCPCS","0278","RC","","","","both","","","2257.57","1354.54","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1284.56","56.9","","812.12","238.65","1587.46","163","262.56","1918.93","percent of total billed charges",""
"BONE PLATE 3.5MMX107 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10037952","CDM","C1713","HCPCS","0278","RC","","","","both","","","2257.57","1354.54","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","262.56","11.63","","112.68","112.68","146.99","38","262.56","1918.93","percent of total billed charges",""
"BONE PLATE 3.5MMX107 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10037952","CDM","C1713","HCPCS","0278","RC","","","","both","","","2257.57","1354.54","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1747.36","77.4","","303.98","303.98","5854.79","1 through 10","262.56","1918.93","percent of total billed charges",""
"BONE PLATE 3.5MMX107 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10037952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2257.57","1354.54","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","262.56","11.63","","112.68","112.68","146.99","38","262.56","1747.36","percent of total billed charges",""
"BONE PLATE 3.5MMX107 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10037952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2257.57","1354.54","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1417.30","62.78","","780.86","208.94","10480.28","15","262.56","1747.36","percent of total billed charges",""
"BONE PLATE 3.5MMX107 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10037952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2257.57","1354.54","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","987.01","43.72","","179.76","179.76","179.76","1 through 10","262.56","1747.36","percent of total billed charges",""
"BONE PLATE 3.5MMX107 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10037952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2257.57","1354.54","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1641.70","72.72","","2355.45","298.99","3965.19","155","262.56","1747.36","percent of total billed charges",""
"BONE PLATE 3.5MMX107 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10037952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2257.57","1354.54","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1641.70","72.72","","3643.09","3643.09","3643.09","1 through 10","262.56","1747.36","percent of total billed charges",""
"BONE PLATE 3.5MMX107 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10037952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2257.57","1354.54","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1201.48","53.22","","554.28","554.28","554.28","16","262.56","1747.36","percent of total billed charges",""
"BONE PLATE 3.5MMX107 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10037952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2257.57","1354.54","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1420.01","62.9","","619.64","173.09","2370.64","150","262.56","1747.36","percent of total billed charges",""
"BONE PLATE 3.5MMX107 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10037952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2257.57","1354.54","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1747.36","77.4","","303.98","303.98","5854.79","1 through 10","262.56","1747.36","percent of total billed charges",""
"BONE PLATE 3.5MMX176 13 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025391","CDM","C1713","HCPCS","0278","RC","","","","both","","","2377.73","1426.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","276.53","2021.07","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MMX176 13 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025391","CDM","C1713","HCPCS","0278","RC","","","","both","","","2377.73","1426.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","276.53","2021.07","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MMX176 13 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025391","CDM","C1713","HCPCS","0278","RC","","","","both","","","2377.73","1426.64","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1352.93","56.9","","812.12","238.65","1587.46","163","276.53","2021.07","percent of total billed charges",""
"BONE PLATE 3.5MMX176 13 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025391","CDM","C1713","HCPCS","0278","RC","","","","both","","","2377.73","1426.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","276.53","11.63","","112.68","112.68","146.99","38","276.53","2021.07","percent of total billed charges",""
"BONE PLATE 3.5MMX176 13 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025391","CDM","C1713","HCPCS","0278","RC","","","","both","","","2377.73","1426.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1840.36","77.4","","303.98","303.98","5854.79","1 through 10","276.53","2021.07","percent of total billed charges",""
"BONE PLATE 3.5MMX176 13 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2377.73","1426.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","276.53","11.63","","112.68","112.68","146.99","38","276.53","1840.36","percent of total billed charges",""
"BONE PLATE 3.5MMX176 13 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2377.73","1426.64","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1492.74","62.78","","780.86","208.94","10480.28","15","276.53","1840.36","percent of total billed charges",""
"BONE PLATE 3.5MMX176 13 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2377.73","1426.64","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1039.54","43.72","","179.76","179.76","179.76","1 through 10","276.53","1840.36","percent of total billed charges",""
"BONE PLATE 3.5MMX176 13 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2377.73","1426.64","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1729.09","72.72","","2355.45","298.99","3965.19","155","276.53","1840.36","percent of total billed charges",""
"BONE PLATE 3.5MMX176 13 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2377.73","1426.64","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1729.09","72.72","","3643.09","3643.09","3643.09","1 through 10","276.53","1840.36","percent of total billed charges",""
"BONE PLATE 3.5MMX176 13 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2377.73","1426.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1265.43","53.22","","554.28","554.28","554.28","16","276.53","1840.36","percent of total billed charges",""
"BONE PLATE 3.5MMX176 13 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2377.73","1426.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1495.59","62.9","","619.64","173.09","2370.64","150","276.53","1840.36","percent of total billed charges",""
"BONE PLATE 3.5MMX176 13 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2377.73","1426.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1840.36","77.4","","303.98","303.98","5854.79","1 through 10","276.53","1840.36","percent of total billed charges",""
"BONE PLATE 3.5MMX202 15 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025392","CDM","C1713","HCPCS","0278","RC","","","","both","","","3316.04","1989.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","385.66","2818.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MMX202 15 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025392","CDM","C1713","HCPCS","0278","RC","","","","both","","","3316.04","1989.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","385.66","2818.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MMX202 15 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025392","CDM","C1713","HCPCS","0278","RC","","","","both","","","3316.04","1989.62","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1886.83","56.9","","812.12","238.65","1587.46","163","385.66","2818.63","percent of total billed charges",""
"BONE PLATE 3.5MMX202 15 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025392","CDM","C1713","HCPCS","0278","RC","","","","both","","","3316.04","1989.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","385.66","11.63","","112.68","112.68","146.99","38","385.66","2818.63","percent of total billed charges",""
"BONE PLATE 3.5MMX202 15 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025392","CDM","C1713","HCPCS","0278","RC","","","","both","","","3316.04","1989.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2566.61","77.4","","303.98","303.98","5854.79","1 through 10","385.66","2818.63","percent of total billed charges",""
"BONE PLATE 3.5MMX202 15 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3316.04","1989.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","385.66","11.63","","112.68","112.68","146.99","38","385.66","2566.61","percent of total billed charges",""
"BONE PLATE 3.5MMX202 15 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3316.04","1989.62","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2081.81","62.78","","780.86","208.94","10480.28","15","385.66","2566.61","percent of total billed charges",""
"BONE PLATE 3.5MMX202 15 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3316.04","1989.62","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1449.77","43.72","","179.76","179.76","179.76","1 through 10","385.66","2566.61","percent of total billed charges",""
"BONE PLATE 3.5MMX202 15 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3316.04","1989.62","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2411.42","72.72","","2355.45","298.99","3965.19","155","385.66","2566.61","percent of total billed charges",""
"BONE PLATE 3.5MMX202 15 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3316.04","1989.62","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2411.42","72.72","","3643.09","3643.09","3643.09","1 through 10","385.66","2566.61","percent of total billed charges",""
"BONE PLATE 3.5MMX202 15 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3316.04","1989.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1764.80","53.22","","554.28","554.28","554.28","16","385.66","2566.61","percent of total billed charges",""
"BONE PLATE 3.5MMX202 15 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3316.04","1989.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2085.79","62.9","","619.64","173.09","2370.64","150","385.66","2566.61","percent of total billed charges",""
"BONE PLATE 3.5MMX202 15 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10025392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3316.04","1989.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2566.61","77.4","","303.98","303.98","5854.79","1 through 10","385.66","2566.61","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","both","","","1669.53","1001.72","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","194.17","1419.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","both","","","1669.53","1001.72","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","194.17","1419.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","both","","","1669.53","1001.72","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","949.96","56.9","","812.12","238.65","1587.46","163","194.17","1419.1","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","both","","","1669.53","1001.72","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","194.17","11.63","","112.68","112.68","146.99","38","194.17","1419.1","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","both","","","1669.53","1001.72","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1292.22","77.4","","303.98","303.98","5854.79","1 through 10","194.17","1419.1","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1669.53","1001.72","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","194.17","11.63","","112.68","112.68","146.99","38","194.17","1292.22","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1669.53","1001.72","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1048.13","62.78","","780.86","208.94","10480.28","15","194.17","1292.22","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1669.53","1001.72","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","729.92","43.72","","179.76","179.76","179.76","1 through 10","194.17","1292.22","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1669.53","1001.72","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1214.08","72.72","","2355.45","298.99","3965.19","155","194.17","1292.22","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1669.53","1001.72","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1214.08","72.72","","3643.09","3643.09","3643.09","1 through 10","194.17","1292.22","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1669.53","1001.72","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","888.52","53.22","","554.28","554.28","554.28","16","194.17","1292.22","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1669.53","1001.72","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1050.13","62.9","","619.64","173.09","2370.64","150","194.17","1292.22","percent of total billed charges",""
"BONE PLATE 3.5MMX57 3 HOLE HEAD 4 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10037967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1669.53","1001.72","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1292.22","77.4","","303.98","303.98","5854.79","1 through 10","194.17","1292.22","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","both","","","2132.29","1279.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","247.99","1812.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","both","","","2132.29","1279.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","247.99","1812.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","both","","","2132.29","1279.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1213.27","56.9","","812.12","238.65","1587.46","163","247.99","1812.45","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","both","","","2132.29","1279.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","247.99","11.63","","112.68","112.68","146.99","38","247.99","1812.45","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","both","","","2132.29","1279.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1650.39","77.4","","303.98","303.98","5854.79","1 through 10","247.99","1812.45","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2132.29","1279.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","247.99","11.63","","112.68","112.68","146.99","38","247.99","1650.39","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2132.29","1279.37","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1338.65","62.78","","780.86","208.94","10480.28","15","247.99","1650.39","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2132.29","1279.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","932.24","43.72","","179.76","179.76","179.76","1 through 10","247.99","1650.39","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2132.29","1279.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1550.60","72.72","","2355.45","298.99","3965.19","155","247.99","1650.39","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2132.29","1279.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1550.60","72.72","","3643.09","3643.09","3643.09","1 through 10","247.99","1650.39","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2132.29","1279.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1134.80","53.22","","554.28","554.28","554.28","16","247.99","1650.39","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2132.29","1279.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1341.21","62.9","","619.64","173.09","2370.64","150","247.99","1650.39","percent of total billed charges",""
"BONE PLATE 3.5MMX77 3 HOLE HEAD 6 SHAFT T SHAPE RIGHT ANGLE LCP SS","SUP-ITM-10037968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2132.29","1279.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1650.39","77.4","","303.98","303.98","5854.79","1 through 10","247.99","1650.39","percent of total billed charges",""
"BONE PLATE 3.5MMX89 4 HOLE HEAD 7 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037969","CDM","C1713","HCPCS","0278","RC","","","","both","","","2584.82","1550.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","300.61","2197.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MMX89 4 HOLE HEAD 7 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037969","CDM","C1713","HCPCS","0278","RC","","","","both","","","2584.82","1550.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","300.61","2197.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MMX89 4 HOLE HEAD 7 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037969","CDM","C1713","HCPCS","0278","RC","","","","both","","","2584.82","1550.89","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1470.76","56.9","","812.12","238.65","1587.46","163","300.61","2197.1","percent of total billed charges",""
"BONE PLATE 3.5MMX89 4 HOLE HEAD 7 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037969","CDM","C1713","HCPCS","0278","RC","","","","both","","","2584.82","1550.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","300.61","11.63","","112.68","112.68","146.99","38","300.61","2197.1","percent of total billed charges",""
"BONE PLATE 3.5MMX89 4 HOLE HEAD 7 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037969","CDM","C1713","HCPCS","0278","RC","","","","both","","","2584.82","1550.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2000.65","77.4","","303.98","303.98","5854.79","1 through 10","300.61","2197.1","percent of total billed charges",""
"BONE PLATE 3.5MMX89 4 HOLE HEAD 7 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2584.82","1550.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","300.61","11.63","","112.68","112.68","146.99","38","300.61","2000.65","percent of total billed charges",""
"BONE PLATE 3.5MMX89 4 HOLE HEAD 7 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2584.82","1550.89","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1622.75","62.78","","780.86","208.94","10480.28","15","300.61","2000.65","percent of total billed charges",""
"BONE PLATE 3.5MMX89 4 HOLE HEAD 7 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2584.82","1550.89","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1130.08","43.72","","179.76","179.76","179.76","1 through 10","300.61","2000.65","percent of total billed charges",""
"BONE PLATE 3.5MMX89 4 HOLE HEAD 7 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2584.82","1550.89","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1879.68","72.72","","2355.45","298.99","3965.19","155","300.61","2000.65","percent of total billed charges",""
"BONE PLATE 3.5MMX89 4 HOLE HEAD 7 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2584.82","1550.89","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1879.68","72.72","","3643.09","3643.09","3643.09","1 through 10","300.61","2000.65","percent of total billed charges",""
"BONE PLATE 3.5MMX89 4 HOLE HEAD 7 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2584.82","1550.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1375.64","53.22","","554.28","554.28","554.28","16","300.61","2000.65","percent of total billed charges",""
"BONE PLATE 3.5MMX89 4 HOLE HEAD 7 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2584.82","1550.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1625.85","62.9","","619.64","173.09","2370.64","150","300.61","2000.65","percent of total billed charges",""
"BONE PLATE 3.5MMX89 4 HOLE HEAD 7 SHAFT BONE LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2584.82","1550.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2000.65","77.4","","303.98","303.98","5854.79","1 through 10","300.61","2000.65","percent of total billed charges",""
"BONE PLATE 3.5MMX97 3 HOLE HEAD 8 SHAFT LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037970","CDM","C1713","HCPCS","0278","RC","","","","both","","","3108.95","1865.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","361.57","2642.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MMX97 3 HOLE HEAD 8 SHAFT LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037970","CDM","C1713","HCPCS","0278","RC","","","","both","","","3108.95","1865.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","361.57","2642.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5MMX97 3 HOLE HEAD 8 SHAFT LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037970","CDM","C1713","HCPCS","0278","RC","","","","both","","","3108.95","1865.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1768.99","56.9","","812.12","238.65","1587.46","163","361.57","2642.61","percent of total billed charges",""
"BONE PLATE 3.5MMX97 3 HOLE HEAD 8 SHAFT LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037970","CDM","C1713","HCPCS","0278","RC","","","","both","","","3108.95","1865.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","361.57","11.63","","112.68","112.68","146.99","38","361.57","2642.61","percent of total billed charges",""
"BONE PLATE 3.5MMX97 3 HOLE HEAD 8 SHAFT LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037970","CDM","C1713","HCPCS","0278","RC","","","","both","","","3108.95","1865.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2406.33","77.4","","303.98","303.98","5854.79","1 through 10","361.57","2642.61","percent of total billed charges",""
"BONE PLATE 3.5MMX97 3 HOLE HEAD 8 SHAFT LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3108.95","1865.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","361.57","11.63","","112.68","112.68","146.99","38","361.57","2406.33","percent of total billed charges",""
"BONE PLATE 3.5MMX97 3 HOLE HEAD 8 SHAFT LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3108.95","1865.37","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1951.80","62.78","","780.86","208.94","10480.28","15","361.57","2406.33","percent of total billed charges",""
"BONE PLATE 3.5MMX97 3 HOLE HEAD 8 SHAFT LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3108.95","1865.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1359.23","43.72","","179.76","179.76","179.76","1 through 10","361.57","2406.33","percent of total billed charges",""
"BONE PLATE 3.5MMX97 3 HOLE HEAD 8 SHAFT LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3108.95","1865.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2260.83","72.72","","2355.45","298.99","3965.19","155","361.57","2406.33","percent of total billed charges",""
"BONE PLATE 3.5MMX97 3 HOLE HEAD 8 SHAFT LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3108.95","1865.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2260.83","72.72","","3643.09","3643.09","3643.09","1 through 10","361.57","2406.33","percent of total billed charges",""
"BONE PLATE 3.5MMX97 3 HOLE HEAD 8 SHAFT LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3108.95","1865.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1654.58","53.22","","554.28","554.28","554.28","16","361.57","2406.33","percent of total billed charges",""
"BONE PLATE 3.5MMX97 3 HOLE HEAD 8 SHAFT LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3108.95","1865.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1955.53","62.9","","619.64","173.09","2370.64","150","361.57","2406.33","percent of total billed charges",""
"BONE PLATE 3.5MMX97 3 HOLE HEAD 8 SHAFT LCP STAINLESS T SHAPE RIGHT ANGLE","SUP-ITM-10037970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3108.95","1865.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2406.33","77.4","","303.98","303.98","5854.79","1 through 10","361.57","2406.33","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","1810.14","1086.08","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","210.52","1538.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","1810.14","1086.08","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","210.52","1538.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","1810.14","1086.08","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1029.97","56.9","","812.12","238.65","1587.46","163","210.52","1538.62","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","1810.14","1086.08","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","210.52","11.63","","112.68","112.68","146.99","38","210.52","1538.62","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","1810.14","1086.08","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1401.05","77.4","","303.98","303.98","5854.79","1 through 10","210.52","1538.62","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1810.14","1086.08","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","210.52","11.63","","112.68","112.68","146.99","38","210.52","1401.05","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1810.14","1086.08","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1136.41","62.78","","780.86","208.94","10480.28","15","210.52","1401.05","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1810.14","1086.08","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","791.39","43.72","","179.76","179.76","179.76","1 through 10","210.52","1401.05","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1810.14","1086.08","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1316.33","72.72","","2355.45","298.99","3965.19","155","210.52","1401.05","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1810.14","1086.08","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1316.33","72.72","","3643.09","3643.09","3643.09","1 through 10","210.52","1401.05","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1810.14","1086.08","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","963.36","53.22","","554.28","554.28","554.28","16","210.52","1401.05","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1810.14","1086.08","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1138.58","62.9","","619.64","173.09","2370.64","150","210.52","1401.05","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1810.14","1086.08","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1401.05","77.4","","303.98","303.98","5854.79","1 through 10","210.52","1401.05","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","both","","","2855.83","1713.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","332.13","2427.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","both","","","2855.83","1713.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","332.13","2427.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","both","","","2855.83","1713.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1624.97","56.9","","812.12","238.65","1587.46","163","332.13","2427.46","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","both","","","2855.83","1713.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","332.13","11.63","","112.68","112.68","146.99","38","332.13","2427.46","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","both","","","2855.83","1713.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2210.41","77.4","","303.98","303.98","5854.79","1 through 10","332.13","2427.46","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2855.83","1713.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","332.13","11.63","","112.68","112.68","146.99","38","332.13","2210.41","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2855.83","1713.50","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1792.89","62.78","","780.86","208.94","10480.28","15","332.13","2210.41","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2855.83","1713.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1248.57","43.72","","179.76","179.76","179.76","1 through 10","332.13","2210.41","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2855.83","1713.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2076.76","72.72","","2355.45","298.99","3965.19","155","332.13","2210.41","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2855.83","1713.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2076.76","72.72","","3643.09","3643.09","3643.09","1 through 10","332.13","2210.41","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2855.83","1713.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1519.87","53.22","","554.28","554.28","554.28","16","332.13","2210.41","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2855.83","1713.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1796.32","62.9","","619.64","173.09","2370.64","150","332.13","2210.41","percent of total billed charges",""
"BONE PLATE 3.5X106MM 9 HOLE RECONSTRUCTION SS","SUP-ITM-10004231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2855.83","1713.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2210.41","77.4","","303.98","303.98","5854.79","1 through 10","332.13","2210.41","percent of total billed charges",""
"BONE PLATE 3.5X107MM 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10038037","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.24","1359.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","263.45","1925.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X107MM 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10038037","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.24","1359.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","263.45","1925.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X107MM 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10038037","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.24","1359.14","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1288.92","56.9","","812.12","238.65","1587.46","163","263.45","1925.45","percent of total billed charges",""
"BONE PLATE 3.5X107MM 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10038037","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.24","1359.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","263.45","11.63","","112.68","112.68","146.99","38","263.45","1925.45","percent of total billed charges",""
"BONE PLATE 3.5X107MM 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10038037","CDM","C1713","HCPCS","0278","RC","","","","both","","","2265.24","1359.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1753.30","77.4","","303.98","303.98","5854.79","1 through 10","263.45","1925.45","percent of total billed charges",""
"BONE PLATE 3.5X107MM 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10038037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.24","1359.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","263.45","11.63","","112.68","112.68","146.99","38","263.45","1753.3","percent of total billed charges",""
"BONE PLATE 3.5X107MM 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10038037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.24","1359.14","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1422.12","62.78","","780.86","208.94","10480.28","15","263.45","1753.3","percent of total billed charges",""
"BONE PLATE 3.5X107MM 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10038037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.24","1359.14","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","990.36","43.72","","179.76","179.76","179.76","1 through 10","263.45","1753.3","percent of total billed charges",""
"BONE PLATE 3.5X107MM 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10038037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.24","1359.14","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1647.28","72.72","","2355.45","298.99","3965.19","155","263.45","1753.3","percent of total billed charges",""
"BONE PLATE 3.5X107MM 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10038037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.24","1359.14","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1647.28","72.72","","3643.09","3643.09","3643.09","1 through 10","263.45","1753.3","percent of total billed charges",""
"BONE PLATE 3.5X107MM 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10038037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.24","1359.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1205.56","53.22","","554.28","554.28","554.28","16","263.45","1753.3","percent of total billed charges",""
"BONE PLATE 3.5X107MM 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10038037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.24","1359.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1424.84","62.9","","619.64","173.09","2370.64","150","263.45","1753.3","percent of total billed charges",""
"BONE PLATE 3.5X107MM 3 HOLE HEAD 8 SHAFT LCP SS T SHAPE OBLIQUE","SUP-ITM-10038037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2265.24","1359.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1753.30","77.4","","303.98","303.98","5854.79","1 through 10","263.45","1753.3","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","both","","","940.87","564.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","109.42","799.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","both","","","940.87","564.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","109.42","799.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","both","","","940.87","564.52","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","535.36","56.9","","812.12","238.65","1587.46","163","109.42","799.74","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","both","","","940.87","564.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","109.42","11.63","","112.68","112.68","146.99","38","109.42","799.74","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","both","","","940.87","564.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","728.23","77.4","","303.98","303.98","5854.79","1 through 10","109.42","799.74","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","940.87","564.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","109.42","11.63","","112.68","112.68","146.99","38","109.42","728.23","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","940.87","564.52","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","590.68","62.78","","780.86","208.94","10480.28","15","109.42","728.23","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","940.87","564.52","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","411.35","43.72","","179.76","179.76","179.76","1 through 10","109.42","728.23","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","940.87","564.52","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","684.20","72.72","","2355.45","298.99","3965.19","155","109.42","728.23","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","940.87","564.52","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","684.20","72.72","","3643.09","3643.09","3643.09","1 through 10","109.42","728.23","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","940.87","564.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","500.73","53.22","","554.28","554.28","554.28","16","109.42","728.23","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","940.87","564.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","591.81","62.9","","619.64","173.09","2370.64","150","109.42","728.23","percent of total billed charges",""
"BONE PLATE 3.5X109MM 9 HOLE LCP SS 1/3 TUBULAR COLLAR","SUP-ITM-10038005","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","940.87","564.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","728.23","77.4","","303.98","303.98","5854.79","1 through 10","109.42","728.23","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","1884.29","1130.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","219.14","1601.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","1884.29","1130.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","219.14","1601.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","1884.29","1130.57","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1072.16","56.9","","812.12","238.65","1587.46","163","219.14","1601.65","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","1884.29","1130.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","219.14","11.63","","112.68","112.68","146.99","38","219.14","1601.65","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","1884.29","1130.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1458.44","77.4","","303.98","303.98","5854.79","1 through 10","219.14","1601.65","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1884.29","1130.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","219.14","11.63","","112.68","112.68","146.99","38","219.14","1458.44","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1884.29","1130.57","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1182.96","62.78","","780.86","208.94","10480.28","15","219.14","1458.44","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1884.29","1130.57","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","823.81","43.72","","179.76","179.76","179.76","1 through 10","219.14","1458.44","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1884.29","1130.57","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1370.26","72.72","","2355.45","298.99","3965.19","155","219.14","1458.44","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1884.29","1130.57","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1370.26","72.72","","3643.09","3643.09","3643.09","1 through 10","219.14","1458.44","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1884.29","1130.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1002.82","53.22","","554.28","554.28","554.28","16","219.14","1458.44","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1884.29","1130.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1185.22","62.9","","619.64","173.09","2370.64","150","219.14","1458.44","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1884.29","1130.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1458.44","77.4","","303.98","303.98","5854.79","1 through 10","219.14","1458.44","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","both","","","2109.28","1265.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","245.31","1792.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","both","","","2109.28","1265.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","245.31","1792.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","both","","","2109.28","1265.57","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1200.18","56.9","","812.12","238.65","1587.46","163","245.31","1792.89","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","both","","","2109.28","1265.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","245.31","11.63","","112.68","112.68","146.99","38","245.31","1792.89","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","both","","","2109.28","1265.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1632.58","77.4","","303.98","303.98","5854.79","1 through 10","245.31","1792.89","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2109.28","1265.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","245.31","11.63","","112.68","112.68","146.99","38","245.31","1632.58","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2109.28","1265.57","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1324.21","62.78","","780.86","208.94","10480.28","15","245.31","1632.58","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2109.28","1265.57","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","922.18","43.72","","179.76","179.76","179.76","1 through 10","245.31","1632.58","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2109.28","1265.57","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1533.87","72.72","","2355.45","298.99","3965.19","155","245.31","1632.58","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2109.28","1265.57","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1533.87","72.72","","3643.09","3643.09","3643.09","1 through 10","245.31","1632.58","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2109.28","1265.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1122.56","53.22","","554.28","554.28","554.28","16","245.31","1632.58","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2109.28","1265.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1326.74","62.9","","619.64","173.09","2370.64","150","245.31","1632.58","percent of total billed charges",""
"BONE PLATE 3.5X121MM 10 HOLE DCP SS","SUP-ITM-10041357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2109.28","1265.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1632.58","77.4","","303.98","303.98","5854.79","1 through 10","245.31","1632.58","percent of total billed charges",""
"BONE PLATE 3.5X126MM 9 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038092","CDM","C1713","HCPCS","0278","RC","","","","both","","","2855.83","1713.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","332.13","2427.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X126MM 9 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038092","CDM","C1713","HCPCS","0278","RC","","","","both","","","2855.83","1713.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","332.13","2427.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X126MM 9 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038092","CDM","C1713","HCPCS","0278","RC","","","","both","","","2855.83","1713.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1624.97","56.9","","812.12","238.65","1587.46","163","332.13","2427.46","percent of total billed charges",""
"BONE PLATE 3.5X126MM 9 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038092","CDM","C1713","HCPCS","0278","RC","","","","both","","","2855.83","1713.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","332.13","11.63","","112.68","112.68","146.99","38","332.13","2427.46","percent of total billed charges",""
"BONE PLATE 3.5X126MM 9 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038092","CDM","C1713","HCPCS","0278","RC","","","","both","","","2855.83","1713.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2210.41","77.4","","303.98","303.98","5854.79","1 through 10","332.13","2427.46","percent of total billed charges",""
"BONE PLATE 3.5X126MM 9 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2855.83","1713.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","332.13","11.63","","112.68","112.68","146.99","38","332.13","2210.41","percent of total billed charges",""
"BONE PLATE 3.5X126MM 9 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2855.83","1713.50","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1792.89","62.78","","780.86","208.94","10480.28","15","332.13","2210.41","percent of total billed charges",""
"BONE PLATE 3.5X126MM 9 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2855.83","1713.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1248.57","43.72","","179.76","179.76","179.76","1 through 10","332.13","2210.41","percent of total billed charges",""
"BONE PLATE 3.5X126MM 9 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2855.83","1713.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2076.76","72.72","","2355.45","298.99","3965.19","155","332.13","2210.41","percent of total billed charges",""
"BONE PLATE 3.5X126MM 9 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2855.83","1713.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2076.76","72.72","","3643.09","3643.09","3643.09","1 through 10","332.13","2210.41","percent of total billed charges",""
"BONE PLATE 3.5X126MM 9 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2855.83","1713.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1519.87","53.22","","554.28","554.28","554.28","16","332.13","2210.41","percent of total billed charges",""
"BONE PLATE 3.5X126MM 9 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2855.83","1713.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1796.32","62.9","","619.64","173.09","2370.64","150","332.13","2210.41","percent of total billed charges",""
"BONE PLATE 3.5X126MM 9 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2855.83","1713.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2210.41","77.4","","303.98","303.98","5854.79","1 through 10","332.13","2210.41","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","1851.05","1110.63","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","215.28","1573.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","1851.05","1110.63","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","215.28","1573.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","1851.05","1110.63","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1053.25","56.9","","812.12","238.65","1587.46","163","215.28","1573.39","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","1851.05","1110.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","215.28","11.63","","112.68","112.68","146.99","38","215.28","1573.39","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","1851.05","1110.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1432.71","77.4","","303.98","303.98","5854.79","1 through 10","215.28","1573.39","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1851.05","1110.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","215.28","11.63","","112.68","112.68","146.99","38","215.28","1432.71","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1851.05","1110.63","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1162.09","62.78","","780.86","208.94","10480.28","15","215.28","1432.71","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1851.05","1110.63","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","809.28","43.72","","179.76","179.76","179.76","1 through 10","215.28","1432.71","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1851.05","1110.63","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1346.08","72.72","","2355.45","298.99","3965.19","155","215.28","1432.71","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1851.05","1110.63","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1346.08","72.72","","3643.09","3643.09","3643.09","1 through 10","215.28","1432.71","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1851.05","1110.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","985.13","53.22","","554.28","554.28","554.28","16","215.28","1432.71","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1851.05","1110.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1164.31","62.9","","619.64","173.09","2370.64","150","215.28","1432.71","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1851.05","1110.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1432.71","77.4","","303.98","303.98","5854.79","1 through 10","215.28","1432.71","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","both","","","4727.34","2836.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","549.79","4018.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","both","","","4727.34","2836.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","549.79","4018.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","both","","","4727.34","2836.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2689.86","56.9","","812.12","238.65","1587.46","163","549.79","4018.24","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","both","","","4727.34","2836.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","549.79","11.63","","112.68","112.68","146.99","38","549.79","4018.24","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","both","","","4727.34","2836.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3658.96","77.4","","303.98","303.98","5854.79","1 through 10","549.79","4018.24","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4727.34","2836.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","549.79","11.63","","112.68","112.68","146.99","38","549.79","3658.96","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4727.34","2836.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2967.82","62.78","","780.86","208.94","10480.28","15","549.79","3658.96","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4727.34","2836.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2066.79","43.72","","179.76","179.76","179.76","1 through 10","549.79","3658.96","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4727.34","2836.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3437.72","72.72","","2355.45","298.99","3965.19","155","549.79","3658.96","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4727.34","2836.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3437.72","72.72","","3643.09","3643.09","3643.09","1 through 10","549.79","3658.96","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4727.34","2836.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2515.89","53.22","","554.28","554.28","554.28","16","549.79","3658.96","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4727.34","2836.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2973.50","62.9","","619.64","173.09","2370.64","150","549.79","3658.96","percent of total billed charges",""
"BONE PLATE 3.5X138MM 10 HOLE METAPHYSL LCP SS","SUP-ITM-10029056","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4727.34","2836.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3658.96","77.4","","303.98","303.98","5854.79","1 through 10","549.79","3658.96","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","2809.81","1685.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","326.78","2388.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","2809.81","1685.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","326.78","2388.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","2809.81","1685.89","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1598.78","56.9","","812.12","238.65","1587.46","163","326.78","2388.34","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","2809.81","1685.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","326.78","11.63","","112.68","112.68","146.99","38","326.78","2388.34","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","2809.81","1685.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2174.79","77.4","","303.98","303.98","5854.79","1 through 10","326.78","2388.34","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2809.81","1685.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","326.78","11.63","","112.68","112.68","146.99","38","326.78","2174.79","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2809.81","1685.89","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1764.00","62.78","","780.86","208.94","10480.28","15","326.78","2174.79","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2809.81","1685.89","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1228.45","43.72","","179.76","179.76","179.76","1 through 10","326.78","2174.79","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2809.81","1685.89","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2043.29","72.72","","2355.45","298.99","3965.19","155","326.78","2174.79","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2809.81","1685.89","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2043.29","72.72","","3643.09","3643.09","3643.09","1 through 10","326.78","2174.79","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2809.81","1685.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1495.38","53.22","","554.28","554.28","554.28","16","326.78","2174.79","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2809.81","1685.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1767.37","62.9","","619.64","173.09","2370.64","150","326.78","2174.79","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2809.81","1685.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2174.79","77.4","","303.98","303.98","5854.79","1 through 10","326.78","2174.79","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","both","","","2024.91","1214.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","235.5","1721.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","both","","","2024.91","1214.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","235.5","1721.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","both","","","2024.91","1214.95","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1152.17","56.9","","812.12","238.65","1587.46","163","235.5","1721.17","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","both","","","2024.91","1214.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","235.50","11.63","","112.68","112.68","146.99","38","235.5","1721.17","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","both","","","2024.91","1214.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1567.28","77.4","","303.98","303.98","5854.79","1 through 10","235.5","1721.17","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2024.91","1214.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","235.50","11.63","","112.68","112.68","146.99","38","235.5","1567.28","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2024.91","1214.95","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1271.24","62.78","","780.86","208.94","10480.28","15","235.5","1567.28","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2024.91","1214.95","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","885.29","43.72","","179.76","179.76","179.76","1 through 10","235.5","1567.28","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2024.91","1214.95","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1472.51","72.72","","2355.45","298.99","3965.19","155","235.5","1567.28","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2024.91","1214.95","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1472.51","72.72","","3643.09","3643.09","3643.09","1 through 10","235.5","1567.28","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2024.91","1214.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1077.66","53.22","","554.28","554.28","554.28","16","235.5","1567.28","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2024.91","1214.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1273.67","62.9","","619.64","173.09","2370.64","150","235.5","1567.28","percent of total billed charges",""
"BONE PLATE 3.5X142MM 11 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002172","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2024.91","1214.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1567.28","77.4","","303.98","303.98","5854.79","1 through 10","235.5","1567.28","percent of total billed charges",""
"BONE PLATE 3.5X145MM 12 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10004193","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.15","1397.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","270.88","1979.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X145MM 12 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10004193","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.15","1397.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","270.88","1979.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X145MM 12 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10004193","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.15","1397.49","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1325.29","56.9","","812.12","238.65","1587.46","163","270.88","1979.78","percent of total billed charges",""
"BONE PLATE 3.5X145MM 12 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10004193","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.15","1397.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","270.88","11.63","","112.68","112.68","146.99","38","270.88","1979.78","percent of total billed charges",""
"BONE PLATE 3.5X145MM 12 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10004193","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.15","1397.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1802.76","77.4","","303.98","303.98","5854.79","1 through 10","270.88","1979.78","percent of total billed charges",""
"BONE PLATE 3.5X145MM 12 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10004193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2329.15","1397.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","270.88","11.63","","112.68","112.68","146.99","38","270.88","1802.76","percent of total billed charges",""
"BONE PLATE 3.5X145MM 12 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10004193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2329.15","1397.49","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1462.24","62.78","","780.86","208.94","10480.28","15","270.88","1802.76","percent of total billed charges",""
"BONE PLATE 3.5X145MM 12 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10004193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2329.15","1397.49","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1018.30","43.72","","179.76","179.76","179.76","1 through 10","270.88","1802.76","percent of total billed charges",""
"BONE PLATE 3.5X145MM 12 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10004193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2329.15","1397.49","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1693.76","72.72","","2355.45","298.99","3965.19","155","270.88","1802.76","percent of total billed charges",""
"BONE PLATE 3.5X145MM 12 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10004193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2329.15","1397.49","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1693.76","72.72","","3643.09","3643.09","3643.09","1 through 10","270.88","1802.76","percent of total billed charges",""
"BONE PLATE 3.5X145MM 12 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10004193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2329.15","1397.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1239.57","53.22","","554.28","554.28","554.28","16","270.88","1802.76","percent of total billed charges",""
"BONE PLATE 3.5X145MM 12 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10004193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2329.15","1397.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1465.04","62.9","","619.64","173.09","2370.64","150","270.88","1802.76","percent of total billed charges",""
"BONE PLATE 3.5X145MM 12 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10004193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2329.15","1397.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1802.76","77.4","","303.98","303.98","5854.79","1 through 10","270.88","1802.76","percent of total billed charges",""
"BONE PLATE 3.5X150MM 11 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037659","CDM","C1713","HCPCS","0278","RC","","","","both","","","1955.88","1173.53","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","227.47","1662.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X150MM 11 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037659","CDM","C1713","HCPCS","0278","RC","","","","both","","","1955.88","1173.53","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","227.47","1662.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X150MM 11 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037659","CDM","C1713","HCPCS","0278","RC","","","","both","","","1955.88","1173.53","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1112.90","56.9","","812.12","238.65","1587.46","163","227.47","1662.5","percent of total billed charges",""
"BONE PLATE 3.5X150MM 11 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037659","CDM","C1713","HCPCS","0278","RC","","","","both","","","1955.88","1173.53","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","227.47","11.63","","112.68","112.68","146.99","38","227.47","1662.5","percent of total billed charges",""
"BONE PLATE 3.5X150MM 11 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037659","CDM","C1713","HCPCS","0278","RC","","","","both","","","1955.88","1173.53","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1513.85","77.4","","303.98","303.98","5854.79","1 through 10","227.47","1662.5","percent of total billed charges",""
"BONE PLATE 3.5X150MM 11 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1955.88","1173.53","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","227.47","11.63","","112.68","112.68","146.99","38","227.47","1513.85","percent of total billed charges",""
"BONE PLATE 3.5X150MM 11 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1955.88","1173.53","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1227.90","62.78","","780.86","208.94","10480.28","15","227.47","1513.85","percent of total billed charges",""
"BONE PLATE 3.5X150MM 11 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1955.88","1173.53","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","855.11","43.72","","179.76","179.76","179.76","1 through 10","227.47","1513.85","percent of total billed charges",""
"BONE PLATE 3.5X150MM 11 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1955.88","1173.53","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1422.32","72.72","","2355.45","298.99","3965.19","155","227.47","1513.85","percent of total billed charges",""
"BONE PLATE 3.5X150MM 11 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1955.88","1173.53","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1422.32","72.72","","3643.09","3643.09","3643.09","1 through 10","227.47","1513.85","percent of total billed charges",""
"BONE PLATE 3.5X150MM 11 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1955.88","1173.53","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1040.92","53.22","","554.28","554.28","554.28","16","227.47","1513.85","percent of total billed charges",""
"BONE PLATE 3.5X150MM 11 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1955.88","1173.53","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1230.25","62.9","","619.64","173.09","2370.64","150","227.47","1513.85","percent of total billed charges",""
"BONE PLATE 3.5X150MM 11 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1955.88","1173.53","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1513.85","77.4","","303.98","303.98","5854.79","1 through 10","227.47","1513.85","percent of total billed charges",""
"BONE PLATE 3.5X154MM 11 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038094","CDM","C1713","HCPCS","0278","RC","","","","both","","","3045.03","1827.02","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","354.14","2588.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X154MM 11 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038094","CDM","C1713","HCPCS","0278","RC","","","","both","","","3045.03","1827.02","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","354.14","2588.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X154MM 11 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038094","CDM","C1713","HCPCS","0278","RC","","","","both","","","3045.03","1827.02","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1732.62","56.9","","812.12","238.65","1587.46","163","354.14","2588.28","percent of total billed charges",""
"BONE PLATE 3.5X154MM 11 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038094","CDM","C1713","HCPCS","0278","RC","","","","both","","","3045.03","1827.02","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","354.14","11.63","","112.68","112.68","146.99","38","354.14","2588.28","percent of total billed charges",""
"BONE PLATE 3.5X154MM 11 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038094","CDM","C1713","HCPCS","0278","RC","","","","both","","","3045.03","1827.02","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2356.85","77.4","","303.98","303.98","5854.79","1 through 10","354.14","2588.28","percent of total billed charges",""
"BONE PLATE 3.5X154MM 11 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3045.03","1827.02","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","354.14","11.63","","112.68","112.68","146.99","38","354.14","2356.85","percent of total billed charges",""
"BONE PLATE 3.5X154MM 11 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3045.03","1827.02","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1911.67","62.78","","780.86","208.94","10480.28","15","354.14","2356.85","percent of total billed charges",""
"BONE PLATE 3.5X154MM 11 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3045.03","1827.02","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1331.29","43.72","","179.76","179.76","179.76","1 through 10","354.14","2356.85","percent of total billed charges",""
"BONE PLATE 3.5X154MM 11 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3045.03","1827.02","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2214.35","72.72","","2355.45","298.99","3965.19","155","354.14","2356.85","percent of total billed charges",""
"BONE PLATE 3.5X154MM 11 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3045.03","1827.02","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2214.35","72.72","","3643.09","3643.09","3643.09","1 through 10","354.14","2356.85","percent of total billed charges",""
"BONE PLATE 3.5X154MM 11 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3045.03","1827.02","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1620.56","53.22","","554.28","554.28","554.28","16","354.14","2356.85","percent of total billed charges",""
"BONE PLATE 3.5X154MM 11 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3045.03","1827.02","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1915.32","62.9","","619.64","173.09","2370.64","150","354.14","2356.85","percent of total billed charges",""
"BONE PLATE 3.5X154MM 11 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3045.03","1827.02","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2356.85","77.4","","303.98","303.98","5854.79","1 through 10","354.14","2356.85","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","both","","","3367.17","2020.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","391.6","2862.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","both","","","3367.17","2020.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","391.6","2862.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","both","","","3367.17","2020.30","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1915.92","56.9","","812.12","238.65","1587.46","163","391.6","2862.09","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","both","","","3367.17","2020.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","391.60","11.63","","112.68","112.68","146.99","38","391.6","2862.09","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","both","","","3367.17","2020.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2606.19","77.4","","303.98","303.98","5854.79","1 through 10","391.6","2862.09","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3367.17","2020.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","391.60","11.63","","112.68","112.68","146.99","38","391.6","2606.19","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3367.17","2020.30","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2113.91","62.78","","780.86","208.94","10480.28","15","391.6","2606.19","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3367.17","2020.30","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1472.13","43.72","","179.76","179.76","179.76","1 through 10","391.6","2606.19","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3367.17","2020.30","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2448.61","72.72","","2355.45","298.99","3965.19","155","391.6","2606.19","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3367.17","2020.30","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2448.61","72.72","","3643.09","3643.09","3643.09","1 through 10","391.6","2606.19","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3367.17","2020.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1792.01","53.22","","554.28","554.28","554.28","16","391.6","2606.19","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3367.17","2020.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2117.95","62.9","","619.64","173.09","2370.64","150","391.6","2606.19","percent of total billed charges",""
"BONE PLATE 3.5X154MM 13 HOLE RECONSTRUCTION SS","SUP-ITM-10004233","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3367.17","2020.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2606.19","77.4","","303.98","303.98","5854.79","1 through 10","391.6","2606.19","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","both","","","2139.96","1283.98","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","248.88","1818.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","both","","","2139.96","1283.98","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","248.88","1818.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","both","","","2139.96","1283.98","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1217.64","56.9","","812.12","238.65","1587.46","163","248.88","1818.97","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","both","","","2139.96","1283.98","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","248.88","11.63","","112.68","112.68","146.99","38","248.88","1818.97","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","both","","","2139.96","1283.98","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1656.33","77.4","","303.98","303.98","5854.79","1 through 10","248.88","1818.97","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2139.96","1283.98","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","248.88","11.63","","112.68","112.68","146.99","38","248.88","1656.33","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2139.96","1283.98","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1343.47","62.78","","780.86","208.94","10480.28","15","248.88","1656.33","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2139.96","1283.98","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","935.59","43.72","","179.76","179.76","179.76","1 through 10","248.88","1656.33","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2139.96","1283.98","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1556.18","72.72","","2355.45","298.99","3965.19","155","248.88","1656.33","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2139.96","1283.98","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1556.18","72.72","","3643.09","3643.09","3643.09","1 through 10","248.88","1656.33","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2139.96","1283.98","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1138.89","53.22","","554.28","554.28","554.28","16","248.88","1656.33","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2139.96","1283.98","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1346.03","62.9","","619.64","173.09","2370.64","150","248.88","1656.33","percent of total billed charges",""
"BONE PLATE 3.5X155MM 12 HOLE COMPRESSION LC DCP SS","SUP-ITM-10004034","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2139.96","1283.98","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1656.33","77.4","","303.98","303.98","5854.79","1 through 10","248.88","1656.33","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","2047.92","1228.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","238.17","1740.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","2047.92","1228.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","238.17","1740.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","2047.92","1228.75","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1165.27","56.9","","812.12","238.65","1587.46","163","238.17","1740.73","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","2047.92","1228.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","238.17","11.63","","112.68","112.68","146.99","38","238.17","1740.73","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","2047.92","1228.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1585.09","77.4","","303.98","303.98","5854.79","1 through 10","238.17","1740.73","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2047.92","1228.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","238.17","11.63","","112.68","112.68","146.99","38","238.17","1585.09","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2047.92","1228.75","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1285.68","62.78","","780.86","208.94","10480.28","15","238.17","1585.09","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2047.92","1228.75","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","895.35","43.72","","179.76","179.76","179.76","1 through 10","238.17","1585.09","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2047.92","1228.75","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1489.25","72.72","","2355.45","298.99","3965.19","155","238.17","1585.09","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2047.92","1228.75","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1489.25","72.72","","3643.09","3643.09","3643.09","1 through 10","238.17","1585.09","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2047.92","1228.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1089.90","53.22","","554.28","554.28","554.28","16","238.17","1585.09","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2047.92","1228.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1288.14","62.9","","619.64","173.09","2370.64","150","238.17","1585.09","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2047.92","1228.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1585.09","77.4","","303.98","303.98","5854.79","1 through 10","238.17","1585.09","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","both","","","4934.43","2960.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","573.87","4194.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","both","","","4934.43","2960.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","573.87","4194.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","both","","","4934.43","2960.66","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2807.69","56.9","","812.12","238.65","1587.46","163","573.87","4194.27","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","both","","","4934.43","2960.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","573.87","11.63","","112.68","112.68","146.99","38","573.87","4194.27","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","both","","","4934.43","2960.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3819.25","77.4","","303.98","303.98","5854.79","1 through 10","573.87","4194.27","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4934.43","2960.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","573.87","11.63","","112.68","112.68","146.99","38","573.87","3819.25","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4934.43","2960.66","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3097.84","62.78","","780.86","208.94","10480.28","15","573.87","3819.25","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4934.43","2960.66","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2157.33","43.72","","179.76","179.76","179.76","1 through 10","573.87","3819.25","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4934.43","2960.66","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3588.32","72.72","","2355.45","298.99","3965.19","155","573.87","3819.25","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4934.43","2960.66","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3588.32","72.72","","3643.09","3643.09","3643.09","1 through 10","573.87","3819.25","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4934.43","2960.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2626.10","53.22","","554.28","554.28","554.28","16","573.87","3819.25","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4934.43","2960.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3103.76","62.9","","619.64","173.09","2370.64","150","573.87","3819.25","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4934.43","2960.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3819.25","77.4","","303.98","303.98","5854.79","1 through 10","573.87","3819.25","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","both","","","3495.01","2097.01","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","406.47","2970.76","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","both","","","3495.01","2097.01","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","406.47","2970.76","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","both","","","3495.01","2097.01","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1988.66","56.9","","812.12","238.65","1587.46","163","406.47","2970.76","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","both","","","3495.01","2097.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","406.47","11.63","","112.68","112.68","146.99","38","406.47","2970.76","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","both","","","3495.01","2097.01","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2705.14","77.4","","303.98","303.98","5854.79","1 through 10","406.47","2970.76","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3495.01","2097.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","406.47","11.63","","112.68","112.68","146.99","38","406.47","2705.14","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3495.01","2097.01","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2194.17","62.78","","780.86","208.94","10480.28","15","406.47","2705.14","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3495.01","2097.01","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1528.02","43.72","","179.76","179.76","179.76","1 through 10","406.47","2705.14","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3495.01","2097.01","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2541.57","72.72","","2355.45","298.99","3965.19","155","406.47","2705.14","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3495.01","2097.01","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2541.57","72.72","","3643.09","3643.09","3643.09","1 through 10","406.47","2705.14","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3495.01","2097.01","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1860.04","53.22","","554.28","554.28","554.28","16","406.47","2705.14","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3495.01","2097.01","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2198.36","62.9","","619.64","173.09","2370.64","150","406.47","2705.14","percent of total billed charges",""
"BONE PLATE 3.5X166MM 14 HOLE RECONSTRUCTION SS","SUP-ITM-10004234","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3495.01","2097.01","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2705.14","77.4","","303.98","303.98","5854.79","1 through 10","406.47","2705.14","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","3111.50","1866.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","361.87","2644.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","3111.50","1866.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","361.87","2644.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","3111.50","1866.90","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1770.44","56.9","","812.12","238.65","1587.46","163","361.87","2644.78","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","3111.50","1866.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","361.87","11.63","","112.68","112.68","146.99","38","361.87","2644.78","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","3111.50","1866.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2408.30","77.4","","303.98","303.98","5854.79","1 through 10","361.87","2644.78","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3111.50","1866.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","361.87","11.63","","112.68","112.68","146.99","38","361.87","2408.3","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3111.50","1866.90","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1953.40","62.78","","780.86","208.94","10480.28","15","361.87","2408.3","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3111.50","1866.90","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1360.35","43.72","","179.76","179.76","179.76","1 through 10","361.87","2408.3","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3111.50","1866.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2262.68","72.72","","2355.45","298.99","3965.19","155","361.87","2408.3","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3111.50","1866.90","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2262.68","72.72","","3643.09","3643.09","3643.09","1 through 10","361.87","2408.3","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3111.50","1866.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1655.94","53.22","","554.28","554.28","554.28","16","361.87","2408.3","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3111.50","1866.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1957.13","62.9","","619.64","173.09","2370.64","150","361.87","2408.3","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3111.50","1866.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2408.30","77.4","","303.98","303.98","5854.79","1 through 10","361.87","2408.3","percent of total billed charges",""
"BONE PLATE 3.5X169MM 14 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10001639","CDM","C1713","HCPCS","0278","RC","","","","both","","","3492.45","2095.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","406.17","2968.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X169MM 14 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10001639","CDM","C1713","HCPCS","0278","RC","","","","both","","","3492.45","2095.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","406.17","2968.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X169MM 14 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10001639","CDM","C1713","HCPCS","0278","RC","","","","both","","","3492.45","2095.47","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1987.20","56.9","","812.12","238.65","1587.46","163","406.17","2968.58","percent of total billed charges",""
"BONE PLATE 3.5X169MM 14 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10001639","CDM","C1713","HCPCS","0278","RC","","","","both","","","3492.45","2095.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","406.17","11.63","","112.68","112.68","146.99","38","406.17","2968.58","percent of total billed charges",""
"BONE PLATE 3.5X169MM 14 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10001639","CDM","C1713","HCPCS","0278","RC","","","","both","","","3492.45","2095.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2703.16","77.4","","303.98","303.98","5854.79","1 through 10","406.17","2968.58","percent of total billed charges",""
"BONE PLATE 3.5X169MM 14 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10001639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3492.45","2095.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","406.17","11.63","","112.68","112.68","146.99","38","406.17","2703.16","percent of total billed charges",""
"BONE PLATE 3.5X169MM 14 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10001639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3492.45","2095.47","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2192.56","62.78","","780.86","208.94","10480.28","15","406.17","2703.16","percent of total billed charges",""
"BONE PLATE 3.5X169MM 14 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10001639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3492.45","2095.47","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1526.90","43.72","","179.76","179.76","179.76","1 through 10","406.17","2703.16","percent of total billed charges",""
"BONE PLATE 3.5X169MM 14 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10001639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3492.45","2095.47","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2539.71","72.72","","2355.45","298.99","3965.19","155","406.17","2703.16","percent of total billed charges",""
"BONE PLATE 3.5X169MM 14 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10001639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3492.45","2095.47","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2539.71","72.72","","3643.09","3643.09","3643.09","1 through 10","406.17","2703.16","percent of total billed charges",""
"BONE PLATE 3.5X169MM 14 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10001639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3492.45","2095.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1858.68","53.22","","554.28","554.28","554.28","16","406.17","2703.16","percent of total billed charges",""
"BONE PLATE 3.5X169MM 14 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10001639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3492.45","2095.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2196.75","62.9","","619.64","173.09","2370.64","150","406.17","2703.16","percent of total billed charges",""
"BONE PLATE 3.5X169MM 14 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10001639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3492.45","2095.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2703.16","77.4","","303.98","303.98","5854.79","1 through 10","406.17","2703.16","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","both","","","3789.03","2273.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","440.66","3220.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","both","","","3789.03","2273.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","440.66","3220.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","both","","","3789.03","2273.42","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2155.96","56.9","","812.12","238.65","1587.46","163","440.66","3220.68","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","both","","","3789.03","2273.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","440.66","11.63","","112.68","112.68","146.99","38","440.66","3220.68","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","both","","","3789.03","2273.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2932.71","77.4","","303.98","303.98","5854.79","1 through 10","440.66","3220.68","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3789.03","2273.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","440.66","11.63","","112.68","112.68","146.99","38","440.66","2932.71","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3789.03","2273.42","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2378.75","62.78","","780.86","208.94","10480.28","15","440.66","2932.71","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3789.03","2273.42","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1656.56","43.72","","179.76","179.76","179.76","1 through 10","440.66","2932.71","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3789.03","2273.42","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2755.38","72.72","","2355.45","298.99","3965.19","155","440.66","2932.71","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3789.03","2273.42","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2755.38","72.72","","3643.09","3643.09","3643.09","1 through 10","440.66","2932.71","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3789.03","2273.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2016.52","53.22","","554.28","554.28","554.28","16","440.66","2932.71","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3789.03","2273.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2383.30","62.9","","619.64","173.09","2370.64","150","440.66","2932.71","percent of total billed charges",""
"BONE PLATE 3.5X178MM 15 HOLE RECONSTRUCTION SS","SUP-ITM-10001907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3789.03","2273.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2932.71","77.4","","303.98","303.98","5854.79","1 through 10","440.66","2932.71","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","both","","","3211.22","1926.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","373.46","2729.54","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","both","","","3211.22","1926.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","373.46","2729.54","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","both","","","3211.22","1926.73","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1827.18","56.9","","812.12","238.65","1587.46","163","373.46","2729.54","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","both","","","3211.22","1926.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","373.46","11.63","","112.68","112.68","146.99","38","373.46","2729.54","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","both","","","3211.22","1926.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2485.48","77.4","","303.98","303.98","5854.79","1 through 10","373.46","2729.54","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3211.22","1926.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","373.46","11.63","","112.68","112.68","146.99","38","373.46","2485.48","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3211.22","1926.73","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2016.00","62.78","","780.86","208.94","10480.28","15","373.46","2485.48","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3211.22","1926.73","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1403.95","43.72","","179.76","179.76","179.76","1 through 10","373.46","2485.48","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3211.22","1926.73","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2335.20","72.72","","2355.45","298.99","3965.19","155","373.46","2485.48","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3211.22","1926.73","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2335.20","72.72","","3643.09","3643.09","3643.09","1 through 10","373.46","2485.48","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3211.22","1926.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1709.01","53.22","","554.28","554.28","554.28","16","373.46","2485.48","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3211.22","1926.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2019.86","62.9","","619.64","173.09","2370.64","150","373.46","2485.48","percent of total billed charges",""
"BONE PLATE 3.5X181MM 14 HOLE COMPRESSION LC DCP SS","SUP-ITM-10002375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3211.22","1926.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2485.48","77.4","","303.98","303.98","5854.79","1 through 10","373.46","2485.48","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","both","","","3367.17","2020.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","391.6","2862.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","both","","","3367.17","2020.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","391.6","2862.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","both","","","3367.17","2020.30","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1915.92","56.9","","812.12","238.65","1587.46","163","391.6","2862.09","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","both","","","3367.17","2020.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","391.60","11.63","","112.68","112.68","146.99","38","391.6","2862.09","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","both","","","3367.17","2020.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2606.19","77.4","","303.98","303.98","5854.79","1 through 10","391.6","2862.09","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3367.17","2020.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","391.60","11.63","","112.68","112.68","146.99","38","391.6","2606.19","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3367.17","2020.30","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2113.91","62.78","","780.86","208.94","10480.28","15","391.6","2606.19","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3367.17","2020.30","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1472.13","43.72","","179.76","179.76","179.76","1 through 10","391.6","2606.19","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3367.17","2020.30","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2448.61","72.72","","2355.45","298.99","3965.19","155","391.6","2606.19","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3367.17","2020.30","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2448.61","72.72","","3643.09","3643.09","3643.09","1 through 10","391.6","2606.19","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3367.17","2020.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1792.01","53.22","","554.28","554.28","554.28","16","391.6","2606.19","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3367.17","2020.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2117.95","62.9","","619.64","173.09","2370.64","150","391.6","2606.19","percent of total billed charges",""
"BONE PLATE 3.5X182MM 13 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10012540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3367.17","2020.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2606.19","77.4","","303.98","303.98","5854.79","1 through 10","391.6","2606.19","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","3080.82","1848.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","358.3","2618.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","3080.82","1848.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","358.3","2618.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","3080.82","1848.49","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1752.99","56.9","","812.12","238.65","1587.46","163","358.3","2618.7","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","3080.82","1848.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","358.30","11.63","","112.68","112.68","146.99","38","358.3","2618.7","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","3080.82","1848.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2384.55","77.4","","303.98","303.98","5854.79","1 through 10","358.3","2618.7","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3080.82","1848.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","358.30","11.63","","112.68","112.68","146.99","38","358.3","2384.55","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3080.82","1848.49","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1934.14","62.78","","780.86","208.94","10480.28","15","358.3","2384.55","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3080.82","1848.49","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1346.93","43.72","","179.76","179.76","179.76","1 through 10","358.3","2384.55","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3080.82","1848.49","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2240.37","72.72","","2355.45","298.99","3965.19","155","358.3","2384.55","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3080.82","1848.49","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2240.37","72.72","","3643.09","3643.09","3643.09","1 through 10","358.3","2384.55","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3080.82","1848.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1639.61","53.22","","554.28","554.28","554.28","16","358.3","2384.55","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3080.82","1848.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1937.84","62.9","","619.64","173.09","2370.64","150","358.3","2384.55","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3080.82","1848.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2384.55","77.4","","303.98","303.98","5854.79","1 through 10","358.3","2384.55","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.70","1980.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","383.87","2805.6","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.70","1980.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","383.87","2805.6","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.70","1980.42","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1878.10","56.9","","812.12","238.65","1587.46","163","383.87","2805.6","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.70","1980.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","383.87","11.63","","112.68","112.68","146.99","38","383.87","2805.6","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.70","1980.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2554.74","77.4","","303.98","303.98","5854.79","1 through 10","383.87","2805.6","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3300.70","1980.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","383.87","11.63","","112.68","112.68","146.99","38","383.87","2554.74","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3300.70","1980.42","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2072.18","62.78","","780.86","208.94","10480.28","15","383.87","2554.74","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3300.70","1980.42","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1443.07","43.72","","179.76","179.76","179.76","1 through 10","383.87","2554.74","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3300.70","1980.42","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2400.27","72.72","","2355.45","298.99","3965.19","155","383.87","2554.74","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3300.70","1980.42","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2400.27","72.72","","3643.09","3643.09","3643.09","1 through 10","383.87","2554.74","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3300.70","1980.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1756.63","53.22","","554.28","554.28","554.28","16","383.87","2554.74","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3300.70","1980.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2076.14","62.9","","619.64","173.09","2370.64","150","383.87","2554.74","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LOCKING COMPRESSION LCP TITANIUM","SUP-ITM-10040465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3300.70","1980.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2554.74","77.4","","303.98","303.98","5854.79","1 through 10","383.87","2554.74","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","5778.10","3466.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","671.99","4911.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","5778.10","3466.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","671.99","4911.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","5778.10","3466.86","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3287.74","56.9","","812.12","238.65","1587.46","163","671.99","4911.39","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","5778.10","3466.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","671.99","11.63","","112.68","112.68","146.99","38","671.99","4911.39","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","5778.10","3466.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4472.25","77.4","","303.98","303.98","5854.79","1 through 10","671.99","4911.39","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5778.10","3466.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","671.99","11.63","","112.68","112.68","146.99","38","671.99","4472.25","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5778.10","3466.86","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3627.49","62.78","","780.86","208.94","10480.28","15","671.99","4472.25","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5778.10","3466.86","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2526.19","43.72","","179.76","179.76","179.76","1 through 10","671.99","4472.25","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5778.10","3466.86","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4201.83","72.72","","2355.45","298.99","3965.19","155","671.99","4472.25","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5778.10","3466.86","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4201.83","72.72","","3643.09","3643.09","3643.09","1 through 10","671.99","4472.25","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5778.10","3466.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3075.10","53.22","","554.28","554.28","554.28","16","671.99","4472.25","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5778.10","3466.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3634.42","62.9","","619.64","173.09","2370.64","150","671.99","4472.25","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5778.10","3466.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4472.25","77.4","","303.98","303.98","5854.79","1 through 10","671.99","4472.25","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037660","CDM","C1713","HCPCS","0278","RC","","","","both","","","3433.65","2060.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","399.33","2918.6","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X195MM 15 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037660","CDM","C1713","HCPCS","0278","RC","","","","both","","","3433.65","2060.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","399.33","2918.6","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X195MM 15 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037660","CDM","C1713","HCPCS","0278","RC","","","","both","","","3433.65","2060.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1953.75","56.9","","812.12","238.65","1587.46","163","399.33","2918.6","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037660","CDM","C1713","HCPCS","0278","RC","","","","both","","","3433.65","2060.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","399.33","11.63","","112.68","112.68","146.99","38","399.33","2918.6","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037660","CDM","C1713","HCPCS","0278","RC","","","","both","","","3433.65","2060.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2657.65","77.4","","303.98","303.98","5854.79","1 through 10","399.33","2918.6","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037660","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3433.65","2060.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","399.33","11.63","","112.68","112.68","146.99","38","399.33","2657.65","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037660","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3433.65","2060.19","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2155.65","62.78","","780.86","208.94","10480.28","15","399.33","2657.65","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037660","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3433.65","2060.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1501.19","43.72","","179.76","179.76","179.76","1 through 10","399.33","2657.65","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037660","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3433.65","2060.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2496.95","72.72","","2355.45","298.99","3965.19","155","399.33","2657.65","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037660","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3433.65","2060.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2496.95","72.72","","3643.09","3643.09","3643.09","1 through 10","399.33","2657.65","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037660","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3433.65","2060.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1827.39","53.22","","554.28","554.28","554.28","16","399.33","2657.65","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037660","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3433.65","2060.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2159.77","62.9","","619.64","173.09","2370.64","150","399.33","2657.65","percent of total billed charges",""
"BONE PLATE 3.5X195MM 15 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037660","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3433.65","2060.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2657.65","77.4","","303.98","303.98","5854.79","1 through 10","399.33","2657.65","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","both","","","3495.01","2097.01","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","406.47","2970.76","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","both","","","3495.01","2097.01","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","406.47","2970.76","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","both","","","3495.01","2097.01","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1988.66","56.9","","812.12","238.65","1587.46","163","406.47","2970.76","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","both","","","3495.01","2097.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","406.47","11.63","","112.68","112.68","146.99","38","406.47","2970.76","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","both","","","3495.01","2097.01","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2705.14","77.4","","303.98","303.98","5854.79","1 through 10","406.47","2970.76","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3495.01","2097.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","406.47","11.63","","112.68","112.68","146.99","38","406.47","2705.14","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3495.01","2097.01","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2194.17","62.78","","780.86","208.94","10480.28","15","406.47","2705.14","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3495.01","2097.01","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1528.02","43.72","","179.76","179.76","179.76","1 through 10","406.47","2705.14","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3495.01","2097.01","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2541.57","72.72","","2355.45","298.99","3965.19","155","406.47","2705.14","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3495.01","2097.01","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2541.57","72.72","","3643.09","3643.09","3643.09","1 through 10","406.47","2705.14","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3495.01","2097.01","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1860.04","53.22","","554.28","554.28","554.28","16","406.47","2705.14","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3495.01","2097.01","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2198.36","62.9","","619.64","173.09","2370.64","150","406.47","2705.14","percent of total billed charges",""
"BONE PLATE 3.5X196MM 14 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3495.01","2097.01","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2705.14","77.4","","303.98","303.98","5854.79","1 through 10","406.47","2705.14","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","both","","","3594.72","2156.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","418.07","3055.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","both","","","3594.72","2156.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","418.07","3055.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","both","","","3594.72","2156.83","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2045.40","56.9","","812.12","238.65","1587.46","163","418.07","3055.51","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","both","","","3594.72","2156.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","418.07","11.63","","112.68","112.68","146.99","38","418.07","3055.51","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","both","","","3594.72","2156.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2782.31","77.4","","303.98","303.98","5854.79","1 through 10","418.07","3055.51","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3594.72","2156.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","418.07","11.63","","112.68","112.68","146.99","38","418.07","2782.31","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3594.72","2156.83","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2256.77","62.78","","780.86","208.94","10480.28","15","418.07","2782.31","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3594.72","2156.83","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1571.61","43.72","","179.76","179.76","179.76","1 through 10","418.07","2782.31","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3594.72","2156.83","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2614.08","72.72","","2355.45","298.99","3965.19","155","418.07","2782.31","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3594.72","2156.83","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2614.08","72.72","","3643.09","3643.09","3643.09","1 through 10","418.07","2782.31","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3594.72","2156.83","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1913.11","53.22","","554.28","554.28","554.28","16","418.07","2782.31","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3594.72","2156.83","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2261.08","62.9","","619.64","173.09","2370.64","150","418.07","2782.31","percent of total billed charges",""
"BONE PLATE 3.5X207MM 16 HOLE LCP DCP SS STRAIGHT","SUP-ITM-10037661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3594.72","2156.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2782.31","77.4","","303.98","303.98","5854.79","1 through 10","418.07","2782.31","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","both","","","5688.66","3413.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","661.59","4835.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","both","","","5688.66","3413.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","661.59","4835.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","both","","","5688.66","3413.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3236.85","56.9","","812.12","238.65","1587.46","163","661.59","4835.36","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","both","","","5688.66","3413.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","661.59","11.63","","112.68","112.68","146.99","38","661.59","4835.36","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","both","","","5688.66","3413.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4403.02","77.4","","303.98","303.98","5854.79","1 through 10","661.59","4835.36","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5688.66","3413.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","661.59","11.63","","112.68","112.68","146.99","38","661.59","4403.02","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5688.66","3413.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3571.34","62.78","","780.86","208.94","10480.28","15","661.59","4403.02","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5688.66","3413.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2487.08","43.72","","179.76","179.76","179.76","1 through 10","661.59","4403.02","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5688.66","3413.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4136.79","72.72","","2355.45","298.99","3965.19","155","661.59","4403.02","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5688.66","3413.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4136.79","72.72","","3643.09","3643.09","3643.09","1 through 10","661.59","4403.02","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5688.66","3413.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3027.50","53.22","","554.28","554.28","554.28","16","661.59","4403.02","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5688.66","3413.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3578.17","62.9","","619.64","173.09","2370.64","150","661.59","4403.02","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10002037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5688.66","3413.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4403.02","77.4","","303.98","303.98","5854.79","1 through 10","661.59","4403.02","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3970.56","2382.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","461.78","3374.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3970.56","2382.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","461.78","3374.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3970.56","2382.34","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2259.25","56.9","","812.12","238.65","1587.46","163","461.78","3374.98","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3970.56","2382.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","461.78","11.63","","112.68","112.68","146.99","38","461.78","3374.98","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3970.56","2382.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3073.21","77.4","","303.98","303.98","5854.79","1 through 10","461.78","3374.98","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3970.56","2382.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","461.78","11.63","","112.68","112.68","146.99","38","461.78","3073.21","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3970.56","2382.34","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2492.72","62.78","","780.86","208.94","10480.28","15","461.78","3073.21","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3970.56","2382.34","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1735.93","43.72","","179.76","179.76","179.76","1 through 10","461.78","3073.21","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3970.56","2382.34","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2887.39","72.72","","2355.45","298.99","3965.19","155","461.78","3073.21","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3970.56","2382.34","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2887.39","72.72","","3643.09","3643.09","3643.09","1 through 10","461.78","3073.21","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3970.56","2382.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2113.13","53.22","","554.28","554.28","554.28","16","461.78","3073.21","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3970.56","2382.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2497.48","62.9","","619.64","173.09","2370.64","150","461.78","3073.21","percent of total billed charges",""
"BONE PLATE 3.5X214MM 18 HOLE RECONSTRUCTION SS","SUP-ITM-10004235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3970.56","2382.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3073.21","77.4","","303.98","303.98","5854.79","1 through 10","461.78","3073.21","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.89","2080.13","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","403.2","2946.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.89","2080.13","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","403.2","2946.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.89","2080.13","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1972.66","56.9","","812.12","238.65","1587.46","163","403.2","2946.86","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.89","2080.13","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","403.20","11.63","","112.68","112.68","146.99","38","403.2","2946.86","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.89","2080.13","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2683.37","77.4","","303.98","303.98","5854.79","1 through 10","403.2","2946.86","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3466.89","2080.13","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","403.20","11.63","","112.68","112.68","146.99","38","403.2","2683.37","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3466.89","2080.13","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2176.51","62.78","","780.86","208.94","10480.28","15","403.2","2683.37","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3466.89","2080.13","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1515.72","43.72","","179.76","179.76","179.76","1 through 10","403.2","2683.37","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3466.89","2080.13","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2521.12","72.72","","2355.45","298.99","3965.19","155","403.2","2683.37","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3466.89","2080.13","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2521.12","72.72","","3643.09","3643.09","3643.09","1 through 10","403.2","2683.37","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3466.89","2080.13","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1845.08","53.22","","554.28","554.28","554.28","16","403.2","2683.37","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3466.89","2080.13","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2180.67","62.9","","619.64","173.09","2370.64","150","403.2","2683.37","percent of total billed charges",""
"BONE PLATE 3.5X215MM 16 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011604","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3466.89","2080.13","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2683.37","77.4","","303.98","303.98","5854.79","1 through 10","403.2","2683.37","percent of total billed charges",""
"BONE PLATE 3.5X217MM 18 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10038145","CDM","C1713","HCPCS","0278","RC","","","","both","","","4384.74","2630.84","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","509.95","3727.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X217MM 18 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10038145","CDM","C1713","HCPCS","0278","RC","","","","both","","","4384.74","2630.84","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","509.95","3727.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X217MM 18 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10038145","CDM","C1713","HCPCS","0278","RC","","","","both","","","4384.74","2630.84","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2494.92","56.9","","812.12","238.65","1587.46","163","509.95","3727.03","percent of total billed charges",""
"BONE PLATE 3.5X217MM 18 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10038145","CDM","C1713","HCPCS","0278","RC","","","","both","","","4384.74","2630.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","509.95","11.63","","112.68","112.68","146.99","38","509.95","3727.03","percent of total billed charges",""
"BONE PLATE 3.5X217MM 18 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10038145","CDM","C1713","HCPCS","0278","RC","","","","both","","","4384.74","2630.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3393.79","77.4","","303.98","303.98","5854.79","1 through 10","509.95","3727.03","percent of total billed charges",""
"BONE PLATE 3.5X217MM 18 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10038145","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4384.74","2630.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","509.95","11.63","","112.68","112.68","146.99","38","509.95","3393.79","percent of total billed charges",""
"BONE PLATE 3.5X217MM 18 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10038145","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4384.74","2630.84","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2752.74","62.78","","780.86","208.94","10480.28","15","509.95","3393.79","percent of total billed charges",""
"BONE PLATE 3.5X217MM 18 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10038145","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4384.74","2630.84","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1917.01","43.72","","179.76","179.76","179.76","1 through 10","509.95","3393.79","percent of total billed charges",""
"BONE PLATE 3.5X217MM 18 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10038145","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4384.74","2630.84","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3188.58","72.72","","2355.45","298.99","3965.19","155","509.95","3393.79","percent of total billed charges",""
"BONE PLATE 3.5X217MM 18 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10038145","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4384.74","2630.84","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3188.58","72.72","","3643.09","3643.09","3643.09","1 through 10","509.95","3393.79","percent of total billed charges",""
"BONE PLATE 3.5X217MM 18 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10038145","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4384.74","2630.84","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2333.56","53.22","","554.28","554.28","554.28","16","509.95","3393.79","percent of total billed charges",""
"BONE PLATE 3.5X217MM 18 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10038145","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4384.74","2630.84","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2758.00","62.9","","619.64","173.09","2370.64","150","509.95","3393.79","percent of total billed charges",""
"BONE PLATE 3.5X217MM 18 HOLE COMPRESSION DYNAMIC DCP SS","SUP-ITM-10038145","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4384.74","2630.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3393.79","77.4","","303.98","303.98","5854.79","1 through 10","509.95","3393.79","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","both","","","3789.03","2273.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","440.66","3220.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","both","","","3789.03","2273.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","440.66","3220.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","both","","","3789.03","2273.42","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2155.96","56.9","","812.12","238.65","1587.46","163","440.66","3220.68","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","both","","","3789.03","2273.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","440.66","11.63","","112.68","112.68","146.99","38","440.66","3220.68","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","both","","","3789.03","2273.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2932.71","77.4","","303.98","303.98","5854.79","1 through 10","440.66","3220.68","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3789.03","2273.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","440.66","11.63","","112.68","112.68","146.99","38","440.66","2932.71","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3789.03","2273.42","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2378.75","62.78","","780.86","208.94","10480.28","15","440.66","2932.71","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3789.03","2273.42","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1656.56","43.72","","179.76","179.76","179.76","1 through 10","440.66","2932.71","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3789.03","2273.42","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2755.38","72.72","","2355.45","298.99","3965.19","155","440.66","2932.71","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3789.03","2273.42","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2755.38","72.72","","3643.09","3643.09","3643.09","1 through 10","440.66","2932.71","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3789.03","2273.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2016.52","53.22","","554.28","554.28","554.28","16","440.66","2932.71","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3789.03","2273.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2383.30","62.9","","619.64","173.09","2370.64","150","440.66","2932.71","percent of total billed charges",""
"BONE PLATE 3.5X224MM 16 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3789.03","2273.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2932.71","77.4","","303.98","303.98","5854.79","1 through 10","440.66","2932.71","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","both","","","4031.92","2419.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","468.91","3427.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","both","","","4031.92","2419.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","468.91","3427.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","both","","","4031.92","2419.15","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2294.16","56.9","","812.12","238.65","1587.46","163","468.91","3427.13","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","both","","","4031.92","2419.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","468.91","11.63","","112.68","112.68","146.99","38","468.91","3427.13","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","both","","","4031.92","2419.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3120.71","77.4","","303.98","303.98","5854.79","1 through 10","468.91","3427.13","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4031.92","2419.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","468.91","11.63","","112.68","112.68","146.99","38","468.91","3120.71","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4031.92","2419.15","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2531.24","62.78","","780.86","208.94","10480.28","15","468.91","3120.71","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4031.92","2419.15","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1762.76","43.72","","179.76","179.76","179.76","1 through 10","468.91","3120.71","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4031.92","2419.15","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2932.01","72.72","","2355.45","298.99","3965.19","155","468.91","3120.71","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4031.92","2419.15","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2932.01","72.72","","3643.09","3643.09","3643.09","1 through 10","468.91","3120.71","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4031.92","2419.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2145.79","53.22","","554.28","554.28","554.28","16","468.91","3120.71","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4031.92","2419.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2536.08","62.9","","619.64","173.09","2370.64","150","468.91","3120.71","percent of total billed charges",""
"BONE PLATE 3.5X233MM 18 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037662","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4031.92","2419.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3120.71","77.4","","303.98","303.98","5854.79","1 through 10","468.91","3120.71","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","both","","","4816.82","2890.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","560.2","4094.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","both","","","4816.82","2890.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","560.2","4094.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","both","","","4816.82","2890.09","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2740.77","56.9","","812.12","238.65","1587.46","163","560.2","4094.3","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","both","","","4816.82","2890.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","560.20","11.63","","112.68","112.68","146.99","38","560.2","4094.3","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","both","","","4816.82","2890.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3728.22","77.4","","303.98","303.98","5854.79","1 through 10","560.2","4094.3","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4816.82","2890.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","560.20","11.63","","112.68","112.68","146.99","38","560.2","3728.22","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4816.82","2890.09","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3024.00","62.78","","780.86","208.94","10480.28","15","560.2","3728.22","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4816.82","2890.09","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2105.91","43.72","","179.76","179.76","179.76","1 through 10","560.2","3728.22","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4816.82","2890.09","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3502.79","72.72","","2355.45","298.99","3965.19","155","560.2","3728.22","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4816.82","2890.09","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3502.79","72.72","","3643.09","3643.09","3643.09","1 through 10","560.2","3728.22","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4816.82","2890.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2563.51","53.22","","554.28","554.28","554.28","16","560.2","3728.22","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4816.82","2890.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3029.78","62.9","","619.64","173.09","2370.64","150","560.2","3728.22","percent of total billed charges",""
"BONE PLATE 3.5X238MM 20 HOLE RECONSTRUCTION SS","SUP-ITM-10038093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4816.82","2890.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3728.22","77.4","","303.98","303.98","5854.79","1 through 10","560.2","3728.22","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","both","","","3891.30","2334.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","452.56","3307.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","both","","","3891.30","2334.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","452.56","3307.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","both","","","3891.30","2334.78","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2214.15","56.9","","812.12","238.65","1587.46","163","452.56","3307.61","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","both","","","3891.30","2334.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","452.56","11.63","","112.68","112.68","146.99","38","452.56","3307.61","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","both","","","3891.30","2334.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3011.87","77.4","","303.98","303.98","5854.79","1 through 10","452.56","3307.61","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3891.30","2334.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","452.56","11.63","","112.68","112.68","146.99","38","452.56","3011.87","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3891.30","2334.78","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2442.96","62.78","","780.86","208.94","10480.28","15","452.56","3011.87","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3891.30","2334.78","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1701.28","43.72","","179.76","179.76","179.76","1 through 10","452.56","3011.87","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3891.30","2334.78","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2829.75","72.72","","2355.45","298.99","3965.19","155","452.56","3011.87","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3891.30","2334.78","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2829.75","72.72","","3643.09","3643.09","3643.09","1 through 10","452.56","3011.87","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3891.30","2334.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2070.95","53.22","","554.28","554.28","554.28","16","452.56","3011.87","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3891.30","2334.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2447.63","62.9","","619.64","173.09","2370.64","150","452.56","3011.87","percent of total billed charges",""
"BONE PLATE 3.5X241MM 18 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3891.30","2334.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3011.87","77.4","","303.98","303.98","5854.79","1 through 10","452.56","3011.87","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","both","","","3973.11","2383.87","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","462.07","3377.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","both","","","3973.11","2383.87","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","462.07","3377.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","both","","","3973.11","2383.87","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2260.70","56.9","","812.12","238.65","1587.46","163","462.07","3377.14","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","both","","","3973.11","2383.87","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","462.07","11.63","","112.68","112.68","146.99","38","462.07","3377.14","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","both","","","3973.11","2383.87","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3075.19","77.4","","303.98","303.98","5854.79","1 through 10","462.07","3377.14","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3973.11","2383.87","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","462.07","11.63","","112.68","112.68","146.99","38","462.07","3075.19","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3973.11","2383.87","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2494.32","62.78","","780.86","208.94","10480.28","15","462.07","3075.19","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3973.11","2383.87","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1737.04","43.72","","179.76","179.76","179.76","1 through 10","462.07","3075.19","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3973.11","2383.87","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2889.25","72.72","","2355.45","298.99","3965.19","155","462.07","3075.19","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3973.11","2383.87","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2889.25","72.72","","3643.09","3643.09","3643.09","1 through 10","462.07","3075.19","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3973.11","2383.87","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2114.49","53.22","","554.28","554.28","554.28","16","462.07","3075.19","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3973.11","2383.87","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2499.09","62.9","","619.64","173.09","2370.64","150","462.07","3075.19","percent of total billed charges",""
"BONE PLATE 3.5X252MM 18 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10011602","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3973.11","2383.87","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3075.19","77.4","","303.98","303.98","5854.79","1 through 10","462.07","3075.19","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","both","","","4471.67","2683.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","520.06","3800.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","both","","","4471.67","2683.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","520.06","3800.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","both","","","4471.67","2683.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2544.38","56.9","","812.12","238.65","1587.46","163","520.06","3800.92","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","both","","","4471.67","2683.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","520.06","11.63","","112.68","112.68","146.99","38","520.06","3800.92","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","both","","","4471.67","2683.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3461.07","77.4","","303.98","303.98","5854.79","1 through 10","520.06","3800.92","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4471.67","2683.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","520.06","11.63","","112.68","112.68","146.99","38","520.06","3461.07","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4471.67","2683.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2807.31","62.78","","780.86","208.94","10480.28","15","520.06","3461.07","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4471.67","2683.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1955.01","43.72","","179.76","179.76","179.76","1 through 10","520.06","3461.07","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4471.67","2683.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3251.80","72.72","","2355.45","298.99","3965.19","155","520.06","3461.07","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4471.67","2683.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3251.80","72.72","","3643.09","3643.09","3643.09","1 through 10","520.06","3461.07","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4471.67","2683.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2379.82","53.22","","554.28","554.28","554.28","16","520.06","3461.07","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4471.67","2683.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2812.68","62.9","","619.64","173.09","2370.64","150","520.06","3461.07","percent of total billed charges",""
"BONE PLATE 3.5X259MM 20 HOLE COMPRESSION LC DCP SS","SUP-ITM-10037664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4471.67","2683.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3461.07","77.4","","303.98","303.98","5854.79","1 through 10","520.06","3461.07","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","both","","","1393.40","836.04","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","162.05","1184.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","both","","","1393.40","836.04","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","162.05","1184.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","both","","","1393.40","836.04","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","792.84","56.9","","812.12","238.65","1587.46","163","162.05","1184.39","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","both","","","1393.40","836.04","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","162.05","11.63","","112.68","112.68","146.99","38","162.05","1184.39","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","both","","","1393.40","836.04","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1078.49","77.4","","303.98","303.98","5854.79","1 through 10","162.05","1184.39","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1393.40","836.04","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","162.05","11.63","","112.68","112.68","146.99","38","162.05","1078.49","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1393.40","836.04","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","874.78","62.78","","780.86","208.94","10480.28","15","162.05","1078.49","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1393.40","836.04","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","609.19","43.72","","179.76","179.76","179.76","1 through 10","162.05","1078.49","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1393.40","836.04","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1013.28","72.72","","2355.45","298.99","3965.19","155","162.05","1078.49","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1393.40","836.04","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1013.28","72.72","","3643.09","3643.09","3643.09","1 through 10","162.05","1078.49","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1393.40","836.04","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","741.57","53.22","","554.28","554.28","554.28","16","162.05","1078.49","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1393.40","836.04","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","876.45","62.9","","619.64","173.09","2370.64","150","162.05","1078.49","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10037654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1393.40","836.04","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1078.49","77.4","","303.98","303.98","5854.79","1 through 10","162.05","1078.49","percent of total billed charges",""
"BONE PLATE 3.5X263MM 22 HOLE RECONSTRUCTION SS CS/1BX/1EA","SUP-ITM-10038095","CDM","C1713","HCPCS","0278","RC","","","","both","","","5006.02","3003.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","582.2","4255.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X263MM 22 HOLE RECONSTRUCTION SS CS/1BX/1EA","SUP-ITM-10038095","CDM","C1713","HCPCS","0278","RC","","","","both","","","5006.02","3003.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","582.2","4255.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X263MM 22 HOLE RECONSTRUCTION SS CS/1BX/1EA","SUP-ITM-10038095","CDM","C1713","HCPCS","0278","RC","","","","both","","","5006.02","3003.61","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2848.43","56.9","","812.12","238.65","1587.46","163","582.2","4255.12","percent of total billed charges",""
"BONE PLATE 3.5X263MM 22 HOLE RECONSTRUCTION SS CS/1BX/1EA","SUP-ITM-10038095","CDM","C1713","HCPCS","0278","RC","","","","both","","","5006.02","3003.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","582.20","11.63","","112.68","112.68","146.99","38","582.2","4255.12","percent of total billed charges",""
"BONE PLATE 3.5X263MM 22 HOLE RECONSTRUCTION SS CS/1BX/1EA","SUP-ITM-10038095","CDM","C1713","HCPCS","0278","RC","","","","both","","","5006.02","3003.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3874.66","77.4","","303.98","303.98","5854.79","1 through 10","582.2","4255.12","percent of total billed charges",""
"BONE PLATE 3.5X263MM 22 HOLE RECONSTRUCTION SS CS/1BX/1EA","SUP-ITM-10038095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5006.02","3003.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","582.20","11.63","","112.68","112.68","146.99","38","582.2","3874.66","percent of total billed charges",""
"BONE PLATE 3.5X263MM 22 HOLE RECONSTRUCTION SS CS/1BX/1EA","SUP-ITM-10038095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5006.02","3003.61","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3142.78","62.78","","780.86","208.94","10480.28","15","582.2","3874.66","percent of total billed charges",""
"BONE PLATE 3.5X263MM 22 HOLE RECONSTRUCTION SS CS/1BX/1EA","SUP-ITM-10038095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5006.02","3003.61","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2188.63","43.72","","179.76","179.76","179.76","1 through 10","582.2","3874.66","percent of total billed charges",""
"BONE PLATE 3.5X263MM 22 HOLE RECONSTRUCTION SS CS/1BX/1EA","SUP-ITM-10038095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5006.02","3003.61","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3640.38","72.72","","2355.45","298.99","3965.19","155","582.2","3874.66","percent of total billed charges",""
"BONE PLATE 3.5X263MM 22 HOLE RECONSTRUCTION SS CS/1BX/1EA","SUP-ITM-10038095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5006.02","3003.61","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3640.38","72.72","","3643.09","3643.09","3643.09","1 through 10","582.2","3874.66","percent of total billed charges",""
"BONE PLATE 3.5X263MM 22 HOLE RECONSTRUCTION SS CS/1BX/1EA","SUP-ITM-10038095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5006.02","3003.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2664.20","53.22","","554.28","554.28","554.28","16","582.2","3874.66","percent of total billed charges",""
"BONE PLATE 3.5X263MM 22 HOLE RECONSTRUCTION SS CS/1BX/1EA","SUP-ITM-10038095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5006.02","3003.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3148.79","62.9","","619.64","173.09","2370.64","150","582.2","3874.66","percent of total billed charges",""
"BONE PLATE 3.5X263MM 22 HOLE RECONSTRUCTION SS CS/1BX/1EA","SUP-ITM-10038095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5006.02","3003.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3874.66","77.4","","303.98","303.98","5854.79","1 through 10","582.2","3874.66","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","4318.27","2590.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","502.21","3670.53","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","4318.27","2590.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","502.21","3670.53","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","4318.27","2590.96","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2457.10","56.9","","812.12","238.65","1587.46","163","502.21","3670.53","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","4318.27","2590.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","502.21","11.63","","112.68","112.68","146.99","38","502.21","3670.53","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","4318.27","2590.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3342.34","77.4","","303.98","303.98","5854.79","1 through 10","502.21","3670.53","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4318.27","2590.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","502.21","11.63","","112.68","112.68","146.99","38","502.21","3342.34","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4318.27","2590.96","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2711.01","62.78","","780.86","208.94","10480.28","15","502.21","3342.34","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4318.27","2590.96","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1887.95","43.72","","179.76","179.76","179.76","1 through 10","502.21","3342.34","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4318.27","2590.96","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3140.25","72.72","","2355.45","298.99","3965.19","155","502.21","3342.34","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4318.27","2590.96","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3140.25","72.72","","3643.09","3643.09","3643.09","1 through 10","502.21","3342.34","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4318.27","2590.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2298.18","53.22","","554.28","554.28","554.28","16","502.21","3342.34","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4318.27","2590.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2716.19","62.9","","619.64","173.09","2370.64","150","502.21","3342.34","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4318.27","2590.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3342.34","77.4","","303.98","303.98","5854.79","1 through 10","502.21","3342.34","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","both","","","4325.94","2595.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","503.11","3677.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","both","","","4325.94","2595.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","503.11","3677.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","both","","","4325.94","2595.56","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2461.46","56.9","","812.12","238.65","1587.46","163","503.11","3677.05","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","both","","","4325.94","2595.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","503.11","11.63","","112.68","112.68","146.99","38","503.11","3677.05","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","both","","","4325.94","2595.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3348.28","77.4","","303.98","303.98","5854.79","1 through 10","503.11","3677.05","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4325.94","2595.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","503.11","11.63","","112.68","112.68","146.99","38","503.11","3348.28","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4325.94","2595.56","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2715.83","62.78","","780.86","208.94","10480.28","15","503.11","3348.28","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4325.94","2595.56","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1891.30","43.72","","179.76","179.76","179.76","1 through 10","503.11","3348.28","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4325.94","2595.56","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3145.82","72.72","","2355.45","298.99","3965.19","155","503.11","3348.28","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4325.94","2595.56","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3145.82","72.72","","3643.09","3643.09","3643.09","1 through 10","503.11","3348.28","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4325.94","2595.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2302.27","53.22","","554.28","554.28","554.28","16","503.11","3348.28","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4325.94","2595.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2721.02","62.9","","619.64","173.09","2370.64","150","503.11","3348.28","percent of total billed charges",""
"BONE PLATE 3.5X293MM 22 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4325.94","2595.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3348.28","77.4","","303.98","303.98","5854.79","1 through 10","503.11","3348.28","percent of total billed charges",""
"BONE PLATE 3.5X308MM 22 HOLE RECONSTRUCTION SS","SUP-ITM-10038098","CDM","C1713","HCPCS","0278","RC","","","","both","","","5006.02","3003.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","582.2","4255.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X308MM 22 HOLE RECONSTRUCTION SS","SUP-ITM-10038098","CDM","C1713","HCPCS","0278","RC","","","","both","","","5006.02","3003.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","582.2","4255.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X308MM 22 HOLE RECONSTRUCTION SS","SUP-ITM-10038098","CDM","C1713","HCPCS","0278","RC","","","","both","","","5006.02","3003.61","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2848.43","56.9","","812.12","238.65","1587.46","163","582.2","4255.12","percent of total billed charges",""
"BONE PLATE 3.5X308MM 22 HOLE RECONSTRUCTION SS","SUP-ITM-10038098","CDM","C1713","HCPCS","0278","RC","","","","both","","","5006.02","3003.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","582.20","11.63","","112.68","112.68","146.99","38","582.2","4255.12","percent of total billed charges",""
"BONE PLATE 3.5X308MM 22 HOLE RECONSTRUCTION SS","SUP-ITM-10038098","CDM","C1713","HCPCS","0278","RC","","","","both","","","5006.02","3003.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3874.66","77.4","","303.98","303.98","5854.79","1 through 10","582.2","4255.12","percent of total billed charges",""
"BONE PLATE 3.5X308MM 22 HOLE RECONSTRUCTION SS","SUP-ITM-10038098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5006.02","3003.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","582.20","11.63","","112.68","112.68","146.99","38","582.2","3874.66","percent of total billed charges",""
"BONE PLATE 3.5X308MM 22 HOLE RECONSTRUCTION SS","SUP-ITM-10038098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5006.02","3003.61","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3142.78","62.78","","780.86","208.94","10480.28","15","582.2","3874.66","percent of total billed charges",""
"BONE PLATE 3.5X308MM 22 HOLE RECONSTRUCTION SS","SUP-ITM-10038098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5006.02","3003.61","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2188.63","43.72","","179.76","179.76","179.76","1 through 10","582.2","3874.66","percent of total billed charges",""
"BONE PLATE 3.5X308MM 22 HOLE RECONSTRUCTION SS","SUP-ITM-10038098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5006.02","3003.61","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3640.38","72.72","","2355.45","298.99","3965.19","155","582.2","3874.66","percent of total billed charges",""
"BONE PLATE 3.5X308MM 22 HOLE RECONSTRUCTION SS","SUP-ITM-10038098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5006.02","3003.61","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3640.38","72.72","","3643.09","3643.09","3643.09","1 through 10","582.2","3874.66","percent of total billed charges",""
"BONE PLATE 3.5X308MM 22 HOLE RECONSTRUCTION SS","SUP-ITM-10038098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5006.02","3003.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2664.20","53.22","","554.28","554.28","554.28","16","582.2","3874.66","percent of total billed charges",""
"BONE PLATE 3.5X308MM 22 HOLE RECONSTRUCTION SS","SUP-ITM-10038098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5006.02","3003.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3148.79","62.9","","619.64","173.09","2370.64","150","582.2","3874.66","percent of total billed charges",""
"BONE PLATE 3.5X308MM 22 HOLE RECONSTRUCTION SS","SUP-ITM-10038098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5006.02","3003.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3874.66","77.4","","303.98","303.98","5854.79","1 through 10","582.2","3874.66","percent of total billed charges",""
"BONE PLATE 3.5X33MM 2 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037655","CDM","C1713","HCPCS","0278","RC","","","","both","","","1344.82","806.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","156.4","1143.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X33MM 2 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037655","CDM","C1713","HCPCS","0278","RC","","","","both","","","1344.82","806.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","156.4","1143.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X33MM 2 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037655","CDM","C1713","HCPCS","0278","RC","","","","both","","","1344.82","806.89","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","765.20","56.9","","812.12","238.65","1587.46","163","156.4","1143.1","percent of total billed charges",""
"BONE PLATE 3.5X33MM 2 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037655","CDM","C1713","HCPCS","0278","RC","","","","both","","","1344.82","806.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","156.40","11.63","","112.68","112.68","146.99","38","156.4","1143.1","percent of total billed charges",""
"BONE PLATE 3.5X33MM 2 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037655","CDM","C1713","HCPCS","0278","RC","","","","both","","","1344.82","806.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1040.89","77.4","","303.98","303.98","5854.79","1 through 10","156.4","1143.1","percent of total billed charges",""
"BONE PLATE 3.5X33MM 2 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","156.40","11.63","","112.68","112.68","146.99","38","156.4","1040.89","percent of total billed charges",""
"BONE PLATE 3.5X33MM 2 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","844.28","62.78","","780.86","208.94","10480.28","15","156.4","1040.89","percent of total billed charges",""
"BONE PLATE 3.5X33MM 2 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","587.96","43.72","","179.76","179.76","179.76","1 through 10","156.4","1040.89","percent of total billed charges",""
"BONE PLATE 3.5X33MM 2 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","977.95","72.72","","2355.45","298.99","3965.19","155","156.4","1040.89","percent of total billed charges",""
"BONE PLATE 3.5X33MM 2 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","977.95","72.72","","3643.09","3643.09","3643.09","1 through 10","156.4","1040.89","percent of total billed charges",""
"BONE PLATE 3.5X33MM 2 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","715.71","53.22","","554.28","554.28","554.28","16","156.4","1040.89","percent of total billed charges",""
"BONE PLATE 3.5X33MM 2 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","845.89","62.9","","619.64","173.09","2370.64","150","156.4","1040.89","percent of total billed charges",""
"BONE PLATE 3.5X33MM 2 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1040.89","77.4","","303.98","303.98","5854.79","1 through 10","156.4","1040.89","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.77","440.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","85.34","623.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.77","440.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","85.34","623.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.77","440.26","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","417.52","56.9","","812.12","238.65","1587.46","163","85.34","623.7","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.77","440.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","85.34","11.63","","112.68","112.68","146.99","38","85.34","623.7","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.77","440.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","567.94","77.4","","303.98","303.98","5854.79","1 through 10","85.34","623.7","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","733.77","440.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","85.34","11.63","","112.68","112.68","146.99","38","85.34","567.94","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","733.77","440.26","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","460.66","62.78","","780.86","208.94","10480.28","15","85.34","567.94","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","733.77","440.26","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","320.80","43.72","","179.76","179.76","179.76","1 through 10","85.34","567.94","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","733.77","440.26","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","533.60","72.72","","2355.45","298.99","3965.19","155","85.34","567.94","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","733.77","440.26","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","533.60","72.72","","3643.09","3643.09","3643.09","1 through 10","85.34","567.94","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","733.77","440.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","390.51","53.22","","554.28","554.28","554.28","16","85.34","567.94","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","733.77","440.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","461.54","62.9","","619.64","173.09","2370.64","150","85.34","567.94","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","733.77","440.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","567.94","77.4","","303.98","303.98","5854.79","1 through 10","85.34","567.94","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","both","","","1449.65","869.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","168.59","1232.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","both","","","1449.65","869.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","168.59","1232.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","both","","","1449.65","869.79","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","824.85","56.9","","812.12","238.65","1587.46","163","168.59","1232.2","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","both","","","1449.65","869.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","168.59","11.63","","112.68","112.68","146.99","38","168.59","1232.2","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","both","","","1449.65","869.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1122.03","77.4","","303.98","303.98","5854.79","1 through 10","168.59","1232.2","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1449.65","869.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","168.59","11.63","","112.68","112.68","146.99","38","168.59","1122.03","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1449.65","869.79","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","910.09","62.78","","780.86","208.94","10480.28","15","168.59","1122.03","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1449.65","869.79","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","633.79","43.72","","179.76","179.76","179.76","1 through 10","168.59","1122.03","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1449.65","869.79","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1054.19","72.72","","2355.45","298.99","3965.19","155","168.59","1122.03","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1449.65","869.79","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1054.19","72.72","","3643.09","3643.09","3643.09","1 through 10","168.59","1122.03","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1449.65","869.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","771.50","53.22","","554.28","554.28","554.28","16","168.59","1122.03","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1449.65","869.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","911.83","62.9","","619.64","173.09","2370.64","150","168.59","1122.03","percent of total billed charges",""
"BONE PLATE 3.5X38MM 3 HOLE COMPRESSION LCP DCP SS CS/1BX/1EA","SUP-ITM-10037656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1449.65","869.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1122.03","77.4","","303.98","303.98","5854.79","1 through 10","168.59","1122.03","percent of total billed charges",""
"BONE PLATE 3.5X46MM 3 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037657","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.96","837.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","162.35","1186.57","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X46MM 3 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037657","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.96","837.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","162.35","1186.57","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X46MM 3 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037657","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.96","837.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","794.30","56.9","","812.12","238.65","1587.46","163","162.35","1186.57","percent of total billed charges",""
"BONE PLATE 3.5X46MM 3 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037657","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.96","837.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","162.35","11.63","","112.68","112.68","146.99","38","162.35","1186.57","percent of total billed charges",""
"BONE PLATE 3.5X46MM 3 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037657","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.96","837.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1080.47","77.4","","303.98","303.98","5854.79","1 through 10","162.35","1186.57","percent of total billed charges",""
"BONE PLATE 3.5X46MM 3 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037657","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1395.96","837.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","162.35","11.63","","112.68","112.68","146.99","38","162.35","1080.47","percent of total billed charges",""
"BONE PLATE 3.5X46MM 3 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037657","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1395.96","837.58","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","876.38","62.78","","780.86","208.94","10480.28","15","162.35","1080.47","percent of total billed charges",""
"BONE PLATE 3.5X46MM 3 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037657","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1395.96","837.58","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","610.31","43.72","","179.76","179.76","179.76","1 through 10","162.35","1080.47","percent of total billed charges",""
"BONE PLATE 3.5X46MM 3 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037657","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1395.96","837.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1015.14","72.72","","2355.45","298.99","3965.19","155","162.35","1080.47","percent of total billed charges",""
"BONE PLATE 3.5X46MM 3 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037657","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1395.96","837.58","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1015.14","72.72","","3643.09","3643.09","3643.09","1 through 10","162.35","1080.47","percent of total billed charges",""
"BONE PLATE 3.5X46MM 3 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037657","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1395.96","837.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","742.93","53.22","","554.28","554.28","554.28","16","162.35","1080.47","percent of total billed charges",""
"BONE PLATE 3.5X46MM 3 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037657","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1395.96","837.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","878.06","62.9","","619.64","173.09","2370.64","150","162.35","1080.47","percent of total billed charges",""
"BONE PLATE 3.5X46MM 3 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037657","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1395.96","837.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1080.47","77.4","","303.98","303.98","5854.79","1 through 10","162.35","1080.47","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","both","","","2188.54","1313.12","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","254.53","1860.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","both","","","2188.54","1313.12","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","254.53","1860.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","both","","","2188.54","1313.12","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1245.28","56.9","","812.12","238.65","1587.46","163","254.53","1860.26","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","both","","","2188.54","1313.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","254.53","11.63","","112.68","112.68","146.99","38","254.53","1860.26","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","both","","","2188.54","1313.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1693.93","77.4","","303.98","303.98","5854.79","1 through 10","254.53","1860.26","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2188.54","1313.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","254.53","11.63","","112.68","112.68","146.99","38","254.53","1693.93","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2188.54","1313.12","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1373.97","62.78","","780.86","208.94","10480.28","15","254.53","1693.93","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2188.54","1313.12","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","956.83","43.72","","179.76","179.76","179.76","1 through 10","254.53","1693.93","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2188.54","1313.12","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1591.51","72.72","","2355.45","298.99","3965.19","155","254.53","1693.93","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2188.54","1313.12","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1591.51","72.72","","3643.09","3643.09","3643.09","1 through 10","254.53","1693.93","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2188.54","1313.12","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1164.74","53.22","","554.28","554.28","554.28","16","254.53","1693.93","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2188.54","1313.12","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1376.59","62.9","","619.64","173.09","2370.64","150","254.53","1693.93","percent of total billed charges",""
"BONE PLATE 3.5X46MM 4 HOLE RECONSTRUCTION SS","SUP-ITM-10038096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2188.54","1313.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1693.93","77.4","","303.98","303.98","5854.79","1 through 10","254.53","1693.93","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE DCP COMPRESSION DYNAMIC SS","SUP-ITM-10001950","CDM","C1713","HCPCS","0278","RC","","","","both","","","1641.40","984.84","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","190.89","1395.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X49MM 4 HOLE DCP COMPRESSION DYNAMIC SS","SUP-ITM-10001950","CDM","C1713","HCPCS","0278","RC","","","","both","","","1641.40","984.84","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","190.89","1395.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X49MM 4 HOLE DCP COMPRESSION DYNAMIC SS","SUP-ITM-10001950","CDM","C1713","HCPCS","0278","RC","","","","both","","","1641.40","984.84","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","933.96","56.9","","812.12","238.65","1587.46","163","190.89","1395.19","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE DCP COMPRESSION DYNAMIC SS","SUP-ITM-10001950","CDM","C1713","HCPCS","0278","RC","","","","both","","","1641.40","984.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","190.89","11.63","","112.68","112.68","146.99","38","190.89","1395.19","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE DCP COMPRESSION DYNAMIC SS","SUP-ITM-10001950","CDM","C1713","HCPCS","0278","RC","","","","both","","","1641.40","984.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1270.44","77.4","","303.98","303.98","5854.79","1 through 10","190.89","1395.19","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE DCP COMPRESSION DYNAMIC SS","SUP-ITM-10001950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1641.40","984.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","190.89","11.63","","112.68","112.68","146.99","38","190.89","1270.44","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE DCP COMPRESSION DYNAMIC SS","SUP-ITM-10001950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1641.40","984.84","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1030.47","62.78","","780.86","208.94","10480.28","15","190.89","1270.44","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE DCP COMPRESSION DYNAMIC SS","SUP-ITM-10001950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1641.40","984.84","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","717.62","43.72","","179.76","179.76","179.76","1 through 10","190.89","1270.44","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE DCP COMPRESSION DYNAMIC SS","SUP-ITM-10001950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1641.40","984.84","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1193.63","72.72","","2355.45","298.99","3965.19","155","190.89","1270.44","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE DCP COMPRESSION DYNAMIC SS","SUP-ITM-10001950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1641.40","984.84","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1193.63","72.72","","3643.09","3643.09","3643.09","1 through 10","190.89","1270.44","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE DCP COMPRESSION DYNAMIC SS","SUP-ITM-10001950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1641.40","984.84","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","873.55","53.22","","554.28","554.28","554.28","16","190.89","1270.44","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE DCP COMPRESSION DYNAMIC SS","SUP-ITM-10001950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1641.40","984.84","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1032.44","62.9","","619.64","173.09","2370.64","150","190.89","1270.44","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE DCP COMPRESSION DYNAMIC SS","SUP-ITM-10001950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1641.40","984.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1270.44","77.4","","303.98","303.98","5854.79","1 through 10","190.89","1270.44","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","848.82","509.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","98.72","721.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","848.82","509.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","98.72","721.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","848.82","509.29","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","482.98","56.9","","812.12","238.65","1587.46","163","98.72","721.5","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","848.82","509.29","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","98.72","11.63","","112.68","112.68","146.99","38","98.72","721.5","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","848.82","509.29","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","656.99","77.4","","303.98","303.98","5854.79","1 through 10","98.72","721.5","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","848.82","509.29","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","98.72","11.63","","112.68","112.68","146.99","38","98.72","656.99","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","848.82","509.29","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","532.89","62.78","","780.86","208.94","10480.28","15","98.72","656.99","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","848.82","509.29","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","371.10","43.72","","179.76","179.76","179.76","1 through 10","98.72","656.99","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","848.82","509.29","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","617.26","72.72","","2355.45","298.99","3965.19","155","98.72","656.99","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","848.82","509.29","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","617.26","72.72","","3643.09","3643.09","3643.09","1 through 10","98.72","656.99","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","848.82","509.29","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","451.74","53.22","","554.28","554.28","554.28","16","98.72","656.99","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","848.82","509.29","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","533.91","62.9","","619.64","173.09","2370.64","150","98.72","656.99","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","848.82","509.29","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","656.99","77.4","","303.98","303.98","5854.79","1 through 10","98.72","656.99","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","1564.70","938.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","181.97","1330","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","1564.70","938.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","181.97","1330","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","1564.70","938.82","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","890.31","56.9","","812.12","238.65","1587.46","163","181.97","1330","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","1564.70","938.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","181.97","11.63","","112.68","112.68","146.99","38","181.97","1330","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","1564.70","938.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1211.08","77.4","","303.98","303.98","5854.79","1 through 10","181.97","1330","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1564.70","938.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","181.97","11.63","","112.68","112.68","146.99","38","181.97","1211.08","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1564.70","938.82","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","982.32","62.78","","780.86","208.94","10480.28","15","181.97","1211.08","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1564.70","938.82","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","684.09","43.72","","179.76","179.76","179.76","1 through 10","181.97","1211.08","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1564.70","938.82","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1137.85","72.72","","2355.45","298.99","3965.19","155","181.97","1211.08","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1564.70","938.82","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1137.85","72.72","","3643.09","3643.09","3643.09","1 through 10","181.97","1211.08","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1564.70","938.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","832.73","53.22","","554.28","554.28","554.28","16","181.97","1211.08","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1564.70","938.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","984.20","62.9","","619.64","173.09","2370.64","150","181.97","1211.08","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1564.70","938.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1211.08","77.4","","303.98","303.98","5854.79","1 through 10","181.97","1211.08","percent of total billed charges",""
"BONE PLATE 3.5X50MM 4 3 HOLE LCP SS T SHAPE","SUP-ITM-10037966","CDM","C1713","HCPCS","0278","RC","","","","both","","","1605.61","963.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","186.73","1364.77","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X50MM 4 3 HOLE LCP SS T SHAPE","SUP-ITM-10037966","CDM","C1713","HCPCS","0278","RC","","","","both","","","1605.61","963.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","186.73","1364.77","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X50MM 4 3 HOLE LCP SS T SHAPE","SUP-ITM-10037966","CDM","C1713","HCPCS","0278","RC","","","","both","","","1605.61","963.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","913.59","56.9","","812.12","238.65","1587.46","163","186.73","1364.77","percent of total billed charges",""
"BONE PLATE 3.5X50MM 4 3 HOLE LCP SS T SHAPE","SUP-ITM-10037966","CDM","C1713","HCPCS","0278","RC","","","","both","","","1605.61","963.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","186.73","11.63","","112.68","112.68","146.99","38","186.73","1364.77","percent of total billed charges",""
"BONE PLATE 3.5X50MM 4 3 HOLE LCP SS T SHAPE","SUP-ITM-10037966","CDM","C1713","HCPCS","0278","RC","","","","both","","","1605.61","963.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1242.74","77.4","","303.98","303.98","5854.79","1 through 10","186.73","1364.77","percent of total billed charges",""
"BONE PLATE 3.5X50MM 4 3 HOLE LCP SS T SHAPE","SUP-ITM-10037966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1605.61","963.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","186.73","11.63","","112.68","112.68","146.99","38","186.73","1242.74","percent of total billed charges",""
"BONE PLATE 3.5X50MM 4 3 HOLE LCP SS T SHAPE","SUP-ITM-10037966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1605.61","963.37","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1008.00","62.78","","780.86","208.94","10480.28","15","186.73","1242.74","percent of total billed charges",""
"BONE PLATE 3.5X50MM 4 3 HOLE LCP SS T SHAPE","SUP-ITM-10037966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1605.61","963.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","701.97","43.72","","179.76","179.76","179.76","1 through 10","186.73","1242.74","percent of total billed charges",""
"BONE PLATE 3.5X50MM 4 3 HOLE LCP SS T SHAPE","SUP-ITM-10037966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1605.61","963.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1167.60","72.72","","2355.45","298.99","3965.19","155","186.73","1242.74","percent of total billed charges",""
"BONE PLATE 3.5X50MM 4 3 HOLE LCP SS T SHAPE","SUP-ITM-10037966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1605.61","963.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1167.60","72.72","","3643.09","3643.09","3643.09","1 through 10","186.73","1242.74","percent of total billed charges",""
"BONE PLATE 3.5X50MM 4 3 HOLE LCP SS T SHAPE","SUP-ITM-10037966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1605.61","963.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","854.51","53.22","","554.28","554.28","554.28","16","186.73","1242.74","percent of total billed charges",""
"BONE PLATE 3.5X50MM 4 3 HOLE LCP SS T SHAPE","SUP-ITM-10037966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1605.61","963.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1009.93","62.9","","619.64","173.09","2370.64","150","186.73","1242.74","percent of total billed charges",""
"BONE PLATE 3.5X50MM 4 3 HOLE LCP SS T SHAPE","SUP-ITM-10037966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1605.61","963.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1242.74","77.4","","303.98","303.98","5854.79","1 through 10","186.73","1242.74","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.01","906.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","175.73","1284.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.01","906.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","175.73","1284.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.01","906.61","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","859.76","56.9","","812.12","238.65","1587.46","163","175.73","1284.36","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.01","906.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","175.73","11.63","","112.68","112.68","146.99","38","175.73","1284.36","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1511.01","906.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1169.52","77.4","","303.98","303.98","5854.79","1 through 10","175.73","1284.36","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1511.01","906.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","175.73","11.63","","112.68","112.68","146.99","38","175.73","1169.52","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1511.01","906.61","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","948.61","62.78","","780.86","208.94","10480.28","15","175.73","1169.52","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1511.01","906.61","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","660.61","43.72","","179.76","179.76","179.76","1 through 10","175.73","1169.52","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1511.01","906.61","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1098.81","72.72","","2355.45","298.99","3965.19","155","175.73","1169.52","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1511.01","906.61","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1098.81","72.72","","3643.09","3643.09","3643.09","1 through 10","175.73","1169.52","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1511.01","906.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","804.16","53.22","","554.28","554.28","554.28","16","175.73","1169.52","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1511.01","906.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","950.43","62.9","","619.64","173.09","2370.64","150","175.73","1169.52","percent of total billed charges",""
"BONE PLATE 3.5X51MM 4 HOLE COMPRESSION LCP DCP SS","SUP-ITM-10002222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1511.01","906.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1169.52","77.4","","303.98","303.98","5854.79","1 through 10","175.73","1169.52","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1759.01","1055.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","204.57","1495.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1759.01","1055.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","204.57","1495.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1759.01","1055.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1000.88","56.9","","812.12","238.65","1587.46","163","204.57","1495.16","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1759.01","1055.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","204.57","11.63","","112.68","112.68","146.99","38","204.57","1495.16","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1759.01","1055.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1361.47","77.4","","303.98","303.98","5854.79","1 through 10","204.57","1495.16","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1759.01","1055.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","204.57","11.63","","112.68","112.68","146.99","38","204.57","1361.47","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1759.01","1055.41","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1104.31","62.78","","780.86","208.94","10480.28","15","204.57","1361.47","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1759.01","1055.41","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","769.04","43.72","","179.76","179.76","179.76","1 through 10","204.57","1361.47","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1759.01","1055.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1279.15","72.72","","2355.45","298.99","3965.19","155","204.57","1361.47","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1759.01","1055.41","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1279.15","72.72","","3643.09","3643.09","3643.09","1 through 10","204.57","1361.47","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1759.01","1055.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","936.15","53.22","","554.28","554.28","554.28","16","204.57","1361.47","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1759.01","1055.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1106.42","62.9","","619.64","173.09","2370.64","150","204.57","1361.47","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1759.01","1055.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1361.47","77.4","","303.98","303.98","5854.79","1 through 10","204.57","1361.47","percent of total billed charges",""
"BONE PLATE 3.5X55MM 4 HOLE RECONSTRUCTION CURVED LCP SS","SUP-ITM-10038099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3413.19","2047.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","396.95","2901.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X55MM 4 HOLE RECONSTRUCTION CURVED LCP SS","SUP-ITM-10038099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3413.19","2047.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","396.95","2901.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X55MM 4 HOLE RECONSTRUCTION CURVED LCP SS","SUP-ITM-10038099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3413.19","2047.91","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1942.11","56.9","","812.12","238.65","1587.46","163","396.95","2901.21","percent of total billed charges",""
"BONE PLATE 3.5X55MM 4 HOLE RECONSTRUCTION CURVED LCP SS","SUP-ITM-10038099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3413.19","2047.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","396.95","11.63","","112.68","112.68","146.99","38","396.95","2901.21","percent of total billed charges",""
"BONE PLATE 3.5X55MM 4 HOLE RECONSTRUCTION CURVED LCP SS","SUP-ITM-10038099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3413.19","2047.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2641.81","77.4","","303.98","303.98","5854.79","1 through 10","396.95","2901.21","percent of total billed charges",""
"BONE PLATE 3.5X55MM 4 HOLE RECONSTRUCTION CURVED LCP SS","SUP-ITM-10038099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3413.19","2047.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","396.95","11.63","","112.68","112.68","146.99","38","396.95","2641.81","percent of total billed charges",""
"BONE PLATE 3.5X55MM 4 HOLE RECONSTRUCTION CURVED LCP SS","SUP-ITM-10038099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3413.19","2047.91","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2142.80","62.78","","780.86","208.94","10480.28","15","396.95","2641.81","percent of total billed charges",""
"BONE PLATE 3.5X55MM 4 HOLE RECONSTRUCTION CURVED LCP SS","SUP-ITM-10038099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3413.19","2047.91","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1492.25","43.72","","179.76","179.76","179.76","1 through 10","396.95","2641.81","percent of total billed charges",""
"BONE PLATE 3.5X55MM 4 HOLE RECONSTRUCTION CURVED LCP SS","SUP-ITM-10038099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3413.19","2047.91","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2482.07","72.72","","2355.45","298.99","3965.19","155","396.95","2641.81","percent of total billed charges",""
"BONE PLATE 3.5X55MM 4 HOLE RECONSTRUCTION CURVED LCP SS","SUP-ITM-10038099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3413.19","2047.91","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2482.07","72.72","","3643.09","3643.09","3643.09","1 through 10","396.95","2641.81","percent of total billed charges",""
"BONE PLATE 3.5X55MM 4 HOLE RECONSTRUCTION CURVED LCP SS","SUP-ITM-10038099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3413.19","2047.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1816.50","53.22","","554.28","554.28","554.28","16","396.95","2641.81","percent of total billed charges",""
"BONE PLATE 3.5X55MM 4 HOLE RECONSTRUCTION CURVED LCP SS","SUP-ITM-10038099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3413.19","2047.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2146.90","62.9","","619.64","173.09","2370.64","150","396.95","2641.81","percent of total billed charges",""
"BONE PLATE 3.5X55MM 4 HOLE RECONSTRUCTION CURVED LCP SS","SUP-ITM-10038099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3413.19","2047.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2641.81","77.4","","303.98","303.98","5854.79","1 through 10","396.95","2641.81","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.33","1037.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","201","1469.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.33","1037.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","201","1469.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.33","1037.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","983.42","56.9","","812.12","238.65","1587.46","163","201","1469.08","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.33","1037.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","201.00","11.63","","112.68","112.68","146.99","38","201","1469.08","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.33","1037.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1337.73","77.4","","303.98","303.98","5854.79","1 through 10","201","1469.08","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1728.33","1037.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","201.00","11.63","","112.68","112.68","146.99","38","201","1337.73","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1728.33","1037.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1085.05","62.78","","780.86","208.94","10480.28","15","201","1337.73","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1728.33","1037.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","755.63","43.72","","179.76","179.76","179.76","1 through 10","201","1337.73","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1728.33","1037.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1256.84","72.72","","2355.45","298.99","3965.19","155","201","1337.73","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1728.33","1037.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1256.84","72.72","","3643.09","3643.09","3643.09","1 through 10","201","1337.73","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1728.33","1037.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","919.82","53.22","","554.28","554.28","554.28","16","201","1337.73","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1728.33","1037.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1087.12","62.9","","619.64","173.09","2370.64","150","201","1337.73","percent of total billed charges",""
"BONE PLATE 3.5X56MM 3 HOLE HD 4 SHAFT LC DCP SS T SHAPE RT ANGLE","SUP-ITM-10001592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1728.33","1037.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1337.73","77.4","","303.98","303.98","5854.79","1 through 10","201","1337.73","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","1618.39","971.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","188.22","1375.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","1618.39","971.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","188.22","1375.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","1618.39","971.03","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","920.86","56.9","","812.12","238.65","1587.46","163","188.22","1375.63","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","1618.39","971.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","188.22","11.63","","112.68","112.68","146.99","38","188.22","1375.63","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","1618.39","971.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1252.63","77.4","","303.98","303.98","5854.79","1 through 10","188.22","1375.63","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1618.39","971.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","188.22","11.63","","112.68","112.68","146.99","38","188.22","1252.63","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1618.39","971.03","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1016.03","62.78","","780.86","208.94","10480.28","15","188.22","1252.63","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1618.39","971.03","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","707.56","43.72","","179.76","179.76","179.76","1 through 10","188.22","1252.63","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1618.39","971.03","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1176.89","72.72","","2355.45","298.99","3965.19","155","188.22","1252.63","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1618.39","971.03","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1176.89","72.72","","3643.09","3643.09","3643.09","1 through 10","188.22","1252.63","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1618.39","971.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","861.31","53.22","","554.28","554.28","554.28","16","188.22","1252.63","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1618.39","971.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1017.97","62.9","","619.64","173.09","2370.64","150","188.22","1252.63","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1618.39","971.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1252.63","77.4","","303.98","303.98","5854.79","1 through 10","188.22","1252.63","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038091","CDM","C1713","HCPCS","0278","RC","","","","both","","","2188.54","1313.12","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","254.53","1860.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X56MM 4 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038091","CDM","C1713","HCPCS","0278","RC","","","","both","","","2188.54","1313.12","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","254.53","1860.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X56MM 4 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038091","CDM","C1713","HCPCS","0278","RC","","","","both","","","2188.54","1313.12","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1245.28","56.9","","812.12","238.65","1587.46","163","254.53","1860.26","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038091","CDM","C1713","HCPCS","0278","RC","","","","both","","","2188.54","1313.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","254.53","11.63","","112.68","112.68","146.99","38","254.53","1860.26","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038091","CDM","C1713","HCPCS","0278","RC","","","","both","","","2188.54","1313.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1693.93","77.4","","303.98","303.98","5854.79","1 through 10","254.53","1860.26","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2188.54","1313.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","254.53","11.63","","112.68","112.68","146.99","38","254.53","1693.93","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2188.54","1313.12","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1373.97","62.78","","780.86","208.94","10480.28","15","254.53","1693.93","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2188.54","1313.12","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","956.83","43.72","","179.76","179.76","179.76","1 through 10","254.53","1693.93","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2188.54","1313.12","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1591.51","72.72","","2355.45","298.99","3965.19","155","254.53","1693.93","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2188.54","1313.12","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1591.51","72.72","","3643.09","3643.09","3643.09","1 through 10","254.53","1693.93","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2188.54","1313.12","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1164.74","53.22","","554.28","554.28","554.28","16","254.53","1693.93","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2188.54","1313.12","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1376.59","62.9","","619.64","173.09","2370.64","150","254.53","1693.93","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10038091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2188.54","1313.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1693.93","77.4","","303.98","303.98","5854.79","1 through 10","254.53","1693.93","percent of total billed charges",""
"BONE PLATE 3.5X59MM 4 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037658","CDM","C1713","HCPCS","0278","RC","","","","both","","","1459.88","875.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","169.78","1240.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X59MM 4 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037658","CDM","C1713","HCPCS","0278","RC","","","","both","","","1459.88","875.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","169.78","1240.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X59MM 4 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037658","CDM","C1713","HCPCS","0278","RC","","","","both","","","1459.88","875.93","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","830.67","56.9","","812.12","238.65","1587.46","163","169.78","1240.9","percent of total billed charges",""
"BONE PLATE 3.5X59MM 4 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037658","CDM","C1713","HCPCS","0278","RC","","","","both","","","1459.88","875.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","169.78","11.63","","112.68","112.68","146.99","38","169.78","1240.9","percent of total billed charges",""
"BONE PLATE 3.5X59MM 4 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037658","CDM","C1713","HCPCS","0278","RC","","","","both","","","1459.88","875.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1129.95","77.4","","303.98","303.98","5854.79","1 through 10","169.78","1240.9","percent of total billed charges",""
"BONE PLATE 3.5X59MM 4 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037658","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1459.88","875.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","169.78","11.63","","112.68","112.68","146.99","38","169.78","1129.95","percent of total billed charges",""
"BONE PLATE 3.5X59MM 4 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037658","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1459.88","875.93","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","916.51","62.78","","780.86","208.94","10480.28","15","169.78","1129.95","percent of total billed charges",""
"BONE PLATE 3.5X59MM 4 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037658","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1459.88","875.93","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","638.26","43.72","","179.76","179.76","179.76","1 through 10","169.78","1129.95","percent of total billed charges",""
"BONE PLATE 3.5X59MM 4 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037658","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1459.88","875.93","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1061.62","72.72","","2355.45","298.99","3965.19","155","169.78","1129.95","percent of total billed charges",""
"BONE PLATE 3.5X59MM 4 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037658","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1459.88","875.93","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1061.62","72.72","","3643.09","3643.09","3643.09","1 through 10","169.78","1129.95","percent of total billed charges",""
"BONE PLATE 3.5X59MM 4 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037658","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1459.88","875.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","776.95","53.22","","554.28","554.28","554.28","16","169.78","1129.95","percent of total billed charges",""
"BONE PLATE 3.5X59MM 4 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037658","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1459.88","875.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","918.26","62.9","","619.64","173.09","2370.64","150","169.78","1129.95","percent of total billed charges",""
"BONE PLATE 3.5X59MM 4 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10037658","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1459.88","875.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1129.95","77.4","","303.98","303.98","5854.79","1 through 10","169.78","1129.95","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","1840.82","1104.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","214.09","1564.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","1840.82","1104.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","214.09","1564.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","1840.82","1104.49","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1047.43","56.9","","812.12","238.65","1587.46","163","214.09","1564.7","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","1840.82","1104.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","214.09","11.63","","112.68","112.68","146.99","38","214.09","1564.7","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","1840.82","1104.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1424.79","77.4","","303.98","303.98","5854.79","1 through 10","214.09","1564.7","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1840.82","1104.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","214.09","11.63","","112.68","112.68","146.99","38","214.09","1424.79","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1840.82","1104.49","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1155.67","62.78","","780.86","208.94","10480.28","15","214.09","1424.79","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1840.82","1104.49","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","804.81","43.72","","179.76","179.76","179.76","1 through 10","214.09","1424.79","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1840.82","1104.49","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1338.64","72.72","","2355.45","298.99","3965.19","155","214.09","1424.79","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1840.82","1104.49","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1338.64","72.72","","3643.09","3643.09","3643.09","1 through 10","214.09","1424.79","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1840.82","1104.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","979.68","53.22","","554.28","554.28","554.28","16","214.09","1424.79","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1840.82","1104.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1157.88","62.9","","619.64","173.09","2370.64","150","214.09","1424.79","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1840.82","1104.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1424.79","77.4","","303.98","303.98","5854.79","1 through 10","214.09","1424.79","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","1774.35","1064.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","206.36","1508.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","1774.35","1064.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","206.36","1508.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","1774.35","1064.61","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1009.61","56.9","","812.12","238.65","1587.46","163","206.36","1508.2","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","1774.35","1064.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","206.36","11.63","","112.68","112.68","146.99","38","206.36","1508.2","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","1774.35","1064.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1373.35","77.4","","303.98","303.98","5854.79","1 through 10","206.36","1508.2","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","206.36","11.63","","112.68","112.68","146.99","38","206.36","1373.35","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1113.94","62.78","","780.86","208.94","10480.28","15","206.36","1373.35","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","775.75","43.72","","179.76","179.76","179.76","1 through 10","206.36","1373.35","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1290.31","72.72","","2355.45","298.99","3965.19","155","206.36","1373.35","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1290.31","72.72","","3643.09","3643.09","3643.09","1 through 10","206.36","1373.35","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","944.31","53.22","","554.28","554.28","554.28","16","206.36","1373.35","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1116.07","62.9","","619.64","173.09","2370.64","150","206.36","1373.35","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1373.35","77.4","","303.98","303.98","5854.79","1 through 10","206.36","1373.35","percent of total billed charges",""
"BONE PLATE 3.5X67MM 4 HOLE HD 5 SHAFT T SHAPE RT ANGLE LCP SS","SUP-ITM-10024289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1833.15","1099.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","213.2","1558.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X67MM 4 HOLE HD 5 SHAFT T SHAPE RT ANGLE LCP SS","SUP-ITM-10024289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1833.15","1099.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","213.2","1558.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X67MM 4 HOLE HD 5 SHAFT T SHAPE RT ANGLE LCP SS","SUP-ITM-10024289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1833.15","1099.89","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1043.06","56.9","","812.12","238.65","1587.46","163","213.2","1558.18","percent of total billed charges",""
"BONE PLATE 3.5X67MM 4 HOLE HD 5 SHAFT T SHAPE RT ANGLE LCP SS","SUP-ITM-10024289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1833.15","1099.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","213.20","11.63","","112.68","112.68","146.99","38","213.2","1558.18","percent of total billed charges",""
"BONE PLATE 3.5X67MM 4 HOLE HD 5 SHAFT T SHAPE RT ANGLE LCP SS","SUP-ITM-10024289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1833.15","1099.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1418.86","77.4","","303.98","303.98","5854.79","1 through 10","213.2","1558.18","percent of total billed charges",""
"BONE PLATE 3.5X67MM 4 HOLE HD 5 SHAFT T SHAPE RT ANGLE LCP SS","SUP-ITM-10024289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1833.15","1099.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","213.20","11.63","","112.68","112.68","146.99","38","213.2","1418.86","percent of total billed charges",""
"BONE PLATE 3.5X67MM 4 HOLE HD 5 SHAFT T SHAPE RT ANGLE LCP SS","SUP-ITM-10024289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1833.15","1099.89","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1150.85","62.78","","780.86","208.94","10480.28","15","213.2","1418.86","percent of total billed charges",""
"BONE PLATE 3.5X67MM 4 HOLE HD 5 SHAFT T SHAPE RT ANGLE LCP SS","SUP-ITM-10024289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1833.15","1099.89","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","801.45","43.72","","179.76","179.76","179.76","1 through 10","213.2","1418.86","percent of total billed charges",""
"BONE PLATE 3.5X67MM 4 HOLE HD 5 SHAFT T SHAPE RT ANGLE LCP SS","SUP-ITM-10024289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1833.15","1099.89","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1333.07","72.72","","2355.45","298.99","3965.19","155","213.2","1418.86","percent of total billed charges",""
"BONE PLATE 3.5X67MM 4 HOLE HD 5 SHAFT T SHAPE RT ANGLE LCP SS","SUP-ITM-10024289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1833.15","1099.89","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1333.07","72.72","","3643.09","3643.09","3643.09","1 through 10","213.2","1418.86","percent of total billed charges",""
"BONE PLATE 3.5X67MM 4 HOLE HD 5 SHAFT T SHAPE RT ANGLE LCP SS","SUP-ITM-10024289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1833.15","1099.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","975.60","53.22","","554.28","554.28","554.28","16","213.2","1418.86","percent of total billed charges",""
"BONE PLATE 3.5X67MM 4 HOLE HD 5 SHAFT T SHAPE RT ANGLE LCP SS","SUP-ITM-10024289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1833.15","1099.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1153.05","62.9","","619.64","173.09","2370.64","150","213.2","1418.86","percent of total billed charges",""
"BONE PLATE 3.5X67MM 4 HOLE HD 5 SHAFT T SHAPE RT ANGLE LCP SS","SUP-ITM-10024289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1833.15","1099.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1418.86","77.4","","303.98","303.98","5854.79","1 through 10","213.2","1418.86","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","2142.51","1285.51","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","249.17","1821.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","2142.51","1285.51","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","249.17","1821.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","2142.51","1285.51","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1219.09","56.9","","812.12","238.65","1587.46","163","249.17","1821.13","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","2142.51","1285.51","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","249.17","11.63","","112.68","112.68","146.99","38","249.17","1821.13","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","2142.51","1285.51","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1658.30","77.4","","303.98","303.98","5854.79","1 through 10","249.17","1821.13","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2142.51","1285.51","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","249.17","11.63","","112.68","112.68","146.99","38","249.17","1658.3","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2142.51","1285.51","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1345.07","62.78","","780.86","208.94","10480.28","15","249.17","1658.3","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2142.51","1285.51","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","936.71","43.72","","179.76","179.76","179.76","1 through 10","249.17","1658.3","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2142.51","1285.51","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1558.03","72.72","","2355.45","298.99","3965.19","155","249.17","1658.3","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2142.51","1285.51","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1558.03","72.72","","3643.09","3643.09","3643.09","1 through 10","249.17","1658.3","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2142.51","1285.51","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1140.24","53.22","","554.28","554.28","554.28","16","249.17","1658.3","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2142.51","1285.51","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1347.64","62.9","","619.64","173.09","2370.64","150","249.17","1658.3","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2142.51","1285.51","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1658.30","77.4","","303.98","303.98","5854.79","1 through 10","249.17","1658.3","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","1493.11","895.87","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","173.65","1269.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","1493.11","895.87","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","173.65","1269.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","1493.11","895.87","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","849.58","56.9","","812.12","238.65","1587.46","163","173.65","1269.14","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","1493.11","895.87","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","173.65","11.63","","112.68","112.68","146.99","38","173.65","1269.14","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","1493.11","895.87","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1155.67","77.4","","303.98","303.98","5854.79","1 through 10","173.65","1269.14","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1493.11","895.87","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","173.65","11.63","","112.68","112.68","146.99","38","173.65","1155.67","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1493.11","895.87","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","937.37","62.78","","780.86","208.94","10480.28","15","173.65","1155.67","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1493.11","895.87","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","652.79","43.72","","179.76","179.76","179.76","1 through 10","173.65","1155.67","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1493.11","895.87","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1085.79","72.72","","2355.45","298.99","3965.19","155","173.65","1155.67","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1493.11","895.87","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1085.79","72.72","","3643.09","3643.09","3643.09","1 through 10","173.65","1155.67","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1493.11","895.87","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","794.63","53.22","","554.28","554.28","554.28","16","173.65","1155.67","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1493.11","895.87","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","939.17","62.9","","619.64","173.09","2370.64","150","173.65","1155.67","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1493.11","895.87","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1155.67","77.4","","303.98","303.98","5854.79","1 through 10","173.65","1155.67","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.76","329.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","63.94","467.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.76","329.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","63.94","467.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.76","329.86","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","312.81","56.9","","812.12","238.65","1587.46","163","63.94","467.3","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.76","329.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","63.94","11.63","","112.68","112.68","146.99","38","63.94","467.3","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.76","329.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","425.51","77.4","","303.98","303.98","5854.79","1 through 10","63.94","467.3","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.76","329.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","63.94","11.63","","112.68","112.68","146.99","38","63.94","425.51","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.76","329.86","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","345.14","62.78","","780.86","208.94","10480.28","15","63.94","425.51","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.76","329.86","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","240.36","43.72","","179.76","179.76","179.76","1 through 10","63.94","425.51","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.76","329.86","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","399.79","72.72","","2355.45","298.99","3965.19","155","63.94","425.51","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.76","329.86","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","399.79","72.72","","3643.09","3643.09","3643.09","1 through 10","63.94","425.51","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.76","329.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","292.58","53.22","","554.28","554.28","554.28","16","63.94","425.51","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.76","329.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","345.80","62.9","","619.64","173.09","2370.64","150","63.94","425.51","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.76","329.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","425.51","77.4","","303.98","303.98","5854.79","1 through 10","63.94","425.51","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","1802.47","1081.48","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","209.63","1532.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","1802.47","1081.48","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","209.63","1532.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","1802.47","1081.48","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1025.61","56.9","","812.12","238.65","1587.46","163","209.63","1532.1","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","1802.47","1081.48","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","209.63","11.63","","112.68","112.68","146.99","38","209.63","1532.1","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","1802.47","1081.48","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1395.11","77.4","","303.98","303.98","5854.79","1 through 10","209.63","1532.1","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1802.47","1081.48","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","209.63","11.63","","112.68","112.68","146.99","38","209.63","1395.11","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1802.47","1081.48","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1131.59","62.78","","780.86","208.94","10480.28","15","209.63","1395.11","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1802.47","1081.48","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","788.04","43.72","","179.76","179.76","179.76","1 through 10","209.63","1395.11","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1802.47","1081.48","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1310.76","72.72","","2355.45","298.99","3965.19","155","209.63","1395.11","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1802.47","1081.48","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1310.76","72.72","","3643.09","3643.09","3643.09","1 through 10","209.63","1395.11","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1802.47","1081.48","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","959.27","53.22","","554.28","554.28","554.28","16","209.63","1395.11","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1802.47","1081.48","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1133.75","62.9","","619.64","173.09","2370.64","150","209.63","1395.11","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1802.47","1081.48","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1395.11","77.4","","303.98","303.98","5854.79","1 through 10","209.63","1395.11","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1922.64","1153.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","223.6","1634.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1922.64","1153.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","223.6","1634.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1922.64","1153.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1093.98","56.9","","812.12","238.65","1587.46","163","223.6","1634.24","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1922.64","1153.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","223.60","11.63","","112.68","112.68","146.99","38","223.6","1634.24","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1922.64","1153.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1488.12","77.4","","303.98","303.98","5854.79","1 through 10","223.6","1634.24","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1922.64","1153.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","223.60","11.63","","112.68","112.68","146.99","38","223.6","1488.12","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1922.64","1153.58","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1207.03","62.78","","780.86","208.94","10480.28","15","223.6","1488.12","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1922.64","1153.58","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","840.58","43.72","","179.76","179.76","179.76","1 through 10","223.6","1488.12","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1922.64","1153.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1398.14","72.72","","2355.45","298.99","3965.19","155","223.6","1488.12","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1922.64","1153.58","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1398.14","72.72","","3643.09","3643.09","3643.09","1 through 10","223.6","1488.12","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1922.64","1153.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1023.23","53.22","","554.28","554.28","554.28","16","223.6","1488.12","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1922.64","1153.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1209.34","62.9","","619.64","173.09","2370.64","150","223.6","1488.12","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1922.64","1153.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1488.12","77.4","","303.98","303.98","5854.79","1 through 10","223.6","1488.12","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.30","995.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","192.98","1410.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.30","995.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","192.98","1410.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.30","995.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","944.14","56.9","","812.12","238.65","1587.46","163","192.98","1410.41","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.30","995.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","192.98","11.63","","112.68","112.68","146.99","38","192.98","1410.41","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.30","995.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1284.30","77.4","","303.98","303.98","5854.79","1 through 10","192.98","1410.41","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1659.30","995.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","192.98","11.63","","112.68","112.68","146.99","38","192.98","1284.3","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1659.30","995.58","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1041.71","62.78","","780.86","208.94","10480.28","15","192.98","1284.3","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1659.30","995.58","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","725.45","43.72","","179.76","179.76","179.76","1 through 10","192.98","1284.3","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1659.30","995.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1206.64","72.72","","2355.45","298.99","3965.19","155","192.98","1284.3","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1659.30","995.58","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1206.64","72.72","","3643.09","3643.09","3643.09","1 through 10","192.98","1284.3","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1659.30","995.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","883.08","53.22","","554.28","554.28","554.28","16","192.98","1284.3","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1659.30","995.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1043.70","62.9","","619.64","173.09","2370.64","150","192.98","1284.3","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1659.30","995.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1284.30","77.4","","303.98","303.98","5854.79","1 through 10","192.98","1284.3","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","2073.48","1244.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","241.15","1762.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","2073.48","1244.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","241.15","1762.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","2073.48","1244.09","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1179.81","56.9","","812.12","238.65","1587.46","163","241.15","1762.46","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","2073.48","1244.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","241.15","11.63","","112.68","112.68","146.99","38","241.15","1762.46","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","2073.48","1244.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1604.87","77.4","","303.98","303.98","5854.79","1 through 10","241.15","1762.46","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.48","1244.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","241.15","11.63","","112.68","112.68","146.99","38","241.15","1604.87","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.48","1244.09","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1301.73","62.78","","780.86","208.94","10480.28","15","241.15","1604.87","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.48","1244.09","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","906.53","43.72","","179.76","179.76","179.76","1 through 10","241.15","1604.87","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.48","1244.09","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1507.83","72.72","","2355.45","298.99","3965.19","155","241.15","1604.87","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.48","1244.09","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1507.83","72.72","","3643.09","3643.09","3643.09","1 through 10","241.15","1604.87","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.48","1244.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1103.51","53.22","","554.28","554.28","554.28","16","241.15","1604.87","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.48","1244.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1304.22","62.9","","619.64","173.09","2370.64","150","241.15","1604.87","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.48","1244.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1604.87","77.4","","303.98","303.98","5854.79","1 through 10","241.15","1604.87","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","2474.89","1484.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","287.83","2103.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","2474.89","1484.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","287.83","2103.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","2474.89","1484.93","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1408.21","56.9","","812.12","238.65","1587.46","163","287.83","2103.66","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","2474.89","1484.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","287.83","11.63","","112.68","112.68","146.99","38","287.83","2103.66","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","2474.89","1484.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1915.56","77.4","","303.98","303.98","5854.79","1 through 10","287.83","2103.66","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2474.89","1484.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","287.83","11.63","","112.68","112.68","146.99","38","287.83","1915.56","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2474.89","1484.93","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1553.74","62.78","","780.86","208.94","10480.28","15","287.83","1915.56","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2474.89","1484.93","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1082.02","43.72","","179.76","179.76","179.76","1 through 10","287.83","1915.56","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2474.89","1484.93","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1799.74","72.72","","2355.45","298.99","3965.19","155","287.83","1915.56","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2474.89","1484.93","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1799.74","72.72","","3643.09","3643.09","3643.09","1 through 10","287.83","1915.56","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2474.89","1484.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1317.14","53.22","","554.28","554.28","554.28","16","287.83","1915.56","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2474.89","1484.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1556.71","62.9","","619.64","173.09","2370.64","150","287.83","1915.56","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2474.89","1484.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1915.56","77.4","","303.98","303.98","5854.79","1 through 10","287.83","1915.56","percent of total billed charges",""
"BONE PLATE 3.5X85MM 3 HOLE HD 6 SHAFT T SHAPE LCP OBLIQUE SS LEFT","SUP-ITM-10038036","CDM","C1713","HCPCS","0278","RC","","","","both","","","2058.14","1234.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","239.36","1749.42","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X85MM 3 HOLE HD 6 SHAFT T SHAPE LCP OBLIQUE SS LEFT","SUP-ITM-10038036","CDM","C1713","HCPCS","0278","RC","","","","both","","","2058.14","1234.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","239.36","1749.42","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X85MM 3 HOLE HD 6 SHAFT T SHAPE LCP OBLIQUE SS LEFT","SUP-ITM-10038036","CDM","C1713","HCPCS","0278","RC","","","","both","","","2058.14","1234.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1171.08","56.9","","812.12","238.65","1587.46","163","239.36","1749.42","percent of total billed charges",""
"BONE PLATE 3.5X85MM 3 HOLE HD 6 SHAFT T SHAPE LCP OBLIQUE SS LEFT","SUP-ITM-10038036","CDM","C1713","HCPCS","0278","RC","","","","both","","","2058.14","1234.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","239.36","11.63","","112.68","112.68","146.99","38","239.36","1749.42","percent of total billed charges",""
"BONE PLATE 3.5X85MM 3 HOLE HD 6 SHAFT T SHAPE LCP OBLIQUE SS LEFT","SUP-ITM-10038036","CDM","C1713","HCPCS","0278","RC","","","","both","","","2058.14","1234.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1593.00","77.4","","303.98","303.98","5854.79","1 through 10","239.36","1749.42","percent of total billed charges",""
"BONE PLATE 3.5X85MM 3 HOLE HD 6 SHAFT T SHAPE LCP OBLIQUE SS LEFT","SUP-ITM-10038036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2058.14","1234.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","239.36","11.63","","112.68","112.68","146.99","38","239.36","1593","percent of total billed charges",""
"BONE PLATE 3.5X85MM 3 HOLE HD 6 SHAFT T SHAPE LCP OBLIQUE SS LEFT","SUP-ITM-10038036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2058.14","1234.88","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1292.10","62.78","","780.86","208.94","10480.28","15","239.36","1593","percent of total billed charges",""
"BONE PLATE 3.5X85MM 3 HOLE HD 6 SHAFT T SHAPE LCP OBLIQUE SS LEFT","SUP-ITM-10038036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2058.14","1234.88","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","899.82","43.72","","179.76","179.76","179.76","1 through 10","239.36","1593","percent of total billed charges",""
"BONE PLATE 3.5X85MM 3 HOLE HD 6 SHAFT T SHAPE LCP OBLIQUE SS LEFT","SUP-ITM-10038036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2058.14","1234.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1496.68","72.72","","2355.45","298.99","3965.19","155","239.36","1593","percent of total billed charges",""
"BONE PLATE 3.5X85MM 3 HOLE HD 6 SHAFT T SHAPE LCP OBLIQUE SS LEFT","SUP-ITM-10038036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2058.14","1234.88","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1496.68","72.72","","3643.09","3643.09","3643.09","1 through 10","239.36","1593","percent of total billed charges",""
"BONE PLATE 3.5X85MM 3 HOLE HD 6 SHAFT T SHAPE LCP OBLIQUE SS LEFT","SUP-ITM-10038036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2058.14","1234.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1095.34","53.22","","554.28","554.28","554.28","16","239.36","1593","percent of total billed charges",""
"BONE PLATE 3.5X85MM 3 HOLE HD 6 SHAFT T SHAPE LCP OBLIQUE SS LEFT","SUP-ITM-10038036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2058.14","1234.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1294.57","62.9","","619.64","173.09","2370.64","150","239.36","1593","percent of total billed charges",""
"BONE PLATE 3.5X85MM 3 HOLE HD 6 SHAFT T SHAPE LCP OBLIQUE SS LEFT","SUP-ITM-10038036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2058.14","1234.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1593.00","77.4","","303.98","303.98","5854.79","1 through 10","239.36","1593","percent of total billed charges",""
"BONE PLATE 3.5X85MM SM 7 HOLE DCP SS FRAGMENT","SUP-ITM-10001710","CDM","C1713","HCPCS","0278","RC","","","","both","","","1874.06","1124.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","217.95","1592.95","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X85MM SM 7 HOLE DCP SS FRAGMENT","SUP-ITM-10001710","CDM","C1713","HCPCS","0278","RC","","","","both","","","1874.06","1124.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","217.95","1592.95","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X85MM SM 7 HOLE DCP SS FRAGMENT","SUP-ITM-10001710","CDM","C1713","HCPCS","0278","RC","","","","both","","","1874.06","1124.44","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1066.34","56.9","","812.12","238.65","1587.46","163","217.95","1592.95","percent of total billed charges",""
"BONE PLATE 3.5X85MM SM 7 HOLE DCP SS FRAGMENT","SUP-ITM-10001710","CDM","C1713","HCPCS","0278","RC","","","","both","","","1874.06","1124.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","217.95","11.63","","112.68","112.68","146.99","38","217.95","1592.95","percent of total billed charges",""
"BONE PLATE 3.5X85MM SM 7 HOLE DCP SS FRAGMENT","SUP-ITM-10001710","CDM","C1713","HCPCS","0278","RC","","","","both","","","1874.06","1124.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1450.52","77.4","","303.98","303.98","5854.79","1 through 10","217.95","1592.95","percent of total billed charges",""
"BONE PLATE 3.5X85MM SM 7 HOLE DCP SS FRAGMENT","SUP-ITM-10001710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1874.06","1124.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","217.95","11.63","","112.68","112.68","146.99","38","217.95","1450.52","percent of total billed charges",""
"BONE PLATE 3.5X85MM SM 7 HOLE DCP SS FRAGMENT","SUP-ITM-10001710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1874.06","1124.44","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1176.53","62.78","","780.86","208.94","10480.28","15","217.95","1450.52","percent of total billed charges",""
"BONE PLATE 3.5X85MM SM 7 HOLE DCP SS FRAGMENT","SUP-ITM-10001710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1874.06","1124.44","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","819.34","43.72","","179.76","179.76","179.76","1 through 10","217.95","1450.52","percent of total billed charges",""
"BONE PLATE 3.5X85MM SM 7 HOLE DCP SS FRAGMENT","SUP-ITM-10001710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1874.06","1124.44","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1362.82","72.72","","2355.45","298.99","3965.19","155","217.95","1450.52","percent of total billed charges",""
"BONE PLATE 3.5X85MM SM 7 HOLE DCP SS FRAGMENT","SUP-ITM-10001710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1874.06","1124.44","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1362.82","72.72","","3643.09","3643.09","3643.09","1 through 10","217.95","1450.52","percent of total billed charges",""
"BONE PLATE 3.5X85MM SM 7 HOLE DCP SS FRAGMENT","SUP-ITM-10001710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1874.06","1124.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","997.37","53.22","","554.28","554.28","554.28","16","217.95","1450.52","percent of total billed charges",""
"BONE PLATE 3.5X85MM SM 7 HOLE DCP SS FRAGMENT","SUP-ITM-10001710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1874.06","1124.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1178.78","62.9","","619.64","173.09","2370.64","150","217.95","1450.52","percent of total billed charges",""
"BONE PLATE 3.5X85MM SM 7 HOLE DCP SS FRAGMENT","SUP-ITM-10001710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1874.06","1124.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1450.52","77.4","","303.98","303.98","5854.79","1 through 10","217.95","1450.52","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","2592.49","1555.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","301.51","2203.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","2592.49","1555.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","301.51","2203.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","2592.49","1555.49","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1475.13","56.9","","812.12","238.65","1587.46","163","301.51","2203.62","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","2592.49","1555.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","301.51","11.63","","112.68","112.68","146.99","38","301.51","2203.62","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","2592.49","1555.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2006.59","77.4","","303.98","303.98","5854.79","1 through 10","301.51","2203.62","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2592.49","1555.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","301.51","11.63","","112.68","112.68","146.99","38","301.51","2006.59","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2592.49","1555.49","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1627.57","62.78","","780.86","208.94","10480.28","15","301.51","2006.59","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2592.49","1555.49","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1133.44","43.72","","179.76","179.76","179.76","1 through 10","301.51","2006.59","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2592.49","1555.49","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1885.26","72.72","","2355.45","298.99","3965.19","155","301.51","2006.59","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2592.49","1555.49","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1885.26","72.72","","3643.09","3643.09","3643.09","1 through 10","301.51","2006.59","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2592.49","1555.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1379.72","53.22","","554.28","554.28","554.28","16","301.51","2006.59","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2592.49","1555.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1630.68","62.9","","619.64","173.09","2370.64","150","301.51","2006.59","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2592.49","1555.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2006.59","77.4","","303.98","303.98","5854.79","1 through 10","301.51","2006.59","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","both","","","4011.46","2406.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","466.53","3409.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","both","","","4011.46","2406.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","466.53","3409.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","both","","","4011.46","2406.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2282.52","56.9","","812.12","238.65","1587.46","163","466.53","3409.74","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","both","","","4011.46","2406.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","466.53","11.63","","112.68","112.68","146.99","38","466.53","3409.74","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","both","","","4011.46","2406.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3104.87","77.4","","303.98","303.98","5854.79","1 through 10","466.53","3409.74","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4011.46","2406.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","466.53","11.63","","112.68","112.68","146.99","38","466.53","3104.87","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4011.46","2406.88","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2518.39","62.78","","780.86","208.94","10480.28","15","466.53","3104.87","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4011.46","2406.88","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1753.81","43.72","","179.76","179.76","179.76","1 through 10","466.53","3104.87","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4011.46","2406.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2917.13","72.72","","2355.45","298.99","3965.19","155","466.53","3104.87","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4011.46","2406.88","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2917.13","72.72","","3643.09","3643.09","3643.09","1 through 10","466.53","3104.87","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4011.46","2406.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2134.90","53.22","","554.28","554.28","554.28","16","466.53","3104.87","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4011.46","2406.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2523.21","62.9","","619.64","173.09","2370.64","150","466.53","3104.87","percent of total billed charges",""
"BONE PLATE 3.5X94MM 8 HOLE LCP SS CURVED LOW PROFILE RECONSTRUCTION CS/1BX/1EA","SUP-ITM-10004249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4011.46","2406.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3104.87","77.4","","303.98","303.98","5854.79","1 through 10","466.53","3104.87","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.71","1250.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","242.34","1771.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.71","1250.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","242.34","1771.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.71","1250.23","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1185.63","56.9","","812.12","238.65","1587.46","163","242.34","1771.15","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.71","1250.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","242.34","11.63","","112.68","112.68","146.99","38","242.34","1771.15","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.71","1250.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1612.79","77.4","","303.98","303.98","5854.79","1 through 10","242.34","1771.15","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2083.71","1250.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","242.34","11.63","","112.68","112.68","146.99","38","242.34","1612.79","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2083.71","1250.23","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1308.15","62.78","","780.86","208.94","10480.28","15","242.34","1612.79","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2083.71","1250.23","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","911.00","43.72","","179.76","179.76","179.76","1 through 10","242.34","1612.79","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2083.71","1250.23","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1515.27","72.72","","2355.45","298.99","3965.19","155","242.34","1612.79","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2083.71","1250.23","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1515.27","72.72","","3643.09","3643.09","3643.09","1 through 10","242.34","1612.79","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2083.71","1250.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1108.95","53.22","","554.28","554.28","554.28","16","242.34","1612.79","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2083.71","1250.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1310.65","62.9","","619.64","173.09","2370.64","150","242.34","1612.79","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2083.71","1250.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1612.79","77.4","","303.98","303.98","5854.79","1 through 10","242.34","1612.79","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","2595.05","1557.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","301.8","2205.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","2595.05","1557.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","301.8","2205.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","2595.05","1557.03","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1476.58","56.9","","812.12","238.65","1587.46","163","301.8","2205.79","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","2595.05","1557.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","301.80","11.63","","112.68","112.68","146.99","38","301.8","2205.79","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","2595.05","1557.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2008.57","77.4","","303.98","303.98","5854.79","1 through 10","301.8","2205.79","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2595.05","1557.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","301.80","11.63","","112.68","112.68","146.99","38","301.8","2008.57","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2595.05","1557.03","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1629.17","62.78","","780.86","208.94","10480.28","15","301.8","2008.57","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2595.05","1557.03","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1134.56","43.72","","179.76","179.76","179.76","1 through 10","301.8","2008.57","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2595.05","1557.03","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1887.12","72.72","","2355.45","298.99","3965.19","155","301.8","2008.57","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2595.05","1557.03","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1887.12","72.72","","3643.09","3643.09","3643.09","1 through 10","301.8","2008.57","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2595.05","1557.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1381.09","53.22","","554.28","554.28","554.28","16","301.8","2008.57","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2595.05","1557.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1632.29","62.9","","619.64","173.09","2370.64","150","301.8","2008.57","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2595.05","1557.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2008.57","77.4","","303.98","303.98","5854.79","1 through 10","301.8","2008.57","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","both","","","4504.91","2702.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","523.92","3829.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","both","","","4504.91","2702.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","523.92","3829.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","both","","","4504.91","2702.95","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2563.29","56.9","","812.12","238.65","1587.46","163","523.92","3829.17","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","both","","","4504.91","2702.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","523.92","11.63","","112.68","112.68","146.99","38","523.92","3829.17","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","both","","","4504.91","2702.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3486.80","77.4","","303.98","303.98","5854.79","1 through 10","523.92","3829.17","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4504.91","2702.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","523.92","11.63","","112.68","112.68","146.99","38","523.92","3486.8","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4504.91","2702.95","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2828.18","62.78","","780.86","208.94","10480.28","15","523.92","3486.8","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4504.91","2702.95","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1969.55","43.72","","179.76","179.76","179.76","1 through 10","523.92","3486.8","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4504.91","2702.95","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3275.97","72.72","","2355.45","298.99","3965.19","155","523.92","3486.8","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4504.91","2702.95","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3275.97","72.72","","3643.09","3643.09","3643.09","1 through 10","523.92","3486.8","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4504.91","2702.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2397.51","53.22","","554.28","554.28","554.28","16","523.92","3486.8","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4504.91","2702.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2833.59","62.9","","619.64","173.09","2370.64","150","523.92","3486.8","percent of total billed charges",""
"BONE PLATE 3.5X99.0MM 7 HOLE LCP SS METAPHYSEAL","SUP-ITM-10029053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4504.91","2702.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3486.80","77.4","","303.98","303.98","5854.79","1 through 10","523.92","3486.8","percent of total billed charges",""
"BONE PLATE 33MM 3 HOLE SPINAL PYRAMID LUMBAR ANTERIOR","SUP-ITM-10111228","CDM","C1713","HCPCS","0278","RC","","","","both","","","10185.00","6111.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1184.52","8657.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 33MM 3 HOLE SPINAL PYRAMID LUMBAR ANTERIOR","SUP-ITM-10111228","CDM","C1713","HCPCS","0278","RC","","","","both","","","10185.00","6111.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1184.52","8657.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 33MM 3 HOLE SPINAL PYRAMID LUMBAR ANTERIOR","SUP-ITM-10111228","CDM","C1713","HCPCS","0278","RC","","","","both","","","10185.00","6111.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5795.27","56.9","","812.12","238.65","1587.46","163","1184.52","8657.25","percent of total billed charges",""
"BONE PLATE 33MM 3 HOLE SPINAL PYRAMID LUMBAR ANTERIOR","SUP-ITM-10111228","CDM","C1713","HCPCS","0278","RC","","","","both","","","10185.00","6111.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1184.52","11.63","","112.68","112.68","146.99","38","1184.52","8657.25","percent of total billed charges",""
"BONE PLATE 33MM 3 HOLE SPINAL PYRAMID LUMBAR ANTERIOR","SUP-ITM-10111228","CDM","C1713","HCPCS","0278","RC","","","","both","","","10185.00","6111.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7883.19","77.4","","303.98","303.98","5854.79","1 through 10","1184.52","8657.25","percent of total billed charges",""
"BONE PLATE 33MM 3 HOLE SPINAL PYRAMID LUMBAR ANTERIOR","SUP-ITM-10111228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10185.00","6111.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1184.52","11.63","","112.68","112.68","146.99","38","1184.52","7883.19","percent of total billed charges",""
"BONE PLATE 33MM 3 HOLE SPINAL PYRAMID LUMBAR ANTERIOR","SUP-ITM-10111228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10185.00","6111.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6394.14","62.78","","780.86","208.94","10480.28","15","1184.52","7883.19","percent of total billed charges",""
"BONE PLATE 33MM 3 HOLE SPINAL PYRAMID LUMBAR ANTERIOR","SUP-ITM-10111228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10185.00","6111.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4452.88","43.72","","179.76","179.76","179.76","1 through 10","1184.52","7883.19","percent of total billed charges",""
"BONE PLATE 33MM 3 HOLE SPINAL PYRAMID LUMBAR ANTERIOR","SUP-ITM-10111228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10185.00","6111.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7406.53","72.72","","2355.45","298.99","3965.19","155","1184.52","7883.19","percent of total billed charges",""
"BONE PLATE 33MM 3 HOLE SPINAL PYRAMID LUMBAR ANTERIOR","SUP-ITM-10111228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10185.00","6111.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7406.53","72.72","","3643.09","3643.09","3643.09","1 through 10","1184.52","7883.19","percent of total billed charges",""
"BONE PLATE 33MM 3 HOLE SPINAL PYRAMID LUMBAR ANTERIOR","SUP-ITM-10111228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10185.00","6111.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","5420.46","53.22","","554.28","554.28","554.28","16","1184.52","7883.19","percent of total billed charges",""
"BONE PLATE 33MM 3 HOLE SPINAL PYRAMID LUMBAR ANTERIOR","SUP-ITM-10111228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10185.00","6111.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6406.37","62.9","","619.64","173.09","2370.64","150","1184.52","7883.19","percent of total billed charges",""
"BONE PLATE 33MM 3 HOLE SPINAL PYRAMID LUMBAR ANTERIOR","SUP-ITM-10111228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10185.00","6111.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7883.19","77.4","","303.98","303.98","5854.79","1 through 10","1184.52","7883.19","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","both","","","5123.63","3074.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","595.88","4355.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","both","","","5123.63","3074.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","595.88","4355.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","both","","","5123.63","3074.18","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2915.35","56.9","","812.12","238.65","1587.46","163","595.88","4355.09","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","both","","","5123.63","3074.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","595.88","11.63","","112.68","112.68","146.99","38","595.88","4355.09","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","both","","","5123.63","3074.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3965.69","77.4","","303.98","303.98","5854.79","1 through 10","595.88","4355.09","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5123.63","3074.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","595.88","11.63","","112.68","112.68","146.99","38","595.88","3965.69","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5123.63","3074.18","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3216.61","62.78","","780.86","208.94","10480.28","15","595.88","3965.69","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5123.63","3074.18","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2240.05","43.72","","179.76","179.76","179.76","1 through 10","595.88","3965.69","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5123.63","3074.18","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3725.90","72.72","","2355.45","298.99","3965.19","155","595.88","3965.69","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5123.63","3074.18","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3725.90","72.72","","3643.09","3643.09","3643.09","1 through 10","595.88","3965.69","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5123.63","3074.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2726.80","53.22","","554.28","554.28","554.28","16","595.88","3965.69","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5123.63","3074.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3222.76","62.9","","619.64","173.09","2370.64","150","595.88","3965.69","percent of total billed charges",""
"BONE PLATE 3MMX2.4 TO 2.7 WEDGE VA LCP SS LOCKING OPENING OSTEOTOMY SPACER","SUP-ITM-10092285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5123.63","3074.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3965.69","77.4","","303.98","303.98","5854.79","1 through 10","595.88","3965.69","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","1756.45","1053.87","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","204.28","1492.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","1756.45","1053.87","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","204.28","1492.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","1756.45","1053.87","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","999.42","56.9","","812.12","238.65","1587.46","163","204.28","1492.98","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","1756.45","1053.87","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","204.28","11.63","","112.68","112.68","146.99","38","204.28","1492.98","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","1756.45","1053.87","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1359.49","77.4","","303.98","303.98","5854.79","1 through 10","204.28","1492.98","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1756.45","1053.87","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","204.28","11.63","","112.68","112.68","146.99","38","204.28","1359.49","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1756.45","1053.87","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1102.70","62.78","","780.86","208.94","10480.28","15","204.28","1359.49","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1756.45","1053.87","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","767.92","43.72","","179.76","179.76","179.76","1 through 10","204.28","1359.49","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1756.45","1053.87","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1277.29","72.72","","2355.45","298.99","3965.19","155","204.28","1359.49","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1756.45","1053.87","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1277.29","72.72","","3643.09","3643.09","3643.09","1 through 10","204.28","1359.49","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1756.45","1053.87","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","934.78","53.22","","554.28","554.28","554.28","16","204.28","1359.49","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1756.45","1053.87","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1104.81","62.9","","619.64","173.09","2370.64","150","204.28","1359.49","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1756.45","1053.87","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1359.49","77.4","","303.98","303.98","5854.79","1 through 10","204.28","1359.49","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","1835.71","1101.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","213.49","1560.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","1835.71","1101.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","213.49","1560.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","1835.71","1101.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1044.52","56.9","","812.12","238.65","1587.46","163","213.49","1560.35","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","1835.71","1101.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","213.49","11.63","","112.68","112.68","146.99","38","213.49","1560.35","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","1835.71","1101.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1420.84","77.4","","303.98","303.98","5854.79","1 through 10","213.49","1560.35","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1835.71","1101.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","213.49","11.63","","112.68","112.68","146.99","38","213.49","1420.84","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1835.71","1101.43","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1152.46","62.78","","780.86","208.94","10480.28","15","213.49","1420.84","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1835.71","1101.43","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","802.57","43.72","","179.76","179.76","179.76","1 through 10","213.49","1420.84","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1835.71","1101.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1334.93","72.72","","2355.45","298.99","3965.19","155","213.49","1420.84","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1835.71","1101.43","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1334.93","72.72","","3643.09","3643.09","3643.09","1 through 10","213.49","1420.84","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1835.71","1101.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","976.96","53.22","","554.28","554.28","554.28","16","213.49","1420.84","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1835.71","1101.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1154.66","62.9","","619.64","173.09","2370.64","150","213.49","1420.84","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1835.71","1101.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1420.84","77.4","","303.98","303.98","5854.79","1 through 10","213.49","1420.84","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","1917.53","1150.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","223.01","1629.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","1917.53","1150.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","223.01","1629.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","1917.53","1150.52","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1091.07","56.9","","812.12","238.65","1587.46","163","223.01","1629.9","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","1917.53","1150.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","223.01","11.63","","112.68","112.68","146.99","38","223.01","1629.9","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","1917.53","1150.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1484.17","77.4","","303.98","303.98","5854.79","1 through 10","223.01","1629.9","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1917.53","1150.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","223.01","11.63","","112.68","112.68","146.99","38","223.01","1484.17","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1917.53","1150.52","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1203.83","62.78","","780.86","208.94","10480.28","15","223.01","1484.17","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1917.53","1150.52","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","838.34","43.72","","179.76","179.76","179.76","1 through 10","223.01","1484.17","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1917.53","1150.52","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1394.43","72.72","","2355.45","298.99","3965.19","155","223.01","1484.17","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1917.53","1150.52","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1394.43","72.72","","3643.09","3643.09","3643.09","1 through 10","223.01","1484.17","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1917.53","1150.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1020.51","53.22","","554.28","554.28","554.28","16","223.01","1484.17","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1917.53","1150.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1206.13","62.9","","619.64","173.09","2370.64","150","223.01","1484.17","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1917.53","1150.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1484.17","77.4","","303.98","303.98","5854.79","1 through 10","223.01","1484.17","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","2081.15","1248.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","242.04","1768.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","2081.15","1248.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","242.04","1768.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","2081.15","1248.69","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1184.17","56.9","","812.12","238.65","1587.46","163","242.04","1768.98","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","2081.15","1248.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","242.04","11.63","","112.68","112.68","146.99","38","242.04","1768.98","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","2081.15","1248.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1610.81","77.4","","303.98","303.98","5854.79","1 through 10","242.04","1768.98","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2081.15","1248.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","242.04","11.63","","112.68","112.68","146.99","38","242.04","1610.81","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2081.15","1248.69","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1306.55","62.78","","780.86","208.94","10480.28","15","242.04","1610.81","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2081.15","1248.69","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","909.88","43.72","","179.76","179.76","179.76","1 through 10","242.04","1610.81","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2081.15","1248.69","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1513.41","72.72","","2355.45","298.99","3965.19","155","242.04","1610.81","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2081.15","1248.69","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1513.41","72.72","","3643.09","3643.09","3643.09","1 through 10","242.04","1610.81","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2081.15","1248.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1107.59","53.22","","554.28","554.28","554.28","16","242.04","1610.81","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2081.15","1248.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1309.04","62.9","","619.64","173.09","2370.64","150","242.04","1610.81","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2081.15","1248.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1610.81","77.4","","303.98","303.98","5854.79","1 through 10","242.04","1610.81","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","both","","","6880.11","4128.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","800.16","5848.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","both","","","6880.11","4128.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","800.16","5848.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","both","","","6880.11","4128.07","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3914.78","56.9","","812.12","238.65","1587.46","163","800.16","5848.09","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","both","","","6880.11","4128.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","800.16","11.63","","112.68","112.68","146.99","38","800.16","5848.09","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","both","","","6880.11","4128.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5325.21","77.4","","303.98","303.98","5854.79","1 through 10","800.16","5848.09","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6880.11","4128.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","800.16","11.63","","112.68","112.68","146.99","38","800.16","5325.21","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6880.11","4128.07","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4319.33","62.78","","780.86","208.94","10480.28","15","800.16","5325.21","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6880.11","4128.07","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3007.98","43.72","","179.76","179.76","179.76","1 through 10","800.16","5325.21","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6880.11","4128.07","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5003.22","72.72","","2355.45","298.99","3965.19","155","800.16","5325.21","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6880.11","4128.07","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5003.22","72.72","","3643.09","3643.09","3643.09","1 through 10","800.16","5325.21","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6880.11","4128.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3661.59","53.22","","554.28","554.28","554.28","16","800.16","5325.21","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6880.11","4128.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4327.59","62.9","","619.64","173.09","2370.64","150","800.16","5325.21","percent of total billed charges",""
"BONE PLATE 4.5-5X159MM 6 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6880.11","4128.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5325.21","77.4","","303.98","303.98","5854.79","1 through 10","800.16","5325.21","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","both","","","7016.30","4209.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","816","5963.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","both","","","7016.30","4209.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","816","5963.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","both","","","7016.30","4209.78","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3992.27","56.9","","812.12","238.65","1587.46","163","816","5963.86","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","both","","","7016.30","4209.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","816.00","11.63","","112.68","112.68","146.99","38","816","5963.86","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","both","","","7016.30","4209.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5430.62","77.4","","303.98","303.98","5854.79","1 through 10","816","5963.86","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7016.30","4209.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","816.00","11.63","","112.68","112.68","146.99","38","816","5430.62","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7016.30","4209.78","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4404.83","62.78","","780.86","208.94","10480.28","15","816","5430.62","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7016.30","4209.78","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3067.53","43.72","","179.76","179.76","179.76","1 through 10","816","5430.62","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7016.30","4209.78","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5102.25","72.72","","2355.45","298.99","3965.19","155","816","5430.62","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7016.30","4209.78","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5102.25","72.72","","3643.09","3643.09","3643.09","1 through 10","816","5430.62","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7016.30","4209.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3734.07","53.22","","554.28","554.28","554.28","16","816","5430.62","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7016.30","4209.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4413.25","62.9","","619.64","173.09","2370.64","150","816","5430.62","percent of total billed charges",""
"BONE PLATE 4.5-5X195MM 8 HOLE CONDYLAR VA LCP CURVED RT","SUP-ITM-10095159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7016.30","4209.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5430.62","77.4","","303.98","303.98","5854.79","1 through 10","816","5430.62","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","both","","","7343.68","4406.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","854.07","6242.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","both","","","7343.68","4406.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","854.07","6242.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","both","","","7343.68","4406.21","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4178.55","56.9","","812.12","238.65","1587.46","163","854.07","6242.13","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","both","","","7343.68","4406.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","854.07","11.63","","112.68","112.68","146.99","38","854.07","6242.13","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","both","","","7343.68","4406.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5684.01","77.4","","303.98","303.98","5854.79","1 through 10","854.07","6242.13","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7343.68","4406.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","854.07","11.63","","112.68","112.68","146.99","38","854.07","5684.01","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7343.68","4406.21","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4610.36","62.78","","780.86","208.94","10480.28","15","854.07","5684.01","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7343.68","4406.21","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3210.66","43.72","","179.76","179.76","179.76","1 through 10","854.07","5684.01","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7343.68","4406.21","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5340.32","72.72","","2355.45","298.99","3965.19","155","854.07","5684.01","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7343.68","4406.21","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5340.32","72.72","","3643.09","3643.09","3643.09","1 through 10","854.07","5684.01","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7343.68","4406.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3908.31","53.22","","554.28","554.28","554.28","16","854.07","5684.01","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7343.68","4406.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4619.17","62.9","","619.64","173.09","2370.64","150","854.07","5684.01","percent of total billed charges",""
"BONE PLATE 4.5-5X230MM 10 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095161","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7343.68","4406.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5684.01","77.4","","303.98","303.98","5854.79","1 through 10","854.07","5684.01","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","both","","","7495.58","4497.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","871.74","6371.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","both","","","7495.58","4497.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","871.74","6371.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","both","","","7495.58","4497.35","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4264.99","56.9","","812.12","238.65","1587.46","163","871.74","6371.24","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","both","","","7495.58","4497.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","871.74","11.63","","112.68","112.68","146.99","38","871.74","6371.24","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","both","","","7495.58","4497.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5801.58","77.4","","303.98","303.98","5854.79","1 through 10","871.74","6371.24","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7495.58","4497.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","871.74","11.63","","112.68","112.68","146.99","38","871.74","5801.58","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7495.58","4497.35","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4705.73","62.78","","780.86","208.94","10480.28","15","871.74","5801.58","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7495.58","4497.35","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3277.07","43.72","","179.76","179.76","179.76","1 through 10","871.74","5801.58","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7495.58","4497.35","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5450.79","72.72","","2355.45","298.99","3965.19","155","871.74","5801.58","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7495.58","4497.35","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5450.79","72.72","","3643.09","3643.09","3643.09","1 through 10","871.74","5801.58","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7495.58","4497.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3989.15","53.22","","554.28","554.28","554.28","16","871.74","5801.58","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7495.58","4497.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4714.72","62.9","","619.64","173.09","2370.64","150","871.74","5801.58","percent of total billed charges",""
"BONE PLATE 4.5-5X266MM 12 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7495.58","4497.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5801.58","77.4","","303.98","303.98","5854.79","1 through 10","871.74","5801.58","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","both","","","8155.57","4893.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","948.49","6932.23","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","both","","","8155.57","4893.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","948.49","6932.23","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","both","","","8155.57","4893.34","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4640.52","56.9","","812.12","238.65","1587.46","163","948.49","6932.23","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","both","","","8155.57","4893.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","948.49","11.63","","112.68","112.68","146.99","38","948.49","6932.23","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","both","","","8155.57","4893.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6312.41","77.4","","303.98","303.98","5854.79","1 through 10","948.49","6932.23","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8155.57","4893.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","948.49","11.63","","112.68","112.68","146.99","38","948.49","6312.41","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8155.57","4893.34","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5120.07","62.78","","780.86","208.94","10480.28","15","948.49","6312.41","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8155.57","4893.34","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3565.62","43.72","","179.76","179.76","179.76","1 through 10","948.49","6312.41","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8155.57","4893.34","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5930.73","72.72","","2355.45","298.99","3965.19","155","948.49","6312.41","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8155.57","4893.34","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5930.73","72.72","","3643.09","3643.09","3643.09","1 through 10","948.49","6312.41","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8155.57","4893.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4340.39","53.22","","554.28","554.28","554.28","16","948.49","6312.41","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8155.57","4893.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5129.85","62.9","","619.64","173.09","2370.64","150","948.49","6312.41","percent of total billed charges",""
"BONE PLATE 4.5-5X336MM 16 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8155.57","4893.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6312.41","77.4","","303.98","303.98","5854.79","1 through 10","948.49","6312.41","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","both","","","8684.60","5210.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1010.02","7381.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","both","","","8684.60","5210.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1010.02","7381.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","both","","","8684.60","5210.76","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4941.54","56.9","","812.12","238.65","1587.46","163","1010.02","7381.91","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","both","","","8684.60","5210.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1010.02","11.63","","112.68","112.68","146.99","38","1010.02","7381.91","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","both","","","8684.60","5210.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6721.88","77.4","","303.98","303.98","5854.79","1 through 10","1010.02","7381.91","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8684.60","5210.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1010.02","11.63","","112.68","112.68","146.99","38","1010.02","6721.88","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8684.60","5210.76","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5452.19","62.78","","780.86","208.94","10480.28","15","1010.02","6721.88","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8684.60","5210.76","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3796.91","43.72","","179.76","179.76","179.76","1 through 10","1010.02","6721.88","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8684.60","5210.76","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6315.44","72.72","","2355.45","298.99","3965.19","155","1010.02","6721.88","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8684.60","5210.76","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6315.44","72.72","","3643.09","3643.09","3643.09","1 through 10","1010.02","6721.88","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8684.60","5210.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4621.94","53.22","","554.28","554.28","554.28","16","1010.02","6721.88","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8684.60","5210.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5462.61","62.9","","619.64","173.09","2370.64","150","1010.02","6721.88","percent of total billed charges",""
"BONE PLATE 4.5-5X370MM 18 HOLE CONDYLAR VA LCP CURVED RIGHT","SUP-ITM-10095169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8684.60","5210.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6721.88","77.4","","303.98","303.98","5854.79","1 through 10","1010.02","6721.88","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","both","","","10570.86","6342.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1229.39","8985.23","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","both","","","10570.86","6342.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1229.39","8985.23","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","both","","","10570.86","6342.52","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6014.82","56.9","","812.12","238.65","1587.46","163","1229.39","8985.23","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","both","","","10570.86","6342.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1229.39","11.63","","112.68","112.68","146.99","38","1229.39","8985.23","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","both","","","10570.86","6342.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8181.85","77.4","","303.98","303.98","5854.79","1 through 10","1229.39","8985.23","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10570.86","6342.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1229.39","11.63","","112.68","112.68","146.99","38","1229.39","8181.85","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10570.86","6342.52","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6636.39","62.78","","780.86","208.94","10480.28","15","1229.39","8181.85","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10570.86","6342.52","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4621.58","43.72","","179.76","179.76","179.76","1 through 10","1229.39","8181.85","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10570.86","6342.52","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7687.13","72.72","","2355.45","298.99","3965.19","155","1229.39","8181.85","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10570.86","6342.52","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7687.13","72.72","","3643.09","3643.09","3643.09","1 through 10","1229.39","8181.85","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10570.86","6342.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","5625.81","53.22","","554.28","554.28","554.28","16","1229.39","8181.85","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10570.86","6342.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6649.07","62.9","","619.64","173.09","2370.64","150","1229.39","8181.85","percent of total billed charges",""
"BONE PLATE 4.5-5X405MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10570.86","6342.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8181.85","77.4","","303.98","303.98","5854.79","1 through 10","1229.39","8181.85","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","both","","","11468.60","6881.16","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1333.8","9748.31","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","both","","","11468.60","6881.16","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1333.8","9748.31","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","both","","","11468.60","6881.16","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6525.63","56.9","","812.12","238.65","1587.46","163","1333.8","9748.31","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","both","","","11468.60","6881.16","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1333.80","11.63","","112.68","112.68","146.99","38","1333.8","9748.31","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","both","","","11468.60","6881.16","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8876.70","77.4","","303.98","303.98","5854.79","1 through 10","1333.8","9748.31","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11468.60","6881.16","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1333.80","11.63","","112.68","112.68","146.99","38","1333.8","8876.7","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11468.60","6881.16","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","7199.99","62.78","","780.86","208.94","10480.28","15","1333.8","8876.7","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11468.60","6881.16","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","5014.07","43.72","","179.76","179.76","179.76","1 through 10","1333.8","8876.7","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11468.60","6881.16","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8339.97","72.72","","2355.45","298.99","3965.19","155","1333.8","8876.7","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11468.60","6881.16","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","8339.97","72.72","","3643.09","3643.09","3643.09","1 through 10","1333.8","8876.7","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11468.60","6881.16","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","6103.59","53.22","","554.28","554.28","554.28","16","1333.8","8876.7","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11468.60","6881.16","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7213.75","62.9","","619.64","173.09","2370.64","150","1333.8","8876.7","percent of total billed charges",""
"BONE PLATE 4.5-5X439MM 20 HOLE VA LCP SS CONDYLE RIGHT","SUP-ITM-10097031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11468.60","6881.16","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8876.70","77.4","","303.98","303.98","5854.79","1 through 10","1333.8","8876.7","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","2382.84","1429.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","277.12","2025.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","2382.84","1429.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","277.12","2025.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","2382.84","1429.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1355.84","56.9","","812.12","238.65","1587.46","163","277.12","2025.41","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","2382.84","1429.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","277.12","11.63","","112.68","112.68","146.99","38","277.12","2025.41","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","2382.84","1429.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1844.32","77.4","","303.98","303.98","5854.79","1 through 10","277.12","2025.41","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2382.84","1429.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","277.12","11.63","","112.68","112.68","146.99","38","277.12","1844.32","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2382.84","1429.70","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1495.95","62.78","","780.86","208.94","10480.28","15","277.12","1844.32","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2382.84","1429.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1041.78","43.72","","179.76","179.76","179.76","1 through 10","277.12","1844.32","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2382.84","1429.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1732.80","72.72","","2355.45","298.99","3965.19","155","277.12","1844.32","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2382.84","1429.70","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1732.80","72.72","","3643.09","3643.09","3643.09","1 through 10","277.12","1844.32","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2382.84","1429.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1268.15","53.22","","554.28","554.28","554.28","16","277.12","1844.32","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2382.84","1429.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1498.81","62.9","","619.64","173.09","2370.64","150","277.12","1844.32","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2382.84","1429.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1844.32","77.4","","303.98","303.98","5854.79","1 through 10","277.12","1844.32","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2492.78","1495.67","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","289.91","2118.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2492.78","1495.67","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","289.91","2118.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2492.78","1495.67","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1418.39","56.9","","812.12","238.65","1587.46","163","289.91","2118.86","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2492.78","1495.67","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","289.91","11.63","","112.68","112.68","146.99","38","289.91","2118.86","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2492.78","1495.67","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1929.41","77.4","","303.98","303.98","5854.79","1 through 10","289.91","2118.86","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2492.78","1495.67","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","289.91","11.63","","112.68","112.68","146.99","38","289.91","1929.41","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2492.78","1495.67","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1564.97","62.78","","780.86","208.94","10480.28","15","289.91","1929.41","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2492.78","1495.67","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1089.84","43.72","","179.76","179.76","179.76","1 through 10","289.91","1929.41","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2492.78","1495.67","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1812.75","72.72","","2355.45","298.99","3965.19","155","289.91","1929.41","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2492.78","1495.67","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1812.75","72.72","","3643.09","3643.09","3643.09","1 through 10","289.91","1929.41","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2492.78","1495.67","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1326.66","53.22","","554.28","554.28","554.28","16","289.91","1929.41","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2492.78","1495.67","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1567.96","62.9","","619.64","173.09","2370.64","150","289.91","1929.41","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2492.78","1495.67","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1929.41","77.4","","303.98","303.98","5854.79","1 through 10","289.91","1929.41","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","2707.55","1624.53","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","314.89","2301.42","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","2707.55","1624.53","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","314.89","2301.42","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","2707.55","1624.53","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1540.60","56.9","","812.12","238.65","1587.46","163","314.89","2301.42","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","2707.55","1624.53","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","314.89","11.63","","112.68","112.68","146.99","38","314.89","2301.42","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","2707.55","1624.53","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2095.64","77.4","","303.98","303.98","5854.79","1 through 10","314.89","2301.42","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2707.55","1624.53","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","314.89","11.63","","112.68","112.68","146.99","38","314.89","2095.64","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2707.55","1624.53","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1699.80","62.78","","780.86","208.94","10480.28","15","314.89","2095.64","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2707.55","1624.53","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1183.74","43.72","","179.76","179.76","179.76","1 through 10","314.89","2095.64","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2707.55","1624.53","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1968.93","72.72","","2355.45","298.99","3965.19","155","314.89","2095.64","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2707.55","1624.53","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1968.93","72.72","","3643.09","3643.09","3643.09","1 through 10","314.89","2095.64","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2707.55","1624.53","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1440.96","53.22","","554.28","554.28","554.28","16","314.89","2095.64","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2707.55","1624.53","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1703.05","62.9","","619.64","173.09","2370.64","150","314.89","2095.64","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2707.55","1624.53","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2095.64","77.4","","303.98","303.98","5854.79","1 through 10","314.89","2095.64","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LCP SS CURVED BROAD","SUP-ITM-10013599","CDM","C1713","HCPCS","0278","RC","","","","both","","","3541.03","2124.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","411.82","3009.88","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5X229MM 12 HOLE LCP SS CURVED BROAD","SUP-ITM-10013599","CDM","C1713","HCPCS","0278","RC","","","","both","","","3541.03","2124.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","411.82","3009.88","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5X229MM 12 HOLE LCP SS CURVED BROAD","SUP-ITM-10013599","CDM","C1713","HCPCS","0278","RC","","","","both","","","3541.03","2124.62","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2014.85","56.9","","812.12","238.65","1587.46","163","411.82","3009.88","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LCP SS CURVED BROAD","SUP-ITM-10013599","CDM","C1713","HCPCS","0278","RC","","","","both","","","3541.03","2124.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","411.82","11.63","","112.68","112.68","146.99","38","411.82","3009.88","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LCP SS CURVED BROAD","SUP-ITM-10013599","CDM","C1713","HCPCS","0278","RC","","","","both","","","3541.03","2124.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2740.76","77.4","","303.98","303.98","5854.79","1 through 10","411.82","3009.88","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LCP SS CURVED BROAD","SUP-ITM-10013599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3541.03","2124.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","411.82","11.63","","112.68","112.68","146.99","38","411.82","2740.76","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LCP SS CURVED BROAD","SUP-ITM-10013599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3541.03","2124.62","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2223.06","62.78","","780.86","208.94","10480.28","15","411.82","2740.76","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LCP SS CURVED BROAD","SUP-ITM-10013599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3541.03","2124.62","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1548.14","43.72","","179.76","179.76","179.76","1 through 10","411.82","2740.76","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LCP SS CURVED BROAD","SUP-ITM-10013599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3541.03","2124.62","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2575.04","72.72","","2355.45","298.99","3965.19","155","411.82","2740.76","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LCP SS CURVED BROAD","SUP-ITM-10013599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3541.03","2124.62","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2575.04","72.72","","3643.09","3643.09","3643.09","1 through 10","411.82","2740.76","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LCP SS CURVED BROAD","SUP-ITM-10013599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3541.03","2124.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1884.54","53.22","","554.28","554.28","554.28","16","411.82","2740.76","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LCP SS CURVED BROAD","SUP-ITM-10013599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3541.03","2124.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2227.31","62.9","","619.64","173.09","2370.64","150","411.82","2740.76","percent of total billed charges",""
"BONE PLATE 4.5X229MM 12 HOLE LCP SS CURVED BROAD","SUP-ITM-10013599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3541.03","2124.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2740.76","77.4","","303.98","303.98","5854.79","1 through 10","411.82","2740.76","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","3515.46","2109.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","408.85","2988.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","3515.46","2109.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","408.85","2988.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","3515.46","2109.28","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2000.30","56.9","","812.12","238.65","1587.46","163","408.85","2988.14","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","3515.46","2109.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","408.85","11.63","","112.68","112.68","146.99","38","408.85","2988.14","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","3515.46","2109.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2720.97","77.4","","303.98","303.98","5854.79","1 through 10","408.85","2988.14","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3515.46","2109.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","408.85","11.63","","112.68","112.68","146.99","38","408.85","2720.97","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3515.46","2109.28","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2207.01","62.78","","780.86","208.94","10480.28","15","408.85","2720.97","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3515.46","2109.28","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1536.96","43.72","","179.76","179.76","179.76","1 through 10","408.85","2720.97","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3515.46","2109.28","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2556.44","72.72","","2355.45","298.99","3965.19","155","408.85","2720.97","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3515.46","2109.28","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2556.44","72.72","","3643.09","3643.09","3643.09","1 through 10","408.85","2720.97","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3515.46","2109.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1870.93","53.22","","554.28","554.28","554.28","16","408.85","2720.97","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3515.46","2109.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2211.22","62.9","","619.64","173.09","2370.64","150","408.85","2720.97","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3515.46","2109.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2720.97","77.4","","303.98","303.98","5854.79","1 through 10","408.85","2720.97","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS CURVED BROAD","SUP-ITM-10014595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3939.87","2363.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","458.21","3348.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5X265MM 14 HOLE LCP SS CURVED BROAD","SUP-ITM-10014595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3939.87","2363.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","458.21","3348.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5X265MM 14 HOLE LCP SS CURVED BROAD","SUP-ITM-10014595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3939.87","2363.92","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2241.79","56.9","","812.12","238.65","1587.46","163","458.21","3348.89","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS CURVED BROAD","SUP-ITM-10014595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3939.87","2363.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","458.21","11.63","","112.68","112.68","146.99","38","458.21","3348.89","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS CURVED BROAD","SUP-ITM-10014595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3939.87","2363.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3049.46","77.4","","303.98","303.98","5854.79","1 through 10","458.21","3348.89","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS CURVED BROAD","SUP-ITM-10014595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3939.87","2363.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","458.21","11.63","","112.68","112.68","146.99","38","458.21","3049.46","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS CURVED BROAD","SUP-ITM-10014595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3939.87","2363.92","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2473.45","62.78","","780.86","208.94","10480.28","15","458.21","3049.46","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS CURVED BROAD","SUP-ITM-10014595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3939.87","2363.92","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1722.51","43.72","","179.76","179.76","179.76","1 through 10","458.21","3049.46","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS CURVED BROAD","SUP-ITM-10014595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3939.87","2363.92","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2865.07","72.72","","2355.45","298.99","3965.19","155","458.21","3049.46","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS CURVED BROAD","SUP-ITM-10014595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3939.87","2363.92","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2865.07","72.72","","3643.09","3643.09","3643.09","1 through 10","458.21","3049.46","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS CURVED BROAD","SUP-ITM-10014595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3939.87","2363.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2096.80","53.22","","554.28","554.28","554.28","16","458.21","3049.46","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS CURVED BROAD","SUP-ITM-10014595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3939.87","2363.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2478.18","62.9","","619.64","173.09","2370.64","150","458.21","3049.46","percent of total billed charges",""
"BONE PLATE 4.5X265MM 14 HOLE LCP SS CURVED BROAD","SUP-ITM-10014595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3939.87","2363.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3049.46","77.4","","303.98","303.98","5854.79","1 through 10","458.21","3049.46","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LCP SS CURVED BROAD","SUP-ITM-10013600","CDM","C1713","HCPCS","0278","RC","","","","both","","","4783.59","2870.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","556.33","4066.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5X300MM 16 HOLE LCP SS CURVED BROAD","SUP-ITM-10013600","CDM","C1713","HCPCS","0278","RC","","","","both","","","4783.59","2870.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","556.33","4066.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 4.5X300MM 16 HOLE LCP SS CURVED BROAD","SUP-ITM-10013600","CDM","C1713","HCPCS","0278","RC","","","","both","","","4783.59","2870.15","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2721.86","56.9","","812.12","238.65","1587.46","163","556.33","4066.05","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LCP SS CURVED BROAD","SUP-ITM-10013600","CDM","C1713","HCPCS","0278","RC","","","","both","","","4783.59","2870.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","556.33","11.63","","112.68","112.68","146.99","38","556.33","4066.05","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LCP SS CURVED BROAD","SUP-ITM-10013600","CDM","C1713","HCPCS","0278","RC","","","","both","","","4783.59","2870.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3702.50","77.4","","303.98","303.98","5854.79","1 through 10","556.33","4066.05","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LCP SS CURVED BROAD","SUP-ITM-10013600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4783.59","2870.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","556.33","11.63","","112.68","112.68","146.99","38","556.33","3702.5","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LCP SS CURVED BROAD","SUP-ITM-10013600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4783.59","2870.15","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3003.14","62.78","","780.86","208.94","10480.28","15","556.33","3702.5","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LCP SS CURVED BROAD","SUP-ITM-10013600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4783.59","2870.15","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2091.39","43.72","","179.76","179.76","179.76","1 through 10","556.33","3702.5","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LCP SS CURVED BROAD","SUP-ITM-10013600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4783.59","2870.15","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3478.63","72.72","","2355.45","298.99","3965.19","155","556.33","3702.5","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LCP SS CURVED BROAD","SUP-ITM-10013600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4783.59","2870.15","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3478.63","72.72","","3643.09","3643.09","3643.09","1 through 10","556.33","3702.5","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LCP SS CURVED BROAD","SUP-ITM-10013600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4783.59","2870.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2545.83","53.22","","554.28","554.28","554.28","16","556.33","3702.5","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LCP SS CURVED BROAD","SUP-ITM-10013600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4783.59","2870.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3008.88","62.9","","619.64","173.09","2370.64","150","556.33","3702.5","percent of total billed charges",""
"BONE PLATE 4.5X300MM 16 HOLE LCP SS CURVED BROAD","SUP-ITM-10013600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4783.59","2870.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3702.50","77.4","","303.98","303.98","5854.79","1 through 10","556.33","3702.5","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","2983.67","1790.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","347","2536.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","2983.67","1790.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","347","2536.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","2983.67","1790.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1697.71","56.9","","812.12","238.65","1587.46","163","347","2536.12","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","2983.67","1790.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","347.00","11.63","","112.68","112.68","146.99","38","347","2536.12","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","2983.67","1790.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2309.36","77.4","","303.98","303.98","5854.79","1 through 10","347","2536.12","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2983.67","1790.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","347.00","11.63","","112.68","112.68","146.99","38","347","2309.36","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2983.67","1790.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1873.15","62.78","","780.86","208.94","10480.28","15","347","2309.36","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2983.67","1790.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1304.46","43.72","","179.76","179.76","179.76","1 through 10","347","2309.36","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2983.67","1790.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2169.72","72.72","","2355.45","298.99","3965.19","155","347","2309.36","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2983.67","1790.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2169.72","72.72","","3643.09","3643.09","3643.09","1 through 10","347","2309.36","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2983.67","1790.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1587.91","53.22","","554.28","554.28","554.28","16","347","2309.36","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2983.67","1790.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1876.73","62.9","","619.64","173.09","2370.64","150","347","2309.36","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2983.67","1790.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2309.36","77.4","","303.98","303.98","5854.79","1 through 10","347","2309.36","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095142","CDM","C1713","HCPCS","0278","RC","","","","both","","","3906.64","2343.98","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","454.34","3320.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095142","CDM","C1713","HCPCS","0278","RC","","","","both","","","3906.64","2343.98","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","454.34","3320.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095142","CDM","C1713","HCPCS","0278","RC","","","","both","","","3906.64","2343.98","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2222.88","56.9","","812.12","238.65","1587.46","163","454.34","3320.64","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095142","CDM","C1713","HCPCS","0278","RC","","","","both","","","3906.64","2343.98","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","454.34","11.63","","112.68","112.68","146.99","38","454.34","3320.64","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095142","CDM","C1713","HCPCS","0278","RC","","","","both","","","3906.64","2343.98","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3023.74","77.4","","303.98","303.98","5854.79","1 through 10","454.34","3320.64","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3906.64","2343.98","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","454.34","11.63","","112.68","112.68","146.99","38","454.34","3023.74","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3906.64","2343.98","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2452.59","62.78","","780.86","208.94","10480.28","15","454.34","3023.74","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3906.64","2343.98","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1707.98","43.72","","179.76","179.76","179.76","1 through 10","454.34","3023.74","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3906.64","2343.98","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2840.91","72.72","","2355.45","298.99","3965.19","155","454.34","3023.74","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3906.64","2343.98","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2840.91","72.72","","3643.09","3643.09","3643.09","1 through 10","454.34","3023.74","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3906.64","2343.98","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2079.11","53.22","","554.28","554.28","554.28","16","454.34","3023.74","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3906.64","2343.98","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2457.28","62.9","","619.64","173.09","2370.64","150","454.34","3023.74","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095142","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3906.64","2343.98","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3023.74","77.4","","303.98","303.98","5854.79","1 through 10","454.34","3023.74","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","both","","","3906.64","2343.98","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","454.34","3320.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","both","","","3906.64","2343.98","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","454.34","3320.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","both","","","3906.64","2343.98","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2222.88","56.9","","812.12","238.65","1587.46","163","454.34","3320.64","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","both","","","3906.64","2343.98","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","454.34","11.63","","112.68","112.68","146.99","38","454.34","3320.64","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","both","","","3906.64","2343.98","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3023.74","77.4","","303.98","303.98","5854.79","1 through 10","454.34","3320.64","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3906.64","2343.98","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","454.34","11.63","","112.68","112.68","146.99","38","454.34","3023.74","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3906.64","2343.98","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2452.59","62.78","","780.86","208.94","10480.28","15","454.34","3023.74","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3906.64","2343.98","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1707.98","43.72","","179.76","179.76","179.76","1 through 10","454.34","3023.74","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3906.64","2343.98","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2840.91","72.72","","2355.45","298.99","3965.19","155","454.34","3023.74","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3906.64","2343.98","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2840.91","72.72","","3643.09","3643.09","3643.09","1 through 10","454.34","3023.74","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3906.64","2343.98","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2079.11","53.22","","554.28","554.28","554.28","16","454.34","3023.74","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3906.64","2343.98","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2457.28","62.9","","619.64","173.09","2370.64","150","454.34","3023.74","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP STAINLESS INTERMEDIATE COLUMN DORSEL DISTAL RADIUS","SUP-ITM-10095143","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3906.64","2343.98","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3023.74","77.4","","303.98","303.98","5854.79","1 through 10","454.34","3023.74","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP TI INTERMEDIATE COLUMN DORSEL DISTAL RADIUS PLUS","SUP-ITM-10096106","CDM","C1713","HCPCS","0278","RC","","","","both","","","4297.81","2578.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","499.84","3653.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP TI INTERMEDIATE COLUMN DORSEL DISTAL RADIUS PLUS","SUP-ITM-10096106","CDM","C1713","HCPCS","0278","RC","","","","both","","","4297.81","2578.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","499.84","3653.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP TI INTERMEDIATE COLUMN DORSEL DISTAL RADIUS PLUS","SUP-ITM-10096106","CDM","C1713","HCPCS","0278","RC","","","","both","","","4297.81","2578.69","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2445.45","56.9","","812.12","238.65","1587.46","163","499.84","3653.14","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP TI INTERMEDIATE COLUMN DORSEL DISTAL RADIUS PLUS","SUP-ITM-10096106","CDM","C1713","HCPCS","0278","RC","","","","both","","","4297.81","2578.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","499.84","11.63","","112.68","112.68","146.99","38","499.84","3653.14","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP TI INTERMEDIATE COLUMN DORSEL DISTAL RADIUS PLUS","SUP-ITM-10096106","CDM","C1713","HCPCS","0278","RC","","","","both","","","4297.81","2578.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3326.50","77.4","","303.98","303.98","5854.79","1 through 10","499.84","3653.14","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP TI INTERMEDIATE COLUMN DORSEL DISTAL RADIUS PLUS","SUP-ITM-10096106","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4297.81","2578.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","499.84","11.63","","112.68","112.68","146.99","38","499.84","3326.5","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP TI INTERMEDIATE COLUMN DORSEL DISTAL RADIUS PLUS","SUP-ITM-10096106","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4297.81","2578.69","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2698.17","62.78","","780.86","208.94","10480.28","15","499.84","3326.5","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP TI INTERMEDIATE COLUMN DORSEL DISTAL RADIUS PLUS","SUP-ITM-10096106","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4297.81","2578.69","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1879.00","43.72","","179.76","179.76","179.76","1 through 10","499.84","3326.5","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP TI INTERMEDIATE COLUMN DORSEL DISTAL RADIUS PLUS","SUP-ITM-10096106","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4297.81","2578.69","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3125.37","72.72","","2355.45","298.99","3965.19","155","499.84","3326.5","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP TI INTERMEDIATE COLUMN DORSEL DISTAL RADIUS PLUS","SUP-ITM-10096106","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4297.81","2578.69","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3125.37","72.72","","3643.09","3643.09","3643.09","1 through 10","499.84","3326.5","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP TI INTERMEDIATE COLUMN DORSEL DISTAL RADIUS PLUS","SUP-ITM-10096106","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4297.81","2578.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2287.29","53.22","","554.28","554.28","554.28","16","499.84","3326.5","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP TI INTERMEDIATE COLUMN DORSEL DISTAL RADIUS PLUS","SUP-ITM-10096106","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4297.81","2578.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2703.32","62.9","","619.64","173.09","2370.64","150","499.84","3326.5","percent of total billed charges",""
"BONE PLATE 49MM 2 HOLE HEAD 4 90DEG VA LCP TI INTERMEDIATE COLUMN DORSEL DISTAL RADIUS PLUS","SUP-ITM-10096106","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4297.81","2578.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3326.50","77.4","","303.98","303.98","5854.79","1 through 10","499.84","3326.5","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","3822.27","2293.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","444.53","3248.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","3822.27","2293.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","444.53","3248.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","3822.27","2293.36","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2174.87","56.9","","812.12","238.65","1587.46","163","444.53","3248.93","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","3822.27","2293.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","444.53","11.63","","112.68","112.68","146.99","38","444.53","3248.93","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","3822.27","2293.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2958.44","77.4","","303.98","303.98","5854.79","1 through 10","444.53","3248.93","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3822.27","2293.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","444.53","11.63","","112.68","112.68","146.99","38","444.53","2958.44","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3822.27","2293.36","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2399.62","62.78","","780.86","208.94","10480.28","15","444.53","2958.44","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3822.27","2293.36","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1671.10","43.72","","179.76","179.76","179.76","1 through 10","444.53","2958.44","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3822.27","2293.36","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2779.55","72.72","","2355.45","298.99","3965.19","155","444.53","2958.44","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3822.27","2293.36","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2779.55","72.72","","3643.09","3643.09","3643.09","1 through 10","444.53","2958.44","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3822.27","2293.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2034.21","53.22","","554.28","554.28","554.28","16","444.53","2958.44","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3822.27","2293.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2404.21","62.9","","619.64","173.09","2370.64","150","444.53","2958.44","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3822.27","2293.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2958.44","77.4","","303.98","303.98","5854.79","1 through 10","444.53","2958.44","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.94","512.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","99.31","725.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.94","512.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","99.31","725.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.94","512.36","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","485.89","56.9","","812.12","238.65","1587.46","163","99.31","725.85","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.94","512.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","99.31","11.63","","112.68","112.68","146.99","38","99.31","725.85","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.94","512.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","660.95","77.4","","303.98","303.98","5854.79","1 through 10","99.31","725.85","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","853.94","512.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","99.31","11.63","","112.68","112.68","146.99","38","99.31","660.95","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","853.94","512.36","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","536.10","62.78","","780.86","208.94","10480.28","15","99.31","660.95","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","853.94","512.36","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","373.34","43.72","","179.76","179.76","179.76","1 through 10","99.31","660.95","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","853.94","512.36","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","620.99","72.72","","2355.45","298.99","3965.19","155","99.31","660.95","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","853.94","512.36","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","620.99","72.72","","3643.09","3643.09","3643.09","1 through 10","99.31","660.95","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","853.94","512.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","454.47","53.22","","554.28","554.28","554.28","16","99.31","660.95","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","853.94","512.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","537.13","62.9","","619.64","173.09","2370.64","150","99.31","660.95","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","853.94","512.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","660.95","77.4","","303.98","303.98","5854.79","1 through 10","99.31","660.95","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","2058.14","1234.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","239.36","1749.42","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","2058.14","1234.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","239.36","1749.42","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","2058.14","1234.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1171.08","56.9","","812.12","238.65","1587.46","163","239.36","1749.42","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","2058.14","1234.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","239.36","11.63","","112.68","112.68","146.99","38","239.36","1749.42","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","2058.14","1234.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1593.00","77.4","","303.98","303.98","5854.79","1 through 10","239.36","1749.42","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2058.14","1234.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","239.36","11.63","","112.68","112.68","146.99","38","239.36","1593","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2058.14","1234.88","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1292.10","62.78","","780.86","208.94","10480.28","15","239.36","1593","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2058.14","1234.88","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","899.82","43.72","","179.76","179.76","179.76","1 through 10","239.36","1593","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2058.14","1234.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1496.68","72.72","","2355.45","298.99","3965.19","155","239.36","1593","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2058.14","1234.88","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1496.68","72.72","","3643.09","3643.09","3643.09","1 through 10","239.36","1593","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2058.14","1234.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1095.34","53.22","","554.28","554.28","554.28","16","239.36","1593","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2058.14","1234.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1294.57","62.9","","619.64","173.09","2370.64","150","239.36","1593","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2058.14","1234.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1593.00","77.4","","303.98","303.98","5854.79","1 through 10","239.36","1593","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2919.75","1751.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","339.57","2481.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2919.75","1751.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","339.57","2481.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2919.75","1751.85","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1661.34","56.9","","812.12","238.65","1587.46","163","339.57","2481.79","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2919.75","1751.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","339.57","11.63","","112.68","112.68","146.99","38","339.57","2481.79","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2919.75","1751.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2259.89","77.4","","303.98","303.98","5854.79","1 through 10","339.57","2481.79","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2919.75","1751.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","339.57","11.63","","112.68","112.68","146.99","38","339.57","2259.89","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2919.75","1751.85","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1833.02","62.78","","780.86","208.94","10480.28","15","339.57","2259.89","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2919.75","1751.85","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1276.51","43.72","","179.76","179.76","179.76","1 through 10","339.57","2259.89","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2919.75","1751.85","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2123.24","72.72","","2355.45","298.99","3965.19","155","339.57","2259.89","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2919.75","1751.85","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2123.24","72.72","","3643.09","3643.09","3643.09","1 through 10","339.57","2259.89","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2919.75","1751.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1553.89","53.22","","554.28","554.28","554.28","16","339.57","2259.89","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2919.75","1751.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1836.52","62.9","","619.64","173.09","2370.64","150","339.57","2259.89","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2919.75","1751.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2259.89","77.4","","303.98","303.98","5854.79","1 through 10","339.57","2259.89","percent of total billed charges",""
"BONE PLATE 6 HOLE 4 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095963","CDM","C1713","HCPCS","0278","RC","","","","both","","","4411.34","2646.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","513.04","3749.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 6 HOLE 4 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095963","CDM","C1713","HCPCS","0278","RC","","","","both","","","4411.34","2646.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","513.04","3749.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 6 HOLE 4 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095963","CDM","C1713","HCPCS","0278","RC","","","","both","","","4411.34","2646.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2510.05","56.9","","812.12","238.65","1587.46","163","513.04","3749.64","percent of total billed charges",""
"BONE PLATE 6 HOLE 4 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095963","CDM","C1713","HCPCS","0278","RC","","","","both","","","4411.34","2646.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","513.04","11.63","","112.68","112.68","146.99","38","513.04","3749.64","percent of total billed charges",""
"BONE PLATE 6 HOLE 4 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095963","CDM","C1713","HCPCS","0278","RC","","","","both","","","4411.34","2646.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3414.38","77.4","","303.98","303.98","5854.79","1 through 10","513.04","3749.64","percent of total billed charges",""
"BONE PLATE 6 HOLE 4 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4411.34","2646.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","513.04","11.63","","112.68","112.68","146.99","38","513.04","3414.38","percent of total billed charges",""
"BONE PLATE 6 HOLE 4 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4411.34","2646.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2769.44","62.78","","780.86","208.94","10480.28","15","513.04","3414.38","percent of total billed charges",""
"BONE PLATE 6 HOLE 4 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4411.34","2646.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1928.64","43.72","","179.76","179.76","179.76","1 through 10","513.04","3414.38","percent of total billed charges",""
"BONE PLATE 6 HOLE 4 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4411.34","2646.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3207.93","72.72","","2355.45","298.99","3965.19","155","513.04","3414.38","percent of total billed charges",""
"BONE PLATE 6 HOLE 4 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4411.34","2646.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3207.93","72.72","","3643.09","3643.09","3643.09","1 through 10","513.04","3414.38","percent of total billed charges",""
"BONE PLATE 6 HOLE 4 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4411.34","2646.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2347.72","53.22","","554.28","554.28","554.28","16","513.04","3414.38","percent of total billed charges",""
"BONE PLATE 6 HOLE 4 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4411.34","2646.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2774.73","62.9","","619.64","173.09","2370.64","150","513.04","3414.38","percent of total billed charges",""
"BONE PLATE 6 HOLE 4 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4411.34","2646.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3414.38","77.4","","303.98","303.98","5854.79","1 through 10","513.04","3414.38","percent of total billed charges",""
"BONE PLATE 6 HOLE 5 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095965","CDM","C1713","HCPCS","0278","RC","","","","both","","","4579.40","2747.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","532.58","3892.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 6 HOLE 5 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095965","CDM","C1713","HCPCS","0278","RC","","","","both","","","4579.40","2747.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","532.58","3892.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 6 HOLE 5 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095965","CDM","C1713","HCPCS","0278","RC","","","","both","","","4579.40","2747.64","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2605.68","56.9","","812.12","238.65","1587.46","163","532.58","3892.49","percent of total billed charges",""
"BONE PLATE 6 HOLE 5 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095965","CDM","C1713","HCPCS","0278","RC","","","","both","","","4579.40","2747.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","532.58","11.63","","112.68","112.68","146.99","38","532.58","3892.49","percent of total billed charges",""
"BONE PLATE 6 HOLE 5 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095965","CDM","C1713","HCPCS","0278","RC","","","","both","","","4579.40","2747.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3544.46","77.4","","303.98","303.98","5854.79","1 through 10","532.58","3892.49","percent of total billed charges",""
"BONE PLATE 6 HOLE 5 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4579.40","2747.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","532.58","11.63","","112.68","112.68","146.99","38","532.58","3544.46","percent of total billed charges",""
"BONE PLATE 6 HOLE 5 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4579.40","2747.64","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2874.95","62.78","","780.86","208.94","10480.28","15","532.58","3544.46","percent of total billed charges",""
"BONE PLATE 6 HOLE 5 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4579.40","2747.64","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2002.11","43.72","","179.76","179.76","179.76","1 through 10","532.58","3544.46","percent of total billed charges",""
"BONE PLATE 6 HOLE 5 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4579.40","2747.64","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3330.14","72.72","","2355.45","298.99","3965.19","155","532.58","3544.46","percent of total billed charges",""
"BONE PLATE 6 HOLE 5 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4579.40","2747.64","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3330.14","72.72","","3643.09","3643.09","3643.09","1 through 10","532.58","3544.46","percent of total billed charges",""
"BONE PLATE 6 HOLE 5 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4579.40","2747.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2437.16","53.22","","554.28","554.28","554.28","16","532.58","3544.46","percent of total billed charges",""
"BONE PLATE 6 HOLE 5 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4579.40","2747.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2880.44","62.9","","619.64","173.09","2370.64","150","532.58","3544.46","percent of total billed charges",""
"BONE PLATE 6 HOLE 5 TWO COLUMN VARIABLE ANGLE LCP TI NARROW RIGHT","SUP-ITM-10095965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4579.40","2747.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3544.46","77.4","","303.98","303.98","5854.79","1 through 10","532.58","3544.46","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","both","","","7175.91","4305.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","834.56","6099.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","both","","","7175.91","4305.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","834.56","6099.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","both","","","7175.91","4305.55","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4083.09","56.9","","812.12","238.65","1587.46","163","834.56","6099.52","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","both","","","7175.91","4305.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","834.56","11.63","","112.68","112.68","146.99","38","834.56","6099.52","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","both","","","7175.91","4305.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5554.15","77.4","","303.98","303.98","5854.79","1 through 10","834.56","6099.52","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7175.91","4305.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","834.56","11.63","","112.68","112.68","146.99","38","834.56","5554.15","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7175.91","4305.55","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4505.04","62.78","","780.86","208.94","10480.28","15","834.56","5554.15","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7175.91","4305.55","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3137.31","43.72","","179.76","179.76","179.76","1 through 10","834.56","5554.15","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7175.91","4305.55","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5218.32","72.72","","2355.45","298.99","3965.19","155","834.56","5554.15","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7175.91","4305.55","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5218.32","72.72","","3643.09","3643.09","3643.09","1 through 10","834.56","5554.15","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7175.91","4305.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3819.02","53.22","","554.28","554.28","554.28","16","834.56","5554.15","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7175.91","4305.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4513.65","62.9","","619.64","173.09","2370.64","150","834.56","5554.15","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7175.91","4305.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5554.15","77.4","","303.98","303.98","5854.79","1 through 10","834.56","5554.15","percent of total billed charges",""
"BONE PLATE 69MM 6 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040736","CDM","C1713","HCPCS","0278","RC","","","","both","","","925.53","555.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","107.64","786.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 69MM 6 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040736","CDM","C1713","HCPCS","0278","RC","","","","both","","","925.53","555.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","107.64","786.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 69MM 6 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040736","CDM","C1713","HCPCS","0278","RC","","","","both","","","925.53","555.32","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","526.63","56.9","","812.12","238.65","1587.46","163","107.64","786.7","percent of total billed charges",""
"BONE PLATE 69MM 6 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040736","CDM","C1713","HCPCS","0278","RC","","","","both","","","925.53","555.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","107.64","11.63","","112.68","112.68","146.99","38","107.64","786.7","percent of total billed charges",""
"BONE PLATE 69MM 6 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040736","CDM","C1713","HCPCS","0278","RC","","","","both","","","925.53","555.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","716.36","77.4","","303.98","303.98","5854.79","1 through 10","107.64","786.7","percent of total billed charges",""
"BONE PLATE 69MM 6 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","925.53","555.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","107.64","11.63","","112.68","112.68","146.99","38","107.64","716.36","percent of total billed charges",""
"BONE PLATE 69MM 6 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","925.53","555.32","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","581.05","62.78","","780.86","208.94","10480.28","15","107.64","716.36","percent of total billed charges",""
"BONE PLATE 69MM 6 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","925.53","555.32","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","404.64","43.72","","179.76","179.76","179.76","1 through 10","107.64","716.36","percent of total billed charges",""
"BONE PLATE 69MM 6 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","925.53","555.32","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","673.05","72.72","","2355.45","298.99","3965.19","155","107.64","716.36","percent of total billed charges",""
"BONE PLATE 69MM 6 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","925.53","555.32","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","673.05","72.72","","3643.09","3643.09","3643.09","1 through 10","107.64","716.36","percent of total billed charges",""
"BONE PLATE 69MM 6 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","925.53","555.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","492.57","53.22","","554.28","554.28","554.28","16","107.64","716.36","percent of total billed charges",""
"BONE PLATE 69MM 6 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","925.53","555.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","582.16","62.9","","619.64","173.09","2370.64","150","107.64","716.36","percent of total billed charges",""
"BONE PLATE 69MM 6 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","925.53","555.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","716.36","77.4","","303.98","303.98","5854.79","1 through 10","107.64","716.36","percent of total billed charges",""
"BONE PLATE 75MM 6 HOLE VARIAX TITANIUM SUPERIOR MIDSHIFT RIGHT","SUP-ITM-10144644","CDM","C1713","HCPCS","0278","RC","","","","both","","","7980.72","4788.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","928.16","6783.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 75MM 6 HOLE VARIAX TITANIUM SUPERIOR MIDSHIFT RIGHT","SUP-ITM-10144644","CDM","C1713","HCPCS","0278","RC","","","","both","","","7980.72","4788.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","928.16","6783.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 75MM 6 HOLE VARIAX TITANIUM SUPERIOR MIDSHIFT RIGHT","SUP-ITM-10144644","CDM","C1713","HCPCS","0278","RC","","","","both","","","7980.72","4788.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4541.03","56.9","","812.12","238.65","1587.46","163","928.16","6783.61","percent of total billed charges",""
"BONE PLATE 75MM 6 HOLE VARIAX TITANIUM SUPERIOR MIDSHIFT RIGHT","SUP-ITM-10144644","CDM","C1713","HCPCS","0278","RC","","","","both","","","7980.72","4788.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","928.16","11.63","","112.68","112.68","146.99","38","928.16","6783.61","percent of total billed charges",""
"BONE PLATE 75MM 6 HOLE VARIAX TITANIUM SUPERIOR MIDSHIFT RIGHT","SUP-ITM-10144644","CDM","C1713","HCPCS","0278","RC","","","","both","","","7980.72","4788.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6177.08","77.4","","303.98","303.98","5854.79","1 through 10","928.16","6783.61","percent of total billed charges",""
"BONE PLATE 75MM 6 HOLE VARIAX TITANIUM SUPERIOR MIDSHIFT RIGHT","SUP-ITM-10144644","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7980.72","4788.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","928.16","11.63","","112.68","112.68","146.99","38","928.16","6177.08","percent of total billed charges",""
"BONE PLATE 75MM 6 HOLE VARIAX TITANIUM SUPERIOR MIDSHIFT RIGHT","SUP-ITM-10144644","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7980.72","4788.43","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5010.30","62.78","","780.86","208.94","10480.28","15","928.16","6177.08","percent of total billed charges",""
"BONE PLATE 75MM 6 HOLE VARIAX TITANIUM SUPERIOR MIDSHIFT RIGHT","SUP-ITM-10144644","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7980.72","4788.43","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3489.17","43.72","","179.76","179.76","179.76","1 through 10","928.16","6177.08","percent of total billed charges",""
"BONE PLATE 75MM 6 HOLE VARIAX TITANIUM SUPERIOR MIDSHIFT RIGHT","SUP-ITM-10144644","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7980.72","4788.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5803.58","72.72","","2355.45","298.99","3965.19","155","928.16","6177.08","percent of total billed charges",""
"BONE PLATE 75MM 6 HOLE VARIAX TITANIUM SUPERIOR MIDSHIFT RIGHT","SUP-ITM-10144644","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7980.72","4788.43","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5803.58","72.72","","3643.09","3643.09","3643.09","1 through 10","928.16","6177.08","percent of total billed charges",""
"BONE PLATE 75MM 6 HOLE VARIAX TITANIUM SUPERIOR MIDSHIFT RIGHT","SUP-ITM-10144644","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7980.72","4788.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4247.34","53.22","","554.28","554.28","554.28","16","928.16","6177.08","percent of total billed charges",""
"BONE PLATE 75MM 6 HOLE VARIAX TITANIUM SUPERIOR MIDSHIFT RIGHT","SUP-ITM-10144644","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7980.72","4788.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5019.87","62.9","","619.64","173.09","2370.64","150","928.16","6177.08","percent of total billed charges",""
"BONE PLATE 75MM 6 HOLE VARIAX TITANIUM SUPERIOR MIDSHIFT RIGHT","SUP-ITM-10144644","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7980.72","4788.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6177.08","77.4","","303.98","303.98","5854.79","1 through 10","928.16","6177.08","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","both","","","943.42","566.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","109.72","801.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","both","","","943.42","566.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","109.72","801.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","both","","","943.42","566.05","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","536.81","56.9","","812.12","238.65","1587.46","163","109.72","801.91","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","both","","","943.42","566.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","109.72","11.63","","112.68","112.68","146.99","38","109.72","801.91","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","both","","","943.42","566.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","730.21","77.4","","303.98","303.98","5854.79","1 through 10","109.72","801.91","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","943.42","566.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","109.72","11.63","","112.68","112.68","146.99","38","109.72","730.21","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","943.42","566.05","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","592.28","62.78","","780.86","208.94","10480.28","15","109.72","730.21","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","943.42","566.05","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","412.46","43.72","","179.76","179.76","179.76","1 through 10","109.72","730.21","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","943.42","566.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","686.06","72.72","","2355.45","298.99","3965.19","155","109.72","730.21","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","943.42","566.05","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","686.06","72.72","","3643.09","3643.09","3643.09","1 through 10","109.72","730.21","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","943.42","566.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","502.09","53.22","","554.28","554.28","554.28","16","109.72","730.21","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","943.42","566.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","593.41","62.9","","619.64","173.09","2370.64","150","109.72","730.21","percent of total billed charges",""
"BONE PLATE 81MM 7 HOLE LCP TI ONE THIRD TUBULAR","SUP-ITM-10040737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","943.42","566.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","730.21","77.4","","303.98","303.98","5854.79","1 through 10","109.72","730.21","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","2055.59","1233.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","239.07","1747.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","2055.59","1233.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","239.07","1747.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","2055.59","1233.35","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1169.63","56.9","","812.12","238.65","1587.46","163","239.07","1747.25","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","2055.59","1233.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","239.07","11.63","","112.68","112.68","146.99","38","239.07","1747.25","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","2055.59","1233.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1591.03","77.4","","303.98","303.98","5854.79","1 through 10","239.07","1747.25","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2055.59","1233.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","239.07","11.63","","112.68","112.68","146.99","38","239.07","1591.03","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2055.59","1233.35","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1290.50","62.78","","780.86","208.94","10480.28","15","239.07","1591.03","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2055.59","1233.35","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","898.70","43.72","","179.76","179.76","179.76","1 through 10","239.07","1591.03","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2055.59","1233.35","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1494.83","72.72","","2355.45","298.99","3965.19","155","239.07","1591.03","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2055.59","1233.35","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1494.83","72.72","","3643.09","3643.09","3643.09","1 through 10","239.07","1591.03","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2055.59","1233.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1093.98","53.22","","554.28","554.28","554.28","16","239.07","1591.03","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2055.59","1233.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1292.97","62.9","","619.64","173.09","2370.64","150","239.07","1591.03","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2055.59","1233.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1591.03","77.4","","303.98","303.98","5854.79","1 through 10","239.07","1591.03","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","1551.92","931.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","180.49","1319.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","1551.92","931.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","180.49","1319.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","1551.92","931.15","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","883.04","56.9","","812.12","238.65","1587.46","163","180.49","1319.13","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","1551.92","931.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","180.49","11.63","","112.68","112.68","146.99","38","180.49","1319.13","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","1551.92","931.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1201.19","77.4","","303.98","303.98","5854.79","1 through 10","180.49","1319.13","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1551.92","931.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","180.49","11.63","","112.68","112.68","146.99","38","180.49","1201.19","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1551.92","931.15","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","974.30","62.78","","780.86","208.94","10480.28","15","180.49","1201.19","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1551.92","931.15","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","678.50","43.72","","179.76","179.76","179.76","1 through 10","180.49","1201.19","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1551.92","931.15","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1128.56","72.72","","2355.45","298.99","3965.19","155","180.49","1201.19","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1551.92","931.15","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1128.56","72.72","","3643.09","3643.09","3643.09","1 through 10","180.49","1201.19","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1551.92","931.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","825.93","53.22","","554.28","554.28","554.28","16","180.49","1201.19","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1551.92","931.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","976.16","62.9","","619.64","173.09","2370.64","150","180.49","1201.19","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1551.92","931.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1201.19","77.4","","303.98","303.98","5854.79","1 through 10","180.49","1201.19","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","912.74","547.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","106.15","775.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","912.74","547.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","106.15","775.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","912.74","547.64","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","519.35","56.9","","812.12","238.65","1587.46","163","106.15","775.83","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","912.74","547.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","106.15","11.63","","112.68","112.68","146.99","38","106.15","775.83","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","912.74","547.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","706.46","77.4","","303.98","303.98","5854.79","1 through 10","106.15","775.83","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","912.74","547.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","106.15","11.63","","112.68","112.68","146.99","38","106.15","706.46","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","912.74","547.64","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","573.02","62.78","","780.86","208.94","10480.28","15","106.15","706.46","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","912.74","547.64","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","399.05","43.72","","179.76","179.76","179.76","1 through 10","106.15","706.46","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","912.74","547.64","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","663.74","72.72","","2355.45","298.99","3965.19","155","106.15","706.46","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","912.74","547.64","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","663.74","72.72","","3643.09","3643.09","3643.09","1 through 10","106.15","706.46","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","912.74","547.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","485.76","53.22","","554.28","554.28","554.28","16","106.15","706.46","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","912.74","547.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","574.11","62.9","","619.64","173.09","2370.64","150","106.15","706.46","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","912.74","547.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","706.46","77.4","","303.98","303.98","5854.79","1 through 10","106.15","706.46","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.90","342.54","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","66.4","485.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.90","342.54","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","66.4","485.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.90","342.54","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","324.84","56.9","","812.12","238.65","1587.46","163","66.4","485.27","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.90","342.54","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","66.40","11.63","","112.68","112.68","146.99","38","66.4","485.27","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.90","342.54","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","441.88","77.4","","303.98","303.98","5854.79","1 through 10","66.4","485.27","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.90","342.54","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","66.40","11.63","","112.68","112.68","146.99","38","66.4","441.88","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.90","342.54","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","358.41","62.78","","780.86","208.94","10480.28","15","66.4","441.88","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.90","342.54","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","249.60","43.72","","179.76","179.76","179.76","1 through 10","66.4","441.88","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.90","342.54","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","415.16","72.72","","2355.45","298.99","3965.19","155","66.4","441.88","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.90","342.54","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","415.16","72.72","","3643.09","3643.09","3643.09","1 through 10","66.4","441.88","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.90","342.54","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","303.83","53.22","","554.28","554.28","554.28","16","66.4","441.88","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.90","342.54","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","359.10","62.9","","619.64","173.09","2370.64","150","66.4","441.88","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.90","342.54","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","441.88","77.4","","303.98","303.98","5854.79","1 through 10","66.4","441.88","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","1618.39","971.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","188.22","1375.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","1618.39","971.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","188.22","1375.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","1618.39","971.03","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","920.86","56.9","","812.12","238.65","1587.46","163","188.22","1375.63","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","1618.39","971.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","188.22","11.63","","112.68","112.68","146.99","38","188.22","1375.63","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","1618.39","971.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1252.63","77.4","","303.98","303.98","5854.79","1 through 10","188.22","1375.63","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1618.39","971.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","188.22","11.63","","112.68","112.68","146.99","38","188.22","1252.63","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1618.39","971.03","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1016.03","62.78","","780.86","208.94","10480.28","15","188.22","1252.63","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1618.39","971.03","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","707.56","43.72","","179.76","179.76","179.76","1 through 10","188.22","1252.63","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1618.39","971.03","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1176.89","72.72","","2355.45","298.99","3965.19","155","188.22","1252.63","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1618.39","971.03","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1176.89","72.72","","3643.09","3643.09","3643.09","1 through 10","188.22","1252.63","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1618.39","971.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","861.31","53.22","","554.28","554.28","554.28","16","188.22","1252.63","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1618.39","971.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1017.97","62.9","","619.64","173.09","2370.64","150","188.22","1252.63","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1618.39","971.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1252.63","77.4","","303.98","303.98","5854.79","1 through 10","188.22","1252.63","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","both","","","7523.81","4514.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","875.02","6395.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","both","","","7523.81","4514.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","875.02","6395.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","both","","","7523.81","4514.29","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4281.05","56.9","","812.12","238.65","1587.46","163","875.02","6395.24","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","both","","","7523.81","4514.29","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","875.02","11.63","","112.68","112.68","146.99","38","875.02","6395.24","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","both","","","7523.81","4514.29","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5823.43","77.4","","303.98","303.98","5854.79","1 through 10","875.02","6395.24","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7523.81","4514.29","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","875.02","11.63","","112.68","112.68","146.99","38","875.02","5823.43","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7523.81","4514.29","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4723.45","62.78","","780.86","208.94","10480.28","15","875.02","5823.43","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7523.81","4514.29","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3289.41","43.72","","179.76","179.76","179.76","1 through 10","875.02","5823.43","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7523.81","4514.29","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5471.31","72.72","","2355.45","298.99","3965.19","155","875.02","5823.43","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7523.81","4514.29","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5471.31","72.72","","3643.09","3643.09","3643.09","1 through 10","875.02","5823.43","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7523.81","4514.29","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4004.17","53.22","","554.28","554.28","554.28","16","875.02","5823.43","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7523.81","4514.29","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4732.48","62.9","","619.64","173.09","2370.64","150","875.02","5823.43","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7523.81","4514.29","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5823.43","77.4","","303.98","303.98","5854.79","1 through 10","875.02","5823.43","percent of total billed charges",""
"BONE PLATE HALLUX 2.7MM 2 HOLE HEAD 4 SHAFT LCP SS T SHAPE","SUP-ITM-10038148","CDM","C1713","HCPCS","0278","RC","","","","both","","","3569.15","2141.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","415.09","3033.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE HALLUX 2.7MM 2 HOLE HEAD 4 SHAFT LCP SS T SHAPE","SUP-ITM-10038148","CDM","C1713","HCPCS","0278","RC","","","","both","","","3569.15","2141.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","415.09","3033.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE HALLUX 2.7MM 2 HOLE HEAD 4 SHAFT LCP SS T SHAPE","SUP-ITM-10038148","CDM","C1713","HCPCS","0278","RC","","","","both","","","3569.15","2141.49","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2030.85","56.9","","812.12","238.65","1587.46","163","415.09","3033.78","percent of total billed charges",""
"BONE PLATE HALLUX 2.7MM 2 HOLE HEAD 4 SHAFT LCP SS T SHAPE","SUP-ITM-10038148","CDM","C1713","HCPCS","0278","RC","","","","both","","","3569.15","2141.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","415.09","11.63","","112.68","112.68","146.99","38","415.09","3033.78","percent of total billed charges",""
"BONE PLATE HALLUX 2.7MM 2 HOLE HEAD 4 SHAFT LCP SS T SHAPE","SUP-ITM-10038148","CDM","C1713","HCPCS","0278","RC","","","","both","","","3569.15","2141.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2762.52","77.4","","303.98","303.98","5854.79","1 through 10","415.09","3033.78","percent of total billed charges",""
"BONE PLATE HALLUX 2.7MM 2 HOLE HEAD 4 SHAFT LCP SS T SHAPE","SUP-ITM-10038148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3569.15","2141.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","415.09","11.63","","112.68","112.68","146.99","38","415.09","2762.52","percent of total billed charges",""
"BONE PLATE HALLUX 2.7MM 2 HOLE HEAD 4 SHAFT LCP SS T SHAPE","SUP-ITM-10038148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3569.15","2141.49","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2240.71","62.78","","780.86","208.94","10480.28","15","415.09","2762.52","percent of total billed charges",""
"BONE PLATE HALLUX 2.7MM 2 HOLE HEAD 4 SHAFT LCP SS T SHAPE","SUP-ITM-10038148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3569.15","2141.49","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1560.43","43.72","","179.76","179.76","179.76","1 through 10","415.09","2762.52","percent of total billed charges",""
"BONE PLATE HALLUX 2.7MM 2 HOLE HEAD 4 SHAFT LCP SS T SHAPE","SUP-ITM-10038148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3569.15","2141.49","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2595.49","72.72","","2355.45","298.99","3965.19","155","415.09","2762.52","percent of total billed charges",""
"BONE PLATE HALLUX 2.7MM 2 HOLE HEAD 4 SHAFT LCP SS T SHAPE","SUP-ITM-10038148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3569.15","2141.49","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2595.49","72.72","","3643.09","3643.09","3643.09","1 through 10","415.09","2762.52","percent of total billed charges",""
"BONE PLATE HALLUX 2.7MM 2 HOLE HEAD 4 SHAFT LCP SS T SHAPE","SUP-ITM-10038148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3569.15","2141.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1899.50","53.22","","554.28","554.28","554.28","16","415.09","2762.52","percent of total billed charges",""
"BONE PLATE HALLUX 2.7MM 2 HOLE HEAD 4 SHAFT LCP SS T SHAPE","SUP-ITM-10038148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3569.15","2141.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2245.00","62.9","","619.64","173.09","2370.64","150","415.09","2762.52","percent of total billed charges",""
"BONE PLATE HALLUX 2.7MM 2 HOLE HEAD 4 SHAFT LCP SS T SHAPE","SUP-ITM-10038148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3569.15","2141.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2762.52","77.4","","303.98","303.98","5854.79","1 through 10","415.09","2762.52","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","3489.55","2093.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","405.83","2966.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","3489.55","2093.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","405.83","2966.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","3489.55","2093.73","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1985.55","56.9","","812.12","238.65","1587.46","163","405.83","2966.12","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","3489.55","2093.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","405.83","11.63","","112.68","112.68","146.99","38","405.83","2966.12","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","3489.55","2093.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2700.91","77.4","","303.98","303.98","5854.79","1 through 10","405.83","2966.12","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3489.55","2093.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","405.83","11.63","","112.68","112.68","146.99","38","405.83","2700.91","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3489.55","2093.73","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2190.74","62.78","","780.86","208.94","10480.28","15","405.83","2700.91","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3489.55","2093.73","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1525.63","43.72","","179.76","179.76","179.76","1 through 10","405.83","2700.91","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3489.55","2093.73","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2537.60","72.72","","2355.45","298.99","3965.19","155","405.83","2700.91","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3489.55","2093.73","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2537.60","72.72","","3643.09","3643.09","3643.09","1 through 10","405.83","2700.91","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3489.55","2093.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1857.14","53.22","","554.28","554.28","554.28","16","405.83","2700.91","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3489.55","2093.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2194.93","62.9","","619.64","173.09","2370.64","150","405.83","2700.91","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3489.55","2093.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2700.91","77.4","","303.98","303.98","5854.79","1 through 10","405.83","2700.91","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","8136.51","4881.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","946.28","6916.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","8136.51","4881.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","946.28","6916.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","8136.51","4881.91","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4629.67","56.9","","812.12","238.65","1587.46","163","946.28","6916.03","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","8136.51","4881.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","946.28","11.63","","112.68","112.68","146.99","38","946.28","6916.03","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","8136.51","4881.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6297.66","77.4","","303.98","303.98","5854.79","1 through 10","946.28","6916.03","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8136.51","4881.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","946.28","11.63","","112.68","112.68","146.99","38","946.28","6297.66","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8136.51","4881.91","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5108.10","62.78","","780.86","208.94","10480.28","15","946.28","6297.66","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8136.51","4881.91","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3557.28","43.72","","179.76","179.76","179.76","1 through 10","946.28","6297.66","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8136.51","4881.91","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5916.87","72.72","","2355.45","298.99","3965.19","155","946.28","6297.66","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8136.51","4881.91","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5916.87","72.72","","3643.09","3643.09","3643.09","1 through 10","946.28","6297.66","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8136.51","4881.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4330.25","53.22","","554.28","554.28","554.28","16","946.28","6297.66","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8136.51","4881.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5117.86","62.9","","619.64","173.09","2370.64","150","946.28","6297.66","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8136.51","4881.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6297.66","77.4","","303.98","303.98","5854.79","1 through 10","946.28","6297.66","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","6583.88","3950.33","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","765.71","5596.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","6583.88","3950.33","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","765.71","5596.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","6583.88","3950.33","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3746.23","56.9","","812.12","238.65","1587.46","163","765.71","5596.3","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","6583.88","3950.33","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","765.71","11.63","","112.68","112.68","146.99","38","765.71","5596.3","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","6583.88","3950.33","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5095.92","77.4","","303.98","303.98","5854.79","1 through 10","765.71","5596.3","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6583.88","3950.33","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","765.71","11.63","","112.68","112.68","146.99","38","765.71","5095.92","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6583.88","3950.33","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4133.36","62.78","","780.86","208.94","10480.28","15","765.71","5095.92","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6583.88","3950.33","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2878.47","43.72","","179.76","179.76","179.76","1 through 10","765.71","5095.92","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6583.88","3950.33","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4787.80","72.72","","2355.45","298.99","3965.19","155","765.71","5095.92","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6583.88","3950.33","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4787.80","72.72","","3643.09","3643.09","3643.09","1 through 10","765.71","5095.92","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6583.88","3950.33","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3503.94","53.22","","554.28","554.28","554.28","16","765.71","5095.92","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6583.88","3950.33","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4141.26","62.9","","619.64","173.09","2370.64","150","765.71","5095.92","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6583.88","3950.33","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5095.92","77.4","","303.98","303.98","5854.79","1 through 10","765.71","5095.92","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","8150.43","4890.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","947.9","6927.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","8150.43","4890.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","947.9","6927.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","8150.43","4890.26","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4637.59","56.9","","812.12","238.65","1587.46","163","947.9","6927.87","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","8150.43","4890.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","947.90","11.63","","112.68","112.68","146.99","38","947.9","6927.87","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","8150.43","4890.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6308.43","77.4","","303.98","303.98","5854.79","1 through 10","947.9","6927.87","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8150.43","4890.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","947.90","11.63","","112.68","112.68","146.99","38","947.9","6308.43","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8150.43","4890.26","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5116.84","62.78","","780.86","208.94","10480.28","15","947.9","6308.43","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8150.43","4890.26","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3563.37","43.72","","179.76","179.76","179.76","1 through 10","947.9","6308.43","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8150.43","4890.26","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5926.99","72.72","","2355.45","298.99","3965.19","155","947.9","6308.43","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8150.43","4890.26","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5926.99","72.72","","3643.09","3643.09","3643.09","1 through 10","947.9","6308.43","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8150.43","4890.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4337.66","53.22","","554.28","554.28","554.28","16","947.9","6308.43","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8150.43","4890.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5126.62","62.9","","619.64","173.09","2370.64","150","947.9","6308.43","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8150.43","4890.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6308.43","77.4","","303.98","303.98","5854.79","1 through 10","947.9","6308.43","percent of total billed charges",""
"BONE PLATE XL SMARTLOCK TITANIUM LOCKING DORSAL STANDARD RIGHT","SUP-ITM-10143617","CDM","C1713","HCPCS","0278","RC","","","","both","","","8281.91","4969.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","963.19","7039.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE XL SMARTLOCK TITANIUM LOCKING DORSAL STANDARD RIGHT","SUP-ITM-10143617","CDM","C1713","HCPCS","0278","RC","","","","both","","","8281.91","4969.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","963.19","7039.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE PLATE XL SMARTLOCK TITANIUM LOCKING DORSAL STANDARD RIGHT","SUP-ITM-10143617","CDM","C1713","HCPCS","0278","RC","","","","both","","","8281.91","4969.15","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4712.41","56.9","","812.12","238.65","1587.46","163","963.19","7039.62","percent of total billed charges",""
"BONE PLATE XL SMARTLOCK TITANIUM LOCKING DORSAL STANDARD RIGHT","SUP-ITM-10143617","CDM","C1713","HCPCS","0278","RC","","","","both","","","8281.91","4969.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","963.19","11.63","","112.68","112.68","146.99","38","963.19","7039.62","percent of total billed charges",""
"BONE PLATE XL SMARTLOCK TITANIUM LOCKING DORSAL STANDARD RIGHT","SUP-ITM-10143617","CDM","C1713","HCPCS","0278","RC","","","","both","","","8281.91","4969.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6410.20","77.4","","303.98","303.98","5854.79","1 through 10","963.19","7039.62","percent of total billed charges",""
"BONE PLATE XL SMARTLOCK TITANIUM LOCKING DORSAL STANDARD RIGHT","SUP-ITM-10143617","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8281.91","4969.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","963.19","11.63","","112.68","112.68","146.99","38","963.19","6410.2","percent of total billed charges",""
"BONE PLATE XL SMARTLOCK TITANIUM LOCKING DORSAL STANDARD RIGHT","SUP-ITM-10143617","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8281.91","4969.15","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5199.38","62.78","","780.86","208.94","10480.28","15","963.19","6410.2","percent of total billed charges",""
"BONE PLATE XL SMARTLOCK TITANIUM LOCKING DORSAL STANDARD RIGHT","SUP-ITM-10143617","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8281.91","4969.15","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3620.85","43.72","","179.76","179.76","179.76","1 through 10","963.19","6410.2","percent of total billed charges",""
"BONE PLATE XL SMARTLOCK TITANIUM LOCKING DORSAL STANDARD RIGHT","SUP-ITM-10143617","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8281.91","4969.15","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6022.60","72.72","","2355.45","298.99","3965.19","155","963.19","6410.2","percent of total billed charges",""
"BONE PLATE XL SMARTLOCK TITANIUM LOCKING DORSAL STANDARD RIGHT","SUP-ITM-10143617","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8281.91","4969.15","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6022.60","72.72","","3643.09","3643.09","3643.09","1 through 10","963.19","6410.2","percent of total billed charges",""
"BONE PLATE XL SMARTLOCK TITANIUM LOCKING DORSAL STANDARD RIGHT","SUP-ITM-10143617","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8281.91","4969.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4407.63","53.22","","554.28","554.28","554.28","16","963.19","6410.2","percent of total billed charges",""
"BONE PLATE XL SMARTLOCK TITANIUM LOCKING DORSAL STANDARD RIGHT","SUP-ITM-10143617","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8281.91","4969.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5209.32","62.9","","619.64","173.09","2370.64","150","963.19","6410.2","percent of total billed charges",""
"BONE PLATE XL SMARTLOCK TITANIUM LOCKING DORSAL STANDARD RIGHT","SUP-ITM-10143617","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8281.91","4969.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6410.20","77.4","","303.98","303.98","5854.79","1 through 10","963.19","6410.2","percent of total billed charges",""
"BONE RING 0.75X165MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004043","CDM","C1889","HCPCS","0278","RC","","","","both","","","2508.12","1504.87","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","291.69","2131.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE RING 0.75X165MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004043","CDM","C1889","HCPCS","0278","RC","","","","both","","","2508.12","1504.87","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","291.69","2131.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE RING 0.75X165MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004043","CDM","C1889","HCPCS","0278","RC","","","","both","","","2508.12","1504.87","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1427.12","56.9","","0.63","0.63","0.63","1 through 10","291.69","2131.9","percent of total billed charges",""
"BONE RING 0.75X165MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004043","CDM","C1889","HCPCS","0278","RC","","","","both","","","2508.12","1504.87","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","361.67","14.42","","317.14","317.14","317.14","1 through 10","291.69","2131.9","percent of total billed charges",""
"BONE RING 0.75X165MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004043","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2508.12","1504.87","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","361.67","14.42","","317.14","317.14","317.14","1 through 10","291.69","1941.28","percent of total billed charges",""
"BONE RING 0.75X165MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004043","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2508.12","1504.87","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1574.60","62.78","","1125.09","1125.09","1125.09","1 through 10","291.69","1941.28","percent of total billed charges",""
"BONE RING 0.75X165MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004043","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2508.12","1504.87","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1823.90","72.72","","4732.50","1617.43","14180.40","1 through 10","291.69","1941.28","percent of total billed charges",""
"BONE RING 0.75X165MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004043","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2508.12","1504.87","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1577.61","62.9","","3896.20","3341.38","3896.20","1 through 10","291.69","1941.28","percent of total billed charges",""
"BONE RING 0.75X205MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004045","CDM","C1889","HCPCS","0278","RC","","","","both","","","2970.89","1782.53","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","345.51","2525.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE RING 0.75X205MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004045","CDM","C1889","HCPCS","0278","RC","","","","both","","","2970.89","1782.53","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","345.51","2525.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE RING 0.75X205MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004045","CDM","C1889","HCPCS","0278","RC","","","","both","","","2970.89","1782.53","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1690.44","56.9","","0.63","0.63","0.63","1 through 10","345.51","2525.26","percent of total billed charges",""
"BONE RING 0.75X205MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004045","CDM","C1889","HCPCS","0278","RC","","","","both","","","2970.89","1782.53","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","428.40","14.42","","317.14","317.14","317.14","1 through 10","345.51","2525.26","percent of total billed charges",""
"BONE RING 0.75X205MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004045","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2970.89","1782.53","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","428.40","14.42","","317.14","317.14","317.14","1 through 10","345.51","2299.47","percent of total billed charges",""
"BONE RING 0.75X205MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004045","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2970.89","1782.53","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1865.12","62.78","","1125.09","1125.09","1125.09","1 through 10","345.51","2299.47","percent of total billed charges",""
"BONE RING 0.75X205MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004045","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2970.89","1782.53","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2160.43","72.72","","4732.50","1617.43","14180.40","1 through 10","345.51","2299.47","percent of total billed charges",""
"BONE RING 0.75X205MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004045","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2970.89","1782.53","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1868.69","62.9","","3896.20","3341.38","3896.20","1 through 10","345.51","2299.47","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","both","","","833.48","500.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","96.93","708.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","both","","","833.48","500.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","96.93","708.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","both","","","833.48","500.09","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","474.25","56.9","","812.12","238.65","1587.46","163","96.93","708.46","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","both","","","833.48","500.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","96.93","11.63","","112.68","112.68","146.99","38","96.93","708.46","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","both","","","833.48","500.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","645.11","77.4","","303.98","303.98","5854.79","1 through 10","96.93","708.46","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","833.48","500.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","96.93","11.63","","112.68","112.68","146.99","38","96.93","645.11","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","833.48","500.09","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","523.26","62.78","","780.86","208.94","10480.28","15","96.93","645.11","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","833.48","500.09","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","364.40","43.72","","179.76","179.76","179.76","1 through 10","96.93","645.11","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","833.48","500.09","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","606.11","72.72","","2355.45","298.99","3965.19","155","96.93","645.11","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","833.48","500.09","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","606.11","72.72","","3643.09","3643.09","3643.09","1 through 10","96.93","645.11","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","833.48","500.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","443.58","53.22","","554.28","554.28","554.28","16","96.93","645.11","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","833.48","500.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","524.26","62.9","","619.64","173.09","2370.64","150","96.93","645.11","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","833.48","500.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","645.11","77.4","","303.98","303.98","5854.79","1 through 10","96.93","645.11","percent of total billed charges",""
"BONE SCREW 5MMX125 40 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040855","CDM","C1713","HCPCS","0278","RC","","","","both","","","924.28","554.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","107.49","785.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE SCREW 5MMX125 40 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040855","CDM","C1713","HCPCS","0278","RC","","","","both","","","924.28","554.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","107.49","785.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE SCREW 5MMX125 40 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040855","CDM","C1713","HCPCS","0278","RC","","","","both","","","924.28","554.57","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","525.92","56.9","","812.12","238.65","1587.46","163","107.49","785.64","percent of total billed charges",""
"BONE SCREW 5MMX125 40 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040855","CDM","C1713","HCPCS","0278","RC","","","","both","","","924.28","554.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","107.49","11.63","","112.68","112.68","146.99","38","107.49","785.64","percent of total billed charges",""
"BONE SCREW 5MMX125 40 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040855","CDM","C1713","HCPCS","0278","RC","","","","both","","","924.28","554.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","715.39","77.4","","303.98","303.98","5854.79","1 through 10","107.49","785.64","percent of total billed charges",""
"BONE SCREW 5MMX125 40 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","924.28","554.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","107.49","11.63","","112.68","112.68","146.99","38","107.49","715.39","percent of total billed charges",""
"BONE SCREW 5MMX125 40 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","924.28","554.57","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","580.26","62.78","","780.86","208.94","10480.28","15","107.49","715.39","percent of total billed charges",""
"BONE SCREW 5MMX125 40 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","924.28","554.57","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","404.10","43.72","","179.76","179.76","179.76","1 through 10","107.49","715.39","percent of total billed charges",""
"BONE SCREW 5MMX125 40 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","924.28","554.57","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","672.14","72.72","","2355.45","298.99","3965.19","155","107.49","715.39","percent of total billed charges",""
"BONE SCREW 5MMX125 40 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","924.28","554.57","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","672.14","72.72","","3643.09","3643.09","3643.09","1 through 10","107.49","715.39","percent of total billed charges",""
"BONE SCREW 5MMX125 40 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","924.28","554.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","491.90","53.22","","554.28","554.28","554.28","16","107.49","715.39","percent of total billed charges",""
"BONE SCREW 5MMX125 40 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","924.28","554.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","581.37","62.9","","619.64","173.09","2370.64","150","107.49","715.39","percent of total billed charges",""
"BONE SCREW 5MMX125 40 SCHANZ SELF DRILLING THREAD TI","SUP-ITM-10040855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","924.28","554.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","715.39","77.4","","303.98","303.98","5854.79","1 through 10","107.49","715.39","percent of total billed charges",""
"BONE SCREW 5MMX175 60 SCHANZ TI SELF DRILLING","SUP-ITM-10040857","CDM","C1713","HCPCS","0278","RC","","","","both","","","924.28","554.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","107.49","785.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE SCREW 5MMX175 60 SCHANZ TI SELF DRILLING","SUP-ITM-10040857","CDM","C1713","HCPCS","0278","RC","","","","both","","","924.28","554.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","107.49","785.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE SCREW 5MMX175 60 SCHANZ TI SELF DRILLING","SUP-ITM-10040857","CDM","C1713","HCPCS","0278","RC","","","","both","","","924.28","554.57","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","525.92","56.9","","812.12","238.65","1587.46","163","107.49","785.64","percent of total billed charges",""
"BONE SCREW 5MMX175 60 SCHANZ TI SELF DRILLING","SUP-ITM-10040857","CDM","C1713","HCPCS","0278","RC","","","","both","","","924.28","554.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","107.49","11.63","","112.68","112.68","146.99","38","107.49","785.64","percent of total billed charges",""
"BONE SCREW 5MMX175 60 SCHANZ TI SELF DRILLING","SUP-ITM-10040857","CDM","C1713","HCPCS","0278","RC","","","","both","","","924.28","554.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","715.39","77.4","","303.98","303.98","5854.79","1 through 10","107.49","785.64","percent of total billed charges",""
"BONE SCREW 5MMX175 60 SCHANZ TI SELF DRILLING","SUP-ITM-10040857","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","924.28","554.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","107.49","11.63","","112.68","112.68","146.99","38","107.49","715.39","percent of total billed charges",""
"BONE SCREW 5MMX175 60 SCHANZ TI SELF DRILLING","SUP-ITM-10040857","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","924.28","554.57","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","580.26","62.78","","780.86","208.94","10480.28","15","107.49","715.39","percent of total billed charges",""
"BONE SCREW 5MMX175 60 SCHANZ TI SELF DRILLING","SUP-ITM-10040857","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","924.28","554.57","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","404.10","43.72","","179.76","179.76","179.76","1 through 10","107.49","715.39","percent of total billed charges",""
"BONE SCREW 5MMX175 60 SCHANZ TI SELF DRILLING","SUP-ITM-10040857","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","924.28","554.57","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","672.14","72.72","","2355.45","298.99","3965.19","155","107.49","715.39","percent of total billed charges",""
"BONE SCREW 5MMX175 60 SCHANZ TI SELF DRILLING","SUP-ITM-10040857","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","924.28","554.57","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","672.14","72.72","","3643.09","3643.09","3643.09","1 through 10","107.49","715.39","percent of total billed charges",""
"BONE SCREW 5MMX175 60 SCHANZ TI SELF DRILLING","SUP-ITM-10040857","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","924.28","554.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","491.90","53.22","","554.28","554.28","554.28","16","107.49","715.39","percent of total billed charges",""
"BONE SCREW 5MMX175 60 SCHANZ TI SELF DRILLING","SUP-ITM-10040857","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","924.28","554.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","581.37","62.9","","619.64","173.09","2370.64","150","107.49","715.39","percent of total billed charges",""
"BONE SCREW 5MMX175 60 SCHANZ TI SELF DRILLING","SUP-ITM-10040857","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","924.28","554.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","715.39","77.4","","303.98","303.98","5854.79","1 through 10","107.49","715.39","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","811.51","486.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","94.38","689.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","811.51","486.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","94.38","689.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","811.51","486.91","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","461.75","56.9","","812.12","238.65","1587.46","163","94.38","689.78","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","811.51","486.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","94.38","11.63","","112.68","112.68","146.99","38","94.38","689.78","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","811.51","486.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","628.11","77.4","","303.98","303.98","5854.79","1 through 10","94.38","689.78","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","811.51","486.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","94.38","11.63","","112.68","112.68","146.99","38","94.38","628.11","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","811.51","486.91","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","509.47","62.78","","780.86","208.94","10480.28","15","94.38","628.11","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","811.51","486.91","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","354.79","43.72","","179.76","179.76","179.76","1 through 10","94.38","628.11","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","811.51","486.91","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","590.13","72.72","","2355.45","298.99","3965.19","155","94.38","628.11","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","811.51","486.91","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","590.13","72.72","","3643.09","3643.09","3643.09","1 through 10","94.38","628.11","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","811.51","486.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","431.89","53.22","","554.28","554.28","554.28","16","94.38","628.11","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","811.51","486.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","510.44","62.9","","619.64","173.09","2370.64","150","94.38","628.11","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","811.51","486.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","628.11","77.4","","303.98","303.98","5854.79","1 through 10","94.38","628.11","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","866.79","520.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","100.81","736.77","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","866.79","520.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","100.81","736.77","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","866.79","520.07","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","493.20","56.9","","812.12","238.65","1587.46","163","100.81","736.77","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","866.79","520.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","100.81","11.63","","112.68","112.68","146.99","38","100.81","736.77","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","866.79","520.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","670.90","77.4","","303.98","303.98","5854.79","1 through 10","100.81","736.77","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","866.79","520.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","100.81","11.63","","112.68","112.68","146.99","38","100.81","670.9","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","866.79","520.07","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","544.17","62.78","","780.86","208.94","10480.28","15","100.81","670.9","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","866.79","520.07","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","378.96","43.72","","179.76","179.76","179.76","1 through 10","100.81","670.9","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","866.79","520.07","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","630.33","72.72","","2355.45","298.99","3965.19","155","100.81","670.9","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","866.79","520.07","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","630.33","72.72","","3643.09","3643.09","3643.09","1 through 10","100.81","670.9","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","866.79","520.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","461.31","53.22","","554.28","554.28","554.28","16","100.81","670.9","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","866.79","520.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","545.21","62.9","","619.64","173.09","2370.64","150","100.81","670.9","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","866.79","520.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","670.90","77.4","","303.98","303.98","5854.79","1 through 10","100.81","670.9","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","866.79","520.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","100.81","736.77","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","866.79","520.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","100.81","736.77","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","866.79","520.07","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","493.20","56.9","","812.12","238.65","1587.46","163","100.81","736.77","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","866.79","520.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","100.81","11.63","","112.68","112.68","146.99","38","100.81","736.77","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","866.79","520.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","670.90","77.4","","303.98","303.98","5854.79","1 through 10","100.81","736.77","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","866.79","520.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","100.81","11.63","","112.68","112.68","146.99","38","100.81","670.9","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","866.79","520.07","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","544.17","62.78","","780.86","208.94","10480.28","15","100.81","670.9","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","866.79","520.07","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","378.96","43.72","","179.76","179.76","179.76","1 through 10","100.81","670.9","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","866.79","520.07","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","630.33","72.72","","2355.45","298.99","3965.19","155","100.81","670.9","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","866.79","520.07","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","630.33","72.72","","3643.09","3643.09","3643.09","1 through 10","100.81","670.9","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","866.79","520.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","461.31","53.22","","554.28","554.28","554.28","16","100.81","670.9","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","866.79","520.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","545.21","62.9","","619.64","173.09","2370.64","150","100.81","670.9","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","866.79","520.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","670.90","77.4","","303.98","303.98","5854.79","1 through 10","100.81","670.9","percent of total billed charges",""
"BONE SCREW 7.3MM 16 155 STAINLESS CANNULATED SELF DRILLING TAPPING THREAD HEXAGONAL SOCKET","SUP-ITM-10094955","CDM","C1713","HCPCS","0278","RC","","","","both","","","1149.82","689.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","133.72","977.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE SCREW 7.3MM 16 155 STAINLESS CANNULATED SELF DRILLING TAPPING THREAD HEXAGONAL SOCKET","SUP-ITM-10094955","CDM","C1713","HCPCS","0278","RC","","","","both","","","1149.82","689.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","133.72","977.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE SCREW 7.3MM 16 155 STAINLESS CANNULATED SELF DRILLING TAPPING THREAD HEXAGONAL SOCKET","SUP-ITM-10094955","CDM","C1713","HCPCS","0278","RC","","","","both","","","1149.82","689.89","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","654.25","56.9","","812.12","238.65","1587.46","163","133.72","977.35","percent of total billed charges",""
"BONE SCREW 7.3MM 16 155 STAINLESS CANNULATED SELF DRILLING TAPPING THREAD HEXAGONAL SOCKET","SUP-ITM-10094955","CDM","C1713","HCPCS","0278","RC","","","","both","","","1149.82","689.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","133.72","11.63","","112.68","112.68","146.99","38","133.72","977.35","percent of total billed charges",""
"BONE SCREW 7.3MM 16 155 STAINLESS CANNULATED SELF DRILLING TAPPING THREAD HEXAGONAL SOCKET","SUP-ITM-10094955","CDM","C1713","HCPCS","0278","RC","","","","both","","","1149.82","689.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","889.96","77.4","","303.98","303.98","5854.79","1 through 10","133.72","977.35","percent of total billed charges",""
"BONE SCREW 7.3MM 16 155 STAINLESS CANNULATED SELF DRILLING TAPPING THREAD HEXAGONAL SOCKET","SUP-ITM-10094955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1149.82","689.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","133.72","11.63","","112.68","112.68","146.99","38","133.72","889.96","percent of total billed charges",""
"BONE SCREW 7.3MM 16 155 STAINLESS CANNULATED SELF DRILLING TAPPING THREAD HEXAGONAL SOCKET","SUP-ITM-10094955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1149.82","689.89","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","721.86","62.78","","780.86","208.94","10480.28","15","133.72","889.96","percent of total billed charges",""
"BONE SCREW 7.3MM 16 155 STAINLESS CANNULATED SELF DRILLING TAPPING THREAD HEXAGONAL SOCKET","SUP-ITM-10094955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1149.82","689.89","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","502.70","43.72","","179.76","179.76","179.76","1 through 10","133.72","889.96","percent of total billed charges",""
"BONE SCREW 7.3MM 16 155 STAINLESS CANNULATED SELF DRILLING TAPPING THREAD HEXAGONAL SOCKET","SUP-ITM-10094955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1149.82","689.89","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","836.15","72.72","","2355.45","298.99","3965.19","155","133.72","889.96","percent of total billed charges",""
"BONE SCREW 7.3MM 16 155 STAINLESS CANNULATED SELF DRILLING TAPPING THREAD HEXAGONAL SOCKET","SUP-ITM-10094955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1149.82","689.89","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","836.15","72.72","","3643.09","3643.09","3643.09","1 through 10","133.72","889.96","percent of total billed charges",""
"BONE SCREW 7.3MM 16 155 STAINLESS CANNULATED SELF DRILLING TAPPING THREAD HEXAGONAL SOCKET","SUP-ITM-10094955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1149.82","689.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","611.93","53.22","","554.28","554.28","554.28","16","133.72","889.96","percent of total billed charges",""
"BONE SCREW 7.3MM 16 155 STAINLESS CANNULATED SELF DRILLING TAPPING THREAD HEXAGONAL SOCKET","SUP-ITM-10094955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1149.82","689.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","723.24","62.9","","619.64","173.09","2370.64","150","133.72","889.96","percent of total billed charges",""
"BONE SCREW 7.3MM 16 155 STAINLESS CANNULATED SELF DRILLING TAPPING THREAD HEXAGONAL SOCKET","SUP-ITM-10094955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1149.82","689.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","889.96","77.4","","303.98","303.98","5854.79","1 through 10","133.72","889.96","percent of total billed charges",""
"BONE SCREW 95MM CONDYLAR VA LCP STAINLESS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10097269","CDM","C1713","HCPCS","0278","RC","","","","both","","","1334.11","800.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","155.16","1133.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE SCREW 95MM CONDYLAR VA LCP STAINLESS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10097269","CDM","C1713","HCPCS","0278","RC","","","","both","","","1334.11","800.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","155.16","1133.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BONE SCREW 95MM CONDYLAR VA LCP STAINLESS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10097269","CDM","C1713","HCPCS","0278","RC","","","","both","","","1334.11","800.47","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","759.11","56.9","","812.12","238.65","1587.46","163","155.16","1133.99","percent of total billed charges",""
"BONE SCREW 95MM CONDYLAR VA LCP STAINLESS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10097269","CDM","C1713","HCPCS","0278","RC","","","","both","","","1334.11","800.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","155.16","11.63","","112.68","112.68","146.99","38","155.16","1133.99","percent of total billed charges",""
"BONE SCREW 95MM CONDYLAR VA LCP STAINLESS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10097269","CDM","C1713","HCPCS","0278","RC","","","","both","","","1334.11","800.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1032.60","77.4","","303.98","303.98","5854.79","1 through 10","155.16","1133.99","percent of total billed charges",""
"BONE SCREW 95MM CONDYLAR VA LCP STAINLESS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10097269","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1334.11","800.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","155.16","11.63","","112.68","112.68","146.99","38","155.16","1032.6","percent of total billed charges",""
"BONE SCREW 95MM CONDYLAR VA LCP STAINLESS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10097269","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1334.11","800.47","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","837.55","62.78","","780.86","208.94","10480.28","15","155.16","1032.6","percent of total billed charges",""
"BONE SCREW 95MM CONDYLAR VA LCP STAINLESS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10097269","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1334.11","800.47","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","583.27","43.72","","179.76","179.76","179.76","1 through 10","155.16","1032.6","percent of total billed charges",""
"BONE SCREW 95MM CONDYLAR VA LCP STAINLESS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10097269","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1334.11","800.47","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","970.16","72.72","","2355.45","298.99","3965.19","155","155.16","1032.6","percent of total billed charges",""
"BONE SCREW 95MM CONDYLAR VA LCP STAINLESS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10097269","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1334.11","800.47","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","970.16","72.72","","3643.09","3643.09","3643.09","1 through 10","155.16","1032.6","percent of total billed charges",""
"BONE SCREW 95MM CONDYLAR VA LCP STAINLESS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10097269","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1334.11","800.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","710.01","53.22","","554.28","554.28","554.28","16","155.16","1032.6","percent of total billed charges",""
"BONE SCREW 95MM CONDYLAR VA LCP STAINLESS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10097269","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1334.11","800.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","839.16","62.9","","619.64","173.09","2370.64","150","155.16","1032.6","percent of total billed charges",""
"BONE SCREW 95MM CONDYLAR VA LCP STAINLESS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10097269","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1334.11","800.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1032.60","77.4","","303.98","303.98","5854.79","1 through 10","155.16","1032.6","percent of total billed charges",""
"Borrelia Antibody","PX-30000895","CDM","86619","CPT","0302","RC","","","","outpatient","","","79.00","47.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","61.15","77.4","","58.90","58.90","58.90","1 through 10","16.03","61.15","percent of total billed charges",""
"Borrelia Miyamotoi Dna, Real-Time Pcr, Miscellaneous","PX-30003699","CDM","87798","CPT","0300","RC","","","","both","","","188.00","112.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","131.22","69.8","","127.04","114.48","508.14","20","22.81","180.59","percent of total billed charges",""
"Borrelia Miyamotoi Dna, Real-Time Pcr, Miscellaneous","PX-30003699","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","118.03","62.78","","114.26","114.26","114.26","1 through 10","24.28","145.51","percent of total billed charges",""
"Borrelia Miyamotoi Dna, Real-Time Pcr, Miscellaneous","PX-30003699","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","82.19","43.72","","79.57","79.57","79.57","1 through 10","24.28","145.51","percent of total billed charges",""
"Borrelia Miyamotoi Dna, Real-Time Pcr, Miscellaneous","PX-30003699","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","529.40","79","24.28","145.51","percent of total billed charges",""
"Borrelia Miyamotoi Dna, Real-Time Pcr, Miscellaneous","PX-30003699","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Borrelia Miyamotoi Dna, Real-Time Pcr, Miscellaneous","PX-30003699","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","118.25","62.9","","114.66","114.66","114.66","231","24.28","145.51","percent of total billed charges",""
"Borrelia Miyamotoi Dna, Real-Time Pcr, Miscellaneous","PX-30003699","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","145.51","77.4","","141.05","141.05","564.20","57","24.28","145.51","percent of total billed charges",""
"Borrelia Miyamotoi Dna, Real-Time Pcr, Miscellaneous","PX-30003699","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Brachytx Isodose Pln Smpl W/Dosimetry Cal","PX-33000104","CDM","77316","CPT","0333","RC","","","","both","","","2213.00","1327.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2444.27","","Case rate ($2,444.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2384.66","2384.66","2384.66","1 through 10","374.81","2444.27","other","OPPS APC"
"Brachytx Isodose Pln Smpl W/Dosimetry Cal","PX-33000104","CDM","77316","CPT","0333","RC","","","","both","","","2213.00","1327.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","376.38","354.25","376.38","1 through 10","374.81","2444.27","other","OPPS APC"
"Brachytx Isodose Pln Smpl W/Dosimetry Cal","PX-33000104","CDM","77316","CPT","0333","RC","","","","both","","","2213.00","1327.80","MEDICARE [2001]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","382.50","360.01","382.50","1 through 10","374.81","2444.27","other","OPPS APC"
"Brachytx Isodose Pln Smpl W/Dosimetry Cal","PX-33000104","CDM","77316","CPT","0333","RC","","","","outpatient","","","2213.00","1327.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1712.86","77.4","","1654.63","1654.63","1654.63","1 through 10","257.37","1712.86","percent of total billed charges",""
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/McC","584","MS-DRG","","","","","","","","inpatient","","","23372.53","14023.52","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","16719.41","","Case rate ($16,719.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,466.09, add-ons for qualifying new technology services are included. If operating cost exceeds $19,384.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,994.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $15,085.28 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,021.22 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,189.25. The transfer capital threshold is the transfer adjustment factor * $1,189.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15645.03","15645.03","15645.03","1 through 10","3975","81346.81","other","Inpatient DRG"
"BREAST EXPANDER 200CC TISSUE SMOOTH CRESCENT INJECTION DOME REMOTE FILL BOTTOM LOAD BASE REINFORCED DARCON","SUP-ITM-10024859","CDM","C1889","HCPCS","0278","RC","","","","both","","","3911.06","2346.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","454.86","3324.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BREAST EXPANDER 200CC TISSUE SMOOTH CRESCENT INJECTION DOME REMOTE FILL BOTTOM LOAD BASE REINFORCED DARCON","SUP-ITM-10024859","CDM","C1889","HCPCS","0278","RC","","","","both","","","3911.06","2346.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","454.86","3324.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BREAST EXPANDER 200CC TISSUE SMOOTH CRESCENT INJECTION DOME REMOTE FILL BOTTOM LOAD BASE REINFORCED DARCON","SUP-ITM-10024859","CDM","C1889","HCPCS","0278","RC","","","","both","","","3911.06","2346.64","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2225.39","56.9","","0.63","0.63","0.63","1 through 10","454.86","3324.4","percent of total billed charges",""
"BREAST EXPANDER 200CC TISSUE SMOOTH CRESCENT INJECTION DOME REMOTE FILL BOTTOM LOAD BASE REINFORCED DARCON","SUP-ITM-10024859","CDM","C1889","HCPCS","0278","RC","","","","both","","","3911.06","2346.64","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","563.97","14.42","","317.14","317.14","317.14","1 through 10","454.86","3324.4","percent of total billed charges",""
"BREAST EXPANDER 200CC TISSUE SMOOTH CRESCENT INJECTION DOME REMOTE FILL BOTTOM LOAD BASE REINFORCED DARCON","SUP-ITM-10024859","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3911.06","2346.64","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","563.97","14.42","","317.14","317.14","317.14","1 through 10","454.86","3027.16","percent of total billed charges",""
"BREAST EXPANDER 200CC TISSUE SMOOTH CRESCENT INJECTION DOME REMOTE FILL BOTTOM LOAD BASE REINFORCED DARCON","SUP-ITM-10024859","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3911.06","2346.64","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2455.36","62.78","","1125.09","1125.09","1125.09","1 through 10","454.86","3027.16","percent of total billed charges",""
"BREAST EXPANDER 200CC TISSUE SMOOTH CRESCENT INJECTION DOME REMOTE FILL BOTTOM LOAD BASE REINFORCED DARCON","SUP-ITM-10024859","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3911.06","2346.64","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2844.12","72.72","","4732.50","1617.43","14180.40","1 through 10","454.86","3027.16","percent of total billed charges",""
"BREAST EXPANDER 200CC TISSUE SMOOTH CRESCENT INJECTION DOME REMOTE FILL BOTTOM LOAD BASE REINFORCED DARCON","SUP-ITM-10024859","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3911.06","2346.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2460.06","62.9","","3896.20","3341.38","3896.20","1 through 10","454.86","3027.16","percent of total billed charges",""
"BREAST EXPANDER 225CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166637","CDM","C1889","HCPCS","0278","RC","","","","both","","","8666.95","5200.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","1007.97","7366.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BREAST EXPANDER 225CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166637","CDM","C1889","HCPCS","0278","RC","","","","both","","","8666.95","5200.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","1007.97","7366.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BREAST EXPANDER 225CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166637","CDM","C1889","HCPCS","0278","RC","","","","both","","","8666.95","5200.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4931.49","56.9","","0.63","0.63","0.63","1 through 10","1007.97","7366.91","percent of total billed charges",""
"BREAST EXPANDER 225CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166637","CDM","C1889","HCPCS","0278","RC","","","","both","","","8666.95","5200.17","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1249.77","14.42","","317.14","317.14","317.14","1 through 10","1007.97","7366.91","percent of total billed charges",""
"BREAST EXPANDER 225CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166637","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8666.95","5200.17","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1249.77","14.42","","317.14","317.14","317.14","1 through 10","1007.97","6708.22","percent of total billed charges",""
"BREAST EXPANDER 225CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166637","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8666.95","5200.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5441.11","62.78","","1125.09","1125.09","1125.09","1 through 10","1007.97","6708.22","percent of total billed charges",""
"BREAST EXPANDER 225CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166637","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8666.95","5200.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6302.61","72.72","","4732.50","1617.43","14180.40","1 through 10","1007.97","6708.22","percent of total billed charges",""
"BREAST EXPANDER 225CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166637","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8666.95","5200.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5451.51","62.9","","3896.20","3341.38","3896.20","1 through 10","1007.97","6708.22","percent of total billed charges",""
"BREAST EXPANDER 300CC 16.5CMX10.3 4.7 TISSUE SMOOTH CRESCNT INJ DOME REMOTE FILL BTM LOAD BASE RENFRCD DARCON","SUP-ITM-10024860","CDM","C1889","HCPCS","0278","RC","","","","both","","","3911.06","2346.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","454.86","3324.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BREAST EXPANDER 300CC 16.5CMX10.3 4.7 TISSUE SMOOTH CRESCNT INJ DOME REMOTE FILL BTM LOAD BASE RENFRCD DARCON","SUP-ITM-10024860","CDM","C1889","HCPCS","0278","RC","","","","both","","","3911.06","2346.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","454.86","3324.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BREAST EXPANDER 300CC 16.5CMX10.3 4.7 TISSUE SMOOTH CRESCNT INJ DOME REMOTE FILL BTM LOAD BASE RENFRCD DARCON","SUP-ITM-10024860","CDM","C1889","HCPCS","0278","RC","","","","both","","","3911.06","2346.64","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2225.39","56.9","","0.63","0.63","0.63","1 through 10","454.86","3324.4","percent of total billed charges",""
"BREAST EXPANDER 300CC 16.5CMX10.3 4.7 TISSUE SMOOTH CRESCNT INJ DOME REMOTE FILL BTM LOAD BASE RENFRCD DARCON","SUP-ITM-10024860","CDM","C1889","HCPCS","0278","RC","","","","both","","","3911.06","2346.64","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","563.97","14.42","","317.14","317.14","317.14","1 through 10","454.86","3324.4","percent of total billed charges",""
"BREAST EXPANDER 300CC 16.5CMX10.3 4.7 TISSUE SMOOTH CRESCNT INJ DOME REMOTE FILL BTM LOAD BASE RENFRCD DARCON","SUP-ITM-10024860","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3911.06","2346.64","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","563.97","14.42","","317.14","317.14","317.14","1 through 10","454.86","3027.16","percent of total billed charges",""
"BREAST EXPANDER 300CC 16.5CMX10.3 4.7 TISSUE SMOOTH CRESCNT INJ DOME REMOTE FILL BTM LOAD BASE RENFRCD DARCON","SUP-ITM-10024860","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3911.06","2346.64","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2455.36","62.78","","1125.09","1125.09","1125.09","1 through 10","454.86","3027.16","percent of total billed charges",""
"BREAST EXPANDER 300CC 16.5CMX10.3 4.7 TISSUE SMOOTH CRESCNT INJ DOME REMOTE FILL BTM LOAD BASE RENFRCD DARCON","SUP-ITM-10024860","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3911.06","2346.64","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2844.12","72.72","","4732.50","1617.43","14180.40","1 through 10","454.86","3027.16","percent of total billed charges",""
"BREAST EXPANDER 300CC 16.5CMX10.3 4.7 TISSUE SMOOTH CRESCNT INJ DOME REMOTE FILL BTM LOAD BASE RENFRCD DARCON","SUP-ITM-10024860","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3911.06","2346.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2460.06","62.9","","3896.20","3341.38","3896.20","1 through 10","454.86","3027.16","percent of total billed charges",""
"BREAST EXPANDER 300CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166635","CDM","C1889","HCPCS","0278","RC","","","","both","","","8666.95","5200.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","1007.97","7366.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BREAST EXPANDER 300CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166635","CDM","C1889","HCPCS","0278","RC","","","","both","","","8666.95","5200.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","1007.97","7366.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BREAST EXPANDER 300CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166635","CDM","C1889","HCPCS","0278","RC","","","","both","","","8666.95","5200.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4931.49","56.9","","0.63","0.63","0.63","1 through 10","1007.97","7366.91","percent of total billed charges",""
"BREAST EXPANDER 300CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166635","CDM","C1889","HCPCS","0278","RC","","","","both","","","8666.95","5200.17","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1249.77","14.42","","317.14","317.14","317.14","1 through 10","1007.97","7366.91","percent of total billed charges",""
"BREAST EXPANDER 300CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166635","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8666.95","5200.17","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1249.77","14.42","","317.14","317.14","317.14","1 through 10","1007.97","6708.22","percent of total billed charges",""
"BREAST EXPANDER 300CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166635","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8666.95","5200.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5441.11","62.78","","1125.09","1125.09","1125.09","1 through 10","1007.97","6708.22","percent of total billed charges",""
"BREAST EXPANDER 300CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166635","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8666.95","5200.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6302.61","72.72","","4732.50","1617.43","14180.40","1 through 10","1007.97","6708.22","percent of total billed charges",""
"BREAST EXPANDER 300CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166635","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8666.95","5200.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5451.51","62.9","","3896.20","3341.38","3896.20","1 through 10","1007.97","6708.22","percent of total billed charges",""
"BREAST EXPANDER 550CC 15X10.9CM 7.4 TISSUE CONTOUR PROFILE CPX 4 8100 LOW HEIGHT SILTEX","SUP-ITM-10133042","CDM","C1889","HCPCS","0278","RC","","","","both","","","5747.25","3448.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","668.41","4885.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BREAST EXPANDER 550CC 15X10.9CM 7.4 TISSUE CONTOUR PROFILE CPX 4 8100 LOW HEIGHT SILTEX","SUP-ITM-10133042","CDM","C1889","HCPCS","0278","RC","","","","both","","","5747.25","3448.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","668.41","4885.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BREAST EXPANDER 550CC 15X10.9CM 7.4 TISSUE CONTOUR PROFILE CPX 4 8100 LOW HEIGHT SILTEX","SUP-ITM-10133042","CDM","C1889","HCPCS","0278","RC","","","","both","","","5747.25","3448.35","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3270.19","56.9","","0.63","0.63","0.63","1 through 10","668.41","4885.16","percent of total billed charges",""
"BREAST EXPANDER 550CC 15X10.9CM 7.4 TISSUE CONTOUR PROFILE CPX 4 8100 LOW HEIGHT SILTEX","SUP-ITM-10133042","CDM","C1889","HCPCS","0278","RC","","","","both","","","5747.25","3448.35","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","828.75","14.42","","317.14","317.14","317.14","1 through 10","668.41","4885.16","percent of total billed charges",""
"BREAST EXPANDER 550CC 15X10.9CM 7.4 TISSUE CONTOUR PROFILE CPX 4 8100 LOW HEIGHT SILTEX","SUP-ITM-10133042","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5747.25","3448.35","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","828.75","14.42","","317.14","317.14","317.14","1 through 10","668.41","4448.37","percent of total billed charges",""
"BREAST EXPANDER 550CC 15X10.9CM 7.4 TISSUE CONTOUR PROFILE CPX 4 8100 LOW HEIGHT SILTEX","SUP-ITM-10133042","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5747.25","3448.35","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3608.12","62.78","","1125.09","1125.09","1125.09","1 through 10","668.41","4448.37","percent of total billed charges",""
"BREAST EXPANDER 550CC 15X10.9CM 7.4 TISSUE CONTOUR PROFILE CPX 4 8100 LOW HEIGHT SILTEX","SUP-ITM-10133042","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5747.25","3448.35","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4179.40","72.72","","4732.50","1617.43","14180.40","1 through 10","668.41","4448.37","percent of total billed charges",""
"BREAST EXPANDER 550CC 15X10.9CM 7.4 TISSUE CONTOUR PROFILE CPX 4 8100 LOW HEIGHT SILTEX","SUP-ITM-10133042","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5747.25","3448.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3615.02","62.9","","3896.20","3341.38","3896.20","1 through 10","668.41","4448.37","percent of total billed charges",""
"BREAST EXPANDER 600 CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166627","CDM","C1889","HCPCS","0278","RC","","","","both","","","8666.95","5200.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","1007.97","7366.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BREAST EXPANDER 600 CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166627","CDM","C1889","HCPCS","0278","RC","","","","both","","","8666.95","5200.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","1007.97","7366.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BREAST EXPANDER 600 CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166627","CDM","C1889","HCPCS","0278","RC","","","","both","","","8666.95","5200.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4931.49","56.9","","0.63","0.63","0.63","1 through 10","1007.97","7366.91","percent of total billed charges",""
"BREAST EXPANDER 600 CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166627","CDM","C1889","HCPCS","0278","RC","","","","both","","","8666.95","5200.17","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1249.77","14.42","","317.14","317.14","317.14","1 through 10","1007.97","7366.91","percent of total billed charges",""
"BREAST EXPANDER 600 CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166627","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8666.95","5200.17","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1249.77","14.42","","317.14","317.14","317.14","1 through 10","1007.97","6708.22","percent of total billed charges",""
"BREAST EXPANDER 600 CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166627","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8666.95","5200.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5441.11","62.78","","1125.09","1125.09","1125.09","1 through 10","1007.97","6708.22","percent of total billed charges",""
"BREAST EXPANDER 600 CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166627","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8666.95","5200.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6302.61","72.72","","4732.50","1617.43","14180.40","1 through 10","1007.97","6708.22","percent of total billed charges",""
"BREAST EXPANDER 600 CC TISSUE ARTOURA HIGH PROJECTION","SUP-ITM-10166627","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8666.95","5200.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5451.51","62.9","","3896.20","3341.38","3896.20","1 through 10","1007.97","6708.22","percent of total billed charges",""
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","both","","","5747.25","3448.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","668.41","4885.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","both","","","5747.25","3448.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","668.41","4885.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","both","","","5747.25","3448.35","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3270.19","56.9","","0.63","0.63","0.63","1 through 10","668.41","4885.16","percent of total billed charges",""
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","both","","","5747.25","3448.35","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","828.75","14.42","","317.14","317.14","317.14","1 through 10","668.41","4885.16","percent of total billed charges",""
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5747.25","3448.35","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","828.75","14.42","","317.14","317.14","317.14","1 through 10","668.41","4448.37","percent of total billed charges",""
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5747.25","3448.35","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3608.12","62.78","","1125.09","1125.09","1125.09","1 through 10","668.41","4448.37","percent of total billed charges",""
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5747.25","3448.35","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4179.40","72.72","","4732.50","1617.43","14180.40","1 through 10","668.41","4448.37","percent of total billed charges",""
"BREAST EXPANDER 650CC 14.6X12.6X7.6CM TISSUE TEXTURED MED NO SUTURE TAB SILTEX","SUP-ITM-10133035","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5747.25","3448.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3615.02","62.9","","3896.20","3341.38","3896.20","1 through 10","668.41","4448.37","percent of total billed charges",""
"BREAST IMPLANT 250CC GEL SMOOTH ROUND MODERATE","SUP-ITM-10114481","CDM","C1789","HCPCS","0278","RC","","","","both","","","4491.50","2694.90","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2555.66","56.9","","10696.68","10696.68","10696.68","1 through 10","522.36","3817.78","percent of total billed charges",""
"BREAST IMPLANT 250CC GEL SMOOTH ROUND MODERATE","SUP-ITM-10114481","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","4491.50","2694.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3266.22","72.72","","11667.95","11667.95","11667.95","1 through 10","522.36","3476.42","percent of total billed charges",""
"BREAST IMPLANT 250CC GEL SMOOTH ROUND MODERATE","SUP-ITM-10114481","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","4491.50","2694.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2825.15","62.9","","10108.37","10108.35","10108.37","1 through 10","522.36","3476.42","percent of total billed charges",""
"BREAST IMPLANT 350 TO 400CC 13.3X3.9CM SALINE SMOOTH ROUND MODERATE NOMINAL FILL","SUP-ITM-10002179","CDM","C1789","HCPCS","0278","RC","","","","both","","","2715.63","1629.38","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1545.19","56.9","","10696.68","10696.68","10696.68","1 through 10","315.83","2308.29","percent of total billed charges",""
"BREAST IMPLANT 350 TO 400CC 13.3X3.9CM SALINE SMOOTH ROUND MODERATE NOMINAL FILL","SUP-ITM-10002179","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2715.63","1629.38","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1974.81","72.72","","11667.95","11667.95","11667.95","1 through 10","315.83","2101.9","percent of total billed charges",""
"BREAST IMPLANT 350 TO 400CC 13.3X3.9CM SALINE SMOOTH ROUND MODERATE NOMINAL FILL","SUP-ITM-10002179","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2715.63","1629.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1708.13","62.9","","10108.37","10108.35","10108.37","1 through 10","315.83","2101.9","percent of total billed charges",""
"BREAST IMPLANT 370CC SMOOTH MODERATE PLUS PROFILE XTRA MEMORYGEL","SUP-ITM-10204009","CDM","C1789","HCPCS","0278","RC","","","","both","","","6585.23","3951.14","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3747.00","56.9","","10696.68","10696.68","10696.68","1 through 10","765.86","5597.45","percent of total billed charges",""
"BREAST IMPLANT 370CC SMOOTH MODERATE PLUS PROFILE XTRA MEMORYGEL","SUP-ITM-10204009","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","6585.23","3951.14","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4788.78","72.72","","11667.95","11667.95","11667.95","1 through 10","765.86","5096.97","percent of total billed charges",""
"BREAST IMPLANT 370CC SMOOTH MODERATE PLUS PROFILE XTRA MEMORYGEL","SUP-ITM-10204009","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","6585.23","3951.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4142.11","62.9","","10108.37","10108.35","10108.37","1 through 10","765.86","5096.97","percent of total billed charges",""
"BREAST IMPLANT 415CC SMOOTH ROUND EXTRA HIGH","SUP-ITM-10257883","CDM","C1789","HCPCS","0278","RC","","","","both","","","6585.23","3951.14","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3747.00","56.9","","10696.68","10696.68","10696.68","1 through 10","765.86","5597.45","percent of total billed charges",""
"BREAST IMPLANT 415CC SMOOTH ROUND EXTRA HIGH","SUP-ITM-10257883","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","6585.23","3951.14","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4788.78","72.72","","11667.95","11667.95","11667.95","1 through 10","765.86","5096.97","percent of total billed charges",""
"BREAST IMPLANT 415CC SMOOTH ROUND EXTRA HIGH","SUP-ITM-10257883","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","6585.23","3951.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4142.11","62.9","","10108.37","10108.35","10108.37","1 through 10","765.86","5096.97","percent of total billed charges",""
"BREAST IMPLANT 505CC GEL SMOOTH ROUND MODERATE PLUS HSC PLUS","SUP-ITM-10216972","CDM","C1789","HCPCS","0278","RC","","","","both","","","6219.00","3731.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3538.61","56.9","","10696.68","10696.68","10696.68","1 through 10","723.27","5286.15","percent of total billed charges",""
"BREAST IMPLANT 505CC GEL SMOOTH ROUND MODERATE PLUS HSC PLUS","SUP-ITM-10216972","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4522.46","72.72","","11667.95","11667.95","11667.95","1 through 10","723.27","4813.51","percent of total billed charges",""
"BREAST IMPLANT 505CC GEL SMOOTH ROUND MODERATE PLUS HSC PLUS","SUP-ITM-10216972","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3911.75","62.9","","10108.37","10108.35","10108.37","1 through 10","723.27","4813.51","percent of total billed charges",""
"BREAST IMPLANT 575CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10093822","CDM","C1789","HCPCS","0278","RC","","","","both","","","5348.34","3209.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3043.21","56.9","","10696.68","10696.68","10696.68","1 through 10","622.01","4546.09","percent of total billed charges",""
"BREAST IMPLANT 575CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10093822","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","5348.34","3209.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3889.31","72.72","","11667.95","11667.95","11667.95","1 through 10","622.01","4139.62","percent of total billed charges",""
"BREAST IMPLANT 575CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10093822","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","5348.34","3209.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3364.11","62.9","","10108.37","10108.35","10108.37","1 through 10","622.01","4139.62","percent of total billed charges",""
"BREAST IMPLANT 605CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157913","CDM","C1789","HCPCS","0278","RC","","","","both","","","5223.96","3134.38","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2972.43","56.9","","10696.68","10696.68","10696.68","1 through 10","607.55","4440.37","percent of total billed charges",""
"BREAST IMPLANT 605CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157913","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3798.86","72.72","","11667.95","11667.95","11667.95","1 through 10","607.55","4043.35","percent of total billed charges",""
"BREAST IMPLANT 605CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157913","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3285.87","62.9","","10108.37","10108.35","10108.37","1 through 10","607.55","4043.35","percent of total billed charges",""
"BREAST IMPLANT 620CC MEDIUM HT HIGH PROFILE EA","SUP-ITM-10147465","CDM","C1789","HCPCS","0278","RC","","","","both","","","6353.50","3812.10","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3615.14","56.9","","10696.68","10696.68","10696.68","1 through 10","738.91","5400.48","percent of total billed charges",""
"BREAST IMPLANT 620CC MEDIUM HT HIGH PROFILE EA","SUP-ITM-10147465","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","6353.50","3812.10","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4620.27","72.72","","11667.95","11667.95","11667.95","1 through 10","738.91","4917.61","percent of total billed charges",""
"BREAST IMPLANT 620CC MEDIUM HT HIGH PROFILE EA","SUP-ITM-10147465","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","6353.50","3812.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3996.35","62.9","","10108.37","10108.35","10108.37","1 through 10","738.91","4917.61","percent of total billed charges",""
"BREAST IMPLANT 640CC HIGHLY COHESIVE SILICONE SMOOTH ROUND MODERATE NATRELLE INSPIRA","SUP-ITM-10171797","CDM","C1789","HCPCS","0278","RC","","","","both","","","5048.85","3029.31","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2872.80","56.9","","10696.68","10696.68","10696.68","1 through 10","587.18","4291.52","percent of total billed charges",""
"BREAST IMPLANT 640CC HIGHLY COHESIVE SILICONE SMOOTH ROUND MODERATE NATRELLE INSPIRA","SUP-ITM-10171797","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","5048.85","3029.31","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3671.52","72.72","","11667.95","11667.95","11667.95","1 through 10","587.18","3907.81","percent of total billed charges",""
"BREAST IMPLANT 640CC HIGHLY COHESIVE SILICONE SMOOTH ROUND MODERATE NATRELLE INSPIRA","SUP-ITM-10171797","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","5048.85","3029.31","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3175.73","62.9","","10108.37","10108.35","10108.37","1 through 10","587.18","3907.81","percent of total billed charges",""
"BREAST IMPLANT 650CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157912","CDM","C1789","HCPCS","0278","RC","","","","both","","","5223.96","3134.38","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2972.43","56.9","","10696.68","10696.68","10696.68","1 through 10","607.55","4440.37","percent of total billed charges",""
"BREAST IMPLANT 650CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157912","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3798.86","72.72","","11667.95","11667.95","11667.95","1 through 10","607.55","4043.35","percent of total billed charges",""
"BREAST IMPLANT 650CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157912","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3285.87","62.9","","10108.37","10108.35","10108.37","1 through 10","607.55","4043.35","percent of total billed charges",""
"BREAST IMPLANT 700CC SILICONE SMOOTH ROUND SPECTRUM SILICONE SHELL","SUP-ITM-10020446","CDM","C1789","HCPCS","0278","RC","","","","both","","","5348.34","3209.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3043.21","56.9","","10696.68","10696.68","10696.68","1 through 10","622.01","4546.09","percent of total billed charges",""
"BREAST IMPLANT 700CC SILICONE SMOOTH ROUND SPECTRUM SILICONE SHELL","SUP-ITM-10020446","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","5348.34","3209.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3889.31","72.72","","11667.95","11667.95","11667.95","1 through 10","622.01","4139.62","percent of total billed charges",""
"BREAST IMPLANT 700CC SILICONE SMOOTH ROUND SPECTRUM SILICONE SHELL","SUP-ITM-10020446","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","5348.34","3209.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3364.11","62.9","","10108.37","10108.35","10108.37","1 through 10","622.01","4139.62","percent of total billed charges",""
"BREAST IMPLANT 750CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL OD16.1CM P5CM","SUP-ITM-10075314","CDM","C1789","HCPCS","0278","RC","","","","both","","","5348.34","3209.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3043.21","56.9","","10696.68","10696.68","10696.68","1 through 10","622.01","4546.09","percent of total billed charges",""
"BREAST IMPLANT 750CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL OD16.1CM P5CM","SUP-ITM-10075314","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","5348.34","3209.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3889.31","72.72","","11667.95","11667.95","11667.95","1 through 10","622.01","4139.62","percent of total billed charges",""
"BREAST IMPLANT 750CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL OD16.1CM P5CM","SUP-ITM-10075314","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","5348.34","3209.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3364.11","62.9","","10108.37","10108.35","10108.37","1 through 10","622.01","4139.62","percent of total billed charges",""
"BREAST SIZER 421CC GEL SILICONE SMOOTH ROUND MIDRANGE STYLE 15 NATRELLE","SUP-ITM-10020391","CDM","C1789","HCPCS","0278","RC","","","","both","","","4698.80","2819.28","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2673.62","56.9","","10696.68","10696.68","10696.68","1 through 10","546.47","3993.98","percent of total billed charges",""
"BREAST SIZER 421CC GEL SILICONE SMOOTH ROUND MIDRANGE STYLE 15 NATRELLE","SUP-ITM-10020391","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","4698.80","2819.28","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3416.97","72.72","","11667.95","11667.95","11667.95","1 through 10","546.47","3636.87","percent of total billed charges",""
"BREAST SIZER 421CC GEL SILICONE SMOOTH ROUND MIDRANGE STYLE 15 NATRELLE","SUP-ITM-10020391","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","4698.80","2819.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2955.55","62.9","","10108.37","10108.35","10108.37","1 through 10","546.47","3636.87","percent of total billed charges",""
"Bronchitis And Asthma With Cc/McC","202","MS-DRG","","","","","","","","inpatient","","","16906.36","10143.82","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","7984.93","","Case rate ($7,828.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,259.74, add-ons for qualifying new technology services are included. If operating cost exceeds $11,177.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,344.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,843.94 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,814.88 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $539.54. The transfer capital threshold is the transfer adjustment factor * $539.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","7758.07","7758.07","7758.07","1 through 10","3975","36905.7","other","Inpatient DRG"
"Bronchitis And Asthma With Cc/McC","202","MS-DRG","","","","","","","","inpatient","","","16906.36","10143.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","7671.79","","Case rate ($7,828.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,259.74, add-ons for qualifying new technology services are included. If operating cost exceeds $11,177.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,344.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,843.94 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,814.88 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $539.54. The transfer capital threshold is the transfer adjustment factor * $539.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7739.06","7739.06","7739.06","1 through 10","3975","36905.7","other","Inpatient DRG"
"Bronchitis And Asthma With Cc/McC","202","MS-DRG","","","","","","","","inpatient","","","16906.36","10143.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","29393.64","","Fee schedule rate ($29,393.64). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","13670.72","13670.72","13670.72","1 through 10","3975","36905.7","case rate",""
"Bronchitis And Asthma With Cc/McC","202","MS-DRG","","","","","","","","inpatient","","","16906.36","10143.82","MARTIN'S POINT [160007]","HB WDH MEDICARE","7828.36","","Case rate ($7,828.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,259.74, add-ons for qualifying new technology services are included. If operating cost exceeds $11,177.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,344.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,843.94 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,814.88 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $539.54. The transfer capital threshold is the transfer adjustment factor * $539.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7600.08","7600.08","7600.08","1 through 10","3975","36905.7","other","Inpatient DRG"
"Bronchitis And Asthma With Cc/McC","202","MS-DRG","","","","","","","","inpatient","","","16906.36","10143.82","MEDICARE [2001]","HB WDH MEDICARE","7828.36","","Case rate ($7,828.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,259.74, add-ons for qualifying new technology services are included. If operating cost exceeds $11,177.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,344.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,843.94 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,814.88 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $539.54. The transfer capital threshold is the transfer adjustment factor * $539.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7758.07","0.05","7758.07","12","3975","36905.7","other","Inpatient DRG"
"Bronchitis And Asthma With Cc/McC","202","MS-DRG","","","","","","","","inpatient","","","16906.36","10143.82","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7828.36","","Case rate ($7,828.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,259.74, add-ons for qualifying new technology services are included. If operating cost exceeds $11,177.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,344.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,843.94 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,814.88 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $539.54. The transfer capital threshold is the transfer adjustment factor * $539.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7602.28","7602.28","7602.28","1 through 10","3975","36905.7","other","Inpatient DRG"
"Bronchitis And Asthma With Cc/McC","202","MS-DRG","","","","","","","","inpatient","","","16906.36","10143.82","WELLSENSE NH [1050]","HB WDH MEDICARE","7828.36","","Case rate ($7,828.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,259.74, add-ons for qualifying new technology services are included. If operating cost exceeds $11,177.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,344.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,843.94 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,814.88 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $539.54. The transfer capital threshold is the transfer adjustment factor * $539.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7990.35","7990.35","7990.35","1 through 10","3975","36905.7","other","Inpatient DRG"
"Bronchitis And Asthma Without Cc/McC","203","MS-DRG","","","","","","","","inpatient","","","8059.05","4835.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","25460.07","","Fee schedule rate ($25,460.07). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","7674.23","7674.23","7674.23","1 through 10","3975","25460.07","case rate",""
"Bronchitis And Asthma Without Cc/McC","203","MS-DRG","","","","","","","","inpatient","","","8059.05","4835.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","10025.13","","Fee schedule rate ($10,025.13). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","7159.33","7159.33","7159.33","1 through 10","3975","25460.07","case rate",""
"Bronchitis And Asthma Without Cc/McC","203","MS-DRG","","","","","","","","inpatient","","","8059.05","4835.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","5427.72","","Case rate ($5,538.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,146.23, add-ons for qualifying new technology services are included. If operating cost exceeds $9,064.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,177.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,721.42 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,701.37 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $372.21. The transfer capital threshold is the transfer adjustment factor * $372.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5701.02","5701.02","5701.02","1 through 10","3975","25460.07","other","Inpatient DRG"
"Bronchosc Dx W/W/O Fluorosco & Wash","PX-76000783","CDM","31622","CPT","0761","RC","","","","both","","","8163.00","4897.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","1801.66","","APC Price ($1,801.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1772.82","1772.82","1772.82","1 through 10","1765.62","11514.29","other","OPPS APC"
"Bronchosc Dx W/W/O Fluorosco & Wash","PX-76000783","CDM","31622","CPT","0761","RC","","","","both","","","8163.00","4897.80","MEDICARE [2001]","HB WDH MEDICARE","1801.66","","APC Price ($1,801.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1801.86","1801.86","1801.86","1 through 10","1765.62","11514.29","other","OPPS APC"
"Bronchosc Dx W/W/O Fluorosco & Wash","PX-76000783","CDM","31622","CPT","0761","RC","","","","both","","","8163.00","4897.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1801.66","","APC Price ($1,801.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1801.86","1767.82","1801.86","1 through 10","1765.62","11514.29","other","OPPS APC"
"Bronchoscopy W/Bx Sgl/Multi Sites","PX-76000786","CDM","31625","CPT","0761","RC","","","","both","","","1750.00","1050.00","MEDICARE [2001]","HB WDH MEDICARE","1801.66","","APC Price ($1,801.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3852.42","1653.72","3852.42","1 through 10","995.75","11514.29","other","OPPS APC"
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.94","587.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","113.85","832.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.94","587.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","113.85","832.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.94","587.36","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","557.02","56.9","","812.12","238.65","1587.46","163","113.85","832.1","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.94","587.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","113.85","11.63","","112.68","112.68","146.99","38","113.85","832.1","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.94","587.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","757.70","77.4","","303.98","303.98","5854.79","1 through 10","113.85","832.1","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","978.94","587.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","113.85","11.63","","112.68","112.68","146.99","38","113.85","757.7","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","978.94","587.36","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","614.58","62.78","","780.86","208.94","10480.28","15","113.85","757.7","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","978.94","587.36","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","427.99","43.72","","179.76","179.76","179.76","1 through 10","113.85","757.7","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","978.94","587.36","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","711.89","72.72","","2355.45","298.99","3965.19","155","113.85","757.7","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","978.94","587.36","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","711.89","72.72","","3643.09","3643.09","3643.09","1 through 10","113.85","757.7","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","978.94","587.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","520.99","53.22","","554.28","554.28","554.28","16","113.85","757.7","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","978.94","587.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","615.75","62.9","","619.64","173.09","2370.64","150","113.85","757.7","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","978.94","587.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","757.70","77.4","","303.98","303.98","5854.79","1 through 10","113.85","757.7","percent of total billed charges",""
"Bx Breast 1st Lesion Strtctc","PX-76001930","CDM","19081","CPT","0761","RC","","","","both","","","5975.00","3585.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","5078.75","85","","4901.10","4901.10","4901.10","1 through 10","1658.91","10818.29","percent of total billed charges",""
"Bx Breast 1st Lesion Strtctc","PX-76001930","CDM","19081","CPT","0761","RC","","","","both","","","5975.00","3585.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1683.69","1665.88","2930.69","1 through 10","1658.91","10818.29","other","OPPS APC"
"Bx Breast 1st Lesion Strtctc","PX-76001930","CDM","19081","CPT","0761","RC","","","","outpatient","","","5975.00","3585.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","4284.79","4284.79","4284.79","1 through 10","694.89","4624.65","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Bx Breast 1st Lesion US Imag","PX-76001932","CDM","19083","CPT","0761","RC","","","","both","","","5637.00","3382.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","3934.63","69.8","","2415.43","1175.08","2415.43","1 through 10","1658.91","10818.29","percent of total billed charges",""
"Bx Breast 1st Lesion US Imag","PX-76001932","CDM","19083","CPT","0761","RC","","","","both","","","5637.00","3382.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","4791.45","85","","7071.02","7071.02","7071.02","1 through 10","1658.91","10818.29","percent of total billed charges",""
"Bx Breast 1st Lesion US Imag","PX-76001932","CDM","19083","CPT","0761","RC","","","","both","","","5637.00","3382.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1667.01","1554.42","2938.59","13","1658.91","10818.29","other","OPPS APC"
"Bx Breast Add Lesion Strtctc","PX-76001931","CDM","19082","CPT","0761","RC","","","","outpatient","","","1509.00","905.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","949.16","62.9","","2751.84","2751.84","2751.84","1 through 10","175.5","1167.97","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","both","","","111.00","66.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","77.48","69.8","","67.30","67.30","67.30","1 through 10","13.53","106.86","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","both","","","111.00","66.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","77.48","69.8","","74.69","74.69","74.69","1 through 10","13.53","106.86","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","outpatient","","","111.00","66.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","48.53","43.72","","46.78","46.78","46.78","1 through 10","19.38","85.91","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","outpatient","","","111.00","66.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","80.72","72.72","","77.81","77.81","77.81","1 through 10","19.38","85.91","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","outpatient","","","111.00","66.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","80.72","72.72","","77.81","77.81","77.81","1 through 10","19.38","85.91","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","outpatient","","","111.00","66.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","59.07","53.22","","57.04","57.04","57.04","1 through 10","19.38","85.91","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","outpatient","","","111.00","66.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","69.82","62.9","","67.41","67.41","67.41","1 through 10","19.38","85.91","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","outpatient","","","111.00","66.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","85.91","77.4","","82.93","82.93","82.93","1 through 10","19.38","85.91","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0300","RC","","","","inpatient","","","73.00","43.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","56.11","76.86","","42.88","42.88","44.73","1 through 10","48.33","56.11","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","73.00","43.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","50.95","69.8","","49.56","44.66","49.56","178","3.37","62.05","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","73.00","43.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","62.05","85","","60.35","7.25","60.35","1 through 10","3.37","62.05","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","outpatient","","","73.00","43.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","45.83","62.78","","44.57","44.57","44.57","1 through 10","4.82","56.5","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","outpatient","","","73.00","43.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","31.92","43.72","","31.04","31.04","62.08","19","4.82","56.5","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","outpatient","","","73.00","43.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","53.09","72.72","","51.63","51.63","51.63","311","4.82","56.5","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","outpatient","","","73.00","43.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","53.09","72.72","","51.63","51.63","51.63","1 through 10","4.82","56.5","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","outpatient","","","73.00","43.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","38.85","53.22","","37.85","37.85","37.85","26","4.82","56.5","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","outpatient","","","73.00","43.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","45.92","62.9","","44.73","44.73","85.76","348","4.82","56.5","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","outpatient","","","73.00","43.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","56.50","77.4","","55.03","55.03","55.03","106","4.82","56.5","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","outpatient","","","73.00","43.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","53.09","72.72","","154.89","51.63","154.89","1 through 10","4.82","56.5","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","both","","","183.00","109.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","127.73","69.8","","118.66","14.76","123.55","31","8.42","155.55","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","outpatient","","","183.00","109.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","114.89","62.78","","111.12","111.12","111.12","1 through 10","12.06","141.64","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","outpatient","","","183.00","109.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","80.01","43.72","","77.38","77.38","77.38","1 through 10","12.06","141.64","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","outpatient","","","183.00","109.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","133.08","72.72","","128.71","128.71","128.71","37","12.06","141.64","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","outpatient","","","183.00","109.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","133.08","72.72","","128.71","128.71","128.71","1 through 10","12.06","141.64","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","outpatient","","","183.00","109.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","97.39","53.22","","94.36","94.36","94.36","1 through 10","12.06","141.64","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","outpatient","","","183.00","109.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","115.11","62.9","","111.51","111.51","334.53","26","12.06","141.64","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","outpatient","","","183.00","109.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","141.64","77.4","","137.18","137.18","137.18","21","12.06","141.64","percent of total billed charges",""
"CABLE BONE 1X750MM TI NEEDLE CRIMP","SUP-ITM-10041844","CDM","C1713","HCPCS","0278","RC","","","","both","","","2766.35","1659.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","321.73","2351.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CABLE BONE 1X750MM TI NEEDLE CRIMP","SUP-ITM-10041844","CDM","C1713","HCPCS","0278","RC","","","","both","","","2766.35","1659.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","321.73","2351.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CABLE BONE 1X750MM TI NEEDLE CRIMP","SUP-ITM-10041844","CDM","C1713","HCPCS","0278","RC","","","","both","","","2766.35","1659.81","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1574.05","56.9","","812.12","238.65","1587.46","163","321.73","2351.4","percent of total billed charges",""
"CABLE BONE 1X750MM TI NEEDLE CRIMP","SUP-ITM-10041844","CDM","C1713","HCPCS","0278","RC","","","","both","","","2766.35","1659.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.73","11.63","","112.68","112.68","146.99","38","321.73","2351.4","percent of total billed charges",""
"CABLE BONE 1X750MM TI NEEDLE CRIMP","SUP-ITM-10041844","CDM","C1713","HCPCS","0278","RC","","","","both","","","2766.35","1659.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2141.15","77.4","","303.98","303.98","5854.79","1 through 10","321.73","2351.4","percent of total billed charges",""
"CABLE BONE 1X750MM TI NEEDLE CRIMP","SUP-ITM-10041844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2766.35","1659.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.73","11.63","","112.68","112.68","146.99","38","321.73","2141.15","percent of total billed charges",""
"CABLE BONE 1X750MM TI NEEDLE CRIMP","SUP-ITM-10041844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2766.35","1659.81","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1736.71","62.78","","780.86","208.94","10480.28","15","321.73","2141.15","percent of total billed charges",""
"CABLE BONE 1X750MM TI NEEDLE CRIMP","SUP-ITM-10041844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2766.35","1659.81","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1209.45","43.72","","179.76","179.76","179.76","1 through 10","321.73","2141.15","percent of total billed charges",""
"CABLE BONE 1X750MM TI NEEDLE CRIMP","SUP-ITM-10041844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2766.35","1659.81","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2011.69","72.72","","2355.45","298.99","3965.19","155","321.73","2141.15","percent of total billed charges",""
"CABLE BONE 1X750MM TI NEEDLE CRIMP","SUP-ITM-10041844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2766.35","1659.81","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2011.69","72.72","","3643.09","3643.09","3643.09","1 through 10","321.73","2141.15","percent of total billed charges",""
"CABLE BONE 1X750MM TI NEEDLE CRIMP","SUP-ITM-10041844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2766.35","1659.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1472.25","53.22","","554.28","554.28","554.28","16","321.73","2141.15","percent of total billed charges",""
"CABLE BONE 1X750MM TI NEEDLE CRIMP","SUP-ITM-10041844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2766.35","1659.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1740.03","62.9","","619.64","173.09","2370.64","150","321.73","2141.15","percent of total billed charges",""
"CABLE BONE 1X750MM TI NEEDLE CRIMP","SUP-ITM-10041844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2766.35","1659.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2141.15","77.4","","303.98","303.98","5854.79","1 through 10","321.73","2141.15","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","2467.22","1480.33","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","286.94","2097.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","2467.22","1480.33","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","286.94","2097.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","2467.22","1480.33","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1403.85","56.9","","812.12","238.65","1587.46","163","286.94","2097.14","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","2467.22","1480.33","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","286.94","11.63","","112.68","112.68","146.99","38","286.94","2097.14","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","2467.22","1480.33","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1909.63","77.4","","303.98","303.98","5854.79","1 through 10","286.94","2097.14","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2467.22","1480.33","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","286.94","11.63","","112.68","112.68","146.99","38","286.94","1909.63","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2467.22","1480.33","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1548.92","62.78","","780.86","208.94","10480.28","15","286.94","1909.63","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2467.22","1480.33","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1078.67","43.72","","179.76","179.76","179.76","1 through 10","286.94","1909.63","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2467.22","1480.33","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1794.16","72.72","","2355.45","298.99","3965.19","155","286.94","1909.63","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2467.22","1480.33","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1794.16","72.72","","3643.09","3643.09","3643.09","1 through 10","286.94","1909.63","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2467.22","1480.33","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1313.05","53.22","","554.28","554.28","554.28","16","286.94","1909.63","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2467.22","1480.33","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1551.88","62.9","","619.64","173.09","2370.64","150","286.94","1909.63","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2467.22","1480.33","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1909.63","77.4","","303.98","303.98","5854.79","1 through 10","286.94","1909.63","percent of total billed charges",""
"Cadmium","PX-30000333","CDM","82300","CPT","0301","RC","","","","outpatient","","","124.00","74.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","78.00","62.9","","75.60","75.60","75.60","1 through 10","27.73","95.98","percent of total billed charges",""
"Cadmium","PX-30000333","CDM","82300","CPT","0301","RC","","","","outpatient","","","124.00","74.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","95.98","77.4","","93.00","93.00","93.00","1 through 10","27.73","95.98","percent of total billed charges",""
"Calcitonin","PX-30000335","CDM","82308","CPT","0301","RC","","","","both","","","145.00","87.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","101.21","69.8","","97.72","97.72","97.72","1 through 10","17.41","138.46","percent of total billed charges",""
"Calcitonin","PX-30000335","CDM","82308","CPT","0301","RC","","","","outpatient","","","145.00","87.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","105.44","72.72","","101.81","101.81","101.81","1 through 10","24.96","112.23","percent of total billed charges",""
"Calcitonin","PX-30000335","CDM","82308","CPT","0301","RC","","","","outpatient","","","145.00","87.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","77.17","53.22","","74.63","74.63","74.63","1 through 10","24.96","112.23","percent of total billed charges",""
"Calcitonin","PX-30000335","CDM","82308","CPT","0301","RC","","","","outpatient","","","145.00","87.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","112.23","77.4","","108.50","108.50","108.50","1 through 10","24.96","112.23","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0300","RC","","","","inpatient","","","194.00","116.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","149.11","76.86","","118.44","118.44","118.44","1 through 10","128.43","149.11","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","both","","","194.00","116.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","135.41","69.8","","131.22","33.98","131.22","1 through 10","8.89","164.9","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","outpatient","","","194.00","116.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","121.79","62.78","","118.03","118.03","118.03","1 through 10","12.73","150.16","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","outpatient","","","194.00","116.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","84.82","43.72","","82.19","82.19","82.19","1 through 10","12.73","150.16","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","outpatient","","","194.00","116.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","141.08","72.72","","136.71","136.71","136.72","1 through 10","12.73","150.16","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","outpatient","","","194.00","116.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","103.25","53.22","","100.22","100.22","100.22","1 through 10","12.73","150.16","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","outpatient","","","194.00","116.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","122.03","62.9","","118.44","118.44","118.44","1 through 10","12.73","150.16","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","outpatient","","","194.00","116.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","150.16","77.4","","145.70","136.71","145.70","11","12.73","150.16","percent of total billed charges",""
"Calcium Qn Timed Urine","PX-30000339","CDM","82340","CPT","0301","RC","","","","both","","","85.00","51.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","59.33","69.8","","57.24","57.24","57.24","1 through 10","3.92","72.25","percent of total billed charges",""
"Calcium Qn Timed Urine","PX-30000339","CDM","82340","CPT","0301","RC","","","","outpatient","","","85.00","51.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","61.81","72.72","","59.63","59.63","59.63","1 through 10","5.62","65.79","percent of total billed charges",""
"Calcium Qn Timed Urine","PX-30000339","CDM","82340","CPT","0301","RC","","","","outpatient","","","85.00","51.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","53.47","62.9","","51.66","51.66","51.66","1 through 10","5.62","65.79","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","both","","","73.00","43.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","50.95","69.8","","49.56","5.88","49.56","28","3.35","62.05","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","outpatient","","","73.00","43.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","45.83","62.78","","44.57","44.57","44.57","1 through 10","4.8","56.5","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","outpatient","","","73.00","43.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","31.92","43.72","","31.04","31.04","31.04","1 through 10","4.8","56.5","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","outpatient","","","73.00","43.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","53.09","72.72","","51.63","51.63","51.63","42","4.8","56.5","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","outpatient","","","73.00","43.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","53.09","72.72","","51.63","51.63","51.63","1 through 10","4.8","56.5","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","outpatient","","","73.00","43.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","38.85","53.22","","37.85","37.85","37.85","1 through 10","4.8","56.5","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","outpatient","","","73.00","43.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","45.92","62.9","","44.73","44.73","44.73","73","4.8","56.5","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","outpatient","","","73.00","43.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","56.50","77.4","","55.03","51.63","55.03","33","4.8","56.5","percent of total billed charges",""
"Calculus Analysis Infrared","PX-30000342","CDM","82365","CPT","0301","RC","","","","both","","","148.00","88.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","103.30","69.8","","99.81","89.95","99.81","1 through 10","8.39","125.8","percent of total billed charges",""
"Calculus Analysis Infrared","PX-30000342","CDM","82365","CPT","0301","RC","","","","outpatient","","","148.00","88.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","92.91","62.78","","89.78","89.78","89.78","1 through 10","12.01","114.55","percent of total billed charges",""
"Calculus Analysis Infrared","PX-30000342","CDM","82365","CPT","0301","RC","","","","outpatient","","","148.00","88.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","64.71","43.72","","62.52","62.52","62.52","1 through 10","12.01","114.55","percent of total billed charges",""
"Calculus Analysis Infrared","PX-30000342","CDM","82365","CPT","0301","RC","","","","outpatient","","","148.00","88.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","107.63","72.72","","103.99","103.99","103.99","1 through 10","12.01","114.55","percent of total billed charges",""
"Calculus Analysis Infrared","PX-30000342","CDM","82365","CPT","0301","RC","","","","outpatient","","","148.00","88.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","93.09","62.9","","90.09","90.09","180.18","1 through 10","12.01","114.55","percent of total billed charges",""
"Calculus Analysis Infrared","PX-30000342","CDM","82365","CPT","0301","RC","","","","outpatient","","","148.00","88.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","114.55","77.4","","110.83","110.83","110.83","1 through 10","12.01","114.55","percent of total billed charges",""
"Calculus Analysis Ql","PX-30000340","CDM","82355","CPT","0301","RC","","","","both","","","64.00","38.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","44.67","69.8","","43.28","43.28","43.28","1 through 10","7.53","60.21","percent of total billed charges",""
"Calculus Analysis Ql","PX-30000340","CDM","82355","CPT","0301","RC","","","","outpatient","","","64.00","38.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","46.54","72.72","","45.09","45.09","45.09","1 through 10","13.87","49.54","percent of total billed charges",""
"Calculus Analysis Ql","PX-30000340","CDM","82355","CPT","0301","RC","","","","outpatient","","","64.00","38.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","46.54","72.72","","45.09","45.09","45.09","1 through 10","13.87","49.54","percent of total billed charges",""
"Calculus Analysis Ql","PX-30000340","CDM","82355","CPT","0301","RC","","","","outpatient","","","64.00","38.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","34.06","53.22","","66.10","66.10","66.10","1 through 10","13.87","49.54","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","both","","","202.00","121.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","141.00","69.8","","136.11","122.66","136.11","23","12.76","171.7","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","both","","","202.00","121.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","171.70","85","","165.75","165.75","165.75","1 through 10","12.76","171.7","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","outpatient","","","202.00","121.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","146.89","72.72","","141.80","141.80","141.80","14","23.79","156.35","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","outpatient","","","202.00","121.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","146.89","72.72","","141.80","141.80","141.80","1 through 10","23.79","156.35","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","outpatient","","","202.00","121.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","107.50","53.22","","103.95","103.95","103.95","1 through 10","23.79","156.35","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","outpatient","","","202.00","121.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","127.06","62.9","","122.85","122.85","122.85","45","23.79","156.35","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","outpatient","","","202.00","121.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","156.35","77.4","","151.13","151.13","151.13","16","23.79","156.35","percent of total billed charges",""
"Calr Gene Analysis Common Variants in Exon 9","PX-31000694","CDM","81219","CPT","0310","RC","","","","both","","","657.00","394.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","458.59","69.8","","443.23","443.23","443.23","1 through 10","79.06","627.57","percent of total billed charges",""
"Calr Gene Analysis Common Variants in Exon 9","PX-31000694","CDM","81219","CPT","0310","RC","","","","outpatient","","","657.00","394.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","477.77","72.72","","461.77","461.77","461.77","1 through 10","72.2","508.52","percent of total billed charges",""
"Calr Gene Analysis Common Variants in Exon 9","PX-31000694","CDM","81219","CPT","0310","RC","","","","outpatient","","","657.00","394.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","349.66","53.22","","338.52","338.52","338.52","1 through 10","72.2","508.52","percent of total billed charges",""
"Calr Gene Analysis Common Variants in Exon 9","PX-31000694","CDM","81219","CPT","0310","RC","","","","outpatient","","","657.00","394.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","413.25","62.9","","400.05","384.04","400.05","1 through 10","72.2","508.52","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","both","","","29.15","17.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","3.39","24.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","both","","","29.15","17.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","3.39","24.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","both","","","29.15","17.49","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","16.59","56.9","","812.12","238.65","1587.46","163","3.39","24.78","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","both","","","29.15","17.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","3.39","11.63","","112.68","112.68","146.99","38","3.39","24.78","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","both","","","29.15","17.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","22.56","77.4","","303.98","303.98","5854.79","1 through 10","3.39","24.78","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","29.15","17.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","3.39","11.63","","112.68","112.68","146.99","38","3.39","22.56","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","29.15","17.49","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","18.30","62.78","","780.86","208.94","10480.28","15","3.39","22.56","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","29.15","17.49","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","12.74","43.72","","179.76","179.76","179.76","1 through 10","3.39","22.56","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","29.15","17.49","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","21.20","72.72","","2355.45","298.99","3965.19","155","3.39","22.56","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","29.15","17.49","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","21.20","72.72","","3643.09","3643.09","3643.09","1 through 10","3.39","22.56","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","29.15","17.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","15.51","53.22","","554.28","554.28","554.28","16","3.39","22.56","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","29.15","17.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","18.34","62.9","","619.64","173.09","2370.64","150","3.39","22.56","percent of total billed charges",""
"CAP BONE 2.5MM SM END NAIL PROTECTIVE EXTERNAL FIXATION FOR KIRSCHNER WIRE BX/10EA","SUP-ITM-10004567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","29.15","17.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","22.56","77.4","","303.98","303.98","5854.79","1 through 10","3.39","22.56","percent of total billed charges",""
"CAP ELBOW SM ULNAR LATITUDE","SUP-ITM-10046604","CDM","C1776","HCPCS","0278","RC","","","","both","","","4908.20","2944.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","570.82","4171.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CAP ELBOW SM ULNAR LATITUDE","SUP-ITM-10046604","CDM","C1776","HCPCS","0278","RC","","","","both","","","4908.20","2944.92","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2792.77","56.9","","2911.53","1863.86","5209.05","65","570.82","4171.97","percent of total billed charges",""
"CAP ELBOW SM ULNAR LATITUDE","SUP-ITM-10046604","CDM","C1776","HCPCS","0278","RC","","","","both","","","4908.20","2944.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","570.82","11.63","","400.94","400.94","400.94","1 through 10","570.82","4171.97","percent of total billed charges",""
"CAP ELBOW SM ULNAR LATITUDE","SUP-ITM-10046604","CDM","C1776","HCPCS","0278","RC","","","","both","","","4908.20","2944.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3798.95","77.4","","5214.50","5214.50","16415.28","1 through 10","570.82","4171.97","percent of total billed charges",""
"CAP ELBOW SM ULNAR LATITUDE","SUP-ITM-10046604","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4908.20","2944.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","570.82","11.63","","400.94","400.94","400.94","1 through 10","570.82","3798.95","percent of total billed charges",""
"CAP ELBOW SM ULNAR LATITUDE","SUP-ITM-10046604","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4908.20","2944.92","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2145.87","43.72","","1543.33","1543.33","1671.61","1 through 10","570.82","3798.95","percent of total billed charges",""
"CAP ELBOW SM ULNAR LATITUDE","SUP-ITM-10046604","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4908.20","2944.92","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3569.24","72.72","","3700.21","2382.07","6427.18","53","570.82","3798.95","percent of total billed charges",""
"CAP ELBOW SM ULNAR LATITUDE","SUP-ITM-10046604","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4908.20","2944.92","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3569.24","72.72","","12685.80","12685.80","12685.80","1 through 10","570.82","3798.95","percent of total billed charges",""
"CAP ELBOW SM ULNAR LATITUDE","SUP-ITM-10046604","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4908.20","2944.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3087.26","62.9","","3408.87","2784.05","9859.40","46","570.82","3798.95","percent of total billed charges",""
"CAP ELBOW SM ULNAR LATITUDE","SUP-ITM-10046604","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4908.20","2944.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3798.95","77.4","","5214.50","5214.50","16415.28","1 through 10","570.82","3798.95","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","both","","","1344.82","806.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","156.4","1143.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","both","","","1344.82","806.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","156.4","1143.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","both","","","1344.82","806.89","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","765.20","56.9","","812.12","238.65","1587.46","163","156.4","1143.1","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","both","","","1344.82","806.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","156.40","11.63","","112.68","112.68","146.99","38","156.4","1143.1","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","both","","","1344.82","806.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1040.89","77.4","","303.98","303.98","5854.79","1 through 10","156.4","1143.1","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","156.40","11.63","","112.68","112.68","146.99","38","156.4","1040.89","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","844.28","62.78","","780.86","208.94","10480.28","15","156.4","1040.89","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","587.96","43.72","","179.76","179.76","179.76","1 through 10","156.4","1040.89","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","977.95","72.72","","2355.45","298.99","3965.19","155","156.4","1040.89","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","977.95","72.72","","3643.09","3643.09","3643.09","1 through 10","156.4","1040.89","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","715.71","53.22","","554.28","554.28","554.28","16","156.4","1040.89","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","845.89","62.9","","619.64","173.09","2370.64","150","156.4","1040.89","percent of total billed charges",""
"CAP END 0MM HINDFOOT NAIL EX TI ARTHODESIS SPIRAL BLADE T25 STARDRIVE RECESS","SUP-ITM-10036885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1040.89","77.4","","303.98","303.98","5854.79","1 through 10","156.4","1040.89","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","both","","","1122.39","673.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","130.53","954.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","both","","","1122.39","673.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","130.53","954.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","both","","","1122.39","673.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","638.64","56.9","","812.12","238.65","1587.46","163","130.53","954.03","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","both","","","1122.39","673.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","130.53","11.63","","112.68","112.68","146.99","38","130.53","954.03","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","both","","","1122.39","673.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","868.73","77.4","","303.98","303.98","5854.79","1 through 10","130.53","954.03","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","130.53","11.63","","112.68","112.68","146.99","38","130.53","868.73","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","704.64","62.78","","780.86","208.94","10480.28","15","130.53","868.73","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","490.71","43.72","","179.76","179.76","179.76","1 through 10","130.53","868.73","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","816.20","72.72","","2355.45","298.99","3965.19","155","130.53","868.73","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","816.20","72.72","","3643.09","3643.09","3643.09","1 through 10","130.53","868.73","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","597.34","53.22","","554.28","554.28","554.28","16","130.53","868.73","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","705.98","62.9","","619.64","173.09","2370.64","150","130.53","868.73","percent of total billed charges",""
"CAP END 5MM TIBIAL NAIL T40 STARDRIVE TITANIUM EXTENSION RECESS","SUP-ITM-10018690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","868.73","77.4","","303.98","303.98","5854.79","1 through 10","130.53","868.73","percent of total billed charges",""
"CAP LOCKING HUMERAL NAILUALIS FLEX REVIVE","SUP-ITM-10269601","CDM","C1776","HCPCS","0278","RC","","","","both","","","2494.51","1496.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","290.11","2120.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CAP LOCKING HUMERAL NAILUALIS FLEX REVIVE","SUP-ITM-10269601","CDM","C1776","HCPCS","0278","RC","","","","both","","","2494.51","1496.71","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1419.38","56.9","","2911.53","1863.86","5209.05","65","290.11","2120.33","percent of total billed charges",""
"CAP LOCKING HUMERAL NAILUALIS FLEX REVIVE","SUP-ITM-10269601","CDM","C1776","HCPCS","0278","RC","","","","both","","","2494.51","1496.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","290.11","11.63","","400.94","400.94","400.94","1 through 10","290.11","2120.33","percent of total billed charges",""
"CAP LOCKING HUMERAL NAILUALIS FLEX REVIVE","SUP-ITM-10269601","CDM","C1776","HCPCS","0278","RC","","","","both","","","2494.51","1496.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1930.75","77.4","","5214.50","5214.50","16415.28","1 through 10","290.11","2120.33","percent of total billed charges",""
"CAP LOCKING HUMERAL NAILUALIS FLEX REVIVE","SUP-ITM-10269601","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2494.51","1496.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","290.11","11.63","","400.94","400.94","400.94","1 through 10","290.11","1930.75","percent of total billed charges",""
"CAP LOCKING HUMERAL NAILUALIS FLEX REVIVE","SUP-ITM-10269601","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2494.51","1496.71","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1090.60","43.72","","1543.33","1543.33","1671.61","1 through 10","290.11","1930.75","percent of total billed charges",""
"CAP LOCKING HUMERAL NAILUALIS FLEX REVIVE","SUP-ITM-10269601","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2494.51","1496.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1814.01","72.72","","3700.21","2382.07","6427.18","53","290.11","1930.75","percent of total billed charges",""
"CAP LOCKING HUMERAL NAILUALIS FLEX REVIVE","SUP-ITM-10269601","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2494.51","1496.71","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1814.01","72.72","","12685.80","12685.80","12685.80","1 through 10","290.11","1930.75","percent of total billed charges",""
"CAP LOCKING HUMERAL NAILUALIS FLEX REVIVE","SUP-ITM-10269601","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2494.51","1496.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1569.05","62.9","","3408.87","2784.05","9859.40","46","290.11","1930.75","percent of total billed charges",""
"CAP LOCKING HUMERAL NAILUALIS FLEX REVIVE","SUP-ITM-10269601","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2494.51","1496.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1930.75","77.4","","5214.50","5214.50","16415.28","1 through 10","290.11","1930.75","percent of total billed charges",""
"Carbamazepine (Tegretol) Total","PX-30000180","CDM","80156","CPT","0301","RC","","","","both","","","207.00","124.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","144.49","69.8","","139.60","139.60","139.60","1 through 10","9.47","175.95","percent of total billed charges",""
"Carbamazepine (Tegretol) Total","PX-30000180","CDM","80156","CPT","0301","RC","","","","outpatient","","","207.00","124.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","129.95","62.78","","125.56","125.56","125.56","1 through 10","13.57","160.22","percent of total billed charges",""
"Carbamazepine (Tegretol) Total","PX-30000180","CDM","80156","CPT","0301","RC","","","","outpatient","","","207.00","124.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","150.53","72.72","","145.44","145.44","145.44","1 through 10","13.57","160.22","percent of total billed charges",""
"Carbamazepine (Tegretol) Total","PX-30000180","CDM","80156","CPT","0301","RC","","","","outpatient","","","207.00","124.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","130.20","62.9","","126.00","126.00","126.00","1 through 10","13.57","160.22","percent of total billed charges",""
"Carbon Monoxide (Co-Ox) Qn","PX-30000346","CDM","82375","CPT","0301","RC","","","","both","","","142.00","85.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","99.12","69.8","","95.63","95.63","95.63","1 through 10","8.01","120.7","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","both","","","770.00","462.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","537.46","69.8","","518.61","518.61","518.61","1 through 10","438.13","654.5","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","both","","","770.00","462.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","743.00","743.00","743.00","1 through 10","438.13","654.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","both","","","770.00","462.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","438.13","56.9","","422.77","422.77","422.77","50","438.13","654.5","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","outpatient","","","770.00","462.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","111.03","14.42","","107.14","91.83","107.14","23","89.55","595.98","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","outpatient","","","770.00","462.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","89.55","11.63","","90.94","87.76","102.31","33","89.55","595.98","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","outpatient","","","770.00","462.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","336.64","43.72","","324.84","324.84","324.84","1 through 10","89.55","595.98","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","outpatient","","","770.00","462.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","559.94","72.72","","540.31","540.31","1453.67","27","89.55","595.98","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","outpatient","","","770.00","462.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","559.94","72.72","","540.31","540.31","540.31","1 through 10","89.55","595.98","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","outpatient","","","770.00","462.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","484.33","62.9","","468.09","468.09","468.09","48","89.55","595.98","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","outpatient","","","770.00","462.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","595.98","77.4","","575.83","540.31","575.83","15","89.55","595.98","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","outpatient","","","770.00","462.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","89.55","11.63","","87.76","87.76","87.76","21","89.55","595.98","percent of total billed charges",""
"Carcinoembryonic Antigen (Cea)","PX-30000348","CDM","82378","CPT","0301","RC","","","","both","","","270.00","162.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","188.46","69.8","","182.18","164.17","182.18","26","12.32","229.5","percent of total billed charges",""
"Carcinoembryonic Antigen (Cea)","PX-30000348","CDM","82378","CPT","0301","RC","","","","both","","","270.00","162.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","229.50","85","","221.85","221.85","221.85","1 through 10","12.32","229.5","percent of total billed charges",""
"Carcinoembryonic Antigen (Cea)","PX-30000348","CDM","82378","CPT","0301","RC","","","","outpatient","","","270.00","162.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","196.34","72.72","","189.80","189.80","189.80","29","17.68","208.98","percent of total billed charges",""
"Carcinoembryonic Antigen (Cea)","PX-30000348","CDM","82378","CPT","0301","RC","","","","outpatient","","","270.00","162.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","196.34","72.72","","189.80","189.80","189.80","1 through 10","17.68","208.98","percent of total billed charges",""
"Carcinoembryonic Antigen (Cea)","PX-30000348","CDM","82378","CPT","0301","RC","","","","outpatient","","","270.00","162.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","169.83","62.9","","164.43","164.43","630.60","20","17.68","208.98","percent of total billed charges",""
"Carcinoembryonic Antigen (Cea)","PX-30000348","CDM","82378","CPT","0301","RC","","","","outpatient","","","270.00","162.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","208.98","77.4","","202.28","202.27","202.28","18","17.68","208.98","percent of total billed charges",""
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","26630.93","15978.56","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","6158.73","","Case rate ($6,037.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,607.25, add-ons for qualifying new technology services are included. If operating cost exceeds $9,525.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,213.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,184.40 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,162.38 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $408.71. The transfer capital threshold is the transfer adjustment factor * $408.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","6037.75","6037.75","6037.75","1 through 10","3975","27956.67","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","26630.93","15978.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","11008.19","","Fee schedule rate ($11,008.19). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","10792.24","10792.24","10792.24","1 through 10","3975","27956.67","case rate",""
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","26630.93","15978.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","5917.21","","Case rate ($6,037.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,607.25, add-ons for qualifying new technology services are included. If operating cost exceeds $9,525.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,213.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,184.40 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,162.38 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $408.71. The transfer capital threshold is the transfer adjustment factor * $408.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6023.21","6023.21","6023.21","1 through 10","3975","27956.67","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","26630.93","15978.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","22266.17","","Fee schedule rate ($22,266.17). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","21829.38","21829.38","21829.38","1 through 10","3975","27956.67","case rate",""
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","26630.93","15978.56","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","6219.11","","Case rate ($6,037.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,607.25, add-ons for qualifying new technology services are included. If operating cost exceeds $9,525.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,213.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,184.40 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,162.38 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $408.71. The transfer capital threshold is the transfer adjustment factor * $408.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","5614.21","5027.69","11247.80","1 through 10","3975","27956.67","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","26630.93","15978.56","MARTIN'S POINT [160007]","HB WDH MEDICARE","6037.97","","Case rate ($6,037.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,607.25, add-ons for qualifying new technology services are included. If operating cost exceeds $9,525.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,213.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,184.40 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,162.38 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $408.71. The transfer capital threshold is the transfer adjustment factor * $408.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5937.68","5937.68","5937.68","1 through 10","3975","27956.67","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","26630.93","15978.56","MEDICARE [2001]","HB WDH MEDICARE","6037.97","","Case rate ($6,037.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,607.25, add-ons for qualifying new technology services are included. If operating cost exceeds $9,525.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,213.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,184.40 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,162.38 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $408.71. The transfer capital threshold is the transfer adjustment factor * $408.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6023.21","0.05","6037.75","61","3975","27956.67","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","26630.93","15978.56","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6037.97","","Case rate ($6,037.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,607.25, add-ons for qualifying new technology services are included. If operating cost exceeds $9,525.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,213.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,184.40 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,162.38 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $408.71. The transfer capital threshold is the transfer adjustment factor * $408.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5937.49","5926.45","6037.75","13","3975","27956.67","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","26630.93","15978.56","WELLSENSE NH [1050]","HB WDH MEDICARE","6037.97","","Case rate ($6,037.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,607.25, add-ons for qualifying new technology services are included. If operating cost exceeds $9,525.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,213.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,184.40 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,162.38 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $408.71. The transfer capital threshold is the transfer adjustment factor * $408.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6227.65","6227.65","6235.05","1 through 10","3975","27956.67","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","33630.86","20178.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","18015.31","","Fee schedule rate ($18,015.31). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","17603.64","17603.64","17603.64","1 through 10","3975","45752.12","case rate",""
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","33630.86","20178.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","9406.24","","Case rate ($9,598.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,893.30, add-ons for qualifying new technology services are included. If operating cost exceeds $12,811.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,473.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,484.46 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,448.42 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.87. The transfer capital threshold is the transfer adjustment factor * $668.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9359.58","9359.58","9359.58","1 through 10","3975","45752.12","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","33630.86","20178.52","MARTIN'S POINT [160007]","HB WDH MEDICARE","9598.20","","Case rate ($9,598.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,893.30, add-ons for qualifying new technology services are included. If operating cost exceeds $12,811.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,473.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,484.46 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,448.42 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.87. The transfer capital threshold is the transfer adjustment factor * $668.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9403.33","9403.33","10081.49","1 through 10","3975","45752.12","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","33630.86","20178.52","MEDICARE [2001]","HB WDH MEDICARE","9598.20","","Case rate ($9,598.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,893.30, add-ons for qualifying new technology services are included. If operating cost exceeds $12,811.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,473.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,484.46 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,448.42 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.87. The transfer capital threshold is the transfer adjustment factor * $668.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9543.96","0.05","9567.67","27","3975","45752.12","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","33630.86","20178.52","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","9598.20","","Case rate ($9,598.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,893.30, add-ons for qualifying new technology services are included. If operating cost exceeds $12,811.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,473.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,484.46 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,448.42 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.87. The transfer capital threshold is the transfer adjustment factor * $668.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9390.69","1047.22","9567.67","14","3975","45752.12","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","33630.86","20178.52","WELLSENSE NH [1050]","HB WDH MEDICARE","9598.20","","Case rate ($9,598.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,893.30, add-ons for qualifying new technology services are included. If operating cost exceeds $12,811.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,473.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,484.46 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,448.42 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $668.87. The transfer capital threshold is the transfer adjustment factor * $668.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9852.53","9852.53","9852.53","1 through 10","3975","45752.12","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders Without Cc/McC","310","MS-DRG","","","","","","","","inpatient","","","18648.34","11189.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","17133.18","","Fee schedule rate ($17,133.18). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","12224.03","12224.03","12224.03","1 through 10","3975","21511.86","case rate",""
"Cardiac Arrhythmia And Conduction Disorders Without Cc/McC","310","MS-DRG","","","","","","","","inpatient","","","18648.34","11189.00","MEDICARE [2001]","HB WDH MEDICARE","4748.60","","Case rate ($4,748.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $4,417.17, add-ons for qualifying new technology services are included. If operating cost exceeds $8,335.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,119.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,989.25 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $3,972.30 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.49. The transfer capital threshold is the transfer adjustment factor * $314.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","4677.52","4666.52","4677.52","1 through 10","3975","21511.86","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders Without Cc/McC","310","MS-DRG","","","","","","","","inpatient","","","18648.34","11189.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","4748.60","","Case rate ($4,748.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $4,417.17, add-ons for qualifying new technology services are included. If operating cost exceeds $8,335.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,119.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,989.25 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $3,972.30 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.49. The transfer capital threshold is the transfer adjustment factor * $314.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","4621.57","4621.57","4621.57","1 through 10","3975","21511.86","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders Without Cc/McC","310","MS-DRG","","","","","","","","inpatient","","","18648.34","11189.00","WELLSENSE NH [1050]","HB WDH MEDICARE","4748.60","","Case rate ($4,748.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $4,417.17, add-ons for qualifying new technology services are included. If operating cost exceeds $8,335.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,119.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,989.25 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $3,972.30 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.49. The transfer capital threshold is the transfer adjustment factor * $314.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","4835.37","4835.37","4835.37","1 through 10","3975","21511.86","other","Inpatient DRG"
"Cardiac Congenital And Valvular Disorders With McC","306","MS-DRG","","","","","","","","inpatient","","","20057.96","12034.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","12176.29","","Case rate ($12,424.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,502.20, add-ons for qualifying new technology services are included. If operating cost exceeds $15,420.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,680.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,104.49 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,057.33 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $875.43. The transfer capital threshold is the transfer adjustment factor * $875.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6147.50","6147.50","6147.50","1 through 10","3975","59880.56","other","Inpatient DRG"
"Cardiac Congenital And Valvular Disorders With McC","306","MS-DRG","","","","","","","","inpatient","","","20057.96","12034.78","MEDICARE [2001]","HB WDH MEDICARE","12424.79","","Case rate ($12,424.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,502.20, add-ons for qualifying new technology services are included. If operating cost exceeds $15,420.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,680.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,104.49 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,057.33 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $875.43. The transfer capital threshold is the transfer adjustment factor * $875.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11743.51","11743.51","11743.51","1 through 10","3975","59880.56","other","Inpatient DRG"
"Cardiac Congenital And Valvular Disorders Without McC","307","MS-DRG","","","","","","","","inpatient","","","40750.68","24450.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","27638.25","","Fee schedule rate ($27,638.25). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","3821.22","3821.22","3821.22","1 through 10","3975","34701.69","case rate",""
"Cardiac Congenital And Valvular Disorders Without McC","307","MS-DRG","","","","","","","","inpatient","","","40750.68","24450.41","MEDICARE [2001]","HB WDH MEDICARE","7387.41","","Case rate ($7,387.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,852.76, add-ons for qualifying new technology services are included. If operating cost exceeds $10,770.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,312.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $6,435.22 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,407.89 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $507.32. The transfer capital threshold is the transfer adjustment factor * $507.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7434.99","7434.99","7434.99","1 through 10","3975","34701.69","other","Inpatient DRG"
"Cardiac Defibrillator Implant With Cardiac Catheterization And McC","275","MS-DRG","","","","","","","","inpatient","","","313389.40","188033.64","MEDICARE [2001]","HB WDH MEDICARE","54653.27","","Case rate ($54,653.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $50,478.63, add-ons for qualifying new technology services are included. If operating cost exceeds $54,396.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $51,766.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $50,247.16 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $50,033.76 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,961.25. The transfer capital threshold is the transfer adjustment factor * $3,961.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","53911.90","53911.90","53911.90","1 through 10","4637","270955.91","other","Inpatient DRG"
"Cardiac Defibrillator Implant Without McC","277","MS-DRG","","","","","","","","inpatient","","","228924.53","137354.72","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","175503.46","","Fee schedule rate ($175,503.46). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","179448.31","179448.31","179448.31","1 through 10","3975","175503.46","case rate",""
"Cardiac Defibrillator Implant Without McC","277","MS-DRG","","","","","","","","inpatient","","","228924.53","137354.72","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","36623.42","","Case rate ($35,556.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $32,852.72, add-ons for qualifying new technology services are included. If operating cost exceeds $36,770.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,370.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,546.07 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $32,407.85 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,565.78. The transfer capital threshold is the transfer adjustment factor * $2,565.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","13206.48","13206.48","13206.48","1 through 10","3975","175503.46","other","Inpatient DRG"
"Cardiac Defibrillator Implant Without McC","277","MS-DRG","","","","","","","","inpatient","","","228924.53","137354.72","MEDICARE [2001]","HB WDH MEDICARE","35556.72","","Case rate ($35,556.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $32,852.72, add-ons for qualifying new technology services are included. If operating cost exceeds $36,770.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,370.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $32,546.07 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $32,407.85 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,565.78. The transfer capital threshold is the transfer adjustment factor * $2,565.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","35637.44","35637.44","35637.44","1 through 10","3975","175503.46","other","Inpatient DRG"
"Cardiac Pacemaker Device Replacement With McC","258","MS-DRG","","","","","","","","inpatient","","","80489.67","48293.80","MEDICARE [2001]","HB WDH MEDICARE","24332.48","","Case rate ($24,332.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $22,492.87, add-ons for qualifying new technology services are included. If operating cost exceeds $26,411.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,550.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $22,142.04 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $22,048.00 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,745.57. The transfer capital threshold is the transfer adjustment factor * $1,745.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","0.05","0.05","0.05","1 through 10","3975","119400.11","other","Inpatient DRG"
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","","","","inpatient","","","110371.48","66222.89","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","14817.28","","Case rate ($14,817.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,710.44, add-ons for qualifying new technology services are included. If operating cost exceeds $17,628.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,855.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $13,322.15 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,265.57 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,050.26. The transfer capital threshold is the transfer adjustment factor * $1,050.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","14512.42","14512.42","14512.42","1 through 10","3975","71839.19","other","Inpatient DRG"
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","","","","inpatient","","","110371.48","66222.89","WELLSENSE NH [1050]","HB WDH MEDICARE","14817.28","","Case rate ($14,817.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,710.44, add-ons for qualifying new technology services are included. If operating cost exceeds $17,628.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,855.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $13,322.15 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,265.57 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,050.26. The transfer capital threshold is the transfer adjustment factor * $1,050.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","14519.32","14519.32","14519.32","1 through 10","3975","71839.19","other","Inpatient DRG"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","472.00","283.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","329.46","69.8","","317.59","286.20","317.59","70","68.06","840.68","percent of total billed charges",""
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","472.00","283.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","134.18","","APC Price ($131.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","131.56","128.75","131.56","73","68.06","840.68","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","472.00","283.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","840.68","","Case rate ($840.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","455.00","455.00","455.00","179","68.06","840.68","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","472.00","283.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","361.99","","Case rate ($361.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","353.17","353.17","360.37","104","68.06","840.68","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","472.00","283.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","128.91","","APC Price ($131.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","129.45","128.75","131.56","257","68.06","840.68","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","472.00","283.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","679.51","","Case rate ($679.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","455.00","353.17","455.00","102","68.06","840.68","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","472.00","283.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","268.57","56.9","","258.90","258.90","258.90","240","68.06","840.68","percent of total billed charges",""
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","472.00","283.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","68.06","14.42","","65.61","56.24","65.61","50","68.06","840.68","percent of total billed charges",""
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","472.00","283.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","135.49","","APC Price ($131.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","132.80","129.96","133.40","34","68.06","840.68","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","472.00","283.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","131.55","","APC Price ($131.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","128.93","128.93","131.56","324","68.06","840.68","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","472.00","283.20","MEDICARE [2001]","HB WDH MEDICARE","131.55","","APC Price ($131.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","131.56","131.56","131.56","1265","68.06","840.68","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","472.00","283.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","251.20","53.22","","242.56","242.56","242.56","29","68.06","840.68","percent of total billed charges",""
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","472.00","283.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","296.89","62.9","","286.65","286.65","286.65","70","68.06","840.68","percent of total billed charges",""
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","472.00","283.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","131.55","","APC Price ($131.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","128.93","126.18","131.56","528","68.06","840.68","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","472.00","283.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","365.33","77.4","","3173.67","1763.15","3878.93","57","68.06","840.68","percent of total billed charges",""
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","472.00","283.20","WELLPOINT [1015]","HB WDH ANTHEM PPO","679.51","","Case rate ($679.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","455.00","455.00","455.00","20","68.06","840.68","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","472.00","283.20","WELLSENSE NH [1050]","HB WDH MEDICARE","131.55","","APC Price ($131.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","136.18","136.18","136.18","27","68.06","840.68","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","outpatient","","","472.00","283.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","54.89","11.63","","62.65","53.74","114.91","45","54.89","343.24","percent of total billed charges",""
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","outpatient","","","472.00","283.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","343.24","72.72","","330.88","330.88","2316.16","48","54.89","343.24","percent of total billed charges",""
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","outpatient","","","472.00","283.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","343.24","72.72","","3970.56","1323.52","3970.56","21","54.89","343.24","percent of total billed charges",""
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","outpatient","","","472.00","283.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","54.89","11.63","","53.74","53.74","161.22","1 through 10","54.89","343.24","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","both","","","361.00","216.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","251.98","69.8","","243.60","219.52","243.60","12","16.54","306.85","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","outpatient","","","361.00","216.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","157.83","43.72","","152.59","152.59","152.59","1 through 10","12.81","279.41","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","outpatient","","","361.00","216.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","262.52","72.72","","253.80","253.80","507.59","20","12.81","279.41","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","outpatient","","","361.00","216.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","262.52","72.72","","253.80","253.80","253.80","1 through 10","12.81","279.41","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","outpatient","","","361.00","216.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","227.07","62.9","","219.87","219.87","219.87","39","12.81","279.41","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","outpatient","","","361.00","216.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","279.41","77.4","","270.48","270.48","540.95","1 through 10","12.81","279.41","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","outpatient","","","361.00","216.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","262.52","72.72","","253.80","253.80","253.80","1 through 10","12.81","279.41","percent of total billed charges",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","4993.00","2995.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","3485.11","69.8","","3362.96","3362.96","3362.96","1 through 10","670","4369.32","percent of total billed charges",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","4993.00","2995.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","697.34","","APC Price ($683.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","683.75","683.75","683.75","1 through 10","670","4369.32","other","OPPS APC"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","4993.00","2995.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","4369.32","","Case rate ($4,369.32). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4262.76","4262.76","4262.76","1 through 10","670","4369.32","other","OPPS APC"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","4993.00","2995.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1881.42","","Case rate ($1,881.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1835.56","1835.56","1835.56","1 through 10","670","4369.32","other","OPPS APC"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","4993.00","2995.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","670.00","","APC Price ($683.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","672.81","670.07","683.75","12","670","4369.32","other","OPPS APC"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","4993.00","2995.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","3531.68","","Case rate ($3,531.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3445.52","3445.52","3445.52","1 through 10","670","4369.32","other","OPPS APC"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","4993.00","2995.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2841.02","56.9","","2741.44","2741.44","9174.97","13","670","4369.32","percent of total billed charges",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","4993.00","2995.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","704.18","","APC Price ($683.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","692.17","690.74","693.82","1 through 10","670","4369.32","other","OPPS APC"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","4993.00","2995.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","683.67","","APC Price ($683.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","672.13","634.13","677.57","33","670","4369.32","other","OPPS APC"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","4993.00","2995.80","MEDICARE [2001]","HB WDH MEDICARE","683.67","","APC Price ($683.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","683.75","683.75","683.75","70","670","4369.32","other","OPPS APC"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","4993.00","2995.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","683.67","","APC Price ($683.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","677.98","634.13","683.75","21","670","4369.32","other","OPPS APC"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","4993.00","2995.80","WELLSENSE NH [1050]","HB WDH MEDICARE","683.67","","APC Price ($683.67). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","703.58","703.58","703.58","1 through 10","670","4369.32","other","OPPS APC"
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","outpatient","","","4993.00","2995.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","719.99","14.42","","694.76","694.76","694.76","1 through 10","580.69","3864.58","percent of total billed charges",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","outpatient","","","4993.00","2995.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","580.69","11.63","","569.08","569.08","569.08","1 through 10","580.69","3864.58","percent of total billed charges",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","outpatient","","","4993.00","2995.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2182.94","43.72","","2106.43","2106.43","2106.43","1 through 10","580.69","3864.58","percent of total billed charges",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","outpatient","","","4993.00","2995.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3630.91","72.72","","3503.65","3503.65","3503.65","1 through 10","580.69","3864.58","percent of total billed charges",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","outpatient","","","4993.00","2995.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3140.60","62.9","","3035.34","2568.48","3035.34","1 through 10","580.69","3864.58","percent of total billed charges",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","outpatient","","","4993.00","2995.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3864.58","77.4","","3733.95","3733.95","3733.95","1 through 10","580.69","3864.58","percent of total billed charges",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","outpatient","","","4993.00","2995.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","580.69","11.63","","2155.18","569.08","2155.18","1 through 10","580.69","3864.58","percent of total billed charges",""
"Carotene","PX-30000350","CDM","82380","CPT","0301","RC","","","","outpatient","","","105.00","63.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","76.36","72.72","","148.34","74.17","148.34","1 through 10","8.6","81.27","percent of total billed charges",""
"CARPAL PLATE SM UNIVERSAL2 TITANIUM POROUS VOLAR OFFSET RADIAL COMPONENT DESIGN CENTRAL PEG","SUP-ITM-10021431","CDM","C1776","HCPCS","0278","RC","","","","both","","","13230.72","7938.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1538.73","11246.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CARPAL PLATE SM UNIVERSAL2 TITANIUM POROUS VOLAR OFFSET RADIAL COMPONENT DESIGN CENTRAL PEG","SUP-ITM-10021431","CDM","C1776","HCPCS","0278","RC","","","","both","","","13230.72","7938.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7528.28","56.9","","2911.53","1863.86","5209.05","65","1538.73","11246.11","percent of total billed charges",""
"CARPAL PLATE SM UNIVERSAL2 TITANIUM POROUS VOLAR OFFSET RADIAL COMPONENT DESIGN CENTRAL PEG","SUP-ITM-10021431","CDM","C1776","HCPCS","0278","RC","","","","both","","","13230.72","7938.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1538.73","11.63","","400.94","400.94","400.94","1 through 10","1538.73","11246.11","percent of total billed charges",""
"CARPAL PLATE SM UNIVERSAL2 TITANIUM POROUS VOLAR OFFSET RADIAL COMPONENT DESIGN CENTRAL PEG","SUP-ITM-10021431","CDM","C1776","HCPCS","0278","RC","","","","both","","","13230.72","7938.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10240.58","77.4","","5214.50","5214.50","16415.28","1 through 10","1538.73","11246.11","percent of total billed charges",""
"CARPAL PLATE SM UNIVERSAL2 TITANIUM POROUS VOLAR OFFSET RADIAL COMPONENT DESIGN CENTRAL PEG","SUP-ITM-10021431","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13230.72","7938.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1538.73","11.63","","400.94","400.94","400.94","1 through 10","1538.73","10240.58","percent of total billed charges",""
"CARPAL PLATE SM UNIVERSAL2 TITANIUM POROUS VOLAR OFFSET RADIAL COMPONENT DESIGN CENTRAL PEG","SUP-ITM-10021431","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13230.72","7938.43","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","5784.47","43.72","","1543.33","1543.33","1671.61","1 through 10","1538.73","10240.58","percent of total billed charges",""
"CARPAL PLATE SM UNIVERSAL2 TITANIUM POROUS VOLAR OFFSET RADIAL COMPONENT DESIGN CENTRAL PEG","SUP-ITM-10021431","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13230.72","7938.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","9621.38","72.72","","3700.21","2382.07","6427.18","53","1538.73","10240.58","percent of total billed charges",""
"CARPAL PLATE SM UNIVERSAL2 TITANIUM POROUS VOLAR OFFSET RADIAL COMPONENT DESIGN CENTRAL PEG","SUP-ITM-10021431","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13230.72","7938.43","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","9621.38","72.72","","12685.80","12685.80","12685.80","1 through 10","1538.73","10240.58","percent of total billed charges",""
"CARPAL PLATE SM UNIVERSAL2 TITANIUM POROUS VOLAR OFFSET RADIAL COMPONENT DESIGN CENTRAL PEG","SUP-ITM-10021431","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13230.72","7938.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8322.12","62.9","","3408.87","2784.05","9859.40","46","1538.73","10240.58","percent of total billed charges",""
"CARPAL PLATE SM UNIVERSAL2 TITANIUM POROUS VOLAR OFFSET RADIAL COMPONENT DESIGN CENTRAL PEG","SUP-ITM-10021431","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13230.72","7938.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10240.58","77.4","","5214.50","5214.50","16415.28","1 through 10","1538.73","10240.58","percent of total billed charges",""
"CARTRIDGE KNEE TENSIONER CORI","SUP-ITM-10320475","CDM","C1776","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","401.82","2936.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CARTRIDGE KNEE TENSIONER CORI","SUP-ITM-10320475","CDM","C1776","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1965.90","56.9","","2911.53","1863.86","5209.05","65","401.82","2936.75","percent of total billed charges",""
"CARTRIDGE KNEE TENSIONER CORI","SUP-ITM-10320475","CDM","C1776","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","401.82","11.63","","400.94","400.94","400.94","1 through 10","401.82","2936.75","percent of total billed charges",""
"CARTRIDGE KNEE TENSIONER CORI","SUP-ITM-10320475","CDM","C1776","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2674.17","77.4","","5214.50","5214.50","16415.28","1 through 10","401.82","2936.75","percent of total billed charges",""
"CARTRIDGE KNEE TENSIONER CORI","SUP-ITM-10320475","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","401.82","11.63","","400.94","400.94","400.94","1 through 10","401.82","2674.17","percent of total billed charges",""
"CARTRIDGE KNEE TENSIONER CORI","SUP-ITM-10320475","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1510.53","43.72","","1543.33","1543.33","1671.61","1 through 10","401.82","2674.17","percent of total billed charges",""
"CARTRIDGE KNEE TENSIONER CORI","SUP-ITM-10320475","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2512.48","72.72","","3700.21","2382.07","6427.18","53","401.82","2674.17","percent of total billed charges",""
"CARTRIDGE KNEE TENSIONER CORI","SUP-ITM-10320475","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2512.48","72.72","","12685.80","12685.80","12685.80","1 through 10","401.82","2674.17","percent of total billed charges",""
"CARTRIDGE KNEE TENSIONER CORI","SUP-ITM-10320475","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2173.20","62.9","","3408.87","2784.05","9859.40","46","401.82","2674.17","percent of total billed charges",""
"CARTRIDGE KNEE TENSIONER CORI","SUP-ITM-10320475","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2674.17","77.4","","5214.50","5214.50","16415.28","1 through 10","401.82","2674.17","percent of total billed charges",""
"Catecholamines Fraction","PX-30000353","CDM","82384","CPT","0301","RC","","","","both","","","136.00","81.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","94.93","69.8","","92.14","92.14","92.14","1 through 10","16.41","130.94","percent of total billed charges",""
"Catecholamines Fraction","PX-30000353","CDM","82384","CPT","0301","RC","","","","outpatient","","","136.00","81.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","98.90","72.72","","95.99","95.99","95.99","1 through 10","30.27","105.26","percent of total billed charges",""
"Catecholamines Fraction","PX-30000353","CDM","82384","CPT","0301","RC","","","","outpatient","","","136.00","81.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","85.54","62.9","","83.16","83.16","83.16","1 through 10","30.27","105.26","percent of total billed charges",""
"Catecholamines Fraction","PX-30000353","CDM","82384","CPT","0301","RC","","","","outpatient","","","136.00","81.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","105.26","77.4","","102.30","102.30","102.30","1 through 10","30.27","105.26","percent of total billed charges",""
"Cath Left Heart W/ Ventriculograpy","PX-48000117","CDM","93452","CPT","0481","RC","","","","both","","","12769.00","7661.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","3293.17","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3360.76","3360.76","3360.76","1 through 10","3293.17","21475.95","other","OPPS APC"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","13960.00","8376.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","9744.08","69.8","","9402.76","9402.76","9402.76","1 through 10","3293.17","21475.95","percent of total billed charges",""
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","13960.00","8376.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","21475.95","","Case rate ($21,475.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","14682.32","14682.32","14682.32","1 through 10","3293.17","21475.95","other","OPPS APC"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","13960.00","8376.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","9247.52","","Case rate ($9,247.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9022.08","9022.08","9022.08","1 through 10","3293.17","21475.95","other","OPPS APC"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","13960.00","8376.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","3293.17","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3360.76","3293.54","3360.76","1 through 10","3293.17","21475.95","other","OPPS APC"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","13960.00","8376.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7943.24","56.9","","7665.00","7665.00","7665.00","1 through 10","3293.17","21475.95","percent of total billed charges",""
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","13960.00","8376.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3360.76","3293.54","3360.76","1 through 10","3293.17","21475.95","other","OPPS APC"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","13960.00","8376.00","MEDICARE [2001]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3360.76","3360.76","6721.52","13","3293.17","21475.95","other","OPPS APC"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","both","","","13960.00","8376.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3360.76","3301.45","3360.76","1 through 10","3293.17","21475.95","other","OPPS APC"
"Cath Right Heart","PX-48000116","CDM","93451","CPT","0481","RC","","","","outpatient","","","13960.00","8376.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10151.71","72.72","","9796.11","9796.11","9796.11","1 through 10","1623.55","10805.04","percent of total billed charges",""
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","both","","","948.00","568.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","661.70","69.8","","638.67","638.67","638.67","1 through 10","539.41","805.8","percent of total billed charges",""
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","both","","","948.00","568.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","915.00","915.00","915.00","1 through 10","539.41","805.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","both","","","948.00","568.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","539.41","56.9","","520.64","520.64","520.64","1 through 10","539.41","805.8","percent of total billed charges",""
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","outpatient","","","948.00","568.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","665.39","665.39","671.23","1 through 10","110.25","733.75","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","outpatient","","","948.00","568.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","596.29","62.9","","576.45","576.45","576.45","1 through 10","110.25","733.75","percent of total billed charges",""
"Cath/Intro Saline/Contrast for Sis","PX-76001387","CDM","58340","CPT","0761","RC","","","","outpatient","","","948.00","568.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","733.75","77.4","","709.13","709.13","709.13","1 through 10","110.25","733.75","percent of total billed charges",""
"CATHETER ACCU VU 5FR 100CM .035IN ANGIOGRAPHY PIGTAIL FLUSH BAND BX/5EA","SUP-ITM-10011048","CDM","C1887","HCPCS","0272","RC","","","","both","","","914.88","548.93","AETNA [1001]","HB WDH AETNA COMMERCIAL","638.59","69.8","","211.78","89.23","211.78","1 through 10","106.4","777.65","percent of total billed charges",""
"CATHETER ACCU VU 5FR 100CM .035IN ANGIOGRAPHY PIGTAIL FLUSH BAND BX/5EA","SUP-ITM-10011048","CDM","C1887","HCPCS","0272","RC","","","","both","","","914.88","548.93","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","520.57","56.9","","383.50","68.20","383.50","1 through 10","106.4","777.65","percent of total billed charges",""
"CATHETER ACCU VU 5FR 100CM .035IN ANGIOGRAPHY PIGTAIL FLUSH BAND BX/5EA","SUP-ITM-10011048","CDM","C1887","HCPCS","0272","RC","","","","both","","","914.88","548.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","106.40","11.63","","8.44","7.37","15.65","12","106.4","777.65","percent of total billed charges",""
"CATHETER ACCU VU 5FR 100CM .035IN ANGIOGRAPHY PIGTAIL FLUSH BAND BX/5EA","SUP-ITM-10011048","CDM","C1887","HCPCS","0272","RC","","","","both","","","914.88","548.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","708.12","77.4","","41.50","41.50","214.21","1 through 10","106.4","777.65","percent of total billed charges",""
"CATHETER ACCU VU 5FR 100CM .035IN ANGIOGRAPHY PIGTAIL FLUSH BAND BX/5EA","SUP-ITM-10011048","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","914.88","548.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","106.40","11.63","","8.44","7.37","15.65","12","106.4","708.12","percent of total billed charges",""
"CATHETER ACCU VU 5FR 100CM .035IN ANGIOGRAPHY PIGTAIL FLUSH BAND BX/5EA","SUP-ITM-10011048","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","914.88","548.93","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","665.30","72.72","","92.96","38.94","158.55","24","106.4","708.12","percent of total billed charges",""
"CATHETER ACCU VU 5FR 100CM .035IN ANGIOGRAPHY PIGTAIL FLUSH BAND BX/5EA","SUP-ITM-10011048","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","914.88","548.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","575.46","62.9","","208.96","33.74","457.91","69","106.4","708.12","percent of total billed charges",""
"CATHETER ACCU VU 5FR 100CM .035IN ANGIOGRAPHY PIGTAIL FLUSH BAND BX/5EA","SUP-ITM-10011048","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","914.88","548.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","708.12","77.4","","41.50","41.50","214.21","1 through 10","106.4","708.12","percent of total billed charges",""
"CATHETER ACCU VU 5FR 70CM 0.35IN ANGIOGRAPHY SIDEPORT PIGTAIL FLUSH SIZING 21 BANDS BX/5EA","SUP-ITM-10015625","CDM","C1887","HCPCS","0272","RC","","","","both","","","914.88","548.93","AETNA [1001]","HB WDH AETNA COMMERCIAL","638.59","69.8","","211.78","89.23","211.78","1 through 10","106.4","777.65","percent of total billed charges",""
"CATHETER ACCU VU 5FR 70CM 0.35IN ANGIOGRAPHY SIDEPORT PIGTAIL FLUSH SIZING 21 BANDS BX/5EA","SUP-ITM-10015625","CDM","C1887","HCPCS","0272","RC","","","","both","","","914.88","548.93","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","520.57","56.9","","383.50","68.20","383.50","1 through 10","106.4","777.65","percent of total billed charges",""
"CATHETER ACCU VU 5FR 70CM 0.35IN ANGIOGRAPHY SIDEPORT PIGTAIL FLUSH SIZING 21 BANDS BX/5EA","SUP-ITM-10015625","CDM","C1887","HCPCS","0272","RC","","","","both","","","914.88","548.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","106.40","11.63","","8.44","7.37","15.65","12","106.4","777.65","percent of total billed charges",""
"CATHETER ACCU VU 5FR 70CM 0.35IN ANGIOGRAPHY SIDEPORT PIGTAIL FLUSH SIZING 21 BANDS BX/5EA","SUP-ITM-10015625","CDM","C1887","HCPCS","0272","RC","","","","both","","","914.88","548.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","708.12","77.4","","41.50","41.50","214.21","1 through 10","106.4","777.65","percent of total billed charges",""
"CATHETER ACCU VU 5FR 70CM 0.35IN ANGIOGRAPHY SIDEPORT PIGTAIL FLUSH SIZING 21 BANDS BX/5EA","SUP-ITM-10015625","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","914.88","548.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","106.40","11.63","","8.44","7.37","15.65","12","106.4","708.12","percent of total billed charges",""
"CATHETER ACCU VU 5FR 70CM 0.35IN ANGIOGRAPHY SIDEPORT PIGTAIL FLUSH SIZING 21 BANDS BX/5EA","SUP-ITM-10015625","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","914.88","548.93","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","665.30","72.72","","92.96","38.94","158.55","24","106.4","708.12","percent of total billed charges",""
"CATHETER ACCU VU 5FR 70CM 0.35IN ANGIOGRAPHY SIDEPORT PIGTAIL FLUSH SIZING 21 BANDS BX/5EA","SUP-ITM-10015625","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","914.88","548.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","575.46","62.9","","208.96","33.74","457.91","69","106.4","708.12","percent of total billed charges",""
"CATHETER ACCU VU 5FR 70CM 0.35IN ANGIOGRAPHY SIDEPORT PIGTAIL FLUSH SIZING 21 BANDS BX/5EA","SUP-ITM-10015625","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","914.88","548.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","708.12","77.4","","41.50","41.50","214.21","1 through 10","106.4","708.12","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FR 100CM IMAGER II PEBAX BERENSTEIN TORQUEABLE BX/5EA","SUP-ITM-10083826","CDM","C1887","HCPCS","0272","RC","","","","both","","","178.65","107.19","AETNA [1001]","HB WDH AETNA COMMERCIAL","124.70","69.8","","211.78","89.23","211.78","1 through 10","20.78","151.85","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FR 100CM IMAGER II PEBAX BERENSTEIN TORQUEABLE BX/5EA","SUP-ITM-10083826","CDM","C1887","HCPCS","0272","RC","","","","both","","","178.65","107.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","101.65","56.9","","383.50","68.20","383.50","1 through 10","20.78","151.85","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FR 100CM IMAGER II PEBAX BERENSTEIN TORQUEABLE BX/5EA","SUP-ITM-10083826","CDM","C1887","HCPCS","0272","RC","","","","both","","","178.65","107.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.78","11.63","","8.44","7.37","15.65","12","20.78","151.85","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FR 100CM IMAGER II PEBAX BERENSTEIN TORQUEABLE BX/5EA","SUP-ITM-10083826","CDM","C1887","HCPCS","0272","RC","","","","both","","","178.65","107.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","138.28","77.4","","41.50","41.50","214.21","1 through 10","20.78","151.85","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FR 100CM IMAGER II PEBAX BERENSTEIN TORQUEABLE BX/5EA","SUP-ITM-10083826","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","178.65","107.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.78","11.63","","8.44","7.37","15.65","12","20.78","138.28","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FR 100CM IMAGER II PEBAX BERENSTEIN TORQUEABLE BX/5EA","SUP-ITM-10083826","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","178.65","107.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","129.91","72.72","","92.96","38.94","158.55","24","20.78","138.28","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FR 100CM IMAGER II PEBAX BERENSTEIN TORQUEABLE BX/5EA","SUP-ITM-10083826","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","178.65","107.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","112.37","62.9","","208.96","33.74","457.91","69","20.78","138.28","percent of total billed charges",""
"CATHETER ANGIOGRAPHY 5FR 100CM IMAGER II PEBAX BERENSTEIN TORQUEABLE BX/5EA","SUP-ITM-10083826","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","178.65","107.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","138.28","77.4","","41.50","41.50","214.21","1 through 10","20.78","138.28","percent of total billed charges",""
"CATHETER ANGIOPLASTY 5FRX4.0 120MM 140CM .018IN VASCUTRAK PTA PERIPHERAL","SUP-ITM-10046806","CDM","C1725","HCPCS","0272","RC","","","","both","","","4318.75","2591.25","AETNA [1001]","HB WDH AETNA COMMERCIAL","3014.49","69.8","","351.75","351.75","351.75","1 through 10","502.27","3670.94","percent of total billed charges",""
"CATHETER ANGIOPLASTY 5FRX4.0 120MM 140CM .018IN VASCUTRAK PTA PERIPHERAL","SUP-ITM-10046806","CDM","C1725","HCPCS","0272","RC","","","","both","","","4318.75","2591.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2457.37","56.9","","898.30","898.30","898.30","1 through 10","502.27","3670.94","percent of total billed charges",""
"CATHETER ANGIOPLASTY 5FRX4.0 120MM 140CM .018IN VASCUTRAK PTA PERIPHERAL","SUP-ITM-10046806","CDM","C1725","HCPCS","0272","RC","","","","both","","","4318.75","2591.25","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","622.76","14.42","","64.77","64.77","64.77","1 through 10","502.27","3670.94","percent of total billed charges",""
"CATHETER ANGIOPLASTY 5FRX4.0 120MM 140CM .018IN VASCUTRAK PTA PERIPHERAL","SUP-ITM-10046806","CDM","C1725","HCPCS","0272","RC","","","","both","","","4318.75","2591.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","502.27","11.63","","145.58","110.37","145.58","1 through 10","502.27","3670.94","percent of total billed charges",""
"CATHETER ANGIOPLASTY 5FRX4.0 120MM 140CM .018IN VASCUTRAK PTA PERIPHERAL","SUP-ITM-10046806","CDM","C1725","HCPCS","0272","RC","","","","both","","","4318.75","2591.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3342.71","77.4","","348.09","348.09","348.09","1 through 10","502.27","3670.94","percent of total billed charges",""
"CATHETER ANGIOPLASTY 5FRX4.0 120MM 140CM .018IN VASCUTRAK PTA PERIPHERAL","SUP-ITM-10046806","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4318.75","2591.25","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","622.76","14.42","","64.77","64.77","64.77","1 through 10","502.27","3342.71","percent of total billed charges",""
"CATHETER ANGIOPLASTY 5FRX4.0 120MM 140CM .018IN VASCUTRAK PTA PERIPHERAL","SUP-ITM-10046806","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4318.75","2591.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","502.27","11.63","","145.58","110.37","145.58","1 through 10","502.27","3342.71","percent of total billed charges",""
"CATHETER ANGIOPLASTY 5FRX4.0 120MM 140CM .018IN VASCUTRAK PTA PERIPHERAL","SUP-ITM-10046806","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4318.75","2591.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3140.60","72.72","","406.70","406.70","1055.24","1 through 10","502.27","3342.71","percent of total billed charges",""
"CATHETER ANGIOPLASTY 5FRX4.0 120MM 140CM .018IN VASCUTRAK PTA PERIPHERAL","SUP-ITM-10046806","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4318.75","2591.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2716.49","62.9","","1069.88","677.14","4190.63","20","502.27","3342.71","percent of total billed charges",""
"CATHETER ANGIOPLASTY 5FRX4.0 120MM 140CM .018IN VASCUTRAK PTA PERIPHERAL","SUP-ITM-10046806","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4318.75","2591.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3342.71","77.4","","348.09","348.09","348.09","1 through 10","502.27","3342.71","percent of total billed charges",""
"CATHETER ANGIOPLASTY 7FR 5MM 50 2CM .018IN CUTTING BALLOON DEVICE OVER THE WIRE MICROSURGICAL PERIPHERAL","SUP-ITM-10012828","CDM","C1725","HCPCS","0272","RC","","","","both","","","4861.19","2916.71","AETNA [1001]","HB WDH AETNA COMMERCIAL","3393.11","69.8","","351.75","351.75","351.75","1 through 10","565.36","4132.01","percent of total billed charges",""
"CATHETER ANGIOPLASTY 7FR 5MM 50 2CM .018IN CUTTING BALLOON DEVICE OVER THE WIRE MICROSURGICAL PERIPHERAL","SUP-ITM-10012828","CDM","C1725","HCPCS","0272","RC","","","","both","","","4861.19","2916.71","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2766.02","56.9","","898.30","898.30","898.30","1 through 10","565.36","4132.01","percent of total billed charges",""
"CATHETER ANGIOPLASTY 7FR 5MM 50 2CM .018IN CUTTING BALLOON DEVICE OVER THE WIRE MICROSURGICAL PERIPHERAL","SUP-ITM-10012828","CDM","C1725","HCPCS","0272","RC","","","","both","","","4861.19","2916.71","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","700.98","14.42","","64.77","64.77","64.77","1 through 10","565.36","4132.01","percent of total billed charges",""
"CATHETER ANGIOPLASTY 7FR 5MM 50 2CM .018IN CUTTING BALLOON DEVICE OVER THE WIRE MICROSURGICAL PERIPHERAL","SUP-ITM-10012828","CDM","C1725","HCPCS","0272","RC","","","","both","","","4861.19","2916.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","565.36","11.63","","145.58","110.37","145.58","1 through 10","565.36","4132.01","percent of total billed charges",""
"CATHETER ANGIOPLASTY 7FR 5MM 50 2CM .018IN CUTTING BALLOON DEVICE OVER THE WIRE MICROSURGICAL PERIPHERAL","SUP-ITM-10012828","CDM","C1725","HCPCS","0272","RC","","","","both","","","4861.19","2916.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3762.56","77.4","","348.09","348.09","348.09","1 through 10","565.36","4132.01","percent of total billed charges",""
"CATHETER ANGIOPLASTY 7FR 5MM 50 2CM .018IN CUTTING BALLOON DEVICE OVER THE WIRE MICROSURGICAL PERIPHERAL","SUP-ITM-10012828","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4861.19","2916.71","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","700.98","14.42","","64.77","64.77","64.77","1 through 10","565.36","3762.56","percent of total billed charges",""
"CATHETER ANGIOPLASTY 7FR 5MM 50 2CM .018IN CUTTING BALLOON DEVICE OVER THE WIRE MICROSURGICAL PERIPHERAL","SUP-ITM-10012828","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4861.19","2916.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","565.36","11.63","","145.58","110.37","145.58","1 through 10","565.36","3762.56","percent of total billed charges",""
"CATHETER ANGIOPLASTY 7FR 5MM 50 2CM .018IN CUTTING BALLOON DEVICE OVER THE WIRE MICROSURGICAL PERIPHERAL","SUP-ITM-10012828","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4861.19","2916.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3535.06","72.72","","406.70","406.70","1055.24","1 through 10","565.36","3762.56","percent of total billed charges",""
"CATHETER ANGIOPLASTY 7FR 5MM 50 2CM .018IN CUTTING BALLOON DEVICE OVER THE WIRE MICROSURGICAL PERIPHERAL","SUP-ITM-10012828","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4861.19","2916.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3057.69","62.9","","1069.88","677.14","4190.63","20","565.36","3762.56","percent of total billed charges",""
"CATHETER ANGIOPLASTY 7FR 5MM 50 2CM .018IN CUTTING BALLOON DEVICE OVER THE WIRE MICROSURGICAL PERIPHERAL","SUP-ITM-10012828","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4861.19","2916.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3762.56","77.4","","348.09","348.09","348.09","1 through 10","565.36","3762.56","percent of total billed charges",""
"CATHETER ANGIOSCULPT 4MM 40MM 137CM .018IN OTW SEMI COMPLIANT BALLOON PERIPH SCORED 8ATM NOMINAL 20ATM BURST ANGIOPLASTY","SUP-ITM-10078877","CDM","C1725","HCPCS","0272","RC","","","","both","","","4971.25","2982.75","AETNA [1001]","HB WDH AETNA COMMERCIAL","3469.93","69.8","","351.75","351.75","351.75","1 through 10","578.16","4225.56","percent of total billed charges",""
"CATHETER ANGIOSCULPT 4MM 40MM 137CM .018IN OTW SEMI COMPLIANT BALLOON PERIPH SCORED 8ATM NOMINAL 20ATM BURST ANGIOPLASTY","SUP-ITM-10078877","CDM","C1725","HCPCS","0272","RC","","","","both","","","4971.25","2982.75","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2828.64","56.9","","898.30","898.30","898.30","1 through 10","578.16","4225.56","percent of total billed charges",""
"CATHETER ANGIOSCULPT 4MM 40MM 137CM .018IN OTW SEMI COMPLIANT BALLOON PERIPH SCORED 8ATM NOMINAL 20ATM BURST ANGIOPLASTY","SUP-ITM-10078877","CDM","C1725","HCPCS","0272","RC","","","","both","","","4971.25","2982.75","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","716.85","14.42","","64.77","64.77","64.77","1 through 10","578.16","4225.56","percent of total billed charges",""
"CATHETER ANGIOSCULPT 4MM 40MM 137CM .018IN OTW SEMI COMPLIANT BALLOON PERIPH SCORED 8ATM NOMINAL 20ATM BURST ANGIOPLASTY","SUP-ITM-10078877","CDM","C1725","HCPCS","0272","RC","","","","both","","","4971.25","2982.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","578.16","11.63","","145.58","110.37","145.58","1 through 10","578.16","4225.56","percent of total billed charges",""
"CATHETER ANGIOSCULPT 4MM 40MM 137CM .018IN OTW SEMI COMPLIANT BALLOON PERIPH SCORED 8ATM NOMINAL 20ATM BURST ANGIOPLASTY","SUP-ITM-10078877","CDM","C1725","HCPCS","0272","RC","","","","both","","","4971.25","2982.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3847.75","77.4","","348.09","348.09","348.09","1 through 10","578.16","4225.56","percent of total billed charges",""
"CATHETER ANGIOSCULPT 4MM 40MM 137CM .018IN OTW SEMI COMPLIANT BALLOON PERIPH SCORED 8ATM NOMINAL 20ATM BURST ANGIOPLASTY","SUP-ITM-10078877","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4971.25","2982.75","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","716.85","14.42","","64.77","64.77","64.77","1 through 10","578.16","3847.75","percent of total billed charges",""
"CATHETER ANGIOSCULPT 4MM 40MM 137CM .018IN OTW SEMI COMPLIANT BALLOON PERIPH SCORED 8ATM NOMINAL 20ATM BURST ANGIOPLASTY","SUP-ITM-10078877","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4971.25","2982.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","578.16","11.63","","145.58","110.37","145.58","1 through 10","578.16","3847.75","percent of total billed charges",""
"CATHETER ANGIOSCULPT 4MM 40MM 137CM .018IN OTW SEMI COMPLIANT BALLOON PERIPH SCORED 8ATM NOMINAL 20ATM BURST ANGIOPLASTY","SUP-ITM-10078877","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4971.25","2982.75","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3615.09","72.72","","406.70","406.70","1055.24","1 through 10","578.16","3847.75","percent of total billed charges",""
"CATHETER ANGIOSCULPT 4MM 40MM 137CM .018IN OTW SEMI COMPLIANT BALLOON PERIPH SCORED 8ATM NOMINAL 20ATM BURST ANGIOPLASTY","SUP-ITM-10078877","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4971.25","2982.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3126.92","62.9","","1069.88","677.14","4190.63","20","578.16","3847.75","percent of total billed charges",""
"CATHETER ANGIOSCULPT 4MM 40MM 137CM .018IN OTW SEMI COMPLIANT BALLOON PERIPH SCORED 8ATM NOMINAL 20ATM BURST ANGIOPLASTY","SUP-ITM-10078877","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4971.25","2982.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3847.75","77.4","","348.09","348.09","348.09","1 through 10","578.16","3847.75","percent of total billed charges",""
"CATHETER ANGIOSCULPT 5MM 20MM 137CM .018IN OTW SEMI COMPLIANT BALLOON PERIPH SCORED 8ATM NOMINAL 20ATM BURST ANGIOPLASTY","SUP-ITM-10048924","CDM","C1725","HCPCS","0272","RC","","","","both","","","6357.20","3814.32","AETNA [1001]","HB WDH AETNA COMMERCIAL","4437.33","69.8","","351.75","351.75","351.75","1 through 10","739.34","5403.62","percent of total billed charges",""
"CATHETER ANGIOSCULPT 5MM 20MM 137CM .018IN OTW SEMI COMPLIANT BALLOON PERIPH SCORED 8ATM NOMINAL 20ATM BURST ANGIOPLASTY","SUP-ITM-10048924","CDM","C1725","HCPCS","0272","RC","","","","both","","","6357.20","3814.32","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3617.25","56.9","","898.30","898.30","898.30","1 through 10","739.34","5403.62","percent of total billed charges",""
"CATHETER ANGIOSCULPT 5MM 20MM 137CM .018IN OTW SEMI COMPLIANT BALLOON PERIPH SCORED 8ATM NOMINAL 20ATM BURST ANGIOPLASTY","SUP-ITM-10048924","CDM","C1725","HCPCS","0272","RC","","","","both","","","6357.20","3814.32","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","916.71","14.42","","64.77","64.77","64.77","1 through 10","739.34","5403.62","percent of total billed charges",""
"CATHETER ANGIOSCULPT 5MM 20MM 137CM .018IN OTW SEMI COMPLIANT BALLOON PERIPH SCORED 8ATM NOMINAL 20ATM BURST ANGIOPLASTY","SUP-ITM-10048924","CDM","C1725","HCPCS","0272","RC","","","","both","","","6357.20","3814.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","739.34","11.63","","145.58","110.37","145.58","1 through 10","739.34","5403.62","percent of total billed charges",""
"CATHETER ANGIOSCULPT 5MM 20MM 137CM .018IN OTW SEMI COMPLIANT BALLOON PERIPH SCORED 8ATM NOMINAL 20ATM BURST ANGIOPLASTY","SUP-ITM-10048924","CDM","C1725","HCPCS","0272","RC","","","","both","","","6357.20","3814.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4920.47","77.4","","348.09","348.09","348.09","1 through 10","739.34","5403.62","percent of total billed charges",""
"CATHETER ANGIOSCULPT 5MM 20MM 137CM .018IN OTW SEMI COMPLIANT BALLOON PERIPH SCORED 8ATM NOMINAL 20ATM BURST ANGIOPLASTY","SUP-ITM-10048924","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","6357.20","3814.32","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","916.71","14.42","","64.77","64.77","64.77","1 through 10","739.34","4920.47","percent of total billed charges",""
"CATHETER ANGIOSCULPT 5MM 20MM 137CM .018IN OTW SEMI COMPLIANT BALLOON PERIPH SCORED 8ATM NOMINAL 20ATM BURST ANGIOPLASTY","SUP-ITM-10048924","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","6357.20","3814.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","739.34","11.63","","145.58","110.37","145.58","1 through 10","739.34","4920.47","percent of total billed charges",""
"CATHETER ANGIOSCULPT 5MM 20MM 137CM .018IN OTW SEMI COMPLIANT BALLOON PERIPH SCORED 8ATM NOMINAL 20ATM BURST ANGIOPLASTY","SUP-ITM-10048924","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","6357.20","3814.32","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4622.96","72.72","","406.70","406.70","1055.24","1 through 10","739.34","4920.47","percent of total billed charges",""
"CATHETER ANGIOSCULPT 5MM 20MM 137CM .018IN OTW SEMI COMPLIANT BALLOON PERIPH SCORED 8ATM NOMINAL 20ATM BURST ANGIOPLASTY","SUP-ITM-10048924","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","6357.20","3814.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3998.68","62.9","","1069.88","677.14","4190.63","20","739.34","4920.47","percent of total billed charges",""
"CATHETER ANGIOSCULPT 5MM 20MM 137CM .018IN OTW SEMI COMPLIANT BALLOON PERIPH SCORED 8ATM NOMINAL 20ATM BURST ANGIOPLASTY","SUP-ITM-10048924","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","6357.20","3814.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4920.47","77.4","","348.09","348.09","348.09","1 through 10","739.34","4920.47","percent of total billed charges",""
"CATHETER ARMADA 2X40MM 150CM 14 PTA DILATION BALLOON RX PERIPHERAL COMPLIANT","SUP-ITM-10086386","CDM","C1725","HCPCS","0272","RC","","","","both","","","898.30","538.98","AETNA [1001]","HB WDH AETNA COMMERCIAL","627.01","69.8","","351.75","351.75","351.75","1 through 10","104.47","763.56","percent of total billed charges",""
"CATHETER ARMADA 2X40MM 150CM 14 PTA DILATION BALLOON RX PERIPHERAL COMPLIANT","SUP-ITM-10086386","CDM","C1725","HCPCS","0272","RC","","","","both","","","898.30","538.98","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","511.13","56.9","","898.30","898.30","898.30","1 through 10","104.47","763.56","percent of total billed charges",""
"CATHETER ARMADA 2X40MM 150CM 14 PTA DILATION BALLOON RX PERIPHERAL COMPLIANT","SUP-ITM-10086386","CDM","C1725","HCPCS","0272","RC","","","","both","","","898.30","538.98","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","129.53","14.42","","64.77","64.77","64.77","1 through 10","104.47","763.56","percent of total billed charges",""
"CATHETER ARMADA 2X40MM 150CM 14 PTA DILATION BALLOON RX PERIPHERAL COMPLIANT","SUP-ITM-10086386","CDM","C1725","HCPCS","0272","RC","","","","both","","","898.30","538.98","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","104.47","11.63","","145.58","110.37","145.58","1 through 10","104.47","763.56","percent of total billed charges",""
"CATHETER ARMADA 2X40MM 150CM 14 PTA DILATION BALLOON RX PERIPHERAL COMPLIANT","SUP-ITM-10086386","CDM","C1725","HCPCS","0272","RC","","","","both","","","898.30","538.98","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","695.28","77.4","","348.09","348.09","348.09","1 through 10","104.47","763.56","percent of total billed charges",""
"CATHETER ARMADA 2X40MM 150CM 14 PTA DILATION BALLOON RX PERIPHERAL COMPLIANT","SUP-ITM-10086386","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","898.30","538.98","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","129.53","14.42","","64.77","64.77","64.77","1 through 10","104.47","695.28","percent of total billed charges",""
"CATHETER ARMADA 2X40MM 150CM 14 PTA DILATION BALLOON RX PERIPHERAL COMPLIANT","SUP-ITM-10086386","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","898.30","538.98","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","104.47","11.63","","145.58","110.37","145.58","1 through 10","104.47","695.28","percent of total billed charges",""
"CATHETER ARMADA 2X40MM 150CM 14 PTA DILATION BALLOON RX PERIPHERAL COMPLIANT","SUP-ITM-10086386","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","898.30","538.98","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","653.24","72.72","","406.70","406.70","1055.24","1 through 10","104.47","695.28","percent of total billed charges",""
"CATHETER ARMADA 2X40MM 150CM 14 PTA DILATION BALLOON RX PERIPHERAL COMPLIANT","SUP-ITM-10086386","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","898.30","538.98","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","565.03","62.9","","1069.88","677.14","4190.63","20","104.47","695.28","percent of total billed charges",""
"CATHETER ARMADA 2X40MM 150CM 14 PTA DILATION BALLOON RX PERIPHERAL COMPLIANT","SUP-ITM-10086386","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","898.30","538.98","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","695.28","77.4","","348.09","348.09","348.09","1 through 10","104.47","695.28","percent of total billed charges",""
"CATHETER ARMADA 3X120MM 150CM 18 PTA DILATION BALLOON OTW","SUP-ITM-10154609","CDM","C1725","HCPCS","0272","RC","","","","both","","","801.56","480.94","AETNA [1001]","HB WDH AETNA COMMERCIAL","559.49","69.8","","351.75","351.75","351.75","1 through 10","93.22","681.33","percent of total billed charges",""
"CATHETER ARMADA 3X120MM 150CM 18 PTA DILATION BALLOON OTW","SUP-ITM-10154609","CDM","C1725","HCPCS","0272","RC","","","","both","","","801.56","480.94","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","456.09","56.9","","898.30","898.30","898.30","1 through 10","93.22","681.33","percent of total billed charges",""
"CATHETER ARMADA 3X120MM 150CM 18 PTA DILATION BALLOON OTW","SUP-ITM-10154609","CDM","C1725","HCPCS","0272","RC","","","","both","","","801.56","480.94","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","115.58","14.42","","64.77","64.77","64.77","1 through 10","93.22","681.33","percent of total billed charges",""
"CATHETER ARMADA 3X120MM 150CM 18 PTA DILATION BALLOON OTW","SUP-ITM-10154609","CDM","C1725","HCPCS","0272","RC","","","","both","","","801.56","480.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","93.22","11.63","","145.58","110.37","145.58","1 through 10","93.22","681.33","percent of total billed charges",""
"CATHETER ARMADA 3X120MM 150CM 18 PTA DILATION BALLOON OTW","SUP-ITM-10154609","CDM","C1725","HCPCS","0272","RC","","","","both","","","801.56","480.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","620.41","77.4","","348.09","348.09","348.09","1 through 10","93.22","681.33","percent of total billed charges",""
"CATHETER ARMADA 3X120MM 150CM 18 PTA DILATION BALLOON OTW","SUP-ITM-10154609","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","801.56","480.94","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","115.58","14.42","","64.77","64.77","64.77","1 through 10","93.22","620.41","percent of total billed charges",""
"CATHETER ARMADA 3X120MM 150CM 18 PTA DILATION BALLOON OTW","SUP-ITM-10154609","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","801.56","480.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","93.22","11.63","","145.58","110.37","145.58","1 through 10","93.22","620.41","percent of total billed charges",""
"CATHETER ARMADA 3X120MM 150CM 18 PTA DILATION BALLOON OTW","SUP-ITM-10154609","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","801.56","480.94","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","582.89","72.72","","406.70","406.70","1055.24","1 through 10","93.22","620.41","percent of total billed charges",""
"CATHETER ARMADA 3X120MM 150CM 18 PTA DILATION BALLOON OTW","SUP-ITM-10154609","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","801.56","480.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","504.18","62.9","","1069.88","677.14","4190.63","20","93.22","620.41","percent of total billed charges",""
"CATHETER ARMADA 3X120MM 150CM 18 PTA DILATION BALLOON OTW","SUP-ITM-10154609","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","801.56","480.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","620.41","77.4","","348.09","348.09","348.09","1 through 10","93.22","620.41","percent of total billed charges",""
"CATHETER ARMADA 6X40MM 80CM 35 PTA DILATION BALLOON RX PERIPHERAL LOW PROFILE CROSSFLEX","SUP-ITM-10094419","CDM","C1725","HCPCS","0272","RC","","","","both","","","497.52","298.51","AETNA [1001]","HB WDH AETNA COMMERCIAL","347.27","69.8","","351.75","351.75","351.75","1 through 10","57.86","422.89","percent of total billed charges",""
"CATHETER ARMADA 6X40MM 80CM 35 PTA DILATION BALLOON RX PERIPHERAL LOW PROFILE CROSSFLEX","SUP-ITM-10094419","CDM","C1725","HCPCS","0272","RC","","","","both","","","497.52","298.51","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","283.09","56.9","","898.30","898.30","898.30","1 through 10","57.86","422.89","percent of total billed charges",""
"CATHETER ARMADA 6X40MM 80CM 35 PTA DILATION BALLOON RX PERIPHERAL LOW PROFILE CROSSFLEX","SUP-ITM-10094419","CDM","C1725","HCPCS","0272","RC","","","","both","","","497.52","298.51","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","71.74","14.42","","64.77","64.77","64.77","1 through 10","57.86","422.89","percent of total billed charges",""
"CATHETER ARMADA 6X40MM 80CM 35 PTA DILATION BALLOON RX PERIPHERAL LOW PROFILE CROSSFLEX","SUP-ITM-10094419","CDM","C1725","HCPCS","0272","RC","","","","both","","","497.52","298.51","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","57.86","11.63","","145.58","110.37","145.58","1 through 10","57.86","422.89","percent of total billed charges",""
"CATHETER ARMADA 6X40MM 80CM 35 PTA DILATION BALLOON RX PERIPHERAL LOW PROFILE CROSSFLEX","SUP-ITM-10094419","CDM","C1725","HCPCS","0272","RC","","","","both","","","497.52","298.51","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","385.08","77.4","","348.09","348.09","348.09","1 through 10","57.86","422.89","percent of total billed charges",""
"CATHETER ARMADA 6X40MM 80CM 35 PTA DILATION BALLOON RX PERIPHERAL LOW PROFILE CROSSFLEX","SUP-ITM-10094419","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","497.52","298.51","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","71.74","14.42","","64.77","64.77","64.77","1 through 10","57.86","385.08","percent of total billed charges",""
"CATHETER ARMADA 6X40MM 80CM 35 PTA DILATION BALLOON RX PERIPHERAL LOW PROFILE CROSSFLEX","SUP-ITM-10094419","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","497.52","298.51","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","57.86","11.63","","145.58","110.37","145.58","1 through 10","57.86","385.08","percent of total billed charges",""
"CATHETER ARMADA 6X40MM 80CM 35 PTA DILATION BALLOON RX PERIPHERAL LOW PROFILE CROSSFLEX","SUP-ITM-10094419","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","497.52","298.51","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","361.80","72.72","","406.70","406.70","1055.24","1 through 10","57.86","385.08","percent of total billed charges",""
"CATHETER ARMADA 6X40MM 80CM 35 PTA DILATION BALLOON RX PERIPHERAL LOW PROFILE CROSSFLEX","SUP-ITM-10094419","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","497.52","298.51","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","312.94","62.9","","1069.88","677.14","4190.63","20","57.86","385.08","percent of total billed charges",""
"CATHETER ARMADA 6X40MM 80CM 35 PTA DILATION BALLOON RX PERIPHERAL LOW PROFILE CROSSFLEX","SUP-ITM-10094419","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","497.52","298.51","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","385.08","77.4","","348.09","348.09","348.09","1 through 10","57.86","385.08","percent of total billed charges",""
"CATHETER ATLAS 7F 75CM 12MM 2CM .035IN BALLOON DILATATION PTA","SUP-ITM-10027015","CDM","C1725","HCPCS","0272","RC","","","","both","","","1922.71","1153.63","AETNA [1001]","HB WDH AETNA COMMERCIAL","1342.05","69.8","","351.75","351.75","351.75","1 through 10","223.61","1634.3","percent of total billed charges",""
"CATHETER ATLAS 7F 75CM 12MM 2CM .035IN BALLOON DILATATION PTA","SUP-ITM-10027015","CDM","C1725","HCPCS","0272","RC","","","","both","","","1922.71","1153.63","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1094.02","56.9","","898.30","898.30","898.30","1 through 10","223.61","1634.3","percent of total billed charges",""
"CATHETER ATLAS 7F 75CM 12MM 2CM .035IN BALLOON DILATATION PTA","SUP-ITM-10027015","CDM","C1725","HCPCS","0272","RC","","","","both","","","1922.71","1153.63","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","277.25","14.42","","64.77","64.77","64.77","1 through 10","223.61","1634.3","percent of total billed charges",""
"CATHETER ATLAS 7F 75CM 12MM 2CM .035IN BALLOON DILATATION PTA","SUP-ITM-10027015","CDM","C1725","HCPCS","0272","RC","","","","both","","","1922.71","1153.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","223.61","11.63","","145.58","110.37","145.58","1 through 10","223.61","1634.3","percent of total billed charges",""
"CATHETER ATLAS 7F 75CM 12MM 2CM .035IN BALLOON DILATATION PTA","SUP-ITM-10027015","CDM","C1725","HCPCS","0272","RC","","","","both","","","1922.71","1153.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1488.18","77.4","","348.09","348.09","348.09","1 through 10","223.61","1634.3","percent of total billed charges",""
"CATHETER ATLAS 7F 75CM 12MM 2CM .035IN BALLOON DILATATION PTA","SUP-ITM-10027015","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1922.71","1153.63","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","277.25","14.42","","64.77","64.77","64.77","1 through 10","223.61","1488.18","percent of total billed charges",""
"CATHETER ATLAS 7F 75CM 12MM 2CM .035IN BALLOON DILATATION PTA","SUP-ITM-10027015","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1922.71","1153.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","223.61","11.63","","145.58","110.37","145.58","1 through 10","223.61","1488.18","percent of total billed charges",""
"CATHETER ATLAS 7F 75CM 12MM 2CM .035IN BALLOON DILATATION PTA","SUP-ITM-10027015","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1922.71","1153.63","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1398.19","72.72","","406.70","406.70","1055.24","1 through 10","223.61","1488.18","percent of total billed charges",""
"CATHETER ATLAS 7F 75CM 12MM 2CM .035IN BALLOON DILATATION PTA","SUP-ITM-10027015","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1922.71","1153.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1209.38","62.9","","1069.88","677.14","4190.63","20","223.61","1488.18","percent of total billed charges",""
"CATHETER ATLAS 7F 75CM 12MM 2CM .035IN BALLOON DILATATION PTA","SUP-ITM-10027015","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1922.71","1153.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1488.18","77.4","","348.09","348.09","348.09","1 through 10","223.61","1488.18","percent of total billed charges",""
"CATHETER ATLAS 8F 75CM 16MM 4CM .035IN OTW BALLOON DILATATION PTA","SUP-ITM-10015068","CDM","C1725","HCPCS","0272","RC","","","","both","","","1995.26","1197.16","AETNA [1001]","HB WDH AETNA COMMERCIAL","1392.69","69.8","","351.75","351.75","351.75","1 through 10","232.05","1695.97","percent of total billed charges",""
"CATHETER ATLAS 8F 75CM 16MM 4CM .035IN OTW BALLOON DILATATION PTA","SUP-ITM-10015068","CDM","C1725","HCPCS","0272","RC","","","","both","","","1995.26","1197.16","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1135.30","56.9","","898.30","898.30","898.30","1 through 10","232.05","1695.97","percent of total billed charges",""
"CATHETER ATLAS 8F 75CM 16MM 4CM .035IN OTW BALLOON DILATATION PTA","SUP-ITM-10015068","CDM","C1725","HCPCS","0272","RC","","","","both","","","1995.26","1197.16","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","287.72","14.42","","64.77","64.77","64.77","1 through 10","232.05","1695.97","percent of total billed charges",""
"CATHETER ATLAS 8F 75CM 16MM 4CM .035IN OTW BALLOON DILATATION PTA","SUP-ITM-10015068","CDM","C1725","HCPCS","0272","RC","","","","both","","","1995.26","1197.16","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","232.05","11.63","","145.58","110.37","145.58","1 through 10","232.05","1695.97","percent of total billed charges",""
"CATHETER ATLAS 8F 75CM 16MM 4CM .035IN OTW BALLOON DILATATION PTA","SUP-ITM-10015068","CDM","C1725","HCPCS","0272","RC","","","","both","","","1995.26","1197.16","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1544.33","77.4","","348.09","348.09","348.09","1 through 10","232.05","1695.97","percent of total billed charges",""
"CATHETER ATLAS 8F 75CM 16MM 4CM .035IN OTW BALLOON DILATATION PTA","SUP-ITM-10015068","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1995.26","1197.16","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","287.72","14.42","","64.77","64.77","64.77","1 through 10","232.05","1544.33","percent of total billed charges",""
"CATHETER ATLAS 8F 75CM 16MM 4CM .035IN OTW BALLOON DILATATION PTA","SUP-ITM-10015068","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1995.26","1197.16","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","232.05","11.63","","145.58","110.37","145.58","1 through 10","232.05","1544.33","percent of total billed charges",""
"CATHETER ATLAS 8F 75CM 16MM 4CM .035IN OTW BALLOON DILATATION PTA","SUP-ITM-10015068","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1995.26","1197.16","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1450.95","72.72","","406.70","406.70","1055.24","1 through 10","232.05","1544.33","percent of total billed charges",""
"CATHETER ATLAS 8F 75CM 16MM 4CM .035IN OTW BALLOON DILATATION PTA","SUP-ITM-10015068","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1995.26","1197.16","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1255.02","62.9","","1069.88","677.14","4190.63","20","232.05","1544.33","percent of total billed charges",""
"CATHETER ATLAS 8F 75CM 16MM 4CM .035IN OTW BALLOON DILATATION PTA","SUP-ITM-10015068","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1995.26","1197.16","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1544.33","77.4","","348.09","348.09","348.09","1 through 10","232.05","1544.33","percent of total billed charges",""
"CATHETER ATLAS 8FR 14MMX4X75CM ANGIOPLASTY PTA PERIPHERAL BALLOON","SUP-ITM-10027018","CDM","C1725","HCPCS","0272","RC","","","","both","","","1922.71","1153.63","AETNA [1001]","HB WDH AETNA COMMERCIAL","1342.05","69.8","","351.75","351.75","351.75","1 through 10","223.61","1634.3","percent of total billed charges",""
"CATHETER ATLAS 8FR 14MMX4X75CM ANGIOPLASTY PTA PERIPHERAL BALLOON","SUP-ITM-10027018","CDM","C1725","HCPCS","0272","RC","","","","both","","","1922.71","1153.63","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1094.02","56.9","","898.30","898.30","898.30","1 through 10","223.61","1634.3","percent of total billed charges",""
"CATHETER ATLAS 8FR 14MMX4X75CM ANGIOPLASTY PTA PERIPHERAL BALLOON","SUP-ITM-10027018","CDM","C1725","HCPCS","0272","RC","","","","both","","","1922.71","1153.63","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","277.25","14.42","","64.77","64.77","64.77","1 through 10","223.61","1634.3","percent of total billed charges",""
"CATHETER ATLAS 8FR 14MMX4X75CM ANGIOPLASTY PTA PERIPHERAL BALLOON","SUP-ITM-10027018","CDM","C1725","HCPCS","0272","RC","","","","both","","","1922.71","1153.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","223.61","11.63","","145.58","110.37","145.58","1 through 10","223.61","1634.3","percent of total billed charges",""
"CATHETER ATLAS 8FR 14MMX4X75CM ANGIOPLASTY PTA PERIPHERAL BALLOON","SUP-ITM-10027018","CDM","C1725","HCPCS","0272","RC","","","","both","","","1922.71","1153.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1488.18","77.4","","348.09","348.09","348.09","1 through 10","223.61","1634.3","percent of total billed charges",""
"CATHETER ATLAS 8FR 14MMX4X75CM ANGIOPLASTY PTA PERIPHERAL BALLOON","SUP-ITM-10027018","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1922.71","1153.63","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","277.25","14.42","","64.77","64.77","64.77","1 through 10","223.61","1488.18","percent of total billed charges",""
"CATHETER ATLAS 8FR 14MMX4X75CM ANGIOPLASTY PTA PERIPHERAL BALLOON","SUP-ITM-10027018","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1922.71","1153.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","223.61","11.63","","145.58","110.37","145.58","1 through 10","223.61","1488.18","percent of total billed charges",""
"CATHETER ATLAS 8FR 14MMX4X75CM ANGIOPLASTY PTA PERIPHERAL BALLOON","SUP-ITM-10027018","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1922.71","1153.63","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1398.19","72.72","","406.70","406.70","1055.24","1 through 10","223.61","1488.18","percent of total billed charges",""
"CATHETER ATLAS 8FR 14MMX4X75CM ANGIOPLASTY PTA PERIPHERAL BALLOON","SUP-ITM-10027018","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1922.71","1153.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1209.38","62.9","","1069.88","677.14","4190.63","20","223.61","1488.18","percent of total billed charges",""
"CATHETER ATLAS 8FR 14MMX4X75CM ANGIOPLASTY PTA PERIPHERAL BALLOON","SUP-ITM-10027018","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1922.71","1153.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1488.18","77.4","","348.09","348.09","348.09","1 through 10","223.61","1488.18","percent of total billed charges",""
"CATHETER ATTACHABLE 9.5F PORT DIGNITY MIDSIZE DUAL","SUP-ITM-10170049","CDM","C1788","HCPCS","0278","RC","","","","both","","","1692.95","1015.77","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","963.29","56.9","","766.70","625.15","1875.45","1 through 10","196.89","1439.01","percent of total billed charges",""
"CATHETER ATTACHABLE 9.5F PORT DIGNITY MIDSIZE DUAL","SUP-ITM-10170049","CDM","C1788","HCPCS","0278","RC","","","","both","","","1692.95","1015.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","196.89","11.63","","185.54","151.29","286.33","1 through 10","196.89","1439.01","percent of total billed charges",""
"CATHETER ATTACHABLE 9.5F PORT DIGNITY MIDSIZE DUAL","SUP-ITM-10170049","CDM","C1788","HCPCS","0278","RC","","","","both","","","1692.95","1015.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1310.34","77.4","","1611.50","1044.27","1611.50","1 through 10","196.89","1439.01","percent of total billed charges",""
"CATHETER ATTACHABLE 9.5F PORT DIGNITY MIDSIZE DUAL","SUP-ITM-10170049","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1692.95","1015.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","196.89","11.63","","185.54","151.29","286.33","1 through 10","196.89","1310.34","percent of total billed charges",""
"CATHETER ATTACHABLE 9.5F PORT DIGNITY MIDSIZE DUAL","SUP-ITM-10170049","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1692.95","1015.77","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1062.83","62.78","","845.93","845.93","845.93","1 through 10","196.89","1310.34","percent of total billed charges",""
"CATHETER ATTACHABLE 9.5F PORT DIGNITY MIDSIZE DUAL","SUP-ITM-10170049","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1692.95","1015.77","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1231.11","72.72","","979.87","798.97","1685.81","1 through 10","196.89","1310.34","percent of total billed charges",""
"CATHETER ATTACHABLE 9.5F PORT DIGNITY MIDSIZE DUAL","SUP-ITM-10170049","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1692.95","1015.77","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1064.87","62.9","","1460.47","692.17","1460.47","1 through 10","196.89","1310.34","percent of total billed charges",""
"CATHETER ATTACHABLE 9.5F PORT DIGNITY MIDSIZE DUAL","SUP-ITM-10170049","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1692.95","1015.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1310.34","77.4","","1611.50","1044.27","1611.50","1 through 10","196.89","1310.34","percent of total billed charges",""
"CATHETER BALLOON 12FRX4MM 6 75CM HIGH PRESSURE UROMAX ULTRA DILATATION","SUP-ITM-10155559","CDM","C1726","HCPCS","0272","RC","","","","both","","","2175.75","1305.45","AETNA [1001]","HB WDH AETNA COMMERCIAL","1518.67","69.8","","166.96","137.81","825.49","1 through 10","253.04","1849.39","percent of total billed charges",""
"CATHETER BALLOON 12FRX4MM 6 75CM HIGH PRESSURE UROMAX ULTRA DILATATION","SUP-ITM-10155559","CDM","C1726","HCPCS","0272","RC","","","","both","","","2175.75","1305.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1716.86","1716.86","1716.86","1 through 10","253.04","1849.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER BALLOON 12FRX4MM 6 75CM HIGH PRESSURE UROMAX ULTRA DILATATION","SUP-ITM-10155559","CDM","C1726","HCPCS","0272","RC","","","","both","","","2175.75","1305.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","4281.09","1182.65","4281.09","1 through 10","253.04","1849.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER BALLOON 12FRX4MM 6 75CM HIGH PRESSURE UROMAX ULTRA DILATATION","SUP-ITM-10155559","CDM","C1726","HCPCS","0272","RC","","","","both","","","2175.75","1305.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","253.04","11.63","","262.01","27.19","426.66","1 through 10","253.04","1849.39","percent of total billed charges",""
"CATHETER BALLOON 12FRX4MM 6 75CM HIGH PRESSURE UROMAX ULTRA DILATATION","SUP-ITM-10155559","CDM","C1726","HCPCS","0272","RC","","","","both","","","2175.75","1305.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1684.03","77.4","","1411.46","916.55","1411.46","1 through 10","253.04","1849.39","percent of total billed charges",""
"CATHETER BALLOON 12FRX4MM 6 75CM HIGH PRESSURE UROMAX ULTRA DILATATION","SUP-ITM-10155559","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2175.75","1305.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","253.04","11.63","","262.01","27.19","426.66","1 through 10","253.04","1684.03","percent of total billed charges",""
"CATHETER BALLOON 12FRX4MM 6 75CM HIGH PRESSURE UROMAX ULTRA DILATATION","SUP-ITM-10155559","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2175.75","1305.45","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","951.24","43.72","","517.05","517.05","517.05","1 through 10","253.04","1684.03","percent of total billed charges",""
"CATHETER BALLOON 12FRX4MM 6 75CM HIGH PRESSURE UROMAX ULTRA DILATATION","SUP-ITM-10155559","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2175.75","1305.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1582.21","72.72","","1556.61","860.02","1914.17","1 through 10","253.04","1684.03","percent of total billed charges",""
"CATHETER BALLOON 12FRX4MM 6 75CM HIGH PRESSURE UROMAX ULTRA DILATATION","SUP-ITM-10155559","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2175.75","1305.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1368.55","62.9","","1348.55","745.07","1348.55","19","253.04","1684.03","percent of total billed charges",""
"CATHETER BALLOON 12FRX4MM 6 75CM HIGH PRESSURE UROMAX ULTRA DILATATION","SUP-ITM-10155559","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2175.75","1305.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1684.03","77.4","","1411.46","916.55","1411.46","1 through 10","253.04","1684.03","percent of total billed charges",""
"CATHETER BALLOON 12FRX4MM 6 75CM HIGH PRESSURE UROMAX ULTRA DILATATION","SUP-ITM-10155559","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2175.75","1305.45","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","1582.21","72.72","","860.02","860.02","860.02","1 through 10","253.04","1684.03","percent of total billed charges",""
"CATHETER BARRX 7.5MM 15.7MM ELECTRODE 2.8MM 135CM EP RFA ABLATION FLEXIBLE DUODECAPOLAR","SUP-ITM-10124342","CDM","C1886","HCPCS","0272","RC","","","","both","","","8259.55","4955.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","17905.28","17905.28","17905.28","1 through 10","960.59","7020.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER BARRX 7.5MM 15.7MM ELECTRODE 2.8MM 135CM EP RFA ABLATION FLEXIBLE DUODECAPOLAR","SUP-ITM-10124342","CDM","C1886","HCPCS","0272","RC","","","","both","","","8259.55","4955.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","5539.33","5539.33","5539.33","1 through 10","960.59","7020.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER BARRX 7.5MM 15.7MM ELECTRODE 2.8MM 135CM EP RFA ABLATION FLEXIBLE DUODECAPOLAR","SUP-ITM-10124342","CDM","C1886","HCPCS","0272","RC","","","","both","","","8259.55","4955.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","960.59","11.63","","1314.65","1314.65","1314.65","1 through 10","960.59","7020.62","percent of total billed charges",""
"CATHETER BARRX 7.5MM 15.7MM ELECTRODE 2.8MM 135CM EP RFA ABLATION FLEXIBLE DUODECAPOLAR","SUP-ITM-10124342","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","8259.55","4955.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","960.59","11.63","","1314.65","1314.65","1314.65","1 through 10","960.59","6392.89","percent of total billed charges",""
"CATHETER BARRX 7.5MM 15.7MM ELECTRODE 2.8MM 135CM EP RFA ABLATION FLEXIBLE DUODECAPOLAR","SUP-ITM-10124342","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","8259.55","4955.73","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6006.34","72.72","","16561.06","16561.06","16561.06","1 through 10","960.59","6392.89","percent of total billed charges",""
"CATHETER BARRX360 4CM ELEC 8CM BAL 18-31MM 4PSI 16ABLATIONS .035-.069IN EXPRESS RFA BALLOON SELF SIZING ENDOSCOPY","SUP-ITM-10157611","CDM","C1886","HCPCS","0272","RC","","","","both","","","11887.35","7132.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","17905.28","17905.28","17905.28","1 through 10","1382.5","10104.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER BARRX360 4CM ELEC 8CM BAL 18-31MM 4PSI 16ABLATIONS .035-.069IN EXPRESS RFA BALLOON SELF SIZING ENDOSCOPY","SUP-ITM-10157611","CDM","C1886","HCPCS","0272","RC","","","","both","","","11887.35","7132.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","5539.33","5539.33","5539.33","1 through 10","1382.5","10104.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER BARRX360 4CM ELEC 8CM BAL 18-31MM 4PSI 16ABLATIONS .035-.069IN EXPRESS RFA BALLOON SELF SIZING ENDOSCOPY","SUP-ITM-10157611","CDM","C1886","HCPCS","0272","RC","","","","both","","","11887.35","7132.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1382.50","11.63","","1314.65","1314.65","1314.65","1 through 10","1382.5","10104.25","percent of total billed charges",""
"CATHETER BARRX360 4CM ELEC 8CM BAL 18-31MM 4PSI 16ABLATIONS .035-.069IN EXPRESS RFA BALLOON SELF SIZING ENDOSCOPY","SUP-ITM-10157611","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","11887.35","7132.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1382.50","11.63","","1314.65","1314.65","1314.65","1 through 10","1382.5","9200.81","percent of total billed charges",""
"CATHETER BARRX360 4CM ELEC 8CM BAL 18-31MM 4PSI 16ABLATIONS .035-.069IN EXPRESS RFA BALLOON SELF SIZING ENDOSCOPY","SUP-ITM-10157611","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","11887.35","7132.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8644.48","72.72","","16561.06","16561.06","16561.06","1 through 10","1382.5","9200.81","percent of total billed charges",""
"CATHETER BARRX90 20MM 13MM ELECTRODE 4MM 160CM SHAFT RFA FOCAL ENDOSCOPIC HALO DISP","SUP-ITM-10024997","CDM","C1886","HCPCS","0272","RC","","","","both","","","7207.10","4324.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","17905.28","17905.28","17905.28","1 through 10","838.19","6126.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER BARRX90 20MM 13MM ELECTRODE 4MM 160CM SHAFT RFA FOCAL ENDOSCOPIC HALO DISP","SUP-ITM-10024997","CDM","C1886","HCPCS","0272","RC","","","","both","","","7207.10","4324.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","5539.33","5539.33","5539.33","1 through 10","838.19","6126.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER BARRX90 20MM 13MM ELECTRODE 4MM 160CM SHAFT RFA FOCAL ENDOSCOPIC HALO DISP","SUP-ITM-10024997","CDM","C1886","HCPCS","0272","RC","","","","both","","","7207.10","4324.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","838.19","11.63","","1314.65","1314.65","1314.65","1 through 10","838.19","6126.04","percent of total billed charges",""
"CATHETER BARRX90 20MM 13MM ELECTRODE 4MM 160CM SHAFT RFA FOCAL ENDOSCOPIC HALO DISP","SUP-ITM-10024997","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","7207.10","4324.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","838.19","11.63","","1314.65","1314.65","1314.65","1 through 10","838.19","5578.3","percent of total billed charges",""
"CATHETER BARRX90 20MM 13MM ELECTRODE 4MM 160CM SHAFT RFA FOCAL ENDOSCOPIC HALO DISP","SUP-ITM-10024997","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","7207.10","4324.26","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5241.00","72.72","","16561.06","16561.06","16561.06","1 through 10","838.19","5578.3","percent of total billed charges",""
"Catheter Bladder Smp","PX-76001258","CDM","51702","CPT","0761","RC","","","","both","","","457.00","274.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","131.98","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","846.00","846.00","846.00","1 through 10","131.98","860.68","other","OPPS APC"
"Catheter Bladder Smp","PX-76001258","CDM","51702","CPT","0761","RC","","","","outpatient","","","457.00","274.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","65.90","14.42","","63.59","54.51","63.59","1 through 10","53.15","353.72","percent of total billed charges",""
"CATHETER BREAK-AWAY 9FR 61CM GUIDE ACUITY CS EXTENDED HOOK","SUP-ITM-10080585","CDM","C1887","HCPCS","0272","RC","","","","both","","","808.47","485.08","AETNA [1001]","HB WDH AETNA COMMERCIAL","564.31","69.8","","211.78","89.23","211.78","1 through 10","94.03","687.2","percent of total billed charges",""
"CATHETER BREAK-AWAY 9FR 61CM GUIDE ACUITY CS EXTENDED HOOK","SUP-ITM-10080585","CDM","C1887","HCPCS","0272","RC","","","","both","","","808.47","485.08","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","460.02","56.9","","383.50","68.20","383.50","1 through 10","94.03","687.2","percent of total billed charges",""
"CATHETER BREAK-AWAY 9FR 61CM GUIDE ACUITY CS EXTENDED HOOK","SUP-ITM-10080585","CDM","C1887","HCPCS","0272","RC","","","","both","","","808.47","485.08","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","94.03","11.63","","8.44","7.37","15.65","12","94.03","687.2","percent of total billed charges",""
"CATHETER BREAK-AWAY 9FR 61CM GUIDE ACUITY CS EXTENDED HOOK","SUP-ITM-10080585","CDM","C1887","HCPCS","0272","RC","","","","both","","","808.47","485.08","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","625.76","77.4","","41.50","41.50","214.21","1 through 10","94.03","687.2","percent of total billed charges",""
"CATHETER BREAK-AWAY 9FR 61CM GUIDE ACUITY CS EXTENDED HOOK","SUP-ITM-10080585","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","808.47","485.08","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","94.03","11.63","","8.44","7.37","15.65","12","94.03","625.76","percent of total billed charges",""
"CATHETER BREAK-AWAY 9FR 61CM GUIDE ACUITY CS EXTENDED HOOK","SUP-ITM-10080585","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","808.47","485.08","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","587.92","72.72","","92.96","38.94","158.55","24","94.03","625.76","percent of total billed charges",""
"CATHETER BREAK-AWAY 9FR 61CM GUIDE ACUITY CS EXTENDED HOOK","SUP-ITM-10080585","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","808.47","485.08","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","508.53","62.9","","208.96","33.74","457.91","69","94.03","625.76","percent of total billed charges",""
"CATHETER BREAK-AWAY 9FR 61CM GUIDE ACUITY CS EXTENDED HOOK","SUP-ITM-10080585","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","808.47","485.08","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","625.76","77.4","","41.50","41.50","214.21","1 through 10","94.03","625.76","percent of total billed charges",""
"CATHETER CONQUEST 40 6MMX756CM .035IN OTW ULTRA NON COMPL LOW PROFILE FEMORAL ILIAC RENAL ARTERY ANGIOPLASTY","SUP-ITM-10114392","CDM","C1725","HCPCS","0272","RC","","","","both","","","1057.23","634.34","AETNA [1001]","HB WDH AETNA COMMERCIAL","737.95","69.8","","351.75","351.75","351.75","1 through 10","122.96","898.65","percent of total billed charges",""
"CATHETER CONQUEST 40 6MMX756CM .035IN OTW ULTRA NON COMPL LOW PROFILE FEMORAL ILIAC RENAL ARTERY ANGIOPLASTY","SUP-ITM-10114392","CDM","C1725","HCPCS","0272","RC","","","","both","","","1057.23","634.34","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","601.56","56.9","","898.30","898.30","898.30","1 through 10","122.96","898.65","percent of total billed charges",""
"CATHETER CONQUEST 40 6MMX756CM .035IN OTW ULTRA NON COMPL LOW PROFILE FEMORAL ILIAC RENAL ARTERY ANGIOPLASTY","SUP-ITM-10114392","CDM","C1725","HCPCS","0272","RC","","","","both","","","1057.23","634.34","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","152.45","14.42","","64.77","64.77","64.77","1 through 10","122.96","898.65","percent of total billed charges",""
"CATHETER CONQUEST 40 6MMX756CM .035IN OTW ULTRA NON COMPL LOW PROFILE FEMORAL ILIAC RENAL ARTERY ANGIOPLASTY","SUP-ITM-10114392","CDM","C1725","HCPCS","0272","RC","","","","both","","","1057.23","634.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","122.96","11.63","","145.58","110.37","145.58","1 through 10","122.96","898.65","percent of total billed charges",""
"CATHETER CONQUEST 40 6MMX756CM .035IN OTW ULTRA NON COMPL LOW PROFILE FEMORAL ILIAC RENAL ARTERY ANGIOPLASTY","SUP-ITM-10114392","CDM","C1725","HCPCS","0272","RC","","","","both","","","1057.23","634.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","818.30","77.4","","348.09","348.09","348.09","1 through 10","122.96","898.65","percent of total billed charges",""
"CATHETER CONQUEST 40 6MMX756CM .035IN OTW ULTRA NON COMPL LOW PROFILE FEMORAL ILIAC RENAL ARTERY ANGIOPLASTY","SUP-ITM-10114392","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1057.23","634.34","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","152.45","14.42","","64.77","64.77","64.77","1 through 10","122.96","818.3","percent of total billed charges",""
"CATHETER CONQUEST 40 6MMX756CM .035IN OTW ULTRA NON COMPL LOW PROFILE FEMORAL ILIAC RENAL ARTERY ANGIOPLASTY","SUP-ITM-10114392","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1057.23","634.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","122.96","11.63","","145.58","110.37","145.58","1 through 10","122.96","818.3","percent of total billed charges",""
"CATHETER CONQUEST 40 6MMX756CM .035IN OTW ULTRA NON COMPL LOW PROFILE FEMORAL ILIAC RENAL ARTERY ANGIOPLASTY","SUP-ITM-10114392","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1057.23","634.34","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","768.82","72.72","","406.70","406.70","1055.24","1 through 10","122.96","818.3","percent of total billed charges",""
"CATHETER CONQUEST 40 6MMX756CM .035IN OTW ULTRA NON COMPL LOW PROFILE FEMORAL ILIAC RENAL ARTERY ANGIOPLASTY","SUP-ITM-10114392","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1057.23","634.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","665.00","62.9","","1069.88","677.14","4190.63","20","122.96","818.3","percent of total billed charges",""
"CATHETER CONQUEST 40 6MMX756CM .035IN OTW ULTRA NON COMPL LOW PROFILE FEMORAL ILIAC RENAL ARTERY ANGIOPLASTY","SUP-ITM-10114392","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1057.23","634.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","818.30","77.4","","348.09","348.09","348.09","1 through 10","122.96","818.3","percent of total billed charges",""
"CATHETER CONQUEST 6FR 7MM 6CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10031459","CDM","C1725","HCPCS","0272","RC","","","","both","","","1057.23","634.34","AETNA [1001]","HB WDH AETNA COMMERCIAL","737.95","69.8","","351.75","351.75","351.75","1 through 10","122.96","898.65","percent of total billed charges",""
"CATHETER CONQUEST 6FR 7MM 6CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10031459","CDM","C1725","HCPCS","0272","RC","","","","both","","","1057.23","634.34","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","601.56","56.9","","898.30","898.30","898.30","1 through 10","122.96","898.65","percent of total billed charges",""
"CATHETER CONQUEST 6FR 7MM 6CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10031459","CDM","C1725","HCPCS","0272","RC","","","","both","","","1057.23","634.34","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","152.45","14.42","","64.77","64.77","64.77","1 through 10","122.96","898.65","percent of total billed charges",""
"CATHETER CONQUEST 6FR 7MM 6CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10031459","CDM","C1725","HCPCS","0272","RC","","","","both","","","1057.23","634.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","122.96","11.63","","145.58","110.37","145.58","1 through 10","122.96","898.65","percent of total billed charges",""
"CATHETER CONQUEST 6FR 7MM 6CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10031459","CDM","C1725","HCPCS","0272","RC","","","","both","","","1057.23","634.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","818.30","77.4","","348.09","348.09","348.09","1 through 10","122.96","898.65","percent of total billed charges",""
"CATHETER CONQUEST 6FR 7MM 6CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10031459","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1057.23","634.34","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","152.45","14.42","","64.77","64.77","64.77","1 through 10","122.96","818.3","percent of total billed charges",""
"CATHETER CONQUEST 6FR 7MM 6CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10031459","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1057.23","634.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","122.96","11.63","","145.58","110.37","145.58","1 through 10","122.96","818.3","percent of total billed charges",""
"CATHETER CONQUEST 6FR 7MM 6CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10031459","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1057.23","634.34","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","768.82","72.72","","406.70","406.70","1055.24","1 through 10","122.96","818.3","percent of total billed charges",""
"CATHETER CONQUEST 6FR 7MM 6CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10031459","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1057.23","634.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","665.00","62.9","","1069.88","677.14","4190.63","20","122.96","818.3","percent of total billed charges",""
"CATHETER CONQUEST 6FR 7MM 6CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10031459","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1057.23","634.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","818.30","77.4","","348.09","348.09","348.09","1 through 10","122.96","818.3","percent of total billed charges",""
"CATHETER CRAGG-MCNAMARA 5FR 135CM 20CM .038IN INFUSION VALVED","SUP-ITM-10090875","CDM","C1887","HCPCS","0272","RC","","","","both","","","530.07","318.04","AETNA [1001]","HB WDH AETNA COMMERCIAL","369.99","69.8","","211.78","89.23","211.78","1 through 10","61.65","450.56","percent of total billed charges",""
"CATHETER CRAGG-MCNAMARA 5FR 135CM 20CM .038IN INFUSION VALVED","SUP-ITM-10090875","CDM","C1887","HCPCS","0272","RC","","","","both","","","530.07","318.04","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","301.61","56.9","","383.50","68.20","383.50","1 through 10","61.65","450.56","percent of total billed charges",""
"CATHETER CRAGG-MCNAMARA 5FR 135CM 20CM .038IN INFUSION VALVED","SUP-ITM-10090875","CDM","C1887","HCPCS","0272","RC","","","","both","","","530.07","318.04","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","61.65","11.63","","8.44","7.37","15.65","12","61.65","450.56","percent of total billed charges",""
"CATHETER CRAGG-MCNAMARA 5FR 135CM 20CM .038IN INFUSION VALVED","SUP-ITM-10090875","CDM","C1887","HCPCS","0272","RC","","","","both","","","530.07","318.04","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","410.27","77.4","","41.50","41.50","214.21","1 through 10","61.65","450.56","percent of total billed charges",""
"CATHETER CRAGG-MCNAMARA 5FR 135CM 20CM .038IN INFUSION VALVED","SUP-ITM-10090875","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","530.07","318.04","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","61.65","11.63","","8.44","7.37","15.65","12","61.65","410.27","percent of total billed charges",""
"CATHETER CRAGG-MCNAMARA 5FR 135CM 20CM .038IN INFUSION VALVED","SUP-ITM-10090875","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","530.07","318.04","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","385.47","72.72","","92.96","38.94","158.55","24","61.65","410.27","percent of total billed charges",""
"CATHETER CRAGG-MCNAMARA 5FR 135CM 20CM .038IN INFUSION VALVED","SUP-ITM-10090875","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","530.07","318.04","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","333.41","62.9","","208.96","33.74","457.91","69","61.65","410.27","percent of total billed charges",""
"CATHETER CRAGG-MCNAMARA 5FR 135CM 20CM .038IN INFUSION VALVED","SUP-ITM-10090875","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","530.07","318.04","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","410.27","77.4","","41.50","41.50","214.21","1 through 10","61.65","410.27","percent of total billed charges",""
"CATHETER CRAGG-MCNAMARA 5FR 135CM 30CM .038IN INFUSION VALVED","SUP-ITM-10017642","CDM","C1887","HCPCS","0272","RC","","","","both","","","617.75","370.65","AETNA [1001]","HB WDH AETNA COMMERCIAL","431.19","69.8","","211.78","89.23","211.78","1 through 10","71.84","525.09","percent of total billed charges",""
"CATHETER CRAGG-MCNAMARA 5FR 135CM 30CM .038IN INFUSION VALVED","SUP-ITM-10017642","CDM","C1887","HCPCS","0272","RC","","","","both","","","617.75","370.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","351.50","56.9","","383.50","68.20","383.50","1 through 10","71.84","525.09","percent of total billed charges",""
"CATHETER CRAGG-MCNAMARA 5FR 135CM 30CM .038IN INFUSION VALVED","SUP-ITM-10017642","CDM","C1887","HCPCS","0272","RC","","","","both","","","617.75","370.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.84","11.63","","8.44","7.37","15.65","12","71.84","525.09","percent of total billed charges",""
"CATHETER CRAGG-MCNAMARA 5FR 135CM 30CM .038IN INFUSION VALVED","SUP-ITM-10017642","CDM","C1887","HCPCS","0272","RC","","","","both","","","617.75","370.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","478.14","77.4","","41.50","41.50","214.21","1 through 10","71.84","525.09","percent of total billed charges",""
"CATHETER CRAGG-MCNAMARA 5FR 135CM 30CM .038IN INFUSION VALVED","SUP-ITM-10017642","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","617.75","370.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.84","11.63","","8.44","7.37","15.65","12","71.84","478.14","percent of total billed charges",""
"CATHETER CRAGG-MCNAMARA 5FR 135CM 30CM .038IN INFUSION VALVED","SUP-ITM-10017642","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","617.75","370.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","449.23","72.72","","92.96","38.94","158.55","24","71.84","478.14","percent of total billed charges",""
"CATHETER CRAGG-MCNAMARA 5FR 135CM 30CM .038IN INFUSION VALVED","SUP-ITM-10017642","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","617.75","370.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","388.56","62.9","","208.96","33.74","457.91","69","71.84","478.14","percent of total billed charges",""
"CATHETER CRAGG-MCNAMARA 5FR 135CM 30CM .038IN INFUSION VALVED","SUP-ITM-10017642","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","617.75","370.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","478.14","77.4","","41.50","41.50","214.21","1 through 10","71.84","478.14","percent of total billed charges",""
"CATHETER CRE PRO WIREGUIDED 7.5FR 6-8MM 5.5CM 240CM DILATION BILIARY BALLOON ESOPHAGEAL","SUP-ITM-10170125","CDM","C1726","HCPCS","0272","RC","","","","both","","","1334.25","800.55","AETNA [1001]","HB WDH AETNA COMMERCIAL","931.31","69.8","","166.96","137.81","825.49","1 through 10","155.17","1134.11","percent of total billed charges",""
"CATHETER CRE PRO WIREGUIDED 7.5FR 6-8MM 5.5CM 240CM DILATION BILIARY BALLOON ESOPHAGEAL","SUP-ITM-10170125","CDM","C1726","HCPCS","0272","RC","","","","both","","","1334.25","800.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1716.86","1716.86","1716.86","1 through 10","155.17","1134.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER CRE PRO WIREGUIDED 7.5FR 6-8MM 5.5CM 240CM DILATION BILIARY BALLOON ESOPHAGEAL","SUP-ITM-10170125","CDM","C1726","HCPCS","0272","RC","","","","both","","","1334.25","800.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","4281.09","1182.65","4281.09","1 through 10","155.17","1134.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER CRE PRO WIREGUIDED 7.5FR 6-8MM 5.5CM 240CM DILATION BILIARY BALLOON ESOPHAGEAL","SUP-ITM-10170125","CDM","C1726","HCPCS","0272","RC","","","","both","","","1334.25","800.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","155.17","11.63","","262.01","27.19","426.66","1 through 10","155.17","1134.11","percent of total billed charges",""
"CATHETER CRE PRO WIREGUIDED 7.5FR 6-8MM 5.5CM 240CM DILATION BILIARY BALLOON ESOPHAGEAL","SUP-ITM-10170125","CDM","C1726","HCPCS","0272","RC","","","","both","","","1334.25","800.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1032.71","77.4","","1411.46","916.55","1411.46","1 through 10","155.17","1134.11","percent of total billed charges",""
"CATHETER CRE PRO WIREGUIDED 7.5FR 6-8MM 5.5CM 240CM DILATION BILIARY BALLOON ESOPHAGEAL","SUP-ITM-10170125","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1334.25","800.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","155.17","11.63","","262.01","27.19","426.66","1 through 10","155.17","1032.71","percent of total billed charges",""
"CATHETER CRE PRO WIREGUIDED 7.5FR 6-8MM 5.5CM 240CM DILATION BILIARY BALLOON ESOPHAGEAL","SUP-ITM-10170125","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1334.25","800.55","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","583.33","43.72","","517.05","517.05","517.05","1 through 10","155.17","1032.71","percent of total billed charges",""
"CATHETER CRE PRO WIREGUIDED 7.5FR 6-8MM 5.5CM 240CM DILATION BILIARY BALLOON ESOPHAGEAL","SUP-ITM-10170125","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1334.25","800.55","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","970.27","72.72","","1556.61","860.02","1914.17","1 through 10","155.17","1032.71","percent of total billed charges",""
"CATHETER CRE PRO WIREGUIDED 7.5FR 6-8MM 5.5CM 240CM DILATION BILIARY BALLOON ESOPHAGEAL","SUP-ITM-10170125","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1334.25","800.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","839.24","62.9","","1348.55","745.07","1348.55","19","155.17","1032.71","percent of total billed charges",""
"CATHETER CRE PRO WIREGUIDED 7.5FR 6-8MM 5.5CM 240CM DILATION BILIARY BALLOON ESOPHAGEAL","SUP-ITM-10170125","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1334.25","800.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1032.71","77.4","","1411.46","916.55","1411.46","1 through 10","155.17","1032.71","percent of total billed charges",""
"CATHETER CRE PRO WIREGUIDED 7.5FR 6-8MM 5.5CM 240CM DILATION BILIARY BALLOON ESOPHAGEAL","SUP-ITM-10170125","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1334.25","800.55","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","970.27","72.72","","860.02","860.02","860.02","1 through 10","155.17","1032.71","percent of total billed charges",""
"CATHETER CROSSER 5FR 106CM .014IN OTW CTO RECANALIZATION 14S","SUP-ITM-10155808","CDM","C1887","HCPCS","0272","RC","","","","both","","","10185.00","6111.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","7109.13","69.8","","211.78","89.23","211.78","1 through 10","1184.52","8657.25","percent of total billed charges",""
"CATHETER CROSSER 5FR 106CM .014IN OTW CTO RECANALIZATION 14S","SUP-ITM-10155808","CDM","C1887","HCPCS","0272","RC","","","","both","","","10185.00","6111.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5795.27","56.9","","383.50","68.20","383.50","1 through 10","1184.52","8657.25","percent of total billed charges",""
"CATHETER CROSSER 5FR 106CM .014IN OTW CTO RECANALIZATION 14S","SUP-ITM-10155808","CDM","C1887","HCPCS","0272","RC","","","","both","","","10185.00","6111.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1184.52","11.63","","8.44","7.37","15.65","12","1184.52","8657.25","percent of total billed charges",""
"CATHETER CROSSER 5FR 106CM .014IN OTW CTO RECANALIZATION 14S","SUP-ITM-10155808","CDM","C1887","HCPCS","0272","RC","","","","both","","","10185.00","6111.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7883.19","77.4","","41.50","41.50","214.21","1 through 10","1184.52","8657.25","percent of total billed charges",""
"CATHETER CROSSER 5FR 106CM .014IN OTW CTO RECANALIZATION 14S","SUP-ITM-10155808","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","10185.00","6111.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1184.52","11.63","","8.44","7.37","15.65","12","1184.52","7883.19","percent of total billed charges",""
"CATHETER CROSSER 5FR 106CM .014IN OTW CTO RECANALIZATION 14S","SUP-ITM-10155808","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","10185.00","6111.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7406.53","72.72","","92.96","38.94","158.55","24","1184.52","7883.19","percent of total billed charges",""
"CATHETER CROSSER 5FR 106CM .014IN OTW CTO RECANALIZATION 14S","SUP-ITM-10155808","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","10185.00","6111.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6406.37","62.9","","208.96","33.74","457.91","69","1184.52","7883.19","percent of total billed charges",""
"CATHETER CROSSER 5FR 106CM .014IN OTW CTO RECANALIZATION 14S","SUP-ITM-10155808","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","10185.00","6111.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7883.19","77.4","","41.50","41.50","214.21","1 through 10","1184.52","7883.19","percent of total billed charges",""
"CATHETER DAWSON-MUELLER 8.5FR 25CM .038IN MULTIPURPOSE DRAINAGE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM MAC LOC PIGTAIL LOCKING LF","SUP-ITM-10000499","CDM","C1729","HCPCS","0272","RC","","","","both","","","454.82","272.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","52.90","11.63","","19.51","17.34","54.47","21","52.9","386.6","percent of total billed charges",""
"CATHETER DAWSON-MUELLER 8.5FR 25CM .038IN MULTIPURPOSE DRAINAGE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM MAC LOC PIGTAIL LOCKING LF","SUP-ITM-10000499","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","454.82","272.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","52.90","11.63","","19.51","17.34","54.47","21","52.9","352.03","percent of total billed charges",""
"CATHETER DAWSON-MUELLER 8.5FR 25CM .038IN MULTIPURPOSE DRAINAGE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM MAC LOC PIGTAIL LOCKING LF","SUP-ITM-10000499","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","454.82","272.89","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","198.85","43.72","","61.93","61.93","61.93","1 through 10","52.9","352.03","percent of total billed charges",""
"CATHETER DAWSON-MUELLER 8.5FR 25CM .038IN MULTIPURPOSE DRAINAGE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM MAC LOC PIGTAIL LOCKING LF","SUP-ITM-10000499","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","454.82","272.89","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","330.75","72.72","","330.75","267.63","330.75","1 through 10","52.9","352.03","percent of total billed charges",""
"CATHETER DAWSON-MUELLER 8.5FR 25CM .038IN MULTIPURPOSE DRAINAGE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM MAC LOC PIGTAIL LOCKING LF","SUP-ITM-10000499","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","454.82","272.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","286.08","62.9","","89.25","87.07","231.86","1 through 10","52.9","352.03","percent of total billed charges",""
"CATHETER DAWSON-MUELLER 8.5FR 25CM .038IN MULTIPURPOSE DRAINAGE SINGLE LUMEN ULTRATHANE HYDROPHILIC COATED RADIOPAQUE FIRM MAC LOC PIGTAIL LOCKING LF","SUP-ITM-10000499","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","454.82","272.89","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","330.75","72.72","","267.63","267.63","267.63","1 through 10","52.9","352.03","percent of total billed charges",""
"CATHETER DIALYSIS 43CM PERITONEAL ARGYLE SILICONE TENCKHOFF SWAN NECK 2 CUFF LT","SUP-ITM-10237190","CDM","C1750","HCPCS","0278","RC","","","","both","","","766.32","459.79","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","436.04","56.9","","986.49","974.06","986.49","1 through 10","89.12","651.37","percent of total billed charges",""
"CATHETER DIALYSIS 43CM PERITONEAL ARGYLE SILICONE TENCKHOFF SWAN NECK 2 CUFF LT","SUP-ITM-10237190","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","766.32","459.79","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","335.04","43.72","","951.63","951.63","951.63","1 through 10","89.12","593.13","percent of total billed charges",""
"CATHETER DIALYSIS 43CM PERITONEAL ARGYLE SILICONE TENCKHOFF SWAN NECK 2 CUFF LT","SUP-ITM-10237190","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","766.32","459.79","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","557.27","72.72","","1244.88","1244.88","1244.88","1 through 10","89.12","593.13","percent of total billed charges",""
"CATHETER DIALYSIS 62.5CM PERITONEAL SWAN NECK CURL 2 RIGHT","SUP-ITM-10215746","CDM","C1750","HCPCS","0278","RC","","","","both","","","1711.88","1027.13","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","974.06","56.9","","986.49","974.06","986.49","1 through 10","199.09","1455.1","percent of total billed charges",""
"CATHETER DIALYSIS 62.5CM PERITONEAL SWAN NECK CURL 2 RIGHT","SUP-ITM-10215746","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1711.88","1027.13","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","748.43","43.72","","951.63","951.63","951.63","1 through 10","199.09","1325","percent of total billed charges",""
"CATHETER DIALYSIS 62.5CM PERITONEAL SWAN NECK CURL 2 RIGHT","SUP-ITM-10215746","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1711.88","1027.13","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1244.88","72.72","","1244.88","1244.88","1244.88","1 through 10","199.09","1325","percent of total billed charges",""
"CATHETER DILATATION 17CM 30FR 12 NEPHROSTOMY NEPHROMAX HIGH PRESSURE PTFE SHEATH BALLOON","SUP-ITM-10003665","CDM","C1726","HCPCS","0272","RC","","","","both","","","2508.95","1505.37","AETNA [1001]","HB WDH AETNA COMMERCIAL","1751.25","69.8","","166.96","137.81","825.49","1 through 10","291.79","2132.61","percent of total billed charges",""
"CATHETER DILATATION 17CM 30FR 12 NEPHROSTOMY NEPHROMAX HIGH PRESSURE PTFE SHEATH BALLOON","SUP-ITM-10003665","CDM","C1726","HCPCS","0272","RC","","","","both","","","2508.95","1505.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1716.86","1716.86","1716.86","1 through 10","291.79","2132.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER DILATATION 17CM 30FR 12 NEPHROSTOMY NEPHROMAX HIGH PRESSURE PTFE SHEATH BALLOON","SUP-ITM-10003665","CDM","C1726","HCPCS","0272","RC","","","","both","","","2508.95","1505.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","4281.09","1182.65","4281.09","1 through 10","291.79","2132.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER DILATATION 17CM 30FR 12 NEPHROSTOMY NEPHROMAX HIGH PRESSURE PTFE SHEATH BALLOON","SUP-ITM-10003665","CDM","C1726","HCPCS","0272","RC","","","","both","","","2508.95","1505.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","291.79","11.63","","262.01","27.19","426.66","1 through 10","291.79","2132.61","percent of total billed charges",""
"CATHETER DILATATION 17CM 30FR 12 NEPHROSTOMY NEPHROMAX HIGH PRESSURE PTFE SHEATH BALLOON","SUP-ITM-10003665","CDM","C1726","HCPCS","0272","RC","","","","both","","","2508.95","1505.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1941.93","77.4","","1411.46","916.55","1411.46","1 through 10","291.79","2132.61","percent of total billed charges",""
"CATHETER DILATATION 17CM 30FR 12 NEPHROSTOMY NEPHROMAX HIGH PRESSURE PTFE SHEATH BALLOON","SUP-ITM-10003665","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2508.95","1505.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","291.79","11.63","","262.01","27.19","426.66","1 through 10","291.79","1941.93","percent of total billed charges",""
"CATHETER DILATATION 17CM 30FR 12 NEPHROSTOMY NEPHROMAX HIGH PRESSURE PTFE SHEATH BALLOON","SUP-ITM-10003665","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2508.95","1505.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1096.91","43.72","","517.05","517.05","517.05","1 through 10","291.79","1941.93","percent of total billed charges",""
"CATHETER DILATATION 17CM 30FR 12 NEPHROSTOMY NEPHROMAX HIGH PRESSURE PTFE SHEATH BALLOON","SUP-ITM-10003665","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2508.95","1505.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1824.51","72.72","","1556.61","860.02","1914.17","1 through 10","291.79","1941.93","percent of total billed charges",""
"CATHETER DILATATION 17CM 30FR 12 NEPHROSTOMY NEPHROMAX HIGH PRESSURE PTFE SHEATH BALLOON","SUP-ITM-10003665","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2508.95","1505.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1578.13","62.9","","1348.55","745.07","1348.55","19","291.79","1941.93","percent of total billed charges",""
"CATHETER DILATATION 17CM 30FR 12 NEPHROSTOMY NEPHROMAX HIGH PRESSURE PTFE SHEATH BALLOON","SUP-ITM-10003665","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2508.95","1505.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1941.93","77.4","","1411.46","916.55","1411.46","1 through 10","291.79","1941.93","percent of total billed charges",""
"CATHETER DILATATION 17CM 30FR 12 NEPHROSTOMY NEPHROMAX HIGH PRESSURE PTFE SHEATH BALLOON","SUP-ITM-10003665","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2508.95","1505.37","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","1824.51","72.72","","860.02","860.02","860.02","1 through 10","291.79","1941.93","percent of total billed charges",""
"CATHETER DORADO 5FR 4MM 4CM 135CM .035IN RBP24 PTA BALLOON DILATATION","SUP-ITM-10026306","CDM","C1725","HCPCS","0272","RC","","","","both","","","1052.05","631.23","AETNA [1001]","HB WDH AETNA COMMERCIAL","734.33","69.8","","351.75","351.75","351.75","1 through 10","122.35","894.24","percent of total billed charges",""
"CATHETER DORADO 5FR 4MM 4CM 135CM .035IN RBP24 PTA BALLOON DILATATION","SUP-ITM-10026306","CDM","C1725","HCPCS","0272","RC","","","","both","","","1052.05","631.23","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","598.62","56.9","","898.30","898.30","898.30","1 through 10","122.35","894.24","percent of total billed charges",""
"CATHETER DORADO 5FR 4MM 4CM 135CM .035IN RBP24 PTA BALLOON DILATATION","SUP-ITM-10026306","CDM","C1725","HCPCS","0272","RC","","","","both","","","1052.05","631.23","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","151.71","14.42","","64.77","64.77","64.77","1 through 10","122.35","894.24","percent of total billed charges",""
"CATHETER DORADO 5FR 4MM 4CM 135CM .035IN RBP24 PTA BALLOON DILATATION","SUP-ITM-10026306","CDM","C1725","HCPCS","0272","RC","","","","both","","","1052.05","631.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","122.35","11.63","","145.58","110.37","145.58","1 through 10","122.35","894.24","percent of total billed charges",""
"CATHETER DORADO 5FR 4MM 4CM 135CM .035IN RBP24 PTA BALLOON DILATATION","SUP-ITM-10026306","CDM","C1725","HCPCS","0272","RC","","","","both","","","1052.05","631.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","814.29","77.4","","348.09","348.09","348.09","1 through 10","122.35","894.24","percent of total billed charges",""
"CATHETER DORADO 5FR 4MM 4CM 135CM .035IN RBP24 PTA BALLOON DILATATION","SUP-ITM-10026306","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1052.05","631.23","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","151.71","14.42","","64.77","64.77","64.77","1 through 10","122.35","814.29","percent of total billed charges",""
"CATHETER DORADO 5FR 4MM 4CM 135CM .035IN RBP24 PTA BALLOON DILATATION","SUP-ITM-10026306","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1052.05","631.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","122.35","11.63","","145.58","110.37","145.58","1 through 10","122.35","814.29","percent of total billed charges",""
"CATHETER DORADO 5FR 4MM 4CM 135CM .035IN RBP24 PTA BALLOON DILATATION","SUP-ITM-10026306","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1052.05","631.23","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","765.05","72.72","","406.70","406.70","1055.24","1 through 10","122.35","814.29","percent of total billed charges",""
"CATHETER DORADO 5FR 4MM 4CM 135CM .035IN RBP24 PTA BALLOON DILATATION","SUP-ITM-10026306","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1052.05","631.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","661.74","62.9","","1069.88","677.14","4190.63","20","122.35","814.29","percent of total billed charges",""
"CATHETER DORADO 5FR 4MM 4CM 135CM .035IN RBP24 PTA BALLOON DILATATION","SUP-ITM-10026306","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1052.05","631.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","814.29","77.4","","348.09","348.09","348.09","1 through 10","122.35","814.29","percent of total billed charges",""
"CATHETER DRAINAGE 12FR 25CM .038IN MULTIPURPOSE 6SIDEPORT MAC LOC LOCKING LOOP","SUP-ITM-10026964","CDM","C1729","HCPCS","0272","RC","","","","both","","","487.02","292.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","56.64","11.63","","19.51","17.34","54.47","21","56.64","413.97","percent of total billed charges",""
"CATHETER DRAINAGE 12FR 25CM .038IN MULTIPURPOSE 6SIDEPORT MAC LOC LOCKING LOOP","SUP-ITM-10026964","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","487.02","292.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","56.64","11.63","","19.51","17.34","54.47","21","56.64","376.95","percent of total billed charges",""
"CATHETER DRAINAGE 12FR 25CM .038IN MULTIPURPOSE 6SIDEPORT MAC LOC LOCKING LOOP","SUP-ITM-10026964","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","487.02","292.21","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","212.93","43.72","","61.93","61.93","61.93","1 through 10","56.64","376.95","percent of total billed charges",""
"CATHETER DRAINAGE 12FR 25CM .038IN MULTIPURPOSE 6SIDEPORT MAC LOC LOCKING LOOP","SUP-ITM-10026964","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","487.02","292.21","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","354.16","72.72","","330.75","267.63","330.75","1 through 10","56.64","376.95","percent of total billed charges",""
"CATHETER DRAINAGE 12FR 25CM .038IN MULTIPURPOSE 6SIDEPORT MAC LOC LOCKING LOOP","SUP-ITM-10026964","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","487.02","292.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","306.34","62.9","","89.25","87.07","231.86","1 through 10","56.64","376.95","percent of total billed charges",""
"CATHETER DRAINAGE 12FR 25CM .038IN MULTIPURPOSE 6SIDEPORT MAC LOC LOCKING LOOP","SUP-ITM-10026964","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","487.02","292.21","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","354.16","72.72","","267.63","267.63","267.63","1 through 10","56.64","376.95","percent of total billed charges",""
"CATHETER DRAINAGE 17CM 30FRX12 NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE SHEATH","SUP-ITM-10115610","CDM","C1726","HCPCS","0272","RC","","","","both","","","2826.19","1695.71","AETNA [1001]","HB WDH AETNA COMMERCIAL","1972.68","69.8","","166.96","137.81","825.49","1 through 10","328.69","2402.26","percent of total billed charges",""
"CATHETER DRAINAGE 17CM 30FRX12 NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE SHEATH","SUP-ITM-10115610","CDM","C1726","HCPCS","0272","RC","","","","both","","","2826.19","1695.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1716.86","1716.86","1716.86","1 through 10","328.69","2402.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER DRAINAGE 17CM 30FRX12 NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE SHEATH","SUP-ITM-10115610","CDM","C1726","HCPCS","0272","RC","","","","both","","","2826.19","1695.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","4281.09","1182.65","4281.09","1 through 10","328.69","2402.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER DRAINAGE 17CM 30FRX12 NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE SHEATH","SUP-ITM-10115610","CDM","C1726","HCPCS","0272","RC","","","","both","","","2826.19","1695.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","328.69","11.63","","262.01","27.19","426.66","1 through 10","328.69","2402.26","percent of total billed charges",""
"CATHETER DRAINAGE 17CM 30FRX12 NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE SHEATH","SUP-ITM-10115610","CDM","C1726","HCPCS","0272","RC","","","","both","","","2826.19","1695.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2187.47","77.4","","1411.46","916.55","1411.46","1 through 10","328.69","2402.26","percent of total billed charges",""
"CATHETER DRAINAGE 17CM 30FRX12 NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE SHEATH","SUP-ITM-10115610","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2826.19","1695.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","328.69","11.63","","262.01","27.19","426.66","1 through 10","328.69","2187.47","percent of total billed charges",""
"CATHETER DRAINAGE 17CM 30FRX12 NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE SHEATH","SUP-ITM-10115610","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2826.19","1695.71","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1235.61","43.72","","517.05","517.05","517.05","1 through 10","328.69","2187.47","percent of total billed charges",""
"CATHETER DRAINAGE 17CM 30FRX12 NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE SHEATH","SUP-ITM-10115610","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2826.19","1695.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2055.21","72.72","","1556.61","860.02","1914.17","1 through 10","328.69","2187.47","percent of total billed charges",""
"CATHETER DRAINAGE 17CM 30FRX12 NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE SHEATH","SUP-ITM-10115610","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2826.19","1695.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1777.67","62.9","","1348.55","745.07","1348.55","19","328.69","2187.47","percent of total billed charges",""
"CATHETER DRAINAGE 17CM 30FRX12 NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE SHEATH","SUP-ITM-10115610","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2826.19","1695.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2187.47","77.4","","1411.46","916.55","1411.46","1 through 10","328.69","2187.47","percent of total billed charges",""
"CATHETER DRAINAGE 17CM 30FRX12 NEPHROMAX SILICONE COATED LOW PROFILE HIGH PRESSURE SHEATH","SUP-ITM-10115610","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2826.19","1695.71","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","2055.21","72.72","","860.02","860.02","860.02","1 through 10","328.69","2187.47","percent of total billed charges",""
"CATHETER EMERGE 2MM 20MM 144CM MONORAIL PTCA BALLOON DILATATION CORONARY","SUP-ITM-10170973","CDM","C1725","HCPCS","0272","RC","","","","both","","","449.15","269.49","AETNA [1001]","HB WDH AETNA COMMERCIAL","313.51","69.8","","351.75","351.75","351.75","1 through 10","52.24","381.78","percent of total billed charges",""
"CATHETER EMERGE 2MM 20MM 144CM MONORAIL PTCA BALLOON DILATATION CORONARY","SUP-ITM-10170973","CDM","C1725","HCPCS","0272","RC","","","","both","","","449.15","269.49","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","255.57","56.9","","898.30","898.30","898.30","1 through 10","52.24","381.78","percent of total billed charges",""
"CATHETER EMERGE 2MM 20MM 144CM MONORAIL PTCA BALLOON DILATATION CORONARY","SUP-ITM-10170973","CDM","C1725","HCPCS","0272","RC","","","","both","","","449.15","269.49","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","64.77","14.42","","64.77","64.77","64.77","1 through 10","52.24","381.78","percent of total billed charges",""
"CATHETER EMERGE 2MM 20MM 144CM MONORAIL PTCA BALLOON DILATATION CORONARY","SUP-ITM-10170973","CDM","C1725","HCPCS","0272","RC","","","","both","","","449.15","269.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","52.24","11.63","","145.58","110.37","145.58","1 through 10","52.24","381.78","percent of total billed charges",""
"CATHETER EMERGE 2MM 20MM 144CM MONORAIL PTCA BALLOON DILATATION CORONARY","SUP-ITM-10170973","CDM","C1725","HCPCS","0272","RC","","","","both","","","449.15","269.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","347.64","77.4","","348.09","348.09","348.09","1 through 10","52.24","381.78","percent of total billed charges",""
"CATHETER EMERGE 2MM 20MM 144CM MONORAIL PTCA BALLOON DILATATION CORONARY","SUP-ITM-10170973","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","449.15","269.49","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","64.77","14.42","","64.77","64.77","64.77","1 through 10","52.24","347.64","percent of total billed charges",""
"CATHETER EMERGE 2MM 20MM 144CM MONORAIL PTCA BALLOON DILATATION CORONARY","SUP-ITM-10170973","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","449.15","269.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","52.24","11.63","","145.58","110.37","145.58","1 through 10","52.24","347.64","percent of total billed charges",""
"CATHETER EMERGE 2MM 20MM 144CM MONORAIL PTCA BALLOON DILATATION CORONARY","SUP-ITM-10170973","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","449.15","269.49","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","326.62","72.72","","406.70","406.70","1055.24","1 through 10","52.24","347.64","percent of total billed charges",""
"CATHETER EMERGE 2MM 20MM 144CM MONORAIL PTCA BALLOON DILATATION CORONARY","SUP-ITM-10170973","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","449.15","269.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","282.52","62.9","","1069.88","677.14","4190.63","20","52.24","347.64","percent of total billed charges",""
"CATHETER EMERGE 2MM 20MM 144CM MONORAIL PTCA BALLOON DILATATION CORONARY","SUP-ITM-10170973","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","449.15","269.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","347.64","77.4","","348.09","348.09","348.09","1 through 10","52.24","347.64","percent of total billed charges",""
"CATHETER ENDOFLIP 16CM LF NASAL TIP CT/5EA","SUP-ITM-10213493","CDM","C1726","HCPCS","0272","RC","","","","both","","","3098.44","1859.06","AETNA [1001]","HB WDH AETNA COMMERCIAL","2162.71","69.8","","166.96","137.81","825.49","1 through 10","360.35","2633.67","percent of total billed charges",""
"CATHETER ENDOFLIP 16CM LF NASAL TIP CT/5EA","SUP-ITM-10213493","CDM","C1726","HCPCS","0272","RC","","","","both","","","3098.44","1859.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1716.86","1716.86","1716.86","1 through 10","360.35","2633.67","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER ENDOFLIP 16CM LF NASAL TIP CT/5EA","SUP-ITM-10213493","CDM","C1726","HCPCS","0272","RC","","","","both","","","3098.44","1859.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","4281.09","1182.65","4281.09","1 through 10","360.35","2633.67","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER ENDOFLIP 16CM LF NASAL TIP CT/5EA","SUP-ITM-10213493","CDM","C1726","HCPCS","0272","RC","","","","both","","","3098.44","1859.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","360.35","11.63","","262.01","27.19","426.66","1 through 10","360.35","2633.67","percent of total billed charges",""
"CATHETER ENDOFLIP 16CM LF NASAL TIP CT/5EA","SUP-ITM-10213493","CDM","C1726","HCPCS","0272","RC","","","","both","","","3098.44","1859.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2398.19","77.4","","1411.46","916.55","1411.46","1 through 10","360.35","2633.67","percent of total billed charges",""
"CATHETER ENDOFLIP 16CM LF NASAL TIP CT/5EA","SUP-ITM-10213493","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","3098.44","1859.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","360.35","11.63","","262.01","27.19","426.66","1 through 10","360.35","2398.19","percent of total billed charges",""
"CATHETER ENDOFLIP 16CM LF NASAL TIP CT/5EA","SUP-ITM-10213493","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","3098.44","1859.06","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1354.64","43.72","","517.05","517.05","517.05","1 through 10","360.35","2398.19","percent of total billed charges",""
"CATHETER ENDOFLIP 16CM LF NASAL TIP CT/5EA","SUP-ITM-10213493","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","3098.44","1859.06","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2253.19","72.72","","1556.61","860.02","1914.17","1 through 10","360.35","2398.19","percent of total billed charges",""
"CATHETER ENDOFLIP 16CM LF NASAL TIP CT/5EA","SUP-ITM-10213493","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","3098.44","1859.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1948.92","62.9","","1348.55","745.07","1348.55","19","360.35","2398.19","percent of total billed charges",""
"CATHETER ENDOFLIP 16CM LF NASAL TIP CT/5EA","SUP-ITM-10213493","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","3098.44","1859.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2398.19","77.4","","1411.46","916.55","1411.46","1 through 10","360.35","2398.19","percent of total billed charges",""
"CATHETER ENDOFLIP 16CM LF NASAL TIP CT/5EA","SUP-ITM-10213493","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","3098.44","1859.06","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","2253.19","72.72","","860.02","860.02","860.02","1 through 10","360.35","2398.19","percent of total billed charges",""
"CATHETER ESOFLIP 20MM DILATION BX/5EA","SUP-ITM-10238778","CDM","C1726","HCPCS","0272","RC","","","","both","","","2433.70","1460.22","AETNA [1001]","HB WDH AETNA COMMERCIAL","1698.72","69.8","","166.96","137.81","825.49","1 through 10","283.04","2068.65","percent of total billed charges",""
"CATHETER ESOFLIP 20MM DILATION BX/5EA","SUP-ITM-10238778","CDM","C1726","HCPCS","0272","RC","","","","both","","","2433.70","1460.22","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1716.86","1716.86","1716.86","1 through 10","283.04","2068.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER ESOFLIP 20MM DILATION BX/5EA","SUP-ITM-10238778","CDM","C1726","HCPCS","0272","RC","","","","both","","","2433.70","1460.22","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","4281.09","1182.65","4281.09","1 through 10","283.04","2068.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER ESOFLIP 20MM DILATION BX/5EA","SUP-ITM-10238778","CDM","C1726","HCPCS","0272","RC","","","","both","","","2433.70","1460.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","283.04","11.63","","262.01","27.19","426.66","1 through 10","283.04","2068.65","percent of total billed charges",""
"CATHETER ESOFLIP 20MM DILATION BX/5EA","SUP-ITM-10238778","CDM","C1726","HCPCS","0272","RC","","","","both","","","2433.70","1460.22","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1883.68","77.4","","1411.46","916.55","1411.46","1 through 10","283.04","2068.65","percent of total billed charges",""
"CATHETER ESOFLIP 20MM DILATION BX/5EA","SUP-ITM-10238778","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2433.70","1460.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","283.04","11.63","","262.01","27.19","426.66","1 through 10","283.04","1883.68","percent of total billed charges",""
"CATHETER ESOFLIP 20MM DILATION BX/5EA","SUP-ITM-10238778","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2433.70","1460.22","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1064.01","43.72","","517.05","517.05","517.05","1 through 10","283.04","1883.68","percent of total billed charges",""
"CATHETER ESOFLIP 20MM DILATION BX/5EA","SUP-ITM-10238778","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2433.70","1460.22","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1769.79","72.72","","1556.61","860.02","1914.17","1 through 10","283.04","1883.68","percent of total billed charges",""
"CATHETER ESOFLIP 20MM DILATION BX/5EA","SUP-ITM-10238778","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2433.70","1460.22","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1530.80","62.9","","1348.55","745.07","1348.55","19","283.04","1883.68","percent of total billed charges",""
"CATHETER ESOFLIP 20MM DILATION BX/5EA","SUP-ITM-10238778","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2433.70","1460.22","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1883.68","77.4","","1411.46","916.55","1411.46","1 through 10","283.04","1883.68","percent of total billed charges",""
"CATHETER ESOFLIP 20MM DILATION BX/5EA","SUP-ITM-10238778","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2433.70","1460.22","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","1769.79","72.72","","860.02","860.02","860.02","1 through 10","283.04","1883.68","percent of total billed charges",""
"CATHETER EXODUS ARRAY 12FR 25CM MP BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10261576","CDM","C1729","HCPCS","0272","RC","","","","both","","","573.53","344.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","66.70","11.63","","19.51","17.34","54.47","21","66.7","487.5","percent of total billed charges",""
"CATHETER EXODUS ARRAY 12FR 25CM MP BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10261576","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","573.53","344.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","66.70","11.63","","19.51","17.34","54.47","21","66.7","443.91","percent of total billed charges",""
"CATHETER EXODUS ARRAY 12FR 25CM MP BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10261576","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","573.53","344.12","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","250.75","43.72","","61.93","61.93","61.93","1 through 10","66.7","443.91","percent of total billed charges",""
"CATHETER EXODUS ARRAY 12FR 25CM MP BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10261576","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","573.53","344.12","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","417.07","72.72","","330.75","267.63","330.75","1 through 10","66.7","443.91","percent of total billed charges",""
"CATHETER EXODUS ARRAY 12FR 25CM MP BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10261576","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","573.53","344.12","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","360.75","62.9","","89.25","87.07","231.86","1 through 10","66.7","443.91","percent of total billed charges",""
"CATHETER EXODUS ARRAY 12FR 25CM MP BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10261576","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","573.53","344.12","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","417.07","72.72","","267.63","267.63","267.63","1 through 10","66.7","443.91","percent of total billed charges",""
"CATHETER EXTRACTOR PRO 7 TO 6FR 9 TO 12MM .035IN BALLOON RX RETRIEVAL TRIPLE LUMEN","SUP-ITM-10210681","CDM","C1773","HCPCS","0272","RC","","","","both","","","1032.01","619.21","AETNA [1001]","HB WDH AETNA COMMERCIAL","720.34","69.8","","421.75","101.11","421.75","1 through 10","120.02","877.21","percent of total billed charges",""
"CATHETER EXTRACTOR PRO 7 TO 6FR 9 TO 12MM .035IN BALLOON RX RETRIEVAL TRIPLE LUMEN","SUP-ITM-10210681","CDM","C1773","HCPCS","0272","RC","","","","both","","","1032.01","619.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1032.01","1032.01","1032.01","1 through 10","120.02","877.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER EXTRACTOR PRO 7 TO 6FR 9 TO 12MM .035IN BALLOON RX RETRIEVAL TRIPLE LUMEN","SUP-ITM-10210681","CDM","C1773","HCPCS","0272","RC","","","","both","","","1032.01","619.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","798.78","77.4","","468.85","468.85","468.85","1 through 10","120.02","877.21","percent of total billed charges",""
"CATHETER EXTRACTOR PRO 7 TO 6FR 9 TO 12MM .035IN BALLOON RX RETRIEVAL TRIPLE LUMEN","SUP-ITM-10210681","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","1032.01","619.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","649.13","62.9","","381.13","381.13","381.13","1 through 10","120.02","798.78","percent of total billed charges",""
"CATHETER EXTRACTOR PRO 7 TO 6FR 9 TO 12MM .035IN BALLOON RX RETRIEVAL TRIPLE LUMEN","SUP-ITM-10210681","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","1032.01","619.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","798.78","77.4","","468.85","468.85","468.85","1 through 10","120.02","798.78","percent of total billed charges",""
"CATHETER FUSION TITAN 12FR 4MM 4CM 190CM .035IN DILATION BALLOON BILIARY STERILE DISPOSABLE","SUP-ITM-10073717","CDM","C1726","HCPCS","0272","RC","","","","both","","","2259.57","1355.74","AETNA [1001]","HB WDH AETNA COMMERCIAL","1577.18","69.8","","166.96","137.81","825.49","1 through 10","262.79","1920.63","percent of total billed charges",""
"CATHETER FUSION TITAN 12FR 4MM 4CM 190CM .035IN DILATION BALLOON BILIARY STERILE DISPOSABLE","SUP-ITM-10073717","CDM","C1726","HCPCS","0272","RC","","","","both","","","2259.57","1355.74","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1716.86","1716.86","1716.86","1 through 10","262.79","1920.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER FUSION TITAN 12FR 4MM 4CM 190CM .035IN DILATION BALLOON BILIARY STERILE DISPOSABLE","SUP-ITM-10073717","CDM","C1726","HCPCS","0272","RC","","","","both","","","2259.57","1355.74","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","4281.09","1182.65","4281.09","1 through 10","262.79","1920.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER FUSION TITAN 12FR 4MM 4CM 190CM .035IN DILATION BALLOON BILIARY STERILE DISPOSABLE","SUP-ITM-10073717","CDM","C1726","HCPCS","0272","RC","","","","both","","","2259.57","1355.74","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","262.79","11.63","","262.01","27.19","426.66","1 through 10","262.79","1920.63","percent of total billed charges",""
"CATHETER FUSION TITAN 12FR 4MM 4CM 190CM .035IN DILATION BALLOON BILIARY STERILE DISPOSABLE","SUP-ITM-10073717","CDM","C1726","HCPCS","0272","RC","","","","both","","","2259.57","1355.74","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1748.91","77.4","","1411.46","916.55","1411.46","1 through 10","262.79","1920.63","percent of total billed charges",""
"CATHETER FUSION TITAN 12FR 4MM 4CM 190CM .035IN DILATION BALLOON BILIARY STERILE DISPOSABLE","SUP-ITM-10073717","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2259.57","1355.74","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","262.79","11.63","","262.01","27.19","426.66","1 through 10","262.79","1748.91","percent of total billed charges",""
"CATHETER FUSION TITAN 12FR 4MM 4CM 190CM .035IN DILATION BALLOON BILIARY STERILE DISPOSABLE","SUP-ITM-10073717","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2259.57","1355.74","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","987.88","43.72","","517.05","517.05","517.05","1 through 10","262.79","1748.91","percent of total billed charges",""
"CATHETER FUSION TITAN 12FR 4MM 4CM 190CM .035IN DILATION BALLOON BILIARY STERILE DISPOSABLE","SUP-ITM-10073717","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2259.57","1355.74","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1643.16","72.72","","1556.61","860.02","1914.17","1 through 10","262.79","1748.91","percent of total billed charges",""
"CATHETER FUSION TITAN 12FR 4MM 4CM 190CM .035IN DILATION BALLOON BILIARY STERILE DISPOSABLE","SUP-ITM-10073717","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2259.57","1355.74","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1421.27","62.9","","1348.55","745.07","1348.55","19","262.79","1748.91","percent of total billed charges",""
"CATHETER FUSION TITAN 12FR 4MM 4CM 190CM .035IN DILATION BALLOON BILIARY STERILE DISPOSABLE","SUP-ITM-10073717","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2259.57","1355.74","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1748.91","77.4","","1411.46","916.55","1411.46","1 through 10","262.79","1748.91","percent of total billed charges",""
"CATHETER FUSION TITAN 12FR 4MM 4CM 190CM .035IN DILATION BALLOON BILIARY STERILE DISPOSABLE","SUP-ITM-10073717","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2259.57","1355.74","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","1643.16","72.72","","860.02","860.02","860.02","1 through 10","262.79","1748.91","percent of total billed charges",""
"CATHETER GLIDECATH 4FR 65CM .038IN GUIDING STRAIGHT HYDROPHILIC COATED BX/5EA","SUP-ITM-10007069","CDM","C1887","HCPCS","0272","RC","","","","both","","","352.41","211.45","AETNA [1001]","HB WDH AETNA COMMERCIAL","245.98","69.8","","211.78","89.23","211.78","1 through 10","40.99","299.55","percent of total billed charges",""
"CATHETER GLIDECATH 4FR 65CM .038IN GUIDING STRAIGHT HYDROPHILIC COATED BX/5EA","SUP-ITM-10007069","CDM","C1887","HCPCS","0272","RC","","","","both","","","352.41","211.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","200.52","56.9","","383.50","68.20","383.50","1 through 10","40.99","299.55","percent of total billed charges",""
"CATHETER GLIDECATH 4FR 65CM .038IN GUIDING STRAIGHT HYDROPHILIC COATED BX/5EA","SUP-ITM-10007069","CDM","C1887","HCPCS","0272","RC","","","","both","","","352.41","211.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.99","11.63","","8.44","7.37","15.65","12","40.99","299.55","percent of total billed charges",""
"CATHETER GLIDECATH 4FR 65CM .038IN GUIDING STRAIGHT HYDROPHILIC COATED BX/5EA","SUP-ITM-10007069","CDM","C1887","HCPCS","0272","RC","","","","both","","","352.41","211.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","272.77","77.4","","41.50","41.50","214.21","1 through 10","40.99","299.55","percent of total billed charges",""
"CATHETER GLIDECATH 4FR 65CM .038IN GUIDING STRAIGHT HYDROPHILIC COATED BX/5EA","SUP-ITM-10007069","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","352.41","211.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.99","11.63","","8.44","7.37","15.65","12","40.99","272.77","percent of total billed charges",""
"CATHETER GLIDECATH 4FR 65CM .038IN GUIDING STRAIGHT HYDROPHILIC COATED BX/5EA","SUP-ITM-10007069","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","352.41","211.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","256.27","72.72","","92.96","38.94","158.55","24","40.99","272.77","percent of total billed charges",""
"CATHETER GLIDECATH 4FR 65CM .038IN GUIDING STRAIGHT HYDROPHILIC COATED BX/5EA","SUP-ITM-10007069","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","352.41","211.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","221.67","62.9","","208.96","33.74","457.91","69","40.99","272.77","percent of total billed charges",""
"CATHETER GLIDECATH 4FR 65CM .038IN GUIDING STRAIGHT HYDROPHILIC COATED BX/5EA","SUP-ITM-10007069","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","352.41","211.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","272.77","77.4","","41.50","41.50","214.21","1 through 10","40.99","272.77","percent of total billed charges",""
"CATHETER GOLD PROBE 7FR 2.33MM 300CM ELECTROHEMOSTASIS BIPOLAR STANDARD CONNECTOR SINGLE USE BX/1EA","SUP-ITM-10138924","CDM","C1886","HCPCS","0272","RC","","","","both","","","1109.61","665.77","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","17905.28","17905.28","17905.28","1 through 10","129.05","943.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER GOLD PROBE 7FR 2.33MM 300CM ELECTROHEMOSTASIS BIPOLAR STANDARD CONNECTOR SINGLE USE BX/1EA","SUP-ITM-10138924","CDM","C1886","HCPCS","0272","RC","","","","both","","","1109.61","665.77","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","5539.33","5539.33","5539.33","1 through 10","129.05","943.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER GOLD PROBE 7FR 2.33MM 300CM ELECTROHEMOSTASIS BIPOLAR STANDARD CONNECTOR SINGLE USE BX/1EA","SUP-ITM-10138924","CDM","C1886","HCPCS","0272","RC","","","","both","","","1109.61","665.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","129.05","11.63","","1314.65","1314.65","1314.65","1 through 10","129.05","943.17","percent of total billed charges",""
"CATHETER GOLD PROBE 7FR 2.33MM 300CM ELECTROHEMOSTASIS BIPOLAR STANDARD CONNECTOR SINGLE USE BX/1EA","SUP-ITM-10138924","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","1109.61","665.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","129.05","11.63","","1314.65","1314.65","1314.65","1 through 10","129.05","858.84","percent of total billed charges",""
"CATHETER GOLD PROBE 7FR 2.33MM 300CM ELECTROHEMOSTASIS BIPOLAR STANDARD CONNECTOR SINGLE USE BX/1EA","SUP-ITM-10138924","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","1109.61","665.77","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","806.91","72.72","","16561.06","16561.06","16561.06","1 through 10","129.05","858.84","percent of total billed charges",""
"CATHETER GORE MOLDED OCCLUDER BALLOON","SUP-ITM-10213329","CDM","C1725","HCPCS","0272","RC","","","","both","","","3448.09","2068.85","AETNA [1001]","HB WDH AETNA COMMERCIAL","2406.77","69.8","","351.75","351.75","351.75","1 through 10","401.01","2930.88","percent of total billed charges",""
"CATHETER GORE MOLDED OCCLUDER BALLOON","SUP-ITM-10213329","CDM","C1725","HCPCS","0272","RC","","","","both","","","3448.09","2068.85","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1961.96","56.9","","898.30","898.30","898.30","1 through 10","401.01","2930.88","percent of total billed charges",""
"CATHETER GORE MOLDED OCCLUDER BALLOON","SUP-ITM-10213329","CDM","C1725","HCPCS","0272","RC","","","","both","","","3448.09","2068.85","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","497.21","14.42","","64.77","64.77","64.77","1 through 10","401.01","2930.88","percent of total billed charges",""
"CATHETER GORE MOLDED OCCLUDER BALLOON","SUP-ITM-10213329","CDM","C1725","HCPCS","0272","RC","","","","both","","","3448.09","2068.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","401.01","11.63","","145.58","110.37","145.58","1 through 10","401.01","2930.88","percent of total billed charges",""
"CATHETER GORE MOLDED OCCLUDER BALLOON","SUP-ITM-10213329","CDM","C1725","HCPCS","0272","RC","","","","both","","","3448.09","2068.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2668.82","77.4","","348.09","348.09","348.09","1 through 10","401.01","2930.88","percent of total billed charges",""
"CATHETER GORE MOLDED OCCLUDER BALLOON","SUP-ITM-10213329","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","3448.09","2068.85","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","497.21","14.42","","64.77","64.77","64.77","1 through 10","401.01","2668.82","percent of total billed charges",""
"CATHETER GORE MOLDED OCCLUDER BALLOON","SUP-ITM-10213329","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","3448.09","2068.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","401.01","11.63","","145.58","110.37","145.58","1 through 10","401.01","2668.82","percent of total billed charges",""
"CATHETER GORE MOLDED OCCLUDER BALLOON","SUP-ITM-10213329","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","3448.09","2068.85","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2507.45","72.72","","406.70","406.70","1055.24","1 through 10","401.01","2668.82","percent of total billed charges",""
"CATHETER GORE MOLDED OCCLUDER BALLOON","SUP-ITM-10213329","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","3448.09","2068.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2168.85","62.9","","1069.88","677.14","4190.63","20","401.01","2668.82","percent of total billed charges",""
"CATHETER GORE MOLDED OCCLUDER BALLOON","SUP-ITM-10213329","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","3448.09","2068.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2668.82","77.4","","348.09","348.09","348.09","1 through 10","401.01","2668.82","percent of total billed charges",""
"CATHETER GUIDE 6.0FR 100CM LAUNCHER CORONARY AMPLATZ RT 1 TI6AL4V","SUP-ITM-10006657","CDM","C1887","HCPCS","0272","RC","","","","both","","","276.40","165.84","AETNA [1001]","HB WDH AETNA COMMERCIAL","192.93","69.8","","211.78","89.23","211.78","1 through 10","32.15","234.94","percent of total billed charges",""
"CATHETER GUIDE 6.0FR 100CM LAUNCHER CORONARY AMPLATZ RT 1 TI6AL4V","SUP-ITM-10006657","CDM","C1887","HCPCS","0272","RC","","","","both","","","276.40","165.84","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","157.27","56.9","","383.50","68.20","383.50","1 through 10","32.15","234.94","percent of total billed charges",""
"CATHETER GUIDE 6.0FR 100CM LAUNCHER CORONARY AMPLATZ RT 1 TI6AL4V","SUP-ITM-10006657","CDM","C1887","HCPCS","0272","RC","","","","both","","","276.40","165.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","32.15","11.63","","8.44","7.37","15.65","12","32.15","234.94","percent of total billed charges",""
"CATHETER GUIDE 6.0FR 100CM LAUNCHER CORONARY AMPLATZ RT 1 TI6AL4V","SUP-ITM-10006657","CDM","C1887","HCPCS","0272","RC","","","","both","","","276.40","165.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","213.93","77.4","","41.50","41.50","214.21","1 through 10","32.15","234.94","percent of total billed charges",""
"CATHETER GUIDE 6.0FR 100CM LAUNCHER CORONARY AMPLATZ RT 1 TI6AL4V","SUP-ITM-10006657","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","276.40","165.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","32.15","11.63","","8.44","7.37","15.65","12","32.15","213.93","percent of total billed charges",""
"CATHETER GUIDE 6.0FR 100CM LAUNCHER CORONARY AMPLATZ RT 1 TI6AL4V","SUP-ITM-10006657","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","276.40","165.84","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","201.00","72.72","","92.96","38.94","158.55","24","32.15","213.93","percent of total billed charges",""
"CATHETER GUIDE 6.0FR 100CM LAUNCHER CORONARY AMPLATZ RT 1 TI6AL4V","SUP-ITM-10006657","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","276.40","165.84","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","173.86","62.9","","208.96","33.74","457.91","69","32.15","213.93","percent of total billed charges",""
"CATHETER GUIDE 6.0FR 100CM LAUNCHER CORONARY AMPLATZ RT 1 TI6AL4V","SUP-ITM-10006657","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","276.40","165.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","213.93","77.4","","41.50","41.50","214.21","1 through 10","32.15","213.93","percent of total billed charges",""
"CATHETER HABIB 8FR 180CM ENDOHPB BIPOLAR RF BX/1EA","SUP-ITM-10146438","CDM","C1886","HCPCS","0272","RC","","","","both","","","7967.82","4780.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","17905.28","17905.28","17905.28","1 through 10","926.66","6772.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER HABIB 8FR 180CM ENDOHPB BIPOLAR RF BX/1EA","SUP-ITM-10146438","CDM","C1886","HCPCS","0272","RC","","","","both","","","7967.82","4780.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","5539.33","5539.33","5539.33","1 through 10","926.66","6772.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER HABIB 8FR 180CM ENDOHPB BIPOLAR RF BX/1EA","SUP-ITM-10146438","CDM","C1886","HCPCS","0272","RC","","","","both","","","7967.82","4780.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","926.66","11.63","","1314.65","1314.65","1314.65","1 through 10","926.66","6772.65","percent of total billed charges",""
"CATHETER HABIB 8FR 180CM ENDOHPB BIPOLAR RF BX/1EA","SUP-ITM-10146438","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","7967.82","4780.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","926.66","11.63","","1314.65","1314.65","1314.65","1 through 10","926.66","6167.09","percent of total billed charges",""
"CATHETER HABIB 8FR 180CM ENDOHPB BIPOLAR RF BX/1EA","SUP-ITM-10146438","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","7967.82","4780.69","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5794.20","72.72","","16561.06","16561.06","16561.06","1 through 10","926.66","6167.09","percent of total billed charges",""
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","both","","","1704.01","1022.41","AETNA [1001]","HB WDH AETNA COMMERCIAL","1189.40","69.8","","166.96","137.81","825.49","1 through 10","198.18","1448.41","percent of total billed charges",""
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","both","","","1704.01","1022.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1716.86","1716.86","1716.86","1 through 10","198.18","1448.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","both","","","1704.01","1022.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","4281.09","1182.65","4281.09","1 through 10","198.18","1448.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","both","","","1704.01","1022.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","198.18","11.63","","262.01","27.19","426.66","1 through 10","198.18","1448.41","percent of total billed charges",""
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","both","","","1704.01","1022.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1318.90","77.4","","1411.46","916.55","1411.46","1 through 10","198.18","1448.41","percent of total billed charges",""
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1704.01","1022.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","198.18","11.63","","262.01","27.19","426.66","1 through 10","198.18","1318.9","percent of total billed charges",""
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1704.01","1022.41","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","744.99","43.72","","517.05","517.05","517.05","1 through 10","198.18","1318.9","percent of total billed charges",""
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1704.01","1022.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1239.16","72.72","","1556.61","860.02","1914.17","1 through 10","198.18","1318.9","percent of total billed charges",""
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1704.01","1022.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1071.82","62.9","","1348.55","745.07","1348.55","19","198.18","1318.9","percent of total billed charges",""
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1704.01","1022.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1318.90","77.4","","1411.46","916.55","1411.46","1 through 10","198.18","1318.9","percent of total billed charges",""
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1704.01","1022.41","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","1239.16","72.72","","860.02","860.02","860.02","1 through 10","198.18","1318.9","percent of total billed charges",""
"CATHETER IMPRESS 5FR 15CM .018IN HYDROPHILIC MINI ACCESS KIT VASCULAR BX/10EA","SUP-ITM-10170142","CDM","C1894","HCPCS","0272","RC","","","","both","","","249.93","149.96","AETNA [1001]","HB WDH AETNA COMMERCIAL","174.45","69.8","","94.15","94.15","427.63","1 through 10","29.07","212.44","percent of total billed charges",""
"CATHETER IMPRESS 5FR 15CM .018IN HYDROPHILIC MINI ACCESS KIT VASCULAR BX/10EA","SUP-ITM-10170142","CDM","C1894","HCPCS","0272","RC","","","","both","","","249.93","149.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","29.07","212.44","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER IMPRESS 5FR 15CM .018IN HYDROPHILIC MINI ACCESS KIT VASCULAR BX/10EA","SUP-ITM-10170142","CDM","C1894","HCPCS","0272","RC","","","","both","","","249.93","149.96","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","142.21","56.9","","401.89","65.85","401.89","1 through 10","29.07","212.44","percent of total billed charges",""
"CATHETER IMPRESS 5FR 15CM .018IN HYDROPHILIC MINI ACCESS KIT VASCULAR BX/10EA","SUP-ITM-10170142","CDM","C1894","HCPCS","0272","RC","","","","both","","","249.93","149.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","29.07","11.63","","49.19","10.57","114.40","19","29.07","212.44","percent of total billed charges",""
"CATHETER IMPRESS 5FR 15CM .018IN HYDROPHILIC MINI ACCESS KIT VASCULAR BX/10EA","SUP-ITM-10170142","CDM","C1894","HCPCS","0272","RC","","","","both","","","249.93","149.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","193.45","77.4","","200.75","81.67","643.86","11","29.07","212.44","percent of total billed charges",""
"CATHETER IMPRESS 5FR 15CM .018IN HYDROPHILIC MINI ACCESS KIT VASCULAR BX/10EA","SUP-ITM-10170142","CDM","C1894","HCPCS","0272","RC","","","","both","","","249.93","149.96","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","29.07","212.44","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER IMPRESS 5FR 15CM .018IN HYDROPHILIC MINI ACCESS KIT VASCULAR BX/10EA","SUP-ITM-10170142","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","249.93","149.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","29.07","11.63","","49.19","10.57","114.40","19","29.07","193.45","percent of total billed charges",""
"CATHETER IMPRESS 5FR 15CM .018IN HYDROPHILIC MINI ACCESS KIT VASCULAR BX/10EA","SUP-ITM-10170142","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","249.93","149.96","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","156.91","62.78","","93.27","93.27","93.27","1 through 10","29.07","193.45","percent of total billed charges",""
"CATHETER IMPRESS 5FR 15CM .018IN HYDROPHILIC MINI ACCESS KIT VASCULAR BX/10EA","SUP-ITM-10170142","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","249.93","149.96","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","109.27","43.72","","363.22","363.22","363.22","1 through 10","29.07","193.45","percent of total billed charges",""
"CATHETER IMPRESS 5FR 15CM .018IN HYDROPHILIC MINI ACCESS KIT VASCULAR BX/10EA","SUP-ITM-10170142","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","249.93","149.96","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","181.75","72.72","","271.85","111.24","551.69","14","29.07","193.45","percent of total billed charges",""
"CATHETER IMPRESS 5FR 15CM .018IN HYDROPHILIC MINI ACCESS KIT VASCULAR BX/10EA","SUP-ITM-10170142","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","249.93","149.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","157.21","62.9","","706.53","93.60","938.00","53","29.07","193.45","percent of total billed charges",""
"CATHETER IMPRESS 5FR 15CM .018IN HYDROPHILIC MINI ACCESS KIT VASCULAR BX/10EA","SUP-ITM-10170142","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","249.93","149.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","193.45","77.4","","200.75","81.67","643.86","11","29.07","193.45","percent of total billed charges",""
"CATHETER NAVICROSS 4FR 135CM .035IN STRAIGHT SUPPORT RX S/S DOUBLE BRAID HYDROPHILIC COATED TIP BX/1EA","SUP-ITM-10100042","CDM","C1887","HCPCS","0272","RC","","","","both","","","1247.26","748.36","AETNA [1001]","HB WDH AETNA COMMERCIAL","870.59","69.8","","211.78","89.23","211.78","1 through 10","145.06","1060.17","percent of total billed charges",""
"CATHETER NAVICROSS 4FR 135CM .035IN STRAIGHT SUPPORT RX S/S DOUBLE BRAID HYDROPHILIC COATED TIP BX/1EA","SUP-ITM-10100042","CDM","C1887","HCPCS","0272","RC","","","","both","","","1247.26","748.36","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","709.69","56.9","","383.50","68.20","383.50","1 through 10","145.06","1060.17","percent of total billed charges",""
"CATHETER NAVICROSS 4FR 135CM .035IN STRAIGHT SUPPORT RX S/S DOUBLE BRAID HYDROPHILIC COATED TIP BX/1EA","SUP-ITM-10100042","CDM","C1887","HCPCS","0272","RC","","","","both","","","1247.26","748.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","145.06","11.63","","8.44","7.37","15.65","12","145.06","1060.17","percent of total billed charges",""
"CATHETER NAVICROSS 4FR 135CM .035IN STRAIGHT SUPPORT RX S/S DOUBLE BRAID HYDROPHILIC COATED TIP BX/1EA","SUP-ITM-10100042","CDM","C1887","HCPCS","0272","RC","","","","both","","","1247.26","748.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","965.38","77.4","","41.50","41.50","214.21","1 through 10","145.06","1060.17","percent of total billed charges",""
"CATHETER NAVICROSS 4FR 135CM .035IN STRAIGHT SUPPORT RX S/S DOUBLE BRAID HYDROPHILIC COATED TIP BX/1EA","SUP-ITM-10100042","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1247.26","748.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","145.06","11.63","","8.44","7.37","15.65","12","145.06","965.38","percent of total billed charges",""
"CATHETER NAVICROSS 4FR 135CM .035IN STRAIGHT SUPPORT RX S/S DOUBLE BRAID HYDROPHILIC COATED TIP BX/1EA","SUP-ITM-10100042","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1247.26","748.36","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","907.01","72.72","","92.96","38.94","158.55","24","145.06","965.38","percent of total billed charges",""
"CATHETER NAVICROSS 4FR 135CM .035IN STRAIGHT SUPPORT RX S/S DOUBLE BRAID HYDROPHILIC COATED TIP BX/1EA","SUP-ITM-10100042","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1247.26","748.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","784.53","62.9","","208.96","33.74","457.91","69","145.06","965.38","percent of total billed charges",""
"CATHETER NAVICROSS 4FR 135CM .035IN STRAIGHT SUPPORT RX S/S DOUBLE BRAID HYDROPHILIC COATED TIP BX/1EA","SUP-ITM-10100042","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1247.26","748.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","965.38","77.4","","41.50","41.50","214.21","1 through 10","145.06","965.38","percent of total billed charges",""
"CATHETER OPTICROSS 18 3.6FR 135CM 30MHZ IMAGING PERIPHERAL","SUP-ITM-10237161","CDM","C1753","HCPCS","0272","RC","","","","both","","","5182.50","3109.50","AETNA [1001]","HB WDH AETNA COMMERCIAL","3617.39","69.8","","3668.21","3668.21","3668.21","1 through 10","602.72","4405.13","percent of total billed charges",""
"CATHETER OPTICROSS 18 3.6FR 135CM 30MHZ IMAGING PERIPHERAL","SUP-ITM-10237161","CDM","C1753","HCPCS","0272","RC","","","","both","","","5182.50","3109.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2948.84","56.9","","5182.50","5182.50","5182.50","1 through 10","602.72","4405.13","percent of total billed charges",""
"CATHETER OPTICROSS 18 3.6FR 135CM 30MHZ IMAGING PERIPHERAL","SUP-ITM-10237161","CDM","C1753","HCPCS","0272","RC","","","","both","","","5182.50","3109.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4011.26","77.4","","4016.44","4016.44","4016.44","1 through 10","602.72","4405.13","percent of total billed charges",""
"CATHETER OPTICROSS 18 3.6FR 135CM 30MHZ IMAGING PERIPHERAL","SUP-ITM-10237161","CDM","C1753","HCPCS","0272","RC","","","","outpatient","","","5182.50","3109.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3768.71","72.72","","3768.71","3768.71","3768.71","1 through 10","602.72","4011.26","percent of total billed charges",""
"CATHETER OPTICROSS 18 3.6FR 135CM 30MHZ IMAGING PERIPHERAL","SUP-ITM-10237161","CDM","C1753","HCPCS","0272","RC","","","","outpatient","","","5182.50","3109.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3259.79","62.9","","7255.06","3177.91","9533.73","1 through 10","602.72","4011.26","percent of total billed charges",""
"CATHETER OPTICROSS 18 3.6FR 135CM 30MHZ IMAGING PERIPHERAL","SUP-ITM-10237161","CDM","C1753","HCPCS","0272","RC","","","","outpatient","","","5182.50","3109.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4011.26","77.4","","4016.44","4016.44","4016.44","1 through 10","602.72","4011.26","percent of total billed charges",""
"CATHETER OPTICROSS 35 8FR 15MHZ IMAGING PERIPHERAL","SUP-ITM-10282813","CDM","C1753","HCPCS","0272","RC","","","","both","","","5873.50","3524.10","AETNA [1001]","HB WDH AETNA COMMERCIAL","4099.70","69.8","","3668.21","3668.21","3668.21","1 through 10","683.09","4992.48","percent of total billed charges",""
"CATHETER OPTICROSS 35 8FR 15MHZ IMAGING PERIPHERAL","SUP-ITM-10282813","CDM","C1753","HCPCS","0272","RC","","","","both","","","5873.50","3524.10","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3342.02","56.9","","5182.50","5182.50","5182.50","1 through 10","683.09","4992.48","percent of total billed charges",""
"CATHETER OPTICROSS 35 8FR 15MHZ IMAGING PERIPHERAL","SUP-ITM-10282813","CDM","C1753","HCPCS","0272","RC","","","","both","","","5873.50","3524.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4546.09","77.4","","4016.44","4016.44","4016.44","1 through 10","683.09","4992.48","percent of total billed charges",""
"CATHETER OPTICROSS 35 8FR 15MHZ IMAGING PERIPHERAL","SUP-ITM-10282813","CDM","C1753","HCPCS","0272","RC","","","","outpatient","","","5873.50","3524.10","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4271.21","72.72","","3768.71","3768.71","3768.71","1 through 10","683.09","4546.09","percent of total billed charges",""
"CATHETER OPTICROSS 35 8FR 15MHZ IMAGING PERIPHERAL","SUP-ITM-10282813","CDM","C1753","HCPCS","0272","RC","","","","outpatient","","","5873.50","3524.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3694.43","62.9","","7255.06","3177.91","9533.73","1 through 10","683.09","4546.09","percent of total billed charges",""
"CATHETER OPTICROSS 35 8FR 15MHZ IMAGING PERIPHERAL","SUP-ITM-10282813","CDM","C1753","HCPCS","0272","RC","","","","outpatient","","","5873.50","3524.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4546.09","77.4","","4016.44","4016.44","4016.44","1 through 10","683.09","4546.09","percent of total billed charges",""
"CATHETER OPTICROSS 5FR 6MM 135CM .014IN CORONARY ULTRASOUND PROXIMAL IVUS IMAGING TRILON POLYMER BIO SLIDE COATED","SUP-ITM-10126025","CDM","C1753","HCPCS","0272","RC","","","","both","","","5044.30","3026.58","AETNA [1001]","HB WDH AETNA COMMERCIAL","3520.92","69.8","","3668.21","3668.21","3668.21","1 through 10","586.65","4287.66","percent of total billed charges",""
"CATHETER OPTICROSS 5FR 6MM 135CM .014IN CORONARY ULTRASOUND PROXIMAL IVUS IMAGING TRILON POLYMER BIO SLIDE COATED","SUP-ITM-10126025","CDM","C1753","HCPCS","0272","RC","","","","both","","","5044.30","3026.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2870.21","56.9","","5182.50","5182.50","5182.50","1 through 10","586.65","4287.66","percent of total billed charges",""
"CATHETER OPTICROSS 5FR 6MM 135CM .014IN CORONARY ULTRASOUND PROXIMAL IVUS IMAGING TRILON POLYMER BIO SLIDE COATED","SUP-ITM-10126025","CDM","C1753","HCPCS","0272","RC","","","","both","","","5044.30","3026.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3904.29","77.4","","4016.44","4016.44","4016.44","1 through 10","586.65","4287.66","percent of total billed charges",""
"CATHETER OPTICROSS 5FR 6MM 135CM .014IN CORONARY ULTRASOUND PROXIMAL IVUS IMAGING TRILON POLYMER BIO SLIDE COATED","SUP-ITM-10126025","CDM","C1753","HCPCS","0272","RC","","","","outpatient","","","5044.30","3026.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3668.21","72.72","","3768.71","3768.71","3768.71","1 through 10","586.65","3904.29","percent of total billed charges",""
"CATHETER OPTICROSS 5FR 6MM 135CM .014IN CORONARY ULTRASOUND PROXIMAL IVUS IMAGING TRILON POLYMER BIO SLIDE COATED","SUP-ITM-10126025","CDM","C1753","HCPCS","0272","RC","","","","outpatient","","","5044.30","3026.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3172.86","62.9","","7255.06","3177.91","9533.73","1 through 10","586.65","3904.29","percent of total billed charges",""
"CATHETER OPTICROSS 5FR 6MM 135CM .014IN CORONARY ULTRASOUND PROXIMAL IVUS IMAGING TRILON POLYMER BIO SLIDE COATED","SUP-ITM-10126025","CDM","C1753","HCPCS","0272","RC","","","","outpatient","","","5044.30","3026.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3904.29","77.4","","4016.44","4016.44","4016.44","1 through 10","586.65","3904.29","percent of total billed charges",""
"CATHETER PERIPHERAL CUTTING 7FR 8MM 20MM 135CM .018IN OTW BALLOON","SUP-ITM-10017257","CDM","C1725","HCPCS","0272","RC","","","","both","","","4861.19","2916.71","AETNA [1001]","HB WDH AETNA COMMERCIAL","3393.11","69.8","","351.75","351.75","351.75","1 through 10","565.36","4132.01","percent of total billed charges",""
"CATHETER PERIPHERAL CUTTING 7FR 8MM 20MM 135CM .018IN OTW BALLOON","SUP-ITM-10017257","CDM","C1725","HCPCS","0272","RC","","","","both","","","4861.19","2916.71","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2766.02","56.9","","898.30","898.30","898.30","1 through 10","565.36","4132.01","percent of total billed charges",""
"CATHETER PERIPHERAL CUTTING 7FR 8MM 20MM 135CM .018IN OTW BALLOON","SUP-ITM-10017257","CDM","C1725","HCPCS","0272","RC","","","","both","","","4861.19","2916.71","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","700.98","14.42","","64.77","64.77","64.77","1 through 10","565.36","4132.01","percent of total billed charges",""
"CATHETER PERIPHERAL CUTTING 7FR 8MM 20MM 135CM .018IN OTW BALLOON","SUP-ITM-10017257","CDM","C1725","HCPCS","0272","RC","","","","both","","","4861.19","2916.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","565.36","11.63","","145.58","110.37","145.58","1 through 10","565.36","4132.01","percent of total billed charges",""
"CATHETER PERIPHERAL CUTTING 7FR 8MM 20MM 135CM .018IN OTW BALLOON","SUP-ITM-10017257","CDM","C1725","HCPCS","0272","RC","","","","both","","","4861.19","2916.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3762.56","77.4","","348.09","348.09","348.09","1 through 10","565.36","4132.01","percent of total billed charges",""
"CATHETER PERIPHERAL CUTTING 7FR 8MM 20MM 135CM .018IN OTW BALLOON","SUP-ITM-10017257","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4861.19","2916.71","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","700.98","14.42","","64.77","64.77","64.77","1 through 10","565.36","3762.56","percent of total billed charges",""
"CATHETER PERIPHERAL CUTTING 7FR 8MM 20MM 135CM .018IN OTW BALLOON","SUP-ITM-10017257","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4861.19","2916.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","565.36","11.63","","145.58","110.37","145.58","1 through 10","565.36","3762.56","percent of total billed charges",""
"CATHETER PERIPHERAL CUTTING 7FR 8MM 20MM 135CM .018IN OTW BALLOON","SUP-ITM-10017257","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4861.19","2916.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3535.06","72.72","","406.70","406.70","1055.24","1 through 10","565.36","3762.56","percent of total billed charges",""
"CATHETER PERIPHERAL CUTTING 7FR 8MM 20MM 135CM .018IN OTW BALLOON","SUP-ITM-10017257","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4861.19","2916.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3057.69","62.9","","1069.88","677.14","4190.63","20","565.36","3762.56","percent of total billed charges",""
"CATHETER PERIPHERAL CUTTING 7FR 8MM 20MM 135CM .018IN OTW BALLOON","SUP-ITM-10017257","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4861.19","2916.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3762.56","77.4","","348.09","348.09","348.09","1 through 10","565.36","3762.56","percent of total billed charges",""
"CATHETER PRO RX 7-6FR 15-18MM 200CM .035IN RETRIEVAL EXTRACTOR STONE DISTAL INJECTION","SUP-ITM-10138963","CDM","C1726","HCPCS","0272","RC","","","","both","","","1032.01","619.21","AETNA [1001]","HB WDH AETNA COMMERCIAL","720.34","69.8","","166.96","137.81","825.49","1 through 10","120.02","877.21","percent of total billed charges",""
"CATHETER PRO RX 7-6FR 15-18MM 200CM .035IN RETRIEVAL EXTRACTOR STONE DISTAL INJECTION","SUP-ITM-10138963","CDM","C1726","HCPCS","0272","RC","","","","both","","","1032.01","619.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1716.86","1716.86","1716.86","1 through 10","120.02","877.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER PRO RX 7-6FR 15-18MM 200CM .035IN RETRIEVAL EXTRACTOR STONE DISTAL INJECTION","SUP-ITM-10138963","CDM","C1726","HCPCS","0272","RC","","","","both","","","1032.01","619.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","4281.09","1182.65","4281.09","1 through 10","120.02","877.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER PRO RX 7-6FR 15-18MM 200CM .035IN RETRIEVAL EXTRACTOR STONE DISTAL INJECTION","SUP-ITM-10138963","CDM","C1726","HCPCS","0272","RC","","","","both","","","1032.01","619.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","120.02","11.63","","262.01","27.19","426.66","1 through 10","120.02","877.21","percent of total billed charges",""
"CATHETER PRO RX 7-6FR 15-18MM 200CM .035IN RETRIEVAL EXTRACTOR STONE DISTAL INJECTION","SUP-ITM-10138963","CDM","C1726","HCPCS","0272","RC","","","","both","","","1032.01","619.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","798.78","77.4","","1411.46","916.55","1411.46","1 through 10","120.02","877.21","percent of total billed charges",""
"CATHETER PRO RX 7-6FR 15-18MM 200CM .035IN RETRIEVAL EXTRACTOR STONE DISTAL INJECTION","SUP-ITM-10138963","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1032.01","619.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","120.02","11.63","","262.01","27.19","426.66","1 through 10","120.02","798.78","percent of total billed charges",""
"CATHETER PRO RX 7-6FR 15-18MM 200CM .035IN RETRIEVAL EXTRACTOR STONE DISTAL INJECTION","SUP-ITM-10138963","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1032.01","619.21","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","451.19","43.72","","517.05","517.05","517.05","1 through 10","120.02","798.78","percent of total billed charges",""
"CATHETER PRO RX 7-6FR 15-18MM 200CM .035IN RETRIEVAL EXTRACTOR STONE DISTAL INJECTION","SUP-ITM-10138963","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1032.01","619.21","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","750.48","72.72","","1556.61","860.02","1914.17","1 through 10","120.02","798.78","percent of total billed charges",""
"CATHETER PRO RX 7-6FR 15-18MM 200CM .035IN RETRIEVAL EXTRACTOR STONE DISTAL INJECTION","SUP-ITM-10138963","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1032.01","619.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","649.13","62.9","","1348.55","745.07","1348.55","19","120.02","798.78","percent of total billed charges",""
"CATHETER PRO RX 7-6FR 15-18MM 200CM .035IN RETRIEVAL EXTRACTOR STONE DISTAL INJECTION","SUP-ITM-10138963","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1032.01","619.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","798.78","77.4","","1411.46","916.55","1411.46","1 through 10","120.02","798.78","percent of total billed charges",""
"CATHETER PRO RX 7-6FR 15-18MM 200CM .035IN RETRIEVAL EXTRACTOR STONE DISTAL INJECTION","SUP-ITM-10138963","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1032.01","619.21","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","750.48","72.72","","860.02","860.02","860.02","1 through 10","120.02","798.78","percent of total billed charges",""
"CATHETER PRO XL 7-6FR 12-15MM 200CM .035IN RETRIEVAL BILIARY BALLOON DISTAL INJECTION EXTRACTOR","SUP-ITM-10138959","CDM","C1773","HCPCS","0272","RC","","","","both","","","704.61","422.77","AETNA [1001]","HB WDH AETNA COMMERCIAL","491.82","69.8","","421.75","101.11","421.75","1 through 10","81.95","598.92","percent of total billed charges",""
"CATHETER PRO XL 7-6FR 12-15MM 200CM .035IN RETRIEVAL BILIARY BALLOON DISTAL INJECTION EXTRACTOR","SUP-ITM-10138959","CDM","C1773","HCPCS","0272","RC","","","","both","","","704.61","422.77","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1032.01","1032.01","1032.01","1 through 10","81.95","598.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER PRO XL 7-6FR 12-15MM 200CM .035IN RETRIEVAL BILIARY BALLOON DISTAL INJECTION EXTRACTOR","SUP-ITM-10138959","CDM","C1773","HCPCS","0272","RC","","","","both","","","704.61","422.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","545.37","77.4","","468.85","468.85","468.85","1 through 10","81.95","598.92","percent of total billed charges",""
"CATHETER PRO XL 7-6FR 12-15MM 200CM .035IN RETRIEVAL BILIARY BALLOON DISTAL INJECTION EXTRACTOR","SUP-ITM-10138959","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","704.61","422.77","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","443.20","62.9","","381.13","381.13","381.13","1 through 10","81.95","545.37","percent of total billed charges",""
"CATHETER PRO XL 7-6FR 12-15MM 200CM .035IN RETRIEVAL BILIARY BALLOON DISTAL INJECTION EXTRACTOR","SUP-ITM-10138959","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","704.61","422.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","545.37","77.4","","468.85","468.85","468.85","1 through 10","81.95","545.37","percent of total billed charges",""
"CATHETER PRUITT 4FR 27CM OCCLUSION INTRAVENOUS","SUP-ITM-10030723","CDM","C1889","HCPCS","0278","RC","","","","both","","","1927.89","1156.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","224.21","1638.71","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER PRUITT 4FR 27CM OCCLUSION INTRAVENOUS","SUP-ITM-10030723","CDM","C1889","HCPCS","0278","RC","","","","both","","","1927.89","1156.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","224.21","1638.71","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER PRUITT 4FR 27CM OCCLUSION INTRAVENOUS","SUP-ITM-10030723","CDM","C1889","HCPCS","0278","RC","","","","both","","","1927.89","1156.73","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1096.97","56.9","","0.63","0.63","0.63","1 through 10","224.21","1638.71","percent of total billed charges",""
"CATHETER PRUITT 4FR 27CM OCCLUSION INTRAVENOUS","SUP-ITM-10030723","CDM","C1889","HCPCS","0278","RC","","","","both","","","1927.89","1156.73","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","278.00","14.42","","317.14","317.14","317.14","1 through 10","224.21","1638.71","percent of total billed charges",""
"CATHETER PRUITT 4FR 27CM OCCLUSION INTRAVENOUS","SUP-ITM-10030723","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1927.89","1156.73","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","278.00","14.42","","317.14","317.14","317.14","1 through 10","224.21","1492.19","percent of total billed charges",""
"CATHETER PRUITT 4FR 27CM OCCLUSION INTRAVENOUS","SUP-ITM-10030723","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1927.89","1156.73","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1210.33","62.78","","1125.09","1125.09","1125.09","1 through 10","224.21","1492.19","percent of total billed charges",""
"CATHETER PRUITT 4FR 27CM OCCLUSION INTRAVENOUS","SUP-ITM-10030723","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1927.89","1156.73","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1401.96","72.72","","4732.50","1617.43","14180.40","1 through 10","224.21","1492.19","percent of total billed charges",""
"CATHETER PRUITT 4FR 27CM OCCLUSION INTRAVENOUS","SUP-ITM-10030723","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1927.89","1156.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1212.64","62.9","","3896.20","3341.38","3896.20","1 through 10","224.21","1492.19","percent of total billed charges",""
"CATHETER QUICK-CROSS 1.5FR 135CM .014IN SUPPORT GUIDING BX/5EA","SUP-ITM-10019370","CDM","C1887","HCPCS","0272","RC","","","","both","","","1209.25","725.55","AETNA [1001]","HB WDH AETNA COMMERCIAL","844.06","69.8","","211.78","89.23","211.78","1 through 10","140.64","1027.86","percent of total billed charges",""
"CATHETER QUICK-CROSS 1.5FR 135CM .014IN SUPPORT GUIDING BX/5EA","SUP-ITM-10019370","CDM","C1887","HCPCS","0272","RC","","","","both","","","1209.25","725.55","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","688.06","56.9","","383.50","68.20","383.50","1 through 10","140.64","1027.86","percent of total billed charges",""
"CATHETER QUICK-CROSS 1.5FR 135CM .014IN SUPPORT GUIDING BX/5EA","SUP-ITM-10019370","CDM","C1887","HCPCS","0272","RC","","","","both","","","1209.25","725.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","140.64","11.63","","8.44","7.37","15.65","12","140.64","1027.86","percent of total billed charges",""
"CATHETER QUICK-CROSS 1.5FR 135CM .014IN SUPPORT GUIDING BX/5EA","SUP-ITM-10019370","CDM","C1887","HCPCS","0272","RC","","","","both","","","1209.25","725.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","935.96","77.4","","41.50","41.50","214.21","1 through 10","140.64","1027.86","percent of total billed charges",""
"CATHETER QUICK-CROSS 1.5FR 135CM .014IN SUPPORT GUIDING BX/5EA","SUP-ITM-10019370","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1209.25","725.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","140.64","11.63","","8.44","7.37","15.65","12","140.64","935.96","percent of total billed charges",""
"CATHETER QUICK-CROSS 1.5FR 135CM .014IN SUPPORT GUIDING BX/5EA","SUP-ITM-10019370","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1209.25","725.55","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","879.37","72.72","","92.96","38.94","158.55","24","140.64","935.96","percent of total billed charges",""
"CATHETER QUICK-CROSS 1.5FR 135CM .014IN SUPPORT GUIDING BX/5EA","SUP-ITM-10019370","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1209.25","725.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","760.62","62.9","","208.96","33.74","457.91","69","140.64","935.96","percent of total billed charges",""
"CATHETER QUICK-CROSS 1.5FR 135CM .014IN SUPPORT GUIDING BX/5EA","SUP-ITM-10019370","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1209.25","725.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","935.96","77.4","","41.50","41.50","214.21","1 through 10","140.64","935.96","percent of total billed charges",""
"CATHETER QUICK-CROSS SELECT 5FR .014INX150CM GUIDE HYDROPHILIC VASCULAR RADIOPAQUE PTFE PEBAX ANGLED TIP BX/5EA","SUP-ITM-10282409","CDM","C1887","HCPCS","0272","RC","","","","both","","","1430.37","858.22","AETNA [1001]","HB WDH AETNA COMMERCIAL","998.40","69.8","","211.78","89.23","211.78","1 through 10","166.35","1215.81","percent of total billed charges",""
"CATHETER QUICK-CROSS SELECT 5FR .014INX150CM GUIDE HYDROPHILIC VASCULAR RADIOPAQUE PTFE PEBAX ANGLED TIP BX/5EA","SUP-ITM-10282409","CDM","C1887","HCPCS","0272","RC","","","","both","","","1430.37","858.22","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","813.88","56.9","","383.50","68.20","383.50","1 through 10","166.35","1215.81","percent of total billed charges",""
"CATHETER QUICK-CROSS SELECT 5FR .014INX150CM GUIDE HYDROPHILIC VASCULAR RADIOPAQUE PTFE PEBAX ANGLED TIP BX/5EA","SUP-ITM-10282409","CDM","C1887","HCPCS","0272","RC","","","","both","","","1430.37","858.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","166.35","11.63","","8.44","7.37","15.65","12","166.35","1215.81","percent of total billed charges",""
"CATHETER QUICK-CROSS SELECT 5FR .014INX150CM GUIDE HYDROPHILIC VASCULAR RADIOPAQUE PTFE PEBAX ANGLED TIP BX/5EA","SUP-ITM-10282409","CDM","C1887","HCPCS","0272","RC","","","","both","","","1430.37","858.22","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1107.11","77.4","","41.50","41.50","214.21","1 through 10","166.35","1215.81","percent of total billed charges",""
"CATHETER QUICK-CROSS SELECT 5FR .014INX150CM GUIDE HYDROPHILIC VASCULAR RADIOPAQUE PTFE PEBAX ANGLED TIP BX/5EA","SUP-ITM-10282409","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1430.37","858.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","166.35","11.63","","8.44","7.37","15.65","12","166.35","1107.11","percent of total billed charges",""
"CATHETER QUICK-CROSS SELECT 5FR .014INX150CM GUIDE HYDROPHILIC VASCULAR RADIOPAQUE PTFE PEBAX ANGLED TIP BX/5EA","SUP-ITM-10282409","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1430.37","858.22","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1040.17","72.72","","92.96","38.94","158.55","24","166.35","1107.11","percent of total billed charges",""
"CATHETER QUICK-CROSS SELECT 5FR .014INX150CM GUIDE HYDROPHILIC VASCULAR RADIOPAQUE PTFE PEBAX ANGLED TIP BX/5EA","SUP-ITM-10282409","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1430.37","858.22","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","899.70","62.9","","208.96","33.74","457.91","69","166.35","1107.11","percent of total billed charges",""
"CATHETER QUICK-CROSS SELECT 5FR .014INX150CM GUIDE HYDROPHILIC VASCULAR RADIOPAQUE PTFE PEBAX ANGLED TIP BX/5EA","SUP-ITM-10282409","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","1430.37","858.22","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1107.11","77.4","","41.50","41.50","214.21","1 through 10","166.35","1107.11","percent of total billed charges",""
"CATHETER RELIANT 8FR 10-46MM 100CM.038IN STENT GRAFT BALLOON","SUP-ITM-10018665","CDM","C1725","HCPCS","0272","RC","","","","both","","","3261.52","1956.91","AETNA [1001]","HB WDH AETNA COMMERCIAL","2276.54","69.8","","351.75","351.75","351.75","1 through 10","379.31","2772.29","percent of total billed charges",""
"CATHETER RELIANT 8FR 10-46MM 100CM.038IN STENT GRAFT BALLOON","SUP-ITM-10018665","CDM","C1725","HCPCS","0272","RC","","","","both","","","3261.52","1956.91","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1855.80","56.9","","898.30","898.30","898.30","1 through 10","379.31","2772.29","percent of total billed charges",""
"CATHETER RELIANT 8FR 10-46MM 100CM.038IN STENT GRAFT BALLOON","SUP-ITM-10018665","CDM","C1725","HCPCS","0272","RC","","","","both","","","3261.52","1956.91","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","470.31","14.42","","64.77","64.77","64.77","1 through 10","379.31","2772.29","percent of total billed charges",""
"CATHETER RELIANT 8FR 10-46MM 100CM.038IN STENT GRAFT BALLOON","SUP-ITM-10018665","CDM","C1725","HCPCS","0272","RC","","","","both","","","3261.52","1956.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","379.31","11.63","","145.58","110.37","145.58","1 through 10","379.31","2772.29","percent of total billed charges",""
"CATHETER RELIANT 8FR 10-46MM 100CM.038IN STENT GRAFT BALLOON","SUP-ITM-10018665","CDM","C1725","HCPCS","0272","RC","","","","both","","","3261.52","1956.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2524.42","77.4","","348.09","348.09","348.09","1 through 10","379.31","2772.29","percent of total billed charges",""
"CATHETER RELIANT 8FR 10-46MM 100CM.038IN STENT GRAFT BALLOON","SUP-ITM-10018665","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","3261.52","1956.91","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","470.31","14.42","","64.77","64.77","64.77","1 through 10","379.31","2524.42","percent of total billed charges",""
"CATHETER RELIANT 8FR 10-46MM 100CM.038IN STENT GRAFT BALLOON","SUP-ITM-10018665","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","3261.52","1956.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","379.31","11.63","","145.58","110.37","145.58","1 through 10","379.31","2524.42","percent of total billed charges",""
"CATHETER RELIANT 8FR 10-46MM 100CM.038IN STENT GRAFT BALLOON","SUP-ITM-10018665","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","3261.52","1956.91","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2371.78","72.72","","406.70","406.70","1055.24","1 through 10","379.31","2524.42","percent of total billed charges",""
"CATHETER RELIANT 8FR 10-46MM 100CM.038IN STENT GRAFT BALLOON","SUP-ITM-10018665","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","3261.52","1956.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2051.50","62.9","","1069.88","677.14","4190.63","20","379.31","2524.42","percent of total billed charges",""
"CATHETER RELIANT 8FR 10-46MM 100CM.038IN STENT GRAFT BALLOON","SUP-ITM-10018665","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","3261.52","1956.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2524.42","77.4","","348.09","348.09","348.09","1 through 10","379.31","2524.42","percent of total billed charges",""
"CATHETER SIDEKICK 70CM SUPPORT ANGLED TAPERED S/S","SUP-ITM-10155809","CDM","C1887","HCPCS","0272","RC","","","","both","","","2038.45","1223.07","AETNA [1001]","HB WDH AETNA COMMERCIAL","1422.84","69.8","","211.78","89.23","211.78","1 through 10","237.07","1732.68","percent of total billed charges",""
"CATHETER SIDEKICK 70CM SUPPORT ANGLED TAPERED S/S","SUP-ITM-10155809","CDM","C1887","HCPCS","0272","RC","","","","both","","","2038.45","1223.07","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1159.88","56.9","","383.50","68.20","383.50","1 through 10","237.07","1732.68","percent of total billed charges",""
"CATHETER SIDEKICK 70CM SUPPORT ANGLED TAPERED S/S","SUP-ITM-10155809","CDM","C1887","HCPCS","0272","RC","","","","both","","","2038.45","1223.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","237.07","11.63","","8.44","7.37","15.65","12","237.07","1732.68","percent of total billed charges",""
"CATHETER SIDEKICK 70CM SUPPORT ANGLED TAPERED S/S","SUP-ITM-10155809","CDM","C1887","HCPCS","0272","RC","","","","both","","","2038.45","1223.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1577.76","77.4","","41.50","41.50","214.21","1 through 10","237.07","1732.68","percent of total billed charges",""
"CATHETER SIDEKICK 70CM SUPPORT ANGLED TAPERED S/S","SUP-ITM-10155809","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2038.45","1223.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","237.07","11.63","","8.44","7.37","15.65","12","237.07","1577.76","percent of total billed charges",""
"CATHETER SIDEKICK 70CM SUPPORT ANGLED TAPERED S/S","SUP-ITM-10155809","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2038.45","1223.07","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1482.36","72.72","","92.96","38.94","158.55","24","237.07","1577.76","percent of total billed charges",""
"CATHETER SIDEKICK 70CM SUPPORT ANGLED TAPERED S/S","SUP-ITM-10155809","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2038.45","1223.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1282.19","62.9","","208.96","33.74","457.91","69","237.07","1577.76","percent of total billed charges",""
"CATHETER SIDEKICK 70CM SUPPORT ANGLED TAPERED S/S","SUP-ITM-10155809","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2038.45","1223.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1577.76","77.4","","41.50","41.50","214.21","1 through 10","237.07","1577.76","percent of total billed charges",""
"CATHETER SOFT VU 5FR 80CM .038IN ANGIOGRAPHY PERIPHERAL VASCULAR PIGTAIL NONBRAIDED SO1 BX/5EA","SUP-ITM-10007113","CDM","C1887","HCPCS","0272","RC","","","","both","","","98.12","58.87","AETNA [1001]","HB WDH AETNA COMMERCIAL","68.49","69.8","","211.78","89.23","211.78","1 through 10","11.41","83.4","percent of total billed charges",""
"CATHETER SOFT VU 5FR 80CM .038IN ANGIOGRAPHY PERIPHERAL VASCULAR PIGTAIL NONBRAIDED SO1 BX/5EA","SUP-ITM-10007113","CDM","C1887","HCPCS","0272","RC","","","","both","","","98.12","58.87","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","55.83","56.9","","383.50","68.20","383.50","1 through 10","11.41","83.4","percent of total billed charges",""
"CATHETER SOFT VU 5FR 80CM .038IN ANGIOGRAPHY PERIPHERAL VASCULAR PIGTAIL NONBRAIDED SO1 BX/5EA","SUP-ITM-10007113","CDM","C1887","HCPCS","0272","RC","","","","both","","","98.12","58.87","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","11.41","11.63","","8.44","7.37","15.65","12","11.41","83.4","percent of total billed charges",""
"CATHETER SOFT VU 5FR 80CM .038IN ANGIOGRAPHY PERIPHERAL VASCULAR PIGTAIL NONBRAIDED SO1 BX/5EA","SUP-ITM-10007113","CDM","C1887","HCPCS","0272","RC","","","","both","","","98.12","58.87","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","75.94","77.4","","41.50","41.50","214.21","1 through 10","11.41","83.4","percent of total billed charges",""
"CATHETER SOFT VU 5FR 80CM .038IN ANGIOGRAPHY PERIPHERAL VASCULAR PIGTAIL NONBRAIDED SO1 BX/5EA","SUP-ITM-10007113","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","98.12","58.87","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","11.41","11.63","","8.44","7.37","15.65","12","11.41","75.94","percent of total billed charges",""
"CATHETER SOFT VU 5FR 80CM .038IN ANGIOGRAPHY PERIPHERAL VASCULAR PIGTAIL NONBRAIDED SO1 BX/5EA","SUP-ITM-10007113","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","98.12","58.87","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","71.35","72.72","","92.96","38.94","158.55","24","11.41","75.94","percent of total billed charges",""
"CATHETER SOFT VU 5FR 80CM .038IN ANGIOGRAPHY PERIPHERAL VASCULAR PIGTAIL NONBRAIDED SO1 BX/5EA","SUP-ITM-10007113","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","98.12","58.87","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","61.72","62.9","","208.96","33.74","457.91","69","11.41","75.94","percent of total billed charges",""
"CATHETER SOFT VU 5FR 80CM .038IN ANGIOGRAPHY PERIPHERAL VASCULAR PIGTAIL NONBRAIDED SO1 BX/5EA","SUP-ITM-10007113","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","98.12","58.87","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","75.94","77.4","","41.50","41.50","214.21","1 through 10","11.41","75.94","percent of total billed charges",""
"CATHETER SOFT VU 5FR 90CM .035IN ANGIOGRAPHY PERIPHERAL VASCULAR PIGTAIL NONBRAIDED OMNI FLUSH BX/10EA","SUP-ITM-10149302","CDM","C1887","HCPCS","0272","RC","","","","both","","","87.76","52.66","AETNA [1001]","HB WDH AETNA COMMERCIAL","61.26","69.8","","211.78","89.23","211.78","1 through 10","10.21","74.6","percent of total billed charges",""
"CATHETER SOFT VU 5FR 90CM .035IN ANGIOGRAPHY PERIPHERAL VASCULAR PIGTAIL NONBRAIDED OMNI FLUSH BX/10EA","SUP-ITM-10149302","CDM","C1887","HCPCS","0272","RC","","","","both","","","87.76","52.66","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","49.94","56.9","","383.50","68.20","383.50","1 through 10","10.21","74.6","percent of total billed charges",""
"CATHETER SOFT VU 5FR 90CM .035IN ANGIOGRAPHY PERIPHERAL VASCULAR PIGTAIL NONBRAIDED OMNI FLUSH BX/10EA","SUP-ITM-10149302","CDM","C1887","HCPCS","0272","RC","","","","both","","","87.76","52.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.21","11.63","","8.44","7.37","15.65","12","10.21","74.6","percent of total billed charges",""
"CATHETER SOFT VU 5FR 90CM .035IN ANGIOGRAPHY PERIPHERAL VASCULAR PIGTAIL NONBRAIDED OMNI FLUSH BX/10EA","SUP-ITM-10149302","CDM","C1887","HCPCS","0272","RC","","","","both","","","87.76","52.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","67.93","77.4","","41.50","41.50","214.21","1 through 10","10.21","74.6","percent of total billed charges",""
"CATHETER SOFT VU 5FR 90CM .035IN ANGIOGRAPHY PERIPHERAL VASCULAR PIGTAIL NONBRAIDED OMNI FLUSH BX/10EA","SUP-ITM-10149302","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","87.76","52.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.21","11.63","","8.44","7.37","15.65","12","10.21","67.93","percent of total billed charges",""
"CATHETER SOFT VU 5FR 90CM .035IN ANGIOGRAPHY PERIPHERAL VASCULAR PIGTAIL NONBRAIDED OMNI FLUSH BX/10EA","SUP-ITM-10149302","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","87.76","52.66","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","63.82","72.72","","92.96","38.94","158.55","24","10.21","67.93","percent of total billed charges",""
"CATHETER SOFT VU 5FR 90CM .035IN ANGIOGRAPHY PERIPHERAL VASCULAR PIGTAIL NONBRAIDED OMNI FLUSH BX/10EA","SUP-ITM-10149302","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","87.76","52.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","55.20","62.9","","208.96","33.74","457.91","69","10.21","67.93","percent of total billed charges",""
"CATHETER SOFT VU 5FR 90CM .035IN ANGIOGRAPHY PERIPHERAL VASCULAR PIGTAIL NONBRAIDED OMNI FLUSH BX/10EA","SUP-ITM-10149302","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","87.76","52.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","67.93","77.4","","41.50","41.50","214.21","1 through 10","10.21","67.93","percent of total billed charges",""
"CATHETER SOFT-VU 5FR 100CM .035IN ANGIOGRAPHY HIGH TORQUE JB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10216574","CDM","C1887","HCPCS","0272","RC","","","","both","","","88.10","52.86","AETNA [1001]","HB WDH AETNA COMMERCIAL","61.49","69.8","","211.78","89.23","211.78","1 through 10","10.25","74.89","percent of total billed charges",""
"CATHETER SOFT-VU 5FR 100CM .035IN ANGIOGRAPHY HIGH TORQUE JB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10216574","CDM","C1887","HCPCS","0272","RC","","","","both","","","88.10","52.86","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","50.13","56.9","","383.50","68.20","383.50","1 through 10","10.25","74.89","percent of total billed charges",""
"CATHETER SOFT-VU 5FR 100CM .035IN ANGIOGRAPHY HIGH TORQUE JB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10216574","CDM","C1887","HCPCS","0272","RC","","","","both","","","88.10","52.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.25","11.63","","8.44","7.37","15.65","12","10.25","74.89","percent of total billed charges",""
"CATHETER SOFT-VU 5FR 100CM .035IN ANGIOGRAPHY HIGH TORQUE JB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10216574","CDM","C1887","HCPCS","0272","RC","","","","both","","","88.10","52.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","68.19","77.4","","41.50","41.50","214.21","1 through 10","10.25","74.89","percent of total billed charges",""
"CATHETER SOFT-VU 5FR 100CM .035IN ANGIOGRAPHY HIGH TORQUE JB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10216574","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","88.10","52.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.25","11.63","","8.44","7.37","15.65","12","10.25","68.19","percent of total billed charges",""
"CATHETER SOFT-VU 5FR 100CM .035IN ANGIOGRAPHY HIGH TORQUE JB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10216574","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","88.10","52.86","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","64.07","72.72","","92.96","38.94","158.55","24","10.25","68.19","percent of total billed charges",""
"CATHETER SOFT-VU 5FR 100CM .035IN ANGIOGRAPHY HIGH TORQUE JB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10216574","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","88.10","52.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","55.41","62.9","","208.96","33.74","457.91","69","10.25","68.19","percent of total billed charges",""
"CATHETER SOFT-VU 5FR 100CM .035IN ANGIOGRAPHY HIGH TORQUE JB - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10216574","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","88.10","52.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","68.19","77.4","","41.50","41.50","214.21","1 through 10","10.25","68.19","percent of total billed charges",""
"CATHETER SPRINTER 2.5MM 12MM 138CM OTW PTCA SEMICOMPLIANT BALLOON DILITATION ANGIOPLASTY","SUP-ITM-10012553","CDM","C1725","HCPCS","0272","RC","","","","both","","","587.35","352.41","AETNA [1001]","HB WDH AETNA COMMERCIAL","409.97","69.8","","351.75","351.75","351.75","1 through 10","68.31","499.25","percent of total billed charges",""
"CATHETER SPRINTER 2.5MM 12MM 138CM OTW PTCA SEMICOMPLIANT BALLOON DILITATION ANGIOPLASTY","SUP-ITM-10012553","CDM","C1725","HCPCS","0272","RC","","","","both","","","587.35","352.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","334.20","56.9","","898.30","898.30","898.30","1 through 10","68.31","499.25","percent of total billed charges",""
"CATHETER SPRINTER 2.5MM 12MM 138CM OTW PTCA SEMICOMPLIANT BALLOON DILITATION ANGIOPLASTY","SUP-ITM-10012553","CDM","C1725","HCPCS","0272","RC","","","","both","","","587.35","352.41","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","84.70","14.42","","64.77","64.77","64.77","1 through 10","68.31","499.25","percent of total billed charges",""
"CATHETER SPRINTER 2.5MM 12MM 138CM OTW PTCA SEMICOMPLIANT BALLOON DILITATION ANGIOPLASTY","SUP-ITM-10012553","CDM","C1725","HCPCS","0272","RC","","","","both","","","587.35","352.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","68.31","11.63","","145.58","110.37","145.58","1 through 10","68.31","499.25","percent of total billed charges",""
"CATHETER SPRINTER 2.5MM 12MM 138CM OTW PTCA SEMICOMPLIANT BALLOON DILITATION ANGIOPLASTY","SUP-ITM-10012553","CDM","C1725","HCPCS","0272","RC","","","","both","","","587.35","352.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","454.61","77.4","","348.09","348.09","348.09","1 through 10","68.31","499.25","percent of total billed charges",""
"CATHETER SPRINTER 2.5MM 12MM 138CM OTW PTCA SEMICOMPLIANT BALLOON DILITATION ANGIOPLASTY","SUP-ITM-10012553","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","587.35","352.41","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","84.70","14.42","","64.77","64.77","64.77","1 through 10","68.31","454.61","percent of total billed charges",""
"CATHETER SPRINTER 2.5MM 12MM 138CM OTW PTCA SEMICOMPLIANT BALLOON DILITATION ANGIOPLASTY","SUP-ITM-10012553","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","587.35","352.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","68.31","11.63","","145.58","110.37","145.58","1 through 10","68.31","454.61","percent of total billed charges",""
"CATHETER SPRINTER 2.5MM 12MM 138CM OTW PTCA SEMICOMPLIANT BALLOON DILITATION ANGIOPLASTY","SUP-ITM-10012553","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","587.35","352.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","427.12","72.72","","406.70","406.70","1055.24","1 through 10","68.31","454.61","percent of total billed charges",""
"CATHETER SPRINTER 2.5MM 12MM 138CM OTW PTCA SEMICOMPLIANT BALLOON DILITATION ANGIOPLASTY","SUP-ITM-10012553","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","587.35","352.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","369.44","62.9","","1069.88","677.14","4190.63","20","68.31","454.61","percent of total billed charges",""
"CATHETER SPRINTER 2.5MM 12MM 138CM OTW PTCA SEMICOMPLIANT BALLOON DILITATION ANGIOPLASTY","SUP-ITM-10012553","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","587.35","352.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","454.61","77.4","","348.09","348.09","348.09","1 through 10","68.31","454.61","percent of total billed charges",""
"CATHETER SPRINTER 3.5MM 15MM 138CM OTW PTCA DURATRAC COATED ANGIOPLASTY","SUP-ITM-10012567","CDM","C1725","HCPCS","0272","RC","","","","both","","","587.35","352.41","AETNA [1001]","HB WDH AETNA COMMERCIAL","409.97","69.8","","351.75","351.75","351.75","1 through 10","68.31","499.25","percent of total billed charges",""
"CATHETER SPRINTER 3.5MM 15MM 138CM OTW PTCA DURATRAC COATED ANGIOPLASTY","SUP-ITM-10012567","CDM","C1725","HCPCS","0272","RC","","","","both","","","587.35","352.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","334.20","56.9","","898.30","898.30","898.30","1 through 10","68.31","499.25","percent of total billed charges",""
"CATHETER SPRINTER 3.5MM 15MM 138CM OTW PTCA DURATRAC COATED ANGIOPLASTY","SUP-ITM-10012567","CDM","C1725","HCPCS","0272","RC","","","","both","","","587.35","352.41","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","84.70","14.42","","64.77","64.77","64.77","1 through 10","68.31","499.25","percent of total billed charges",""
"CATHETER SPRINTER 3.5MM 15MM 138CM OTW PTCA DURATRAC COATED ANGIOPLASTY","SUP-ITM-10012567","CDM","C1725","HCPCS","0272","RC","","","","both","","","587.35","352.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","68.31","11.63","","145.58","110.37","145.58","1 through 10","68.31","499.25","percent of total billed charges",""
"CATHETER SPRINTER 3.5MM 15MM 138CM OTW PTCA DURATRAC COATED ANGIOPLASTY","SUP-ITM-10012567","CDM","C1725","HCPCS","0272","RC","","","","both","","","587.35","352.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","454.61","77.4","","348.09","348.09","348.09","1 through 10","68.31","499.25","percent of total billed charges",""
"CATHETER SPRINTER 3.5MM 15MM 138CM OTW PTCA DURATRAC COATED ANGIOPLASTY","SUP-ITM-10012567","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","587.35","352.41","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","84.70","14.42","","64.77","64.77","64.77","1 through 10","68.31","454.61","percent of total billed charges",""
"CATHETER SPRINTER 3.5MM 15MM 138CM OTW PTCA DURATRAC COATED ANGIOPLASTY","SUP-ITM-10012567","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","587.35","352.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","68.31","11.63","","145.58","110.37","145.58","1 through 10","68.31","454.61","percent of total billed charges",""
"CATHETER SPRINTER 3.5MM 15MM 138CM OTW PTCA DURATRAC COATED ANGIOPLASTY","SUP-ITM-10012567","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","587.35","352.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","427.12","72.72","","406.70","406.70","1055.24","1 through 10","68.31","454.61","percent of total billed charges",""
"CATHETER SPRINTER 3.5MM 15MM 138CM OTW PTCA DURATRAC COATED ANGIOPLASTY","SUP-ITM-10012567","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","587.35","352.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","369.44","62.9","","1069.88","677.14","4190.63","20","68.31","454.61","percent of total billed charges",""
"CATHETER SPRINTER 3.5MM 15MM 138CM OTW PTCA DURATRAC COATED ANGIOPLASTY","SUP-ITM-10012567","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","587.35","352.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","454.61","77.4","","348.09","348.09","348.09","1 through 10","68.31","454.61","percent of total billed charges",""
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","both","","","11882.50","7129.50","AETNA [1001]","HB WDH AETNA COMMERCIAL","8293.99","69.8","","1552.48","1552.48","1552.48","1 through 10","1381.93","10100.13","percent of total billed charges",""
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","both","","","11882.50","7129.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","1381.93","10100.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","both","","","11882.50","7129.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","1381.93","10100.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","both","","","11882.50","7129.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6761.14","56.9","","0.63","0.63","0.63","1 through 10","1381.93","10100.13","percent of total billed charges",""
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","both","","","11882.50","7129.50","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1713.46","14.42","","317.14","317.14","317.14","1 through 10","1381.93","10100.13","percent of total billed charges",""
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","11882.50","7129.50","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1713.46","14.42","","317.14","317.14","317.14","1 through 10","1381.93","9197.06","percent of total billed charges",""
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","11882.50","7129.50","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","7459.83","62.78","","1125.09","1125.09","1125.09","1 through 10","1381.93","9197.06","percent of total billed charges",""
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","11882.50","7129.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8640.95","72.72","","4732.50","1617.43","14180.40","1 through 10","1381.93","9197.06","percent of total billed charges",""
"CATHETER SPYSCOPE DS II DELIVERY 2.0 ACCESS","SUP-ITM-10233922","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","11882.50","7129.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7474.09","62.9","","3896.20","3341.38","3896.20","1 through 10","1381.93","9197.06","percent of total billed charges",""
"CATHETER STENT 8MMX15CM 120 VASCULAR VIABAHN EPTFE GRFT HEP BIOACTIVE SURF PERIPH RADIOPQ MARK DELIV","SUP-ITM-10135258","CDM","C1874","HCPCS","0278","RC","","","","both","","","15655.00","9393.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","8907.70","56.9","","4336.72","1572.72","9255.66","15","1820.68","13306.75","percent of total billed charges",""
"CATHETER STENT 8MMX15CM 120 VASCULAR VIABAHN EPTFE GRFT HEP BIOACTIVE SURF PERIPH RADIOPQ MARK DELIV","SUP-ITM-10135258","CDM","C1874","HCPCS","0278","RC","","","","both","","","15655.00","9393.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12116.97","77.4","","2142.10","2142.10","2142.10","1 through 10","1820.68","13306.75","percent of total billed charges",""
"CATHETER STENT 8MMX15CM 120 VASCULAR VIABAHN EPTFE GRFT HEP BIOACTIVE SURF PERIPH RADIOPQ MARK DELIV","SUP-ITM-10135258","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","15655.00","9393.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","11384.32","72.72","","2261.23","2261.23","2261.23","1 through 10","1820.68","12116.97","percent of total billed charges",""
"CATHETER STENT 8MMX15CM 120 VASCULAR VIABAHN EPTFE GRFT HEP BIOACTIVE SURF PERIPH RADIOPQ MARK DELIV","SUP-ITM-10135258","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","15655.00","9393.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","9847.00","62.9","","4353.04","1741.32","8465.73","1 through 10","1820.68","12116.97","percent of total billed charges",""
"CATHETER STENT 8MMX15CM 120 VASCULAR VIABAHN EPTFE GRFT HEP BIOACTIVE SURF PERIPH RADIOPQ MARK DELIV","SUP-ITM-10135258","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","15655.00","9393.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12116.97","77.4","","2142.10","2142.10","2142.10","1 through 10","1820.68","12116.97","percent of total billed charges",""
"CATHETER SUPERTORQUE PLUS 6FR 100CM .038IN VASCULAR AMPLATZ RIGHT MODIFIED DIAGNOSTIC BX/5EA","SUP-ITM-10000417","CDM","C1887","HCPCS","0272","RC","","","","both","","","58.74","35.24","AETNA [1001]","HB WDH AETNA COMMERCIAL","41.00","69.8","","211.78","89.23","211.78","1 through 10","6.83","49.93","percent of total billed charges",""
"CATHETER SUPERTORQUE PLUS 6FR 100CM .038IN VASCULAR AMPLATZ RIGHT MODIFIED DIAGNOSTIC BX/5EA","SUP-ITM-10000417","CDM","C1887","HCPCS","0272","RC","","","","both","","","58.74","35.24","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","33.42","56.9","","383.50","68.20","383.50","1 through 10","6.83","49.93","percent of total billed charges",""
"CATHETER SUPERTORQUE PLUS 6FR 100CM .038IN VASCULAR AMPLATZ RIGHT MODIFIED DIAGNOSTIC BX/5EA","SUP-ITM-10000417","CDM","C1887","HCPCS","0272","RC","","","","both","","","58.74","35.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","6.83","11.63","","8.44","7.37","15.65","12","6.83","49.93","percent of total billed charges",""
"CATHETER SUPERTORQUE PLUS 6FR 100CM .038IN VASCULAR AMPLATZ RIGHT MODIFIED DIAGNOSTIC BX/5EA","SUP-ITM-10000417","CDM","C1887","HCPCS","0272","RC","","","","both","","","58.74","35.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","45.46","77.4","","41.50","41.50","214.21","1 through 10","6.83","49.93","percent of total billed charges",""
"CATHETER SUPERTORQUE PLUS 6FR 100CM .038IN VASCULAR AMPLATZ RIGHT MODIFIED DIAGNOSTIC BX/5EA","SUP-ITM-10000417","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","58.74","35.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","6.83","11.63","","8.44","7.37","15.65","12","6.83","45.46","percent of total billed charges",""
"CATHETER SUPERTORQUE PLUS 6FR 100CM .038IN VASCULAR AMPLATZ RIGHT MODIFIED DIAGNOSTIC BX/5EA","SUP-ITM-10000417","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","58.74","35.24","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","42.72","72.72","","92.96","38.94","158.55","24","6.83","45.46","percent of total billed charges",""
"CATHETER SUPERTORQUE PLUS 6FR 100CM .038IN VASCULAR AMPLATZ RIGHT MODIFIED DIAGNOSTIC BX/5EA","SUP-ITM-10000417","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","58.74","35.24","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","36.95","62.9","","208.96","33.74","457.91","69","6.83","45.46","percent of total billed charges",""
"CATHETER SUPERTORQUE PLUS 6FR 100CM .038IN VASCULAR AMPLATZ RIGHT MODIFIED DIAGNOSTIC BX/5EA","SUP-ITM-10000417","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","58.74","35.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","45.46","77.4","","41.50","41.50","214.21","1 through 10","6.83","45.46","percent of total billed charges",""
"CATHETER TEMPO 5FR 65CM BERENSTEIN II DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10081552","CDM","C1887","HCPCS","0272","RC","","","","both","","","114.02","68.41","AETNA [1001]","HB WDH AETNA COMMERCIAL","79.59","69.8","","211.78","89.23","211.78","1 through 10","13.26","96.92","percent of total billed charges",""
"CATHETER TEMPO 5FR 65CM BERENSTEIN II DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10081552","CDM","C1887","HCPCS","0272","RC","","","","both","","","114.02","68.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","64.88","56.9","","383.50","68.20","383.50","1 through 10","13.26","96.92","percent of total billed charges",""
"CATHETER TEMPO 5FR 65CM BERENSTEIN II DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10081552","CDM","C1887","HCPCS","0272","RC","","","","both","","","114.02","68.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","13.26","11.63","","8.44","7.37","15.65","12","13.26","96.92","percent of total billed charges",""
"CATHETER TEMPO 5FR 65CM BERENSTEIN II DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10081552","CDM","C1887","HCPCS","0272","RC","","","","both","","","114.02","68.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","88.25","77.4","","41.50","41.50","214.21","1 through 10","13.26","96.92","percent of total billed charges",""
"CATHETER TEMPO 5FR 65CM BERENSTEIN II DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10081552","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","114.02","68.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","13.26","11.63","","8.44","7.37","15.65","12","13.26","88.25","percent of total billed charges",""
"CATHETER TEMPO 5FR 65CM BERENSTEIN II DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10081552","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","114.02","68.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","82.92","72.72","","92.96","38.94","158.55","24","13.26","88.25","percent of total billed charges",""
"CATHETER TEMPO 5FR 65CM BERENSTEIN II DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10081552","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","114.02","68.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","71.72","62.9","","208.96","33.74","457.91","69","13.26","88.25","percent of total billed charges",""
"CATHETER TEMPO 5FR 65CM BERENSTEIN II DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10081552","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","114.02","68.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","88.25","77.4","","41.50","41.50","214.21","1 through 10","13.26","88.25","percent of total billed charges",""
"CATHETER TEMPO AQUA 5FR 100CM HEADHUNTER I DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10081597","CDM","C1887","HCPCS","0272","RC","","","","both","","","420.82","252.49","AETNA [1001]","HB WDH AETNA COMMERCIAL","293.73","69.8","","211.78","89.23","211.78","1 through 10","48.94","357.7","percent of total billed charges",""
"CATHETER TEMPO AQUA 5FR 100CM HEADHUNTER I DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10081597","CDM","C1887","HCPCS","0272","RC","","","","both","","","420.82","252.49","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","239.45","56.9","","383.50","68.20","383.50","1 through 10","48.94","357.7","percent of total billed charges",""
"CATHETER TEMPO AQUA 5FR 100CM HEADHUNTER I DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10081597","CDM","C1887","HCPCS","0272","RC","","","","both","","","420.82","252.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","48.94","11.63","","8.44","7.37","15.65","12","48.94","357.7","percent of total billed charges",""
"CATHETER TEMPO AQUA 5FR 100CM HEADHUNTER I DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10081597","CDM","C1887","HCPCS","0272","RC","","","","both","","","420.82","252.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","325.71","77.4","","41.50","41.50","214.21","1 through 10","48.94","357.7","percent of total billed charges",""
"CATHETER TEMPO AQUA 5FR 100CM HEADHUNTER I DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10081597","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","420.82","252.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","48.94","11.63","","8.44","7.37","15.65","12","48.94","325.71","percent of total billed charges",""
"CATHETER TEMPO AQUA 5FR 100CM HEADHUNTER I DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10081597","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","420.82","252.49","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","306.02","72.72","","92.96","38.94","158.55","24","48.94","325.71","percent of total billed charges",""
"CATHETER TEMPO AQUA 5FR 100CM HEADHUNTER I DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10081597","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","420.82","252.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","264.70","62.9","","208.96","33.74","457.91","69","48.94","325.71","percent of total billed charges",""
"CATHETER TEMPO AQUA 5FR 100CM HEADHUNTER I DIAGNOSTIC PERIPHERAL BX/5EA","SUP-ITM-10081597","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","420.82","252.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","325.71","77.4","","41.50","41.50","214.21","1 through 10","48.94","325.71","percent of total billed charges",""
"CATHETER TRAY 7FRX5CM SINGLE LUMEN PICC ARROW FLEX STRAIGHT GUIDEWIRE SCALPEL VESSEL DILATOR CS/25EA","SUP-ITM-10005787","CDM","C1751","HCPCS","0272","RC","","","","both","","","77.67","46.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","9.03","11.63","","214.95","191.07","214.95","1 through 10","9.03","66.02","percent of total billed charges",""
"CATHETER TRAY 7FRX5CM SINGLE LUMEN PICC ARROW FLEX STRAIGHT GUIDEWIRE SCALPEL VESSEL DILATOR CS/25EA","SUP-ITM-10005787","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","77.67","46.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","9.03","11.63","","214.95","191.07","214.95","1 through 10","9.03","60.12","percent of total billed charges",""
"CATHETER TRAY 7FRX5CM SINGLE LUMEN PICC ARROW FLEX STRAIGHT GUIDEWIRE SCALPEL VESSEL DILATOR CS/25EA","SUP-ITM-10005787","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","77.67","46.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","56.48","72.72","","3405.48","1135.16","3405.48","1 through 10","9.03","60.12","percent of total billed charges",""
"CATHETER TRAY 7FRX5CM SINGLE LUMEN PICC ARROW FLEX STRAIGHT GUIDEWIRE SCALPEL VESSEL DILATOR CS/25EA","SUP-ITM-10005787","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","77.67","46.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","48.85","62.9","","3937.48","3937.48","3937.48","1 through 10","9.03","60.12","percent of total billed charges",""
"CATHETER ULTRAVERSE 4FR 2MM 40MM 150CM .014IN OTW PTA SEMI COMPLIANT LOW PROFILE ATRAUMATIC TIP LF STERILE DISP","SUP-ITM-10079716","CDM","C1725","HCPCS","0272","RC","","","","both","","","967.40","580.44","AETNA [1001]","HB WDH AETNA COMMERCIAL","675.25","69.8","","351.75","351.75","351.75","1 through 10","112.51","822.29","percent of total billed charges",""
"CATHETER ULTRAVERSE 4FR 2MM 40MM 150CM .014IN OTW PTA SEMI COMPLIANT LOW PROFILE ATRAUMATIC TIP LF STERILE DISP","SUP-ITM-10079716","CDM","C1725","HCPCS","0272","RC","","","","both","","","967.40","580.44","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","550.45","56.9","","898.30","898.30","898.30","1 through 10","112.51","822.29","percent of total billed charges",""
"CATHETER ULTRAVERSE 4FR 2MM 40MM 150CM .014IN OTW PTA SEMI COMPLIANT LOW PROFILE ATRAUMATIC TIP LF STERILE DISP","SUP-ITM-10079716","CDM","C1725","HCPCS","0272","RC","","","","both","","","967.40","580.44","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","139.50","14.42","","64.77","64.77","64.77","1 through 10","112.51","822.29","percent of total billed charges",""
"CATHETER ULTRAVERSE 4FR 2MM 40MM 150CM .014IN OTW PTA SEMI COMPLIANT LOW PROFILE ATRAUMATIC TIP LF STERILE DISP","SUP-ITM-10079716","CDM","C1725","HCPCS","0272","RC","","","","both","","","967.40","580.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","112.51","11.63","","145.58","110.37","145.58","1 through 10","112.51","822.29","percent of total billed charges",""
"CATHETER ULTRAVERSE 4FR 2MM 40MM 150CM .014IN OTW PTA SEMI COMPLIANT LOW PROFILE ATRAUMATIC TIP LF STERILE DISP","SUP-ITM-10079716","CDM","C1725","HCPCS","0272","RC","","","","both","","","967.40","580.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","748.77","77.4","","348.09","348.09","348.09","1 through 10","112.51","822.29","percent of total billed charges",""
"CATHETER ULTRAVERSE 4FR 2MM 40MM 150CM .014IN OTW PTA SEMI COMPLIANT LOW PROFILE ATRAUMATIC TIP LF STERILE DISP","SUP-ITM-10079716","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","967.40","580.44","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","139.50","14.42","","64.77","64.77","64.77","1 through 10","112.51","748.77","percent of total billed charges",""
"CATHETER ULTRAVERSE 4FR 2MM 40MM 150CM .014IN OTW PTA SEMI COMPLIANT LOW PROFILE ATRAUMATIC TIP LF STERILE DISP","SUP-ITM-10079716","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","967.40","580.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","112.51","11.63","","145.58","110.37","145.58","1 through 10","112.51","748.77","percent of total billed charges",""
"CATHETER ULTRAVERSE 4FR 2MM 40MM 150CM .014IN OTW PTA SEMI COMPLIANT LOW PROFILE ATRAUMATIC TIP LF STERILE DISP","SUP-ITM-10079716","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","967.40","580.44","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","703.49","72.72","","406.70","406.70","1055.24","1 through 10","112.51","748.77","percent of total billed charges",""
"CATHETER ULTRAVERSE 4FR 2MM 40MM 150CM .014IN OTW PTA SEMI COMPLIANT LOW PROFILE ATRAUMATIC TIP LF STERILE DISP","SUP-ITM-10079716","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","967.40","580.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","608.49","62.9","","1069.88","677.14","4190.63","20","112.51","748.77","percent of total billed charges",""
"CATHETER ULTRAVERSE 4FR 2MM 40MM 150CM .014IN OTW PTA SEMI COMPLIANT LOW PROFILE ATRAUMATIC TIP LF STERILE DISP","SUP-ITM-10079716","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","967.40","580.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","748.77","77.4","","348.09","348.09","348.09","1 through 10","112.51","748.77","percent of total billed charges",""
"CATHETER ULTRAVERSE 5FR 6MM 100MM 130CM.035IN PTA DILATATION PERIPHERAL BALLOON","SUP-ITM-10147292","CDM","C1725","HCPCS","0272","RC","","","","both","","","483.70","290.22","AETNA [1001]","HB WDH AETNA COMMERCIAL","337.62","69.8","","351.75","351.75","351.75","1 through 10","56.25","411.15","percent of total billed charges",""
"CATHETER ULTRAVERSE 5FR 6MM 100MM 130CM.035IN PTA DILATATION PERIPHERAL BALLOON","SUP-ITM-10147292","CDM","C1725","HCPCS","0272","RC","","","","both","","","483.70","290.22","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","275.23","56.9","","898.30","898.30","898.30","1 through 10","56.25","411.15","percent of total billed charges",""
"CATHETER ULTRAVERSE 5FR 6MM 100MM 130CM.035IN PTA DILATATION PERIPHERAL BALLOON","SUP-ITM-10147292","CDM","C1725","HCPCS","0272","RC","","","","both","","","483.70","290.22","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","69.75","14.42","","64.77","64.77","64.77","1 through 10","56.25","411.15","percent of total billed charges",""
"CATHETER ULTRAVERSE 5FR 6MM 100MM 130CM.035IN PTA DILATATION PERIPHERAL BALLOON","SUP-ITM-10147292","CDM","C1725","HCPCS","0272","RC","","","","both","","","483.70","290.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","56.25","11.63","","145.58","110.37","145.58","1 through 10","56.25","411.15","percent of total billed charges",""
"CATHETER ULTRAVERSE 5FR 6MM 100MM 130CM.035IN PTA DILATATION PERIPHERAL BALLOON","SUP-ITM-10147292","CDM","C1725","HCPCS","0272","RC","","","","both","","","483.70","290.22","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","374.38","77.4","","348.09","348.09","348.09","1 through 10","56.25","411.15","percent of total billed charges",""
"CATHETER ULTRAVERSE 5FR 6MM 100MM 130CM.035IN PTA DILATATION PERIPHERAL BALLOON","SUP-ITM-10147292","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","483.70","290.22","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","69.75","14.42","","64.77","64.77","64.77","1 through 10","56.25","374.38","percent of total billed charges",""
"CATHETER ULTRAVERSE 5FR 6MM 100MM 130CM.035IN PTA DILATATION PERIPHERAL BALLOON","SUP-ITM-10147292","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","483.70","290.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","56.25","11.63","","145.58","110.37","145.58","1 through 10","56.25","374.38","percent of total billed charges",""
"CATHETER ULTRAVERSE 5FR 6MM 100MM 130CM.035IN PTA DILATATION PERIPHERAL BALLOON","SUP-ITM-10147292","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","483.70","290.22","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","351.75","72.72","","406.70","406.70","1055.24","1 through 10","56.25","374.38","percent of total billed charges",""
"CATHETER ULTRAVERSE 5FR 6MM 100MM 130CM.035IN PTA DILATATION PERIPHERAL BALLOON","SUP-ITM-10147292","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","483.70","290.22","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","304.25","62.9","","1069.88","677.14","4190.63","20","56.25","374.38","percent of total billed charges",""
"CATHETER ULTRAVERSE 5FR 6MM 100MM 130CM.035IN PTA DILATATION PERIPHERAL BALLOON","SUP-ITM-10147292","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","483.70","290.22","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","374.38","77.4","","348.09","348.09","348.09","1 through 10","56.25","374.38","percent of total billed charges",""
"CATHETER URETERAL 10.0FR 50CM DUAL LUMEN FLEXIBLE TIP HYDROPHILIC COATED POLYURETHANE","SUP-ITM-10078530","CDM","C1758","HCPCS","0272","RC","","","","both","","","382.81","229.69","AETNA [1001]","HB WDH AETNA COMMERCIAL","267.20","69.8","","50.27","50.27","50.27","1 through 10","44.52","325.39","percent of total billed charges",""
"CATHETER URETERAL 10.0FR 50CM DUAL LUMEN FLEXIBLE TIP HYDROPHILIC COATED POLYURETHANE","SUP-ITM-10078530","CDM","C1758","HCPCS","0272","RC","","","","both","","","382.81","229.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","64.87","64.87","64.87","1 through 10","44.52","325.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER URETERAL 10.0FR 50CM DUAL LUMEN FLEXIBLE TIP HYDROPHILIC COATED POLYURETHANE","SUP-ITM-10078530","CDM","C1758","HCPCS","0272","RC","","","","both","","","382.81","229.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","44.52","11.63","","28.87","11.98","61.67","1 through 10","44.52","325.39","percent of total billed charges",""
"CATHETER URETERAL 10.0FR 50CM DUAL LUMEN FLEXIBLE TIP HYDROPHILIC COATED POLYURETHANE","SUP-ITM-10078530","CDM","C1758","HCPCS","0272","RC","","","","both","","","382.81","229.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","296.29","77.4","","162.47","162.47","162.47","1 through 10","44.52","325.39","percent of total billed charges",""
"CATHETER URETERAL 10.0FR 50CM DUAL LUMEN FLEXIBLE TIP HYDROPHILIC COATED POLYURETHANE","SUP-ITM-10078530","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","382.81","229.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","44.52","11.63","","28.87","11.98","61.67","1 through 10","44.52","296.29","percent of total billed charges",""
"CATHETER URETERAL 10.0FR 50CM DUAL LUMEN FLEXIBLE TIP HYDROPHILIC COATED POLYURETHANE","SUP-ITM-10078530","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","382.81","229.69","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","240.33","62.78","","40.73","40.73","40.73","1 through 10","44.52","296.29","percent of total billed charges",""
"CATHETER URETERAL 10.0FR 50CM DUAL LUMEN FLEXIBLE TIP HYDROPHILIC COATED POLYURETHANE","SUP-ITM-10078530","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","382.81","229.69","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","167.36","43.72","","91.66","74.28","91.66","1 through 10","44.52","296.29","percent of total billed charges",""
"CATHETER URETERAL 10.0FR 50CM DUAL LUMEN FLEXIBLE TIP HYDROPHILIC COATED POLYURETHANE","SUP-ITM-10078530","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","382.81","229.69","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","278.38","72.72","","152.45","47.17","239.03","1 through 10","44.52","296.29","percent of total billed charges",""
"CATHETER URETERAL 10.0FR 50CM DUAL LUMEN FLEXIBLE TIP HYDROPHILIC COATED POLYURETHANE","SUP-ITM-10078530","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","382.81","229.69","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","278.38","72.72","","152.45","152.45","152.45","1 through 10","44.52","296.29","percent of total billed charges",""
"CATHETER URETERAL 10.0FR 50CM DUAL LUMEN FLEXIBLE TIP HYDROPHILIC COATED POLYURETHANE","SUP-ITM-10078530","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","382.81","229.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","203.73","53.22","","72.98","72.98","72.98","1 through 10","44.52","296.29","percent of total billed charges",""
"CATHETER URETERAL 10.0FR 50CM DUAL LUMEN FLEXIBLE TIP HYDROPHILIC COATED POLYURETHANE","SUP-ITM-10078530","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","382.81","229.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","240.79","62.9","","211.13","40.87","215.56","13","44.52","296.29","percent of total billed charges",""
"CATHETER URETERAL 10.0FR 50CM DUAL LUMEN FLEXIBLE TIP HYDROPHILIC COATED POLYURETHANE","SUP-ITM-10078530","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","382.81","229.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","296.29","77.4","","162.47","162.47","162.47","1 through 10","44.52","296.29","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DOUBLE LUMEN ROUND TIP POLYURETHANE","SUP-ITM-10078509","CDM","C1758","HCPCS","0272","RC","","","","both","","","279.16","167.50","AETNA [1001]","HB WDH AETNA COMMERCIAL","194.85","69.8","","50.27","50.27","50.27","1 through 10","32.47","237.29","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DOUBLE LUMEN ROUND TIP POLYURETHANE","SUP-ITM-10078509","CDM","C1758","HCPCS","0272","RC","","","","both","","","279.16","167.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","64.87","64.87","64.87","1 through 10","32.47","237.29","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER URETERAL 10FR 50CM DOUBLE LUMEN ROUND TIP POLYURETHANE","SUP-ITM-10078509","CDM","C1758","HCPCS","0272","RC","","","","both","","","279.16","167.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","32.47","11.63","","28.87","11.98","61.67","1 through 10","32.47","237.29","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DOUBLE LUMEN ROUND TIP POLYURETHANE","SUP-ITM-10078509","CDM","C1758","HCPCS","0272","RC","","","","both","","","279.16","167.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","216.07","77.4","","162.47","162.47","162.47","1 through 10","32.47","237.29","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DOUBLE LUMEN ROUND TIP POLYURETHANE","SUP-ITM-10078509","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","279.16","167.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","32.47","11.63","","28.87","11.98","61.67","1 through 10","32.47","216.07","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DOUBLE LUMEN ROUND TIP POLYURETHANE","SUP-ITM-10078509","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","279.16","167.50","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","175.26","62.78","","40.73","40.73","40.73","1 through 10","32.47","216.07","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DOUBLE LUMEN ROUND TIP POLYURETHANE","SUP-ITM-10078509","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","279.16","167.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","122.05","43.72","","91.66","74.28","91.66","1 through 10","32.47","216.07","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DOUBLE LUMEN ROUND TIP POLYURETHANE","SUP-ITM-10078509","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","279.16","167.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","203.01","72.72","","152.45","47.17","239.03","1 through 10","32.47","216.07","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DOUBLE LUMEN ROUND TIP POLYURETHANE","SUP-ITM-10078509","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","279.16","167.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","203.01","72.72","","152.45","152.45","152.45","1 through 10","32.47","216.07","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DOUBLE LUMEN ROUND TIP POLYURETHANE","SUP-ITM-10078509","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","279.16","167.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","148.57","53.22","","72.98","72.98","72.98","1 through 10","32.47","216.07","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DOUBLE LUMEN ROUND TIP POLYURETHANE","SUP-ITM-10078509","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","279.16","167.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","175.59","62.9","","211.13","40.87","215.56","13","32.47","216.07","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DOUBLE LUMEN ROUND TIP POLYURETHANE","SUP-ITM-10078509","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","279.16","167.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","216.07","77.4","","162.47","162.47","162.47","1 through 10","32.47","216.07","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","both","","","639.18","383.51","AETNA [1001]","HB WDH AETNA COMMERCIAL","446.15","69.8","","50.27","50.27","50.27","1 through 10","74.34","543.3","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","both","","","639.18","383.51","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","64.87","64.87","64.87","1 through 10","74.34","543.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","both","","","639.18","383.51","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","74.34","11.63","","28.87","11.98","61.67","1 through 10","74.34","543.3","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","both","","","639.18","383.51","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","494.73","77.4","","162.47","162.47","162.47","1 through 10","74.34","543.3","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","639.18","383.51","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","74.34","11.63","","28.87","11.98","61.67","1 through 10","74.34","494.73","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","639.18","383.51","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","401.28","62.78","","40.73","40.73","40.73","1 through 10","74.34","494.73","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","639.18","383.51","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","279.45","43.72","","91.66","74.28","91.66","1 through 10","74.34","494.73","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","639.18","383.51","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","464.81","72.72","","152.45","47.17","239.03","1 through 10","74.34","494.73","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","639.18","383.51","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","464.81","72.72","","152.45","152.45","152.45","1 through 10","74.34","494.73","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","639.18","383.51","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","340.17","53.22","","72.98","72.98","72.98","1 through 10","74.34","494.73","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","639.18","383.51","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","402.04","62.9","","211.13","40.87","215.56","13","74.34","494.73","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","639.18","383.51","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","494.73","77.4","","162.47","162.47","162.47","1 through 10","74.34","494.73","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","both","","","97.85","58.71","AETNA [1001]","HB WDH AETNA COMMERCIAL","68.30","69.8","","50.27","50.27","50.27","1 through 10","11.38","83.17","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","both","","","97.85","58.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","64.87","64.87","64.87","1 through 10","11.38","83.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","both","","","97.85","58.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","11.38","11.63","","28.87","11.98","61.67","1 through 10","11.38","83.17","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","both","","","97.85","58.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","75.74","77.4","","162.47","162.47","162.47","1 through 10","11.38","83.17","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","97.85","58.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","11.38","11.63","","28.87","11.98","61.67","1 through 10","11.38","75.74","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","97.85","58.71","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","61.43","62.78","","40.73","40.73","40.73","1 through 10","11.38","75.74","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","97.85","58.71","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","42.78","43.72","","91.66","74.28","91.66","1 through 10","11.38","75.74","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","97.85","58.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","71.16","72.72","","152.45","47.17","239.03","1 through 10","11.38","75.74","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","97.85","58.71","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","71.16","72.72","","152.45","152.45","152.45","1 through 10","11.38","75.74","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","97.85","58.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","52.08","53.22","","72.98","72.98","72.98","1 through 10","11.38","75.74","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","97.85","58.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","61.55","62.9","","211.13","40.87","215.56","13","11.38","75.74","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","97.85","58.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","75.74","77.4","","162.47","162.47","162.47","1 through 10","11.38","75.74","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","both","","","91.47","54.88","AETNA [1001]","HB WDH AETNA COMMERCIAL","63.85","69.8","","50.27","50.27","50.27","1 through 10","10.64","77.75","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","both","","","91.47","54.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","64.87","64.87","64.87","1 through 10","10.64","77.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","both","","","91.47","54.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.64","11.63","","28.87","11.98","61.67","1 through 10","10.64","77.75","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","both","","","91.47","54.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","70.80","77.4","","162.47","162.47","162.47","1 through 10","10.64","77.75","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","91.47","54.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.64","11.63","","28.87","11.98","61.67","1 through 10","10.64","70.8","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","91.47","54.88","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","57.42","62.78","","40.73","40.73","40.73","1 through 10","10.64","70.8","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","91.47","54.88","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","39.99","43.72","","91.66","74.28","91.66","1 through 10","10.64","70.8","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","91.47","54.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","66.52","72.72","","152.45","47.17","239.03","1 through 10","10.64","70.8","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","91.47","54.88","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","66.52","72.72","","152.45","152.45","152.45","1 through 10","10.64","70.8","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","91.47","54.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","48.68","53.22","","72.98","72.98","72.98","1 through 10","10.64","70.8","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","91.47","54.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","57.53","62.9","","211.13","40.87","215.56","13","10.64","70.8","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","91.47","54.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","70.80","77.4","","162.47","162.47","162.47","1 through 10","10.64","70.8","percent of total billed charges",""
"CATHETER URETERAL 6FR 70CM AXXCESS PERCUFLEX BX/10EA","SUP-ITM-10065047","CDM","C1758","HCPCS","0272","RC","","","","both","","","101.51","60.91","AETNA [1001]","HB WDH AETNA COMMERCIAL","70.85","69.8","","50.27","50.27","50.27","1 through 10","11.81","86.28","percent of total billed charges",""
"CATHETER URETERAL 6FR 70CM AXXCESS PERCUFLEX BX/10EA","SUP-ITM-10065047","CDM","C1758","HCPCS","0272","RC","","","","both","","","101.51","60.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","64.87","64.87","64.87","1 through 10","11.81","86.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER URETERAL 6FR 70CM AXXCESS PERCUFLEX BX/10EA","SUP-ITM-10065047","CDM","C1758","HCPCS","0272","RC","","","","both","","","101.51","60.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","11.81","11.63","","28.87","11.98","61.67","1 through 10","11.81","86.28","percent of total billed charges",""
"CATHETER URETERAL 6FR 70CM AXXCESS PERCUFLEX BX/10EA","SUP-ITM-10065047","CDM","C1758","HCPCS","0272","RC","","","","both","","","101.51","60.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","78.57","77.4","","162.47","162.47","162.47","1 through 10","11.81","86.28","percent of total billed charges",""
"CATHETER URETERAL 6FR 70CM AXXCESS PERCUFLEX BX/10EA","SUP-ITM-10065047","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","101.51","60.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","11.81","11.63","","28.87","11.98","61.67","1 through 10","11.81","78.57","percent of total billed charges",""
"CATHETER URETERAL 6FR 70CM AXXCESS PERCUFLEX BX/10EA","SUP-ITM-10065047","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","101.51","60.91","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","63.73","62.78","","40.73","40.73","40.73","1 through 10","11.81","78.57","percent of total billed charges",""
"CATHETER URETERAL 6FR 70CM AXXCESS PERCUFLEX BX/10EA","SUP-ITM-10065047","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","101.51","60.91","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","44.38","43.72","","91.66","74.28","91.66","1 through 10","11.81","78.57","percent of total billed charges",""
"CATHETER URETERAL 6FR 70CM AXXCESS PERCUFLEX BX/10EA","SUP-ITM-10065047","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","101.51","60.91","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","73.82","72.72","","152.45","47.17","239.03","1 through 10","11.81","78.57","percent of total billed charges",""
"CATHETER URETERAL 6FR 70CM AXXCESS PERCUFLEX BX/10EA","SUP-ITM-10065047","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","101.51","60.91","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","73.82","72.72","","152.45","152.45","152.45","1 through 10","11.81","78.57","percent of total billed charges",""
"CATHETER URETERAL 6FR 70CM AXXCESS PERCUFLEX BX/10EA","SUP-ITM-10065047","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","101.51","60.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","54.02","53.22","","72.98","72.98","72.98","1 through 10","11.81","78.57","percent of total billed charges",""
"CATHETER URETERAL 6FR 70CM AXXCESS PERCUFLEX BX/10EA","SUP-ITM-10065047","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","101.51","60.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","63.85","62.9","","211.13","40.87","215.56","13","11.81","78.57","percent of total billed charges",""
"CATHETER URETERAL 6FR 70CM AXXCESS PERCUFLEX BX/10EA","SUP-ITM-10065047","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","101.51","60.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","78.57","77.4","","162.47","162.47","162.47","1 through 10","11.81","78.57","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","both","","","83.11","49.87","AETNA [1001]","HB WDH AETNA COMMERCIAL","58.01","69.8","","50.27","50.27","50.27","1 through 10","9.67","70.64","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","both","","","83.11","49.87","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","64.87","64.87","64.87","1 through 10","9.67","70.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","both","","","83.11","49.87","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","9.67","11.63","","28.87","11.98","61.67","1 through 10","9.67","70.64","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","both","","","83.11","49.87","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","64.33","77.4","","162.47","162.47","162.47","1 through 10","9.67","70.64","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","83.11","49.87","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","9.67","11.63","","28.87","11.98","61.67","1 through 10","9.67","64.33","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","83.11","49.87","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","52.18","62.78","","40.73","40.73","40.73","1 through 10","9.67","64.33","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","83.11","49.87","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","36.34","43.72","","91.66","74.28","91.66","1 through 10","9.67","64.33","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","83.11","49.87","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","60.44","72.72","","152.45","47.17","239.03","1 through 10","9.67","64.33","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","83.11","49.87","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","60.44","72.72","","152.45","152.45","152.45","1 through 10","9.67","64.33","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","83.11","49.87","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","44.23","53.22","","72.98","72.98","72.98","1 through 10","9.67","64.33","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","83.11","49.87","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","52.28","62.9","","211.13","40.87","215.56","13","9.67","64.33","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","83.11","49.87","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","64.33","77.4","","162.47","162.47","162.47","1 through 10","9.67","64.33","percent of total billed charges",""
"CATHETER VIABAHN VBX 8MM 29MM 80CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188089","CDM","C1874","HCPCS","0278","RC","","","","both","","","12200.80","7320.48","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6942.26","56.9","","4336.72","1572.72","9255.66","15","1418.95","10370.68","percent of total billed charges",""
"CATHETER VIABAHN VBX 8MM 29MM 80CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188089","CDM","C1874","HCPCS","0278","RC","","","","both","","","12200.80","7320.48","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9443.42","77.4","","2142.10","2142.10","2142.10","1 through 10","1418.95","10370.68","percent of total billed charges",""
"CATHETER VIABAHN VBX 8MM 29MM 80CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188089","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12200.80","7320.48","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8872.42","72.72","","2261.23","2261.23","2261.23","1 through 10","1418.95","9443.42","percent of total billed charges",""
"CATHETER VIABAHN VBX 8MM 29MM 80CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188089","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12200.80","7320.48","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7674.30","62.9","","4353.04","1741.32","8465.73","1 through 10","1418.95","9443.42","percent of total billed charges",""
"CATHETER VIABAHN VBX 8MM 29MM 80CM STENT GRAFT ENDOPROSTHESIS","SUP-ITM-10188089","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12200.80","7320.48","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9443.42","77.4","","2142.10","2142.10","2142.10","1 through 10","1418.95","9443.42","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 100CM .07IN PTFE NYLON AMPLATZ LEFT 1.5 GUIDING","SUP-ITM-10019373","CDM","C1887","HCPCS","0272","RC","","","","both","","","351.79","211.07","AETNA [1001]","HB WDH AETNA COMMERCIAL","245.55","69.8","","211.78","89.23","211.78","1 through 10","40.91","299.02","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 100CM .07IN PTFE NYLON AMPLATZ LEFT 1.5 GUIDING","SUP-ITM-10019373","CDM","C1887","HCPCS","0272","RC","","","","both","","","351.79","211.07","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","200.17","56.9","","383.50","68.20","383.50","1 through 10","40.91","299.02","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 100CM .07IN PTFE NYLON AMPLATZ LEFT 1.5 GUIDING","SUP-ITM-10019373","CDM","C1887","HCPCS","0272","RC","","","","both","","","351.79","211.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.91","11.63","","8.44","7.37","15.65","12","40.91","299.02","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 100CM .07IN PTFE NYLON AMPLATZ LEFT 1.5 GUIDING","SUP-ITM-10019373","CDM","C1887","HCPCS","0272","RC","","","","both","","","351.79","211.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","272.29","77.4","","41.50","41.50","214.21","1 through 10","40.91","299.02","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 100CM .07IN PTFE NYLON AMPLATZ LEFT 1.5 GUIDING","SUP-ITM-10019373","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","351.79","211.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.91","11.63","","8.44","7.37","15.65","12","40.91","272.29","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 100CM .07IN PTFE NYLON AMPLATZ LEFT 1.5 GUIDING","SUP-ITM-10019373","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","351.79","211.07","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","255.82","72.72","","92.96","38.94","158.55","24","40.91","272.29","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 100CM .07IN PTFE NYLON AMPLATZ LEFT 1.5 GUIDING","SUP-ITM-10019373","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","351.79","211.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","221.28","62.9","","208.96","33.74","457.91","69","40.91","272.29","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 100CM .07IN PTFE NYLON AMPLATZ LEFT 1.5 GUIDING","SUP-ITM-10019373","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","351.79","211.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","272.29","77.4","","41.50","41.50","214.21","1 through 10","40.91","272.29","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 55CM .07IN PTFE NYLON INTERNAL MAMMARY ARTERY GUIDING","SUP-ITM-10012014","CDM","C1887","HCPCS","0272","RC","","","","both","","","399.05","239.43","AETNA [1001]","HB WDH AETNA COMMERCIAL","278.54","69.8","","211.78","89.23","211.78","1 through 10","46.41","339.19","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 55CM .07IN PTFE NYLON INTERNAL MAMMARY ARTERY GUIDING","SUP-ITM-10012014","CDM","C1887","HCPCS","0272","RC","","","","both","","","399.05","239.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","227.06","56.9","","383.50","68.20","383.50","1 through 10","46.41","339.19","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 55CM .07IN PTFE NYLON INTERNAL MAMMARY ARTERY GUIDING","SUP-ITM-10012014","CDM","C1887","HCPCS","0272","RC","","","","both","","","399.05","239.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","46.41","11.63","","8.44","7.37","15.65","12","46.41","339.19","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 55CM .07IN PTFE NYLON INTERNAL MAMMARY ARTERY GUIDING","SUP-ITM-10012014","CDM","C1887","HCPCS","0272","RC","","","","both","","","399.05","239.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","308.86","77.4","","41.50","41.50","214.21","1 through 10","46.41","339.19","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 55CM .07IN PTFE NYLON INTERNAL MAMMARY ARTERY GUIDING","SUP-ITM-10012014","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","399.05","239.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","46.41","11.63","","8.44","7.37","15.65","12","46.41","308.86","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 55CM .07IN PTFE NYLON INTERNAL MAMMARY ARTERY GUIDING","SUP-ITM-10012014","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","399.05","239.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","290.19","72.72","","92.96","38.94","158.55","24","46.41","308.86","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 55CM .07IN PTFE NYLON INTERNAL MAMMARY ARTERY GUIDING","SUP-ITM-10012014","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","399.05","239.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","251.00","62.9","","208.96","33.74","457.91","69","46.41","308.86","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 55CM .07IN PTFE NYLON INTERNAL MAMMARY ARTERY GUIDING","SUP-ITM-10012014","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","399.05","239.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","308.86","77.4","","41.50","41.50","214.21","1 through 10","46.41","308.86","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 55CM .07IN PTFE NYLON JUDKINS RIGHT 4 GUIDING","SUP-ITM-10081322","CDM","C1887","HCPCS","0272","RC","","","","both","","","399.05","239.43","AETNA [1001]","HB WDH AETNA COMMERCIAL","278.54","69.8","","211.78","89.23","211.78","1 through 10","46.41","339.19","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 55CM .07IN PTFE NYLON JUDKINS RIGHT 4 GUIDING","SUP-ITM-10081322","CDM","C1887","HCPCS","0272","RC","","","","both","","","399.05","239.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","227.06","56.9","","383.50","68.20","383.50","1 through 10","46.41","339.19","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 55CM .07IN PTFE NYLON JUDKINS RIGHT 4 GUIDING","SUP-ITM-10081322","CDM","C1887","HCPCS","0272","RC","","","","both","","","399.05","239.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","46.41","11.63","","8.44","7.37","15.65","12","46.41","339.19","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 55CM .07IN PTFE NYLON JUDKINS RIGHT 4 GUIDING","SUP-ITM-10081322","CDM","C1887","HCPCS","0272","RC","","","","both","","","399.05","239.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","308.86","77.4","","41.50","41.50","214.21","1 through 10","46.41","339.19","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 55CM .07IN PTFE NYLON JUDKINS RIGHT 4 GUIDING","SUP-ITM-10081322","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","399.05","239.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","46.41","11.63","","8.44","7.37","15.65","12","46.41","308.86","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 55CM .07IN PTFE NYLON JUDKINS RIGHT 4 GUIDING","SUP-ITM-10081322","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","399.05","239.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","290.19","72.72","","92.96","38.94","158.55","24","46.41","308.86","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 55CM .07IN PTFE NYLON JUDKINS RIGHT 4 GUIDING","SUP-ITM-10081322","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","399.05","239.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","251.00","62.9","","208.96","33.74","457.91","69","46.41","308.86","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 6FR 55CM .07IN PTFE NYLON JUDKINS RIGHT 4 GUIDING","SUP-ITM-10081322","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","399.05","239.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","308.86","77.4","","41.50","41.50","214.21","1 through 10","46.41","308.86","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 7FR 55CM .070IN HOCKEY STICK WIRE GUIDING","SUP-ITM-10081336","CDM","C1887","HCPCS","0272","RC","","","","both","","","399.05","239.43","AETNA [1001]","HB WDH AETNA COMMERCIAL","278.54","69.8","","211.78","89.23","211.78","1 through 10","46.41","339.19","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 7FR 55CM .070IN HOCKEY STICK WIRE GUIDING","SUP-ITM-10081336","CDM","C1887","HCPCS","0272","RC","","","","both","","","399.05","239.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","227.06","56.9","","383.50","68.20","383.50","1 through 10","46.41","339.19","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 7FR 55CM .070IN HOCKEY STICK WIRE GUIDING","SUP-ITM-10081336","CDM","C1887","HCPCS","0272","RC","","","","both","","","399.05","239.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","46.41","11.63","","8.44","7.37","15.65","12","46.41","339.19","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 7FR 55CM .070IN HOCKEY STICK WIRE GUIDING","SUP-ITM-10081336","CDM","C1887","HCPCS","0272","RC","","","","both","","","399.05","239.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","308.86","77.4","","41.50","41.50","214.21","1 through 10","46.41","339.19","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 7FR 55CM .070IN HOCKEY STICK WIRE GUIDING","SUP-ITM-10081336","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","399.05","239.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","46.41","11.63","","8.44","7.37","15.65","12","46.41","308.86","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 7FR 55CM .070IN HOCKEY STICK WIRE GUIDING","SUP-ITM-10081336","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","399.05","239.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","290.19","72.72","","92.96","38.94","158.55","24","46.41","308.86","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 7FR 55CM .070IN HOCKEY STICK WIRE GUIDING","SUP-ITM-10081336","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","399.05","239.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","251.00","62.9","","208.96","33.74","457.91","69","46.41","308.86","percent of total billed charges",""
"CATHETER VISTA BRITE TIP 7FR 55CM .070IN HOCKEY STICK WIRE GUIDING","SUP-ITM-10081336","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","399.05","239.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","308.86","77.4","","41.50","41.50","214.21","1 through 10","46.41","308.86","percent of total billed charges",""
"CATHETER XXL 7FR 14MM 20MM 75CM .035IN PTA BALLOON DILATATION","SUP-ITM-10008562","CDM","C1725","HCPCS","0272","RC","","","","both","","","1796.60","1077.96","AETNA [1001]","HB WDH AETNA COMMERCIAL","1254.03","69.8","","351.75","351.75","351.75","1 through 10","208.94","1527.11","percent of total billed charges",""
"CATHETER XXL 7FR 14MM 20MM 75CM .035IN PTA BALLOON DILATATION","SUP-ITM-10008562","CDM","C1725","HCPCS","0272","RC","","","","both","","","1796.60","1077.96","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1022.27","56.9","","898.30","898.30","898.30","1 through 10","208.94","1527.11","percent of total billed charges",""
"CATHETER XXL 7FR 14MM 20MM 75CM .035IN PTA BALLOON DILATATION","SUP-ITM-10008562","CDM","C1725","HCPCS","0272","RC","","","","both","","","1796.60","1077.96","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","259.07","14.42","","64.77","64.77","64.77","1 through 10","208.94","1527.11","percent of total billed charges",""
"CATHETER XXL 7FR 14MM 20MM 75CM .035IN PTA BALLOON DILATATION","SUP-ITM-10008562","CDM","C1725","HCPCS","0272","RC","","","","both","","","1796.60","1077.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","208.94","11.63","","145.58","110.37","145.58","1 through 10","208.94","1527.11","percent of total billed charges",""
"CATHETER XXL 7FR 14MM 20MM 75CM .035IN PTA BALLOON DILATATION","SUP-ITM-10008562","CDM","C1725","HCPCS","0272","RC","","","","both","","","1796.60","1077.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1390.57","77.4","","348.09","348.09","348.09","1 through 10","208.94","1527.11","percent of total billed charges",""
"CATHETER XXL 7FR 14MM 20MM 75CM .035IN PTA BALLOON DILATATION","SUP-ITM-10008562","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1796.60","1077.96","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","259.07","14.42","","64.77","64.77","64.77","1 through 10","208.94","1390.57","percent of total billed charges",""
"CATHETER XXL 7FR 14MM 20MM 75CM .035IN PTA BALLOON DILATATION","SUP-ITM-10008562","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1796.60","1077.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","208.94","11.63","","145.58","110.37","145.58","1 through 10","208.94","1390.57","percent of total billed charges",""
"CATHETER XXL 7FR 14MM 20MM 75CM .035IN PTA BALLOON DILATATION","SUP-ITM-10008562","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1796.60","1077.96","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1306.49","72.72","","406.70","406.70","1055.24","1 through 10","208.94","1390.57","percent of total billed charges",""
"CATHETER XXL 7FR 14MM 20MM 75CM .035IN PTA BALLOON DILATATION","SUP-ITM-10008562","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1796.60","1077.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1130.06","62.9","","1069.88","677.14","4190.63","20","208.94","1390.57","percent of total billed charges",""
"CATHETER XXL 7FR 14MM 20MM 75CM .035IN PTA BALLOON DILATATION","SUP-ITM-10008562","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","1796.60","1077.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1390.57","77.4","","348.09","348.09","348.09","1 through 10","208.94","1390.57","percent of total billed charges",""
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","both","","","400.00","240.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","279.20","69.8","","269.43","269.43","269.43","1 through 10","203.44","1326.74","percent of total billed charges",""
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","both","","","400.00","240.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1326.74","","Case rate ($1,326.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","413.34","413.29","590.01","1 through 10","203.44","1326.74","other","OPPS APC"
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","both","","","400.00","240.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","571.29","","Case rate ($571.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","386.00","386.00","386.00","1 through 10","203.44","1326.74","other","OPPS APC"
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","both","","","400.00","240.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","203.44","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","205.47","203.47","386.00","18","203.44","1326.74","other","OPPS APC"
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","both","","","400.00","240.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1072.40","","Case rate ($1,072.40). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","386.00","386.00","386.00","1 through 10","203.44","1326.74","other","OPPS APC"
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","both","","","400.00","240.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","213.82","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","427.70","213.85","427.70","1 through 10","203.44","1326.74","other","OPPS APC"
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","both","","","400.00","240.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","207.59","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","204.37","203.47","204.37","1 through 10","203.44","1326.74","other","OPPS APC"
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","both","","","400.00","240.00","MEDICARE [2001]","HB WDH MEDICARE","207.59","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.62","103.81","207.62","20","203.44","1326.74","other","OPPS APC"
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","both","","","400.00","240.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","207.59","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.47","191.94","207.62","15","203.44","1326.74","other","OPPS APC"
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","outpatient","","","400.00","240.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","57.68","14.42","","55.66","55.66","55.66","1 through 10","46.52","309.6","percent of total billed charges",""
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","outpatient","","","400.00","240.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","46.52","11.63","","53.15","53.15","97.48","15","46.52","309.6","percent of total billed charges",""
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","outpatient","","","400.00","240.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","","","Payment is accumulated by procedure count. Procedure 1, 62.78% of billed. Procedures 2 - 9999, 31.39% of billed.","726.99","726.99","726.99","1 through 10","46.52","309.6","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","outpatient","","","400.00","240.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","280.70","280.70","280.70","1 through 10","46.52","309.6","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","outpatient","","","400.00","240.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","251.60","62.9","","729.54","243.18","729.54","1 through 10","46.52","309.6","percent of total billed charges",""
"Cautery Chemical Tissue Granulat","PX-76000218","CDM","17250","CPT","0761","RC","","","","outpatient","","","400.00","240.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","46.52","11.63","","45.59","45.59","45.59","1 through 10","46.52","309.6","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","both","","","78.00","46.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","54.44","69.8","","52.35","47.18","52.35","1 through 10","3.64","66.3","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","inpatient","","","78.00","46.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","59.95","76.86","","47.25","47.25","47.25","1 through 10","51.64","59.95","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","outpatient","","","78.00","46.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","48.97","62.78","","47.09","47.09","47.09","1 through 10","5.13","60.37","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","outpatient","","","78.00","46.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","56.72","72.72","","54.54","54.54","163.62","14","5.13","60.37","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","outpatient","","","78.00","46.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","56.72","72.72","","54.54","54.54","54.54","1 through 10","5.13","60.37","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","outpatient","","","78.00","46.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","49.06","62.9","","141.75","47.25","181.60","32","5.13","60.37","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","outpatient","","","78.00","46.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","60.37","77.4","","58.13","58.13","58.13","1 through 10","5.13","60.37","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","outpatient","","","78.00","46.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","56.72","72.72","","54.54","54.54","54.54","1 through 10","5.13","60.37","percent of total billed charges",""
"Cellulitis With McC","602","MS-DRG","","","","","","","","inpatient","","","26719.30","16031.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","11025.20","","Case rate ($11,250.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,418.08, add-ons for qualifying new technology services are included. If operating cost exceeds $14,336.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,594.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,015.75 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,973.21 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.59. The transfer capital threshold is the transfer adjustment factor * $789.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7540.49","7540.49","11300.11","1 through 10","3975","54009.54","other","Inpatient DRG"
"Cellulitis With McC","602","MS-DRG","","","","","","","","inpatient","","","26719.30","16031.58","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","11587.71","","Case rate ($11,250.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,418.08, add-ons for qualifying new technology services are included. If operating cost exceeds $14,336.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,594.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,015.75 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,973.21 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.59. The transfer capital threshold is the transfer adjustment factor * $789.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11146.75","11146.75","11146.75","1 through 10","3975","54009.54","other","Inpatient DRG"
"Cellulitis With McC","602","MS-DRG","","","","","","","","inpatient","","","26719.30","16031.58","MARTIN'S POINT [160007]","HB WDH MEDICARE","11250.20","","Case rate ($11,250.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,418.08, add-ons for qualifying new technology services are included. If operating cost exceeds $14,336.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,594.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,015.75 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,973.21 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.59. The transfer capital threshold is the transfer adjustment factor * $789.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11300.11","11300.11","11300.11","1 through 10","3975","54009.54","other","Inpatient DRG"
"Cellulitis With McC","602","MS-DRG","","","","","","","","inpatient","","","26719.30","16031.58","MEDICARE [2001]","HB WDH MEDICARE","11250.20","","Case rate ($11,250.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,418.08, add-ons for qualifying new technology services are included. If operating cost exceeds $14,336.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,594.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,015.75 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,973.21 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.59. The transfer capital threshold is the transfer adjustment factor * $789.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11530.72","0.05","11560.37","17","3975","54009.54","other","Inpatient DRG"
"Cellulitis With McC","602","MS-DRG","","","","","","","","inpatient","","","26719.30","16031.58","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","11250.20","","Case rate ($11,250.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,418.08, add-ons for qualifying new technology services are included. If operating cost exceeds $14,336.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,594.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,015.75 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,973.21 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.59. The transfer capital threshold is the transfer adjustment factor * $789.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11300.11","5209.56","11300.11","1 through 10","3975","54009.54","other","Inpatient DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","21143.77","12686.26","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","7207.16","","Case rate ($7,065.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,555.94, add-ons for qualifying new technology services are included. If operating cost exceeds $10,474.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,288.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,137.14 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,111.07 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.82. The transfer capital threshold is the transfer adjustment factor * $483.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","11559.60","11559.60","11559.60","1 through 10","3975","33094.29","other","Inpatient DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","21143.77","12686.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","33094.29","","Fee schedule rate ($33,094.29). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","18653.07","18653.07","18653.07","1 through 10","3975","33094.29","case rate",""
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","21143.77","12686.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","13031.17","","Fee schedule rate ($13,031.17). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","12857.85","12857.85","12857.85","1 through 10","3975","33094.29","case rate",""
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","21143.77","12686.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","6924.52","","Case rate ($7,065.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,555.94, add-ons for qualifying new technology services are included. If operating cost exceeds $10,474.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,288.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,137.14 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,111.07 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.82. The transfer capital threshold is the transfer adjustment factor * $483.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6966.07","6949.10","6999.59","1 through 10","3975","33094.29","other","Inpatient DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","21143.77","12686.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","26358.03","","Fee schedule rate ($26,358.03). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","26007.46","26007.46","26007.46","1 through 10","3975","33094.29","case rate",""
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","21143.77","12686.26","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","7277.82","","Case rate ($7,065.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,555.94, add-ons for qualifying new technology services are included. If operating cost exceeds $10,474.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,288.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,137.14 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,111.07 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.82. The transfer capital threshold is the transfer adjustment factor * $483.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","6698.39","6698.39","6698.39","1 through 10","3975","33094.29","other","Inpatient DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","21143.77","12686.26","MEDICARE [2001]","HB WDH MEDICARE","7065.84","","Case rate ($7,065.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,555.94, add-ons for qualifying new technology services are included. If operating cost exceeds $10,474.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,288.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,137.14 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,111.07 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.82. The transfer capital threshold is the transfer adjustment factor * $483.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7090.92","4744.03","7108.23","26","3975","33094.29","other","Inpatient DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","21143.77","12686.26","TRICARE [160005]","HB WDH MEDICARE","7065.84","","Case rate ($7,065.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,555.94, add-ons for qualifying new technology services are included. If operating cost exceeds $10,474.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,288.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,137.14 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,111.07 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.82. The transfer capital threshold is the transfer adjustment factor * $483.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","3654.26","3654.26","3654.26","1 through 10","3975","33094.29","other","Inpatient DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","21143.77","12686.26","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7065.84","","Case rate ($7,065.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,555.94, add-ons for qualifying new technology services are included. If operating cost exceeds $10,474.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,288.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,137.14 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,111.07 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.82. The transfer capital threshold is the transfer adjustment factor * $483.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7090.92","957.19","7108.23","1 through 10","3975","33094.29","other","Inpatient DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","21143.77","12686.26","WELLSENSE NH [1050]","HB WDH MEDICARE","7065.84","","Case rate ($7,065.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,555.94, add-ons for qualifying new technology services are included. If operating cost exceeds $10,474.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,288.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,137.14 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,111.07 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.82. The transfer capital threshold is the transfer adjustment factor * $483.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7344.44","7344.44","7344.44","1 through 10","3975","33094.29","other","Inpatient DRG"
"CEMENT BONE 10CC HYDROSET XT INJECTABLE FREEZE DRIED","SUP-ITM-10232529","CDM","C1713","HCPCS","0278","RC","","","","both","","","13289.98","7973.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1545.62","11296.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CEMENT BONE 10CC HYDROSET XT INJECTABLE FREEZE DRIED","SUP-ITM-10232529","CDM","C1713","HCPCS","0278","RC","","","","both","","","13289.98","7973.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1545.62","11296.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CEMENT BONE 10CC HYDROSET XT INJECTABLE FREEZE DRIED","SUP-ITM-10232529","CDM","C1713","HCPCS","0278","RC","","","","both","","","13289.98","7973.99","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7562.00","56.9","","812.12","238.65","1587.46","163","1545.62","11296.48","percent of total billed charges",""
"CEMENT BONE 10CC HYDROSET XT INJECTABLE FREEZE DRIED","SUP-ITM-10232529","CDM","C1713","HCPCS","0278","RC","","","","both","","","13289.98","7973.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1545.62","11.63","","112.68","112.68","146.99","38","1545.62","11296.48","percent of total billed charges",""
"CEMENT BONE 10CC HYDROSET XT INJECTABLE FREEZE DRIED","SUP-ITM-10232529","CDM","C1713","HCPCS","0278","RC","","","","both","","","13289.98","7973.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10286.44","77.4","","303.98","303.98","5854.79","1 through 10","1545.62","11296.48","percent of total billed charges",""
"CEMENT BONE 10CC HYDROSET XT INJECTABLE FREEZE DRIED","SUP-ITM-10232529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13289.98","7973.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1545.62","11.63","","112.68","112.68","146.99","38","1545.62","10286.44","percent of total billed charges",""
"CEMENT BONE 10CC HYDROSET XT INJECTABLE FREEZE DRIED","SUP-ITM-10232529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13289.98","7973.99","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","8343.45","62.78","","780.86","208.94","10480.28","15","1545.62","10286.44","percent of total billed charges",""
"CEMENT BONE 10CC HYDROSET XT INJECTABLE FREEZE DRIED","SUP-ITM-10232529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13289.98","7973.99","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","5810.38","43.72","","179.76","179.76","179.76","1 through 10","1545.62","10286.44","percent of total billed charges",""
"CEMENT BONE 10CC HYDROSET XT INJECTABLE FREEZE DRIED","SUP-ITM-10232529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13289.98","7973.99","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","9664.47","72.72","","2355.45","298.99","3965.19","155","1545.62","10286.44","percent of total billed charges",""
"CEMENT BONE 10CC HYDROSET XT INJECTABLE FREEZE DRIED","SUP-ITM-10232529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13289.98","7973.99","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","9664.47","72.72","","3643.09","3643.09","3643.09","1 through 10","1545.62","10286.44","percent of total billed charges",""
"CEMENT BONE 10CC HYDROSET XT INJECTABLE FREEZE DRIED","SUP-ITM-10232529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13289.98","7973.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","7072.93","53.22","","554.28","554.28","554.28","16","1545.62","10286.44","percent of total billed charges",""
"CEMENT BONE 10CC HYDROSET XT INJECTABLE FREEZE DRIED","SUP-ITM-10232529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13289.98","7973.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8359.40","62.9","","619.64","173.09","2370.64","150","1545.62","10286.44","percent of total billed charges",""
"CEMENT BONE 10CC HYDROSET XT INJECTABLE FREEZE DRIED","SUP-ITM-10232529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13289.98","7973.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10286.44","77.4","","303.98","303.98","5854.79","1 through 10","1545.62","10286.44","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","670.27","402.16","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","77.95","569.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","670.27","402.16","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","77.95","569.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","670.27","402.16","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","381.38","56.9","","812.12","238.65","1587.46","163","77.95","569.73","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","670.27","402.16","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","77.95","11.63","","112.68","112.68","146.99","38","77.95","569.73","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","670.27","402.16","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","518.79","77.4","","303.98","303.98","5854.79","1 through 10","77.95","569.73","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","670.27","402.16","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","77.95","11.63","","112.68","112.68","146.99","38","77.95","518.79","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","670.27","402.16","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","420.80","62.78","","780.86","208.94","10480.28","15","77.95","518.79","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","670.27","402.16","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","293.04","43.72","","179.76","179.76","179.76","1 through 10","77.95","518.79","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","670.27","402.16","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","487.42","72.72","","2355.45","298.99","3965.19","155","77.95","518.79","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","670.27","402.16","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","487.42","72.72","","3643.09","3643.09","3643.09","1 through 10","77.95","518.79","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","670.27","402.16","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","356.72","53.22","","554.28","554.28","554.28","16","77.95","518.79","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","670.27","402.16","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","421.60","62.9","","619.64","173.09","2370.64","150","77.95","518.79","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","670.27","402.16","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","518.79","77.4","","303.98","303.98","5854.79","1 through 10","77.95","518.79","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.15","246.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","47.82","349.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.15","246.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","47.82","349.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.15","246.69","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","233.94","56.9","","812.12","238.65","1587.46","163","47.82","349.48","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.15","246.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","47.82","11.63","","112.68","112.68","146.99","38","47.82","349.48","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.15","246.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","318.23","77.4","","303.98","303.98","5854.79","1 through 10","47.82","349.48","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.15","246.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","47.82","11.63","","112.68","112.68","146.99","38","47.82","318.23","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.15","246.69","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","258.12","62.78","","780.86","208.94","10480.28","15","47.82","318.23","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.15","246.69","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","179.75","43.72","","179.76","179.76","179.76","1 through 10","47.82","318.23","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.15","246.69","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","298.99","72.72","","2355.45","298.99","3965.19","155","47.82","318.23","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.15","246.69","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","298.99","72.72","","3643.09","3643.09","3643.09","1 through 10","47.82","318.23","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.15","246.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","218.81","53.22","","554.28","554.28","554.28","16","47.82","318.23","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.15","246.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","258.61","62.9","","619.64","173.09","2370.64","150","47.82","318.23","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.15","246.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","318.23","77.4","","303.98","303.98","5854.79","1 through 10","47.82","318.23","percent of total billed charges",""
"CEMENT BONE 40GM CEMEX LOW VISCOSITY","SUP-ITM-10194929","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.60","248.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","48.22","352.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CEMENT BONE 40GM CEMEX LOW VISCOSITY","SUP-ITM-10194929","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.60","248.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","48.22","352.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CEMENT BONE 40GM CEMEX LOW VISCOSITY","SUP-ITM-10194929","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.60","248.76","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","235.91","56.9","","812.12","238.65","1587.46","163","48.22","352.41","percent of total billed charges",""
"CEMENT BONE 40GM CEMEX LOW VISCOSITY","SUP-ITM-10194929","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.60","248.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","48.22","11.63","","112.68","112.68","146.99","38","48.22","352.41","percent of total billed charges",""
"CEMENT BONE 40GM CEMEX LOW VISCOSITY","SUP-ITM-10194929","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.60","248.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","320.90","77.4","","303.98","303.98","5854.79","1 through 10","48.22","352.41","percent of total billed charges",""
"CEMENT BONE 40GM CEMEX LOW VISCOSITY","SUP-ITM-10194929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","48.22","11.63","","112.68","112.68","146.99","38","48.22","320.9","percent of total billed charges",""
"CEMENT BONE 40GM CEMEX LOW VISCOSITY","SUP-ITM-10194929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","260.29","62.78","","780.86","208.94","10480.28","15","48.22","320.9","percent of total billed charges",""
"CEMENT BONE 40GM CEMEX LOW VISCOSITY","SUP-ITM-10194929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","181.26","43.72","","179.76","179.76","179.76","1 through 10","48.22","320.9","percent of total billed charges",""
"CEMENT BONE 40GM CEMEX LOW VISCOSITY","SUP-ITM-10194929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","301.50","72.72","","2355.45","298.99","3965.19","155","48.22","320.9","percent of total billed charges",""
"CEMENT BONE 40GM CEMEX LOW VISCOSITY","SUP-ITM-10194929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","301.50","72.72","","3643.09","3643.09","3643.09","1 through 10","48.22","320.9","percent of total billed charges",""
"CEMENT BONE 40GM CEMEX LOW VISCOSITY","SUP-ITM-10194929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","220.65","53.22","","554.28","554.28","554.28","16","48.22","320.9","percent of total billed charges",""
"CEMENT BONE 40GM CEMEX LOW VISCOSITY","SUP-ITM-10194929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","260.78","62.9","","619.64","173.09","2370.64","150","48.22","320.9","percent of total billed charges",""
"CEMENT BONE 40GM CEMEX LOW VISCOSITY","SUP-ITM-10194929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","320.90","77.4","","303.98","303.98","5854.79","1 through 10","48.22","320.9","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","both","","","1968.66","1181.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","228.96","1673.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","both","","","1968.66","1181.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","228.96","1673.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","both","","","1968.66","1181.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1120.17","56.9","","812.12","238.65","1587.46","163","228.96","1673.36","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","both","","","1968.66","1181.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","228.96","11.63","","112.68","112.68","146.99","38","228.96","1673.36","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","both","","","1968.66","1181.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1523.74","77.4","","303.98","303.98","5854.79","1 through 10","228.96","1673.36","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","228.96","11.63","","112.68","112.68","146.99","38","228.96","1523.74","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1235.92","62.78","","780.86","208.94","10480.28","15","228.96","1523.74","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","860.70","43.72","","179.76","179.76","179.76","1 through 10","228.96","1523.74","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1431.61","72.72","","2355.45","298.99","3965.19","155","228.96","1523.74","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1431.61","72.72","","3643.09","3643.09","3643.09","1 through 10","228.96","1523.74","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1047.72","53.22","","554.28","554.28","554.28","16","228.96","1523.74","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1238.29","62.9","","619.64","173.09","2370.64","150","228.96","1523.74","percent of total billed charges",""
"CEMENT BONE INJECTABLE TRAUMACEM V PLUS","SUP-ITM-10274365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1968.66","1181.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1523.74","77.4","","303.98","303.98","5854.79","1 through 10","228.96","1523.74","percent of total billed charges",""
"CEMENT BONE PALACOS MEDIUM VISCOSITY W/GENTAMICIN","SUP-ITM-10258272","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.36","812.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","157.51","1151.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CEMENT BONE PALACOS MEDIUM VISCOSITY W/GENTAMICIN","SUP-ITM-10258272","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.36","812.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","157.51","1151.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CEMENT BONE PALACOS MEDIUM VISCOSITY W/GENTAMICIN","SUP-ITM-10258272","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.36","812.62","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","770.63","56.9","","812.12","238.65","1587.46","163","157.51","1151.21","percent of total billed charges",""
"CEMENT BONE PALACOS MEDIUM VISCOSITY W/GENTAMICIN","SUP-ITM-10258272","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.36","812.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","157.51","11.63","","112.68","112.68","146.99","38","157.51","1151.21","percent of total billed charges",""
"CEMENT BONE PALACOS MEDIUM VISCOSITY W/GENTAMICIN","SUP-ITM-10258272","CDM","C1713","HCPCS","0278","RC","","","","both","","","1354.36","812.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1048.27","77.4","","303.98","303.98","5854.79","1 through 10","157.51","1151.21","percent of total billed charges",""
"CEMENT BONE PALACOS MEDIUM VISCOSITY W/GENTAMICIN","SUP-ITM-10258272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1354.36","812.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","157.51","11.63","","112.68","112.68","146.99","38","157.51","1048.27","percent of total billed charges",""
"CEMENT BONE PALACOS MEDIUM VISCOSITY W/GENTAMICIN","SUP-ITM-10258272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1354.36","812.62","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","850.27","62.78","","780.86","208.94","10480.28","15","157.51","1048.27","percent of total billed charges",""
"CEMENT BONE PALACOS MEDIUM VISCOSITY W/GENTAMICIN","SUP-ITM-10258272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1354.36","812.62","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","592.13","43.72","","179.76","179.76","179.76","1 through 10","157.51","1048.27","percent of total billed charges",""
"CEMENT BONE PALACOS MEDIUM VISCOSITY W/GENTAMICIN","SUP-ITM-10258272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1354.36","812.62","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","984.89","72.72","","2355.45","298.99","3965.19","155","157.51","1048.27","percent of total billed charges",""
"CEMENT BONE PALACOS MEDIUM VISCOSITY W/GENTAMICIN","SUP-ITM-10258272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1354.36","812.62","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","984.89","72.72","","3643.09","3643.09","3643.09","1 through 10","157.51","1048.27","percent of total billed charges",""
"CEMENT BONE PALACOS MEDIUM VISCOSITY W/GENTAMICIN","SUP-ITM-10258272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1354.36","812.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","720.79","53.22","","554.28","554.28","554.28","16","157.51","1048.27","percent of total billed charges",""
"CEMENT BONE PALACOS MEDIUM VISCOSITY W/GENTAMICIN","SUP-ITM-10258272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1354.36","812.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","851.89","62.9","","619.64","173.09","2370.64","150","157.51","1048.27","percent of total billed charges",""
"CEMENT BONE PALACOS MEDIUM VISCOSITY W/GENTAMICIN","SUP-ITM-10258272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1354.36","812.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1048.27","77.4","","303.98","303.98","5854.79","1 through 10","157.51","1048.27","percent of total billed charges",""
"CEMENT BONE SIMPLEX HV GENTAMICIN BX/10EA","SUP-ITM-10124472","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.10","870.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","168.76","1233.44","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CEMENT BONE SIMPLEX HV GENTAMICIN BX/10EA","SUP-ITM-10124472","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.10","870.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","168.76","1233.44","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CEMENT BONE SIMPLEX HV GENTAMICIN BX/10EA","SUP-ITM-10124472","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.10","870.66","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","825.68","56.9","","812.12","238.65","1587.46","163","168.76","1233.44","percent of total billed charges",""
"CEMENT BONE SIMPLEX HV GENTAMICIN BX/10EA","SUP-ITM-10124472","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.10","870.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","168.76","11.63","","112.68","112.68","146.99","38","168.76","1233.44","percent of total billed charges",""
"CEMENT BONE SIMPLEX HV GENTAMICIN BX/10EA","SUP-ITM-10124472","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.10","870.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1123.15","77.4","","303.98","303.98","5854.79","1 through 10","168.76","1233.44","percent of total billed charges",""
"CEMENT BONE SIMPLEX HV GENTAMICIN BX/10EA","SUP-ITM-10124472","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1451.10","870.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","168.76","11.63","","112.68","112.68","146.99","38","168.76","1123.15","percent of total billed charges",""
"CEMENT BONE SIMPLEX HV GENTAMICIN BX/10EA","SUP-ITM-10124472","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1451.10","870.66","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","911.00","62.78","","780.86","208.94","10480.28","15","168.76","1123.15","percent of total billed charges",""
"CEMENT BONE SIMPLEX HV GENTAMICIN BX/10EA","SUP-ITM-10124472","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1451.10","870.66","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","634.42","43.72","","179.76","179.76","179.76","1 through 10","168.76","1123.15","percent of total billed charges",""
"CEMENT BONE SIMPLEX HV GENTAMICIN BX/10EA","SUP-ITM-10124472","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1451.10","870.66","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1055.24","72.72","","2355.45","298.99","3965.19","155","168.76","1123.15","percent of total billed charges",""
"CEMENT BONE SIMPLEX HV GENTAMICIN BX/10EA","SUP-ITM-10124472","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1451.10","870.66","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1055.24","72.72","","3643.09","3643.09","3643.09","1 through 10","168.76","1123.15","percent of total billed charges",""
"CEMENT BONE SIMPLEX HV GENTAMICIN BX/10EA","SUP-ITM-10124472","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1451.10","870.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","772.28","53.22","","554.28","554.28","554.28","16","168.76","1123.15","percent of total billed charges",""
"CEMENT BONE SIMPLEX HV GENTAMICIN BX/10EA","SUP-ITM-10124472","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1451.10","870.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","912.74","62.9","","619.64","173.09","2370.64","150","168.76","1123.15","percent of total billed charges",""
"CEMENT BONE SIMPLEX HV GENTAMICIN BX/10EA","SUP-ITM-10124472","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1451.10","870.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1123.15","77.4","","303.98","303.98","5854.79","1 through 10","168.76","1123.15","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","1727.50","1036.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","200.91","1468.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","1727.50","1036.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","200.91","1468.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","1727.50","1036.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","982.95","56.9","","812.12","238.65","1587.46","163","200.91","1468.38","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","1727.50","1036.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","200.91","11.63","","112.68","112.68","146.99","38","200.91","1468.38","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","1727.50","1036.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1337.09","77.4","","303.98","303.98","5854.79","1 through 10","200.91","1468.38","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1727.50","1036.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","200.91","11.63","","112.68","112.68","146.99","38","200.91","1337.09","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1727.50","1036.50","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1084.52","62.78","","780.86","208.94","10480.28","15","200.91","1337.09","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1727.50","1036.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","755.26","43.72","","179.76","179.76","179.76","1 through 10","200.91","1337.09","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1727.50","1036.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1256.24","72.72","","2355.45","298.99","3965.19","155","200.91","1337.09","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1727.50","1036.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1256.24","72.72","","3643.09","3643.09","3643.09","1 through 10","200.91","1337.09","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1727.50","1036.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","919.38","53.22","","554.28","554.28","554.28","16","200.91","1337.09","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1727.50","1036.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1086.60","62.9","","619.64","173.09","2370.64","150","200.91","1337.09","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1727.50","1036.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1337.09","77.4","","303.98","303.98","5854.79","1 through 10","200.91","1337.09","percent of total billed charges",""
"Ceruloplasmin","PX-30000355","CDM","82390","CPT","0301","RC","","","","both","","","59.00","35.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","41.18","69.8","","39.79","12.25","39.79","1 through 10","6.98","55.69","percent of total billed charges",""
"Ceruloplasmin","PX-30000355","CDM","82390","CPT","0301","RC","","","","outpatient","","","59.00","35.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","42.90","72.72","","41.45","41.45","41.45","20","10.02","45.67","percent of total billed charges",""
"Ceruloplasmin","PX-30000355","CDM","82390","CPT","0301","RC","","","","outpatient","","","59.00","35.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","37.11","62.9","","35.91","35.91","138.72","27","10.02","45.67","percent of total billed charges",""
"Ceruloplasmin","PX-30000355","CDM","82390","CPT","0301","RC","","","","outpatient","","","59.00","35.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","45.67","77.4","","44.18","10.11","44.18","1 through 10","10.02","45.67","percent of total billed charges",""
"CERVICAL PLATE 15.0MM LEVEL 1 ZEVO","SUP-ITM-10165266","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","401.82","2936.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CERVICAL PLATE 15.0MM LEVEL 1 ZEVO","SUP-ITM-10165266","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","401.82","2936.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CERVICAL PLATE 15.0MM LEVEL 1 ZEVO","SUP-ITM-10165266","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1965.90","56.9","","812.12","238.65","1587.46","163","401.82","2936.75","percent of total billed charges",""
"CERVICAL PLATE 15.0MM LEVEL 1 ZEVO","SUP-ITM-10165266","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","401.82","11.63","","112.68","112.68","146.99","38","401.82","2936.75","percent of total billed charges",""
"CERVICAL PLATE 15.0MM LEVEL 1 ZEVO","SUP-ITM-10165266","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2674.17","77.4","","303.98","303.98","5854.79","1 through 10","401.82","2936.75","percent of total billed charges",""
"CERVICAL PLATE 15.0MM LEVEL 1 ZEVO","SUP-ITM-10165266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","401.82","11.63","","112.68","112.68","146.99","38","401.82","2674.17","percent of total billed charges",""
"CERVICAL PLATE 15.0MM LEVEL 1 ZEVO","SUP-ITM-10165266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2169.05","62.78","","780.86","208.94","10480.28","15","401.82","2674.17","percent of total billed charges",""
"CERVICAL PLATE 15.0MM LEVEL 1 ZEVO","SUP-ITM-10165266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1510.53","43.72","","179.76","179.76","179.76","1 through 10","401.82","2674.17","percent of total billed charges",""
"CERVICAL PLATE 15.0MM LEVEL 1 ZEVO","SUP-ITM-10165266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2512.48","72.72","","2355.45","298.99","3965.19","155","401.82","2674.17","percent of total billed charges",""
"CERVICAL PLATE 15.0MM LEVEL 1 ZEVO","SUP-ITM-10165266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2512.48","72.72","","3643.09","3643.09","3643.09","1 through 10","401.82","2674.17","percent of total billed charges",""
"CERVICAL PLATE 15.0MM LEVEL 1 ZEVO","SUP-ITM-10165266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1838.75","53.22","","554.28","554.28","554.28","16","401.82","2674.17","percent of total billed charges",""
"CERVICAL PLATE 15.0MM LEVEL 1 ZEVO","SUP-ITM-10165266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2173.20","62.9","","619.64","173.09","2370.64","150","401.82","2674.17","percent of total billed charges",""
"CERVICAL PLATE 15.0MM LEVEL 1 ZEVO","SUP-ITM-10165266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2674.17","77.4","","303.98","303.98","5854.79","1 through 10","401.82","2674.17","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","401.82","2936.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","401.82","2936.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1965.90","56.9","","812.12","238.65","1587.46","163","401.82","2936.75","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","401.82","11.63","","112.68","112.68","146.99","38","401.82","2936.75","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2674.17","77.4","","303.98","303.98","5854.79","1 through 10","401.82","2936.75","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","401.82","11.63","","112.68","112.68","146.99","38","401.82","2674.17","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2169.05","62.78","","780.86","208.94","10480.28","15","401.82","2674.17","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1510.53","43.72","","179.76","179.76","179.76","1 through 10","401.82","2674.17","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2512.48","72.72","","2355.45","298.99","3965.19","155","401.82","2674.17","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2512.48","72.72","","3643.09","3643.09","3643.09","1 through 10","401.82","2674.17","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1838.75","53.22","","554.28","554.28","554.28","16","401.82","2674.17","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2173.20","62.9","","619.64","173.09","2370.64","150","401.82","2674.17","percent of total billed charges",""
"CERVICAL PLATE 21MM LEVEL 1 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2674.17","77.4","","303.98","303.98","5854.79","1 through 10","401.82","2674.17","percent of total billed charges",""
"CERVICAL PLATE 37.5MM LEVEL 2 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10100938","CDM","C1713","HCPCS","0278","RC","","","","both","","","4076.90","2446.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","474.14","3465.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CERVICAL PLATE 37.5MM LEVEL 2 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10100938","CDM","C1713","HCPCS","0278","RC","","","","both","","","4076.90","2446.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","474.14","3465.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CERVICAL PLATE 37.5MM LEVEL 2 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10100938","CDM","C1713","HCPCS","0278","RC","","","","both","","","4076.90","2446.14","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2319.76","56.9","","812.12","238.65","1587.46","163","474.14","3465.37","percent of total billed charges",""
"CERVICAL PLATE 37.5MM LEVEL 2 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10100938","CDM","C1713","HCPCS","0278","RC","","","","both","","","4076.90","2446.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","474.14","11.63","","112.68","112.68","146.99","38","474.14","3465.37","percent of total billed charges",""
"CERVICAL PLATE 37.5MM LEVEL 2 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10100938","CDM","C1713","HCPCS","0278","RC","","","","both","","","4076.90","2446.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3155.52","77.4","","303.98","303.98","5854.79","1 through 10","474.14","3465.37","percent of total billed charges",""
"CERVICAL PLATE 37.5MM LEVEL 2 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10100938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4076.90","2446.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","474.14","11.63","","112.68","112.68","146.99","38","474.14","3155.52","percent of total billed charges",""
"CERVICAL PLATE 37.5MM LEVEL 2 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10100938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4076.90","2446.14","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2559.48","62.78","","780.86","208.94","10480.28","15","474.14","3155.52","percent of total billed charges",""
"CERVICAL PLATE 37.5MM LEVEL 2 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10100938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4076.90","2446.14","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1782.42","43.72","","179.76","179.76","179.76","1 through 10","474.14","3155.52","percent of total billed charges",""
"CERVICAL PLATE 37.5MM LEVEL 2 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10100938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4076.90","2446.14","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2964.72","72.72","","2355.45","298.99","3965.19","155","474.14","3155.52","percent of total billed charges",""
"CERVICAL PLATE 37.5MM LEVEL 2 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10100938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4076.90","2446.14","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2964.72","72.72","","3643.09","3643.09","3643.09","1 through 10","474.14","3155.52","percent of total billed charges",""
"CERVICAL PLATE 37.5MM LEVEL 2 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10100938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4076.90","2446.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2169.73","53.22","","554.28","554.28","554.28","16","474.14","3155.52","percent of total billed charges",""
"CERVICAL PLATE 37.5MM LEVEL 2 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10100938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4076.90","2446.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2564.37","62.9","","619.64","173.09","2370.64","150","474.14","3155.52","percent of total billed charges",""
"CERVICAL PLATE 37.5MM LEVEL 2 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10100938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4076.90","2446.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3155.52","77.4","","303.98","303.98","5854.79","1 through 10","474.14","3155.52","percent of total billed charges",""
"CERVICAL PLATE 60MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10092643","CDM","C1713","HCPCS","0278","RC","","","","both","","","4664.25","2798.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","542.45","3964.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CERVICAL PLATE 60MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10092643","CDM","C1713","HCPCS","0278","RC","","","","both","","","4664.25","2798.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","542.45","3964.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CERVICAL PLATE 60MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10092643","CDM","C1713","HCPCS","0278","RC","","","","both","","","4664.25","2798.55","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2653.96","56.9","","812.12","238.65","1587.46","163","542.45","3964.61","percent of total billed charges",""
"CERVICAL PLATE 60MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10092643","CDM","C1713","HCPCS","0278","RC","","","","both","","","4664.25","2798.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","542.45","11.63","","112.68","112.68","146.99","38","542.45","3964.61","percent of total billed charges",""
"CERVICAL PLATE 60MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10092643","CDM","C1713","HCPCS","0278","RC","","","","both","","","4664.25","2798.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3610.13","77.4","","303.98","303.98","5854.79","1 through 10","542.45","3964.61","percent of total billed charges",""
"CERVICAL PLATE 60MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10092643","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4664.25","2798.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","542.45","11.63","","112.68","112.68","146.99","38","542.45","3610.13","percent of total billed charges",""
"CERVICAL PLATE 60MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10092643","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4664.25","2798.55","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2928.22","62.78","","780.86","208.94","10480.28","15","542.45","3610.13","percent of total billed charges",""
"CERVICAL PLATE 60MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10092643","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4664.25","2798.55","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2039.21","43.72","","179.76","179.76","179.76","1 through 10","542.45","3610.13","percent of total billed charges",""
"CERVICAL PLATE 60MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10092643","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4664.25","2798.55","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3391.84","72.72","","2355.45","298.99","3965.19","155","542.45","3610.13","percent of total billed charges",""
"CERVICAL PLATE 60MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10092643","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4664.25","2798.55","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3391.84","72.72","","3643.09","3643.09","3643.09","1 through 10","542.45","3610.13","percent of total billed charges",""
"CERVICAL PLATE 60MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10092643","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4664.25","2798.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2482.31","53.22","","554.28","554.28","554.28","16","542.45","3610.13","percent of total billed charges",""
"CERVICAL PLATE 60MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10092643","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4664.25","2798.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2933.81","62.9","","619.64","173.09","2370.64","150","542.45","3610.13","percent of total billed charges",""
"CERVICAL PLATE 60MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10092643","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4664.25","2798.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3610.13","77.4","","303.98","303.98","5854.79","1 through 10","542.45","3610.13","percent of total billed charges",""
"CERVICAL PLATE 75MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111108","CDM","C1713","HCPCS","0278","RC","","","","both","","","5113.40","3068.04","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","594.69","4346.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CERVICAL PLATE 75MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111108","CDM","C1713","HCPCS","0278","RC","","","","both","","","5113.40","3068.04","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","594.69","4346.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CERVICAL PLATE 75MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111108","CDM","C1713","HCPCS","0278","RC","","","","both","","","5113.40","3068.04","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2909.52","56.9","","812.12","238.65","1587.46","163","594.69","4346.39","percent of total billed charges",""
"CERVICAL PLATE 75MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111108","CDM","C1713","HCPCS","0278","RC","","","","both","","","5113.40","3068.04","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","594.69","11.63","","112.68","112.68","146.99","38","594.69","4346.39","percent of total billed charges",""
"CERVICAL PLATE 75MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111108","CDM","C1713","HCPCS","0278","RC","","","","both","","","5113.40","3068.04","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3957.77","77.4","","303.98","303.98","5854.79","1 through 10","594.69","4346.39","percent of total billed charges",""
"CERVICAL PLATE 75MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5113.40","3068.04","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","594.69","11.63","","112.68","112.68","146.99","38","594.69","3957.77","percent of total billed charges",""
"CERVICAL PLATE 75MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5113.40","3068.04","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3210.19","62.78","","780.86","208.94","10480.28","15","594.69","3957.77","percent of total billed charges",""
"CERVICAL PLATE 75MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5113.40","3068.04","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2235.58","43.72","","179.76","179.76","179.76","1 through 10","594.69","3957.77","percent of total billed charges",""
"CERVICAL PLATE 75MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5113.40","3068.04","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3718.46","72.72","","2355.45","298.99","3965.19","155","594.69","3957.77","percent of total billed charges",""
"CERVICAL PLATE 75MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5113.40","3068.04","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3718.46","72.72","","3643.09","3643.09","3643.09","1 through 10","594.69","3957.77","percent of total billed charges",""
"CERVICAL PLATE 75MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5113.40","3068.04","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2721.35","53.22","","554.28","554.28","554.28","16","594.69","3957.77","percent of total billed charges",""
"CERVICAL PLATE 75MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5113.40","3068.04","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3216.33","62.9","","619.64","173.09","2370.64","150","594.69","3957.77","percent of total billed charges",""
"CERVICAL PLATE 75MM LEVEL 3 ATLANTIS VISION ELITE TITANIUM","SUP-ITM-10111108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5113.40","3068.04","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3957.77","77.4","","303.98","303.98","5854.79","1 through 10","594.69","3957.77","percent of total billed charges",""
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","","","","inpatient","","","136542.87","81925.72","MEDICARE [2001]","HB WDH MEDICARE","22842.41","","Case rate ($22,842.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $21,117.55, add-ons for qualifying new technology services are included. If operating cost exceeds $25,035.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,441.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $20,760.85 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $20,672.68 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,636.69. The transfer capital threshold is the transfer adjustment factor * $1,636.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22305.79","22305.79","22305.79","1 through 10","21039.96","111952.09","other","Inpatient DRG"
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","","","","inpatient","","","21287.67","12772.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","40283.91","","Fee schedule rate ($40,283.91). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","40150.35","40150.35","40150.35","1 through 10","4417","40283.91","case rate",""
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","","","","inpatient","","","21287.67","12772.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","15862.15","","Fee schedule rate ($15,862.15). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","15809.55","15809.55","15809.55","1 through 10","4417","40283.91","case rate",""
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","","","","inpatient","","","21287.67","12772.60","MEDICARE [2001]","HB WDH MEDICARE","8504.22","","Case rate ($8,504.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,883.56, add-ons for qualifying new technology services are included. If operating cost exceeds $11,801.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,393.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,470.41 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,438.68 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $588.93. The transfer capital threshold is the transfer adjustment factor * $588.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8616.63","8616.63","8616.63","1 through 10","4417","40283.91","other","Inpatient DRG"
"Cesarean Section With Sterilization With McC","783","MS-DRG","","","","","","","","inpatient","","","24849.15","14909.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","93294.05","","Fee schedule rate ($93,294.05). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","37995.91","37995.91","37995.91","1 through 10","4417","93294.05","case rate",""
"Cesarean Section With Sterilization With McC","783","MS-DRG","","","","","","","","inpatient","","","24849.15","14909.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","74304.29","","Fee schedule rate ($74,304.29). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","23881.15","23881.15","23881.15","1 through 10","4417","93294.05","case rate",""
"Cesarean Section With Sterilization Without Cc/McC","785","MS-DRG","","","","","","","","inpatient","","","19955.39","11973.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","36396.50","","Fee schedule rate ($36,396.50). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","20677.36","20677.36","20677.36","1 through 10","4417","36396.5","case rate",""
"Cesarean Section With Sterilization Without Cc/McC","785","MS-DRG","","","","","","","","inpatient","","","19955.39","11973.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","14331.45","","Fee schedule rate ($14,331.45). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","12751.29","12751.29","12751.29","1 through 10","4417","36396.5","case rate",""
"Cesarean Section With Sterilization Without Cc/McC","785","MS-DRG","","","","","","","","inpatient","","","19955.39","11973.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","7571.95","","Case rate ($7,726.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,165.72, add-ons for qualifying new technology services are included. If operating cost exceeds $11,083.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,337.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,749.51 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,720.85 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $532.10. The transfer capital threshold is the transfer adjustment factor * $532.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7053.00","7053.00","7053.00","1 through 10","4417","36396.5","other","Inpatient DRG"
"Cesarean Section With Sterilization Without Cc/McC","785","MS-DRG","","","","","","","","inpatient","","","19955.39","11973.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","28988.09","","Fee schedule rate ($28,988.09). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","21133.32","21133.32","22518.87","1 through 10","4417","36396.5","case rate",""
"Cesarean Section With Sterilization Without Cc/McC","785","MS-DRG","","","","","","","","inpatient","","","19955.39","11973.23","TRICARE [160005]","HB WDH MEDICARE","7726.48","","Case rate ($7,726.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,165.72, add-ons for qualifying new technology services are included. If operating cost exceeds $11,083.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,337.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,749.51 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,720.85 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $532.10. The transfer capital threshold is the transfer adjustment factor * $532.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6642.19","6642.19","6642.19","1 through 10","4417","36396.5","other","Inpatient DRG"
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","","","","inpatient","","","21810.13","13086.08","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","42438.51","","Fee schedule rate ($42,438.51). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","20135.14","16896.94","25550.04","1 through 10","4417","42438.51","case rate",""
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","","","","inpatient","","","21810.13","13086.08","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","16710.54","","Fee schedule rate ($16,710.54). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","15500.08","15500.08","15890.20","24","4417","42438.51","case rate",""
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","","","","inpatient","","","21810.13","13086.08","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","8756.56","","Case rate ($8,935.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,281.42, add-ons for qualifying new technology services are included. If operating cost exceeds $12,199.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,425.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,869.97 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,836.55 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $620.43. The transfer capital threshold is the transfer adjustment factor * $620.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8477.53","8477.53","8477.53","1 through 10","4417","42438.51","other","Inpatient DRG"
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","","","","inpatient","","","21810.13","13086.08","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","33800.26","","Fee schedule rate ($33,800.26). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","21300.46","18815.02","26644.20","23","4417","42438.51","case rate",""
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","","","","inpatient","","","21810.13","13086.08","MEDICARE [2001]","HB WDH MEDICARE","8935.27","","Case rate ($8,935.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,281.42, add-ons for qualifying new technology services are included. If operating cost exceeds $12,199.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,425.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,869.97 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,836.55 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $620.43. The transfer capital threshold is the transfer adjustment factor * $620.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8477.53","8477.53","8477.53","1 through 10","4417","42438.51","other","Inpatient DRG"
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","","","","inpatient","","","21810.13","13086.08","TRICARE [160005]","HB WDH MEDICARE","8935.27","","Case rate ($8,935.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,281.42, add-ons for qualifying new technology services are included. If operating cost exceeds $12,199.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,425.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,869.97 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,836.55 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $620.43. The transfer capital threshold is the transfer adjustment factor * $620.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8513.93","8513.93","24663.03","1 through 10","4417","42438.51","other","Inpatient DRG"
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","","","","inpatient","","","21810.13","13086.08","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8935.27","","Case rate ($8,935.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,281.42, add-ons for qualifying new technology services are included. If operating cost exceeds $12,199.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,425.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,869.97 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,836.55 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $620.43. The transfer capital threshold is the transfer adjustment factor * $620.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8325.13","8325.13","8325.13","1 through 10","4417","42438.51","other","Inpatient DRG"
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","","","","inpatient","","","21810.13","13086.08","WELLSENSE NH [1050]","HB WDH MEDICARE","8935.27","","Case rate ($8,935.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,281.42, add-ons for qualifying new technology services are included. If operating cost exceeds $12,199.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,425.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,869.97 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,836.55 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $620.43. The transfer capital threshold is the transfer adjustment factor * $620.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8322.78","8322.78","8322.78","1 through 10","4417","42438.51","other","Inpatient DRG"
"Cesarean Section Without Sterilization With McC","786","MS-DRG","","","","","","","","inpatient","","","24552.41","14731.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","62681.16","","Fee schedule rate ($62,681.16). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","32521.86","32521.86","32521.86","1 through 10","4417","62681.16","case rate",""
"Cesarean Section Without Sterilization With McC","786","MS-DRG","","","","","","","","inpatient","","","24552.41","14731.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","24681.27","","Fee schedule rate ($24,681.27). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","20537.16","20537.16","20537.16","1 through 10","4417","62681.16","case rate",""
"Cesarean Section Without Sterilization With McC","786","MS-DRG","","","","","","","","inpatient","","","24552.41","14731.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","12725.39","","Case rate ($12,985.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,019.35, add-ons for qualifying new technology services are included. If operating cost exceeds $15,937.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,721.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,623.85 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,574.48 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $916.37. The transfer capital threshold is the transfer adjustment factor * $916.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12637.66","12637.66","12637.66","1 through 10","4417","62681.16","other","Inpatient DRG"
"Cesarean Section Without Sterilization With McC","786","MS-DRG","","","","","","","","inpatient","","","24552.41","14731.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","49922.58","","Fee schedule rate ($49,922.58). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","20515.57","20515.57","24694.45","1 through 10","4417","62681.16","case rate",""
"Cesarean Section Without Sterilization Without Cc/McC","788","MS-DRG","","","","","","","","inpatient","","","19540.30","11724.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","36434.50","","Fee schedule rate ($36,434.50). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","22156.13","17289.01","30747.54","1 through 10","4417","36434.5","case rate",""
"Cesarean Section Without Sterilization Without Cc/McC","788","MS-DRG","","","","","","","","inpatient","","","19540.30","11724.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","14346.41","","Fee schedule rate ($14,346.41). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","13206.74","13206.74","13206.74","18","4417","36434.5","case rate",""
"Cesarean Section Without Sterilization Without Cc/McC","788","MS-DRG","","","","","","","","inpatient","","","19540.30","11724.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","7579.41","","Case rate ($7,734.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,172.74, add-ons for qualifying new technology services are included. If operating cost exceeds $11,090.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,337.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,756.56 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,727.87 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $532.66. The transfer capital threshold is the transfer adjustment factor * $532.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7289.03","7271.24","7289.03","1 through 10","4417","36434.5","other","Inpatient DRG"
"Cesarean Section Without Sterilization Without Cc/McC","788","MS-DRG","","","","","","","","inpatient","","","19540.30","11724.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","29018.35","","Fee schedule rate ($29,018.35). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","18184.99","16766.53","24839.33","26","4417","36434.5","case rate",""
"Cesarean Section Without Sterilization Without Cc/McC","788","MS-DRG","","","","","","","","inpatient","","","19540.30","11724.18","MEDICARE [2001]","HB WDH MEDICARE","7734.09","","Case rate ($7,734.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,172.74, add-ons for qualifying new technology services are included. If operating cost exceeds $11,090.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,337.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,756.56 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,727.87 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $532.66. The transfer capital threshold is the transfer adjustment factor * $532.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7271.24","7271.24","7289.50","1 through 10","4417","36434.5","other","Inpatient DRG"
"Cesarean Section Without Sterilization Without Cc/McC","788","MS-DRG","","","","","","","","inpatient","","","19540.30","11724.18","TRICARE [160005]","HB WDH MEDICARE","7734.09","","Case rate ($7,734.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,172.74, add-ons for qualifying new technology services are included. If operating cost exceeds $11,090.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,337.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,756.56 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,727.87 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $532.66. The transfer capital threshold is the transfer adjustment factor * $532.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6643.87","6580.30","7250.86","1 through 10","4417","36434.5","other","Inpatient DRG"
"Cesarean Section Without Sterilization Without Cc/McC","788","MS-DRG","","","","","","","","inpatient","","","19540.30","11724.18","WELLPOINT [1015]","HB WDH ANTHEM PPO","29018.35","","Fee schedule rate ($29,018.35). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","15120.71","15120.71","15120.71","1 through 10","4417","36434.5","case rate",""
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","both","","","2515.00","1509.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","699.25","","Case rate ($699.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","682.20","682.20","682.20","1 through 10","249.01","2137.75","other","OPPS APC"
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","both","","","2515.00","1509.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","261.72","","APC Price ($254.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","260.88","260.88","260.88","1 through 10","249.01","2137.75","other","OPPS APC"
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","both","","","2515.00","1509.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","254.10","","APC Price ($254.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","254.13","254.13","254.13","1 through 10","249.01","2137.75","other","OPPS APC"
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","both","","","2515.00","1509.00","MEDICARE [2001]","HB WDH MEDICARE","254.10","","APC Price ($254.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","254.13","254.13","508.26","1 through 10","249.01","2137.75","other","OPPS APC"
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","both","","","2515.00","1509.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","254.10","","APC Price ($254.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","254.13","254.13","254.13","1 through 10","249.01","2137.75","other","OPPS APC"
"Change Tube Ureterostomy","PX-76001242","CDM","50688","CPT","0761","RC","","","","both","","","14520.00","8712.00","MEDICARE [2001]","HB WDH MEDICARE","2140.20","","APC Price ($2,140.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2140.45","2140.45","2140.45","1 through 10","2097.4","13677.84","other","OPPS APC"
"Chem IV Infus Tq Ea Add’L Seq Diff Drug Up to 1 Hr - 96417","PX-33000081","CDM","96417","CPT","0335","RC","","","","both","","","590.00","354.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","411.82","69.8","","397.16","357.90","397.16","32","72.87","501.5","percent of total billed charges",""
"Chem IV Infus Tq Ea Add’L Seq Diff Drug Up to 1 Hr - 96417","PX-33000081","CDM","96417","CPT","0335","RC","","","","both","","","590.00","354.00","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","75.84","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","74.36","68.64","74.36","30","72.87","501.5","other","OPPS APC"
"Chem IV Infus Tq Ea Add’L Seq Diff Drug Up to 1 Hr - 96417","PX-33000081","CDM","96417","CPT","0335","RC","","","","both","","","590.00","354.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","475.23","","Case rate ($475.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","463.64","446.16","463.64","48","72.87","501.5","other","OPPS APC"
"Chem IV Infus Tq Ea Add’L Seq Diff Drug Up to 1 Hr - 96417","PX-33000081","CDM","96417","CPT","0335","RC","","","","both","","","590.00","354.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","204.63","","Case rate ($204.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.65","199.65","199.65","54","72.87","501.5","other","OPPS APC"
"Chem IV Infus Tq Ea Add’L Seq Diff Drug Up to 1 Hr - 96417","PX-33000081","CDM","96417","CPT","0335","RC","","","","both","","","590.00","354.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","72.87","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","72.93","68.64","74.37","52","72.87","501.5","other","OPPS APC"
"Chem IV Infus Tq Ea Add’L Seq Diff Drug Up to 1 Hr - 96417","PX-33000081","CDM","96417","CPT","0335","RC","","","","both","","","590.00","354.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","384.13","","Case rate ($384.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","374.75","199.65","374.76","84","72.87","501.5","other","OPPS APC"
"Chem IV Infus Tq Ea Add’L Seq Diff Drug Up to 1 Hr - 96417","PX-33000081","CDM","96417","CPT","0335","RC","","","","both","","","590.00","354.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","335.71","56.9","","323.77","323.76","971.30","57","72.87","501.5","percent of total billed charges",""
"Chem IV Infus Tq Ea Add’L Seq Diff Drug Up to 1 Hr - 96417","PX-33000081","CDM","96417","CPT","0335","RC","","","","both","","","590.00","354.00","HARVARD PILGRIM [120001]","HB WDH MEDICARE","74.36","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","67.54","67.54","67.54","1 through 10","72.87","501.5","other","OPPS APC"
"Chem IV Infus Tq Ea Add’L Seq Diff Drug Up to 1 Hr - 96417","PX-33000081","CDM","96417","CPT","0335","RC","","","","both","","","590.00","354.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","76.59","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","75.06","75.06","75.37","43","72.87","501.5","other","OPPS APC"
"Chem IV Infus Tq Ea Add’L Seq Diff Drug Up to 1 Hr - 96417","PX-33000081","CDM","96417","CPT","0335","RC","","","","both","","","590.00","354.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","74.36","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","73.17","72.87","74.36","104","72.87","501.5","other","OPPS APC"
"Chem IV Infus Tq Ea Add’L Seq Diff Drug Up to 1 Hr - 96417","PX-33000081","CDM","96417","CPT","0335","RC","","","","both","","","590.00","354.00","MEDICARE [2001]","HB WDH MEDICARE","74.36","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","74.36","74.36","223.08","513","72.87","501.5","other","OPPS APC"
"Chem IV Infus Tq Ea Add’L Seq Diff Drug Up to 1 Hr - 96417","PX-33000081","CDM","96417","CPT","0335","RC","","","","both","","","590.00","354.00","TRICARE [160005]","HB WDH MEDICARE","74.36","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","74.36","74.36","74.36","1 through 10","72.87","501.5","other","OPPS APC"
"Chem IV Infus Tq Ea Add’L Seq Diff Drug Up to 1 Hr - 96417","PX-33000081","CDM","96417","CPT","0335","RC","","","","both","","","590.00","354.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","74.36","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","73.18","72.88","74.36","158","72.87","501.5","other","OPPS APC"
"Chem IV Infus Tq Ea Add’L Seq Diff Drug Up to 1 Hr - 96417","PX-33000081","CDM","96417","CPT","0335","RC","","","","both","","","590.00","354.00","WELLPOINT [1015]","HB WDH ANTHEM PPO","384.13","","Case rate ($384.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","374.75","360.62","374.75","1 through 10","72.87","501.5","other","OPPS APC"
"Chem IV Infus Tq Ea Add’L Seq Diff Drug Up to 1 Hr - 96417","PX-33000081","CDM","96417","CPT","0335","RC","","","","both","","","590.00","354.00","WELLSENSE NH [1050]","HB WDH MEDICARE","74.36","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","229.56","76.52","229.56","12","72.87","501.5","other","OPPS APC"
"Chem IV Infus Tq Ea Add’L Seq Diff Drug Up to 1 Hr - 96417","PX-33000081","CDM","96417","CPT","0335","RC","","","","outpatient","","","590.00","354.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","85.08","14.42","","82.05","70.33","82.05","32","68.62","456.66","percent of total billed charges",""
"Chem IV Infus Tq Ea Add’L Seq Diff Drug Up to 1 Hr - 96417","PX-33000081","CDM","96417","CPT","0335","RC","","","","outpatient","","","590.00","354.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","68.62","11.63","","78.35","69.65","143.70","66","68.62","456.66","percent of total billed charges",""
"Chem IV Infus Tq Ea Add’L Seq Diff Drug Up to 1 Hr - 96417","PX-33000081","CDM","96417","CPT","0335","RC","","","","outpatient","","","590.00","354.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","371.11","62.9","","358.47","358.47","358.47","29","68.62","456.66","percent of total billed charges",""
"Chem IV Infus Tq Ea Add’L Seq Diff Drug Up to 1 Hr - 96417","PX-33000081","CDM","96417","CPT","0335","RC","","","","outpatient","","","590.00","354.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","456.66","77.4","","440.98","440.98","440.98","1 through 10","68.62","456.66","percent of total billed charges",""
"Chem IV Infus Tq Ea Add’L Seq Diff Drug Up to 1 Hr - 96417","PX-33000081","CDM","96417","CPT","0335","RC","","","","outpatient","","","590.00","354.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","68.62","11.63","","201.63","67.21","349.79","26","68.62","456.66","percent of total billed charges",""
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","940.00","564.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","656.12","69.8","","633.09","633.09","633.09","1 through 10","339.61","2214.69","percent of total billed charges",""
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","940.00","564.00","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","353.47","","APC Price ($346.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","346.58","346.58","346.58","15","339.61","2214.69","other","OPPS APC"
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","940.00","564.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2214.69","","Case rate ($2,214.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2160.68","688.23","2160.68","1 through 10","339.61","2214.69","other","OPPS APC"
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","940.00","564.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","953.65","","Case rate ($953.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","930.40","930.40","930.40","1 through 10","339.61","2214.69","other","OPPS APC"
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","940.00","564.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","339.61","","APC Price ($346.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","346.58","339.65","346.58","18","339.61","2214.69","other","OPPS APC"
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","940.00","564.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1790.12","","Case rate ($1,790.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","930.40","930.40","1746.45","15","339.61","2214.69","other","OPPS APC"
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","940.00","564.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","534.86","56.9","","516.08","516.08","516.08","1 through 10","339.61","2214.69","percent of total billed charges",""
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","940.00","564.00","HARVARD PILGRIM [120001]","HB WDH MEDICARE","346.54","","APC Price ($346.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","323.38","323.38","323.38","1 through 10","339.61","2214.69","other","OPPS APC"
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","940.00","564.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","356.93","","APC Price ($346.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","351.27","349.84","351.27","30","339.61","2214.69","other","OPPS APC"
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","940.00","564.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","346.54","","APC Price ($346.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","339.65","329.98","346.58","1 through 10","339.61","2214.69","other","OPPS APC"
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","940.00","564.00","MEDICARE [2001]","HB WDH MEDICARE","346.54","","APC Price ($346.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","346.58","329.98","346.58","108","339.61","2214.69","other","OPPS APC"
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","940.00","564.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","346.54","","APC Price ($346.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","341.04","324.71","341.04","79","339.61","2214.69","other","OPPS APC"
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","940.00","564.00","WELLPOINT [1015]","HB WDH ANTHEM PPO","1790.12","","Case rate ($1,790.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1746.45","1746.45","1746.45","1 through 10","339.61","2214.69","other","OPPS APC"
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","outpatient","","","940.00","564.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","135.55","14.42","","112.11","112.11","130.79","1 through 10","109.32","727.56","percent of total billed charges",""
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","outpatient","","","940.00","564.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","109.32","11.63","","124.89","111.02","124.89","26","109.32","727.56","percent of total billed charges",""
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","outpatient","","","940.00","564.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","591.26","62.9","","571.41","571.41","571.41","1 through 10","109.32","727.56","percent of total billed charges",""
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","outpatient","","","940.00","564.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","727.56","77.4","","702.93","702.92","702.93","1 through 10","109.32","727.56","percent of total billed charges",""
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","outpatient","","","940.00","564.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","109.32","11.63","","543.44","543.44","543.44","1 through 10","109.32","727.56","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","6014.00","3608.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","4197.77","69.8","","5803.00","4050.49","5803.00","1 through 10","302.23","5111.9","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","6014.00","3608.40","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","314.57","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","308.44","308.44","308.44","1 through 10","302.23","5111.9","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","6014.00","3608.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1971.01","","Case rate ($1,971.01). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1730.66","1730.66","1730.66","1 through 10","302.23","5111.9","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","6014.00","3608.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1593.15","","Case rate ($1,593.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1398.85","1364.63","1398.85","1 through 10","302.23","5111.9","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","6014.00","3608.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3421.97","56.9","","3301.91","2649.55","6518.99","1 through 10","302.23","5111.9","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","6014.00","3608.40","HARVARD PILGRIM [120001]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","288.31","288.31","288.31","1 through 10","302.23","5111.9","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","6014.00","3608.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","317.65","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","902.27","317.69","902.27","1 through 10","302.23","5111.9","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","6014.00","3608.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","303.17","283.61","303.17","1 through 10","302.23","5111.9","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","6014.00","3608.40","MEDICARE [2001]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","308.44","288.58","308.44","1 through 10","302.23","5111.9","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","6014.00","3608.40","TRICARE [160005]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","308.44","308.44","308.44","1 through 10","302.23","5111.9","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","6014.00","3608.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","308.44","308.44","308.44","1 through 10","302.23","5111.9","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","6014.00","3608.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","699.43","11.63","","710.29","710.29","710.29","1 through 10","699.43","4654.84","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","6014.00","3608.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3782.81","62.9","","3655.89","3655.89","3655.89","1 through 10","699.43","4654.84","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","6014.00","3608.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","699.43","11.63","","685.43","685.43","685.43","1 through 10","699.43","4654.84","percent of total billed charges",""
"Chemiluminescent Assay","PX-30000356","CDM","82397","CPT","0301","RC","","","","both","","","75.00","45.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","52.35","69.8","","48.86","45.92","50.95","1 through 10","9.18","72.25","percent of total billed charges",""
"Chemiluminescent Assay","PX-30000356","CDM","82397","CPT","0301","RC","","","","both","","","75.00","45.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","63.75","85","","62.05","62.05","62.05","1 through 10","9.18","72.25","percent of total billed charges",""
"Chemiluminescent Assay","PX-30000356","CDM","82397","CPT","0301","RC","","","","outpatient","","","75.00","45.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","32.79","43.72","","31.92","31.92","31.92","1 through 10","9.96","58.05","percent of total billed charges",""
"Chemiluminescent Assay","PX-30000356","CDM","82397","CPT","0301","RC","","","","outpatient","","","75.00","45.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","54.54","72.72","","53.09","53.09","364.33","1 through 10","9.96","58.05","percent of total billed charges",""
"Chemiluminescent Assay","PX-30000356","CDM","82397","CPT","0301","RC","","","","outpatient","","","75.00","45.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","54.54","72.72","","53.09","53.09","53.09","1 through 10","9.96","58.05","percent of total billed charges",""
"Chemiluminescent Assay","PX-30000356","CDM","82397","CPT","0301","RC","","","","outpatient","","","75.00","45.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","39.92","53.22","","38.92","38.92","38.92","1 through 10","9.96","58.05","percent of total billed charges",""
"Chemiluminescent Assay","PX-30000356","CDM","82397","CPT","0301","RC","","","","outpatient","","","75.00","45.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","47.18","62.9","","45.99","45.99","137.97","13","9.96","58.05","percent of total billed charges",""
"Chemiluminescent Assay","PX-30000356","CDM","82397","CPT","0301","RC","","","","outpatient","","","75.00","45.00","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","54.54","72.72","","56.58","56.58","56.58","1 through 10","9.96","58.05","percent of total billed charges",""
"Chemiluminescent Assay","PX-30000356","CDM","82397","CPT","0301","RC","","","","outpatient","","","75.00","45.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","58.05","77.4","","56.58","56.58","56.58","1 through 10","9.96","58.05","percent of total billed charges",""
"Chemo Infus > 8 External Pmp","PX-33000129","CDM","96416","CPT","0335","RC","","","","both","","","1226.00","735.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2214.69","","Case rate ($2,214.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2160.68","2144.94","2160.68","22","339.61","2214.69","other","OPPS APC"
"Chemo Infus > 8 External Pmp","PX-33000129","CDM","96416","CPT","0335","RC","","","","both","","","1226.00","735.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","697.59","56.9","","673.14","673.12","2019.39","46","339.61","2214.69","percent of total billed charges",""
"Chemo Infus > 8 External Pmp","PX-33000129","CDM","96416","CPT","0335","RC","","","","outpatient","","","1226.00","735.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","176.79","14.42","","170.59","170.59","170.59","1 through 10","142.58","948.92","percent of total billed charges",""
"Chemo Infus > 8 External Pmp","PX-33000129","CDM","96416","CPT","0335","RC","","","","outpatient","","","1226.00","735.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","142.58","11.63","","162.90","139.73","162.90","1 through 10","142.58","948.92","percent of total billed charges",""
"Chemo Infus > 8 External Pmp","PX-33000129","CDM","96416","CPT","0335","RC","","","","outpatient","","","1226.00","735.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","948.92","77.4","","916.83","916.82","916.83","12","142.58","948.92","percent of total billed charges",""
"Chemo Infus > 8 External Pmp","PX-33000129","CDM","96416","CPT","0335","RC","","","","outpatient","","","1226.00","735.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","142.58","11.63","","1086.88","139.73","1086.88","14","142.58","948.92","percent of total billed charges",""
"Chemo Infus > 8 Implanted Pmp","PX-33000130","CDM","96416","CPT","0335","RC","","","","both","","","1226.00","735.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2214.69","","Case rate ($2,214.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2160.68","2144.94","2160.68","22","339.61","2214.69","other","OPPS APC"
"Chemo Infus > 8 Implanted Pmp","PX-33000130","CDM","96416","CPT","0335","RC","","","","both","","","1226.00","735.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","697.59","56.9","","673.14","673.12","2019.39","46","339.61","2214.69","percent of total billed charges",""
"Chemo Infus > 8 Implanted Pmp","PX-33000130","CDM","96416","CPT","0335","RC","","","","outpatient","","","1226.00","735.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","176.79","14.42","","170.59","170.59","170.59","1 through 10","142.58","948.92","percent of total billed charges",""
"Chemo Infus > 8 Implanted Pmp","PX-33000130","CDM","96416","CPT","0335","RC","","","","outpatient","","","1226.00","735.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","142.58","11.63","","162.90","139.73","162.90","1 through 10","142.58","948.92","percent of total billed charges",""
"Chemo Infus > 8 Implanted Pmp","PX-33000130","CDM","96416","CPT","0335","RC","","","","outpatient","","","1226.00","735.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","948.92","77.4","","916.83","916.82","916.83","12","142.58","948.92","percent of total billed charges",""
"Chemo Infus > 8 Implanted Pmp","PX-33000130","CDM","96416","CPT","0335","RC","","","","outpatient","","","1226.00","735.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","142.58","11.63","","1086.88","139.73","1086.88","14","142.58","948.92","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1223.00","733.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","853.65","69.8","","823.64","742.22","823.64","87","339.61","2214.69","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1223.00","733.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","353.47","","APC Price ($346.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","346.58","346.58","346.58","116","339.61","2214.69","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1223.00","733.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2214.69","","Case rate ($2,214.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2144.94","1382.80","2160.68","120","339.61","2214.69","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1223.00","733.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","953.65","","Case rate ($953.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","930.40","923.62","930.40","195","339.61","2214.69","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1223.00","733.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","339.61","","APC Price ($346.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","339.65","329.98","346.58","203","339.61","2214.69","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1223.00","733.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1790.12","","Case rate ($1,790.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1746.45","930.40","1746.45","168","339.61","2214.69","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1223.00","733.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","695.89","56.9","","671.42","671.42","2014.26","183","339.61","2214.69","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1223.00","733.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","853.65","69.8","","206.99","206.99","206.99","1 through 10","339.61","2214.69","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1223.00","733.80","HARVARD PILGRIM [120001]","HB WDH MEDICARE","346.54","","APC Price ($346.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","324.70","324.70","324.70","1 through 10","339.61","2214.69","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1223.00","733.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","356.93","","APC Price ($346.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","349.84","349.84","351.27","126","339.61","2214.69","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1223.00","733.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","346.54","","APC Price ($346.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","341.03","339.65","346.58","215","339.61","2214.69","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1223.00","733.80","MEDICARE [2001]","HB WDH MEDICARE","346.54","","APC Price ($346.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","346.58","346.58","346.58","1649","339.61","2214.69","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1223.00","733.80","TRICARE [160005]","HB WDH MEDICARE","346.54","","APC Price ($346.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","346.58","346.58","346.58","23","339.61","2214.69","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1223.00","733.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","346.54","","APC Price ($346.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","341.04","339.65","346.58","714","339.61","2214.69","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1223.00","733.80","WELLPOINT [1015]","HB WDH ANTHEM PPO","1790.12","","Case rate ($1,790.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1746.45","1549.20","1746.45","20","339.61","2214.69","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1223.00","733.80","WELLSENSE NH [1050]","HB WDH MEDICARE","346.54","","APC Price ($346.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1069.89","356.63","1783.15","45","339.61","2214.69","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","outpatient","","","1223.00","733.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","176.36","14.42","","170.16","145.85","170.16","138","142.23","946.6","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","outpatient","","","1223.00","733.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","142.23","11.63","","162.49","139.37","298.00","138","142.23","946.6","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","outpatient","","","1223.00","733.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","769.27","62.9","","743.40","743.40","743.40","81","142.23","946.6","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","outpatient","","","1223.00","733.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","946.60","77.4","","914.50","339.65","914.50","14","142.23","946.6","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","outpatient","","","1223.00","733.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","142.23","11.63","","543.44","139.37","1630.32","91","142.23","946.6","percent of total billed charges",""
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","263.00","157.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","183.57","69.8","","177.29","177.29","177.29","14","72.87","475.23","percent of total billed charges",""
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","263.00","157.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","75.84","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","74.36","74.36","74.36","72","72.87","475.23","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","263.00","157.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","475.23","","Case rate ($475.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","463.64","446.16","463.64","46","72.87","475.23","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","263.00","157.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","204.63","","Case rate ($204.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.65","199.65","199.65","36","72.87","475.23","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","263.00","157.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","72.87","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","74.36","72.87","74.37","78","72.87","475.23","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","263.00","157.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","384.13","","Case rate ($384.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","360.62","199.65","374.76","123","72.87","475.23","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","263.00","157.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","149.65","56.9","","144.53","144.53","433.58","76","72.87","475.23","percent of total billed charges",""
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","263.00","157.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","183.57","69.8","","44.01","44.01","44.01","1 through 10","72.87","475.23","percent of total billed charges",""
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","263.00","157.80","HARVARD PILGRIM [120001]","HB WDH MEDICARE","74.36","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","67.54","67.54","67.54","1 through 10","72.87","475.23","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","263.00","157.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","76.59","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","75.06","75.06","75.36","24","72.87","475.23","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","263.00","157.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","74.36","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","73.17","72.87","73.17","130","72.87","475.23","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","263.00","157.80","MEDICARE [2001]","HB WDH MEDICARE","74.36","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","74.36","74.36","74.37","562","72.87","475.23","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","263.00","157.80","TRICARE [160005]","HB WDH MEDICARE","74.36","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","74.36","74.36","148.73","1 through 10","72.87","475.23","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","263.00","157.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","74.36","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","73.18","72.88","74.36","293","72.87","475.23","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","263.00","157.80","WELLPOINT [1015]","HB WDH ANTHEM PPO","384.13","","Case rate ($384.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","374.76","374.75","374.76","16","72.87","475.23","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","263.00","157.80","WELLSENSE NH [1050]","HB WDH MEDICARE","74.36","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","76.52","76.52","76.83","1 through 10","72.87","475.23","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","outpatient","","","263.00","157.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","37.92","14.42","","36.63","31.40","36.63","31","30.59","203.56","percent of total billed charges",""
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","outpatient","","","263.00","157.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","30.59","11.63","","34.98","31.09","34.98","18","30.59","203.56","percent of total billed charges",""
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","outpatient","","","263.00","157.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","165.43","62.9","","160.02","160.02","160.02","28","30.59","203.56","percent of total billed charges",""
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","outpatient","","","263.00","157.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","203.56","77.4","","196.85","196.85","590.55","1 through 10","30.59","203.56","percent of total billed charges",""
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","outpatient","","","263.00","157.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","30.59","11.63","","30.01","30.00","90.00","14","30.59","203.56","percent of total billed charges",""
"Chemo IV Infusion Prolong W/Pump","PX-33000080","CDM","96416","CPT","0335","RC","","","","both","","","1226.00","735.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2214.69","","Case rate ($2,214.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2160.68","2144.94","2160.68","22","339.61","2214.69","other","OPPS APC"
"Chemo IV Infusion Prolong W/Pump","PX-33000080","CDM","96416","CPT","0335","RC","","","","both","","","1226.00","735.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","697.59","56.9","","673.14","673.12","2019.39","46","339.61","2214.69","percent of total billed charges",""
"Chemo IV Infusion Prolong W/Pump","PX-33000080","CDM","96416","CPT","0335","RC","","","","outpatient","","","1226.00","735.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","176.79","14.42","","170.59","170.59","170.59","1 through 10","142.58","948.92","percent of total billed charges",""
"Chemo IV Infusion Prolong W/Pump","PX-33000080","CDM","96416","CPT","0335","RC","","","","outpatient","","","1226.00","735.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","142.58","11.63","","162.90","139.73","162.90","1 through 10","142.58","948.92","percent of total billed charges",""
"Chemo IV Infusion Prolong W/Pump","PX-33000080","CDM","96416","CPT","0335","RC","","","","outpatient","","","1226.00","735.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","948.92","77.4","","916.83","916.82","916.83","12","142.58","948.92","percent of total billed charges",""
"Chemo IV Infusion Prolong W/Pump","PX-33000080","CDM","96416","CPT","0335","RC","","","","outpatient","","","1226.00","735.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","142.58","11.63","","1086.88","139.73","1086.88","14","142.58","948.92","percent of total billed charges",""
"Chemodenerv 1 Extremity 1-4","PX-76001950","CDM","64642","CPT","0761","RC","","","","both","","","5247.00","3148.20","MEDICARE [2001]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","723.60","723.60","723.60","1 through 10","709.05","4623.96","other","OPPS APC"
"Chemodenerv Musc Neck Dyston","PX-76001949","CDM","64616","CPT","0761","RC","","","","both","","","6700.00","4020.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","302.23","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","288.58","288.58","288.58","1 through 10","302.23","5695","other","OPPS APC"
"Chemodenervation 1 Extremity 5 or More Muscles","PX-76001967","CDM","64644","CPT","0761","RC","","","","both","","","5722.00","3433.20","MEDICARE [2001]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2170.80","723.60","2170.80","1 through 10","709.05","4863.7","other","OPPS APC"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","","","","inpatient","","","26211.54","15726.92","MEDICARE [2001]","HB WDH MEDICARE","16314.19","","Case rate ($16,314.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,092.08, add-ons for qualifying new technology services are included. If operating cost exceeds $19,010.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,964.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $14,709.68 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,647.21 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,159.64. The transfer capital threshold is the transfer adjustment factor * $1,159.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15788.57","15788.57","15788.57","1 through 10","3975","79321.41","other","Inpatient DRG"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","","","","inpatient","","","44107.84","26464.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","10182.57","","Case rate ($10,390.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,624.46, add-ons for qualifying new technology services are included. If operating cost exceeds $13,542.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,531.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,218.74 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,179.59 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.76. The transfer capital threshold is the transfer adjustment factor * $726.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10032.93","10032.93","10032.93","1 through 10","3975","49711.73","other","Inpatient DRG"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","","","","inpatient","","","44107.84","26464.70","MEDICARE [2001]","HB WDH MEDICARE","10390.38","","Case rate ($10,390.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,624.46, add-ons for qualifying new technology services are included. If operating cost exceeds $13,542.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,531.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,218.74 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,179.59 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.76. The transfer capital threshold is the transfer adjustment factor * $726.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","134.65","134.65","3798.85","1 through 10","3975","49711.73","other","Inpatient DRG"
"Chemotx Admn Ivp/ IV <16 Min Ea Add’L Seq Diff Drug - 96411","PX-33000077","CDM","96411","CPT","0331","RC","","","","both","","","507.00","304.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","353.89","69.8","","307.58","307.58","341.32","1 through 10","72.87","475.23","percent of total billed charges",""
"Chemotx Admn Ivp/ IV <16 Min Ea Add’L Seq Diff Drug - 96411","PX-33000077","CDM","96411","CPT","0331","RC","","","","both","","","507.00","304.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","75.84","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","74.36","68.64","74.36","11","72.87","475.23","other","OPPS APC"
"Chemotx Admn Ivp/ IV <16 Min Ea Add’L Seq Diff Drug - 96411","PX-33000077","CDM","96411","CPT","0331","RC","","","","both","","","507.00","304.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","475.23","","Case rate ($475.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","463.64","446.16","463.64","12","72.87","475.23","other","OPPS APC"
"Chemotx Admn Ivp/ IV <16 Min Ea Add’L Seq Diff Drug - 96411","PX-33000077","CDM","96411","CPT","0331","RC","","","","both","","","507.00","304.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","204.63","","Case rate ($204.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.65","192.12","199.65","17","72.87","475.23","other","OPPS APC"
"Chemotx Admn Ivp/ IV <16 Min Ea Add’L Seq Diff Drug - 96411","PX-33000077","CDM","96411","CPT","0331","RC","","","","both","","","507.00","304.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","72.87","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","73.17","68.64","74.36","46","72.87","475.23","other","OPPS APC"
"Chemotx Admn Ivp/ IV <16 Min Ea Add’L Seq Diff Drug - 96411","PX-33000077","CDM","96411","CPT","0331","RC","","","","both","","","507.00","304.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","384.13","","Case rate ($384.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.65","199.65","688.65","33","72.87","475.23","other","OPPS APC"
"Chemotx Admn Ivp/ IV <16 Min Ea Add’L Seq Diff Drug - 96411","PX-33000077","CDM","96411","CPT","0331","RC","","","","both","","","507.00","304.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","288.48","56.9","","278.24","278.24","834.72","27","72.87","475.23","percent of total billed charges",""
"Chemotx Admn Ivp/ IV <16 Min Ea Add’L Seq Diff Drug - 96411","PX-33000077","CDM","96411","CPT","0331","RC","","","","both","","","507.00","304.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","76.59","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","75.36","69.29","75.36","27","72.87","475.23","other","OPPS APC"
"Chemotx Admn Ivp/ IV <16 Min Ea Add’L Seq Diff Drug - 96411","PX-33000077","CDM","96411","CPT","0331","RC","","","","both","","","507.00","304.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","74.36","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","73.17","72.87","73.17","58","72.87","475.23","other","OPPS APC"
"Chemotx Admn Ivp/ IV <16 Min Ea Add’L Seq Diff Drug - 96411","PX-33000077","CDM","96411","CPT","0331","RC","","","","both","","","507.00","304.20","MEDICARE [2001]","HB WDH MEDICARE","74.36","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","74.36","74.36","205.92","156","72.87","475.23","other","OPPS APC"
"Chemotx Admn Ivp/ IV <16 Min Ea Add’L Seq Diff Drug - 96411","PX-33000077","CDM","96411","CPT","0331","RC","","","","both","","","507.00","304.20","TRICARE [160005]","HB WDH MEDICARE","74.36","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","74.36","74.36","74.36","1 through 10","72.87","475.23","other","OPPS APC"
"Chemotx Admn Ivp/ IV <16 Min Ea Add’L Seq Diff Drug - 96411","PX-33000077","CDM","96411","CPT","0331","RC","","","","both","","","507.00","304.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","74.36","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","73.18","68.64","73.18","109","72.87","475.23","other","OPPS APC"
"Chemotx Admn Ivp/ IV <16 Min Ea Add’L Seq Diff Drug - 96411","PX-33000077","CDM","96411","CPT","0331","RC","","","","both","","","507.00","304.20","WELLPOINT [1015]","HB WDH ANTHEM PPO","384.13","","Case rate ($384.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","374.75","360.62","374.75","1 through 10","72.87","475.23","other","OPPS APC"
"Chemotx Admn Ivp/ IV <16 Min Ea Add’L Seq Diff Drug - 96411","PX-33000077","CDM","96411","CPT","0331","RC","","","","both","","","507.00","304.20","WELLSENSE NH [1050]","HB WDH MEDICARE","74.36","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","382.60","382.60","382.60","1 through 10","72.87","475.23","other","OPPS APC"
"Chemotx Admn Ivp/ IV <16 Min Ea Add’L Seq Diff Drug - 96411","PX-33000077","CDM","96411","CPT","0331","RC","","","","outpatient","","","507.00","304.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","73.11","14.42","","70.51","60.44","70.51","17","58.96","392.42","percent of total billed charges",""
"Chemotx Admn Ivp/ IV <16 Min Ea Add’L Seq Diff Drug - 96411","PX-33000077","CDM","96411","CPT","0331","RC","","","","outpatient","","","507.00","304.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","58.96","11.63","","115.52","57.76","123.50","36","58.96","392.42","percent of total billed charges",""
"Chemotx Admn Ivp/ IV <16 Min Ea Add’L Seq Diff Drug - 96411","PX-33000077","CDM","96411","CPT","0331","RC","","","","outpatient","","","507.00","304.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","318.90","62.9","","308.07","308.07","308.07","1 through 10","58.96","392.42","percent of total billed charges",""
"Chemotx Admn Ivp/ IV <16 Min Ea Add’L Seq Diff Drug - 96411","PX-33000077","CDM","96411","CPT","0331","RC","","","","outpatient","","","507.00","304.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","392.42","77.4","","378.98","378.97","378.98","1 through 10","58.96","392.42","percent of total billed charges",""
"Chemotx Admn Ivp/ IV <16 Min Ea Add’L Seq Diff Drug - 96411","PX-33000077","CDM","96411","CPT","0331","RC","","","","outpatient","","","507.00","304.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","58.96","11.63","","116.60","116.60","349.80","25","58.96","392.42","percent of total billed charges",""
"Chest Pain","313","MS-DRG","","","","","","","","inpatient","","","32073.26","19243.96","MEDICARE [2001]","HB WDH MEDICARE","5918.62","","Case rate ($5,918.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,497.08, add-ons for qualifying new technology services are included. If operating cost exceeds $9,415.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,205.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,073.76 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,052.21 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.99. The transfer capital threshold is the transfer adjustment factor * $399.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5827.78","2466.86","5841.81","16","3975","27360.07","other","Inpatient DRG"
"Chest Pain","313","MS-DRG","","","","","","","","inpatient","","","32073.26","19243.96","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","5918.62","","Case rate ($5,918.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,497.08, add-ons for qualifying new technology services are included. If operating cost exceeds $9,415.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,205.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $5,073.76 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,052.21 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.99. The transfer capital threshold is the transfer adjustment factor * $399.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5724.98","5724.98","5724.98","1 through 10","3975","27360.07","other","Inpatient DRG"
"Chest Physiotherapy Initial","PX-46000008","CDM","94667","CPT","0410","RC","","","","both","","","285.00","171.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","695.68","","Case rate ($695.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","275.00","275.00","275.00","1 through 10","131.98","860.68","other","OPPS APC"
"Chest Physiotherapy Initial","PX-46000008","CDM","94667","CPT","0410","RC","","","","outpatient","","","285.00","171.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","41.10","14.42","","33.99","33.99","33.99","1 through 10","33.15","220.59","percent of total billed charges",""
"Chest Physiotherapy Initial","PX-46000008","CDM","94667","CPT","0410","RC","","","","outpatient","","","285.00","171.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","33.15","11.63","","37.87","32.49","69.47","1 through 10","33.15","220.59","percent of total billed charges",""
"Chest Physiotherapy Initial","PX-46000008","CDM","94667","CPT","0410","RC","","","","outpatient","","","285.00","171.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","33.15","11.63","","32.49","32.49","32.49","1 through 10","33.15","220.59","percent of total billed charges",""
"Chest Physiotherapy Subseq","PX-46000009","CDM","94668","CPT","0410","RC","","","","outpatient","","","370.00","222.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","43.03","11.63","","126.50","126.50","126.51","1 through 10","43.03","286.38","percent of total billed charges",""
"Chloride Urine","PX-30000360","CDM","82436","CPT","0301","RC","","","","both","","","71.00","42.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","49.56","69.8","","48.16","12.47","48.16","1 through 10","3.74","60.35","percent of total billed charges",""
"Chloride Urine","PX-30000360","CDM","82436","CPT","0301","RC","","","","outpatient","","","71.00","42.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","44.66","62.9","","43.47","43.47","43.47","1 through 10","6.03","54.95","percent of total billed charges",""
"Cholecystectomy Except By Laparoscope Without C.D.E. With McC","414","MS-DRG","","","","","","","","inpatient","","","108725.79","65235.47","MEDICARE [2001]","HB WDH MEDICARE","27529.31","","Case rate ($27,529.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $25,443.51, add-ons for qualifying new technology services are included. If operating cost exceeds $29,361.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,784.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $25,105.26 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $24,998.64 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,979.18. The transfer capital threshold is the transfer adjustment factor * $1,979.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26951.80","26951.80","26951.80","1 through 10","3975","135379.16","other","Inpatient DRG"
"Cholecystost Perc Compl Px","PX-75000245","CDM","47490","CPT","0361","RC","","","","both","","","13115.00","7869.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","10146.41","","Case rate ($10,146.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9899.05","9899.05","9899.05","1 through 10","3613.28","23563.47","other","OPPS APC"
"Cholesterol Hdl","PX-30000559","CDM","83718","CPT","0301","RC","","","","both","","","116.00","69.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","80.97","69.8","","70.45","70.45","70.45","1 through 10","5.32","98.6","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","both","","","135.00","81.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","94.23","69.8","","91.44","91.44","91.44","1 through 10","6.83","114.75","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","outpatient","","","135.00","81.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","98.17","72.72","","95.26","95.26","95.26","1 through 10","8.54","104.49","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","outpatient","","","135.00","81.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","71.85","53.22","","130.68","130.68","130.68","1 through 10","8.54","104.49","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","outpatient","","","135.00","81.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","84.92","62.9","","82.53","82.53","82.53","1 through 10","8.54","104.49","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","outpatient","","","135.00","81.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","104.49","77.4","","101.53","95.26","101.53","1 through 10","8.54","104.49","percent of total billed charges",""
"Cholesterol Total","PX-30000364","CDM","82465","CPT","0301","RC","","","","outpatient","","","62.00","37.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","27.11","43.72","","26.23","26.23","26.23","1 through 10","4.06","47.99","percent of total billed charges",""
"Cholesterol Total","PX-30000364","CDM","82465","CPT","0301","RC","","","","outpatient","","","62.00","37.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","45.09","72.72","","43.63","43.63","43.63","1 through 10","4.06","47.99","percent of total billed charges",""
"Cholesterol Total","PX-30000364","CDM","82465","CPT","0301","RC","","","","outpatient","","","62.00","37.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","39.00","62.9","","37.80","37.80","37.80","1 through 10","4.06","47.99","percent of total billed charges",""
"Cholesterol Total","PX-30000364","CDM","82465","CPT","0301","RC","","","","outpatient","","","62.00","37.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","47.99","77.4","","46.50","46.50","46.50","1 through 10","4.06","47.99","percent of total billed charges",""
"Chrom Count 15-20/2","PX-31000122","CDM","88262","CPT","0311","RC","","","","both","","","862.00","517.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","601.68","69.8","","582.13","582.13","582.13","1 through 10","81.57","732.7","percent of total billed charges",""
"Chrom Count 15-20/2","PX-31000122","CDM","88262","CPT","0311","RC","","","","both","","","862.00","517.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","601.68","69.8","","582.13","582.13","582.13","1 through 10","81.57","732.7","percent of total billed charges",""
"Chrom Count 15-20/2","PX-31000122","CDM","88262","CPT","0311","RC","","","","outpatient","","","862.00","517.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","626.85","72.72","","606.48","606.48","606.48","1 through 10","144.91","667.19","percent of total billed charges",""
"Chrom Count 15-20/2","PX-31000122","CDM","88262","CPT","0311","RC","","","","outpatient","","","862.00","517.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","542.20","62.9","","525.42","525.42","1576.26","1 through 10","144.91","667.19","percent of total billed charges",""
"Chrom Count 15-20/2","PX-31000122","CDM","88262","CPT","0311","RC","","","","outpatient","","","862.00","517.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","667.19","77.4","","646.35","646.35","646.35","1 through 10","144.91","667.19","percent of total billed charges",""
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","","","","inpatient","","","22551.26","13530.76","MEDICARE [2001]","HB WDH MEDICARE","6853.72","","Case rate ($6,853.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,360.17, add-ons for qualifying new technology services are included. If operating cost exceeds $10,278.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,273.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,940.53 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,915.30 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.32. The transfer capital threshold is the transfer adjustment factor * $468.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6927.17","0.05","6944.06","15","3975","32034.08","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","","","","inpatient","","","22551.26","13530.76","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6853.72","","Case rate ($6,853.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,360.17, add-ons for qualifying new technology services are included. If operating cost exceeds $10,278.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,273.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,940.53 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,915.30 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $468.32. The transfer capital threshold is the transfer adjustment factor * $468.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5246.29","2766.56","8755.88","1 through 10","3975","32034.08","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","24814.40","14888.64","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","9043.41","","Case rate ($8,866.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,217.56, add-ons for qualifying new technology services are included. If operating cost exceeds $12,135.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,420.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,805.84 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,772.69 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.38. The transfer capital threshold is the transfer adjustment factor * $615.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","8918.44","8918.44","8918.44","1 through 10","3975","42092.71","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","24814.40","14888.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","16574.38","","Fee schedule rate ($16,574.38). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","16393.47","16393.47","16393.47","1 through 10","3975","42092.71","case rate",""
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","24814.40","14888.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","8688.77","","Case rate ($8,866.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,217.56, add-ons for qualifying new technology services are included. If operating cost exceeds $12,135.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,420.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,805.84 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,772.69 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.38. The transfer capital threshold is the transfer adjustment factor * $615.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8795.23","8773.59","8795.23","1 through 10","3975","42092.71","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","24814.40","14888.64","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","9132.07","","Case rate ($8,866.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,217.56, add-ons for qualifying new technology services are included. If operating cost exceeds $12,135.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,420.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,805.84 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,772.69 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.38. The transfer capital threshold is the transfer adjustment factor * $615.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","8519.36","5039.49","35310.17","1 through 10","3975","42092.71","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","24814.40","14888.64","MARTIN'S POINT [160007]","HB WDH MEDICARE","8866.09","","Case rate ($8,866.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,217.56, add-ons for qualifying new technology services are included. If operating cost exceeds $12,135.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,420.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,805.84 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,772.69 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.38. The transfer capital threshold is the transfer adjustment factor * $615.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8791.71","8791.71","8791.71","1 through 10","3975","42092.71","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","24814.40","14888.64","MEDICARE [2001]","HB WDH MEDICARE","8866.09","","Case rate ($8,866.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,217.56, add-ons for qualifying new technology services are included. If operating cost exceeds $12,135.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,420.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,805.84 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,772.69 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.38. The transfer capital threshold is the transfer adjustment factor * $615.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8918.44","0.05","8940.52","44","3975","42092.71","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","24814.40","14888.64","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8866.09","","Case rate ($8,866.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,217.56, add-ons for qualifying new technology services are included. If operating cost exceeds $12,135.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,420.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,805.84 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,772.69 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.38. The transfer capital threshold is the transfer adjustment factor * $615.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8918.44","7763.51","8941.10","1 through 10","3975","42092.71","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","24814.40","14888.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","22696.77","","Fee schedule rate ($22,696.77). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","13261.13","13261.13","13261.13","1 through 10","3975","42092.71","case rate",""
"Chronic Obstructive Pulmonary Disease Without Cc/McC","192","MS-DRG","","","","","","","","inpatient","","","21742.69","13045.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","19430.31","","Fee schedule rate ($19,430.31). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","25568.38","25568.38","25568.38","1 through 10","3975","24396.06","case rate",""
"Chronic Obstructive Pulmonary Disease Without Cc/McC","192","MS-DRG","","","","","","","","inpatient","","","21742.69","13045.61","MEDICARE [2001]","HB WDH MEDICARE","5325.63","","Case rate ($5,325.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $4,949.76, add-ons for qualifying new technology services are included. If operating cost exceeds $8,867.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,161.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,524.10 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,504.89 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $356.66. The transfer capital threshold is the transfer adjustment factor * $356.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1384.07","1384.07","5341.33","1 through 10","3975","24396.06","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease Without Cc/McC","192","MS-DRG","","","","","","","","inpatient","","","21742.69","13045.61","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","5325.63","","Case rate ($5,325.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $4,949.76, add-ons for qualifying new technology services are included. If operating cost exceeds $8,867.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,161.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,524.10 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,504.89 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $356.66. The transfer capital threshold is the transfer adjustment factor * $356.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5341.00","5341.00","9641.18","1 through 10","3975","24396.06","other","Inpatient DRG"
"CINCH TISSUE SIZE 5 3.8M WHIPKNOT SOFT ARTHROSCOPY CANNULA","SUP-ITM-10049273","CDM","C1713","HCPCS","0278","RC","","","","both","","","773.92","464.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","90.01","657.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CINCH TISSUE SIZE 5 3.8M WHIPKNOT SOFT ARTHROSCOPY CANNULA","SUP-ITM-10049273","CDM","C1713","HCPCS","0278","RC","","","","both","","","773.92","464.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","90.01","657.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CINCH TISSUE SIZE 5 3.8M WHIPKNOT SOFT ARTHROSCOPY CANNULA","SUP-ITM-10049273","CDM","C1713","HCPCS","0278","RC","","","","both","","","773.92","464.35","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","440.36","56.9","","812.12","238.65","1587.46","163","90.01","657.83","percent of total billed charges",""
"CINCH TISSUE SIZE 5 3.8M WHIPKNOT SOFT ARTHROSCOPY CANNULA","SUP-ITM-10049273","CDM","C1713","HCPCS","0278","RC","","","","both","","","773.92","464.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","90.01","11.63","","112.68","112.68","146.99","38","90.01","657.83","percent of total billed charges",""
"CINCH TISSUE SIZE 5 3.8M WHIPKNOT SOFT ARTHROSCOPY CANNULA","SUP-ITM-10049273","CDM","C1713","HCPCS","0278","RC","","","","both","","","773.92","464.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","599.01","77.4","","303.98","303.98","5854.79","1 through 10","90.01","657.83","percent of total billed charges",""
"CINCH TISSUE SIZE 5 3.8M WHIPKNOT SOFT ARTHROSCOPY CANNULA","SUP-ITM-10049273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","773.92","464.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","90.01","11.63","","112.68","112.68","146.99","38","90.01","599.01","percent of total billed charges",""
"CINCH TISSUE SIZE 5 3.8M WHIPKNOT SOFT ARTHROSCOPY CANNULA","SUP-ITM-10049273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","773.92","464.35","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","485.87","62.78","","780.86","208.94","10480.28","15","90.01","599.01","percent of total billed charges",""
"CINCH TISSUE SIZE 5 3.8M WHIPKNOT SOFT ARTHROSCOPY CANNULA","SUP-ITM-10049273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","773.92","464.35","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","338.36","43.72","","179.76","179.76","179.76","1 through 10","90.01","599.01","percent of total billed charges",""
"CINCH TISSUE SIZE 5 3.8M WHIPKNOT SOFT ARTHROSCOPY CANNULA","SUP-ITM-10049273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","773.92","464.35","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","562.79","72.72","","2355.45","298.99","3965.19","155","90.01","599.01","percent of total billed charges",""
"CINCH TISSUE SIZE 5 3.8M WHIPKNOT SOFT ARTHROSCOPY CANNULA","SUP-ITM-10049273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","773.92","464.35","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","562.79","72.72","","3643.09","3643.09","3643.09","1 through 10","90.01","599.01","percent of total billed charges",""
"CINCH TISSUE SIZE 5 3.8M WHIPKNOT SOFT ARTHROSCOPY CANNULA","SUP-ITM-10049273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","773.92","464.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","411.88","53.22","","554.28","554.28","554.28","16","90.01","599.01","percent of total billed charges",""
"CINCH TISSUE SIZE 5 3.8M WHIPKNOT SOFT ARTHROSCOPY CANNULA","SUP-ITM-10049273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","773.92","464.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","486.80","62.9","","619.64","173.09","2370.64","150","90.01","599.01","percent of total billed charges",""
"CINCH TISSUE SIZE 5 3.8M WHIPKNOT SOFT ARTHROSCOPY CANNULA","SUP-ITM-10049273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","773.92","464.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","599.01","77.4","","303.98","303.98","5854.79","1 through 10","90.01","599.01","percent of total billed charges",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","61008.51","36605.11","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","17612.88","","Case rate ($17,267.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,972.01, add-ons for qualifying new technology services are included. If operating cost exceeds $19,890.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,034.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $15,593.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,527.14 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,229.31. The transfer capital threshold is the transfer adjustment factor * $1,229.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","17145.37","17145.37","17145.37","1 through 10","15803","84086.62","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","61008.51","36605.11","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","33109.86","","Fee schedule rate ($33,109.86). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","32309.59","32309.59","32309.59","1 through 10","15803","84086.62","case rate",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","61008.51","36605.11","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","16922.18","","Case rate ($17,267.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,972.01, add-ons for qualifying new technology services are included. If operating cost exceeds $19,890.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,034.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $15,593.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,527.14 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,229.31. The transfer capital threshold is the transfer adjustment factor * $1,229.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16878.63","16845.11","230134.64","1 through 10","15803","84086.62","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","61008.51","36605.11","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","66971.01","","Fee schedule rate ($66,971.01). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","65214.48","65214.48","65352.33","1 through 10","15803","84086.62","case rate",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","61008.51","36605.11","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","17785.56","","Case rate ($17,267.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,972.01, add-ons for qualifying new technology services are included. If operating cost exceeds $19,890.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,034.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $15,593.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,527.14 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,229.31. The transfer capital threshold is the transfer adjustment factor * $1,229.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9944.38","5549.96","16771.92","1 through 10","15803","84086.62","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","61008.51","36605.11","MARTIN'S POINT [160007]","HB WDH MEDICARE","17267.53","","Case rate ($17,267.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,972.01, add-ons for qualifying new technology services are included. If operating cost exceeds $19,890.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,034.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $15,593.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,527.14 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,229.31. The transfer capital threshold is the transfer adjustment factor * $1,229.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16809.96","6521.37","16882.61","1 through 10","15803","84086.62","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","61008.51","36605.11","MEDICARE [2001]","HB WDH MEDICARE","17267.53","","Case rate ($17,267.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,972.01, add-ons for qualifying new technology services are included. If operating cost exceeds $19,890.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,034.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $15,593.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,527.14 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,229.31. The transfer capital threshold is the transfer adjustment factor * $1,229.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17145.37","0.05","17188.89","29","15803","84086.62","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","61008.51","36605.11","TRICARE [160005]","HB WDH MEDICARE","17267.53","","Case rate ($17,267.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,972.01, add-ons for qualifying new technology services are included. If operating cost exceeds $19,890.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,034.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $15,593.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,527.14 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,229.31. The transfer capital threshold is the transfer adjustment factor * $1,229.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16761.22","16761.22","16761.22","1 through 10","15803","84086.62","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","61008.51","36605.11","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","17267.53","","Case rate ($17,267.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,972.01, add-ons for qualifying new technology services are included. If operating cost exceeds $19,890.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,034.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $15,593.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,527.14 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,229.31. The transfer capital threshold is the transfer adjustment factor * $1,229.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16871.65","16816.61","17190.04","12","15803","84086.62","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","61008.51","36605.11","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","45340.27","","Fee schedule rate ($45,340.27). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","45350.52","45350.52","45350.52","1 through 10","15803","84086.62","case rate",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","61008.51","36605.11","WELLSENSE NH [1050]","HB WDH MEDICARE","17267.53","","Case rate ($17,267.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,972.01, add-ons for qualifying new technology services are included. If operating cost exceeds $19,890.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,034.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $15,593.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,527.14 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,229.31. The transfer capital threshold is the transfer adjustment factor * $1,229.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17731.16","17731.16","17731.16","1 through 10","15803","84086.62","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without McC","287","MS-DRG","","","","","","","","inpatient","","","46375.16","27825.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","16011.78","","Fee schedule rate ($16,011.78). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","15907.36","15907.36","15907.36","1 through 10","7642.26","40663.91","case rate",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without McC","287","MS-DRG","","","","","","","","inpatient","","","46375.16","27825.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","8408.62","","Case rate ($8,580.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,953.72, add-ons for qualifying new technology services are included. If operating cost exceeds $11,871.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,399.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $7,540.88 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,508.85 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $594.49. The transfer capital threshold is the transfer adjustment factor * $594.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8667.17","8667.17","8688.59","1 through 10","7642.26","40663.91","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without McC","287","MS-DRG","","","","","","","","inpatient","","","46375.16","27825.10","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","8837.63","","Case rate ($8,580.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,953.72, add-ons for qualifying new technology services are included. If operating cost exceeds $11,871.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,399.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $7,540.88 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,508.85 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $594.49. The transfer capital threshold is the transfer adjustment factor * $594.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","39794.42","39794.42","39794.42","1 through 10","7642.26","40663.91","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without McC","287","MS-DRG","","","","","","","","inpatient","","","46375.16","27825.10","MARTIN'S POINT [160007]","HB WDH MEDICARE","8580.22","","Case rate ($8,580.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,953.72, add-ons for qualifying new technology services are included. If operating cost exceeds $11,871.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,399.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $7,540.88 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,508.85 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $594.49. The transfer capital threshold is the transfer adjustment factor * $594.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8541.43","8137.78","11471.46","1 through 10","7642.26","40663.91","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without McC","287","MS-DRG","","","","","","","","inpatient","","","46375.16","27825.10","MEDICARE [2001]","HB WDH MEDICARE","8580.22","","Case rate ($8,580.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,953.72, add-ons for qualifying new technology services are included. If operating cost exceeds $11,871.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,399.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $7,540.88 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,508.85 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $594.49. The transfer capital threshold is the transfer adjustment factor * $594.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8667.17","0.05","8688.59","35","7642.26","40663.91","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without McC","287","MS-DRG","","","","","","","","inpatient","","","46375.16","27825.10","TRICARE [160005]","HB WDH MEDICARE","8580.22","","Case rate ($8,580.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,953.72, add-ons for qualifying new technology services are included. If operating cost exceeds $11,871.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,399.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $7,540.88 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,508.85 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $594.49. The transfer capital threshold is the transfer adjustment factor * $594.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11729.85","11729.85","11729.85","1 through 10","7642.26","40663.91","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without McC","287","MS-DRG","","","","","","","","inpatient","","","46375.16","27825.10","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8580.22","","Case rate ($8,580.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,953.72, add-ons for qualifying new technology services are included. If operating cost exceeds $11,871.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,399.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $7,540.88 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,508.85 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $594.49. The transfer capital threshold is the transfer adjustment factor * $594.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8667.17","8296.19","8689.16","1 through 10","7642.26","40663.91","other","Inpatient DRG"
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","","","","inpatient","","","30378.42","18227.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","8305.06","","Case rate ($8,474.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,856.18, add-ons for qualifying new technology services are included. If operating cost exceeds $11,774.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,391.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,442.93 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,411.32 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $586.77. The transfer capital threshold is the transfer adjustment factor * $586.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8517.02","8517.02","8517.02","1 through 10","3975","40135.71","other","Inpatient DRG"
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","","","","inpatient","","","30378.42","18227.05","MEDICARE [2001]","HB WDH MEDICARE","8474.55","","Case rate ($8,474.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,856.18, add-ons for qualifying new technology services are included. If operating cost exceeds $11,774.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,391.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,442.93 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,411.32 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $586.77. The transfer capital threshold is the transfer adjustment factor * $586.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8517.02","8517.02","8538.06","12","3975","40135.71","other","Inpatient DRG"
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","","","","inpatient","","","30378.42","18227.05","WELLSENSE NH [1050]","HB WDH MEDICARE","8474.55","","Case rate ($8,474.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,856.18, add-ons for qualifying new technology services are included. If operating cost exceeds $11,774.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,391.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,442.93 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,411.32 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $586.77. The transfer capital threshold is the transfer adjustment factor * $586.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8778.81","8778.81","8778.81","1 through 10","3975","40135.71","other","Inpatient DRG"
"Cirrhosis And Alcoholic Hepatitis With McC","432","MS-DRG","","","","","","","","inpatient","","","52385.35","31431.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","15099.82","","Case rate ($15,407.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,255.66, add-ons for qualifying new technology services are included. If operating cost exceeds $18,173.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,898.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,869.69 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,810.79 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,093.42. The transfer capital threshold is the transfer adjustment factor * $1,093.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15265.80","15265.80","15265.80","1 through 10","4637","74791.8","other","Inpatient DRG"
"Cirrhosis And Alcoholic Hepatitis With McC","432","MS-DRG","","","","","","","","inpatient","","","52385.35","31431.21","MEDICARE [2001]","HB WDH MEDICARE","15407.98","","Case rate ($15,407.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,255.66, add-ons for qualifying new technology services are included. If operating cost exceeds $18,173.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,898.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,869.69 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,810.79 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,093.42. The transfer capital threshold is the transfer adjustment factor * $1,093.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15227.28","15227.28","15227.28","1 through 10","4637","74791.8","other","Inpatient DRG"
"Cirrhosis And Alcoholic Hepatitis With McC","432","MS-DRG","","","","","","","","inpatient","","","52385.35","31431.21","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","15407.98","","Case rate ($15,407.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,255.66, add-ons for qualifying new technology services are included. If operating cost exceeds $18,173.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,898.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,869.69 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,810.79 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,093.42. The transfer capital threshold is the transfer adjustment factor * $1,093.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14972.84","14972.84","14972.84","1 through 10","4637","74791.8","other","Inpatient DRG"
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10073386","CDM","C1713","HCPCS","0278","RC","","","","both","","","6402.00","3841.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","744.55","5441.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10073386","CDM","C1713","HCPCS","0278","RC","","","","both","","","6402.00","3841.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","744.55","5441.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10073386","CDM","C1713","HCPCS","0278","RC","","","","both","","","6402.00","3841.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3642.74","56.9","","812.12","238.65","1587.46","163","744.55","5441.7","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10073386","CDM","C1713","HCPCS","0278","RC","","","","both","","","6402.00","3841.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","744.55","11.63","","112.68","112.68","146.99","38","744.55","5441.7","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10073386","CDM","C1713","HCPCS","0278","RC","","","","both","","","6402.00","3841.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4955.15","77.4","","303.98","303.98","5854.79","1 through 10","744.55","5441.7","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10073386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6402.00","3841.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","744.55","11.63","","112.68","112.68","146.99","38","744.55","4955.15","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10073386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6402.00","3841.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4019.18","62.78","","780.86","208.94","10480.28","15","744.55","4955.15","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10073386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6402.00","3841.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2798.95","43.72","","179.76","179.76","179.76","1 through 10","744.55","4955.15","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10073386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6402.00","3841.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4655.53","72.72","","2355.45","298.99","3965.19","155","744.55","4955.15","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10073386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6402.00","3841.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4655.53","72.72","","3643.09","3643.09","3643.09","1 through 10","744.55","4955.15","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10073386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6402.00","3841.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3407.14","53.22","","554.28","554.28","554.28","16","744.55","4955.15","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10073386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6402.00","3841.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4026.86","62.9","","619.64","173.09","2370.64","150","744.55","4955.15","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10073386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6402.00","3841.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4955.15","77.4","","303.98","303.98","5854.79","1 through 10","744.55","4955.15","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","both","","","6400.18","3840.11","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","744.34","5440.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","both","","","6400.18","3840.11","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","744.34","5440.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","both","","","6400.18","3840.11","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3641.70","56.9","","812.12","238.65","1587.46","163","744.34","5440.15","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","both","","","6400.18","3840.11","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","744.34","11.63","","112.68","112.68","146.99","38","744.34","5440.15","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","both","","","6400.18","3840.11","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4953.74","77.4","","303.98","303.98","5854.79","1 through 10","744.34","5440.15","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6400.18","3840.11","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","744.34","11.63","","112.68","112.68","146.99","38","744.34","4953.74","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6400.18","3840.11","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4018.03","62.78","","780.86","208.94","10480.28","15","744.34","4953.74","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6400.18","3840.11","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2798.16","43.72","","179.76","179.76","179.76","1 through 10","744.34","4953.74","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6400.18","3840.11","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4654.21","72.72","","2355.45","298.99","3965.19","155","744.34","4953.74","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6400.18","3840.11","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4654.21","72.72","","3643.09","3643.09","3643.09","1 through 10","744.34","4953.74","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6400.18","3840.11","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3406.18","53.22","","554.28","554.28","554.28","16","744.34","4953.74","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6400.18","3840.11","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4025.71","62.9","","619.64","173.09","2370.64","150","744.34","4953.74","percent of total billed charges",""
"CLAVICLE PLATE 2.7MM XL SHAFT VA-LCP STAINLESS STEEL RT","SUP-ITM-10297637","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6400.18","3840.11","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4953.74","77.4","","303.98","303.98","5854.79","1 through 10","744.34","4953.74","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037954","CDM","C1713","HCPCS","0278","RC","","","","both","","","6481.23","3888.74","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","753.77","5509.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037954","CDM","C1713","HCPCS","0278","RC","","","","both","","","6481.23","3888.74","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","753.77","5509.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037954","CDM","C1713","HCPCS","0278","RC","","","","both","","","6481.23","3888.74","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3687.82","56.9","","812.12","238.65","1587.46","163","753.77","5509.05","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037954","CDM","C1713","HCPCS","0278","RC","","","","both","","","6481.23","3888.74","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","753.77","11.63","","112.68","112.68","146.99","38","753.77","5509.05","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037954","CDM","C1713","HCPCS","0278","RC","","","","both","","","6481.23","3888.74","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5016.47","77.4","","303.98","303.98","5854.79","1 through 10","753.77","5509.05","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6481.23","3888.74","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","753.77","11.63","","112.68","112.68","146.99","38","753.77","5016.47","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6481.23","3888.74","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4068.92","62.78","","780.86","208.94","10480.28","15","753.77","5016.47","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6481.23","3888.74","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2833.59","43.72","","179.76","179.76","179.76","1 through 10","753.77","5016.47","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6481.23","3888.74","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4713.15","72.72","","2355.45","298.99","3965.19","155","753.77","5016.47","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6481.23","3888.74","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4713.15","72.72","","3643.09","3643.09","3643.09","1 through 10","753.77","5016.47","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6481.23","3888.74","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3449.31","53.22","","554.28","554.28","554.28","16","753.77","5016.47","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6481.23","3888.74","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4076.69","62.9","","619.64","173.09","2370.64","150","753.77","5016.47","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6481.23","3888.74","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5016.47","77.4","","303.98","303.98","5854.79","1 through 10","753.77","5016.47","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 4 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037949","CDM","C1713","HCPCS","0278","RC","","","","both","","","6197.44","3718.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","720.76","5267.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CLAVICLE PLATE 3.5X15MM 4 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037949","CDM","C1713","HCPCS","0278","RC","","","","both","","","6197.44","3718.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","720.76","5267.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CLAVICLE PLATE 3.5X15MM 4 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037949","CDM","C1713","HCPCS","0278","RC","","","","both","","","6197.44","3718.46","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3526.34","56.9","","812.12","238.65","1587.46","163","720.76","5267.82","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 4 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037949","CDM","C1713","HCPCS","0278","RC","","","","both","","","6197.44","3718.46","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","720.76","11.63","","112.68","112.68","146.99","38","720.76","5267.82","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 4 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037949","CDM","C1713","HCPCS","0278","RC","","","","both","","","6197.44","3718.46","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4796.82","77.4","","303.98","303.98","5854.79","1 through 10","720.76","5267.82","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 4 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6197.44","3718.46","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","720.76","11.63","","112.68","112.68","146.99","38","720.76","4796.82","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 4 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6197.44","3718.46","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3890.75","62.78","","780.86","208.94","10480.28","15","720.76","4796.82","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 4 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6197.44","3718.46","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2709.52","43.72","","179.76","179.76","179.76","1 through 10","720.76","4796.82","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 4 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6197.44","3718.46","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4506.78","72.72","","2355.45","298.99","3965.19","155","720.76","4796.82","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 4 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6197.44","3718.46","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4506.78","72.72","","3643.09","3643.09","3643.09","1 through 10","720.76","4796.82","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 4 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6197.44","3718.46","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3298.28","53.22","","554.28","554.28","554.28","16","720.76","4796.82","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 4 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6197.44","3718.46","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3898.19","62.9","","619.64","173.09","2370.64","150","720.76","4796.82","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 4 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6197.44","3718.46","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4796.82","77.4","","303.98","303.98","5854.79","1 through 10","720.76","4796.82","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","4877.45","2926.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","567.25","4145.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","4877.45","2926.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","567.25","4145.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","4877.45","2926.47","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2775.27","56.9","","812.12","238.65","1587.46","163","567.25","4145.83","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","4877.45","2926.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","567.25","11.63","","112.68","112.68","146.99","38","567.25","4145.83","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","4877.45","2926.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3775.15","77.4","","303.98","303.98","5854.79","1 through 10","567.25","4145.83","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4877.45","2926.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","567.25","11.63","","112.68","112.68","146.99","38","567.25","3775.15","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4877.45","2926.47","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3062.06","62.78","","780.86","208.94","10480.28","15","567.25","3775.15","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4877.45","2926.47","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2132.42","43.72","","179.76","179.76","179.76","1 through 10","567.25","3775.15","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4877.45","2926.47","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3546.88","72.72","","2355.45","298.99","3965.19","155","567.25","3775.15","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4877.45","2926.47","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3546.88","72.72","","3643.09","3643.09","3643.09","1 through 10","567.25","3775.15","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4877.45","2926.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2595.78","53.22","","554.28","554.28","554.28","16","567.25","3775.15","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4877.45","2926.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3067.92","62.9","","619.64","173.09","2370.64","150","567.25","3775.15","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4877.45","2926.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3775.15","77.4","","303.98","303.98","5854.79","1 through 10","567.25","3775.15","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK TITANIUM LEFT","SUP-ITM-10040693","CDM","C1713","HCPCS","0278","RC","","","","both","","","5363.76","3218.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","623.81","4559.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK TITANIUM LEFT","SUP-ITM-10040693","CDM","C1713","HCPCS","0278","RC","","","","both","","","5363.76","3218.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","623.81","4559.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK TITANIUM LEFT","SUP-ITM-10040693","CDM","C1713","HCPCS","0278","RC","","","","both","","","5363.76","3218.26","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3051.98","56.9","","812.12","238.65","1587.46","163","623.81","4559.2","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK TITANIUM LEFT","SUP-ITM-10040693","CDM","C1713","HCPCS","0278","RC","","","","both","","","5363.76","3218.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","623.81","11.63","","112.68","112.68","146.99","38","623.81","4559.2","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK TITANIUM LEFT","SUP-ITM-10040693","CDM","C1713","HCPCS","0278","RC","","","","both","","","5363.76","3218.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4151.55","77.4","","303.98","303.98","5854.79","1 through 10","623.81","4559.2","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK TITANIUM LEFT","SUP-ITM-10040693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5363.76","3218.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","623.81","11.63","","112.68","112.68","146.99","38","623.81","4151.55","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK TITANIUM LEFT","SUP-ITM-10040693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5363.76","3218.26","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3367.37","62.78","","780.86","208.94","10480.28","15","623.81","4151.55","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK TITANIUM LEFT","SUP-ITM-10040693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5363.76","3218.26","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2345.04","43.72","","179.76","179.76","179.76","1 through 10","623.81","4151.55","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK TITANIUM LEFT","SUP-ITM-10040693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5363.76","3218.26","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3900.53","72.72","","2355.45","298.99","3965.19","155","623.81","4151.55","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK TITANIUM LEFT","SUP-ITM-10040693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5363.76","3218.26","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3900.53","72.72","","3643.09","3643.09","3643.09","1 through 10","623.81","4151.55","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK TITANIUM LEFT","SUP-ITM-10040693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5363.76","3218.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2854.59","53.22","","554.28","554.28","554.28","16","623.81","4151.55","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK TITANIUM LEFT","SUP-ITM-10040693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5363.76","3218.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3373.81","62.9","","619.64","173.09","2370.64","150","623.81","4151.55","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK TITANIUM LEFT","SUP-ITM-10040693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5363.76","3218.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4151.55","77.4","","303.98","303.98","5854.79","1 through 10","623.81","4151.55","percent of total billed charges",""
"CLAVICLE PLATE 3.5X18MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037958","CDM","C1713","HCPCS","0278","RC","","","","both","","","6481.23","3888.74","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","753.77","5509.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CLAVICLE PLATE 3.5X18MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037958","CDM","C1713","HCPCS","0278","RC","","","","both","","","6481.23","3888.74","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","753.77","5509.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CLAVICLE PLATE 3.5X18MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037958","CDM","C1713","HCPCS","0278","RC","","","","both","","","6481.23","3888.74","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3687.82","56.9","","812.12","238.65","1587.46","163","753.77","5509.05","percent of total billed charges",""
"CLAVICLE PLATE 3.5X18MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037958","CDM","C1713","HCPCS","0278","RC","","","","both","","","6481.23","3888.74","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","753.77","11.63","","112.68","112.68","146.99","38","753.77","5509.05","percent of total billed charges",""
"CLAVICLE PLATE 3.5X18MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037958","CDM","C1713","HCPCS","0278","RC","","","","both","","","6481.23","3888.74","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5016.47","77.4","","303.98","303.98","5854.79","1 through 10","753.77","5509.05","percent of total billed charges",""
"CLAVICLE PLATE 3.5X18MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6481.23","3888.74","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","753.77","11.63","","112.68","112.68","146.99","38","753.77","5016.47","percent of total billed charges",""
"CLAVICLE PLATE 3.5X18MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6481.23","3888.74","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4068.92","62.78","","780.86","208.94","10480.28","15","753.77","5016.47","percent of total billed charges",""
"CLAVICLE PLATE 3.5X18MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6481.23","3888.74","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2833.59","43.72","","179.76","179.76","179.76","1 through 10","753.77","5016.47","percent of total billed charges",""
"CLAVICLE PLATE 3.5X18MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6481.23","3888.74","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4713.15","72.72","","2355.45","298.99","3965.19","155","753.77","5016.47","percent of total billed charges",""
"CLAVICLE PLATE 3.5X18MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6481.23","3888.74","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4713.15","72.72","","3643.09","3643.09","3643.09","1 through 10","753.77","5016.47","percent of total billed charges",""
"CLAVICLE PLATE 3.5X18MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6481.23","3888.74","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3449.31","53.22","","554.28","554.28","554.28","16","753.77","5016.47","percent of total billed charges",""
"CLAVICLE PLATE 3.5X18MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6481.23","3888.74","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4076.69","62.9","","619.64","173.09","2370.64","150","753.77","5016.47","percent of total billed charges",""
"CLAVICLE PLATE 3.5X18MM 5 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6481.23","3888.74","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5016.47","77.4","","303.98","303.98","5854.79","1 through 10","753.77","5016.47","percent of total billed charges",""
"CLAVICLE PLATE 3.5X18MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037961","CDM","C1713","HCPCS","0278","RC","","","","both","","","6665.32","3999.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","775.18","5665.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CLAVICLE PLATE 3.5X18MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037961","CDM","C1713","HCPCS","0278","RC","","","","both","","","6665.32","3999.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","775.18","5665.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CLAVICLE PLATE 3.5X18MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037961","CDM","C1713","HCPCS","0278","RC","","","","both","","","6665.32","3999.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3792.57","56.9","","812.12","238.65","1587.46","163","775.18","5665.52","percent of total billed charges",""
"CLAVICLE PLATE 3.5X18MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037961","CDM","C1713","HCPCS","0278","RC","","","","both","","","6665.32","3999.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","775.18","11.63","","112.68","112.68","146.99","38","775.18","5665.52","percent of total billed charges",""
"CLAVICLE PLATE 3.5X18MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037961","CDM","C1713","HCPCS","0278","RC","","","","both","","","6665.32","3999.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5158.96","77.4","","303.98","303.98","5854.79","1 through 10","775.18","5665.52","percent of total billed charges",""
"CLAVICLE PLATE 3.5X18MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6665.32","3999.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","775.18","11.63","","112.68","112.68","146.99","38","775.18","5158.96","percent of total billed charges",""
"CLAVICLE PLATE 3.5X18MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6665.32","3999.19","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4184.49","62.78","","780.86","208.94","10480.28","15","775.18","5158.96","percent of total billed charges",""
"CLAVICLE PLATE 3.5X18MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6665.32","3999.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2914.08","43.72","","179.76","179.76","179.76","1 through 10","775.18","5158.96","percent of total billed charges",""
"CLAVICLE PLATE 3.5X18MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6665.32","3999.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4847.02","72.72","","2355.45","298.99","3965.19","155","775.18","5158.96","percent of total billed charges",""
"CLAVICLE PLATE 3.5X18MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6665.32","3999.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4847.02","72.72","","3643.09","3643.09","3643.09","1 through 10","775.18","5158.96","percent of total billed charges",""
"CLAVICLE PLATE 3.5X18MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6665.32","3999.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3547.28","53.22","","554.28","554.28","554.28","16","775.18","5158.96","percent of total billed charges",""
"CLAVICLE PLATE 3.5X18MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6665.32","3999.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4192.49","62.9","","619.64","173.09","2370.64","150","775.18","5158.96","percent of total billed charges",""
"CLAVICLE PLATE 3.5X18MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6665.32","3999.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5158.96","77.4","","303.98","303.98","5854.79","1 through 10","775.18","5158.96","percent of total billed charges",""
"Closure of Split Wound Simple - 12020","PX-76000119","CDM","12020","CPT","0761","RC","","","","both","","","1831.00","1098.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1041.84","56.9","","280.45","280.45","280.45","1 through 10","199.25","4087.16","percent of total billed charges",""
"Closure of Split Wound Simple - 12020","PX-76000119","CDM","12020","CPT","0761","RC","","","","both","","","1831.00","1098.60","MEDICARE [2001]","HB WDH MEDICARE","639.53","","APC Price ($639.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","639.60","639.60","639.60","1 through 10","199.25","4087.16","other","OPPS APC"
"Closure of Split Wound Simple - 12020","PX-76000119","CDM","12020","CPT","0761","RC","","","","outpatient","","","1831.00","1098.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1151.70","62.9","","810.81","810.81","810.81","1 through 10","212.95","1417.19","percent of total billed charges",""
"Coag Fibrinolysis Func Activity Nos","PX-30001094","CDM","85397","CPT","0305","RC","","","","outpatient","","","356.00","213.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","275.54","77.4","","266.60","266.60","266.60","1 through 10","29.07","275.54","percent of total billed charges",""
"Coagulation Disorders","813","MS-DRG","","","","","","","","inpatient","","","43357.12","26014.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","22822.88","","Fee schedule rate ($22,822.88). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","22597.59","22597.59","22597.59","1 through 10","3975","57961.55","case rate",""
"Coagulation Disorders","813","MS-DRG","","","","","","","","inpatient","","","43357.12","26014.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","11800.03","","Case rate ($12,040.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,147.84, add-ons for qualifying new technology services are included. If operating cost exceeds $15,066.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,652.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,748.62 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,702.98 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.37. The transfer capital threshold is the transfer adjustment factor * $847.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12125.32","12125.32","12125.32","1 through 10","3975","57961.55","other","Inpatient DRG"
"Coagulation Disorders","813","MS-DRG","","","","","","","","inpatient","","","43357.12","26014.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","46163.63","","Fee schedule rate ($46,163.63). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","45707.95","45707.95","45707.95","1 through 10","3975","57961.55","case rate",""
"Coagulation Disorders","813","MS-DRG","","","","","","","","inpatient","","","43357.12","26014.27","MEDICARE [2001]","HB WDH MEDICARE","12040.85","","Case rate ($12,040.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,147.84, add-ons for qualifying new technology services are included. If operating cost exceeds $15,066.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,652.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,748.62 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,702.98 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.37. The transfer capital threshold is the transfer adjustment factor * $847.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12125.32","0.05","12156.56","17","3975","57961.55","other","Inpatient DRG"
"Coagulation Disorders","813","MS-DRG","","","","","","","","inpatient","","","43357.12","26014.27","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","12040.85","","Case rate ($12,040.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,147.84, add-ons for qualifying new technology services are included. If operating cost exceeds $15,066.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,652.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,748.62 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,702.98 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $847.37. The transfer capital threshold is the transfer adjustment factor * $847.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11912.64","11912.64","11912.64","1 through 10","3975","57961.55","other","Inpatient DRG"
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0300","RC","","","","inpatient","","","826.00","495.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","634.86","76.86","","503.37","503.37","503.37","1 through 10","546.81","634.86","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","both","","","826.00","495.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","576.55","69.8","","557.70","502.57","557.70","21","40.39","702.1","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","both","","","826.00","495.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","576.55","69.8","","557.70","557.70","557.70","1 through 10","40.39","702.1","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","outpatient","","","826.00","495.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","518.56","62.78","","501.61","501.61","501.61","1 through 10","51.55","639.32","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","outpatient","","","826.00","495.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","361.13","43.72","","349.32","349.32","698.64","1 through 10","51.55","639.32","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","outpatient","","","826.00","495.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","600.67","72.72","","581.03","581.03","581.03","35","51.55","639.32","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","outpatient","","","826.00","495.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","600.67","72.72","","581.03","581.03","581.03","1 through 10","51.55","639.32","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","outpatient","","","826.00","495.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","439.60","53.22","","425.95","47.55","425.95","1 through 10","51.55","639.32","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","outpatient","","","826.00","495.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","519.55","62.9","","503.37","503.37","1510.11","61","51.55","639.32","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","outpatient","","","826.00","495.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","639.32","77.4","","619.23","619.23","619.23","22","51.55","639.32","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","outpatient","","","826.00","495.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","600.67","72.72","","581.03","581.03","581.03","1 through 10","51.55","639.32","percent of total billed charges",""
"Coccidioides Antibody","PX-30000905","CDM","86635","CPT","0302","RC","","","","both","","","80.00","48.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","55.84","69.8","","48.43","48.43","48.43","1 through 10","7.46","68","percent of total billed charges",""
"Coccidioides Antibody","PX-30000905","CDM","86635","CPT","0302","RC","","","","outpatient","","","80.00","48.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","61.92","77.4","","238.68","238.68","238.68","1 through 10","13.75","61.92","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 8MM 7CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10087171","CDM","C1889","HCPCS","0278","RC","","","","both","","","592.88","355.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","68.95","503.95","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION .018IN 8MM 7CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10087171","CDM","C1889","HCPCS","0278","RC","","","","both","","","592.88","355.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","68.95","503.95","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION .018IN 8MM 7CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10087171","CDM","C1889","HCPCS","0278","RC","","","","both","","","592.88","355.73","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","337.35","56.9","","0.63","0.63","0.63","1 through 10","68.95","503.95","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 8MM 7CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10087171","CDM","C1889","HCPCS","0278","RC","","","","both","","","592.88","355.73","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","85.49","14.42","","317.14","317.14","317.14","1 through 10","68.95","503.95","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 8MM 7CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10087171","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","592.88","355.73","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","85.49","14.42","","317.14","317.14","317.14","1 through 10","68.95","458.89","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 8MM 7CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10087171","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","592.88","355.73","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","372.21","62.78","","1125.09","1125.09","1125.09","1 through 10","68.95","458.89","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 8MM 7CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10087171","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","592.88","355.73","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","431.14","72.72","","4732.50","1617.43","14180.40","1 through 10","68.95","458.89","percent of total billed charges",""
"COIL EMBOLIZATION .018IN 8MM 7CM EXTENDED LENGTH MICROCOIL PLATINUM NESTER","SUP-ITM-10087171","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","592.88","355.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","372.92","62.9","","3896.20","3341.38","3896.20","1 through 10","68.95","458.89","percent of total billed charges",""
"COIL EMBOLIZATION .035IN 8MM 4MM TORNADO PLATINUM","SUP-ITM-10013620","CDM","C1889","HCPCS","0278","RC","","","","both","","","657.49","394.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","76.47","558.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION .035IN 8MM 4MM TORNADO PLATINUM","SUP-ITM-10013620","CDM","C1889","HCPCS","0278","RC","","","","both","","","657.49","394.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","76.47","558.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION .035IN 8MM 4MM TORNADO PLATINUM","SUP-ITM-10013620","CDM","C1889","HCPCS","0278","RC","","","","both","","","657.49","394.49","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","374.11","56.9","","0.63","0.63","0.63","1 through 10","76.47","558.87","percent of total billed charges",""
"COIL EMBOLIZATION .035IN 8MM 4MM TORNADO PLATINUM","SUP-ITM-10013620","CDM","C1889","HCPCS","0278","RC","","","","both","","","657.49","394.49","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","94.81","14.42","","317.14","317.14","317.14","1 through 10","76.47","558.87","percent of total billed charges",""
"COIL EMBOLIZATION .035IN 8MM 4MM TORNADO PLATINUM","SUP-ITM-10013620","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","657.49","394.49","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","94.81","14.42","","317.14","317.14","317.14","1 through 10","76.47","508.9","percent of total billed charges",""
"COIL EMBOLIZATION .035IN 8MM 4MM TORNADO PLATINUM","SUP-ITM-10013620","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","657.49","394.49","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","412.77","62.78","","1125.09","1125.09","1125.09","1 through 10","76.47","508.9","percent of total billed charges",""
"COIL EMBOLIZATION .035IN 8MM 4MM TORNADO PLATINUM","SUP-ITM-10013620","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","657.49","394.49","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","478.13","72.72","","4732.50","1617.43","14180.40","1 through 10","76.47","508.9","percent of total billed charges",""
"COIL EMBOLIZATION .035IN 8MM 4MM TORNADO PLATINUM","SUP-ITM-10013620","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","657.49","394.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","413.56","62.9","","3896.20","3341.38","3896.20","1 through 10","76.47","508.9","percent of total billed charges",""
"COIL EMBOLIZATION 4MM 14CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10019840","CDM","C1889","HCPCS","0278","RC","","","","both","","","625.84","375.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","72.79","531.96","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION 4MM 14CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10019840","CDM","C1889","HCPCS","0278","RC","","","","both","","","625.84","375.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","72.79","531.96","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION 4MM 14CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10019840","CDM","C1889","HCPCS","0278","RC","","","","both","","","625.84","375.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","356.10","56.9","","0.63","0.63","0.63","1 through 10","72.79","531.96","percent of total billed charges",""
"COIL EMBOLIZATION 4MM 14CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10019840","CDM","C1889","HCPCS","0278","RC","","","","both","","","625.84","375.50","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","90.25","14.42","","317.14","317.14","317.14","1 through 10","72.79","531.96","percent of total billed charges",""
"COIL EMBOLIZATION 4MM 14CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10019840","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","625.84","375.50","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","90.25","14.42","","317.14","317.14","317.14","1 through 10","72.79","484.4","percent of total billed charges",""
"COIL EMBOLIZATION 4MM 14CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10019840","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","625.84","375.50","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","392.90","62.78","","1125.09","1125.09","1125.09","1 through 10","72.79","484.4","percent of total billed charges",""
"COIL EMBOLIZATION 4MM 14CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10019840","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","625.84","375.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","455.11","72.72","","4732.50","1617.43","14180.40","1 through 10","72.79","484.4","percent of total billed charges",""
"COIL EMBOLIZATION 4MM 14CM .035IN NESTER SOFT PLATINUM SYNTHETIC FIBER STRETCH","SUP-ITM-10019840","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","625.84","375.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","393.65","62.9","","3896.20","3341.38","3896.20","1 through 10","72.79","484.4","percent of total billed charges",""
"COIL EMBOLIZATION L 10CM OD 4MM .035IN INTERLOCK FIBERED IDC SYNTHETIC DETACHABLE 2D HELICAL SHAPE OCCLUSION","SUP-ITM-10090433","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.25","1800.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","348.93","2550.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COIL EMBOLIZATION L 10CM OD 4MM .035IN INTERLOCK FIBERED IDC SYNTHETIC DETACHABLE 2D HELICAL SHAPE OCCLUSION","SUP-ITM-10090433","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.25","1800.15","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1707.14","56.9","","2911.53","1863.86","5209.05","65","348.93","2550.21","percent of total billed charges",""
"COIL EMBOLIZATION L 10CM OD 4MM .035IN INTERLOCK FIBERED IDC SYNTHETIC DETACHABLE 2D HELICAL SHAPE OCCLUSION","SUP-ITM-10090433","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.25","1800.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","348.93","11.63","","400.94","400.94","400.94","1 through 10","348.93","2550.21","percent of total billed charges",""
"COIL EMBOLIZATION L 10CM OD 4MM .035IN INTERLOCK FIBERED IDC SYNTHETIC DETACHABLE 2D HELICAL SHAPE OCCLUSION","SUP-ITM-10090433","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.25","1800.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2322.19","77.4","","5214.50","5214.50","16415.28","1 through 10","348.93","2550.21","percent of total billed charges",""
"COIL EMBOLIZATION L 10CM OD 4MM .035IN INTERLOCK FIBERED IDC SYNTHETIC DETACHABLE 2D HELICAL SHAPE OCCLUSION","SUP-ITM-10090433","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.25","1800.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","348.93","11.63","","400.94","400.94","400.94","1 through 10","348.93","2322.19","percent of total billed charges",""
"COIL EMBOLIZATION L 10CM OD 4MM .035IN INTERLOCK FIBERED IDC SYNTHETIC DETACHABLE 2D HELICAL SHAPE OCCLUSION","SUP-ITM-10090433","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.25","1800.15","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1311.71","43.72","","1543.33","1543.33","1671.61","1 through 10","348.93","2322.19","percent of total billed charges",""
"COIL EMBOLIZATION L 10CM OD 4MM .035IN INTERLOCK FIBERED IDC SYNTHETIC DETACHABLE 2D HELICAL SHAPE OCCLUSION","SUP-ITM-10090433","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.25","1800.15","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2181.78","72.72","","3700.21","2382.07","6427.18","53","348.93","2322.19","percent of total billed charges",""
"COIL EMBOLIZATION L 10CM OD 4MM .035IN INTERLOCK FIBERED IDC SYNTHETIC DETACHABLE 2D HELICAL SHAPE OCCLUSION","SUP-ITM-10090433","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.25","1800.15","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2181.78","72.72","","12685.80","12685.80","12685.80","1 through 10","348.93","2322.19","percent of total billed charges",""
"COIL EMBOLIZATION L 10CM OD 4MM .035IN INTERLOCK FIBERED IDC SYNTHETIC DETACHABLE 2D HELICAL SHAPE OCCLUSION","SUP-ITM-10090433","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.25","1800.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1887.16","62.9","","3408.87","2784.05","9859.40","46","348.93","2322.19","percent of total billed charges",""
"COIL EMBOLIZATION L 10CM OD 4MM .035IN INTERLOCK FIBERED IDC SYNTHETIC DETACHABLE 2D HELICAL SHAPE OCCLUSION","SUP-ITM-10090433","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.25","1800.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2322.19","77.4","","5214.50","5214.50","16415.28","1 through 10","348.93","2322.19","percent of total billed charges",""
"COIL FIBERED 22MMX60CM EMBOLD","SUP-ITM-10307261","CDM","C1889","HCPCS","0278","RC","","","","both","","","6057.65","3634.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","704.5","5149","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COIL FIBERED 22MMX60CM EMBOLD","SUP-ITM-10307261","CDM","C1889","HCPCS","0278","RC","","","","both","","","6057.65","3634.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","704.5","5149","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COIL FIBERED 22MMX60CM EMBOLD","SUP-ITM-10307261","CDM","C1889","HCPCS","0278","RC","","","","both","","","6057.65","3634.59","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3446.80","56.9","","0.63","0.63","0.63","1 through 10","704.5","5149","percent of total billed charges",""
"COIL FIBERED 22MMX60CM EMBOLD","SUP-ITM-10307261","CDM","C1889","HCPCS","0278","RC","","","","both","","","6057.65","3634.59","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","873.51","14.42","","317.14","317.14","317.14","1 through 10","704.5","5149","percent of total billed charges",""
"COIL FIBERED 22MMX60CM EMBOLD","SUP-ITM-10307261","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6057.65","3634.59","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","873.51","14.42","","317.14","317.14","317.14","1 through 10","704.5","4688.62","percent of total billed charges",""
"COIL FIBERED 22MMX60CM EMBOLD","SUP-ITM-10307261","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6057.65","3634.59","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3802.99","62.78","","1125.09","1125.09","1125.09","1 through 10","704.5","4688.62","percent of total billed charges",""
"COIL FIBERED 22MMX60CM EMBOLD","SUP-ITM-10307261","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6057.65","3634.59","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4405.12","72.72","","4732.50","1617.43","14180.40","1 through 10","704.5","4688.62","percent of total billed charges",""
"COIL FIBERED 22MMX60CM EMBOLD","SUP-ITM-10307261","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6057.65","3634.59","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3810.26","62.9","","3896.20","3341.38","3896.20","1 through 10","704.5","4688.62","percent of total billed charges",""
"COIL FIBERED 6MMX20CM EMBOLD","SUP-ITM-10307274","CDM","C1889","HCPCS","0278","RC","","","","both","","","6827.08","4096.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","793.99","5803.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COIL FIBERED 6MMX20CM EMBOLD","SUP-ITM-10307274","CDM","C1889","HCPCS","0278","RC","","","","both","","","6827.08","4096.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","793.99","5803.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COIL FIBERED 6MMX20CM EMBOLD","SUP-ITM-10307274","CDM","C1889","HCPCS","0278","RC","","","","both","","","6827.08","4096.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3884.61","56.9","","0.63","0.63","0.63","1 through 10","793.99","5803.02","percent of total billed charges",""
"COIL FIBERED 6MMX20CM EMBOLD","SUP-ITM-10307274","CDM","C1889","HCPCS","0278","RC","","","","both","","","6827.08","4096.25","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","984.46","14.42","","317.14","317.14","317.14","1 through 10","793.99","5803.02","percent of total billed charges",""
"COIL FIBERED 6MMX20CM EMBOLD","SUP-ITM-10307274","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6827.08","4096.25","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","984.46","14.42","","317.14","317.14","317.14","1 through 10","793.99","5284.16","percent of total billed charges",""
"COIL FIBERED 6MMX20CM EMBOLD","SUP-ITM-10307274","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6827.08","4096.25","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4286.04","62.78","","1125.09","1125.09","1125.09","1 through 10","793.99","5284.16","percent of total billed charges",""
"COIL FIBERED 6MMX20CM EMBOLD","SUP-ITM-10307274","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6827.08","4096.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4964.65","72.72","","4732.50","1617.43","14180.40","1 through 10","793.99","5284.16","percent of total billed charges",""
"COIL FIBERED 6MMX20CM EMBOLD","SUP-ITM-10307274","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6827.08","4096.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4294.23","62.9","","3896.20","3341.38","3896.20","1 through 10","793.99","5284.16","percent of total billed charges",""
"COIL INTERLOCK 10MM 25CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090449","CDM","C1889","HCPCS","0278","RC","","","","both","","","4489.50","2693.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","522.13","3816.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COIL INTERLOCK 10MM 25CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090449","CDM","C1889","HCPCS","0278","RC","","","","both","","","4489.50","2693.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","522.13","3816.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COIL INTERLOCK 10MM 25CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090449","CDM","C1889","HCPCS","0278","RC","","","","both","","","4489.50","2693.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2554.53","56.9","","0.63","0.63","0.63","1 through 10","522.13","3816.08","percent of total billed charges",""
"COIL INTERLOCK 10MM 25CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090449","CDM","C1889","HCPCS","0278","RC","","","","both","","","4489.50","2693.70","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","647.39","14.42","","317.14","317.14","317.14","1 through 10","522.13","3816.08","percent of total billed charges",""
"COIL INTERLOCK 10MM 25CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090449","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4489.50","2693.70","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","647.39","14.42","","317.14","317.14","317.14","1 through 10","522.13","3474.87","percent of total billed charges",""
"COIL INTERLOCK 10MM 25CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090449","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4489.50","2693.70","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2818.51","62.78","","1125.09","1125.09","1125.09","1 through 10","522.13","3474.87","percent of total billed charges",""
"COIL INTERLOCK 10MM 25CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090449","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4489.50","2693.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3264.76","72.72","","4732.50","1617.43","14180.40","1 through 10","522.13","3474.87","percent of total billed charges",""
"COIL INTERLOCK 10MM 25CM .035IN EMBOLIZATION FIBERED IDC CUBE OCCLUSION","SUP-ITM-10090449","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4489.50","2693.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2823.90","62.9","","3896.20","3341.38","3896.20","1 through 10","522.13","3474.87","percent of total billed charges",""
"COIL INTERLOCK 18MM 50CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10134627","CDM","C1889","HCPCS","0278","RC","","","","both","","","3648.48","2189.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","424.32","3101.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COIL INTERLOCK 18MM 50CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10134627","CDM","C1889","HCPCS","0278","RC","","","","both","","","3648.48","2189.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","424.32","3101.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COIL INTERLOCK 18MM 50CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10134627","CDM","C1889","HCPCS","0278","RC","","","","both","","","3648.48","2189.09","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2075.99","56.9","","0.63","0.63","0.63","1 through 10","424.32","3101.21","percent of total billed charges",""
"COIL INTERLOCK 18MM 50CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10134627","CDM","C1889","HCPCS","0278","RC","","","","both","","","3648.48","2189.09","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","526.11","14.42","","317.14","317.14","317.14","1 through 10","424.32","3101.21","percent of total billed charges",""
"COIL INTERLOCK 18MM 50CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10134627","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3648.48","2189.09","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","526.11","14.42","","317.14","317.14","317.14","1 through 10","424.32","2823.92","percent of total billed charges",""
"COIL INTERLOCK 18MM 50CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10134627","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3648.48","2189.09","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2290.52","62.78","","1125.09","1125.09","1125.09","1 through 10","424.32","2823.92","percent of total billed charges",""
"COIL INTERLOCK 18MM 50CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10134627","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3648.48","2189.09","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2653.17","72.72","","4732.50","1617.43","14180.40","1 through 10","424.32","2823.92","percent of total billed charges",""
"COIL INTERLOCK 18MM 50CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10134627","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3648.48","2189.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2294.89","62.9","","3896.20","3341.38","3896.20","1 through 10","424.32","2823.92","percent of total billed charges",""
"COIL INTERLOCK 5MM 15CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10072506","CDM","C1889","HCPCS","0278","RC","","","","both","","","2591.25","1554.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","301.36","2202.56","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COIL INTERLOCK 5MM 15CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10072506","CDM","C1889","HCPCS","0278","RC","","","","both","","","2591.25","1554.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","301.36","2202.56","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COIL INTERLOCK 5MM 15CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10072506","CDM","C1889","HCPCS","0278","RC","","","","both","","","2591.25","1554.75","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1474.42","56.9","","0.63","0.63","0.63","1 through 10","301.36","2202.56","percent of total billed charges",""
"COIL INTERLOCK 5MM 15CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10072506","CDM","C1889","HCPCS","0278","RC","","","","both","","","2591.25","1554.75","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","373.66","14.42","","317.14","317.14","317.14","1 through 10","301.36","2202.56","percent of total billed charges",""
"COIL INTERLOCK 5MM 15CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10072506","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2591.25","1554.75","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","373.66","14.42","","317.14","317.14","317.14","1 through 10","301.36","2005.63","percent of total billed charges",""
"COIL INTERLOCK 5MM 15CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10072506","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2591.25","1554.75","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1626.79","62.78","","1125.09","1125.09","1125.09","1 through 10","301.36","2005.63","percent of total billed charges",""
"COIL INTERLOCK 5MM 15CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10072506","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2591.25","1554.75","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1884.36","72.72","","4732.50","1617.43","14180.40","1 through 10","301.36","2005.63","percent of total billed charges",""
"COIL INTERLOCK 5MM 15CM .018IN EMBOLIZATION FIBERED IDC SYNTHETIC DETACHABLE 2D OCCLUSION","SUP-ITM-10072506","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2591.25","1554.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1629.90","62.9","","3896.20","3341.38","3896.20","1 through 10","301.36","2005.63","percent of total billed charges",""
"COIL INTERLOCK 8MM 40CM .035IN EMBOLIZATION FIBERED IDC 2D HELICAL OCCLUSION","SUP-ITM-10090437","CDM","C1889","HCPCS","0278","RC","","","","both","","","5873.50","3524.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","683.09","4992.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COIL INTERLOCK 8MM 40CM .035IN EMBOLIZATION FIBERED IDC 2D HELICAL OCCLUSION","SUP-ITM-10090437","CDM","C1889","HCPCS","0278","RC","","","","both","","","5873.50","3524.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","683.09","4992.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COIL INTERLOCK 8MM 40CM .035IN EMBOLIZATION FIBERED IDC 2D HELICAL OCCLUSION","SUP-ITM-10090437","CDM","C1889","HCPCS","0278","RC","","","","both","","","5873.50","3524.10","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3342.02","56.9","","0.63","0.63","0.63","1 through 10","683.09","4992.48","percent of total billed charges",""
"COIL INTERLOCK 8MM 40CM .035IN EMBOLIZATION FIBERED IDC 2D HELICAL OCCLUSION","SUP-ITM-10090437","CDM","C1889","HCPCS","0278","RC","","","","both","","","5873.50","3524.10","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","846.96","14.42","","317.14","317.14","317.14","1 through 10","683.09","4992.48","percent of total billed charges",""
"COIL INTERLOCK 8MM 40CM .035IN EMBOLIZATION FIBERED IDC 2D HELICAL OCCLUSION","SUP-ITM-10090437","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5873.50","3524.10","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","846.96","14.42","","317.14","317.14","317.14","1 through 10","683.09","4546.09","percent of total billed charges",""
"COIL INTERLOCK 8MM 40CM .035IN EMBOLIZATION FIBERED IDC 2D HELICAL OCCLUSION","SUP-ITM-10090437","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5873.50","3524.10","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3687.38","62.78","","1125.09","1125.09","1125.09","1 through 10","683.09","4546.09","percent of total billed charges",""
"COIL INTERLOCK 8MM 40CM .035IN EMBOLIZATION FIBERED IDC 2D HELICAL OCCLUSION","SUP-ITM-10090437","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5873.50","3524.10","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4271.21","72.72","","4732.50","1617.43","14180.40","1 through 10","683.09","4546.09","percent of total billed charges",""
"COIL INTERLOCK 8MM 40CM .035IN EMBOLIZATION FIBERED IDC 2D HELICAL OCCLUSION","SUP-ITM-10090437","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5873.50","3524.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3694.43","62.9","","3896.20","3341.38","3896.20","1 through 10","683.09","4546.09","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 12MM 60CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX STANDARD FRAME PERIPH","SUP-ITM-10113744","CDM","C1889","HCPCS","0278","RC","","","","both","","","6256.50","3753.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","727.63","5318.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COIL RUBY EMBOLIZATION 12MM 60CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX STANDARD FRAME PERIPH","SUP-ITM-10113744","CDM","C1889","HCPCS","0278","RC","","","","both","","","6256.50","3753.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","727.63","5318.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COIL RUBY EMBOLIZATION 12MM 60CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX STANDARD FRAME PERIPH","SUP-ITM-10113744","CDM","C1889","HCPCS","0278","RC","","","","both","","","6256.50","3753.90","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3559.95","56.9","","0.63","0.63","0.63","1 through 10","727.63","5318.03","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 12MM 60CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX STANDARD FRAME PERIPH","SUP-ITM-10113744","CDM","C1889","HCPCS","0278","RC","","","","both","","","6256.50","3753.90","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","902.19","14.42","","317.14","317.14","317.14","1 through 10","727.63","5318.03","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 12MM 60CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX STANDARD FRAME PERIPH","SUP-ITM-10113744","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6256.50","3753.90","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","902.19","14.42","","317.14","317.14","317.14","1 through 10","727.63","4842.53","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 12MM 60CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX STANDARD FRAME PERIPH","SUP-ITM-10113744","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6256.50","3753.90","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3927.83","62.78","","1125.09","1125.09","1125.09","1 through 10","727.63","4842.53","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 12MM 60CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX STANDARD FRAME PERIPH","SUP-ITM-10113744","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6256.50","3753.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4549.73","72.72","","4732.50","1617.43","14180.40","1 through 10","727.63","4842.53","percent of total billed charges",""
"COIL RUBY EMBOLIZATION 12MM 60CM .02IN FULLY DETACHABLE RESHEATHABLE LG VOLUME COMPLEX STANDARD FRAME PERIPH","SUP-ITM-10113744","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6256.50","3753.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3935.34","62.9","","3896.20","3341.38","3896.20","1 through 10","727.63","4842.53","percent of total billed charges",""
"Col-Chr/Ms Nondrug Analyte Nes Qual/Quan Ea Spec","PX-30003057","CDM","82542","CPT","0301","RC","","","","outpatient","","","168.00","100.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","122.17","72.72","","117.81","117.81","117.81","1 through 10","16.24","130.03","percent of total billed charges",""
"Col-Chr/Ms Nondrug Analyte Nes Qual/Quan Ea Spec","PX-30003057","CDM","82542","CPT","0301","RC","","","","outpatient","","","168.00","100.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","105.67","62.9","","102.06","102.06","102.06","1 through 10","16.24","130.03","percent of total billed charges",""
"Col-Chr/Ms Nondrug Analyte Nes Qual/Quan Ea Spec","PX-30003057","CDM","82542","CPT","0301","RC","","","","outpatient","","","168.00","100.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","130.03","77.4","","125.55","125.55","125.55","1 through 10","16.24","130.03","percent of total billed charges",""
"Cold Agglutinin Screen","PX-30000796","CDM","86156","CPT","0302","RC","","","","outpatient","","","58.00","34.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","42.18","72.72","","40.72","40.72","40.72","1 through 10","6.02","44.89","percent of total billed charges",""
"Collagen Cross Links","PX-30000379","CDM","82523","CPT","0301","RC","","","","both","","","101.00","60.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","70.50","69.8","","68.40","68.40","68.40","1 through 10","12.14","96.33","percent of total billed charges",""
"Collagen Cross Links","PX-30000379","CDM","82523","CPT","0301","RC","","","","outpatient","","","101.00","60.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","73.45","72.72","","71.27","71.27","71.27","1 through 10","11.88","78.17","percent of total billed charges",""
"Collagen Cross Links","PX-30000379","CDM","82523","CPT","0301","RC","","","","outpatient","","","101.00","60.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","63.53","62.9","","61.74","61.74","61.74","1 through 10","11.88","78.17","percent of total billed charges",""
"Collect Blood Port/Access Dvc","PX-76001106","CDM","36591","CPT","0761","RC","","","","both","","","175.00","105.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","122.15","69.8","","117.96","117.96","117.96","1 through 10","99.58","860.68","percent of total billed charges",""
"Collect Blood Port/Access Dvc","PX-76001106","CDM","36591","CPT","0761","RC","","","","both","","","175.00","105.00","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","137.36","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","134.69","134.69","134.69","19","99.58","860.68","other","OPPS APC"
"Collect Blood Port/Access Dvc","PX-76001106","CDM","36591","CPT","0761","RC","","","","both","","","175.00","105.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","860.68","","Case rate ($860.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","169.00","169.00","169.00","12","99.58","860.68","other","OPPS APC"
"Collect Blood Port/Access Dvc","PX-76001106","CDM","36591","CPT","0761","RC","","","","both","","","175.00","105.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","370.61","","Case rate ($370.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","169.00","169.00","169.00","19","99.58","860.68","other","OPPS APC"
"Collect Blood Port/Access Dvc","PX-76001106","CDM","36591","CPT","0761","RC","","","","both","","","175.00","105.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","131.98","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","134.69","132.00","134.69","26","99.58","860.68","other","OPPS APC"
"Collect Blood Port/Access Dvc","PX-76001106","CDM","36591","CPT","0761","RC","","","","both","","","175.00","105.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","695.68","","Case rate ($695.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","169.00","169.00","169.00","1 through 10","99.58","860.68","other","OPPS APC"
"Collect Blood Port/Access Dvc","PX-76001106","CDM","36591","CPT","0761","RC","","","","both","","","175.00","105.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","99.58","56.9","","96.16","96.16","96.16","1 through 10","99.58","860.68","percent of total billed charges",""
"Collect Blood Port/Access Dvc","PX-76001106","CDM","36591","CPT","0761","RC","","","","both","","","175.00","105.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","138.71","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","138.73","135.96","138.73","18","99.58","860.68","other","OPPS APC"
"Collect Blood Port/Access Dvc","PX-76001106","CDM","36591","CPT","0761","RC","","","","both","","","175.00","105.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","132.10","122.07","134.69","1 through 10","99.58","860.68","other","OPPS APC"
"Collect Blood Port/Access Dvc","PX-76001106","CDM","36591","CPT","0761","RC","","","","both","","","175.00","105.00","MEDICARE [2001]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","134.69","134.69","134.69","113","99.58","860.68","other","OPPS APC"
"Collect Blood Port/Access Dvc","PX-76001106","CDM","36591","CPT","0761","RC","","","","both","","","175.00","105.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","132.00","132.00","132.00","31","99.58","860.68","other","OPPS APC"
"Collect Blood Port/Access Dvc","PX-76001106","CDM","36591","CPT","0761","RC","","","","outpatient","","","175.00","105.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","25.24","14.42","","24.37","24.37","24.37","1 through 10","20.35","135.45","percent of total billed charges",""
"Collect Blood Port/Access Dvc","PX-76001106","CDM","36591","CPT","0761","RC","","","","outpatient","","","175.00","105.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.35","11.63","","23.27","12.89","23.27","1 through 10","20.35","135.45","percent of total billed charges",""
"Collect Blood Port/Access Dvc","PX-76001106","CDM","36591","CPT","0761","RC","","","","outpatient","","","175.00","105.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","122.90","122.90","122.90","1 through 10","20.35","135.45","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Collect Blood Port/Access Dvc","PX-76001106","CDM","36591","CPT","0761","RC","","","","outpatient","","","175.00","105.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","110.08","62.9","","106.47","106.47","106.47","23","20.35","135.45","percent of total billed charges",""
"Collect Blood Port/Access Dvc","PX-76001106","CDM","36591","CPT","0761","RC","","","","outpatient","","","175.00","105.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","135.45","77.4","","130.98","130.97","130.98","11","20.35","135.45","percent of total billed charges",""
"Collect Blood Port/Access Dvc","PX-76001106","CDM","36591","CPT","0761","RC","","","","outpatient","","","175.00","105.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.35","11.63","","12.89","12.89","211.19","1 through 10","20.35","135.45","percent of total billed charges",""
"Collect Finger/Heel/Ear Stick","PX-30000004","CDM","36416","CPT","0300","RC","","","","both","","","16.00","9.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","6.00","6.00","6.00","1 through 10","7.48","13.6","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Collect Finger/Heel/Ear Stick","PX-30000004","CDM","36416","CPT","0300","RC","","","","both","","","16.00","9.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","6.00","6.00","6.00","1 through 10","7.48","13.6","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Collect Finger/Heel/Ear Stick","PX-30000004","CDM","36416","CPT","0300","RC","","","","outpatient","","","16.00","9.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2.31","14.42","","13.52","13.52","13.52","1 through 10","1.86","12.38","percent of total billed charges",""
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3425.00","2055.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","2390.65","69.8","","2306.89","2078.85","3564.69","1 through 10","933.47","6087.46","percent of total billed charges",""
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3425.00","2055.00","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","971.57","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","952.63","476.31","952.63","14","933.47","6087.46","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3425.00","2055.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","6087.46","","Case rate ($6,087.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4298.80","4278.00","5127.80","22","933.47","6087.46","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3425.00","2055.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","2621.26","","Case rate ($2,621.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2557.35","2492.60","2557.35","29","933.47","6087.46","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3425.00","2055.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","933.47","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","933.58","933.58","952.63","21","933.47","6087.46","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3425.00","2055.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","4920.44","","Case rate ($4,920.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4298.80","2557.35","4800.40","20","933.47","6087.46","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3425.00","2055.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1948.83","56.9","","1880.54","1880.54","2434.18","38","933.47","6087.46","percent of total billed charges",""
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3425.00","2055.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","981.09","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","961.59","480.80","961.59","1 through 10","933.47","6087.46","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3425.00","2055.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","933.58","476.31","952.63","35","933.47","6087.46","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3425.00","2055.00","MEDICARE [2001]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","952.63","476.31","952.63","179","933.47","6087.46","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3425.00","2055.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","933.58","872.70","952.63","54","933.47","6087.46","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3425.00","2055.00","WELLPOINT [1015]","HB WDH ANTHEM PPO","4920.44","","Case rate ($4,920.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4297.05","4297.05","4297.05","1 through 10","933.47","6087.46","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","3425.00","2055.00","WELLSENSE NH [1050]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7458.05","980.25","7462.06","1 through 10","933.47","6087.46","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","outpatient","","","3425.00","2055.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","493.89","14.42","","476.58","408.50","476.58","1 through 10","398.33","2650.95","percent of total billed charges",""
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","outpatient","","","3425.00","2055.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","398.33","11.63","","404.53","390.37","404.53","1 through 10","398.33","2650.95","percent of total billed charges",""
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","outpatient","","","3425.00","2055.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2650.95","77.4","","2561.38","2561.37","2561.38","1 through 10","398.33","2650.95","percent of total billed charges",""
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","outpatient","","","3425.00","2055.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","398.33","11.63","","1524.21","390.37","8002.01","1 through 10","398.33","2650.95","percent of total billed charges",""
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","3079.00","1847.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","2149.14","69.8","","2073.76","1868.76","2073.76","11","933.47","6087.46","percent of total billed charges",""
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","3079.00","1847.40","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","971.57","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","952.63","476.31","952.63","1 through 10","933.47","6087.46","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","3079.00","1847.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","6087.46","","Case rate ($6,087.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3965.87","3954.40","4802.11","38","933.47","6087.46","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","3079.00","1847.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","2621.26","","Case rate ($2,621.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2557.35","2492.60","2557.35","41","933.47","6087.46","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","3079.00","1847.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","933.47","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","933.58","466.79","952.63","16","933.47","6087.46","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","3079.00","1847.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","4920.44","","Case rate ($4,920.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3964.80","2400.20","3970.52","24","933.47","6087.46","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","3079.00","1847.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1751.95","56.9","","1690.50","1690.50","2244.14","53","933.47","6087.46","percent of total billed charges",""
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","3079.00","1847.40","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","2149.14","69.8","","2073.76","2073.76","2073.76","1 through 10","933.47","6087.46","percent of total billed charges",""
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","3079.00","1847.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","981.09","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","961.59","961.59","961.59","1 through 10","933.47","6087.46","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","3079.00","1847.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","933.58","933.58","952.63","23","933.47","6087.46","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","3079.00","1847.40","MEDICARE [2001]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","952.63","476.31","952.63","75","933.47","6087.46","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","3079.00","1847.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","933.58","476.31","952.63","32","933.47","6087.46","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","3079.00","1847.40","WELLSENSE NH [1050]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","980.25","490.14","980.25","1 through 10","933.47","6087.46","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","outpatient","","","3079.00","1847.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","443.99","14.42","","428.42","367.22","428.42","1 through 10","358.09","2383.15","percent of total billed charges",""
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","outpatient","","","3079.00","1847.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","358.09","11.63","","363.65","350.92","750.33","11","358.09","2383.15","percent of total billed charges",""
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","outpatient","","","3079.00","1847.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2383.15","77.4","","2302.53","2302.51","2302.53","1 through 10","358.09","2383.15","percent of total billed charges",""
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","outpatient","","","3079.00","1847.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","358.09","11.63","","1501.35","350.92","7324.51","12","358.09","2383.15","percent of total billed charges",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","4950.22","69.8","","4777.11","4777.11","4777.11","1 through 10","1207.22","7872.71","percent of total billed charges",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","1256.49","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","1232.00","574.90","1232.00","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","7872.71","","Case rate ($7,872.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7680.71","3840.36","7680.71","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","3389.98","","Case rate ($3,389.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1653.67","1609.17","3307.34","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1207.22","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","616.00","563.40","1232.00","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","6363.44","","Case rate ($6,363.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3104.10","1653.67","6208.20","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","CHAMPVA [160001]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","616.00","616.00","616.00","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4035.35","56.9","","4447.87","3894.23","8090.04","20","1207.22","7872.71","percent of total billed charges",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","4950.22","69.8","","4777.11","4777.11","4777.11","1 through 10","1207.22","7872.71","percent of total billed charges",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","1268.81","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1243.58","621.79","1243.58","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","616.00","603.68","1232.00","16","1207.22","7872.71","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","MEDICARE [2001]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","616.00","616.00","1232.00","50","1207.22","7872.71","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","TRICARE [160005]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","616.00","616.00","616.00","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1126.80","563.41","1207.36","86","1207.22","7872.71","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","WELLSENSE NH [1050]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","633.86","633.86","633.86","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","7092.00","4255.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1022.67","14.42","","845.92","845.92","845.92","1 through 10","824.8","5489.21","percent of total billed charges",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","7092.00","4255.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","824.80","11.63","","1728.47","942.42","1728.47","1 through 10","824.8","5489.21","percent of total billed charges",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","7092.00","4255.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","6011.12","4976.96","9049.42","16","824.8","5489.21","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","7092.00","4255.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4460.87","62.9","","4311.72","4311.72","4311.72","1 through 10","824.8","5489.21","percent of total billed charges",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","7092.00","4255.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5489.21","77.4","","5304.10","5304.10","5304.10","1 through 10","824.8","5489.21","percent of total billed charges",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","7092.00","4255.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","824.80","11.63","","808.39","808.39","1931.78","1 through 10","824.8","5489.21","percent of total billed charges",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","3730.11","69.8","","3243.75","3243.75","3599.59","1 through 10","933.47","6087.46","percent of total billed charges",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","6087.46","","Case rate ($6,087.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5939.00","2969.50","5939.00","1 through 10","933.47","6087.46","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","2621.26","","Case rate ($2,621.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2557.35","1278.68","2557.35","12","933.47","6087.46","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","933.47","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","872.70","466.79","937.39","1 through 10","933.47","6087.46","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","4920.44","","Case rate ($4,920.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4800.40","2400.20","4800.40","11","933.47","6087.46","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3040.74","56.9","","2934.33","2934.33","6483.97","24","933.47","6087.46","percent of total billed charges",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","981.09","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","969.62","480.80","970.59","1 through 10","933.47","6087.46","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","940.08","872.70","952.63","11","933.47","6087.46","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","MEDICARE [2001]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","952.63","476.31","952.63","65","933.47","6087.46","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","TRICARE [160005]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","952.63","952.63","952.63","1 through 10","933.47","6087.46","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","874.49","466.80","952.63","35","933.47","6087.46","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","WELLSENSE NH [1050]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","981.25","490.14","981.25","1 through 10","933.47","6087.46","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","5344.00","3206.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","770.60","14.42","","637.41","637.41","743.64","1 through 10","621.51","4136.26","percent of total billed charges",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","5344.00","3206.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","621.51","11.63","","710.12","710.12","710.12","1 through 10","621.51","4136.26","percent of total billed charges",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","5344.00","3206.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","2254.64","1298.92","2254.64","1 through 10","621.51","4136.26","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","5344.00","3206.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","2403.40","2160.51","3750.17","48","621.51","4136.26","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","5344.00","3206.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2844.08","53.22","","2749.20","2749.20","2749.20","1 through 10","621.51","4136.26","percent of total billed charges",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","5344.00","3206.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3361.38","62.9","","3248.91","3248.91","3248.91","80","621.51","4136.26","percent of total billed charges",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","5344.00","3206.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4136.26","77.4","","3996.68","3996.68","3996.68","1 through 10","621.51","4136.26","percent of total billed charges",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","5344.00","3206.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","621.51","11.63","","609.12","609.12","10854.59","1 through 10","621.51","4136.26","percent of total billed charges",""
"Colonoscopy Flx Ablation Tumor Polyp/Other Les","PX-75000420","CDM","45388","CPT","0750","RC","","","","both","","","7535.00","4521.00","MEDICARE [2001]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1232.00","1232.00","1232.00","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colonoscopy Flx Ablation Tumor Polyp/Other Les","PX-75000420","CDM","45388","CPT","0750","RC","","","","both","","","7535.00","4521.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","616.00","616.00","616.00","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","3730.11","69.8","","3243.75","3243.75","3599.59","1 through 10","933.47","6087.46","percent of total billed charges",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","6087.46","","Case rate ($6,087.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5939.00","2969.50","5939.00","1 through 10","933.47","6087.46","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","2621.26","","Case rate ($2,621.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2557.35","1278.68","2557.35","12","933.47","6087.46","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","933.47","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","872.70","466.79","937.39","1 through 10","933.47","6087.46","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","4920.44","","Case rate ($4,920.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4800.40","2400.20","4800.40","11","933.47","6087.46","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3040.74","56.9","","2934.33","2934.33","6483.97","24","933.47","6087.46","percent of total billed charges",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","981.09","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","969.62","480.80","970.59","1 through 10","933.47","6087.46","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","940.08","872.70","952.63","11","933.47","6087.46","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","MEDICARE [2001]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","952.63","476.31","952.63","65","933.47","6087.46","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","TRICARE [160005]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","952.63","952.63","952.63","1 through 10","933.47","6087.46","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","874.49","466.80","952.63","35","933.47","6087.46","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","5344.00","3206.40","WELLSENSE NH [1050]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","981.25","490.14","981.25","1 through 10","933.47","6087.46","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","5344.00","3206.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","770.60","14.42","","637.41","637.41","743.64","1 through 10","621.51","4136.26","percent of total billed charges",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","5344.00","3206.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","621.51","11.63","","710.12","710.12","710.12","1 through 10","621.51","4136.26","percent of total billed charges",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","5344.00","3206.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","2254.64","1298.92","2254.64","1 through 10","621.51","4136.26","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","5344.00","3206.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","2403.40","2160.51","3750.17","48","621.51","4136.26","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","5344.00","3206.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2844.08","53.22","","2749.20","2749.20","2749.20","1 through 10","621.51","4136.26","percent of total billed charges",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","5344.00","3206.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3361.38","62.9","","3248.91","3248.91","3248.91","80","621.51","4136.26","percent of total billed charges",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","5344.00","3206.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4136.26","77.4","","3996.68","3996.68","3996.68","1 through 10","621.51","4136.26","percent of total billed charges",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","5344.00","3206.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","621.51","11.63","","609.12","609.12","10854.59","1 through 10","621.51","4136.26","percent of total billed charges",""
"Colonoscopy Thru Stoma","PX-75000157","CDM","44388","CPT","0750","RC","","","","both","","","2299.00","1379.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","933.47","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","933.58","933.58","933.58","1 through 10","933.47","6087.46","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","5774.00","3464.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","4030.25","69.8","","3889.26","3889.26","3889.26","1 through 10","1207.22","7872.71","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","5774.00","3464.40","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","1256.49","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","1232.00","1149.79","1232.00","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","5774.00","3464.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","7872.71","","Case rate ($7,872.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6578.78","6565.80","7680.71","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","5774.00","3464.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","3389.98","","Case rate ($3,389.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3307.34","3218.34","3307.34","20","1207.22","7872.71","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","5774.00","3464.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1207.22","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1232.00","1207.36","1232.00","12","1207.22","7872.71","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","5774.00","3464.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","6363.44","","Case rate ($6,363.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6208.20","6041.15","6208.20","21","1207.22","7872.71","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","5774.00","3464.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3285.41","56.9","","3170.47","3170.46","3724.10","18","1207.22","7872.71","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","5774.00","3464.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","1268.81","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2489.20","1243.58","2489.20","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","5774.00","3464.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1213.86","1207.36","1213.86","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","5774.00","3464.40","MEDICARE [2001]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1232.00","1232.00","1232.00","42","1207.22","7872.71","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","5774.00","3464.40","TRICARE [160005]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1232.00","1232.00","1232.00","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","5774.00","3464.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1207.36","1126.80","1207.36","85","1207.22","7872.71","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","5774.00","3464.40","WELLSENSE NH [1050]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","10959.26","1268.23","10959.26","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","5774.00","3464.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","832.61","14.42","","803.48","688.70","803.48","1 through 10","671.52","4469.08","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","5774.00","3464.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","671.52","11.63","","767.26","658.14","1407.22","14","671.52","4469.08","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","5774.00","3464.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","2436.08","2436.08","2436.08","1 through 10","671.52","4469.08","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","5774.00","3464.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","5081.36","4051.96","12155.88","11","671.52","4469.08","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","5774.00","3464.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3631.85","62.9","","3510.36","3510.36","10531.08","26","671.52","4469.08","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","5774.00","3464.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4469.08","77.4","","4318.30","4318.30","4318.30","1 through 10","671.52","4469.08","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","5774.00","3464.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","671.52","11.63","","12918.47","658.14","12942.90","11","671.52","4469.08","percent of total billed charges",""
"Colposcopy Entire Vagina","PX-76001360","CDM","57420","CPT","0761","RC","","","","both","","","789.00","473.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2031.08","","Case rate ($2,031.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","761.00","761.00","761.00","1 through 10","311.45","2031.08","other","OPPS APC"
"Colposcopy Entire Vagina","PX-76001360","CDM","57420","CPT","0761","RC","","","","both","","","789.00","473.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","327.34","","APC Price ($317.81). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","327.38","327.38","327.38","1 through 10","311.45","2031.08","other","OPPS APC"
"Colposcopy W/Bx Cervix","PX-76001364","CDM","57455","CPT","0761","RC","","","","both","","","937.00","562.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","317.81","","APC Price ($317.81). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","317.84","317.84","317.84","1 through 10","311.45","2031.08","other","OPPS APC"
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","both","","","1146.00","687.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","652.07","56.9","","1433.13","1433.13","1433.13","1 through 10","311.45","2031.08","percent of total billed charges",""
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","both","","","1146.00","687.60","MEDICARE [2001]","HB WDH MEDICARE","317.81","","APC Price ($317.81). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","317.84","317.84","317.84","1 through 10","311.45","2031.08","other","OPPS APC"
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","outpatient","","","1146.00","687.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","5494.72","5494.72","5494.72","1 through 10","133.28","887","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","outpatient","","","1146.00","687.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","887.00","77.4","","2608.14","2608.14","2608.14","1 through 10","133.28","887","percent of total billed charges",""
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","both","","","1060.00","636.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","891.52","","APC Price ($909.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","909.82","909.82","909.82","1 through 10","603.14","5813.95","other","OPPS APC"
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","both","","","1060.00","636.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","909.71","","APC Price ($909.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","909.82","909.82","909.82","1 through 10","603.14","5813.95","other","OPPS APC"
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","both","","","1060.00","636.00","MEDICARE [2001]","HB WDH MEDICARE","909.71","","APC Price ($909.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","909.82","909.82","909.82","1 through 10","603.14","5813.95","other","OPPS APC"
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","both","","","1060.00","636.00","WELLSENSE NH [1050]","HB WDH MEDICARE","909.71","","APC Price ($909.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2962.88","2962.88","2962.88","1 through 10","603.14","5813.95","other","OPPS APC"
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","outpatient","","","1060.00","636.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","666.74","62.9","","644.49","644.49","644.49","1 through 10","123.28","820.44","percent of total billed charges",""
"Colsc Flexible W/Control Bleeding Any Method","PX-75000197","CDM","45382","CPT","0750","RC","","","","both","","","7401.00","4440.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","5165.90","69.8","","4659.85","4659.85","4659.85","1 through 10","1207.22","7872.71","percent of total billed charges",""
"Colsc Flexible W/Control Bleeding Any Method","PX-75000197","CDM","45382","CPT","0750","RC","","","","both","","","7401.00","4440.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1207.36","1207.36","1207.36","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colsc Flexible W/Control Bleeding Any Method","PX-75000197","CDM","45382","CPT","0750","RC","","","","both","","","7401.00","4440.60","MEDICARE [2001]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1232.00","1232.00","1232.00","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colsc Flexible W/Transendoscopic Balloon Dilat","PX-75000419","CDM","45386","CPT","0750","RC","","","","both","","","6090.00","3654.00","MEDICARE [2001]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1232.00","1232.00","1232.00","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colsc Flx W/Ndsc US Xm Rctm Et Al Lmtd&Adj Strux","PX-75000423","CDM","45391","CPT","0750","RC","","","","both","","","7187.00","4312.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","3389.98","","Case rate ($3,389.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3307.34","3307.34","3307.34","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colsc Flx W/Ndsc US Xm Rctm Et Al Lmtd&Adj Strux","PX-75000423","CDM","45391","CPT","0750","RC","","","","both","","","7187.00","4312.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","1268.81","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1250.58","1250.58","1250.58","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","4950.22","69.8","","4777.11","4777.11","4777.11","1 through 10","1207.22","7872.71","percent of total billed charges",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","1256.49","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","1232.00","574.90","1232.00","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","7872.71","","Case rate ($7,872.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7680.71","3840.36","7680.71","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","3389.98","","Case rate ($3,389.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1653.67","1609.17","3307.34","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1207.22","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","616.00","563.40","1232.00","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","6363.44","","Case rate ($6,363.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3104.10","1653.67","6208.20","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","CHAMPVA [160001]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","616.00","616.00","616.00","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4035.35","56.9","","4447.87","3894.23","8090.04","20","1207.22","7872.71","percent of total billed charges",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","4950.22","69.8","","4777.11","4777.11","4777.11","1 through 10","1207.22","7872.71","percent of total billed charges",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","1268.81","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1243.58","621.79","1243.58","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","616.00","603.68","1232.00","16","1207.22","7872.71","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","MEDICARE [2001]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","616.00","616.00","1232.00","50","1207.22","7872.71","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","TRICARE [160005]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","616.00","616.00","616.00","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1126.80","563.41","1207.36","86","1207.22","7872.71","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","7092.00","4255.20","WELLSENSE NH [1050]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","633.86","633.86","633.86","1 through 10","1207.22","7872.71","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","7092.00","4255.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1022.67","14.42","","845.92","845.92","845.92","1 through 10","824.8","5489.21","percent of total billed charges",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","7092.00","4255.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","824.80","11.63","","1728.47","942.42","1728.47","1 through 10","824.8","5489.21","percent of total billed charges",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","7092.00","4255.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","6011.12","4976.96","9049.42","16","824.8","5489.21","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","7092.00","4255.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4460.87","62.9","","4311.72","4311.72","4311.72","1 through 10","824.8","5489.21","percent of total billed charges",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","7092.00","4255.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5489.21","77.4","","5304.10","5304.10","5304.10","1 through 10","824.8","5489.21","percent of total billed charges",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","7092.00","4255.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","824.80","11.63","","808.39","808.39","1931.78","1 through 10","824.8","5489.21","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","both","","","16211.71","9727.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1885.42","13779.95","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","both","","","16211.71","9727.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1885.42","13779.95","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","both","","","16211.71","9727.03","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","9224.46","56.9","","812.12","238.65","1587.46","163","1885.42","13779.95","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","both","","","16211.71","9727.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1885.42","11.63","","112.68","112.68","146.99","38","1885.42","13779.95","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","both","","","16211.71","9727.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12547.86","77.4","","303.98","303.98","5854.79","1 through 10","1885.42","13779.95","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16211.71","9727.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1885.42","11.63","","112.68","112.68","146.99","38","1885.42","12547.86","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16211.71","9727.03","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","10177.71","62.78","","780.86","208.94","10480.28","15","1885.42","12547.86","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16211.71","9727.03","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","7087.76","43.72","","179.76","179.76","179.76","1 through 10","1885.42","12547.86","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16211.71","9727.03","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","11789.16","72.72","","2355.45","298.99","3965.19","155","1885.42","12547.86","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16211.71","9727.03","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","11789.16","72.72","","3643.09","3643.09","3643.09","1 through 10","1885.42","12547.86","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16211.71","9727.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","8627.87","53.22","","554.28","554.28","554.28","16","1885.42","12547.86","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16211.71","9727.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","10197.17","62.9","","619.64","173.09","2370.64","150","1885.42","12547.86","percent of total billed charges",""
"COLUMN CHROMATOGRAPHY 12ML 15X68MM S12R","SUP-ITM-10051356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16211.71","9727.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12547.86","77.4","","303.98","303.98","5854.79","1 through 10","1885.42","12547.86","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","both","","","11938.03","7162.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1388.39","10147.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","both","","","11938.03","7162.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1388.39","10147.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","both","","","11938.03","7162.82","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6792.74","56.9","","812.12","238.65","1587.46","163","1388.39","10147.33","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","both","","","11938.03","7162.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1388.39","11.63","","112.68","112.68","146.99","38","1388.39","10147.33","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","both","","","11938.03","7162.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9240.04","77.4","","303.98","303.98","5854.79","1 through 10","1388.39","10147.33","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11938.03","7162.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1388.39","11.63","","112.68","112.68","146.99","38","1388.39","9240.04","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11938.03","7162.82","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","7494.70","62.78","","780.86","208.94","10480.28","15","1388.39","9240.04","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11938.03","7162.82","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","5219.31","43.72","","179.76","179.76","179.76","1 through 10","1388.39","9240.04","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11938.03","7162.82","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8681.34","72.72","","2355.45","298.99","3965.19","155","1388.39","9240.04","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11938.03","7162.82","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","8681.34","72.72","","3643.09","3643.09","3643.09","1 through 10","1388.39","9240.04","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11938.03","7162.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","6353.42","53.22","","554.28","554.28","554.28","16","1388.39","9240.04","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11938.03","7162.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7509.02","62.9","","619.64","173.09","2370.64","150","1388.39","9240.04","percent of total billed charges",""
"COLUMN LABORATORY UNO S1","SUP-ITM-10051351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11938.03","7162.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9240.04","77.4","","303.98","303.98","5854.79","1 through 10","1388.39","9240.04","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","both","","","17743.86","10646.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","2063.61","15082.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","both","","","17743.86","10646.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","2063.61","15082.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","both","","","17743.86","10646.32","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","10096.26","56.9","","812.12","238.65","1587.46","163","2063.61","15082.28","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","both","","","17743.86","10646.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2063.61","11.63","","112.68","112.68","146.99","38","2063.61","15082.28","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","both","","","17743.86","10646.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","13733.75","77.4","","303.98","303.98","5854.79","1 through 10","2063.61","15082.28","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17743.86","10646.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2063.61","11.63","","112.68","112.68","146.99","38","2063.61","13733.75","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17743.86","10646.32","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","11139.60","62.78","","780.86","208.94","10480.28","15","2063.61","13733.75","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17743.86","10646.32","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","7757.62","43.72","","179.76","179.76","179.76","1 through 10","2063.61","13733.75","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17743.86","10646.32","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","12903.33","72.72","","2355.45","298.99","3965.19","155","2063.61","13733.75","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17743.86","10646.32","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","12903.33","72.72","","3643.09","3643.09","3643.09","1 through 10","2063.61","13733.75","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17743.86","10646.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","9443.28","53.22","","554.28","554.28","554.28","16","2063.61","13733.75","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17743.86","10646.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","11160.89","62.9","","619.64","173.09","2370.64","150","2063.61","13733.75","percent of total billed charges",""
"COLUMN LABORATORY UNO S6","SUP-ITM-10051352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17743.86","10646.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","13733.75","77.4","","303.98","303.98","5854.79","1 through 10","2063.61","13733.75","percent of total billed charges",""
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","both","","","244.00","146.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","170.31","69.8","","164.03","164.03","164.03","1 through 10","123.42","1144.2","percent of total billed charges",""
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","both","","","244.00","146.40","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","182.61","","APC Price ($179.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","166.42","166.42","166.42","1 through 10","123.42","1144.2","other","OPPS APC"
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","both","","","244.00","146.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1144.20","","Case rate ($1,144.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11.81","11.81","279.08","19","123.42","1144.2","other","OPPS APC"
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","both","","","244.00","146.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","492.69","","Case rate ($492.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11.81","11.81","25.09","11","123.42","1144.2","other","OPPS APC"
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","both","","","244.00","146.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","175.45","","APC Price ($179.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","14.93","14.63","21.18","1 through 10","123.42","1144.2","other","OPPS APC"
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","both","","","244.00","146.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","924.85","","Case rate ($924.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","25.09","11.81","25.09","1 through 10","123.42","1144.2","other","OPPS APC"
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","both","","","244.00","146.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","179.03","","APC Price ($179.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","175.57","175.57","175.57","1 through 10","123.42","1144.2","other","OPPS APC"
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","both","","","244.00","146.40","MEDICARE [2001]","HB WDH MEDICARE","179.03","","APC Price ($179.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","179.05","166.42","179.05","1 through 10","123.42","1144.2","other","OPPS APC"
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","both","","","244.00","146.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","179.03","","APC Price ($179.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","175.47","87.74","175.67","1 through 10","123.42","1144.2","other","OPPS APC"
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","outpatient","","","244.00","146.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","35.18","14.42","","235.00","235.00","235.00","15","28.38","188.86","percent of total billed charges",""
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","outpatient","","","244.00","146.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","28.38","11.63","","83.28","59.34","235.00","21","28.38","188.86","percent of total billed charges",""
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","outpatient","","","244.00","146.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","106.68","43.72","","102.74","102.74","205.48","1 through 10","28.38","188.86","percent of total billed charges",""
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","outpatient","","","244.00","146.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","177.44","72.72","","170.89","170.89","170.89","1 through 10","28.38","188.86","percent of total billed charges",""
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","outpatient","","","244.00","146.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","153.48","62.9","","148.05","148.05","148.05","1 through 10","28.38","188.86","percent of total billed charges",""
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","outpatient","","","244.00","146.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","188.86","77.4","","182.13","182.13","182.13","1 through 10","28.38","188.86","percent of total billed charges",""
"Compatibility Test Ea Unit Electron","PX-30000087","CDM","86923","CPT","0302","RC","","","","outpatient","","","244.00","146.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","28.38","11.63","","83.25","27.76","83.25","1 through 10","28.38","188.86","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0300","RC","","","","inpatient","","","171.00","102.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","131.43","76.86","","99.64","99.64","99.64","1 through 10","113.2","131.43","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","both","","","171.00","102.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","119.36","69.8","","115.17","115.17","115.17","30","7.8","145.35","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","outpatient","","","171.00","102.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","74.76","43.72","","72.14","72.14","144.28","1 through 10","11.19","132.35","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","outpatient","","","171.00","102.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","124.35","72.72","","119.99","119.99","239.98","44","11.19","132.35","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","outpatient","","","171.00","102.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","124.35","72.72","","119.99","119.99","119.99","1 through 10","11.19","132.35","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","outpatient","","","171.00","102.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","91.01","53.22","","87.96","87.96","87.96","1 through 10","11.19","132.35","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","outpatient","","","171.00","102.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","107.56","62.9","","103.95","103.95","103.95","28","11.19","132.35","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","outpatient","","","171.00","102.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","132.35","77.4","","127.88","127.88","255.75","19","11.19","132.35","percent of total billed charges",""
"Complement Total (Ch50)","PX-30000800","CDM","86162","CPT","0302","RC","","","","both","","","110.00","66.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","76.78","69.8","","66.67","66.67","66.67","1 through 10","13.21","105.34","percent of total billed charges",""
"Complement Total (Ch50)","PX-30000800","CDM","86162","CPT","0302","RC","","","","outpatient","","","110.00","66.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","79.99","72.72","","77.08","77.08","77.08","1 through 10","18.93","85.14","percent of total billed charges",""
"Complement Total (Ch50)","PX-30000800","CDM","86162","CPT","0302","RC","","","","outpatient","","","110.00","66.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","69.19","62.9","","66.78","66.78","66.78","1 through 10","18.93","85.14","percent of total billed charges",""
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","both","","","1921.00","1152.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","1340.86","69.8","","1294.09","335.09","1294.09","1 through 10","561.39","3660.99","percent of total billed charges",""
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","both","","","1921.00","1152.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","3660.99","","Case rate ($3,660.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2978.00","2978.00","3332.00","12","561.39","3660.99","other","OPPS APC"
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","both","","","1921.00","1152.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1576.42","","Case rate ($1,576.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1537.99","1504.55","1537.99","1 through 10","561.39","3660.99","other","OPPS APC"
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","both","","","1921.00","1152.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","561.39","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","973.95","572.91","973.95","1 through 10","561.39","3660.99","other","OPPS APC"
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","both","","","1921.00","1152.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","2959.14","","Case rate ($2,959.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2886.96","1854.00","2886.96","1 through 10","561.39","3660.99","other","OPPS APC"
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","both","","","1921.00","1152.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1093.05","56.9","","1054.93","1054.93","3164.79","21","561.39","3660.99","percent of total billed charges",""
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","both","","","1921.00","1152.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","572.84","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","572.91","572.91","572.91","1 through 10","561.39","3660.99","other","OPPS APC"
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","both","","","1921.00","1152.60","TRICARE [160005]","HB WDH MEDICARE","572.84","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","572.91","572.91","572.91","1 through 10","561.39","3660.99","other","OPPS APC"
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","outpatient","","","1921.00","1152.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","277.01","14.42","","267.35","229.15","267.35","1 through 10","223.41","1486.85","percent of total billed charges",""
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","outpatient","","","1921.00","1152.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","223.41","11.63","","255.30","226.93","656.94","35","223.41","1486.85","percent of total billed charges",""
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","outpatient","","","1921.00","1152.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1396.95","72.72","","1348.23","1348.23","1348.23","18","223.41","1486.85","percent of total billed charges",""
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","outpatient","","","1921.00","1152.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1396.95","72.72","","1348.23","1348.23","1348.23","1 through 10","223.41","1486.85","percent of total billed charges",""
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","outpatient","","","1921.00","1152.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1208.31","62.9","","3504.06","1168.02","3504.06","1 through 10","223.41","1486.85","percent of total billed charges",""
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","outpatient","","","1921.00","1152.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1486.85","77.4","","1436.85","1436.85","1436.85","1 through 10","223.41","1486.85","percent of total billed charges",""
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","outpatient","","","1921.00","1152.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","223.41","11.63","","218.98","218.98","656.94","14","223.41","1486.85","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","both","","","139.00","83.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","97.02","69.8","","84.29","20.48","93.53","14","11.69","118.15","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","outpatient","","","139.00","83.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","87.26","62.78","","84.13","84.13","84.13","1 through 10","16.74","107.59","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","outpatient","","","139.00","83.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","101.08","72.72","","97.44","97.44","292.32","23","16.74","107.59","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","outpatient","","","139.00","83.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","101.08","72.72","","97.44","97.44","97.44","1 through 10","16.74","107.59","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","outpatient","","","139.00","83.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","73.98","53.22","","71.44","71.44","71.44","1 through 10","16.74","107.59","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","outpatient","","","139.00","83.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","87.43","62.9","","84.42","84.42","84.42","31","16.74","107.59","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","outpatient","","","139.00","83.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","107.59","77.4","","103.85","103.85","103.85","11","16.74","107.59","percent of total billed charges",""
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","","","","inpatient","","","38222.92","22933.75","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","8942.57","","Case rate ($8,682.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,047.75, add-ons for qualifying new technology services are included. If operating cost exceeds $11,965.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,406.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,635.31 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,602.88 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $601.93. The transfer capital threshold is the transfer adjustment factor * $601.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","62188.63","62188.63","62188.63","1 through 10","3975","41173.11","other","Inpatient DRG"
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","","","","inpatient","","","38222.92","22933.75","MARTIN'S POINT [160007]","HB WDH MEDICARE","8682.11","","Case rate ($8,682.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,047.75, add-ons for qualifying new technology services are included. If operating cost exceeds $11,965.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,406.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,635.31 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,602.88 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $601.93. The transfer capital threshold is the transfer adjustment factor * $601.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8489.40","8489.40","8489.40","1 through 10","3975","41173.11","other","Inpatient DRG"
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","","","","inpatient","","","38222.92","22933.75","MEDICARE [2001]","HB WDH MEDICARE","8682.11","","Case rate ($8,682.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,047.75, add-ons for qualifying new technology services are included. If operating cost exceeds $11,965.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,406.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,635.31 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,602.88 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $601.93. The transfer capital threshold is the transfer adjustment factor * $601.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8169.11","8169.11","8169.11","1 through 10","3975","41173.11","other","Inpatient DRG"
"Complicated Peptic Ulcer With McC","380","MS-DRG","","","","","","","","inpatient","","","41213.07","24727.84","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","15055.13","","Case rate ($15,362.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,213.56, add-ons for qualifying new technology services are included. If operating cost exceeds $18,131.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,895.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $13,827.41 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,768.69 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,090.09. The transfer capital threshold is the transfer adjustment factor * $1,090.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14665.42","14665.42","14665.42","1 through 10","5757","39841.69","other","Inpatient DRG"
"Complicated Peptic Ulcer With McC","380","MS-DRG","","","","","","","","inpatient","","","41213.07","24727.84","MEDICARE [2001]","HB WDH MEDICARE","15362.38","","Case rate ($15,362.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,213.56, add-ons for qualifying new technology services are included. If operating cost exceeds $18,131.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,895.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $13,827.41 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,768.69 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,090.09. The transfer capital threshold is the transfer adjustment factor * $1,090.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14964.71","6268.28","14964.71","1 through 10","5757","39841.69","other","Inpatient DRG"
"Complications Of Treatment With Cc","920","MS-DRG","","","","","","","","inpatient","","","30158.82","18095.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","38087.50","","Fee schedule rate ($38,087.50). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","37662.73","37662.73","37662.73","1 through 10","3975","38087.5","case rate",""
"Complications Of Treatment With Cc","920","MS-DRG","","","","","","","","inpatient","","","30158.82","18095.29","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","8306.73","","Case rate ($8,064.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,477.97, add-ons for qualifying new technology services are included. If operating cost exceeds $11,396.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,361.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,063.10 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,033.10 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.82. The transfer capital threshold is the transfer adjustment factor * $556.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","4973.20","4973.20","4973.20","1 through 10","3975","38087.5","other","Inpatient DRG"
"Complications Of Treatment With Cc","920","MS-DRG","","","","","","","","inpatient","","","30158.82","18095.29","MARTIN'S POINT [160007]","HB WDH MEDICARE","8064.79","","Case rate ($8,064.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,477.97, add-ons for qualifying new technology services are included. If operating cost exceeds $11,396.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,361.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,063.10 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,033.10 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.82. The transfer capital threshold is the transfer adjustment factor * $556.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7997.67","7997.67","7997.67","1 through 10","3975","38087.5","other","Inpatient DRG"
"Complications Of Treatment With Cc","920","MS-DRG","","","","","","","","inpatient","","","30158.82","18095.29","MEDICARE [2001]","HB WDH MEDICARE","8064.79","","Case rate ($8,064.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,477.97, add-ons for qualifying new technology services are included. If operating cost exceeds $11,396.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,361.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,063.10 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,033.10 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.82. The transfer capital threshold is the transfer adjustment factor * $556.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8110.31","8110.31","8130.28","1 through 10","3975","38087.5","other","Inpatient DRG"
"Complications Of Treatment With Cc","920","MS-DRG","","","","","","","","inpatient","","","30158.82","18095.29","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8064.79","","Case rate ($8,064.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,477.97, add-ons for qualifying new technology services are included. If operating cost exceeds $11,396.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,361.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,063.10 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,033.10 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.82. The transfer capital threshold is the transfer adjustment factor * $556.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7967.68","7967.68","7967.68","1 through 10","3975","38087.5","other","Inpatient DRG"
"Complications Of Treatment With McC","919","MS-DRG","","","","","","","","inpatient","","","42104.63","25262.78","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","14650.67","","Case rate ($14,363.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,291.52, add-ons for qualifying new technology services are included. If operating cost exceeds $17,209.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,822.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,901.45 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,846.66 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.09. The transfer capital threshold is the transfer adjustment factor * $1,017.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","6715.03","6715.03","6715.03","1 through 10","3975","69570.58","other","Inpatient DRG"
"Complications Of Treatment With McC","919","MS-DRG","","","","","","","","inpatient","","","42104.63","25262.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","69570.58","","Fee schedule rate ($69,570.58). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","44889.76","44889.76","44889.76","1 through 10","3975","69570.58","case rate",""
"Complications Of Treatment With McC","919","MS-DRG","","","","","","","","inpatient","","","42104.63","25262.78","MARTIN'S POINT [160007]","HB WDH MEDICARE","14363.40","","Case rate ($14,363.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,291.52, add-ons for qualifying new technology services are included. If operating cost exceeds $17,209.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,822.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,901.45 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,846.66 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.09. The transfer capital threshold is the transfer adjustment factor * $1,017.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14598.85","14598.85","14598.85","1 through 10","3975","69570.58","other","Inpatient DRG"
"Complications Of Treatment With McC","919","MS-DRG","","","","","","","","inpatient","","","42104.63","25262.78","MEDICARE [2001]","HB WDH MEDICARE","14363.40","","Case rate ($14,363.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,291.52, add-ons for qualifying new technology services are included. If operating cost exceeds $17,209.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,822.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,901.45 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,846.66 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.09. The transfer capital threshold is the transfer adjustment factor * $1,017.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14204.86","14204.86","14240.71","1 through 10","3975","69570.58","other","Inpatient DRG"
"Complications Of Treatment With McC","919","MS-DRG","","","","","","","","inpatient","","","42104.63","25262.78","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","14363.40","","Case rate ($14,363.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,291.52, add-ons for qualifying new technology services are included. If operating cost exceeds $17,209.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,822.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,901.45 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,846.66 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.09. The transfer capital threshold is the transfer adjustment factor * $1,017.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13954.97","13954.97","13954.97","1 through 10","3975","69570.58","other","Inpatient DRG"
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0300","RC","","","","inpatient","","","149.00","89.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","114.52","76.86","","90.72","90.72","90.72","1 through 10","98.64","114.52","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","149.00","89.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","104.00","69.8","","100.51","90.58","100.51","1104","6.86","126.65","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","149.00","89.40","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","104.00","69.8","","100.51","13.62","100.51","1 through 10","6.86","126.65","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","149.00","89.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","126.65","85","","54.18","14.78","122.40","31","6.86","126.65","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","outpatient","","","149.00","89.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","93.54","62.78","","90.40","90.40","90.40","53","9.84","115.33","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","outpatient","","","149.00","89.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","65.14","43.72","","62.96","62.96","62.96","118","9.84","115.33","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","outpatient","","","149.00","89.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","108.35","72.72","","104.72","104.72","104.72","1761","9.84","115.33","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","outpatient","","","149.00","89.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","108.35","72.72","","104.72","104.72","104.72","78","9.84","115.33","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","outpatient","","","149.00","89.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","79.30","53.22","","76.77","76.77","76.77","100","9.84","115.33","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","outpatient","","","149.00","89.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","93.72","62.9","","90.72","90.72","90.72","1955","9.84","115.33","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","outpatient","","","149.00","89.40","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","108.35","72.72","","111.60","104.72","614.59","1 through 10","9.84","115.33","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","outpatient","","","149.00","89.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","115.33","77.4","","111.60","111.60","111.60","750","9.84","115.33","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","outpatient","","","149.00","89.40","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","108.35","72.72","","104.72","104.72","209.44","18","9.84","115.33","percent of total billed charges",""
"Concentration Any Type","PX-30001138","CDM","87015","CPT","0306","RC","","","","both","","","56.00","33.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","39.09","69.8","","310.86","37.69","310.86","1 through 10","4.34","47.6","percent of total billed charges",""
"Concentration Any Type","PX-30001138","CDM","87015","CPT","0306","RC","","","","outpatient","","","56.00","33.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","24.48","43.72","","23.61","23.61","23.61","1 through 10","6.22","43.34","percent of total billed charges",""
"Concentration Any Type","PX-30001138","CDM","87015","CPT","0306","RC","","","","outpatient","","","56.00","33.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","40.72","72.72","","39.27","39.27","117.81","11","6.22","43.34","percent of total billed charges",""
"Concentration Any Type","PX-30001138","CDM","87015","CPT","0306","RC","","","","outpatient","","","56.00","33.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","35.22","62.9","","102.06","102.06","102.06","1 through 10","6.22","43.34","percent of total billed charges",""
"Concentration Any Type","PX-30001138","CDM","87015","CPT","0306","RC","","","","outpatient","","","56.00","33.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","43.34","77.4","","41.85","41.85","41.85","1 through 10","6.22","43.34","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","both","","","7998.43","4799.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","930.22","6798.67","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","both","","","7998.43","4799.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","930.22","6798.67","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","both","","","7998.43","4799.06","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4551.11","56.9","","812.12","238.65","1587.46","163","930.22","6798.67","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","both","","","7998.43","4799.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","930.22","11.63","","112.68","112.68","146.99","38","930.22","6798.67","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","both","","","7998.43","4799.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6190.78","77.4","","303.98","303.98","5854.79","1 through 10","930.22","6798.67","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7998.43","4799.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","930.22","11.63","","112.68","112.68","146.99","38","930.22","6190.78","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7998.43","4799.06","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5021.41","62.78","","780.86","208.94","10480.28","15","930.22","6190.78","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7998.43","4799.06","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3496.91","43.72","","179.76","179.76","179.76","1 through 10","930.22","6190.78","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7998.43","4799.06","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5816.46","72.72","","2355.45","298.99","3965.19","155","930.22","6190.78","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7998.43","4799.06","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5816.46","72.72","","3643.09","3643.09","3643.09","1 through 10","930.22","6190.78","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7998.43","4799.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4256.76","53.22","","554.28","554.28","554.28","16","930.22","6190.78","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7998.43","4799.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5031.01","62.9","","619.64","173.09","2370.64","150","930.22","6190.78","percent of total billed charges",""
"CONDYLAR PLATE 4.5-5X301MM 14 HOLE VA LCP CURVED RIGHT","SUP-ITM-10095165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7998.43","4799.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6190.78","77.4","","303.98","303.98","5854.79","1 through 10","930.22","6190.78","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018453","CDM","C1713","HCPCS","0278","RC","","","","both","","","6361.50","3816.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","739.84","5407.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018453","CDM","C1713","HCPCS","0278","RC","","","","both","","","6361.50","3816.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","739.84","5407.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018453","CDM","C1713","HCPCS","0278","RC","","","","both","","","6361.50","3816.90","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3619.69","56.9","","812.12","238.65","1587.46","163","739.84","5407.28","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018453","CDM","C1713","HCPCS","0278","RC","","","","both","","","6361.50","3816.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","739.84","11.63","","112.68","112.68","146.99","38","739.84","5407.28","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018453","CDM","C1713","HCPCS","0278","RC","","","","both","","","6361.50","3816.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4923.80","77.4","","303.98","303.98","5854.79","1 through 10","739.84","5407.28","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6361.50","3816.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","739.84","11.63","","112.68","112.68","146.99","38","739.84","4923.8","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6361.50","3816.90","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3993.75","62.78","","780.86","208.94","10480.28","15","739.84","4923.8","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6361.50","3816.90","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2781.25","43.72","","179.76","179.76","179.76","1 through 10","739.84","4923.8","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6361.50","3816.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4626.08","72.72","","2355.45","298.99","3965.19","155","739.84","4923.8","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6361.50","3816.90","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4626.08","72.72","","3643.09","3643.09","3643.09","1 through 10","739.84","4923.8","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6361.50","3816.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3385.59","53.22","","554.28","554.28","554.28","16","739.84","4923.8","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6361.50","3816.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4001.38","62.9","","619.64","173.09","2370.64","150","739.84","4923.8","percent of total billed charges",""
"CONDYLAR PLATE 4.5X314MM 14 HOLE LCP SS CURVED RIGHT","SUP-ITM-10018453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6361.50","3816.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4923.80","77.4","","303.98","303.98","5854.79","1 through 10","739.84","4923.8","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","both","","","5386.62","3231.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","626.46","4578.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","both","","","5386.62","3231.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","626.46","4578.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","both","","","5386.62","3231.97","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3064.99","56.9","","812.12","238.65","1587.46","163","626.46","4578.63","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","both","","","5386.62","3231.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","626.46","11.63","","112.68","112.68","146.99","38","626.46","4578.63","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","both","","","5386.62","3231.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4169.24","77.4","","303.98","303.98","5854.79","1 through 10","626.46","4578.63","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5386.62","3231.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","626.46","11.63","","112.68","112.68","146.99","38","626.46","4169.24","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5386.62","3231.97","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3381.72","62.78","","780.86","208.94","10480.28","15","626.46","4169.24","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5386.62","3231.97","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2355.03","43.72","","179.76","179.76","179.76","1 through 10","626.46","4169.24","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5386.62","3231.97","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3917.15","72.72","","2355.45","298.99","3965.19","155","626.46","4169.24","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5386.62","3231.97","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3917.15","72.72","","3643.09","3643.09","3643.09","1 through 10","626.46","4169.24","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5386.62","3231.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2866.76","53.22","","554.28","554.28","554.28","16","626.46","4169.24","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5386.62","3231.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3388.18","62.9","","619.64","173.09","2370.64","150","626.46","4169.24","percent of total billed charges",""
"CONDYLAR PLATE 80X204MM 12 HOLE 95DEG DCP SS ANGLED BLADE","SUP-ITM-10002481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5386.62","3231.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4169.24","77.4","","303.98","303.98","5854.79","1 through 10","626.46","4169.24","percent of total billed charges",""
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","","","","inpatient","","","35936.50","21561.90","MEDICARE [2001]","HB WDH MEDICARE","9213.52","","Case rate ($9,213.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,538.24, add-ons for qualifying new technology services are included. If operating cost exceeds $12,456.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,445.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,127.88 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,093.37 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.76. The transfer capital threshold is the transfer adjustment factor * $640.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9203.03","9203.03","9203.03","1 through 10","3975","43829.32","other","Inpatient DRG"
"Connective Tissue Disorders With McC","545","MS-DRG","","","","","","","","inpatient","","","26304.91","15782.95","MEDICARE [2001]","HB WDH MEDICARE","19311.84","","Case rate ($19,311.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $17,858.87, add-ons for qualifying new technology services are included. If operating cost exceeds $21,777.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,183.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $17,488.27 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,414.00 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,378.69. The transfer capital threshold is the transfer adjustment factor * $1,378.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19511.66","19511.66","19511.66","1 through 10","3975","94304.85","other","Inpatient DRG"
"Connective Tissue Disorders With McC","545","MS-DRG","","","","","","","","inpatient","","","26304.91","15782.95","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","19311.84","","Case rate ($19,311.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $17,858.87, add-ons for qualifying new technology services are included. If operating cost exceeds $21,777.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,183.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $17,488.27 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,414.00 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,378.69. The transfer capital threshold is the transfer adjustment factor * $1,378.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","54627.19","54627.19","54627.19","1 through 10","3975","94304.85","other","Inpatient DRG"
"CONNECTOR 5.0X15MM REPAIR NERVE AXOGUARD COAPTATION AID PERIPHERAL","SUP-ITM-10173773","CDM","C1763","HCPCS","0278","RC","","","","both","","","8385.65","5031.39","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4771.43","56.9","","1156.60","963.29","1156.60","1 through 10","975.25","7127.8","percent of total billed charges",""
"CONNECTOR 5.0X15MM REPAIR NERVE AXOGUARD COAPTATION AID PERIPHERAL","SUP-ITM-10173773","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","8385.65","5031.39","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6098.04","72.72","","8111.92","3502.08","8111.92","1 through 10","975.25","6490.49","percent of total billed charges",""
"CONNECTOR 5.0X15MM REPAIR NERVE AXOGUARD COAPTATION AID PERIPHERAL","SUP-ITM-10173773","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","8385.65","5031.39","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5274.57","62.9","","1066.56","1066.56","1066.56","1 through 10","975.25","6490.49","percent of total billed charges",""
"CONNECTOR DIA 1.5MM LENGTH 10 PROTCTR GRFT NERV AXOGUARD PORCN 3D EXTRACELLULAR MATRX FLEX WRP TRNSLUCNT PERIPH","SUP-ITM-10124171","CDM","C1763","HCPCS","0278","RC","","","","both","","","5679.35","3407.61","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3231.55","56.9","","1156.60","963.29","1156.60","1 through 10","660.51","4827.45","percent of total billed charges",""
"CONNECTOR DIA 1.5MM LENGTH 10 PROTCTR GRFT NERV AXOGUARD PORCN 3D EXTRACELLULAR MATRX FLEX WRP TRNSLUCNT PERIPH","SUP-ITM-10124171","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","5679.35","3407.61","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4130.02","72.72","","8111.92","3502.08","8111.92","1 through 10","660.51","4395.82","percent of total billed charges",""
"CONNECTOR DIA 1.5MM LENGTH 10 PROTCTR GRFT NERV AXOGUARD PORCN 3D EXTRACELLULAR MATRX FLEX WRP TRNSLUCNT PERIPH","SUP-ITM-10124171","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","5679.35","3407.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3572.31","62.9","","1066.56","1066.56","1066.56","1 through 10","660.51","4395.82","percent of total billed charges",""
"CONNECTOR DIA 2.0MM LENGTH 15 NERVE AXOGUARD PERIPHERAL COAPTATION AID PORCINE","SUP-ITM-10140131","CDM","C1763","HCPCS","0278","RC","","","","both","","","8385.65","5031.39","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4771.43","56.9","","1156.60","963.29","1156.60","1 through 10","975.25","7127.8","percent of total billed charges",""
"CONNECTOR DIA 2.0MM LENGTH 15 NERVE AXOGUARD PERIPHERAL COAPTATION AID PORCINE","SUP-ITM-10140131","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","8385.65","5031.39","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6098.04","72.72","","8111.92","3502.08","8111.92","1 through 10","975.25","6490.49","percent of total billed charges",""
"CONNECTOR DIA 2.0MM LENGTH 15 NERVE AXOGUARD PERIPHERAL COAPTATION AID PORCINE","SUP-ITM-10140131","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","8385.65","5031.39","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5274.57","62.9","","1066.56","1066.56","1066.56","1 through 10","975.25","6490.49","percent of total billed charges",""
"CONNECTOR DIA 3MMX15 REPAIR NERVE AXOGUARD COAPTATION AID PERIPHERAL","SUP-ITM-10152892","CDM","C1763","HCPCS","0278","RC","","","","both","","","8385.65","5031.39","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4771.43","56.9","","1156.60","963.29","1156.60","1 through 10","975.25","7127.8","percent of total billed charges",""
"CONNECTOR DIA 3MMX15 REPAIR NERVE AXOGUARD COAPTATION AID PERIPHERAL","SUP-ITM-10152892","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","8385.65","5031.39","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6098.04","72.72","","8111.92","3502.08","8111.92","1 through 10","975.25","6490.49","percent of total billed charges",""
"CONNECTOR DIA 3MMX15 REPAIR NERVE AXOGUARD COAPTATION AID PERIPHERAL","SUP-ITM-10152892","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","8385.65","5031.39","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5274.57","62.9","","1066.56","1066.56","1066.56","1 through 10","975.25","6490.49","percent of total billed charges",""
"CONNECTOR EAR .5MM OMEGA OSSICULAR PROSTHESIS","SUP-ITM-10281728","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","1494.63","896.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","940.12","62.9","","2038.65","2038.65","2038.65","1 through 10","795.44","1156.84","percent of total billed charges",""
"CONNECTORX40 50 5.5MM ROD RELINE LP ADJUSTABLE","SUP-ITM-10170318","CDM","C1889","HCPCS","0278","RC","","","","both","","","3351.35","2010.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","389.76","2848.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CONNECTORX40 50 5.5MM ROD RELINE LP ADJUSTABLE","SUP-ITM-10170318","CDM","C1889","HCPCS","0278","RC","","","","both","","","3351.35","2010.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","389.76","2848.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CONNECTORX40 50 5.5MM ROD RELINE LP ADJUSTABLE","SUP-ITM-10170318","CDM","C1889","HCPCS","0278","RC","","","","both","","","3351.35","2010.81","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1906.92","56.9","","0.63","0.63","0.63","1 through 10","389.76","2848.65","percent of total billed charges",""
"CONNECTORX40 50 5.5MM ROD RELINE LP ADJUSTABLE","SUP-ITM-10170318","CDM","C1889","HCPCS","0278","RC","","","","both","","","3351.35","2010.81","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","483.26","14.42","","317.14","317.14","317.14","1 through 10","389.76","2848.65","percent of total billed charges",""
"CONNECTORX40 50 5.5MM ROD RELINE LP ADJUSTABLE","SUP-ITM-10170318","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3351.35","2010.81","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","483.26","14.42","","317.14","317.14","317.14","1 through 10","389.76","2593.94","percent of total billed charges",""
"CONNECTORX40 50 5.5MM ROD RELINE LP ADJUSTABLE","SUP-ITM-10170318","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3351.35","2010.81","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2103.98","62.78","","1125.09","1125.09","1125.09","1 through 10","389.76","2593.94","percent of total billed charges",""
"CONNECTORX40 50 5.5MM ROD RELINE LP ADJUSTABLE","SUP-ITM-10170318","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3351.35","2010.81","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2437.10","72.72","","4732.50","1617.43","14180.40","1 through 10","389.76","2593.94","percent of total billed charges",""
"CONNECTORX40 50 5.5MM ROD RELINE LP ADJUSTABLE","SUP-ITM-10170318","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3351.35","2010.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2108.00","62.9","","3896.20","3341.38","3896.20","1 through 10","389.76","2593.94","percent of total billed charges",""
"Consult Path Surgery W/Frozen","PX-31000157","CDM","88331","CPT","0312","RC","","","","outpatient","","","451.00","270.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","327.97","72.72","","317.06","317.06","317.06","1 through 10","52.45","349.07","percent of total billed charges",""
"Consult Path Surgery W/Frozen","PX-31000157","CDM","88331","CPT","0312","RC","","","","outpatient","","","451.00","270.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","283.68","62.9","","274.68","274.68","274.68","1 through 10","52.45","349.07","percent of total billed charges",""
"Control Nosebleed Ant Smp","PX-76000748","CDM","30901","CPT","0761","RC","","","","both","","","582.00","349.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","331.16","56.9","","238.04","238.04","238.04","1 through 10","59.63","860.68","percent of total billed charges",""
"Control Nosebleed Ant Smp","PX-76000748","CDM","30901","CPT","0761","RC","","","","outpatient","","","582.00","349.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","366.08","62.9","","241.29","241.29","241.29","1 through 10","67.69","450.47","percent of total billed charges",""
"Control Nosebleed Posterior Initial","PX-76000750","CDM","30905","CPT","0761","RC","","","","both","","","1084.00","650.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","134.67","","APC Price ($134.67). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","132.00","132.00","132.00","1 through 10","111.75","921.4","other","OPPS APC"
"Control Nosebleed Posterior Initial","PX-76000750","CDM","30905","CPT","0761","RC","","","","both","","","1084.00","650.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","134.67","","APC Price ($134.67). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","134.69","134.69","134.69","1 through 10","111.75","921.4","other","OPPS APC"
"CONTROL REMOTE","SUP-ITM-10294639","CDM","C1787","HCPCS","0270","RC","","","","both","","","5092.50","3055.50","AETNA [1001]","HB WDH AETNA COMMERCIAL","3554.57","69.8","","1412.58","1412.58","1412.58","1 through 10","592.26","4328.63","percent of total billed charges",""
"CONTROL REMOTE","SUP-ITM-10294639","CDM","C1787","HCPCS","0270","RC","","","","both","","","5092.50","3055.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","18158.40","2245.75","18158.40","1 through 10","592.26","4328.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CONTROL REMOTE","SUP-ITM-10294639","CDM","C1787","HCPCS","0270","RC","","","","both","","","5092.50","3055.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2897.63","56.9","","15498.18","15498.18","15498.18","1 through 10","592.26","4328.63","percent of total billed charges",""
"CONTROL REMOTE","SUP-ITM-10294639","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","5092.50","3055.50","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","3703.27","72.72","","4236.03","4236.03","4236.03","1 through 10","592.26","3941.6","percent of total billed charges",""
"CONTROL REMOTE PATIENT WITH LITERATURE","SUP-ITM-10266924","CDM","C1787","HCPCS","0270","RC","","","","both","","","5825.13","3495.08","AETNA [1001]","HB WDH AETNA COMMERCIAL","4065.94","69.8","","1412.58","1412.58","1412.58","1 through 10","677.46","4951.36","percent of total billed charges",""
"CONTROL REMOTE PATIENT WITH LITERATURE","SUP-ITM-10266924","CDM","C1787","HCPCS","0270","RC","","","","both","","","5825.13","3495.08","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","18158.40","2245.75","18158.40","1 through 10","677.46","4951.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CONTROL REMOTE PATIENT WITH LITERATURE","SUP-ITM-10266924","CDM","C1787","HCPCS","0270","RC","","","","both","","","5825.13","3495.08","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3314.50","56.9","","15498.18","15498.18","15498.18","1 through 10","677.46","4951.36","percent of total billed charges",""
"CONTROL REMOTE PATIENT WITH LITERATURE","SUP-ITM-10266924","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","5825.13","3495.08","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","4236.03","72.72","","4236.03","4236.03","4236.03","1 through 10","677.46","4508.65","percent of total billed charges",""
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","88.00","52.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","61.42","69.8","","59.33","53.47","59.33","1 through 10","27.08","396.58","percent of total billed charges",""
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","88.00","52.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","63.30","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","59.60","59.60","59.60","1 through 10","27.08","396.58","other","OPPS APC"
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","88.00","52.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","396.58","","Case rate ($396.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3.50","3.50","3.50","1 through 10","27.08","396.58","other","OPPS APC"
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","88.00","52.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","170.77","","Case rate ($170.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3.50","2.66","3.50","1 through 10","27.08","396.58","other","OPPS APC"
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","88.00","52.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","60.82","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5.39","5.28","90.39","15","27.08","396.58","other","OPPS APC"
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","88.00","52.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","320.55","","Case rate ($320.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3.50","3.50","3.50","13","27.08","396.58","other","OPPS APC"
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","88.00","52.80","MEDICARE [2001]","HB WDH MEDICARE","62.06","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","31.04","31.04","62.07","1 through 10","27.08","396.58","other","OPPS APC"
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","88.00","52.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","62.06","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","30.42","30.42","58.41","1 through 10","27.08","396.58","other","OPPS APC"
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","outpatient","","","88.00","52.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","38.47","43.72","","37.16","37.16","37.16","1 through 10","6.44","68.11","percent of total billed charges",""
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","outpatient","","","88.00","52.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","63.99","72.72","","61.81","61.81","123.62","1 through 10","6.44","68.11","percent of total billed charges",""
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","outpatient","","","88.00","52.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","55.35","62.9","","53.55","53.55","53.55","1 through 10","6.44","68.11","percent of total billed charges",""
"Coombs Indirect Ql","PX-30000071","CDM","86885","CPT","0302","RC","","","","both","","","32.00","19.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","175.45","","APC Price ($179.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","67.72","5.72","67.72","1 through 10","22.34","1144.2","other","OPPS APC"
"Coombs Indirect Titer","PX-30000072","CDM","86886","CPT","0302","RC","","","","both","","","70.00","42.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","48.86","69.8","","47.46","42.77","47.46","1 through 10","27.08","1144.2","percent of total billed charges",""
"Coombs Indirect Titer","PX-30000072","CDM","86886","CPT","0302","RC","","","","both","","","70.00","42.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","492.69","","Case rate ($492.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3.37","3.37","3.37","1 through 10","27.08","1144.2","other","OPPS APC"
"Coombs Indirect Titer","PX-30000072","CDM","86886","CPT","0302","RC","","","","both","","","70.00","42.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","175.45","","APC Price ($179.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5.18","5.18","5.18","1 through 10","27.08","1144.2","other","OPPS APC"
"Coombs Indirect Titer","PX-30000072","CDM","86886","CPT","0302","RC","","","","both","","","70.00","42.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","924.85","","Case rate ($924.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3.37","3.37","3.37","1 through 10","27.08","1144.2","other","OPPS APC"
"Coombs Indirect Titer","PX-30000072","CDM","86886","CPT","0302","RC","","","","outpatient","","","70.00","42.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","50.90","72.72","","49.45","49.45","49.45","1 through 10","4.82","54.18","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","both","","","68.00","40.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","47.46","69.8","","46.07","14.14","46.07","27","8.07","64.73","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","outpatient","","","68.00","40.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","42.69","62.78","","41.43","41.43","41.43","1 through 10","11.56","52.63","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","outpatient","","","68.00","40.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","29.73","43.72","","28.86","28.86","28.86","1 through 10","11.56","52.63","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","outpatient","","","68.00","40.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","49.45","72.72","","48.00","48.00","48.00","25","11.56","52.63","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","outpatient","","","68.00","40.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","36.19","53.22","","35.18","35.18","35.18","1 through 10","11.56","52.63","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","outpatient","","","68.00","40.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","42.77","62.9","","41.58","41.58","41.58","54","11.56","52.63","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","outpatient","","","68.00","40.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","52.63","77.4","","51.15","51.15","51.15","12","11.56","52.63","percent of total billed charges",""
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","8670.00","5202.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","6051.66","69.8","","5839.47","5839.47","5839.47","1 through 10","1658.91","10818.29","percent of total billed charges",""
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","8670.00","5202.00","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","1726.62","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","1692.96","1692.96","1692.96","1 through 10","1658.91","10818.29","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","8670.00","5202.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","4658.35","","Case rate ($4,658.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4544.78","4421.65","4544.78","1 through 10","1658.91","10818.29","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","8670.00","5202.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1658.91","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1659.10","1659.10","1659.10","1 through 10","1658.91","10818.29","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","8670.00","5202.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4933.23","56.9","","4760.25","4760.25","4760.25","1 through 10","1658.91","10818.29","percent of total billed charges",""
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","8670.00","5202.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","1743.54","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1719.87","1719.87","1719.87","1 through 10","1658.91","10818.29","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","8670.00","5202.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1660.00","1660.00","1692.96","1 through 10","1658.91","10818.29","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","8670.00","5202.00","MEDICARE [2001]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1692.96","1579.69","1692.96","13","1658.91","10818.29","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","8670.00","5202.00","TRICARE [160005]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1692.96","1692.96","1692.96","1 through 10","1658.91","10818.29","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","8670.00","5202.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1665.88","1556.00","1667.01","15","1658.91","10818.29","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","both","","","8670.00","5202.00","WELLSENSE NH [1050]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1749.46","1749.26","1749.46","1 through 10","1658.91","10818.29","other","OPPS APC"
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","outpatient","","","8670.00","5202.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1008.32","11.63","","1024.00","988.16","1152.00","1 through 10","1008.32","6710.58","percent of total billed charges",""
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","outpatient","","","8670.00","5202.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3790.52","43.72","","10972.86","10972.86","10972.86","1 through 10","1008.32","6710.58","percent of total billed charges",""
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","outpatient","","","8670.00","5202.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6304.82","72.72","","18251.28","6083.76","24335.04","1 through 10","1008.32","6710.58","percent of total billed charges",""
"Core Needle Bx Lung/Mediastinum Perq W/Img","PX-76002705","CDM","32408","CPT","0761","RC","","","","outpatient","","","8670.00","5202.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1008.32","11.63","","988.16","988.16","988.16","1 through 10","1008.32","6710.58","percent of total billed charges",""
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","13594.00","8156.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","21475.95","","Case rate ($21,475.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","20952.20","14989.60","20952.20","1 through 10","1960.25","21475.95","other","OPPS APC"
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","13594.00","8156.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","9247.52","","Case rate ($9,247.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9022.08","8886.89","9022.08","1 through 10","1960.25","21475.95","other","OPPS APC"
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","13594.00","8156.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","3293.17","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3300.54","3130.51","16478.76","1 through 10","1960.25","21475.95","other","OPPS APC"
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","13594.00","8156.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","17358.81","","Case rate ($17,358.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","16935.33","15820.55","16935.33","1 through 10","1960.25","21475.95","other","OPPS APC"
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","13594.00","8156.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7734.99","56.9","","7464.14","7464.14","14238.69","1 through 10","1960.25","21475.95","percent of total billed charges",""
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","13594.00","8156.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1960.25","14.42","","1891.62","1891.62","1891.62","1 through 10","1960.25","21475.95","percent of total billed charges",""
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","13594.00","8156.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","3461.19","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3403.35","3402.85","3403.35","1 through 10","1960.25","21475.95","other","OPPS APC"
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","13594.00","8156.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3301.04","3300.04","3301.44","1 through 10","1960.25","21475.95","other","OPPS APC"
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","13594.00","8156.40","MEDICARE [2001]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3360.76","3174.96","3360.76","19","1960.25","21475.95","other","OPPS APC"
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","13594.00","8156.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8550.63","62.9","","29229.40","8264.34","30084.68","1 through 10","1960.25","21475.95","percent of total billed charges",""
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","13594.00","8156.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3360.76","3293.55","6173.39","1 through 10","1960.25","21475.95","other","OPPS APC"
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","13594.00","8156.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10521.76","77.4","","10166.45","10166.45","10166.45","1 through 10","1960.25","21475.95","percent of total billed charges",""
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","both","","","13594.00","8156.40","WELLSENSE NH [1050]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3458.22","3458.22","3458.22","1 through 10","1960.25","21475.95","other","OPPS APC"
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","outpatient","","","13594.00","8156.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1580.98","11.63","","3315.82","1549.44","3315.82","1 through 10","1580.98","9885.56","percent of total billed charges",""
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","outpatient","","","13594.00","8156.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","9885.56","72.72","","9539.41","9539.41","9539.41","1 through 10","1580.98","9885.56","percent of total billed charges",""
"Coronary Artery Angio S&I","PX-48000119","CDM","93454","CPT","0481","RC","","","","outpatient","","","13594.00","8156.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1580.98","11.63","","1549.44","1549.44","1549.44","1 through 10","1580.98","9885.56","percent of total billed charges",""
"Coronary Artery/Graft Angio S&I","PX-48000120","CDM","93455","CPT","0481","RC","","","","both","","","15493.00","9295.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","8815.52","56.9","","8506.55","8506.55","8506.55","1 through 10","3293.17","21475.95","percent of total billed charges",""
"Coronary Artery/Graft Angio S&I","PX-48000120","CDM","93455","CPT","0481","RC","","","","both","","","15493.00","9295.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5845.75","3301.04","5845.75","1 through 10","3293.17","21475.95","other","OPPS APC"
"Coronary Artery/Graft Angio S&I","PX-48000120","CDM","93455","CPT","0481","RC","","","","both","","","15493.00","9295.80","MEDICARE [2001]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3360.76","3360.76","5957.40","1 through 10","3293.17","21475.95","other","OPPS APC"
"Coronary Artery/Graft Angio S&I","PX-48000120","CDM","93455","CPT","0481","RC","","","","both","","","15493.00","9295.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5843.76","3174.96","5846.76","1 through 10","3293.17","21475.95","other","OPPS APC"
"Coronary Intravascular Lithotripsy With Intraluminal Device With McC","323","MS-DRG","","","","","","","","inpatient","","","241127.91","144676.75","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","34010.50","","Case rate ($33,343.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $30,810.08, add-ons for qualifying new technology services are included. If operating cost exceeds $34,728.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,209.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $30,494.72 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $30,365.21 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,404.06. The transfer capital threshold is the transfer adjustment factor * $2,404.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","12825.00","12825.00","12825.00","1 through 10","3975","164441.63","other","Inpatient DRG"
"Coronary Intravascular Lithotripsy With Intraluminal Device With McC","323","MS-DRG","","","","","","","","inpatient","","","241127.91","144676.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","32676.76","","Case rate ($33,343.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $30,810.08, add-ons for qualifying new technology services are included. If operating cost exceeds $34,728.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,209.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $30,494.72 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $30,365.21 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,404.06. The transfer capital threshold is the transfer adjustment factor * $2,404.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","31971.65","31971.65","31971.65","1 through 10","3975","164441.63","other","Inpatient DRG"
"Coronary Intravascular Lithotripsy With Intraluminal Device With McC","323","MS-DRG","","","","","","","","inpatient","","","241127.91","144676.75","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","34343.94","","Case rate ($33,343.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $30,810.08, add-ons for qualifying new technology services are included. If operating cost exceeds $34,728.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,209.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $30,494.72 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $30,365.21 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,404.06. The transfer capital threshold is the transfer adjustment factor * $2,404.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","236424.52","236424.52","236424.52","1 through 10","3975","164441.63","other","Inpatient DRG"
"Coronary Intravascular Lithotripsy With Intraluminal Device With McC","323","MS-DRG","","","","","","","","inpatient","","","241127.91","144676.75","MEDICARE [2001]","HB WDH MEDICARE","33343.63","","Case rate ($33,343.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $30,810.08, add-ons for qualifying new technology services are included. If operating cost exceeds $34,728.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,209.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $30,494.72 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $30,365.21 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,404.06. The transfer capital threshold is the transfer adjustment factor * $2,404.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","57052.28","57052.28","103384.92","1 through 10","3975","164441.63","other","Inpatient DRG"
"Coronary Intravascular Lithotripsy With Intraluminal Device Without McC","324","MS-DRG","","","","","","","","inpatient","","","196412.72","117847.63","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","23912.14","","Case rate ($24,400.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $22,555.32, add-ons for qualifying new technology services are included. If operating cost exceeds $26,473.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,555.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $22,204.76 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $22,110.45 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,750.52. The transfer capital threshold is the transfer adjustment factor * $1,750.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","24616.42","24616.42","24616.42","1 through 10","3975","119738.32","other","Inpatient DRG"
"Coronary Intravascular Lithotripsy With Intraluminal Device Without McC","324","MS-DRG","","","","","","","","inpatient","","","196412.72","117847.63","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","95365.90","","Fee schedule rate ($95,365.90). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","94342.03","94342.03","94342.03","1 through 10","3975","119738.32","case rate",""
"Coronary Intravascular Lithotripsy With Intraluminal Device Without McC","324","MS-DRG","","","","","","","","inpatient","","","196412.72","117847.63","MEDICARE [2001]","HB WDH MEDICARE","24400.14","","Case rate ($24,400.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $22,555.32, add-ons for qualifying new technology services are included. If operating cost exceeds $26,473.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,555.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $22,204.76 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $22,110.45 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,750.52. The transfer capital threshold is the transfer adjustment factor * $1,750.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24616.42","21464.44","24616.42","1 through 10","3975","119738.32","other","Inpatient DRG"
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","","","","inpatient","","","185570.07","111342.04","MARTIN'S POINT [160007]","HB WDH MEDICARE","24851.73","","Case rate ($24,851.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $22,972.13, add-ons for qualifying new technology services are included. If operating cost exceeds $26,890.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,588.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $22,623.34 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $22,527.26 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,783.52. The transfer capital threshold is the transfer adjustment factor * $1,783.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","197053.71","197053.71","197053.71","1 through 10","3975","121995.52","other","Inpatient DRG"
"Cortisol Free","PX-30000382","CDM","82530","CPT","0301","RC","","","","both","","","91.00","54.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","77.35","85","","15.04","15.04","15.04","1 through 10","10.86","85.77","percent of total billed charges",""
"Cortisol Free","PX-30000382","CDM","82530","CPT","0301","RC","","","","outpatient","","","91.00","54.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","39.79","43.72","","38.47","38.47","38.47","1 through 10","15.58","70.43","percent of total billed charges",""
"Cortisol Free","PX-30000382","CDM","82530","CPT","0301","RC","","","","outpatient","","","91.00","54.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","66.18","72.72","","63.99","63.99","63.99","1 through 10","15.58","70.43","percent of total billed charges",""
"Cortisol Free","PX-30000382","CDM","82530","CPT","0301","RC","","","","outpatient","","","91.00","54.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","57.24","62.9","","55.44","55.44","55.44","1 through 10","15.58","70.43","percent of total billed charges",""
"Cortisol Free","PX-30000382","CDM","82530","CPT","0301","RC","","","","outpatient","","","91.00","54.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","70.43","77.4","","68.20","68.20","68.20","1 through 10","15.58","70.43","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0300","RC","","","","inpatient","","","231.00","138.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","177.55","76.86","","140.49","140.49","140.49","1 through 10","152.92","177.55","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","both","","","231.00","138.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","161.24","69.8","","155.65","140.27","155.65","27","10.6","196.35","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","outpatient","","","231.00","138.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","145.02","62.78","","140.00","140.00","140.00","1 through 10","15.19","178.79","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","outpatient","","","231.00","138.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","100.99","43.72","","97.50","97.50","97.50","1 through 10","15.19","178.79","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","outpatient","","","231.00","138.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","167.98","72.72","","162.17","162.17","162.17","31","15.19","178.79","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","outpatient","","","231.00","138.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","167.98","72.72","","162.17","162.17","162.17","1 through 10","15.19","178.79","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","outpatient","","","231.00","138.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","122.94","53.22","","118.88","118.88","118.88","1 through 10","15.19","178.79","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","outpatient","","","231.00","138.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","145.30","62.9","","140.49","140.49","140.49","64","15.19","178.79","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","outpatient","","","231.00","138.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","178.79","77.4","","172.83","172.83","172.83","18","15.19","178.79","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","both","","","5389.80","3233.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","626.83","4581.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","both","","","5389.80","3233.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3066.80","56.9","","2911.53","1863.86","5209.05","65","626.83","4581.33","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","both","","","5389.80","3233.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","626.83","11.63","","400.94","400.94","400.94","1 through 10","626.83","4581.33","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","both","","","5389.80","3233.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4171.71","77.4","","5214.50","5214.50","16415.28","1 through 10","626.83","4581.33","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5389.80","3233.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","626.83","11.63","","400.94","400.94","400.94","1 through 10","626.83","4171.71","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5389.80","3233.88","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2356.42","43.72","","1543.33","1543.33","1671.61","1 through 10","626.83","4171.71","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5389.80","3233.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3919.46","72.72","","3700.21","2382.07","6427.18","53","626.83","4171.71","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5389.80","3233.88","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3919.46","72.72","","12685.80","12685.80","12685.80","1 through 10","626.83","4171.71","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5389.80","3233.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3390.18","62.9","","3408.87","2784.05","9859.40","46","626.83","4171.71","percent of total billed charges",""
"COUPLER KNEE 6MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018355","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5389.80","3233.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4171.71","77.4","","5214.50","5214.50","16415.28","1 through 10","626.83","4171.71","percent of total billed charges",""
"COUPLER OSS 10CM KNEE TOTAL FEMORAL DIAPH ONC 03","SUP-ITM-10114885","CDM","C1776","HCPCS","0278","RC","","","","both","","","11075.86","6645.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1288.12","9414.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COUPLER OSS 10CM KNEE TOTAL FEMORAL DIAPH ONC 03","SUP-ITM-10114885","CDM","C1776","HCPCS","0278","RC","","","","both","","","11075.86","6645.52","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6302.16","56.9","","2911.53","1863.86","5209.05","65","1288.12","9414.48","percent of total billed charges",""
"COUPLER OSS 10CM KNEE TOTAL FEMORAL DIAPH ONC 03","SUP-ITM-10114885","CDM","C1776","HCPCS","0278","RC","","","","both","","","11075.86","6645.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1288.12","11.63","","400.94","400.94","400.94","1 through 10","1288.12","9414.48","percent of total billed charges",""
"COUPLER OSS 10CM KNEE TOTAL FEMORAL DIAPH ONC 03","SUP-ITM-10114885","CDM","C1776","HCPCS","0278","RC","","","","both","","","11075.86","6645.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8572.72","77.4","","5214.50","5214.50","16415.28","1 through 10","1288.12","9414.48","percent of total billed charges",""
"COUPLER OSS 10CM KNEE TOTAL FEMORAL DIAPH ONC 03","SUP-ITM-10114885","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11075.86","6645.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1288.12","11.63","","400.94","400.94","400.94","1 through 10","1288.12","8572.72","percent of total billed charges",""
"COUPLER OSS 10CM KNEE TOTAL FEMORAL DIAPH ONC 03","SUP-ITM-10114885","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11075.86","6645.52","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4842.37","43.72","","1543.33","1543.33","1671.61","1 through 10","1288.12","8572.72","percent of total billed charges",""
"COUPLER OSS 10CM KNEE TOTAL FEMORAL DIAPH ONC 03","SUP-ITM-10114885","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11075.86","6645.52","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8054.37","72.72","","3700.21","2382.07","6427.18","53","1288.12","8572.72","percent of total billed charges",""
"COUPLER OSS 10CM KNEE TOTAL FEMORAL DIAPH ONC 03","SUP-ITM-10114885","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11075.86","6645.52","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","8054.37","72.72","","12685.80","12685.80","12685.80","1 through 10","1288.12","8572.72","percent of total billed charges",""
"COUPLER OSS 10CM KNEE TOTAL FEMORAL DIAPH ONC 03","SUP-ITM-10114885","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11075.86","6645.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6966.72","62.9","","3408.87","2784.05","9859.40","46","1288.12","8572.72","percent of total billed charges",""
"COUPLER OSS 10CM KNEE TOTAL FEMORAL DIAPH ONC 03","SUP-ITM-10114885","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11075.86","6645.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8572.72","77.4","","5214.50","5214.50","16415.28","1 through 10","1288.12","8572.72","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.50","207.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","40.18","293.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.50","207.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","40.18","293.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.50","207.30","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","196.59","56.9","","812.12","238.65","1587.46","163","40.18","293.68","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.50","207.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.18","11.63","","112.68","112.68","146.99","38","40.18","293.68","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.50","207.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","267.42","77.4","","303.98","303.98","5854.79","1 through 10","40.18","293.68","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.18","11.63","","112.68","112.68","146.99","38","40.18","267.42","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","216.90","62.78","","780.86","208.94","10480.28","15","40.18","267.42","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","151.05","43.72","","179.76","179.76","179.76","1 through 10","40.18","267.42","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","251.25","72.72","","2355.45","298.99","3965.19","155","40.18","267.42","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","251.25","72.72","","3643.09","3643.09","3643.09","1 through 10","40.18","267.42","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","183.88","53.22","","554.28","554.28","554.28","16","40.18","267.42","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","217.32","62.9","","619.64","173.09","2370.64","150","40.18","267.42","percent of total billed charges",""
"COVER HOLE MD ACETABULAR HIP REFLECTION TITANIUM APEX THREADED WATERTIGHT","SUP-ITM-10015183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","267.42","77.4","","303.98","303.98","5854.79","1 through 10","40.18","267.42","percent of total billed charges",""
"COVER HOLE SCREW ACETABULAR HIP REFLECTION TITANIUM THREADED","SUP-ITM-10001885","CDM","C1776","HCPCS","0278","RC","","","","both","","","345.50","207.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","40.18","293.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"COVER HOLE SCREW ACETABULAR HIP REFLECTION TITANIUM THREADED","SUP-ITM-10001885","CDM","C1776","HCPCS","0278","RC","","","","both","","","345.50","207.30","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","196.59","56.9","","2911.53","1863.86","5209.05","65","40.18","293.68","percent of total billed charges",""
"COVER HOLE SCREW ACETABULAR HIP REFLECTION TITANIUM THREADED","SUP-ITM-10001885","CDM","C1776","HCPCS","0278","RC","","","","both","","","345.50","207.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.18","11.63","","400.94","400.94","400.94","1 through 10","40.18","293.68","percent of total billed charges",""
"COVER HOLE SCREW ACETABULAR HIP REFLECTION TITANIUM THREADED","SUP-ITM-10001885","CDM","C1776","HCPCS","0278","RC","","","","both","","","345.50","207.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","267.42","77.4","","5214.50","5214.50","16415.28","1 through 10","40.18","293.68","percent of total billed charges",""
"COVER HOLE SCREW ACETABULAR HIP REFLECTION TITANIUM THREADED","SUP-ITM-10001885","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.18","11.63","","400.94","400.94","400.94","1 through 10","40.18","267.42","percent of total billed charges",""
"COVER HOLE SCREW ACETABULAR HIP REFLECTION TITANIUM THREADED","SUP-ITM-10001885","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","151.05","43.72","","1543.33","1543.33","1671.61","1 through 10","40.18","267.42","percent of total billed charges",""
"COVER HOLE SCREW ACETABULAR HIP REFLECTION TITANIUM THREADED","SUP-ITM-10001885","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","251.25","72.72","","3700.21","2382.07","6427.18","53","40.18","267.42","percent of total billed charges",""
"COVER HOLE SCREW ACETABULAR HIP REFLECTION TITANIUM THREADED","SUP-ITM-10001885","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","251.25","72.72","","12685.80","12685.80","12685.80","1 through 10","40.18","267.42","percent of total billed charges",""
"COVER HOLE SCREW ACETABULAR HIP REFLECTION TITANIUM THREADED","SUP-ITM-10001885","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","217.32","62.9","","3408.87","2784.05","9859.40","46","40.18","267.42","percent of total billed charges",""
"COVER HOLE SCREW ACETABULAR HIP REFLECTION TITANIUM THREADED","SUP-ITM-10001885","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","267.42","77.4","","5214.50","5214.50","16415.28","1 through 10","40.18","267.42","percent of total billed charges",""
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","both","","","426.00","255.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1358.06","","Case rate ($1,358.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1324.94","149.80","1350.91","1 through 10","208.24","1358.06","other","OPPS APC"
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","both","","","426.00","255.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","584.78","","Case rate ($584.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","570.52","122.82","570.52","1 through 10","208.24","1358.06","other","OPPS APC"
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","both","","","426.00","255.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","208.24","","APC Price ($212.49). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","212.52","207.82","212.52","1 through 10","208.24","1358.06","other","OPPS APC"
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","both","","","426.00","255.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","242.39","56.9","","233.86","217.73","388.46","1 through 10","208.24","1358.06","percent of total billed charges",""
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","both","","","426.00","255.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","362.10","85","","277.59","277.59","277.59","1 through 10","208.24","1358.06","percent of total billed charges",""
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","both","","","426.00","255.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","212.49","","APC Price ($212.49). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","212.52","212.52","212.52","1 through 10","208.24","1358.06","other","OPPS APC"
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","outpatient","","","426.00","255.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","61.43","14.42","","59.27","50.80","59.27","15","49.54","329.72","percent of total billed charges",""
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","outpatient","","","426.00","255.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","49.54","11.63","","103.79","56.59","103.79","1 through 10","49.54","329.72","percent of total billed charges",""
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","outpatient","","","426.00","255.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","309.79","72.72","","298.88","298.88","298.88","1 through 10","49.54","329.72","percent of total billed charges",""
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","outpatient","","","426.00","255.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","267.95","62.9","","964.68","258.93","964.68","23","49.54","329.72","percent of total billed charges",""
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","outpatient","","","426.00","255.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","49.54","11.63","","48.54","48.54","48.54","1 through 10","49.54","329.72","percent of total billed charges",""
"CPR","PX-48000001","CDM","92950","CPT","0480","RC","","","","both","","","2228.00","1336.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","1555.14","69.8","","1500.70","1500.70","1500.70","1 through 10","318.83","2079.19","percent of total billed charges",""
"Cranial And Peripheral Nerve Disorders With McC","073","MS-DRG","","","","","","","","inpatient","","","72868.68","43721.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","24004.95","","Fee schedule rate ($24,004.95). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","22562.56","22562.56","22562.56","1 through 10","3975","60963.56","case rate",""
"Cranial And Peripheral Nerve Disorders With McC","073","MS-DRG","","","","","","","","inpatient","","","72868.68","43721.21","MARTIN'S POINT [160007]","HB WDH MEDICARE","12641.46","","Case rate ($12,641.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,702.19, add-ons for qualifying new technology services are included. If operating cost exceeds $15,620.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,696.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $11,305.33 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,257.32 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.26. The transfer capital threshold is the transfer adjustment factor * $891.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11912.61","11912.61","11912.61","1 through 10","3975","60963.56","other","Inpatient DRG"
"Cranial And Peripheral Nerve Disorders With McC","073","MS-DRG","","","","","","","","inpatient","","","72868.68","43721.21","MEDICARE [2001]","HB WDH MEDICARE","12641.46","","Case rate ($12,641.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,702.19, add-ons for qualifying new technology services are included. If operating cost exceeds $15,620.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,696.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $11,305.33 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,257.32 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.26. The transfer capital threshold is the transfer adjustment factor * $891.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","12137.59","1 through 10","3975","60963.56","other","Inpatient DRG"
"Cranial And Peripheral Nerve Disorders With McC","073","MS-DRG","","","","","","","","inpatient","","","72868.68","43721.21","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","12641.46","","Case rate ($12,641.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,702.19, add-ons for qualifying new technology services are included. If operating cost exceeds $15,620.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,696.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $11,305.33 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,257.32 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $891.26. The transfer capital threshold is the transfer adjustment factor * $891.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11874.60","9242.99","11894.84","1 through 10","3975","60963.56","other","Inpatient DRG"
"Cranial And Peripheral Nerve Disorders Without McC","074","MS-DRG","","","","","","","","inpatient","","","35202.87","21121.72","MEDICARE [2001]","HB WDH MEDICARE","8281.47","","Case rate ($8,281.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,677.96, add-ons for qualifying new technology services are included. If operating cost exceeds $11,596.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,377.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,263.94 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,233.09 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $572.65. The transfer capital threshold is the transfer adjustment factor * $572.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8330.77","0.05","8330.77","1 through 10","3975","39170.5","other","Inpatient DRG"
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","both","","","1948.21","1168.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","226.58","1655.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","both","","","1948.21","1168.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","226.58","1655.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","both","","","1948.21","1168.93","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1108.53","56.9","","812.12","238.65","1587.46","163","226.58","1655.98","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","both","","","1948.21","1168.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","226.58","11.63","","112.68","112.68","146.99","38","226.58","1655.98","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","both","","","1948.21","1168.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1507.91","77.4","","303.98","303.98","5854.79","1 through 10","226.58","1655.98","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1948.21","1168.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","226.58","11.63","","112.68","112.68","146.99","38","226.58","1507.91","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1948.21","1168.93","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1223.09","62.78","","780.86","208.94","10480.28","15","226.58","1507.91","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1948.21","1168.93","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","851.76","43.72","","179.76","179.76","179.76","1 through 10","226.58","1507.91","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1948.21","1168.93","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1416.74","72.72","","2355.45","298.99","3965.19","155","226.58","1507.91","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1948.21","1168.93","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1416.74","72.72","","3643.09","3643.09","3643.09","1 through 10","226.58","1507.91","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1948.21","1168.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1036.84","53.22","","554.28","554.28","554.28","16","226.58","1507.91","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1948.21","1168.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1225.42","62.9","","619.64","173.09","2370.64","150","226.58","1507.91","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 2XRIGHT 2.7 35MM 3 HOLE BONE LCP STAINLESS L SHAPE","SUP-ITM-10027823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1948.21","1168.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1507.91","77.4","","303.98","303.98","5854.79","1 through 10","226.58","1507.91","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3.5MMX85 3 HOLE HEAD OBLIQUE 6 SHAFT BONE LCP STAINLESS T SHAPE","SUP-ITM-10037945","CDM","C1713","HCPCS","0278","RC","","","","both","","","2053.03","1231.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","238.77","1745.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CRANIOMAXILLOFACIAL PLATE 3.5MMX85 3 HOLE HEAD OBLIQUE 6 SHAFT BONE LCP STAINLESS T SHAPE","SUP-ITM-10037945","CDM","C1713","HCPCS","0278","RC","","","","both","","","2053.03","1231.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","238.77","1745.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"CRANIOMAXILLOFACIAL PLATE 3.5MMX85 3 HOLE HEAD OBLIQUE 6 SHAFT BONE LCP STAINLESS T SHAPE","SUP-ITM-10037945","CDM","C1713","HCPCS","0278","RC","","","","both","","","2053.03","1231.82","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1168.17","56.9","","812.12","238.65","1587.46","163","238.77","1745.08","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3.5MMX85 3 HOLE HEAD OBLIQUE 6 SHAFT BONE LCP STAINLESS T SHAPE","SUP-ITM-10037945","CDM","C1713","HCPCS","0278","RC","","","","both","","","2053.03","1231.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","238.77","11.63","","112.68","112.68","146.99","38","238.77","1745.08","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3.5MMX85 3 HOLE HEAD OBLIQUE 6 SHAFT BONE LCP STAINLESS T SHAPE","SUP-ITM-10037945","CDM","C1713","HCPCS","0278","RC","","","","both","","","2053.03","1231.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1589.05","77.4","","303.98","303.98","5854.79","1 through 10","238.77","1745.08","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3.5MMX85 3 HOLE HEAD OBLIQUE 6 SHAFT BONE LCP STAINLESS T SHAPE","SUP-ITM-10037945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2053.03","1231.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","238.77","11.63","","112.68","112.68","146.99","38","238.77","1589.05","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3.5MMX85 3 HOLE HEAD OBLIQUE 6 SHAFT BONE LCP STAINLESS T SHAPE","SUP-ITM-10037945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2053.03","1231.82","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1288.89","62.78","","780.86","208.94","10480.28","15","238.77","1589.05","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3.5MMX85 3 HOLE HEAD OBLIQUE 6 SHAFT BONE LCP STAINLESS T SHAPE","SUP-ITM-10037945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2053.03","1231.82","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","897.58","43.72","","179.76","179.76","179.76","1 through 10","238.77","1589.05","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3.5MMX85 3 HOLE HEAD OBLIQUE 6 SHAFT BONE LCP STAINLESS T SHAPE","SUP-ITM-10037945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2053.03","1231.82","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1492.96","72.72","","2355.45","298.99","3965.19","155","238.77","1589.05","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3.5MMX85 3 HOLE HEAD OBLIQUE 6 SHAFT BONE LCP STAINLESS T SHAPE","SUP-ITM-10037945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2053.03","1231.82","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1492.96","72.72","","3643.09","3643.09","3643.09","1 through 10","238.77","1589.05","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3.5MMX85 3 HOLE HEAD OBLIQUE 6 SHAFT BONE LCP STAINLESS T SHAPE","SUP-ITM-10037945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2053.03","1231.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1092.62","53.22","","554.28","554.28","554.28","16","238.77","1589.05","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3.5MMX85 3 HOLE HEAD OBLIQUE 6 SHAFT BONE LCP STAINLESS T SHAPE","SUP-ITM-10037945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2053.03","1231.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1291.36","62.9","","619.64","173.09","2370.64","150","238.77","1589.05","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 3.5MMX85 3 HOLE HEAD OBLIQUE 6 SHAFT BONE LCP STAINLESS T SHAPE","SUP-ITM-10037945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2053.03","1231.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1589.05","77.4","","303.98","303.98","5854.79","1 through 10","238.77","1589.05","percent of total billed charges",""
"Craniotomy And Endovascular Intracranial Procedures Without Cc/McC","027","MS-DRG","","","","","","","","inpatient","","","54524.11","32714.47","MARTIN'S POINT [160007]","HB WDH MEDICARE","19625.05","","Case rate ($19,625.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $18,147.97, add-ons for qualifying new technology services are included. If operating cost exceeds $22,066.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,206.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $17,778.60 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,703.10 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,401.58. The transfer capital threshold is the transfer adjustment factor * $1,401.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Includes an additional $800 of payment.","24687.56","24687.56","24687.56","1 through 10","4637","95870.45","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Creatine Kinase (Cpk) Isoenzyme","PX-30000390","CDM","82552","CPT","0301","RC","","","","both","","","189.00","113.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","131.92","69.8","","127.73","127.73","127.73","1 through 10","8.7","160.65","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0300","RC","","","","inpatient","","","93.00","55.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","71.48","76.86","","56.70","54.23","56.70","1 through 10","61.57","71.48","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","both","","","93.00","55.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","64.91","69.8","","62.82","56.61","62.82","19","4.23","79.05","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","outpatient","","","93.00","55.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","40.66","43.72","","39.35","39.35","39.35","1 through 10","6.07","71.98","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","outpatient","","","93.00","55.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","67.63","72.72","","65.45","65.45","65.45","51","6.07","71.98","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","outpatient","","","93.00","55.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","67.63","72.72","","65.45","65.45","65.45","1 through 10","6.07","71.98","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","outpatient","","","93.00","55.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","49.49","53.22","","47.98","47.98","47.98","1 through 10","6.07","71.98","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","outpatient","","","93.00","55.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","58.50","62.9","","56.70","56.70","216.92","76","6.07","71.98","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","outpatient","","","93.00","55.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","71.98","77.4","","69.75","69.75","69.75","21","6.07","71.98","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","both","","","72.00","43.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","50.26","69.8","","48.86","44.03","48.86","57","3.33","61.2","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","both","","","72.00","43.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","61.20","85","","27.09","27.09","27.09","1 through 10","3.33","61.2","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","outpatient","","","72.00","43.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","45.20","62.78","","43.95","43.95","43.95","1 through 10","4.77","55.73","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","outpatient","","","72.00","43.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","31.48","43.72","","30.60","30.60","30.60","1 through 10","4.77","55.73","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","outpatient","","","72.00","43.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","52.36","72.72","","50.90","50.90","50.90","57","4.77","55.73","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","outpatient","","","72.00","43.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","38.32","53.22","","37.32","37.32","37.32","1 through 10","4.77","55.73","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","outpatient","","","72.00","43.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","45.29","62.9","","44.10","44.10","88.20","55","4.77","55.73","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","outpatient","","","72.00","43.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","55.73","77.4","","54.25","54.25","54.25","24","4.77","55.73","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","both","","","72.00","43.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","50.26","69.8","","48.86","44.03","48.86","57","3.33","61.2","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","both","","","72.00","43.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","61.20","85","","27.09","27.09","27.09","1 through 10","3.33","61.2","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","outpatient","","","72.00","43.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","45.20","62.78","","43.95","43.95","43.95","1 through 10","4.77","55.73","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","outpatient","","","72.00","43.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","31.48","43.72","","30.60","30.60","30.60","1 through 10","4.77","55.73","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","outpatient","","","72.00","43.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","52.36","72.72","","50.90","50.90","50.90","57","4.77","55.73","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","outpatient","","","72.00","43.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","38.32","53.22","","37.32","37.32","37.32","1 through 10","4.77","55.73","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","outpatient","","","72.00","43.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","45.29","62.9","","44.10","44.10","88.20","55","4.77","55.73","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","outpatient","","","72.00","43.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","55.73","77.4","","54.25","54.25","54.25","24","4.77","55.73","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0300","RC","","","","inpatient","","","73.00","43.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","56.11","76.86","","42.88","42.88","42.88","1 through 10","48.33","56.11","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","73.00","43.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","50.95","69.8","","49.56","44.66","49.56","178","3.37","62.05","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","73.00","43.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","62.05","85","","9.86","4.66","12.59","1 through 10","3.37","62.05","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","outpatient","","","73.00","43.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","45.83","62.78","","44.57","44.57","44.57","1 through 10","4.82","56.5","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","outpatient","","","73.00","43.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","31.92","43.72","","31.04","31.04","31.04","19","4.82","56.5","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","outpatient","","","73.00","43.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","53.09","72.72","","51.63","51.63","103.26","267","4.82","56.5","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","outpatient","","","73.00","43.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","53.09","72.72","","51.63","51.63","51.63","1 through 10","4.82","56.5","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","outpatient","","","73.00","43.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","38.85","53.22","","37.85","37.85","37.85","23","4.82","56.5","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","outpatient","","","73.00","43.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","45.92","62.9","","44.73","44.73","44.73","302","4.82","56.5","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","outpatient","","","73.00","43.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","56.50","77.4","","55.03","55.03","55.03","126","4.82","56.5","percent of total billed charges",""
"Critical Care; Ea Add 30 Minutes","PX-45000007","CDM","99292","CPT","0450","RC","","","","both","","","2082.00","1249.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","1453.24","69.8","","1321.31","1321.31","1321.31","1 through 10","1184.66","1769.7","percent of total billed charges",""
"Critical Care; Ea Add 30 Minutes","PX-45000007","CDM","99292","CPT","0450","RC","","","","both","","","2082.00","1249.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1184.66","56.9","","1077.12","1046.24","1077.12","1 through 10","1184.66","1769.7","percent of total billed charges",""
"Critical Care; Ea Add 30 Minutes","PX-45000007","CDM","99292","CPT","0450","RC","","","","outpatient","","","2082.00","1249.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","242.14","11.63","","260.67","260.67","478.08","1 through 10","242.14","1611.47","percent of total billed charges",""
"Critical Care; Ea Add 30 Minutes","PX-45000007","CDM","99292","CPT","0450","RC","","","","outpatient","","","2082.00","1249.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1611.47","77.4","","1467.08","1467.08","1467.08","1 through 10","242.14","1611.47","percent of total billed charges",""
"Critical Care; Ea Add 30 Minutes","PX-45000007","CDM","99292","CPT","0450","RC","","","","outpatient","","","2082.00","1249.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","242.14","11.63","","223.59","223.59","223.59","1 through 10","242.14","1611.47","percent of total billed charges",""
"Crossmatch Immediate Spin","PX-30000084","CDM","86920","CPT","0302","RC","","","","both","","","378.00","226.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","175.45","","APC Price ($179.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","391.86","26.86","391.86","1 through 10","155.02","1144.2","other","OPPS APC"
"Crossmatch Immediate Spin","PX-30000084","CDM","86920","CPT","0302","RC","","","","outpatient","","","378.00","226.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","165.26","43.72","","159.58","159.58","159.58","1 through 10","6.94","292.57","percent of total billed charges",""
"Cryoglobulin Ql or Sqn","PX-30000398","CDM","82595","CPT","0301","RC","","","","outpatient","","","34.00","20.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","24.72","72.72","","24.00","24.00","24.00","1 through 10","6.03","26.32","percent of total billed charges",""
"Cryoglobulin Ql or Sqn","PX-30000398","CDM","82595","CPT","0301","RC","","","","outpatient","","","34.00","20.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","26.32","77.4","","25.58","25.58","25.58","1 through 10","6.03","26.32","percent of total billed charges",""
"Crystal ID Light Microscopy","PX-30000113","CDM","89060","CPT","0300","RC","","","","both","","","108.00","64.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","75.38","69.8","","72.59","65.42","72.59","1 through 10","4.76","91.8","percent of total billed charges",""
"Crystal ID Light Microscopy","PX-30000113","CDM","89060","CPT","0300","RC","","","","outpatient","","","108.00","64.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","67.80","62.78","","65.29","65.29","65.29","1 through 10","8.56","83.59","percent of total billed charges",""
"Crystal ID Light Microscopy","PX-30000113","CDM","89060","CPT","0300","RC","","","","outpatient","","","108.00","64.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","78.54","72.72","","75.63","75.63","75.63","1 through 10","8.56","83.59","percent of total billed charges",""
"Crystal ID Light Microscopy","PX-30000113","CDM","89060","CPT","0300","RC","","","","outpatient","","","108.00","64.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","67.93","62.9","","65.52","65.52","65.52","1 through 10","8.56","83.59","percent of total billed charges",""
"Crystal ID Light Microscopy","PX-30000113","CDM","89060","CPT","0300","RC","","","","outpatient","","","108.00","64.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","83.59","77.4","","80.60","80.60","80.60","1 through 10","8.56","83.59","percent of total billed charges",""
"Crystal ID Light Microscopy","PX-30000113","CDM","89060","CPT","0300","RC","","","","outpatient","","","108.00","64.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","78.54","72.72","","75.63","75.63","75.63","1 through 10","8.56","83.59","percent of total billed charges",""
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","9982.00","5989.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2384.56","","Case rate ($2,384.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2326.40","2326.40","2326.40","1 through 10","365.65","8484.7","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","9982.00","5989.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1026.79","","Case rate ($1,026.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1048.83","1001.76","1048.83","1 through 10","365.65","8484.7","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","9982.00","5989.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","365.65","","APC Price ($373.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","367.19","365.70","373.16","1 through 10","365.65","8484.7","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","9982.00","5989.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1927.41","","Case rate ($1,927.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1880.39","1001.76","1880.39","1 through 10","365.65","8484.7","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","9982.00","5989.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5679.76","56.9","","5480.61","5480.61","5480.61","1 through 10","365.65","8484.7","percent of total billed charges",""
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","9982.00","5989.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","384.31","","APC Price ($373.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","384.35","376.66","384.35","1 through 10","365.65","8484.7","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","9982.00","5989.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","373.12","","APC Price ($373.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","367.19","365.70","373.16","13","365.65","8484.7","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","9982.00","5989.20","MEDICARE [2001]","HB WDH MEDICARE","373.12","","APC Price ($373.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","373.16","373.16","1 through 10","365.65","8484.7","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","9982.00","5989.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","373.12","","APC Price ($373.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","367.22","365.70","368.70","1 through 10","365.65","8484.7","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","9982.00","5989.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1439.40","14.42","","1388.93","1190.52","1388.93","1 through 10","1160.91","7726.07","percent of total billed charges",""
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","9982.00","5989.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1160.91","11.63","","1326.33","1178.96","1326.33","1 through 10","1160.91","7726.07","percent of total billed charges",""
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","9982.00","5989.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","7004.39","7004.39","7004.39","1 through 10","1160.91","7726.07","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","9982.00","5989.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","7004.39","7004.39","7004.39","1 through 10","1160.91","7726.07","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","9982.00","5989.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6278.68","62.9","","6068.16","6068.16","6068.16","1 through 10","1160.91","7726.07","percent of total billed charges",""
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","9982.00","5989.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7726.07","77.4","","7464.80","7464.80","7464.80","1 through 10","1160.91","7726.07","percent of total billed charges",""
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","9982.00","5989.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1160.91","11.63","","3413.10","1137.70","3413.10","1 through 10","1160.91","7726.07","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","7687.00","4612.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1613.96","","Case rate ($1,613.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1574.60","1551.94","1574.60","1 through 10","247.49","6533.95","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","7687.00","4612.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","694.97","","Case rate ($694.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","678.03","668.27","678.03","1 through 10","247.49","6533.95","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","7687.00","4612.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","247.49","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","252.57","247.52","252.57","26","247.49","6533.95","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","7687.00","4612.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1304.55","","Case rate ($1,304.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1272.72","1254.41","7418.00","1 through 10","247.49","6533.95","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","7687.00","4612.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4373.90","56.9","","4220.84","328.17","12662.52","15","247.49","6533.95","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","7687.00","4612.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","260.12","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","260.15","254.95","260.15","1 through 10","247.49","6533.95","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","7687.00","4612.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","248.53","248.53","252.57","20","247.49","6533.95","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","7687.00","4612.20","MEDICARE [2001]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","21","247.49","6533.95","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","7687.00","4612.20","TRICARE [160005]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","1 through 10","247.49","6533.95","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","7687.00","4612.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.52","247.52","252.57","34","247.49","6533.95","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","7687.00","4612.20","WELLSENSE NH [1050]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","262.22","261.50","262.22","1 through 10","247.49","6533.95","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","7687.00","4612.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1108.47","14.42","","1069.68","916.86","1069.68","1 through 10","894","5949.74","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","7687.00","4612.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","894.00","11.63","","1021.46","876.18","1873.42","20","894","5949.74","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","7687.00","4612.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4825.90","62.78","","13971.06","4657.02","13971.06","1 through 10","894","5949.74","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","7687.00","4612.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3360.76","43.72","","3243.15","3243.15","3243.15","1 through 10","894","5949.74","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","7687.00","4612.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5589.99","72.72","","5394.37","5394.37","5394.37","17","894","5949.74","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","7687.00","4612.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5589.99","72.72","","5394.37","5394.37","5394.37","1 through 10","894","5949.74","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","7687.00","4612.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4835.12","62.9","","4673.34","4673.34","4673.34","14","894","5949.74","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","7687.00","4612.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5949.74","77.4","","5748.95","5394.37","5748.95","1 through 10","894","5949.74","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","7687.00","4612.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","5589.99","72.72","","5394.37","5394.37","5394.37","1 through 10","894","5949.74","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","7687.00","4612.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","894.00","11.63","","876.18","876.18","876.18","1 through 10","894","5949.74","percent of total billed charges",""
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","9042.00","5425.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2384.56","","Case rate ($2,384.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2326.40","2326.40","2326.40","1 through 10","365.65","7685.7","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","9042.00","5425.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1026.79","","Case rate ($1,026.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1001.76","1001.76","1048.83","1 through 10","365.65","7685.7","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","9042.00","5425.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","365.65","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","373.16","365.70","634.37","1 through 10","365.65","7685.7","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","9042.00","5425.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1927.41","","Case rate ($1,927.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1880.39","1880.39","1880.39","1 through 10","365.65","7685.7","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","9042.00","5425.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5144.90","56.9","","4964.53","4964.53","4964.53","1 through 10","365.65","7685.7","percent of total billed charges",""
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","9042.00","5425.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1303.86","14.42","","1078.41","1078.41","1078.41","1 through 10","365.65","7685.7","percent of total billed charges",""
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","9042.00","5425.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","384.31","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","384.35","380.26","384.35","1 through 10","365.65","7685.7","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","9042.00","5425.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","367.19","367.19","373.16","22","365.65","7685.7","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","9042.00","5425.20","MEDICARE [2001]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","373.16","373.16","14","365.65","7685.7","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","9042.00","5425.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5687.42","62.9","","5496.75","5496.75","5496.75","1 through 10","365.65","7685.7","percent of total billed charges",""
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","9042.00","5425.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","7685.70","85","","6090.05","6090.05","6090.05","1 through 10","365.65","7685.7","percent of total billed charges",""
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","9042.00","5425.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","368.72","365.70","373.16","30","365.65","7685.7","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","9042.00","5425.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6998.51","77.4","","6396.81","6396.81","6396.81","1 through 10","365.65","7685.7","percent of total billed charges",""
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","9042.00","5425.20","WELLSENSE NH [1050]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","385.58","385.58","385.58","1 through 10","365.65","7685.7","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","outpatient","","","9042.00","5425.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1051.58","11.63","","1201.43","1030.57","2203.53","1 through 10","1051.58","6575.34","percent of total billed charges",""
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","outpatient","","","9042.00","5425.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5676.57","62.78","","5477.56","5477.56","5477.56","1 through 10","1051.58","6575.34","percent of total billed charges",""
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","outpatient","","","9042.00","5425.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6575.34","72.72","","6344.82","6344.82","6344.82","1 through 10","1051.58","6575.34","percent of total billed charges",""
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","outpatient","","","9042.00","5425.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6575.34","72.72","","6344.82","6344.82","6344.82","1 through 10","1051.58","6575.34","percent of total billed charges",""
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","outpatient","","","9042.00","5425.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1051.58","11.63","","1030.57","597.06","1030.57","1 through 10","1051.58","6575.34","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0350","RC","","","","inpatient","","","7913.00","4747.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6081.93","76.86","","4810.68","4619.15","4810.68","1 through 10","5238.41","6081.93","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","7913.00","4747.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","5329.93","748.17","5329.93","1 through 10","365.65","6726.05","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","7913.00","4747.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2384.56","","Case rate ($2,384.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2326.40","2326.40","2435.72","25","365.65","6726.05","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","7913.00","4747.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1026.79","","Case rate ($1,026.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1001.76","1001.76","1048.83","66","365.65","6726.05","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","7913.00","4747.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","365.65","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","373.16","365.70","374.71","65","365.65","6726.05","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","7913.00","4747.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1927.41","","Case rate ($1,927.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1880.39","1880.38","7636.00","33","365.65","6726.05","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","7913.00","4747.80","CHAMPVA [160001]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","373.16","373.16","1 through 10","365.65","6726.05","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","7913.00","4747.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4502.50","56.9","","4344.88","4312.06","11980.88","142","365.65","6726.05","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","7913.00","4747.80","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","4502.50","56.9","","15887.61","15887.61","15887.61","1 through 10","365.65","6726.05","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","7913.00","4747.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","5329.93","5329.93","5329.93","1 through 10","365.65","6726.05","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","7913.00","4747.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","384.31","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","383.16","376.66","384.35","28","365.65","6726.05","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","7913.00","4747.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","367.19","367.19","373.16","78","365.65","6726.05","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","7913.00","4747.80","MEDICARE [2001]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","373.16","374.71","112","365.65","6726.05","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","7913.00","4747.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","6726.05","85","","6490.60","4167.93","6490.60","1 through 10","365.65","6726.05","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","7913.00","4747.80","TRICARE [160005]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","373.16","373.16","11","365.65","6726.05","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","7913.00","4747.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.40","365.70","373.16","94","365.65","6726.05","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","7913.00","4747.80","WELLSENSE NH [1050]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","385.58","385.58","771.16","1 through 10","365.65","6726.05","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","7913.00","4747.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1141.05","14.42","","1101.11","943.81","1101.11","65","920.28","6124.66","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","7913.00","4747.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","920.28","11.63","","1051.48","901.94","1928.49","92","920.28","6124.66","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","7913.00","4747.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4967.78","62.78","","4793.88","4793.88","4793.88","1 through 10","920.28","6124.66","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","7913.00","4747.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3459.56","43.72","","3338.46","3338.46","10015.38","1 through 10","920.28","6124.66","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","7913.00","4747.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5754.33","72.72","","5552.90","5552.90","172139.90","114","920.28","6124.66","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","7913.00","4747.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4211.30","53.22","","4070.75","4070.75","4070.75","1 through 10","920.28","6124.66","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","7913.00","4747.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4977.28","62.9","","4810.68","4810.68","18476.60","105","920.28","6124.66","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","7913.00","4747.80","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","5754.33","72.72","","5552.90","5552.90","5552.90","1 through 10","920.28","6124.66","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","7913.00","4747.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6124.66","77.4","","5917.90","5917.90","5917.90","33","920.28","6124.66","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","7913.00","4747.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","5754.33","72.72","","5552.90","5552.90","5552.90","1 through 10","920.28","6124.66","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","7913.00","4747.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","920.28","11.63","","901.94","901.94","901.94","54","920.28","6124.66","percent of total billed charges",""
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","6971.00","4182.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1188.62","","Case rate ($1,188.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1159.63","1159.63","1163.69","1 through 10","182.27","5925.35","other","OPPS APC"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","6971.00","4182.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","511.82","","Case rate ($511.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","499.34","499.34","499.34","1 through 10","182.27","5925.35","other","OPPS APC"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","6971.00","4182.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","182.27","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.29","179.02","186.01","1 through 10","182.27","5925.35","other","OPPS APC"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","6971.00","4182.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","960.75","","Case rate ($960.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","940.60","940.60","940.60","1 through 10","182.27","5925.35","other","OPPS APC"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","6971.00","4182.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3966.50","56.9","","3827.66","3827.66","3827.66","1 through 10","182.27","5925.35","percent of total billed charges",""
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","6971.00","4182.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","191.57","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","191.59","191.36","191.59","1 through 10","182.27","5925.35","other","OPPS APC"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","6971.00","4182.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","183.03","183.03","186.01","1 through 10","182.27","5925.35","other","OPPS APC"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","6971.00","4182.60","MEDICARE [2001]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","186.01","186.01","22","182.27","5925.35","other","OPPS APC"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","6971.00","4182.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.29","178.94","186.01","1 through 10","182.27","5925.35","other","OPPS APC"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","6971.00","4182.60","WELLSENSE NH [1050]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","193.00","192.18","193.00","1 through 10","182.27","5925.35","other","OPPS APC"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","outpatient","","","6971.00","4182.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1005.22","14.42","","970.03","970.03","970.03","1 through 10","810.73","5395.55","percent of total billed charges",""
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","outpatient","","","6971.00","4182.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","4891.87","4891.87","4891.87","1 through 10","810.73","5395.55","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","outpatient","","","6971.00","4182.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4384.76","62.9","","4238.01","4238.01","4238.01","1 through 10","810.73","5395.55","percent of total billed charges",""
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","outpatient","","","6971.00","4182.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5395.55","77.4","","5213.43","5213.43","5213.43","1 through 10","810.73","5395.55","percent of total billed charges",""
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","outpatient","","","6971.00","4182.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","810.73","11.63","","794.57","794.57","794.57","1 through 10","810.73","5395.55","percent of total billed charges",""
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","6081.00","3648.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1188.62","","Case rate ($1,188.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1159.63","1159.63","1163.69","1 through 10","182.27","5168.85","other","OPPS APC"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","6081.00","3648.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","511.82","","Case rate ($511.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","499.34","499.34","501.09","1 through 10","182.27","5168.85","other","OPPS APC"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","6081.00","3648.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","182.27","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","179.02","179.02","179.02","1 through 10","182.27","5168.85","other","OPPS APC"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","6081.00","3648.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","960.75","","Case rate ($960.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","937.31","937.31","937.31","1 through 10","182.27","5168.85","other","OPPS APC"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","6081.00","3648.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3460.09","56.9","","3338.89","3338.89","3338.89","1 through 10","182.27","5168.85","percent of total billed charges",""
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","6081.00","3648.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","191.57","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","191.59","191.59","191.59","1 through 10","182.27","5168.85","other","OPPS APC"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","6081.00","3648.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","183.03","179.02","186.01","1 through 10","182.27","5168.85","other","OPPS APC"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","6081.00","3648.60","MEDICARE [2001]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","186.01","186.01","1 through 10","182.27","5168.85","other","OPPS APC"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","6081.00","3648.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.99","183.49","186.01","1 through 10","182.27","5168.85","other","OPPS APC"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","outpatient","","","6081.00","3648.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","876.88","14.42","","846.17","846.17","846.17","1 through 10","707.22","4706.69","percent of total billed charges",""
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","outpatient","","","6081.00","3648.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","707.22","11.63","","1481.97","808.02","1481.97","1 through 10","707.22","4706.69","percent of total billed charges",""
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","outpatient","","","6081.00","3648.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","2565.49","2565.49","2565.49","1 through 10","707.22","4706.69","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","outpatient","","","6081.00","3648.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","4267.21","4267.21","4267.21","1 through 10","707.22","4706.69","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","outpatient","","","6081.00","3648.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3824.95","62.9","","3696.84","3696.84","3696.84","1 through 10","707.22","4706.69","percent of total billed charges",""
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","outpatient","","","6081.00","3648.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4706.69","77.4","","4547.70","4547.70","4547.70","1 through 10","707.22","4706.69","percent of total billed charges",""
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","outpatient","","","6081.00","3648.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","707.22","11.63","","693.10","693.10","693.10","1 through 10","707.22","4706.69","percent of total billed charges",""
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","3121.00","1872.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","2102.38","2102.38","2102.38","1 through 10","108.88","2652.85","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","3121.00","1872.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","696.33","696.33","696.33","1 through 10","108.88","2652.85","other","OPPS APC"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","3121.00","1872.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","298.29","1 through 10","108.88","2652.85","other","OPPS APC"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","3121.00","1872.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","111.11","111.11","111.11","1 through 10","108.88","2652.85","other","OPPS APC"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","3121.00","1872.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","559.93","559.93","1 through 10","108.88","2652.85","other","OPPS APC"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","3121.00","1872.60","HARVARD PILGRIM [120001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.98","104.98","104.98","1 through 10","108.88","2652.85","other","OPPS APC"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","3121.00","1872.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","109.33","111.11","1 through 10","108.88","2652.85","other","OPPS APC"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","3121.00","1872.60","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","2652.85","other","OPPS APC"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","3121.00","1872.60","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","34.74","34.74","34.74","1 through 10","108.88","2652.85","other","OPPS APC"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","3121.00","1872.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","109.34","111.11","1 through 10","108.88","2652.85","other","OPPS APC"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","3121.00","1872.60","WELLSENSE NH [1050]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","114.80","114.80","114.80","1 through 10","108.88","2652.85","other","OPPS APC"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","outpatient","","","3121.00","1872.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","362.97","11.63","","355.77","355.77","355.77","1 through 10","362.97","2415.65","percent of total billed charges",""
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","outpatient","","","3121.00","1872.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","2190.33","2190.33","2190.33","1 through 10","362.97","2415.65","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","outpatient","","","3121.00","1872.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","362.97","11.63","","175.29","175.29","175.29","1 through 10","362.97","2415.65","percent of total billed charges",""
"CT C-Spine W/Contrast","PX-35000035","CDM","72126","CPT","0352","RC","","","","outpatient","","","5770.00","3462.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3629.33","62.9","","3507.84","3507.84","3507.84","1 through 10","671.05","4465.98","percent of total billed charges",""
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","4533.00","2719.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","349.03","349.03","349.03","1 through 10","108.88","3853.05","other","OPPS APC"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","4533.00","2719.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","230.88","107.12","412.59","1 through 10","108.88","3853.05","other","OPPS APC"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","4533.00","2719.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2579.28","56.9","","2488.81","2488.81","11746.49","1 through 10","108.88","3853.05","percent of total billed charges",""
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","4533.00","2719.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","3053.05","3053.05","3053.05","1 through 10","108.88","3853.05","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","4533.00","2719.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","109.33","111.11","1 through 10","108.88","3853.05","other","OPPS APC"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","4533.00","2719.80","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","234.63","111.11","234.63","1 through 10","108.88","3853.05","other","OPPS APC"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","4533.00","2719.80","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","3853.05","other","OPPS APC"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","4533.00","2719.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.34","109.34","111.11","1 through 10","108.88","3853.05","other","OPPS APC"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","outpatient","","","4533.00","2719.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","653.66","14.42","","630.73","540.63","630.73","1 through 10","527.19","3508.54","percent of total billed charges",""
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","outpatient","","","4533.00","2719.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","527.19","11.63","","602.30","516.64","1549.92","1 through 10","527.19","3508.54","percent of total billed charges",""
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","outpatient","","","4533.00","2719.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","","","Payment is accumulated by procedure count. Procedure 1, 62.78% of billed. Procedures 2 - 9999, 31.39% of billed.","4119.00","4119.00","4119.00","1 through 10","527.19","3508.54","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","outpatient","","","4533.00","2719.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3180.77","1590.38","4529.00","1 through 10","527.19","3508.54","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","outpatient","","","4533.00","2719.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2851.26","62.9","","2755.62","2646.00","8266.86","1 through 10","527.19","3508.54","percent of total billed charges",""
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","outpatient","","","4533.00","2719.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3508.54","77.4","","3389.85","3389.85","3389.85","1 through 10","527.19","3508.54","percent of total billed charges",""
"CT Colonography Screen Postprocess","PX-35000003","CDM","74263","CPT","0350","RC","","","","both","","","10532.00","6319.20","MEDICARE [2001]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","1 through 10","247.49","8952.2","other","OPPS APC"
"CT Colonography W/O Cntrst","PX-35000001","CDM","74261","CPT","0350","RC","","","","both","","","12582.00","7549.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","111.11","108.89","111.11","1 through 10","108.88","10694.7","other","OPPS APC"
"CT Colonography W/O Cntrst","PX-35000001","CDM","74261","CPT","0350","RC","","","","both","","","12582.00","7549.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7159.16","56.9","","6908.23","6908.23","6908.23","1 through 10","108.88","10694.7","percent of total billed charges",""
"CT Colonography W/O Cntrst","PX-35000001","CDM","74261","CPT","0350","RC","","","","both","","","12582.00","7549.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.33","108.89","111.11","1 through 10","108.88","10694.7","other","OPPS APC"
"CT Colonography W/O Cntrst","PX-35000001","CDM","74261","CPT","0350","RC","","","","both","","","12582.00","7549.20","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","107.12","111.11","1 through 10","108.88","10694.7","other","OPPS APC"
"CT Colonography W/O Cntrst","PX-35000001","CDM","74261","CPT","0350","RC","","","","outpatient","","","12582.00","7549.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1463.29","11.63","","1434.05","1434.05","1434.05","1 through 10","1463.29","9738.47","percent of total billed charges",""
"CT Colonography W/O Cntrst|REDUCED SERVICES","PX-35000001","CDM","74261","CPT","0350","RC","","","52","both","","","12582.00","7549.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","55.56","55.56","55.56","1 through 10","108.88","114.43","other","OPPS APC"
"CT Follow Up/Ltd","PX-35000004","CDM","76380","CPT","0350","RC","","","","both","","","3332.00","1999.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","475.18","","Case rate ($475.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","465.18","465.18","465.18","1 through 10","90.15","2832.2","other","OPPS APC"
"CT Guided Needle Placement","PX-35000084","CDM","77012","CPT","0352","RC","","","","both","","","1355.00","813.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","771.00","56.9","","1798.54","744.25","1798.54","1 through 10","771","1151.75","percent of total billed charges",""
"CT Guided Needle Placement","PX-35000084","CDM","77012","CPT","0352","RC","","","","outpatient","","","1355.00","813.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","195.39","14.42","","188.61","188.61","188.61","1 through 10","157.59","1048.77","percent of total billed charges",""
"CT Guided Needle Placement","PX-35000084","CDM","77012","CPT","0352","RC","","","","outpatient","","","1355.00","813.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","157.59","11.63","","180.11","180.11","180.11","1 through 10","157.59","1048.77","percent of total billed charges",""
"CT Guided Needle Placement","PX-35000084","CDM","77012","CPT","0352","RC","","","","outpatient","","","1355.00","813.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","985.36","72.72","","951.18","951.18","951.18","1 through 10","157.59","1048.77","percent of total billed charges",""
"CT Guided Needle Placement","PX-35000084","CDM","77012","CPT","0352","RC","","","","outpatient","","","1355.00","813.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","852.30","62.9","","1499.56","824.04","1499.56","1 through 10","157.59","1048.77","percent of total billed charges",""
"CT Guided Needle Placement","PX-35000084","CDM","77012","CPT","0352","RC","","","","outpatient","","","1355.00","813.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1048.77","77.4","","1013.70","1013.70","1013.70","1 through 10","157.59","1048.77","percent of total billed charges",""
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","both","","","4433.00","2659.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1188.62","","Case rate ($1,188.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1159.63","1159.63","1159.63","1 through 10","182.27","3768.05","other","OPPS APC"
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","both","","","4433.00","2659.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","182.27","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.29","182.29","182.29","1 through 10","182.27","3768.05","other","OPPS APC"
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","both","","","4433.00","2659.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2522.38","56.9","","3312.57","3312.57","3312.57","1 through 10","182.27","3768.05","percent of total billed charges",""
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","both","","","4433.00","2659.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","454.65","445.56","454.65","1 through 10","182.27","3768.05","other","OPPS APC"
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","both","","","4433.00","2659.80","MEDICARE [2001]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","454.65","186.01","454.65","1 through 10","182.27","3768.05","other","OPPS APC"
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","both","","","4433.00","2659.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","182.49","449.26","1 through 10","182.27","3768.05","other","OPPS APC"
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","both","","","4433.00","2659.80","WELLSENSE NH [1050]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","192.18","192.18","192.18","1 through 10","182.27","3768.05","other","OPPS APC"
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","outpatient","","","4433.00","2659.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","639.24","14.42","","616.89","616.89","616.89","1 through 10","515.56","3431.14","percent of total billed charges",""
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","outpatient","","","4433.00","2659.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2788.36","62.9","","2695.14","2695.14","2695.14","1 through 10","515.56","3431.14","percent of total billed charges",""
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","outpatient","","","4433.00","2659.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","515.56","11.63","","505.30","505.30","505.30","1 through 10","515.56","3431.14","percent of total billed charges",""
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","3843.00","2305.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","279.45","696.33","1 through 10","108.88","3266.55","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","3843.00","2305.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","299.84","1 through 10","108.88","3266.55","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","3843.00","2305.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","111.11","108.89","437.27","26","108.88","3266.55","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","3843.00","2305.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","562.84","559.93","1182.34","1 through 10","108.88","3266.55","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","3843.00","2305.80","CHAMPVA [160001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","107.12","107.12","107.12","1 through 10","108.88","3266.55","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","3843.00","2305.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2186.67","56.9","","2109.85","420.03","5817.85","27","108.88","3266.55","percent of total billed charges",""
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","3843.00","2305.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","5176.37","2588.18","5176.37","1 through 10","108.88","3266.55","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","3843.00","2305.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","114.44","112.15","236.84","12","108.88","3266.55","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","3843.00","2305.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.33","109.33","234.63","26","108.88","3266.55","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","3843.00","2305.80","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","234.63","32","108.88","3266.55","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","3843.00","2305.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","108.89","445.56","47","108.88","3266.55","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","3843.00","2305.80","WELLSENSE NH [1050]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","115.94","114.80","347.82","1 through 10","108.88","3266.55","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","3843.00","2305.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","554.16","14.42","","534.69","458.31","534.69","1 through 10","446.94","2974.48","percent of total billed charges",""
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","3843.00","2305.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","446.94","11.63","","936.46","453.86","1313.94","27","446.94","2974.48","percent of total billed charges",""
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","3843.00","2305.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","","","Payment is accumulated by procedure count. Procedure 1, 62.78% of billed. Procedures 2 - 9999, 31.39% of billed.","6983.64","1163.94","6983.64","1 through 10","446.94","2974.48","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","3843.00","2305.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","4863.42","4863.42","4863.42","1 through 10","446.94","2974.48","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","3843.00","2305.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","2696.46","1348.23","2696.46","12","446.94","2974.48","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","3843.00","2305.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","2696.46","2696.46","2696.46","1 through 10","446.94","2974.48","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","3843.00","2305.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2417.25","62.9","","2336.04","2336.04","8972.16","22","446.94","2974.48","percent of total billed charges",""
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","3843.00","2305.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2974.48","77.4","","2873.70","2873.70","2873.75","1 through 10","446.94","2974.48","percent of total billed charges",""
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","3843.00","2305.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","446.94","11.63","","437.98","437.98","1313.94","18","446.94","2974.48","percent of total billed charges",""
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","6254.00","3752.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2384.56","","Case rate ($2,384.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2326.40","2326.40","2326.40","1 through 10","365.65","5315.9","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","6254.00","3752.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","384.31","","APC Price ($373.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","383.79","383.79","383.79","1 through 10","365.65","5315.9","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","6254.00","3752.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","373.12","","APC Price ($373.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","367.19","367.19","373.16","1 through 10","365.65","5315.9","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","6254.00","3752.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","373.12","","APC Price ($373.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","371.07","368.70","373.16","1 through 10","365.65","5315.9","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","6254.00","3752.40","WELLSENSE NH [1050]","HB WDH MEDICARE","373.12","","APC Price ($373.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","385.58","385.58","385.58","1 through 10","365.65","5315.9","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","outpatient","","","6254.00","3752.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3933.77","62.9","","3802.05","3802.05","3802.05","1 through 10","727.34","4840.6","percent of total billed charges",""
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","outpatient","","","6254.00","3752.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4840.60","77.4","","4677.13","4677.13","4677.13","1 through 10","727.34","4840.6","percent of total billed charges",""
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","both","","","2600.00","1560.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","92.00","92.00","92.00","1 through 10","90.15","2210","other","OPPS APC"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","both","","","2600.00","1560.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","92.00","92.00","92.00","1 through 10","90.15","2210","other","OPPS APC"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","outpatient","","","2600.00","1560.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1635.40","62.9","","1580.67","1580.67","1580.67","1 through 10","302.38","2012.4","percent of total billed charges",""
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","4497.00","2698.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","692.73","692.73","1 through 10","108.88","3822.45","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","4497.00","2698.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","298.29","1 through 10","108.88","3822.45","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","4497.00","2698.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","111.11","108.89","409.28","1 through 10","108.88","3822.45","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","4497.00","2698.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2558.79","56.9","","2568.85","2568.85","2568.85","1 through 10","108.88","3822.45","percent of total billed charges",""
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","4497.00","2698.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","114.44","114.44","241.67","1 through 10","108.88","3822.45","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","4497.00","2698.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.33","105.41","111.11","1 through 10","108.88","3822.45","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","4497.00","2698.20","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","454.65","1 through 10","108.88","3822.45","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","4497.00","2698.20","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","3822.45","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","4497.00","2698.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","3822.45","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","4497.00","2698.20","WELLSENSE NH [1050]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","115.94","115.94","115.94","1 through 10","108.88","3822.45","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","outpatient","","","4497.00","2698.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","523.00","11.63","","512.51","512.51","512.51","1 through 10","523","3480.68","percent of total billed charges",""
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","outpatient","","","4497.00","2698.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","1577.66","1577.66","1577.66","1 through 10","523","3480.68","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","outpatient","","","4497.00","2698.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3155.32","3155.32","3155.32","1 through 10","523","3480.68","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","outpatient","","","4497.00","2698.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","523.00","11.63","","512.51","512.51","512.51","1 through 10","523","3480.68","percent of total billed charges",""
"CT Lwr Ext W/Contrast","PX-35000064","CDM","73701","CPT","0352","RC","","","","both","","","5821.00","3492.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","186.01","186.01","1 through 10","182.27","4947.85","other","OPPS APC"
"CT Lwr Ext W/O Contrast","PX-35000061","CDM","73700","CPT","0352","RC","","","","both","","","4497.00","2698.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","107.12","111.11","28","108.88","3822.45","other","OPPS APC"
"CT Lwr Ext W/O Contrast","PX-35000061","CDM","73700","CPT","0352","RC","","","","outpatient","","","4497.00","2698.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3155.32","3155.32","3155.32","1 through 10","523","3480.68","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","both","","","3853.00","2311.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","182.27","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","186.01","186.01","186.01","1 through 10","182.27","3275.05","other","OPPS APC"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","both","","","3853.00","2311.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2192.36","56.9","","2115.54","2115.54","2115.54","1 through 10","182.27","3275.05","percent of total billed charges",""
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","both","","","3853.00","2311.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","183.03","183.03","183.03","1 through 10","182.27","3275.05","other","OPPS APC"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","both","","","3853.00","2311.80","MEDICARE [2001]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","186.01","186.01","1 through 10","182.27","3275.05","other","OPPS APC"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","both","","","3853.00","2311.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.29","182.29","182.29","1 through 10","182.27","3275.05","other","OPPS APC"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","outpatient","","","3853.00","2311.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","448.10","11.63","","455.08","455.08","455.08","1 through 10","448.1","2982.22","percent of total billed charges",""
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","outpatient","","","3853.00","2311.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2423.54","62.9","","2342.34","2342.34","2342.34","1 through 10","448.1","2982.22","percent of total billed charges",""
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","outpatient","","","3853.00","2311.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","448.10","11.63","","439.15","439.15","439.15","1 through 10","448.1","2982.22","percent of total billed charges",""
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","3344.00","2006.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","2252.45","2252.45","2252.45","1 through 10","108.88","2842.4","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","3344.00","2006.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","696.33","692.73","696.33","1 through 10","108.88","2842.4","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","3344.00","2006.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","298.29","17","108.88","2842.4","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","3344.00","2006.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","109.33","107.12","111.11","1 through 10","108.88","2842.4","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","3344.00","2006.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","298.29","3786.93","15","108.88","2842.4","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","3344.00","2006.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1902.74","56.9","","1836.16","1836.16","1836.16","13","108.88","2842.4","percent of total billed charges",""
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","3344.00","2006.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","114.44","114.44","458.92","1 through 10","108.88","2842.4","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","3344.00","2006.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.33","109.33","234.63","16","108.88","2842.4","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","3344.00","2006.40","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","107.12","676.87","15","108.88","2842.4","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","3344.00","2006.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","109.34","111.11","21","108.88","2842.4","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","3344.00","2006.40","WELLSENSE NH [1050]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","115.94","115.94","115.94","1 through 10","108.88","2842.4","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","3344.00","2006.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","482.20","14.42","","465.33","465.33","465.33","1 through 10","388.91","2588.26","percent of total billed charges",""
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","3344.00","2006.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","388.91","11.63","","444.36","381.16","814.99","1 through 10","388.91","2588.26","percent of total billed charges",""
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","3344.00","2006.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","","","Payment is accumulated by procedure count. Procedure 1, 62.78% of billed. Procedures 2 - 9999, 31.39% of billed.","2025.91","2025.91","2025.91","1 through 10","388.91","2588.26","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","3344.00","2006.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","2346.67","2346.67","2346.67","12","388.91","2588.26","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","3344.00","2006.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1779.68","53.22","","1720.31","1720.31","1720.31","1 through 10","388.91","2588.26","percent of total billed charges",""
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","3344.00","2006.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2103.38","62.9","","2033.01","2033.01","2033.01","12","388.91","2588.26","percent of total billed charges",""
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","3344.00","2006.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2588.26","77.4","","2500.93","2500.93","2500.93","1 through 10","388.91","2588.26","percent of total billed charges",""
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","3344.00","2006.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","388.91","11.63","","381.16","174.22","381.16","1 through 10","388.91","2588.26","percent of total billed charges",""
"CT Neck W&W/O Contrast","PX-35000026","CDM","70492","CPT","0351","RC","","","","both","","","5673.00","3403.80","MEDICARE [2001]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","454.65","186.01","454.65","1 through 10","182.27","4822.05","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","4630.00","2778.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1188.62","","Case rate ($1,188.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1159.63","1159.63","2834.42","1 through 10","182.27","3935.5","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","4630.00","2778.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","511.82","","Case rate ($511.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","499.34","499.34","1220.51","17","182.27","3935.5","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","4630.00","2778.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","182.27","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","186.01","182.87","445.56","13","182.27","3935.5","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","4630.00","2778.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","960.75","","Case rate ($960.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","937.31","499.34","2291.02","1 through 10","182.27","3935.5","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","4630.00","2778.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2634.47","56.9","","2542.29","2542.29","7626.87","17","182.27","3935.5","percent of total billed charges",""
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","4630.00","2778.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","191.57","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","465.42","187.76","468.29","1 through 10","182.27","3935.5","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","4630.00","2778.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","428.52","183.03","447.38","21","182.27","3935.5","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","4630.00","2778.00","MEDICARE [2001]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","454.65","186.01","826.67","31","182.27","3935.5","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","4630.00","2778.00","TRICARE [160005]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","186.01","186.01","1 through 10","182.27","3935.5","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","4630.00","2778.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","183.04","454.65","38","182.27","3935.5","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","4630.00","2778.00","WELLSENSE NH [1050]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","193.00","193.00","193.00","1 through 10","182.27","3935.5","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","4630.00","2778.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","667.65","14.42","","644.29","552.24","644.29","1 through 10","538.47","3583.62","percent of total billed charges",""
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","4630.00","2778.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","538.47","11.63","","527.74","527.74","615.24","1 through 10","538.47","3583.62","percent of total billed charges",""
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","4630.00","2778.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3249.13","1624.57","6498.26","1 through 10","538.47","3583.62","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","4630.00","2778.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2912.27","62.9","","2814.84","2814.84","8444.52","18","538.47","3583.62","percent of total billed charges",""
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","4630.00","2778.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3583.62","77.4","","3462.70","3462.70","4808.76","1 through 10","538.47","3583.62","percent of total billed charges",""
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","4630.00","2778.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","538.47","11.63","","527.74","527.74","727.44","1 through 10","538.47","3583.62","percent of total billed charges",""
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","both","","","3479.00","2087.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","241.67","241.67","241.67","1 through 10","111.1","2957.15","other","OPPS APC"
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","both","","","3479.00","2087.40","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","234.63","107.12","234.63","1 through 10","111.1","2957.15","other","OPPS APC"
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","both","","","3479.00","2087.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","232.94","108.89","234.63","1 through 10","111.1","2957.15","other","OPPS APC"
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","outpatient","","","3479.00","2087.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2188.29","62.9","","2114.91","2114.91","2114.91","1 through 10","404.61","2692.75","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000017","CDM","70481","CPT","0351","RC","","","","both","","","7170.00","4302.00","MEDICARE [2001]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","454.65","454.65","454.65","1 through 10","182.27","6094.5","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/Contrast","PX-35000017","CDM","70481","CPT","0351","RC","","","","both","","","7170.00","4302.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","448.56","448.56","448.56","1 through 10","182.27","6094.5","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","5857.00","3514.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","692.73","692.73","1 through 10","108.88","4978.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","5857.00","3514.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","299.84","298.29","6872.51","1 through 10","108.88","4978.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","5857.00","3514.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","108.89","107.12","109.33","1 through 10","108.88","4978.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","5857.00","3514.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","559.93","559.93","1 through 10","108.88","4978.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","5857.00","3514.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3332.63","56.9","","3215.99","375.87","3215.99","1 through 10","108.88","4978.45","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","5857.00","3514.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","114.44","110.33","466.04","1 through 10","108.88","4978.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","5857.00","3514.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","109.33","111.11","1 through 10","108.88","4978.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","5857.00","3514.20","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","454.65","1 through 10","108.88","4978.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","5857.00","3514.20","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","234.63","234.63","234.63","1 through 10","108.88","4978.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","5857.00","3514.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.34","107.12","111.40","1 through 10","108.88","4978.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","5857.00","3514.20","WELLSENSE NH [1050]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","115.94","115.94","115.94","1 through 10","108.88","4978.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","5857.00","3514.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","844.58","14.42","","815.02","815.02","815.02","1 through 10","681.17","4533.32","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","5857.00","3514.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","681.17","11.63","","778.28","778.28","778.28","1 through 10","681.17","4533.32","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","5857.00","3514.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","4110.13","4110.13","4110.13","1 through 10","681.17","4533.32","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","5857.00","3514.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3684.05","62.9","","3560.76","3560.76","3560.76","1 through 10","681.17","4533.32","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","5857.00","3514.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4533.32","77.4","","4380.30","4380.30","4380.30","1 through 10","681.17","4533.32","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","5857.00","3514.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","681.17","11.63","","667.59","667.59","667.59","1 through 10","681.17","4533.32","percent of total billed charges",""
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","6106.00","3663.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1188.62","","Case rate ($1,188.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1163.69","1163.69","1163.69","1 through 10","182.27","5190.1","other","OPPS APC"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","6106.00","3663.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","511.82","","Case rate ($511.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","499.34","499.34","501.09","1 through 10","182.27","5190.1","other","OPPS APC"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","6106.00","3663.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","182.27","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","186.01","183.03","186.01","1 through 10","182.27","5190.1","other","OPPS APC"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","6106.00","3663.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","960.75","","Case rate ($960.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","937.31","937.31","937.31","1 through 10","182.27","5190.1","other","OPPS APC"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","6106.00","3663.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3474.31","56.9","","3352.55","3352.55","3352.55","1 through 10","182.27","5190.1","percent of total billed charges",""
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","6106.00","3663.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","191.57","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","191.59","191.59","191.59","1 through 10","182.27","5190.1","other","OPPS APC"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","6106.00","3663.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","183.03","183.03","183.03","1 through 10","182.27","5190.1","other","OPPS APC"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","6106.00","3663.60","MEDICARE [2001]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","186.01","186.01","1 through 10","182.27","5190.1","other","OPPS APC"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","6106.00","3663.60","TRICARE [160005]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","186.01","186.01","1 through 10","182.27","5190.1","other","OPPS APC"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","6106.00","3663.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","175.44","445.56","1 through 10","182.27","5190.1","other","OPPS APC"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","outpatient","","","6106.00","3663.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4726.04","77.4","","4566.30","4566.30","4566.30","1 through 10","710.13","4726.04","percent of total billed charges",""
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","both","","","3159.00","1895.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","114.44","114.44","114.44","1 through 10","108.88","2685.15","other","OPPS APC"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","both","","","3159.00","1895.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.33","109.33","109.33","1 through 10","108.88","2685.15","other","OPPS APC"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","both","","","3159.00","1895.40","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","107.12","111.11","1 through 10","108.88","2685.15","other","OPPS APC"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","both","","","3159.00","1895.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","2685.15","other","OPPS APC"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","both","","","3159.00","1895.40","WELLPOINT [1015]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","559.93","559.93","1 through 10","108.88","2685.15","other","OPPS APC"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","outpatient","","","3159.00","1895.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","367.39","11.63","","419.71","419.71","419.71","1 through 10","367.39","2445.07","percent of total billed charges",""
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","outpatient","","","3159.00","1895.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1987.01","62.9","","1920.24","1920.24","1920.24","1 through 10","367.39","2445.07","percent of total billed charges",""
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","outpatient","","","3159.00","1895.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","367.39","11.63","","360.02","360.02","360.02","1 through 10","367.39","2445.07","percent of total billed charges",""
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","both","","","4520.00","2712.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","629.88","629.88","629.88","1 through 10","108.88","3842","other","OPPS APC"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","both","","","4520.00","2712.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","230.88","111.11","234.63","1 through 10","108.88","3842","other","OPPS APC"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","both","","","4520.00","2712.00","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","107.12","107.12","107.12","1 through 10","108.88","3842","other","OPPS APC"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","both","","","4520.00","2712.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","233.64","228.60","233.64","1 through 10","108.88","3842","other","OPPS APC"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","outpatient","","","4520.00","2712.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","651.78","14.42","","629.00","629.00","629.00","1 through 10","525.68","3498.48","percent of total billed charges",""
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","outpatient","","","4520.00","2712.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2843.08","62.9","","2748.06","2748.06","2748.06","1 through 10","525.68","3498.48","percent of total billed charges",""
"CT Thoracic Spine W/Contrast","PX-35000038","CDM","72129","CPT","0352","RC","","","","both","","","5821.00","3492.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1188.62","","Case rate ($1,188.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1159.63","1159.63","1159.63","1 through 10","182.27","4947.85","other","OPPS APC"
"CT Upr Ext W/O Contrast","PX-35000049","CDM","73200","CPT","0352","RC","","","","both","","","4483.00","2689.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","108.89","111.11","12","108.88","3810.55","other","OPPS APC"
"CT Upr Ext W/O Contrast","PX-35000049","CDM","73200","CPT","0352","RC","","","","outpatient","","","4483.00","2689.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3145.87","3145.87","3145.87","1 through 10","521.37","521.37","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","both","","","11244.00","6746.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","511.82","","Case rate ($511.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","499.34","499.34","499.34","1 through 10","182.27","9557.4","other","OPPS APC"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","both","","","11244.00","6746.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","182.27","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","183.03","183.03","183.03","1 through 10","182.27","9557.4","other","OPPS APC"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","both","","","11244.00","6746.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","960.75","","Case rate ($960.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","937.31","499.34","937.31","1 through 10","182.27","9557.4","other","OPPS APC"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","both","","","11244.00","6746.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","191.57","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","191.59","191.36","191.59","1 through 10","182.27","9557.4","other","OPPS APC"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","both","","","11244.00","6746.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","183.03","183.03","183.03","1 through 10","182.27","9557.4","other","OPPS APC"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","both","","","11244.00","6746.40","MEDICARE [2001]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","186.01","186.01","1 through 10","182.27","9557.4","other","OPPS APC"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","both","","","11244.00","6746.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","185.29","186.01","1 through 10","182.27","9557.4","other","OPPS APC"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","outpatient","","","11244.00","6746.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1307.68","11.63","","1494.05","1494.05","1494.05","1 through 10","1307.68","8702.86","percent of total billed charges",""
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","outpatient","","","11244.00","6746.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1307.68","11.63","","1281.56","1281.56","1281.56","1 through 10","1307.68","8702.86","percent of total billed charges",""
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","7800.00","4680.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1188.62","","Case rate ($1,188.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1159.63","1159.63","1159.63","1 through 10","182.27","6630","other","OPPS APC"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","7800.00","4680.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","511.82","","Case rate ($511.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","499.34","499.34","499.34","1 through 10","182.27","6630","other","OPPS APC"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","7800.00","4680.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","182.27","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","316.22","316.22","316.22","1 through 10","182.27","6630","other","OPPS APC"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","7800.00","4680.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4438.20","56.9","","4282.86","4282.86","4282.86","1 through 10","182.27","6630","percent of total billed charges",""
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","7800.00","4680.00","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","4438.20","56.9","","4282.86","4282.86","4282.86","1 through 10","182.27","6630","percent of total billed charges",""
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","7800.00","4680.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1124.76","14.42","","930.34","930.34","930.34","1 through 10","182.27","6630","percent of total billed charges",""
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","7800.00","4680.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","183.03","183.03","183.03","1 through 10","182.27","6630","other","OPPS APC"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","7800.00","4680.00","MEDICARE [2001]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","186.01","186.01","1 through 10","182.27","6630","other","OPPS APC"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","7800.00","4680.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.29","185.29","185.29","1 through 10","182.27","6630","other","OPPS APC"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","7800.00","4680.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6037.20","77.4","","5833.43","5833.43","5833.43","1 through 10","182.27","6630","percent of total billed charges",""
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","outpatient","","","7800.00","4680.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","907.14","11.63","","2667.18","889.06","2667.18","1 through 10","907.14","4906.2","percent of total billed charges",""
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","outpatient","","","7800.00","4680.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","2736.82","2736.82","2736.82","1 through 10","907.14","4906.2","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","3947.00","2368.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","2550.49","238.99","2550.49","1 through 10","182.27","3354.95","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","3947.00","2368.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1188.62","","Case rate ($1,188.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1159.63","1159.63","2578.99","1 through 10","182.27","3354.95","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","3947.00","2368.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","511.82","","Case rate ($511.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","501.09","499.34","4308.34","1 through 10","182.27","3354.95","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","3947.00","2368.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","182.27","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","186.01","182.29","428.52","1 through 10","182.27","3354.95","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","3947.00","2368.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","960.75","","Case rate ($960.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2291.02","499.34","2291.02","1 through 10","182.27","3354.95","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","3947.00","2368.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2245.84","56.9","","2167.32","338.35","8671.87","18","182.27","3354.95","percent of total billed charges",""
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","3947.00","2368.20","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","2245.84","56.9","","2167.32","2167.32","2167.32","1 through 10","182.27","3354.95","percent of total billed charges",""
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","3947.00","2368.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","2658.68","2658.68","2658.68","1 through 10","182.27","3354.95","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","3947.00","2368.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","191.57","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","191.59","187.76","458.92","1 through 10","182.27","3354.95","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","3947.00","2368.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","183.03","183.03","447.38","18","182.27","3354.95","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","3947.00","2368.20","MEDICARE [2001]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","186.01","454.65","20","182.27","3354.95","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","3947.00","2368.20","TRICARE [160005]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","186.01","186.01","1 through 10","182.27","3354.95","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","3947.00","2368.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.29","182.29","186.01","29","182.27","3354.95","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","3947.00","2368.20","WELLSENSE NH [1050]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","193.00","193.00","193.00","1 through 10","182.27","3354.95","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","3947.00","2368.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","569.16","14.42","","549.26","470.79","549.26","1 through 10","459.04","3054.98","percent of total billed charges",""
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","3947.00","2368.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","459.04","11.63","","961.97","449.90","1349.70","27","459.04","3054.98","percent of total billed charges",""
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","3947.00","2368.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","","","Payment is accumulated by procedure count. Procedure 1, 62.78% of billed. Procedures 2 - 9999, 31.39% of billed.","2391.29","2391.29","2391.29","1 through 10","459.04","3054.98","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","3947.00","2368.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","2769.90","1384.95","3433.45","1 through 10","459.04","3054.98","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","3947.00","2368.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2482.66","62.9","","2399.67","2399.67","8955.68","31","459.04","3054.98","percent of total billed charges",""
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","3947.00","2368.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3054.98","77.4","","2951.98","2951.97","9615.09","1 through 10","459.04","3054.98","percent of total billed charges",""
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","3947.00","2368.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","459.04","11.63","","449.90","449.90","586.90","11","459.04","3054.98","percent of total billed charges",""
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0350","RC","","","","inpatient","","","7205.00","4323.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5537.76","76.86","","4380.39","4380.39","4380.39","1 through 10","4769.71","5537.76","percent of total billed charges",""
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","7205.00","4323.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1188.62","","Case rate ($1,188.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2834.42","2834.42","2842.38","1 through 10","182.27","6124.25","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","7205.00","4323.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","511.82","","Case rate ($511.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1223.94","1220.51","6953.00","1 through 10","182.27","6124.25","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","7205.00","4323.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","182.27","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","447.38","446.86","447.38","1 through 10","182.27","6124.25","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","7205.00","4323.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","960.75","","Case rate ($960.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2297.45","499.34","6953.00","1 through 10","182.27","6124.25","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","7205.00","4323.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4099.65","56.9","","5544.85","3864.77","13133.76","26","182.27","6124.25","percent of total billed charges",""
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","7205.00","4323.00","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","4099.65","56.9","","3956.26","3956.26","3956.26","1 through 10","182.27","6124.25","percent of total billed charges",""
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","7205.00","4323.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","191.57","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","464.92","191.59","468.29","1 through 10","182.27","6124.25","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","7205.00","4323.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","447.38","183.03","454.65","11","182.27","6124.25","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","7205.00","4323.00","MEDICARE [2001]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","454.65","437.27","826.67","15","182.27","6124.25","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","7205.00","4323.00","TRICARE [160005]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","454.65","454.65","454.65","1 through 10","182.27","6124.25","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","7205.00","4323.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","448.56","182.29","454.65","15","182.27","6124.25","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","7205.00","4323.00","WELLSENSE NH [1050]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","469.43","469.43","469.43","1 through 10","182.27","6124.25","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","7205.00","4323.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1038.96","14.42","","859.39","859.39","1002.62","1 through 10","837.94","5576.67","percent of total billed charges",""
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","7205.00","4323.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","837.94","11.63","","957.43","896.69","2463.78","19","837.94","5576.67","percent of total billed charges",""
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","7205.00","4323.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","5056.22","5056.22","7382.73","21","837.94","5576.67","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","7205.00","4323.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4531.95","62.9","","4380.39","4380.39","13141.17","16","837.94","5576.67","percent of total billed charges",""
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","7205.00","4323.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5576.67","77.4","","5388.58","5388.57","5388.58","1 through 10","837.94","5576.67","percent of total billed charges",""
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","7205.00","4323.00","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","5056.22","2528.11","5056.22","1 through 10","837.94","5576.67","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","7205.00","4323.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","837.94","11.63","","821.26","821.26","2463.78","11","837.94","5576.67","percent of total billed charges",""
"Cta Lwr Ext W&W/O Contrast","PX-35000070","CDM","73706","CPT","0352","RC","","","","both","","","9078.00","5446.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","183.04","183.04","183.04","1 through 10","182.27","7716.3","other","OPPS APC"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0350","RC","","","","inpatient","","","7184.00","4310.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5521.62","76.86","","4367.16","4367.16","4367.16","1 through 10","4755.81","5521.62","percent of total billed charges",""
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","7184.00","4310.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","511.82","","Case rate ($511.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6932.00","499.34","6932.00","1 through 10","182.27","6106.4","other","OPPS APC"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","7184.00","4310.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","182.27","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.29","182.29","182.29","1 through 10","182.27","6106.4","other","OPPS APC"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","7184.00","4310.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","960.75","","Case rate ($960.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6932.00","6932.00","6932.00","1 through 10","182.27","6106.4","other","OPPS APC"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","7184.00","4310.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4087.70","56.9","","3944.31","3853.61","13094.09","27","182.27","6106.4","percent of total billed charges",""
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","7184.00","4310.40","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","4087.70","56.9","","3944.31","3944.31","3944.31","1 through 10","182.27","6106.4","percent of total billed charges",""
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","7184.00","4310.40","HARVARD PILGRIM [120001]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","179.02","179.02","179.02","1 through 10","182.27","6106.4","other","OPPS APC"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","7184.00","4310.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","183.03","183.03","454.65","1 through 10","182.27","6106.4","other","OPPS APC"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","7184.00","4310.40","MEDICARE [2001]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","186.01","186.01","1 through 10","182.27","6106.4","other","OPPS APC"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","7184.00","4310.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","450.36","450.36","450.36","1 through 10","182.27","6106.4","other","OPPS APC"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","7184.00","4310.40","WELLSENSE NH [1050]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","193.00","193.00","193.00","1 through 10","182.27","6106.4","other","OPPS APC"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","7184.00","4310.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1035.93","14.42","","856.80","856.80","999.59","1 through 10","835.5","5560.42","percent of total billed charges",""
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","7184.00","4310.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","835.50","11.63","","954.54","818.78","2456.34","21","835.5","5560.42","percent of total billed charges",""
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","7184.00","4310.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","1515.34","1515.34","1515.34","1 through 10","835.5","5560.42","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","7184.00","4310.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","2520.48","2520.47","5040.94","21","835.5","5560.42","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","7184.00","4310.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4518.74","62.9","","4367.16","4367.16","13101.48","15","835.5","5560.42","percent of total billed charges",""
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","7184.00","4310.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5560.42","77.4","","5372.30","5372.30","5372.30","1 through 10","835.5","5560.42","percent of total billed charges",""
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","7184.00","4310.40","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","2520.48","2520.48","2520.48","1 through 10","835.5","5560.42","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","7184.00","4310.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","835.50","11.63","","818.78","818.78","2456.34","1 through 10","835.5","5560.42","percent of total billed charges",""
"Cult Type Amp Prb Cult/Isol Ea","PX-30001172","CDM","87150","CPT","0306","RC","","","","both","","","245.00","147.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","171.01","69.8","","165.43","149.07","165.43","59","22.81","208.25","percent of total billed charges",""
"Cult Type Amp Prb Cult/Isol Ea","PX-30001172","CDM","87150","CPT","0306","RC","","","","both","","","245.00","147.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","208.25","85","","237.00","153.84","237.00","1 through 10","22.81","208.25","percent of total billed charges",""
"Cult Type Amp Prb Cult/Isol Ea","PX-30001172","CDM","87150","CPT","0306","RC","","","","outpatient","","","245.00","147.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","153.81","62.78","","148.79","148.79","148.79","1 through 10","24.28","189.63","percent of total billed charges",""
"Cult Type Amp Prb Cult/Isol Ea","PX-30001172","CDM","87150","CPT","0306","RC","","","","outpatient","","","245.00","147.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","178.16","72.72","","172.35","172.35","172.35","69","24.28","189.63","percent of total billed charges",""
"Cult Type Amp Prb Cult/Isol Ea","PX-30001172","CDM","87150","CPT","0306","RC","","","","outpatient","","","245.00","147.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","178.16","72.72","","172.35","172.35","172.35","1 through 10","24.28","189.63","percent of total billed charges",""
"Cult Type Amp Prb Cult/Isol Ea","PX-30001172","CDM","87150","CPT","0306","RC","","","","outpatient","","","245.00","147.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","130.39","53.22","","126.34","126.34","126.34","1 through 10","24.28","189.63","percent of total billed charges",""
"Cult Type Amp Prb Cult/Isol Ea","PX-30001172","CDM","87150","CPT","0306","RC","","","","outpatient","","","245.00","147.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","154.11","62.9","","149.31","149.31","447.93","84","24.28","189.63","percent of total billed charges",""
"Cult Type Amp Prb Cult/Isol Ea","PX-30001172","CDM","87150","CPT","0306","RC","","","","outpatient","","","245.00","147.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","189.63","77.4","","183.68","183.68","183.68","40","24.28","189.63","percent of total billed charges",""
"Cult Type Amp Prb Cult/Isol Ea","PX-30001172","CDM","87150","CPT","0306","RC","","","","outpatient","","","245.00","147.00","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","178.16","72.72","","172.35","172.35","172.35","1 through 10","24.28","189.63","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","both","","","70.00","42.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","48.86","69.8","","47.46","42.77","47.47","94","5.25","59.5","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","both","","","70.00","42.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","48.86","69.8","","47.46","47.46","47.46","1 through 10","5.25","59.5","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","both","","","70.00","42.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","59.50","85","","57.80","7.28","57.80","1 through 10","5.25","59.5","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","outpatient","","","70.00","42.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","43.95","62.78","","42.69","29.73","128.07","19","7.53","54.18","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","outpatient","","","70.00","42.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","30.60","43.72","","29.73","29.73","89.19","11","7.53","54.18","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","outpatient","","","70.00","42.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","50.90","72.72","","49.45","49.45","49.45","106","7.53","54.18","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","outpatient","","","70.00","42.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","50.90","72.72","","49.45","49.45","49.45","1 through 10","7.53","54.18","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","outpatient","","","70.00","42.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","37.25","53.22","","36.25","36.25","36.25","1 through 10","7.53","54.18","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","outpatient","","","70.00","42.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","44.03","62.9","","42.84","42.84","85.68","149","7.53","54.18","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","outpatient","","","70.00","42.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","54.18","77.4","","52.70","52.70","52.70","70","7.53","54.18","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","outpatient","","","70.00","42.00","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","50.90","72.72","","49.45","49.45","49.45","1 through 10","7.53","54.18","percent of total billed charges",""
"Culture Afb/TB/Mycobacteria","PX-30001166","CDM","87116","CPT","0306","RC","","","","both","","","86.00","51.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","60.03","69.8","","57.93","57.93","57.94","1 through 10","7.02","73.1","percent of total billed charges",""
"Culture Afb/TB/Mycobacteria","PX-30001166","CDM","87116","CPT","0306","RC","","","","outpatient","","","86.00","51.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","37.60","43.72","","36.29","36.29","36.29","1 through 10","10.08","66.56","percent of total billed charges",""
"Culture Afb/TB/Mycobacteria","PX-30001166","CDM","87116","CPT","0306","RC","","","","outpatient","","","86.00","51.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","62.54","72.72","","60.36","60.36","252.34","11","10.08","66.56","percent of total billed charges",""
"Culture Afb/TB/Mycobacteria","PX-30001166","CDM","87116","CPT","0306","RC","","","","outpatient","","","86.00","51.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","54.09","62.9","","156.87","156.87","156.87","1 through 10","10.08","66.56","percent of total billed charges",""
"Culture Afb/TB/Mycobacteria","PX-30001166","CDM","87116","CPT","0306","RC","","","","outpatient","","","86.00","51.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","66.56","77.4","","64.33","64.33","64.33","1 through 10","10.08","66.56","percent of total billed charges",""
"Culture Anaerobic","PX-30001147","CDM","87075","CPT","0306","RC","","","","both","","","81.00","48.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","56.54","69.8","","54.44","49.06","54.44","18","6.16","68.85","percent of total billed charges",""
"Culture Anaerobic","PX-30001147","CDM","87075","CPT","0306","RC","","","","outpatient","","","81.00","48.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","50.85","62.78","","48.97","48.97","48.97","1 through 10","8.81","62.69","percent of total billed charges",""
"Culture Anaerobic","PX-30001147","CDM","87075","CPT","0306","RC","","","","outpatient","","","81.00","48.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","58.90","72.72","","56.72","48.60","56.72","12","8.81","62.69","percent of total billed charges",""
"Culture Anaerobic","PX-30001147","CDM","87075","CPT","0306","RC","","","","outpatient","","","81.00","48.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","43.11","53.22","","41.58","41.58","41.58","1 through 10","8.81","62.69","percent of total billed charges",""
"Culture Anaerobic","PX-30001147","CDM","87075","CPT","0306","RC","","","","outpatient","","","81.00","48.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","50.95","62.9","","49.14","49.14","147.42","14","8.81","62.69","percent of total billed charges",""
"Culture Anaerobic","PX-30001147","CDM","87075","CPT","0306","RC","","","","outpatient","","","81.00","48.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","62.69","77.4","","60.45","60.45","60.45","1 through 10","8.81","62.69","percent of total billed charges",""
"Culture Anaerobic ID","PX-30001148","CDM","87076","CPT","0306","RC","","","","both","","","70.00","42.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","48.86","69.8","","47.47","47.46","47.47","1 through 10","5.25","59.5","percent of total billed charges",""
"Culture Anaerobic ID","PX-30001148","CDM","87076","CPT","0306","RC","","","","outpatient","","","70.00","42.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","50.90","72.72","","49.45","49.45","49.45","1 through 10","9.79","54.18","percent of total billed charges",""
"Culture Anaerobic ID","PX-30001148","CDM","87076","CPT","0306","RC","","","","outpatient","","","70.00","42.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","54.18","77.4","","52.70","52.70","52.70","1 through 10","9.79","54.18","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0300","RC","","","","inpatient","","","74.00","44.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","56.88","76.86","","45.36","45.36","45.36","1 through 10","48.99","56.88","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","74.00","44.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","51.65","69.8","","50.26","45.29","50.26","72","5.6","62.9","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","74.00","44.40","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","51.65","69.8","","50.26","50.26","50.26","1 through 10","5.6","62.9","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","74.00","44.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","62.90","85","","50.26","46.74","50.26","1 through 10","5.6","62.9","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","outpatient","","","74.00","44.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","46.46","62.78","","135.60","45.20","135.60","12","8.03","57.28","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","outpatient","","","74.00","44.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","32.35","43.72","","31.48","31.48","31.48","1 through 10","8.03","57.28","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","outpatient","","","74.00","44.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","53.81","72.72","","52.36","52.36","52.36","108","8.03","57.28","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","outpatient","","","74.00","44.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","53.81","72.72","","52.36","52.36","52.36","1 through 10","8.03","57.28","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","outpatient","","","74.00","44.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","39.38","53.22","","38.38","38.38","38.38","1 through 10","8.03","57.28","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","outpatient","","","74.00","44.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","46.55","62.9","","45.36","45.36","136.08","135","8.03","57.28","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","outpatient","","","74.00","44.40","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","53.81","72.72","","514.40","514.40","514.40","1 through 10","8.03","57.28","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","outpatient","","","74.00","44.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","57.28","77.4","","55.80","55.80","55.80","52","8.03","57.28","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","outpatient","","","74.00","44.40","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","53.81","72.72","","52.36","52.36","52.36","1 through 10","8.03","57.28","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0300","RC","","","","inpatient","","","88.00","52.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","67.64","76.86","","53.55","51.71","103.42","12","58.26","67.64","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","both","","","88.00","52.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","61.42","69.8","","59.33","53.23","59.33","19","6.71","74.8","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","both","","","88.00","52.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","74.80","85","","144.50","144.50","144.50","1 through 10","6.71","74.8","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","outpatient","","","88.00","52.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","55.25","62.78","","53.36","53.36","53.36","1 through 10","9.61","68.11","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","outpatient","","","88.00","52.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","38.47","43.72","","37.16","37.16","37.16","1 through 10","9.61","68.11","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","outpatient","","","88.00","52.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","63.99","72.72","","61.81","61.81","123.62","47","9.61","68.11","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","outpatient","","","88.00","52.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","63.99","72.72","","123.62","123.62","123.62","1 through 10","9.61","68.11","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","outpatient","","","88.00","52.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","55.35","62.9","","53.55","53.55","206.84","65","9.61","68.11","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","outpatient","","","88.00","52.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","68.11","77.4","","65.88","61.81","127.26","14","9.61","68.11","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","outpatient","","","88.00","52.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","63.99","72.72","","61.81","61.81","61.81","1 through 10","9.61","68.11","percent of total billed charges",""
"Culture Fungus ID Yeast","PX-30001159","CDM","87106","CPT","0306","RC","","","","outpatient","","","88.00","52.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","63.99","72.72","","61.81","61.81","61.81","1 through 10","9.61","68.11","percent of total billed charges",""
"Culture Fungus ID Yeast","PX-30001159","CDM","87106","CPT","0306","RC","","","","outpatient","","","88.00","52.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","55.35","62.9","","160.65","53.55","160.65","1 through 10","9.61","68.11","percent of total billed charges",""
"Culture Fungus ID Yeast","PX-30001159","CDM","87106","CPT","0306","RC","","","","outpatient","","","88.00","52.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","68.11","77.4","","65.88","65.88","65.88","1 through 10","9.61","68.11","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","both","","","107.00","64.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","74.69","69.8","","71.89","71.89","71.90","1 through 10","5.47","90.95","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","outpatient","","","107.00","64.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","77.81","72.72","","74.90","74.90","74.90","1 through 10","7.82","82.82","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","outpatient","","","107.00","64.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","67.30","62.9","","64.89","64.89","194.67","1 through 10","7.82","82.82","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","outpatient","","","107.00","64.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","82.82","77.4","","79.83","79.83","79.83","1 through 10","7.82","82.82","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","both","","","58.00","34.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","40.48","69.8","","39.09","35.23","39.09","47","4.31","49.3","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","both","","","58.00","34.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","49.30","85","","186.58","186.58","186.58","1 through 10","4.31","49.3","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","outpatient","","","58.00","34.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","36.41","62.78","","70.31","70.31","70.31","1 through 10","5.38","44.89","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","outpatient","","","58.00","34.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","25.36","43.72","","24.49","24.49","24.49","1 through 10","5.38","44.89","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","outpatient","","","58.00","34.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","42.18","72.72","","40.73","40.72","122.18","61","5.38","44.89","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","outpatient","","","58.00","34.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","42.18","72.72","","40.73","40.72","40.73","1 through 10","5.38","44.89","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","outpatient","","","58.00","34.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","30.87","53.22","","29.86","29.85","29.86","1 through 10","5.38","44.89","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","outpatient","","","58.00","34.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","36.48","62.9","","35.28","35.28","105.84","76","5.38","44.89","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","outpatient","","","58.00","34.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","44.89","77.4","","43.40","43.40","43.40","30","5.38","44.89","percent of total billed charges",""
"Culture Stool Other","PX-30001142","CDM","87046","CPT","0306","RC","","","","both","","","81.00","48.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","56.54","69.8","","49.06","49.06","49.06","1 through 10","6.14","68.85","percent of total billed charges",""
"Culture Stool Other","PX-30001142","CDM","87046","CPT","0306","RC","","","","outpatient","","","81.00","48.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","58.90","72.72","","56.72","56.72","56.72","1 through 10","2.83","62.69","percent of total billed charges",""
"Culture Typing if Ea Antiserum","PX-30001168","CDM","87140","CPT","0306","RC","","","","both","","","43.00","25.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","30.01","69.8","","29.32","29.32","29.32","1 through 10","3.62","36.55","percent of total billed charges",""
"Culture Typing if Ea Antiserum","PX-30001168","CDM","87140","CPT","0306","RC","","","","outpatient","","","43.00","25.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","31.27","72.72","","30.54","30.54","30.54","1 through 10","5.19","33.28","percent of total billed charges",""
"Culture Typing if Ea Antiserum","PX-30001168","CDM","87140","CPT","0306","RC","","","","outpatient","","","43.00","25.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","27.05","62.9","","26.46","26.46","26.46","1 through 10","5.19","33.28","percent of total billed charges",""
"Culture Typing if Ea Antiserum","PX-30001168","CDM","87140","CPT","0306","RC","","","","outpatient","","","43.00","25.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","33.28","77.4","","32.55","32.55","32.55","1 through 10","5.19","33.28","percent of total billed charges",""
"Culture Typing Other Method","PX-30001175","CDM","87158","CPT","0306","RC","","","","both","","","55.00","33.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","38.39","69.8","","36.99","36.99","36.99","1 through 10","5.03","46.75","percent of total billed charges",""
"Culture Typing Sequencing Meth Ea I","PX-30001174","CDM","87153","CPT","0306","RC","","","","both","","","807.00","484.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","563.29","69.8","","544.44","544.44","544.44","1 through 10","74.98","685.95","percent of total billed charges",""
"Culture Typing Sequencing Meth Ea I","PX-30001174","CDM","87153","CPT","0306","RC","","","","outpatient","","","807.00","484.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","586.85","72.72","","567.22","567.22","567.22","1 through 10","100.3","624.62","percent of total billed charges",""
"Culture Typing Sequencing Meth Ea I","PX-30001174","CDM","87153","CPT","0306","RC","","","","outpatient","","","807.00","484.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","624.62","77.4","","604.50","604.50","604.50","1 through 10","100.3","624.62","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0300","RC","","","","inpatient","","","70.00","42.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","53.80","76.86","","81.98","40.99","81.98","1 through 10","46.34","53.8","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","70.00","42.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","48.86","69.8","","47.46","42.77","47.46","204","5.25","59.5","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","70.00","42.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","48.86","69.8","","47.46","47.46","47.46","1 through 10","5.25","59.5","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","70.00","42.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","59.50","85","","47.46","7.26","57.80","1 through 10","5.25","59.5","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","70.00","42.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","43.95","62.78","","42.69","42.69","128.07","23","5.98","54.18","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","70.00","42.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","30.60","43.72","","29.73","29.73","89.19","21","5.98","54.18","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","70.00","42.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","50.90","72.72","","49.45","49.45","49.45","288","5.98","54.18","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","70.00","42.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","50.90","72.72","","49.45","49.45","49.45","17","5.98","54.18","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","70.00","42.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","37.25","53.22","","36.25","36.25","108.75","13","5.98","54.18","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","70.00","42.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","44.03","62.9","","42.84","42.84","128.52","356","5.98","54.18","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","70.00","42.00","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","50.90","72.72","","49.45","49.45","49.45","1 through 10","5.98","54.18","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","70.00","42.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","54.18","77.4","","52.70","52.70","52.70","148","5.98","54.18","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","70.00","42.00","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","50.90","72.72","","49.45","49.45","49.45","1 through 10","5.98","54.18","percent of total billed charges",""
"Culture Virus Tissue Inoc/Obsv","PX-30001200","CDM","87252","CPT","0306","RC","","","","both","","","141.00","84.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","98.42","69.8","","94.93","24.58","94.93","1 through 10","16.95","133.94","percent of total billed charges",""
"Culture Virus Tissue Inoc/Obsv","PX-30001200","CDM","87252","CPT","0306","RC","","","","outpatient","","","141.00","84.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","102.54","72.72","","98.90","98.90","98.90","1 through 10","24.29","109.13","percent of total billed charges",""
"Culture Virus Tissue Inoc/Obsv","PX-30001200","CDM","87252","CPT","0306","RC","","","","outpatient","","","141.00","84.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","75.04","53.22","","217.50","217.50","217.50","1 through 10","24.29","109.13","percent of total billed charges",""
"Curettage Endocervical","PX-76001369","CDM","57505","CPT","0761","RC","","","","both","","","835.00","501.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","891.52","","APC Price ($909.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","770.76","445.81","770.76","1 through 10","475.12","5813.95","other","OPPS APC"
"Curettage Postpartum","PX-72000011","CDM","59160","CPT","0761","RC","","","","both","","","4568.00","2740.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","9141.46","","Case rate ($9,141.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8918.60","8918.60","8918.60","1 through 10","2599.19","21229.64","other","OPPS APC"
"Curettage Postpartum","PX-72000011","CDM","59160","CPT","0761","RC","","","","both","","","4568.00","2740.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","17159.72","","Case rate ($17,159.72). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","16741.10","8918.60","16741.10","1 through 10","2599.19","21229.64","other","OPPS APC"
"Curettage Postpartum","PX-72000011","CDM","59160","CPT","0761","RC","","","","outpatient","","","4568.00","2740.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2873.27","62.9","","4760.28","4760.28","4760.28","1 through 10","531.26","3535.63","percent of total billed charges",""
"Curettage Postpartum","PX-72000011","CDM","59160","CPT","0761","RC","","","","outpatient","","","4568.00","2740.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","531.26","11.63","","892.48","892.48","892.48","1 through 10","531.26","3535.63","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","both","","","183.00","109.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","127.73","69.8","","123.55","111.33","123.55","22","8.42","155.55","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","outpatient","","","183.00","109.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","133.08","72.72","","128.71","128.71","128.71","31","11.77","141.64","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","outpatient","","","183.00","109.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","133.08","72.72","","128.71","128.71","128.71","1 through 10","11.77","141.64","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","outpatient","","","183.00","109.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","97.39","53.22","","94.36","94.36","94.36","1 through 10","11.77","141.64","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","outpatient","","","183.00","109.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","115.11","62.9","","111.51","111.51","334.53","43","11.77","141.64","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","outpatient","","","183.00","109.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","141.64","77.4","","137.18","137.18","137.18","19","11.77","141.64","percent of total billed charges",""
"Cyclosporine (Sandimmune)","PX-30000021","CDM","80158","CPT","0301","RC","","","","both","","","98.00","58.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","68.40","69.8","","20.57","20.57","66.31","15","11.73","93.29","percent of total billed charges",""
"Cyclosporine (Sandimmune)","PX-30000021","CDM","80158","CPT","0301","RC","","","","outpatient","","","98.00","58.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","71.27","72.72","","69.08","69.08","69.08","30","16.83","75.85","percent of total billed charges",""
"Cyclosporine (Sandimmune)","PX-30000021","CDM","80158","CPT","0301","RC","","","","outpatient","","","98.00","58.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","52.16","53.22","","50.64","50.64","50.64","1 through 10","16.83","75.85","percent of total billed charges",""
"Cyclosporine (Sandimmune)","PX-30000021","CDM","80158","CPT","0301","RC","","","","outpatient","","","98.00","58.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","61.64","62.9","","59.85","59.85","179.55","15","16.83","75.85","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","both","","","212.00","127.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","147.98","69.8","","143.09","143.09","143.09","20","12.04","180.2","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","outpatient","","","212.00","127.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","154.17","72.72","","149.08","149.08","149.08","25","13.76","164.09","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","outpatient","","","212.00","127.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","112.83","53.22","","109.29","109.29","109.29","1 through 10","13.76","164.09","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","outpatient","","","212.00","127.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","133.35","62.9","","129.15","129.15","387.45","24","13.76","164.09","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","outpatient","","","212.00","127.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","164.09","77.4","","158.88","158.88","158.88","15","13.76","164.09","percent of total billed charges",""
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","both","","","4002.00","2401.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","2097.40","","APC Price ($2,140.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2110.48","2110.48","2110.48","1 through 10","2097.4","13677.84","other","OPPS APC"
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","both","","","4002.00","2401.20","MEDICARE [2001]","HB WDH MEDICARE","2140.20","","APC Price ($2,140.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2140.45","1984.56","2140.45","1 through 10","2097.4","13677.84","other","OPPS APC"
"Cyto Urne 3-5 Probe Ea Spec Man","PX-31000070","CDM","88120","CPT","0311","RC","","","","both","","","2603.00","1561.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","179.03","","APC Price ($179.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","175.57","175.57","175.57","1 through 10","175.45","2462.21","other","OPPS APC"
"Cyto Urne 3-5 Probe Ea Spec Man","PX-31000070","CDM","88120","CPT","0311","RC","","","","both","","","2603.00","1561.80","MEDICARE [2001]","HB WDH MEDICARE","179.03","","APC Price ($179.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","179.05","179.05","179.05","1 through 10","175.45","2462.21","other","OPPS APC"
"Cyto Urne 3-5 Probe Ea Spec Man","PX-31000070","CDM","88120","CPT","0311","RC","","","","both","","","2603.00","1561.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","179.03","","APC Price ($179.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","179.05","175.47","179.05","1 through 10","175.45","2462.21","other","OPPS APC"
"Cytogenetics & Mcg","PX-31000026","CDM","88291","CPT","0311","RC","","","","both","","","170.00","102.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","118.66","69.8","","114.47","114.47","114.47","1 through 10","33.46","144.5","percent of total billed charges",""
"Cytogenetics & Mcg","PX-31000026","CDM","88291","CPT","0311","RC","","","","both","","","170.00","102.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","118.66","69.8","","114.47","114.47","114.47","1 through 10","33.46","144.5","percent of total billed charges",""
"Cytogenetics & Mcg","PX-31000026","CDM","88291","CPT","0311","RC","","","","outpatient","","","170.00","102.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","123.62","72.72","","119.26","119.26","119.26","1 through 10","18.3","131.58","percent of total billed charges",""
"Cytogenetics & Mcg","PX-31000026","CDM","88291","CPT","0311","RC","","","","outpatient","","","170.00","102.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","106.93","62.9","","103.32","103.32","309.96","1 through 10","18.3","131.58","percent of total billed charges",""
"Cytogenetics & Mcg","PX-31000026","CDM","88291","CPT","0311","RC","","","","outpatient","","","170.00","102.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","131.58","77.4","","127.10","127.10","127.10","1 through 10","18.3","131.58","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody","PX-30000910","CDM","86644","CPT","0302","RC","","","","both","","","77.00","46.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","53.75","69.8","","51.65","51.65","51.65","1 through 10","9.35","73.73","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody","PX-30000910","CDM","86644","CPT","0302","RC","","","","outpatient","","","77.00","46.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","55.99","72.72","","53.81","53.81","53.81","1 through 10","13.41","59.6","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody","PX-30000910","CDM","86644","CPT","0302","RC","","","","outpatient","","","77.00","46.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","48.43","62.9","","46.62","46.62","46.62","1 through 10","13.41","59.6","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody","PX-30000910","CDM","86644","CPT","0302","RC","","","","outpatient","","","77.00","46.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","59.60","77.4","","57.35","57.35","57.35","1 through 10","13.41","59.6","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody Igm","PX-30000912","CDM","86645","CPT","0302","RC","","","","both","","","92.00","55.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","64.22","69.8","","62.12","62.12","62.12","1 through 10","10.95","87.29","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody Igm","PX-30000912","CDM","86645","CPT","0302","RC","","","","outpatient","","","92.00","55.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","66.90","72.72","","64.72","54.86","64.72","1 through 10","13.31","71.21","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody Igm","PX-30000912","CDM","86645","CPT","0302","RC","","","","outpatient","","","92.00","55.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","57.87","62.9","","56.07","56.07","56.07","1 through 10","13.31","71.21","percent of total billed charges",""
"Cytomegalovirus (Cmv) Antibody Igm","PX-30000912","CDM","86645","CPT","0302","RC","","","","outpatient","","","92.00","55.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","71.21","77.4","","68.98","68.98","68.98","1 through 10","13.31","71.21","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","676.00","405.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","288.36","","Case rate ($288.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","627.00","627.00","627.00","1 through 10","54.71","574.6","other","OPPS APC"
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","676.00","405.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","57.50","","APC Price ($55.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","180.73","56.35","180.73","1 through 10","54.71","574.6","other","OPPS APC"
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","676.00","405.60","MEDICARE [2001]","HB WDH MEDICARE","55.82","","APC Price ($55.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","55.83","55.83","55.83","1 through 10","54.71","574.6","other","OPPS APC"
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","676.00","405.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","55.82","","APC Price ($55.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.72","51.75","54.72","1 through 10","54.71","574.6","other","OPPS APC"
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","outpatient","","","676.00","405.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","491.59","72.72","","475.59","475.59","475.59","12","65.19","523.22","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","outpatient","","","676.00","405.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","491.59","72.72","","475.59","475.59","475.59","1 through 10","65.19","523.22","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","outpatient","","","676.00","405.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","425.20","62.9","","412.02","412.02","1581.56","13","65.19","523.22","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","outpatient","","","676.00","405.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","523.22","77.4","","506.85","506.85","506.85","1 through 10","65.19","523.22","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","both","","","308.00","184.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","214.98","69.8","","208.00","187.44","208.00","278","17.3","261.8","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","both","","","308.00","184.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","214.98","69.8","","506.60","506.60","506.60","1 through 10","17.3","261.8","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","both","","","308.00","184.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","261.80","85","","163.49","136.96","649.10","1 through 10","17.3","261.8","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","outpatient","","","308.00","184.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","193.36","62.78","","187.08","187.08","561.24","21","24.68","238.39","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","outpatient","","","308.00","184.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","134.66","43.72","","130.29","130.29","130.29","14","24.68","238.39","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","outpatient","","","308.00","184.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","223.98","72.72","","216.71","216.71","650.13","501","24.68","238.39","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","outpatient","","","308.00","184.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","223.98","72.72","","216.71","216.71","216.71","18","24.68","238.39","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","outpatient","","","308.00","184.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","163.92","53.22","","158.86","158.86","476.58","27","24.68","238.39","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","outpatient","","","308.00","184.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","193.73","62.9","","375.48","187.74","563.22","622","24.68","238.39","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","outpatient","","","308.00","184.80","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","223.98","72.72","","230.95","48.72","230.95","1 through 10","24.68","238.39","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","outpatient","","","308.00","184.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","238.39","77.4","","230.95","230.95","230.95","167","24.68","238.39","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Auto/Man Resc","PX-31000095","CDM","88175","CPT","0311","RC","","","","outpatient","","","308.00","184.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","223.98","72.72","","216.71","216.71","216.71","1 through 10","24.68","238.39","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-31000076","CDM","88142","CPT","0311","RC","","","","both","","","236.00","141.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","164.73","69.8","","159.14","143.41","318.28","1 through 10","13.17","200.6","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-31000076","CDM","88142","CPT","0311","RC","","","","both","","","236.00","141.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","200.60","85","","147.99","147.99","147.99","1 through 10","13.17","200.6","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-31000076","CDM","88142","CPT","0311","RC","","","","outpatient","","","236.00","141.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","103.18","43.72","","99.68","99.68","99.68","1 through 10","18.88","182.66","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-31000076","CDM","88142","CPT","0311","RC","","","","outpatient","","","236.00","141.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","171.62","72.72","","165.80","165.80","165.80","15","18.88","182.66","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-31000076","CDM","88142","CPT","0311","RC","","","","outpatient","","","236.00","141.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","171.62","72.72","","165.80","165.80","165.80","1 through 10","18.88","182.66","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-31000076","CDM","88142","CPT","0311","RC","","","","outpatient","","","236.00","141.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","148.44","62.9","","143.64","143.64","430.92","14","18.88","182.66","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-31000076","CDM","88142","CPT","0311","RC","","","","outpatient","","","236.00","141.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","182.66","77.4","","176.70","176.70","176.70","1 through 10","18.88","182.66","percent of total billed charges",""
"Debr/Rem Tiss Addl 20 Sq Cm/Part","PX-76001693","CDM","97598","CPT","0761","RC","","","","both","","","182.00","109.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","103.56","56.9","","200.34","100.14","722.07","28","103.56","154.7","percent of total billed charges",""
"Debr/Rem Tiss Addl 20 Sq Cm/Part","PX-76001693","CDM","97598","CPT","0761","RC","","","","outpatient","","","182.00","109.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","26.24","14.42","","25.38","25.38","25.38","1 through 10","21.17","140.87","percent of total billed charges",""
"Debr/Rem Tiss Addl 20 Sq Cm/Part","PX-76001693","CDM","97598","CPT","0761","RC","","","","outpatient","","","182.00","109.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","21.17","11.63","","44.45","44.45","44.45","22","21.17","140.87","percent of total billed charges",""
"Debr/Rem Tiss Addl 20 Sq Cm/Part","PX-76001693","CDM","97598","CPT","0761","RC","","","","outpatient","","","182.00","109.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","21.17","11.63","","20.79","20.79","20.79","12","21.17","140.87","percent of total billed charges",""
"Debride Skin/Subq Tissu/Muscle/Bone","PX-76000024","CDM","11044","CPT","0761","RC","","","","both","","","4869.00","2921.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1692.96","1692.96","1692.96","1 through 10","1658.91","10818.29","other","OPPS APC"
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","both","","","1601.00","960.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","1117.50","69.8","","1078.41","1078.41","1078.41","1 through 10","409.06","2667.66","percent of total billed charges",""
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","both","","","1601.00","960.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2667.66","","Case rate ($2,667.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2602.60","1567.55","2602.60","1 through 10","409.06","2667.66","other","OPPS APC"
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","both","","","1601.00","960.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1148.69","","Case rate ($1,148.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1087.47","1087.47","1087.47","1 through 10","409.06","2667.66","other","OPPS APC"
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","both","","","1601.00","960.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","2156.24","","Case rate ($2,156.24). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1545.00","1545.00","1545.00","1 through 10","409.06","2667.66","other","OPPS APC"
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","both","","","1601.00","960.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","910.97","56.9","","879.10","879.10","879.10","1 through 10","409.06","2667.66","percent of total billed charges",""
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","both","","","1601.00","960.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","429.94","","APC Price ($417.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","429.81","429.81","429.81","1 through 10","409.06","2667.66","other","OPPS APC"
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","both","","","1601.00","960.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","417.41","","APC Price ($417.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","410.01","409.11","410.01","1 through 10","409.06","2667.66","other","OPPS APC"
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","both","","","1601.00","960.60","MEDICARE [2001]","HB WDH MEDICARE","417.41","","APC Price ($417.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.46","417.46","417.46","1 through 10","409.06","2667.66","other","OPPS APC"
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","both","","","1601.00","960.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","417.41","","APC Price ($417.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","409.12","409.12","409.12","1 through 10","409.06","2667.66","other","OPPS APC"
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","outpatient","","","1601.00","960.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","230.86","14.42","","2651.96","2651.96","2651.96","1 through 10","186.2","1239.17","percent of total billed charges",""
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","outpatient","","","1601.00","960.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","186.20","11.63","","390.19","390.19","390.19","1 through 10","186.2","1239.17","percent of total billed charges",""
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","outpatient","","","1601.00","960.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1007.03","62.9","","13517.28","973.35","13517.28","1 through 10","186.2","1239.17","percent of total billed charges",""
"Debride Skin/Subq Tissue","PX-76000022","CDM","11042","CPT","0761","RC","","","","outpatient","","","1601.00","960.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1239.17","77.4","","1123.52","1123.52","1123.52","1 through 10","186.2","1239.17","percent of total billed charges",""
"Debride Skin/Subq Tissue/Muscle","PX-76000023","CDM","11043","CPT","0761","RC","","","","both","","","2299.00","1379.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1308.13","56.9","","1262.04","1262.04","1262.04","1 through 10","626.74","4087.16","percent of total billed charges",""
"Debride Skin/Subq Tissue/Muscle","PX-76000023","CDM","11043","CPT","0761","RC","","","","both","","","2299.00","1379.40","MEDICARE [2001]","HB WDH MEDICARE","639.53","","APC Price ($639.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","639.60","611.94","1918.80","1 through 10","626.74","4087.16","other","OPPS APC"
"Debride Skin/Subq Tissue/Muscle","PX-76000023","CDM","11043","CPT","0761","RC","","","","both","","","2299.00","1379.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","639.53","","APC Price ($639.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","639.60","639.60","639.60","1 through 10","626.74","4087.16","other","OPPS APC"
"Debride Skin/Subq Tissue/Muscle","PX-76000023","CDM","11043","CPT","0761","RC","","","","outpatient","","","2299.00","1379.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1446.07","62.9","","1397.34","1397.34","1397.34","1 through 10","267.37","1779.43","percent of total billed charges",""
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","768.00","460.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","536.06","69.8","","517.22","517.22","517.22","13","203.44","1326.74","percent of total billed charges",""
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","768.00","460.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","211.75","","APC Price ($207.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","207.62","207.62","207.62","16","203.44","1326.74","other","OPPS APC"
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","768.00","460.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1326.74","","Case rate ($1,326.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","763.70","741.00","1267.96","68","203.44","1326.74","other","OPPS APC"
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","768.00","460.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","571.29","","Case rate ($571.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","557.37","557.37","557.37","68","203.44","1326.74","other","OPPS APC"
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","768.00","460.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","203.44","","APC Price ($207.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","204.47","203.47","207.62","66","203.44","1326.74","other","OPPS APC"
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","768.00","460.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1072.40","","Case rate ($1,072.40). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","741.00","557.37","917.00","29","203.44","1326.74","other","OPPS APC"
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","768.00","460.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","436.99","56.9","","421.63","421.62","421.63","44","203.44","1326.74","percent of total billed charges",""
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","768.00","460.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","213.82","","APC Price ($207.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","210.57","209.57","213.85","45","203.44","1326.74","other","OPPS APC"
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","768.00","460.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","207.59","","APC Price ($207.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","204.37","203.47","207.62","172","203.44","1326.74","other","OPPS APC"
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","768.00","460.80","MEDICARE [2001]","HB WDH MEDICARE","207.59","","APC Price ($207.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.62","207.62","207.62","645","203.44","1326.74","other","OPPS APC"
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","768.00","460.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","207.59","","APC Price ($207.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","204.30","203.47","207.62","266","203.44","1326.74","other","OPPS APC"
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","768.00","460.80","WELLSENSE NH [1050]","HB WDH MEDICARE","207.59","","APC Price ($207.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","213.64","213.64","213.64","30","203.44","1326.74","other","OPPS APC"
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","outpatient","","","768.00","460.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","110.75","14.42","","106.85","91.59","106.85","24","89.32","594.43","percent of total billed charges",""
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","outpatient","","","768.00","460.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","89.32","11.63","","102.04","87.53","187.14","49","89.32","594.43","percent of total billed charges",""
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","outpatient","","","768.00","460.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","482.15","62.78","","465.20","465.20","465.20","1 through 10","89.32","594.43","percent of total billed charges",""
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","outpatient","","","768.00","460.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","558.49","72.72","","538.86","538.86","555.48","34","89.32","594.43","percent of total billed charges",""
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","outpatient","","","768.00","460.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","483.07","62.9","","466.83","466.83","466.83","53","89.32","594.43","percent of total billed charges",""
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","outpatient","","","768.00","460.80","PHCS MULTIPLAN [1022]","HB WDH AMERIHEALTH CARITAS","110.75","14.42","","106.85","106.85","106.85","1 through 10","89.32","594.43","percent of total billed charges",""
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","outpatient","","","768.00","460.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","594.43","77.4","","538.86","503.72","739.84","1 through 10","89.32","594.43","percent of total billed charges",""
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","outpatient","","","768.00","460.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","89.32","11.63","","87.53","87.53","437.65","35","89.32","594.43","percent of total billed charges",""
"Decalcification","PX-31000153","CDM","88311","CPT","0312","RC","","","","outpatient","","","209.00","125.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","151.98","72.72","","146.90","146.89","146.90","11","24.31","161.77","percent of total billed charges",""
"Decalcification","PX-31000153","CDM","88311","CPT","0312","RC","","","","outpatient","","","209.00","125.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","111.23","53.22","","107.69","107.69","107.69","1 through 10","24.31","161.77","percent of total billed charges",""
"Decalcification","PX-31000153","CDM","88311","CPT","0312","RC","","","","outpatient","","","209.00","125.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","131.46","62.9","","127.26","127.26","127.26","1 through 10","24.31","161.77","percent of total billed charges",""
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","both","","","275.00","165.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","191.95","69.8","","166.69","166.69","166.69","1 through 10","156.48","2214.69","percent of total billed charges",""
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","both","","","275.00","165.00","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","353.47","","APC Price ($346.54). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","346.58","329.98","346.58","1 through 10","156.48","2214.69","other","OPPS APC"
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","both","","","275.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2214.69","","Case rate ($2,214.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","540.93","265.00","2160.68","1 through 10","156.48","2214.69","other","OPPS APC"
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","both","","","275.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","953.65","","Case rate ($953.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","923.62","265.00","930.40","1 through 10","156.48","2214.69","other","OPPS APC"
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","both","","","275.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","339.61","","APC Price ($346.54). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","346.58","329.98","346.58","1 through 10","156.48","2214.69","other","OPPS APC"
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","both","","","275.00","165.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1790.12","","Case rate ($1,790.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1259.36","265.00","1746.45","1 through 10","156.48","2214.69","other","OPPS APC"
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","both","","","275.00","165.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","156.48","56.9","","150.79","150.78","150.79","1 through 10","156.48","2214.69","percent of total billed charges",""
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","both","","","275.00","165.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","356.93","","APC Price ($346.54). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","355.14","349.84","355.14","1 through 10","156.48","2214.69","other","OPPS APC"
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","both","","","275.00","165.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","346.54","","APC Price ($346.54). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","329.98","242.54","339.65","1 through 10","156.48","2214.69","other","OPPS APC"
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","both","","","275.00","165.00","MEDICARE [2001]","HB WDH MEDICARE","346.54","","APC Price ($346.54). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","346.58","346.58","346.58","42","156.48","2214.69","other","OPPS APC"
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","both","","","275.00","165.00","TRICARE [160005]","HB WDH MEDICARE","346.54","","APC Price ($346.54). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","346.58","346.58","346.58","1 through 10","156.48","2214.69","other","OPPS APC"
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","both","","","275.00","165.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","346.54","","APC Price ($346.54). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","340.71","265.00","344.95","1 through 10","156.48","2214.69","other","OPPS APC"
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","both","","","275.00","165.00","WELLPOINT [1015]","HB WDH ANTHEM PPO","1790.12","","Case rate ($1,790.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1733.72","1733.72","1733.72","1 through 10","156.48","2214.69","other","OPPS APC"
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","both","","","275.00","165.00","WELLSENSE NH [1050]","HB WDH MEDICARE","346.54","","APC Price ($346.54). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1080.49","1080.49","1080.49","1 through 10","156.48","2214.69","other","OPPS APC"
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","outpatient","","","275.00","165.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","39.66","14.42","","38.21","32.75","38.21","1 through 10","31.98","212.85","percent of total billed charges",""
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","outpatient","","","275.00","165.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","31.98","11.63","","36.49","32.44","36.49","1 through 10","31.98","212.85","percent of total billed charges",""
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","outpatient","","","275.00","165.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","115.86","115.86","115.86","1 through 10","31.98","212.85","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","outpatient","","","275.00","165.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","212.85","77.4","","205.34","205.34","205.34","1 through 10","31.98","212.85","percent of total billed charges",""
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","outpatient","","","275.00","165.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","31.98","11.63","","543.44","31.30","543.44","1 through 10","31.98","212.85","percent of total billed charges",""
"Degenerative Nervous System Disorders With McC","056","MS-DRG","","","","","","","","inpatient","","","58630.06","35178.04","MARTIN'S POINT [160007]","HB WDH MEDICARE","18106.09","","Case rate ($18,106.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $16,745.98, add-ons for qualifying new technology services are included. If operating cost exceeds $20,664.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,095.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $16,370.63 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $16,301.11 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,290.58. The transfer capital threshold is the transfer adjustment factor * $1,290.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24215.18","24215.18","24215.18","1 through 10","3975","88278.03","other","Inpatient DRG"
"Degenerative Nervous System Disorders With McC","056","MS-DRG","","","","","","","","inpatient","","","58630.06","35178.04","MEDICARE [2001]","HB WDH MEDICARE","18106.09","","Case rate ($18,106.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $16,745.98, add-ons for qualifying new technology services are included. If operating cost exceeds $20,664.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,095.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $16,370.63 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $16,301.11 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,290.58. The transfer capital threshold is the transfer adjustment factor * $1,290.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19339.62","1332.53","19388.86","1 through 10","3975","88278.03","other","Inpatient DRG"
"Degenerative Nervous System Disorders With McC","056","MS-DRG","","","","","","","","inpatient","","","58630.06","35178.04","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","18106.09","","Case rate ($18,106.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $16,745.98, add-ons for qualifying new technology services are included. If operating cost exceeds $20,664.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,095.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $16,370.63 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $16,301.11 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,290.58. The transfer capital threshold is the transfer adjustment factor * $1,290.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18992.33","18992.33","18992.33","1 through 10","3975","88278.03","other","Inpatient DRG"
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","31029.31","18617.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","19385.91","","Fee schedule rate ($19,385.91). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","14160.60","14160.60","14160.60","1 through 10","3975","49232.93","case rate",""
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","31029.31","18617.59","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","10603.42","","Case rate ($10,294.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,536.05, add-ons for qualifying new technology services are included. If operating cost exceeds $13,454.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,524.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,129.95 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,091.18 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $719.76. The transfer capital threshold is the transfer adjustment factor * $719.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","4980.39","4980.39","4980.39","1 through 10","3975","49232.93","other","Inpatient DRG"
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","31029.31","18617.59","MEDICARE [2001]","HB WDH MEDICARE","10294.58","","Case rate ($10,294.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,536.05, add-ons for qualifying new technology services are included. If operating cost exceeds $13,454.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,524.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,129.95 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,091.18 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $719.76. The transfer capital threshold is the transfer adjustment factor * $719.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8414.81","0.05","10539.81","23","3975","49232.93","other","Inpatient DRG"
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","31029.31","18617.59","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","10294.58","","Case rate ($10,294.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,536.05, add-ons for qualifying new technology services are included. If operating cost exceeds $13,454.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,524.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,129.95 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,091.18 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $719.76. The transfer capital threshold is the transfer adjustment factor * $719.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10513.58","10329.02","48312.79","1 through 10","3975","49232.93","other","Inpatient DRG"
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","31029.31","18617.59","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","26546.84","","Fee schedule rate ($26,546.84). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","27341.86","27341.86","27341.86","1 through 10","3975","49232.93","case rate",""
"Del Placenta","PX-72000019","CDM","59414","CPT","0720","RC","","","","outpatient","","","2362.00","1417.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","340.60","14.42","","328.63","328.63","328.63","1 through 10","274.7","1828.19","percent of total billed charges",""
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","","","","inpatient","","","17386.32","10431.79","MEDICARE [2001]","HB WDH MEDICARE","7361.58","","Case rate ($7,361.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,828.91, add-ons for qualifying new technology services are included. If operating cost exceeds $10,747.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,310.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,411.26 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,384.03 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $505.43. The transfer capital threshold is the transfer adjustment factor * $505.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7560.63","7560.63","7560.63","1 through 10","3975","34572.49","other","Inpatient DRG"
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","","","","inpatient","","","17386.32","10431.79","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7361.58","","Case rate ($7,361.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,828.91, add-ons for qualifying new technology services are included. If operating cost exceeds $10,747.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,310.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,411.26 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,384.03 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $505.43. The transfer capital threshold is the transfer adjustment factor * $505.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7560.63","7560.63","7560.63","1 through 10","3975","34572.49","other","Inpatient DRG"
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","","","","inpatient","","","17386.32","10431.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","18641.80","","Fee schedule rate ($18,641.80). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","19272.89","19272.89","19272.89","1 through 10","3975","34572.49","case rate",""
"Dental And Oral Diseases With McC","157","MS-DRG","","","","","","","","inpatient","","","62899.10","37739.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","25688.27","","Fee schedule rate ($25,688.27). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","23904.11","23904.11","23904.11","1 through 10","3975","65238.57","case rate",""
"Dental And Oral Diseases With McC","157","MS-DRG","","","","","","","","inpatient","","","62899.10","37739.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","13226.79","","Case rate ($13,496.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,491.59, add-ons for qualifying new technology services are included. If operating cost exceeds $16,409.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,758.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,098.10 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,046.72 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $953.76. The transfer capital threshold is the transfer adjustment factor * $953.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12800.64","12800.64","12800.64","1 through 10","3975","65238.57","other","Inpatient DRG"
"Dental And Oral Diseases With McC","157","MS-DRG","","","","","","","","inpatient","","","62899.10","37739.46","MARTIN'S POINT [160007]","HB WDH MEDICARE","13496.72","","Case rate ($13,496.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,491.59, add-ons for qualifying new technology services are included. If operating cost exceeds $16,409.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,758.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,098.10 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,046.72 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $953.76. The transfer capital threshold is the transfer adjustment factor * $953.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Includes an additional $800 of payment.","16441.41","16441.41","16441.41","1 through 10","3975","65238.57","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Dental And Oral Diseases Without Cc/McC","159","MS-DRG","","","","","","","","inpatient","","","16054.52","9632.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","10601.20","","Fee schedule rate ($10,601.20). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","9628.79","9628.79","9628.79","1 through 10","3975","26923.07","case rate",""
"Dental And Oral Diseases Without Cc/McC","159","MS-DRG","","","","","","","","inpatient","","","16054.52","9632.71","MEDICARE [2001]","HB WDH MEDICARE","5831.19","","Case rate ($5,831.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,416.39, add-ons for qualifying new technology services are included. If operating cost exceeds $9,334.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,198.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,992.72 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,971.52 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $393.60. The transfer capital threshold is the transfer adjustment factor * $393.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","654.06","654.06","654.06","1 through 10","3975","26923.07","other","Inpatient DRG"
"Dental And Oral Diseases Without Cc/McC","159","MS-DRG","","","","","","","","inpatient","","","16054.52","9632.71","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","5831.19","","Case rate ($5,831.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,416.39, add-ons for qualifying new technology services are included. If operating cost exceeds $9,334.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,198.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,992.72 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,971.52 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $393.60. The transfer capital threshold is the transfer adjustment factor * $393.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5434.80","5434.80","5434.80","1 through 10","3975","26923.07","other","Inpatient DRG"
"Deoxyribonuclease (Dna) Antibody","PX-30000805","CDM","86215","CPT","0302","RC","","","","both","","","71.00","42.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","49.56","69.8","","48.16","48.16","48.16","1 through 10","8.61","67.73","percent of total billed charges",""
"Deoxyribonuclease (Dna) Antibody","PX-30000805","CDM","86215","CPT","0302","RC","","","","outpatient","","","71.00","42.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","44.57","62.78","","30.17","30.17","30.17","1 through 10","12.34","54.95","percent of total billed charges",""
"Deoxyribonuclease (Dna) Antibody","PX-30000805","CDM","86215","CPT","0302","RC","","","","outpatient","","","71.00","42.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","44.66","62.9","","43.47","43.47","43.47","1 through 10","12.34","54.95","percent of total billed charges",""
"Dest Lesion Vulva Smp","PX-76001333","CDM","56501","CPT","0761","RC","","","","both","","","5331.00","3198.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1872.88","","APC Price ($1,911.11). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1880.75","1880.75","1880.75","1 through 10","1872.88","12213.74","other","OPPS APC"
"Dest Lesion Vulva Smp","PX-76001333","CDM","56501","CPT","0761","RC","","","","outpatient","","","5331.00","3198.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","768.73","14.42","","1296.43","1296.43","1296.43","1 through 10","620","4126.19","percent of total billed charges",""
"Dest Nerve Cerv/Thor Sgl","PX-76001585","CDM","64633","CPT","0761","RC","","","","both","","","10995.00","6597.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","2040.18","","APC Price ($2,040.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2007.75","2007.51","2007.77","22","1999.37","13038.64","other","OPPS APC"
"Dest Nerve Cerv/Thor Sgl","PX-76001585","CDM","64633","CPT","0761","RC","","","","outpatient","","","10995.00","6597.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","7715.59","7715.59","7715.59","1 through 10","1278.72","8510.13","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Dest Nerve Cerv/Thor Sgl Ea Add","PX-76001586","CDM","64634","CPT","0761","RC","","","","outpatient","","","3323.00","1993.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","2332.13","2332.13","5826.72","1 through 10","386.46","2572","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Dest Nerve Lumbar/Sacral Ea Add","PX-76001588","CDM","64636","CPT","0761","RC","","","","both","","","2914.00","1748.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","2812.00","2812.00","2812.00","1 through 10","1658.07","2476.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Dest Nerve Lumbar/Sacral Ea Add","PX-76001588","CDM","64636","CPT","0761","RC","","","","outpatient","","","2914.00","1748.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","19301.34","4089.77","19301.34","1 through 10","338.9","2255.44","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Dest Nerve Lumbar/Sacral Ea Add","PX-76001588","CDM","64636","CPT","0761","RC","","","","outpatient","","","2914.00","1748.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2255.44","77.4","","2179.30","2044.89","2179.30","1 through 10","338.9","2255.44","percent of total billed charges",""
"Dest Nerve Lumbar/Sacral Sgl","PX-76001587","CDM","64635","CPT","0761","RC","","","","both","","","10839.00","6503.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","10539.01","","Case rate ($10,539.01). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9884.24","9884.24","9884.24","1 through 10","1999.37","13038.64","other","OPPS APC"
"Dest Nerve Lumbar/Sacral Sgl","PX-76001587","CDM","64635","CPT","0761","RC","","","","both","","","10839.00","6503.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","2040.18","","APC Price ($2,040.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2007.51","1851.52","2007.77","48","1999.37","13038.64","other","OPPS APC"
"Dest Nerve Lumbar/Sacral Sgl","PX-76001587","CDM","64635","CPT","0761","RC","","","","outpatient","","","10839.00","6503.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","15211.57","15211.57","15211.57","1 through 10","1260.58","8389.39","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Dest Nerve Lumbar/Sacral Sgl","PX-76001587","CDM","64635","CPT","0761","RC","","","","outpatient","","","10839.00","6503.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8389.39","77.4","","8105.73","7605.78","8105.73","1 through 10","1260.58","8389.39","percent of total billed charges",""
"Dest Nerve Neurolytic Peripheral","PX-76001589","CDM","64640","CPT","0761","RC","","","","both","","","4627.00","2776.20","MEDICARE [2001]","HB WDH MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","666.07","620.16","930.25","1 through 10","911.54","5944.45","other","OPPS APC"
"Dest Nerve Neurolytic Peripheral","PX-76001589","CDM","64640","CPT","0761","RC","","","","both","","","4627.00","2776.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1373.06","1373.06","1373.06","1 through 10","911.54","5944.45","other","OPPS APC"
"Dest Nerve Neurolytic Peripheral|BILATERAL PROCEDURE","PX-76001589","CDM","64640","CPT","0761","RC","","","50","both","","","4627.00","2776.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","958.04","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1419.50","1419.50","1419.50","1 through 10","911.54","958.04","other","OPPS APC"
"Dest Nerve Neurolytic Peripheral|BILATERAL PROCEDURE","PX-76001589","CDM","64640","CPT","0761","RC","","","50","both","","","4627.00","2776.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1368.37","1367.47","1368.37","1 through 10","911.54","958.04","other","OPPS APC"
"Dest Nerve Neurolytic Peripheral|BILATERAL PROCEDURE","PX-76001589","CDM","64640","CPT","0761","RC","","","50","both","","","4627.00","2776.20","MEDICARE [2001]","HB WDH MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1395.37","1332.14","2790.74","1 through 10","911.54","958.04","other","OPPS APC"
"Dest Nerve Neurolytic Peripheral|BILATERAL PROCEDURE","PX-76001589","CDM","64640","CPT","0761","RC","","","50","both","","","4627.00","2776.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1395.37","1395.37","1395.37","1 through 10","911.54","958.04","other","OPPS APC"
"Dest Nerve Neurolytic Peripheral|BILATERAL PROCEDURE","PX-76001589","CDM","64640","CPT","0761","RC","","","50","both","","","4627.00","2776.20","WELLSENSE NH [1050]","HB WDH MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","18960.25","18960.25","18960.25","1 through 10","911.54","958.04","other","OPPS APC"
"Dest Nerve Neurolytic Pudendal","PX-76001584","CDM","64630","CPT","0761","RC","","","","outpatient","","","9263.00","5557.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","6500.44","6500.44","6500.44","1 through 10","1077.29","7169.56","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Destruction Neurolytic Agt Genicular Nerve W/Img","PX-76002665","CDM","64624","CPT","0761","RC","","","","both","","","7195.00","4317.00","MEDICARE [2001]","HB WDH MEDICARE","2040.18","","APC Price ($2,040.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2040.41","2040.41","2040.41","1 through 10","1999.37","13038.64","other","OPPS APC"
"Destruction Neurolytic Agt Genicular Nerve W/Img","PX-76002665","CDM","64624","CPT","0761","RC","","","","both","","","7195.00","4317.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","2040.18","","APC Price ($2,040.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2007.51","1851.15","2025.69","1 through 10","1999.37","13038.64","other","OPPS APC"
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","925.11","555.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","107.59","786.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","925.11","555.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","107.59","786.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","925.11","555.07","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","526.39","56.9","","812.12","238.65","1587.46","163","107.59","786.34","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","925.11","555.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","107.59","11.63","","112.68","112.68","146.99","38","107.59","786.34","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","925.11","555.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","716.04","77.4","","303.98","303.98","5854.79","1 through 10","107.59","786.34","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","925.11","555.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","107.59","11.63","","112.68","112.68","146.99","38","107.59","716.04","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","925.11","555.07","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","580.78","62.78","","780.86","208.94","10480.28","15","107.59","716.04","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","925.11","555.07","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","404.46","43.72","","179.76","179.76","179.76","1 through 10","107.59","716.04","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","925.11","555.07","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","672.74","72.72","","2355.45","298.99","3965.19","155","107.59","716.04","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","925.11","555.07","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","672.74","72.72","","3643.09","3643.09","3643.09","1 through 10","107.59","716.04","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","925.11","555.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","492.34","53.22","","554.28","554.28","554.28","16","107.59","716.04","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","925.11","555.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","581.89","62.9","","619.64","173.09","2370.64","150","107.59","716.04","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","925.11","555.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","716.04","77.4","","303.98","303.98","5854.79","1 through 10","107.59","716.04","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.05","1251.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","242.49","1772.29","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.05","1251.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","242.49","1772.29","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.05","1251.03","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1186.39","56.9","","812.12","238.65","1587.46","163","242.49","1772.29","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.05","1251.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","242.49","11.63","","112.68","112.68","146.99","38","242.49","1772.29","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.05","1251.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1613.83","77.4","","303.98","303.98","5854.79","1 through 10","242.49","1772.29","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2085.05","1251.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","242.49","11.63","","112.68","112.68","146.99","38","242.49","1613.83","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2085.05","1251.03","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1308.99","62.78","","780.86","208.94","10480.28","15","242.49","1613.83","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2085.05","1251.03","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","911.58","43.72","","179.76","179.76","179.76","1 through 10","242.49","1613.83","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2085.05","1251.03","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1516.25","72.72","","2355.45","298.99","3965.19","155","242.49","1613.83","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2085.05","1251.03","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1516.25","72.72","","3643.09","3643.09","3643.09","1 through 10","242.49","1613.83","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2085.05","1251.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1109.66","53.22","","554.28","554.28","554.28","16","242.49","1613.83","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2085.05","1251.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1311.50","62.9","","619.64","173.09","2370.64","150","242.49","1613.83","percent of total billed charges",""
"DEVICE BROW 3.5MM IMPLANT FIXATION BIOABSORBABLE TINE HEIGHT ENDOTINE FOREHEAD IMPLANTABLE PK/2EA","SUP-ITM-10238788","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2085.05","1251.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1613.83","77.4","","303.98","303.98","5854.79","1 through 10","242.49","1613.83","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","1554.75","932.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","180.82","1321.54","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","1554.75","932.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","180.82","1321.54","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","1554.75","932.85","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","884.65","56.9","","812.12","238.65","1587.46","163","180.82","1321.54","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","1554.75","932.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","180.82","11.63","","112.68","112.68","146.99","38","180.82","1321.54","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","1554.75","932.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1203.38","77.4","","303.98","303.98","5854.79","1 through 10","180.82","1321.54","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1554.75","932.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","180.82","11.63","","112.68","112.68","146.99","38","180.82","1203.38","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1554.75","932.85","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","976.07","62.78","","780.86","208.94","10480.28","15","180.82","1203.38","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1554.75","932.85","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","679.74","43.72","","179.76","179.76","179.76","1 through 10","180.82","1203.38","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1554.75","932.85","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1130.61","72.72","","2355.45","298.99","3965.19","155","180.82","1203.38","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1554.75","932.85","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1130.61","72.72","","3643.09","3643.09","3643.09","1 through 10","180.82","1203.38","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1554.75","932.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","827.44","53.22","","554.28","554.28","554.28","16","180.82","1203.38","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1554.75","932.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","977.94","62.9","","619.64","173.09","2370.64","150","180.82","1203.38","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1554.75","932.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1203.38","77.4","","303.98","303.98","5854.79","1 through 10","180.82","1203.38","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","both","","","5747.25","3448.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","668.41","4885.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","both","","","5747.25","3448.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","668.41","4885.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","both","","","5747.25","3448.35","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3270.19","56.9","","812.12","238.65","1587.46","163","668.41","4885.16","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","both","","","5747.25","3448.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","668.41","11.63","","112.68","112.68","146.99","38","668.41","4885.16","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","both","","","5747.25","3448.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4448.37","77.4","","303.98","303.98","5854.79","1 through 10","668.41","4885.16","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5747.25","3448.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","668.41","11.63","","112.68","112.68","146.99","38","668.41","4448.37","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5747.25","3448.35","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3608.12","62.78","","780.86","208.94","10480.28","15","668.41","4448.37","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5747.25","3448.35","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2512.70","43.72","","179.76","179.76","179.76","1 through 10","668.41","4448.37","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5747.25","3448.35","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4179.40","72.72","","2355.45","298.99","3965.19","155","668.41","4448.37","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5747.25","3448.35","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4179.40","72.72","","3643.09","3643.09","3643.09","1 through 10","668.41","4448.37","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5747.25","3448.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3058.69","53.22","","554.28","554.28","554.28","16","668.41","4448.37","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5747.25","3448.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3615.02","62.9","","619.64","173.09","2370.64","150","668.41","4448.37","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5747.25","3448.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4448.37","77.4","","303.98","303.98","5854.79","1 through 10","668.41","4448.37","percent of total billed charges",""
"DEVICE LOCKDOWN 9CM ACROMIOCLAVICULAR AC","SUP-ITM-10171411","CDM","C1776","HCPCS","0278","RC","","","","both","","","9991.00","5994.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1161.95","8492.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DEVICE LOCKDOWN 9CM ACROMIOCLAVICULAR AC","SUP-ITM-10171411","CDM","C1776","HCPCS","0278","RC","","","","both","","","9991.00","5994.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5684.88","56.9","","2911.53","1863.86","5209.05","65","1161.95","8492.35","percent of total billed charges",""
"DEVICE LOCKDOWN 9CM ACROMIOCLAVICULAR AC","SUP-ITM-10171411","CDM","C1776","HCPCS","0278","RC","","","","both","","","9991.00","5994.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1161.95","11.63","","400.94","400.94","400.94","1 through 10","1161.95","8492.35","percent of total billed charges",""
"DEVICE LOCKDOWN 9CM ACROMIOCLAVICULAR AC","SUP-ITM-10171411","CDM","C1776","HCPCS","0278","RC","","","","both","","","9991.00","5994.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7733.03","77.4","","5214.50","5214.50","16415.28","1 through 10","1161.95","8492.35","percent of total billed charges",""
"DEVICE LOCKDOWN 9CM ACROMIOCLAVICULAR AC","SUP-ITM-10171411","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9991.00","5994.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1161.95","11.63","","400.94","400.94","400.94","1 through 10","1161.95","7733.03","percent of total billed charges",""
"DEVICE LOCKDOWN 9CM ACROMIOCLAVICULAR AC","SUP-ITM-10171411","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9991.00","5994.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4368.07","43.72","","1543.33","1543.33","1671.61","1 through 10","1161.95","7733.03","percent of total billed charges",""
"DEVICE LOCKDOWN 9CM ACROMIOCLAVICULAR AC","SUP-ITM-10171411","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9991.00","5994.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7265.46","72.72","","3700.21","2382.07","6427.18","53","1161.95","7733.03","percent of total billed charges",""
"DEVICE LOCKDOWN 9CM ACROMIOCLAVICULAR AC","SUP-ITM-10171411","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9991.00","5994.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7265.46","72.72","","12685.80","12685.80","12685.80","1 through 10","1161.95","7733.03","percent of total billed charges",""
"DEVICE LOCKDOWN 9CM ACROMIOCLAVICULAR AC","SUP-ITM-10171411","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9991.00","5994.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6284.34","62.9","","3408.87","2784.05","9859.40","46","1161.95","7733.03","percent of total billed charges",""
"DEVICE LOCKDOWN 9CM ACROMIOCLAVICULAR AC","SUP-ITM-10171411","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9991.00","5994.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7733.03","77.4","","5214.50","5214.50","16415.28","1 through 10","1161.95","7733.03","percent of total billed charges",""
"DEVICE RETRIVAL DEPLOYMENT URETER LITHOVUE EMPOWER DISPOSABLE","SUP-ITM-10237966","CDM","C2617","HCPCS","0278","RC","","","","both","","","1071.05","642.63","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","764.25","764.25","764.25","1 through 10","124.56","910.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DEVICE RETRIVAL DEPLOYMENT URETER LITHOVUE EMPOWER DISPOSABLE","SUP-ITM-10237966","CDM","C2617","HCPCS","0278","RC","","","","both","","","1071.05","642.63","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","609.43","56.9","","434.86","434.86","472.36","15","124.56","910.39","percent of total billed charges",""
"DEVICE RETRIVAL DEPLOYMENT URETER LITHOVUE EMPOWER DISPOSABLE","SUP-ITM-10237966","CDM","C2617","HCPCS","0278","RC","","","","both","","","1071.05","642.63","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","609.43","56.9","","434.86","434.86","434.86","1 through 10","124.56","910.39","percent of total billed charges",""
"DEVICE RETRIVAL DEPLOYMENT URETER LITHOVUE EMPOWER DISPOSABLE","SUP-ITM-10237966","CDM","C2617","HCPCS","0278","RC","","","","both","","","1071.05","642.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","124.56","11.63","","105.24","93.54","105.24","1 through 10","124.56","910.39","percent of total billed charges",""
"DEVICE RETRIVAL DEPLOYMENT URETER LITHOVUE EMPOWER DISPOSABLE","SUP-ITM-10237966","CDM","C2617","HCPCS","0278","RC","","","","both","","","1071.05","642.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","828.99","77.4","","592.29","592.29","592.29","1 through 10","124.56","910.39","percent of total billed charges",""
"DEVICE RETRIVAL DEPLOYMENT URETER LITHOVUE EMPOWER DISPOSABLE","SUP-ITM-10237966","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1071.05","642.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","124.56","11.63","","105.24","93.54","105.24","1 through 10","124.56","828.99","percent of total billed charges",""
"DEVICE RETRIVAL DEPLOYMENT URETER LITHOVUE EMPOWER DISPOSABLE","SUP-ITM-10237966","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1071.05","642.63","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","468.26","43.72","","334.13","334.13","334.13","1 through 10","124.56","828.99","percent of total billed charges",""
"DEVICE RETRIVAL DEPLOYMENT URETER LITHOVUE EMPOWER DISPOSABLE","SUP-ITM-10237966","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1071.05","642.63","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","778.87","72.72","","555.76","555.76","555.76","1 through 10","124.56","828.99","percent of total billed charges",""
"DEVICE RETRIVAL DEPLOYMENT URETER LITHOVUE EMPOWER DISPOSABLE","SUP-ITM-10237966","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1071.05","642.63","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","778.87","72.72","","555.76","555.76","555.76","1 through 10","124.56","828.99","percent of total billed charges",""
"DEVICE RETRIVAL DEPLOYMENT URETER LITHOVUE EMPOWER DISPOSABLE","SUP-ITM-10237966","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1071.05","642.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","570.01","53.22","","859.65","859.65","859.65","1 through 10","124.56","828.99","percent of total billed charges",""
"DEVICE RETRIVAL DEPLOYMENT URETER LITHOVUE EMPOWER DISPOSABLE","SUP-ITM-10237966","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1071.05","642.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","673.69","62.9","","481.48","481.48","481.48","1 through 10","124.56","828.99","percent of total billed charges",""
"DEVICE RETRIVAL DEPLOYMENT URETER LITHOVUE EMPOWER DISPOSABLE","SUP-ITM-10237966","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1071.05","642.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","828.99","77.4","","592.29","592.29","592.29","1 through 10","124.56","828.99","percent of total billed charges",""
"DEVICE TRANSORAL REFLUX ESOPHYX Z EA","SUP-ITM-10215200","CDM","C1889","HCPCS","0278","RC","","","","both","","","19500.00","11700.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","2267.85","16575","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DEVICE TRANSORAL REFLUX ESOPHYX Z EA","SUP-ITM-10215200","CDM","C1889","HCPCS","0278","RC","","","","both","","","19500.00","11700.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","2267.85","16575","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DEVICE TRANSORAL REFLUX ESOPHYX Z EA","SUP-ITM-10215200","CDM","C1889","HCPCS","0278","RC","","","","both","","","19500.00","11700.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","11095.50","56.9","","0.63","0.63","0.63","1 through 10","2267.85","16575","percent of total billed charges",""
"DEVICE TRANSORAL REFLUX ESOPHYX Z EA","SUP-ITM-10215200","CDM","C1889","HCPCS","0278","RC","","","","both","","","19500.00","11700.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2811.90","14.42","","317.14","317.14","317.14","1 through 10","2267.85","16575","percent of total billed charges",""
"DEVICE TRANSORAL REFLUX ESOPHYX Z EA","SUP-ITM-10215200","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","19500.00","11700.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2811.90","14.42","","317.14","317.14","317.14","1 through 10","2267.85","15093","percent of total billed charges",""
"DEVICE TRANSORAL REFLUX ESOPHYX Z EA","SUP-ITM-10215200","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","19500.00","11700.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","12242.10","62.78","","1125.09","1125.09","1125.09","1 through 10","2267.85","15093","percent of total billed charges",""
"DEVICE TRANSORAL REFLUX ESOPHYX Z EA","SUP-ITM-10215200","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","19500.00","11700.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","14180.40","72.72","","4732.50","1617.43","14180.40","1 through 10","2267.85","15093","percent of total billed charges",""
"DEVICE TRANSORAL REFLUX ESOPHYX Z EA","SUP-ITM-10215200","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","19500.00","11700.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","12265.50","62.9","","3896.20","3341.38","3896.20","1 through 10","2267.85","15093","percent of total billed charges",""
"Dfci Lamotrigine (Lamictral)","PX-30001725","CDM","80175","CPT","0301","RC","","","","both","","","71.00","42.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","49.56","69.8","","43.40","43.40","48.16","1 through 10","8.61","67.73","percent of total billed charges",""
"Dfci Lamotrigine (Lamictral)","PX-30001725","CDM","80175","CPT","0301","RC","","","","both","","","71.00","42.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","60.35","85","","16.56","16.56","16.56","1 through 10","8.61","67.73","percent of total billed charges",""
"Dfci Lamotrigine (Lamictral)","PX-30001725","CDM","80175","CPT","0301","RC","","","","outpatient","","","71.00","42.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","51.63","72.72","","50.18","50.18","150.54","11","11.77","54.95","percent of total billed charges",""
"Dfci Lamotrigine (Lamictral)","PX-30001725","CDM","80175","CPT","0301","RC","","","","outpatient","","","71.00","42.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","44.66","62.9","","43.47","43.47","43.47","1 through 10","11.77","54.95","percent of total billed charges",""
"Dfci Lamotrigine (Lamictral)","PX-30001725","CDM","80175","CPT","0301","RC","","","","outpatient","","","71.00","42.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","54.95","77.4","","53.48","51.22","53.48","1 through 10","11.77","54.95","percent of total billed charges",""
"Dfci Lamotrigine (Lamictral)","PX-30001725","CDM","80175","CPT","0301","RC","","","","outpatient","","","71.00","42.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","51.63","72.72","","50.18","50.18","50.18","1 through 10","11.77","54.95","percent of total billed charges",""
"DHEA","PX-30000404","CDM","82626","CPT","0301","RC","","","","both","","","136.00","81.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","94.93","69.8","","92.14","92.14","92.14","1 through 10","16.43","130.94","percent of total billed charges",""
"DHEA","PX-30000404","CDM","82626","CPT","0301","RC","","","","outpatient","","","136.00","81.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","98.90","72.72","","95.99","95.99","95.99","1 through 10","23.54","105.26","percent of total billed charges",""
"DHEA","PX-30000404","CDM","82626","CPT","0301","RC","","","","outpatient","","","136.00","81.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","85.54","62.9","","83.16","83.16","83.16","1 through 10","23.54","105.26","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","both","","","120.00","72.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","83.76","69.8","","80.97","72.96","80.97","18","14.45","114.38","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","both","","","120.00","72.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","102.00","85","","20.01","20.01","20.01","1 through 10","14.45","114.38","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","outpatient","","","120.00","72.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","75.34","62.78","","72.82","50.72","72.82","1 through 10","20.72","92.88","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","outpatient","","","120.00","72.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","52.46","43.72","","50.72","50.72","50.72","1 through 10","20.72","92.88","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","outpatient","","","120.00","72.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","87.26","72.72","","84.36","84.36","84.36","18","20.72","92.88","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","outpatient","","","120.00","72.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","87.26","72.72","","84.36","84.36","84.36","1 through 10","20.72","92.88","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","outpatient","","","120.00","72.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","75.48","62.9","","73.08","73.08","73.08","33","20.72","92.88","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","outpatient","","","120.00","72.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","92.88","77.4","","89.90","89.90","89.90","11","20.72","92.88","percent of total billed charges",""
"Diab Self Mgt Individ Trng 30 Min","PX-94000025","CDM","G0108","HCPCS","0510","RC","","","","both","","","222.00","133.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","154.96","69.8","","134.61","134.61","134.61","1 through 10","154.96","154.96","percent of total billed charges",""
"Diab Self Mgt Individ Trng 30 Min","PX-94000025","CDM","G0108","HCPCS","0942","RC","","","","both","","","222.00","133.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","126.32","56.9","","121.77","116.65","121.77","31","53.69","188.7","percent of total billed charges",""
"Diab Self Mgt Individ Trng 30 Min","PX-94000025","CDM","G0108","HCPCS","0942","RC","","","","outpatient","","","222.00","133.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","32.01","14.42","","30.86","30.86","30.86","16","25.82","171.83","percent of total billed charges",""
"Diab Self Mgt Individ Trng 30 Min","PX-94000025","CDM","G0108","HCPCS","0942","RC","","","","outpatient","","","222.00","133.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","25.82","11.63","","25.28","25.28","54.05","58","25.82","171.83","percent of total billed charges",""
"Diab Self Mgt Individ Trng 30 Min","PX-94000025","CDM","G0108","HCPCS","0942","RC","","","","outpatient","","","222.00","133.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","139.37","62.78","","134.35","134.35","134.35","1 through 10","25.82","171.83","percent of total billed charges",""
"Diab Self Mgt Individ Trng 30 Min","PX-94000025","CDM","G0108","HCPCS","0942","RC","","","","outpatient","","","222.00","133.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","161.44","72.72","","155.62","155.62","311.24","29","25.82","171.83","percent of total billed charges",""
"Diab Self Mgt Individ Trng 30 Min","PX-94000025","CDM","G0108","HCPCS","0942","RC","","","","outpatient","","","222.00","133.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","161.44","72.72","","155.62","155.62","155.62","1 through 10","25.82","171.83","percent of total billed charges",""
"Diab Self Mgt Individ Trng 30 Min","PX-94000025","CDM","G0108","HCPCS","0942","RC","","","","outpatient","","","222.00","133.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","118.15","53.22","","114.09","114.08","114.09","1 through 10","25.82","171.83","percent of total billed charges",""
"Diab Self Mgt Individ Trng 30 Min","PX-94000025","CDM","G0108","HCPCS","0942","RC","","","","outpatient","","","222.00","133.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","139.64","62.9","","134.82","134.82","134.82","1 through 10","25.82","171.83","percent of total billed charges",""
"Diab Self Mgt Individ Trng 30 Min","PX-94000025","CDM","G0108","HCPCS","0942","RC","","","","outpatient","","","222.00","133.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","171.83","77.4","","165.85","165.85","165.85","14","25.82","171.83","percent of total billed charges",""
"Diab Self Mgt Individ Trng 30 Min","PX-94000025","CDM","G0108","HCPCS","0942","RC","","","","outpatient","","","222.00","133.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","161.44","72.72","","155.62","155.62","155.62","1 through 10","25.82","171.83","percent of total billed charges",""
"Diab Self Mgt Individ Trng 30 Min","PX-94000025","CDM","G0108","HCPCS","0942","RC","","","","outpatient","","","222.00","133.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","25.82","11.63","","25.28","25.28","25.28","49","25.82","171.83","percent of total billed charges",""
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","21539.05","12923.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","34055.69","","Fee schedule rate ($34,055.69). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","18069.41","18069.41","18069.41","1 through 10","3975","34055.69","case rate",""
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","21539.05","12923.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","13409.73","","Fee schedule rate ($13,409.73). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","13389.22","13389.22","13389.22","1 through 10","3975","34055.69","case rate",""
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","21539.05","12923.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","7113.01","","Case rate ($7,258.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,733.48, add-ons for qualifying new technology services are included. If operating cost exceeds $10,651.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,302.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,315.42 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,288.60 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $497.88. The transfer capital threshold is the transfer adjustment factor * $497.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7218.26","7218.26","7269.13","1 through 10","3975","34055.69","other","Inpatient DRG"
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","21539.05","12923.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","27123.74","","Fee schedule rate ($27,123.74). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","27082.25","27082.25","27082.25","1 through 10","3975","34055.69","case rate",""
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","21539.05","12923.43","MARTIN'S POINT [160007]","HB WDH MEDICARE","7258.17","","Case rate ($7,258.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,733.48, add-ons for qualifying new technology services are included. If operating cost exceeds $10,651.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,302.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,315.42 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,288.60 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $497.88. The transfer capital threshold is the transfer adjustment factor * $497.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6375.64","6375.64","6375.64","1 through 10","3975","34055.69","other","Inpatient DRG"
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","21539.05","12923.43","MEDICARE [2001]","HB WDH MEDICARE","7258.17","","Case rate ($7,258.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,733.48, add-ons for qualifying new technology services are included. If operating cost exceeds $10,651.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,302.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,315.42 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,288.60 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $497.88. The transfer capital threshold is the transfer adjustment factor * $497.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7365.57","0.05","7383.60","22","3975","34055.69","other","Inpatient DRG"
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","21539.05","12923.43","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7258.17","","Case rate ($7,258.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,733.48, add-ons for qualifying new technology services are included. If operating cost exceeds $10,651.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,302.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,315.42 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,288.60 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $497.88. The transfer capital threshold is the transfer adjustment factor * $497.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7365.57","5070.89","7383.60","1 through 10","3975","34055.69","other","Inpatient DRG"
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","35697.92","21418.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","54594.74","","Fee schedule rate ($54,594.74). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","53989.80","53989.80","53989.80","1 through 10","4637","54594.74","case rate",""
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","35697.92","21418.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","21497.17","","Fee schedule rate ($21,497.17). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","21258.96","21258.96","21258.96","1 through 10","4637","54594.74","case rate",""
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","35697.92","21418.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","11139.94","","Case rate ($11,367.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,526.14, add-ons for qualifying new technology services are included. If operating cost exceeds $14,444.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,603.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,124.27 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,081.27 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $798.15. The transfer capital threshold is the transfer adjustment factor * $798.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5820.30","5820.30","5820.30","1 through 10","4637","54594.74","other","Inpatient DRG"
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","35697.92","21418.75","MARTIN'S POINT [160007]","HB WDH MEDICARE","11367.29","","Case rate ($11,367.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,526.14, add-ons for qualifying new technology services are included. If operating cost exceeds $14,444.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,603.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,124.27 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,081.27 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $798.15. The transfer capital threshold is the transfer adjustment factor * $798.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11255.27","11255.27","11255.27","1 through 10","4637","54594.74","other","Inpatient DRG"
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","35697.92","21418.75","MEDICARE [2001]","HB WDH MEDICARE","11367.29","","Case rate ($11,367.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,526.14, add-ons for qualifying new technology services are included. If operating cost exceeds $14,444.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,603.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,124.27 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,081.27 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $798.15. The transfer capital threshold is the transfer adjustment factor * $798.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11433.38","0.05","21774.34","20","4637","54594.74","other","Inpatient DRG"
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","35697.92","21418.75","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","11367.29","","Case rate ($11,367.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,526.14, add-ons for qualifying new technology services are included. If operating cost exceeds $14,444.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,603.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,124.27 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,081.27 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $798.15. The transfer capital threshold is the transfer adjustment factor * $798.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11244.52","11244.52","11462.01","1 through 10","4637","54594.74","other","Inpatient DRG"
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","35697.92","21418.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","29437.98","","Fee schedule rate ($29,437.98). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","28970.18","28970.18","28970.18","1 through 10","4637","54594.74","case rate",""
"Diabetes Without Cc/McC","639","MS-DRG","","","","","","","","inpatient","","","22889.67","13733.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","9294.94","","Fee schedule rate ($9,294.94). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","9147.06","9147.06","9147.06","1 through 10","3975","23605.66","case rate",""
"Diabetes Without Cc/McC","639","MS-DRG","","","","","","","","inpatient","","","22889.67","13733.80","MEDICARE [2001]","HB WDH MEDICARE","5167.50","","Case rate ($5,167.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $4,803.81, add-ons for qualifying new technology services are included. If operating cost exceeds $8,721.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,150.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $4,377.53 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,358.94 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $345.10. The transfer capital threshold is the transfer adjustment factor * $345.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5185.14","5185.14","5185.14","1 through 10","3975","23605.66","other","Inpatient DRG"
"Diagnostic Bone Marrow Biopsies & Aspirations","PX-76002481","CDM","38222","CPT","0761","RC","","","","both","","","8708.00","5224.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","3049.96","","APC Price ($2,990.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","2990.50","2990.50","2990.50","1 through 10","2930.35","19109.85","other","OPPS APC"
"Diagnostic Bone Marrow Biopsies & Aspirations","PX-76002481","CDM","38222","CPT","0761","RC","","","","both","","","8708.00","5224.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","19109.85","","Case rate ($19,109.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8403.00","8403.00","8403.00","1 through 10","2930.35","19109.85","other","OPPS APC"
"Diagnostic Bone Marrow Biopsies & Aspirations","PX-76002481","CDM","38222","CPT","0761","RC","","","","both","","","8708.00","5224.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","8228.68","","Case rate ($8,228.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7749.44","7749.44","7749.44","1 through 10","2930.35","19109.85","other","OPPS APC"
"Diagnostic Bone Marrow Biopsies & Aspirations","PX-76002481","CDM","38222","CPT","0761","RC","","","","both","","","8708.00","5224.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4954.85","56.9","","4781.31","4781.31","4781.31","1 through 10","2930.35","19109.85","percent of total billed charges",""
"Diagnostic Bone Marrow Biopsies & Aspirations","PX-76002481","CDM","38222","CPT","0761","RC","","","","both","","","8708.00","5224.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","2990.16","","APC Price ($2,990.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2930.69","2713.22","2990.50","1 through 10","2930.35","19109.85","other","OPPS APC"
"Diagnostic Bone Marrow Biopsies & Aspirations","PX-76002481","CDM","38222","CPT","0761","RC","","","","both","","","8708.00","5224.80","MEDICARE [2001]","HB WDH MEDICARE","2990.16","","APC Price ($2,990.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2990.50","2990.50","8971.50","38","2930.35","19109.85","other","OPPS APC"
"Diagnostic Bone Marrow Biopsies & Aspirations","PX-76002481","CDM","38222","CPT","0761","RC","","","","both","","","8708.00","5224.80","TRICARE [160005]","HB WDH MEDICARE","2990.16","","APC Price ($2,990.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2990.50","2990.50","2990.50","1 through 10","2930.35","19109.85","other","OPPS APC"
"Diagnostic Bone Marrow Biopsies & Aspirations","PX-76002481","CDM","38222","CPT","0761","RC","","","","both","","","8708.00","5224.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","2990.16","","APC Price ($2,990.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2938.59","2721.12","2939.69","11","2930.35","19109.85","other","OPPS APC"
"Diagnostic Bone Marrow Biopsies & Aspirations","PX-76002481","CDM","38222","CPT","0761","RC","","","","outpatient","","","8708.00","5224.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","6110.66","6110.66","6110.66","1 through 10","1012.74","6739.99","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Diagnostic Bone Marrow Biopsies & Aspirations","PX-76002481","CDM","38222","CPT","0761","RC","","","","outpatient","","","8708.00","5224.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5477.33","62.9","","5293.89","5293.89","5293.89","1 through 10","1012.74","6739.99","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0350","RC","","","","inpatient","","","4655.00","2793.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3577.83","76.86","","2829.96","2829.96","2829.96","1 through 10","3081.61","3577.83","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","4655.00","2793.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","3135.42","3135.42","3135.42","1 through 10","182.27","3956.75","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","4655.00","2793.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1188.62","","Case rate ($1,188.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2834.42","1159.63","2842.38","29","182.27","3956.75","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","4655.00","2793.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","511.82","","Case rate ($511.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1220.51","499.34","1223.94","82","182.27","3956.75","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","4655.00","2793.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","182.27","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","445.56","182.29","454.65","104","182.27","3956.75","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","4655.00","2793.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","960.75","","Case rate ($960.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2291.02","937.31","2291.02","34","182.27","3956.75","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","4655.00","2793.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2648.70","56.9","","2555.95","2555.95","2555.95","60","182.27","3956.75","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","4655.00","2793.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","3135.42","2914.18","3135.42","1 through 10","182.27","3956.75","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","4655.00","2793.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","191.57","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","458.92","191.59","468.29","67","182.27","3956.75","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","4655.00","2793.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","447.38","183.03","454.65","125","182.27","3956.75","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","4655.00","2793.00","MEDICARE [2001]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","454.65","186.01","454.65","291","182.27","3956.75","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","4655.00","2793.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","3956.75","85","","2451.82","2451.82","2451.82","1 through 10","182.27","3956.75","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","4655.00","2793.00","TRICARE [160005]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","454.65","117.37","454.65","1 through 10","182.27","3956.75","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","4655.00","2793.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","445.76","185.29","454.65","251","182.27","3956.75","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","4655.00","2793.00","WELLPOINT [1015]","HB WDH ANTHEM PPO","960.75","","Case rate ($960.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2291.02","2291.02","2297.45","1 through 10","182.27","3956.75","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","4655.00","2793.00","WELLSENSE NH [1050]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","467.83","193.00","469.43","21","182.27","3956.75","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","4655.00","2793.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","671.25","14.42","","647.75","555.21","647.75","38","541.38","3602.97","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","4655.00","2793.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","541.38","11.63","","530.57","309.27","1134.46","51","541.38","3602.97","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","4655.00","2793.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","981.95","981.95","1963.90","1 through 10","541.38","3602.97","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","4655.00","2793.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","1633.29","1633.29","3266.58","33","541.38","3602.97","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","4655.00","2793.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2928.00","62.9","","2829.96","2829.96","10869.04","28","541.38","3602.97","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","4655.00","2793.00","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3266.58","3266.58","3266.58","1 through 10","541.38","3602.97","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","4655.00","2793.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3602.97","77.4","","3481.30","3481.30","3481.30","12","541.38","3602.97","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","4655.00","2793.00","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","1633.29","1633.29","1633.29","1 through 10","541.38","3602.97","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","4655.00","2793.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","541.38","11.63","","530.57","530.57","727.44","31","541.38","3602.97","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","3479.00","2087.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","2343.19","2343.19","2343.19","1 through 10","108.88","2957.15","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","3479.00","2087.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","692.73","1462.78","33","108.88","2957.15","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","3479.00","2087.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","299.84","64","108.88","2957.15","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","3479.00","2087.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","109.33","108.89","111.11","111","108.88","2957.15","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","3479.00","2087.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","298.29","1182.34","24","108.88","2957.15","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","3479.00","2087.40","CHAMPVA [160001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3220.00","3220.00","3220.00","1 through 10","108.88","2957.15","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","3479.00","2087.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1979.55","56.9","","1910.13","1910.13","1910.13","30","108.88","2957.15","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","3479.00","2087.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","114.44","114.44","114.44","86","108.88","2957.15","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","3479.00","2087.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.33","109.33","111.11","190","108.88","2957.15","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","3479.00","2087.40","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","234.63","265","108.88","2957.15","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","3479.00","2087.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","2957.15","85","","187.61","187.61","187.61","1 through 10","108.88","2957.15","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","3479.00","2087.40","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","2957.15","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","3479.00","2087.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","108.89","111.11","307","108.88","2957.15","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","3479.00","2087.40","WELLPOINT [1015]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","559.93","559.93","1 through 10","108.88","2957.15","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","3479.00","2087.40","WELLSENSE NH [1050]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","115.94","115.19","115.94","30","108.88","2957.15","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","3479.00","2087.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","501.67","14.42","","484.08","414.93","484.08","14","404.61","2692.75","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","3479.00","2087.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","404.61","11.63","","462.26","396.51","847.81","37","404.61","2692.75","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","3479.00","2087.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","","","Payment is accumulated by procedure count. Procedure 1, 62.78% of billed. Procedures 2 - 9999, 31.39% of billed.","3161.28","3161.28","3161.28","1 through 10","404.61","2692.75","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","3479.00","2087.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","1467.68","1467.68","1467.68","1 through 10","404.61","2692.75","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","3479.00","2087.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","2441.21","2441.21","2441.21","27","404.61","2692.75","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","3479.00","2087.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1851.52","53.22","","1789.62","1789.62","1789.62","1 through 10","404.61","2692.75","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","3479.00","2087.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2188.29","62.9","","2114.91","2114.91","2114.91","61","404.61","2692.75","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","3479.00","2087.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2692.75","77.4","","2601.68","2601.68","2601.68","23","404.61","2692.75","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","3479.00","2087.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","404.61","11.63","","396.51","174.94","396.51","24","404.61","2692.75","percent of total billed charges",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","both","","","2503.00","1501.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","1747.09","69.8","","1685.67","1685.67","1685.67","1 through 10","709.05","4623.96","percent of total billed charges",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","both","","","2503.00","1501.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","737.99","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","723.60","723.60","723.60","1 through 10","709.05","4623.96","other","OPPS APC"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","both","","","2503.00","1501.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1991.07","","Case rate ($1,991.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1886.00","1886.00","1886.00","1 through 10","709.05","4623.96","other","OPPS APC"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","both","","","2503.00","1501.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","709.05","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","673.80","673.80","673.80","1 through 10","709.05","4623.96","other","OPPS APC"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","both","","","2503.00","1501.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","3737.50","","Case rate ($3,737.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3646.32","2420.59","3646.32","1 through 10","709.05","4623.96","other","OPPS APC"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","both","","","2503.00","1501.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1424.21","56.9","","2415.00","1374.14","2415.00","1 through 10","709.05","4623.96","percent of total billed charges",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","both","","","2503.00","1501.80","MEDICARE [2001]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","723.60","723.60","723.60","1 through 10","709.05","4623.96","other","OPPS APC"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","both","","","2503.00","1501.80","TRICARE [160005]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","723.60","723.60","723.60","1 through 10","709.05","4623.96","other","OPPS APC"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","both","","","2503.00","1501.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","712.03","668.23","717.03","1 through 10","709.05","4623.96","other","OPPS APC"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","inpatient","","","2503.00","1501.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1923.81","76.86","","1521.45","1521.45","1521.45","1 through 10","1656.99","1923.81","percent of total billed charges",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","outpatient","","","2503.00","1501.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1820.18","72.72","","1756.19","1756.19","1756.19","1 through 10","291.1","1937.32","percent of total billed charges",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","outpatient","","","2503.00","1501.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1820.18","72.72","","1756.19","1756.19","1756.19","1 through 10","291.1","1937.32","percent of total billed charges",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","outpatient","","","2503.00","1501.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1574.39","62.9","","4564.35","1521.45","5679.28","11","291.1","1937.32","percent of total billed charges",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","outpatient","","","2503.00","1501.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1937.32","77.4","","1871.63","1871.63","1871.63","1 through 10","291.1","1937.32","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","1353.00","811.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","944.39","69.8","","911.59","911.59","911.59","1 through 10","111.96","1150.05","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","1353.00","811.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","769.86","56.9","","963.83","963.83","1182.35","68","111.96","1150.05","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","1353.00","811.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","944.39","69.8","","911.59","911.59","911.59","1 through 10","111.96","1150.05","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","1353.00","811.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","1150.05","85","","1110.10","227.35","1110.10","1 through 10","111.96","1150.05","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","outpatient","","","1353.00","811.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","195.10","14.42","","188.33","161.42","188.33","21","157.35","1047.22","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","outpatient","","","1353.00","811.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","157.35","11.63","","179.84","154.25","329.82","35","157.35","1047.22","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","outpatient","","","1353.00","811.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","849.41","62.78","","819.91","819.91","819.91","1 through 10","157.35","1047.22","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","outpatient","","","1353.00","811.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","591.53","43.72","","570.98","570.98","570.98","1 through 10","157.35","1047.22","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","outpatient","","","1353.00","811.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","983.90","72.72","","949.72","949.72","949.72","38","157.35","1047.22","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","outpatient","","","1353.00","811.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","720.07","53.22","","696.23","696.23","696.23","1 through 10","157.35","1047.22","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","outpatient","","","1353.00","811.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","851.04","62.9","","822.78","822.78","822.78","72","157.35","1047.22","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","outpatient","","","1353.00","811.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1047.22","77.4","","1012.15","1012.15","1012.15","25","157.35","1047.22","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","outpatient","","","1353.00","811.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","157.35","11.63","","154.25","154.25","175.56","26","157.35","1047.22","percent of total billed charges",""
"Diagnostic Mammography 2d Digital (Incl. Cad)","PX-40000013","CDM","77065","HCPCS","0401","RC","","","","both","","","1064.00","638.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","742.67","69.8","","716.85","687.53","716.85","1 through 10","87.88","904.4","percent of total billed charges",""
"Diagnostic Mammography 2d Digital (Incl. Cad)","PX-40000013","CDM","77065","HCPCS","0401","RC","","","","both","","","1064.00","638.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","605.42","56.9","","939.31","754.67","939.31","1 through 10","87.88","904.4","percent of total billed charges",""
"Diagnostic Mammography 2d Digital (Incl. Cad)","PX-40000013","CDM","77065","HCPCS","0401","RC","","","","both","","","1064.00","638.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","904.40","85","","1484.10","179.58","1484.10","1 through 10","87.88","904.4","percent of total billed charges",""
"Diagnostic Mammography 2d Digital (Incl. Cad)","PX-40000013","CDM","77065","HCPCS","0401","RC","","","","outpatient","","","1064.00","638.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","773.74","72.72","","746.83","718.75","746.83","1 through 10","123.74","823.54","percent of total billed charges",""
"Diagnostic Mammography 2d Digital (Incl. Cad)","PX-40000013","CDM","77065","HCPCS","0401","RC","","","","outpatient","","","1064.00","638.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","823.54","77.4","","213.46","213.46","213.46","1 through 10","123.74","823.54","percent of total billed charges",""
"Digestive Malignancy With Cc","375","MS-DRG","","","","","","","","inpatient","","","36392.75","21835.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","9447.96","","Case rate ($9,640.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,932.59, add-ons for qualifying new technology services are included. If operating cost exceeds $12,850.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,477.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $8,523.92 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,487.72 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.99. The transfer capital threshold is the transfer adjustment factor * $671.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9550.96","9550.96","9550.96","1 through 10","3975","45964.92","other","Inpatient DRG"
"Digestive Malignancy With Cc","375","MS-DRG","","","","","","","","inpatient","","","36392.75","21835.65","MARTIN'S POINT [160007]","HB WDH MEDICARE","9640.78","","Case rate ($9,640.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,932.59, add-ons for qualifying new technology services are included. If operating cost exceeds $12,850.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,477.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $8,523.92 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,487.72 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.99. The transfer capital threshold is the transfer adjustment factor * $671.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13166.63","13166.63","13166.63","1 through 10","3975","45964.92","other","Inpatient DRG"
"Digestive Malignancy With Cc","375","MS-DRG","","","","","","","","inpatient","","","36392.75","21835.65","MEDICARE [2001]","HB WDH MEDICARE","9640.78","","Case rate ($9,640.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,932.59, add-ons for qualifying new technology services are included. If operating cost exceeds $12,850.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,477.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $8,523.92 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,487.72 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.99. The transfer capital threshold is the transfer adjustment factor * $671.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9716.01","0.05","9716.01","1 through 10","3975","45964.92","other","Inpatient DRG"
"Digestive Malignancy With Cc","375","MS-DRG","","","","","","","","inpatient","","","36392.75","21835.65","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","9640.78","","Case rate ($9,640.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,932.59, add-ons for qualifying new technology services are included. If operating cost exceeds $12,850.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,477.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $8,523.92 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,487.72 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $671.99. The transfer capital threshold is the transfer adjustment factor * $671.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9521.69","9521.69","9521.69","1 through 10","3975","45964.92","other","Inpatient DRG"
"Digestive Malignancy With McC","374","MS-DRG","","","","","","","","inpatient","","","43555.54","26133.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","16370.12","","Case rate ($16,704.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,452.05, add-ons for qualifying new technology services are included. If operating cost exceeds $19,370.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,993.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,071.19 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,007.18 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,188.14. The transfer capital threshold is the transfer adjustment factor * $1,188.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","16048.94","16048.94","16048.94","1 through 10","3975","81270.81","other","Inpatient DRG"
"Digestive Malignancy With McC","374","MS-DRG","","","","","","","","inpatient","","","43555.54","26133.32","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","17205.33","","Case rate ($16,704.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,452.05, add-ons for qualifying new technology services are included. If operating cost exceeds $19,370.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,993.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,071.19 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,007.18 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,188.14. The transfer capital threshold is the transfer adjustment factor * $1,188.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","38417.79","38417.79","38417.79","1 through 10","3975","81270.81","other","Inpatient DRG"
"Digestive Malignancy With McC","374","MS-DRG","","","","","","","","inpatient","","","43555.54","26133.32","MEDICARE [2001]","HB WDH MEDICARE","16704.20","","Case rate ($16,704.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,452.05, add-ons for qualifying new technology services are included. If operating cost exceeds $19,370.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,993.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,071.19 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,007.18 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,188.14. The transfer capital threshold is the transfer adjustment factor * $1,188.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16417.98","16417.98","16417.98","1 through 10","3975","81270.81","other","Inpatient DRG"
"Digestive Malignancy With McC","374","MS-DRG","","","","","","","","inpatient","","","43555.54","26133.32","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","16704.20","","Case rate ($16,704.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,452.05, add-ons for qualifying new technology services are included. If operating cost exceeds $19,370.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,993.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $15,071.19 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,007.18 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,188.14. The transfer capital threshold is the transfer adjustment factor * $1,188.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16048.95","16048.95","16130.21","1 through 10","3975","81270.81","other","Inpatient DRG"
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","847.00","508.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","591.21","69.8","","570.27","570.27","570.27","1 through 10","15.72","719.95","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","847.00","508.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","481.94","56.9","","817.00","817.00","958.17","68","15.72","719.95","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","847.00","508.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","591.21","69.8","","570.27","570.27","570.27","1 through 10","15.72","719.95","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","847.00","508.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","719.95","85","","694.45","449.35","694.45","1 through 10","15.72","719.95","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","outpatient","","","847.00","508.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","122.14","14.42","","117.81","100.98","117.81","20","98.51","655.58","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","outpatient","","","847.00","508.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","98.51","11.63","","112.50","96.50","206.33","35","98.51","655.58","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","outpatient","","","847.00","508.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","450.77","53.22","","435.54","435.54","435.54","1 through 10","98.51","655.58","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","outpatient","","","847.00","508.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","532.76","62.9","","514.71","514.71","514.71","71","98.51","655.58","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","outpatient","","","847.00","508.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","655.58","77.4","","633.18","633.18","633.18","25","98.51","655.58","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","outpatient","","","847.00","508.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","98.51","11.63","","96.50","96.50","96.50","21","98.51","655.58","percent of total billed charges",""
"Digital Breast Tomosynthesis Unilateral","PX-32000399","CDM","77061","CPT","0401","RC","","","","both","","","426.00","255.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","297.35","69.8","","286.88","286.88","286.88","1 through 10","15.72","362.1","percent of total billed charges",""
"Digital Breast Tomosynthesis Unilateral","PX-32000399","CDM","77061","CPT","0401","RC","","","","both","","","426.00","255.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","242.39","56.9","","749.02","375.90","749.02","1 through 10","15.72","362.1","percent of total billed charges",""
"Digital Breast Tomosynthesis Unilateral","PX-32000399","CDM","77061","CPT","0401","RC","","","","both","","","426.00","255.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","362.10","85","","349.35","226.05","349.35","1 through 10","15.72","362.1","percent of total billed charges",""
"Digital Breast Tomosynthesis Unilateral","PX-32000399","CDM","77061","CPT","0401","RC","","","","outpatient","","","426.00","255.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","329.72","77.4","","85.42","85.42","85.42","1 through 10","49.54","329.72","percent of total billed charges",""
"Digoxin (Lanoxin)","PX-30000181","CDM","80162","CPT","0301","RC","","","","outpatient","","","188.00","112.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","118.25","62.9","","213.96","213.96","213.96","1 through 10","12.36","145.51","percent of total billed charges",""
"Dihydrotestosterone (Dht)","PX-30003537","CDM","82642","CPT","0301","RC","","","","outpatient","","","336.00","201.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","260.06","77.4","","251.88","251.88","251.88","1 through 10","146.9","260.06","percent of total billed charges",""
"DILATOR BALLOON 12MM DIA 5.5CM 240 40 TO 50 GUIDEWIRE .035IN GUID GASTROINTESTINAL OBLONG FILL SALINE","SUP-ITM-10074025","CDM","C1726","HCPCS","0272","RC","","","","both","","","2245.75","1347.45","AETNA [1001]","HB WDH AETNA COMMERCIAL","1567.53","69.8","","166.96","137.81","825.49","1 through 10","261.18","1908.89","percent of total billed charges",""
"DILATOR BALLOON 12MM DIA 5.5CM 240 40 TO 50 GUIDEWIRE .035IN GUID GASTROINTESTINAL OBLONG FILL SALINE","SUP-ITM-10074025","CDM","C1726","HCPCS","0272","RC","","","","both","","","2245.75","1347.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1716.86","1716.86","1716.86","1 through 10","261.18","1908.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DILATOR BALLOON 12MM DIA 5.5CM 240 40 TO 50 GUIDEWIRE .035IN GUID GASTROINTESTINAL OBLONG FILL SALINE","SUP-ITM-10074025","CDM","C1726","HCPCS","0272","RC","","","","both","","","2245.75","1347.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","4281.09","1182.65","4281.09","1 through 10","261.18","1908.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DILATOR BALLOON 12MM DIA 5.5CM 240 40 TO 50 GUIDEWIRE .035IN GUID GASTROINTESTINAL OBLONG FILL SALINE","SUP-ITM-10074025","CDM","C1726","HCPCS","0272","RC","","","","both","","","2245.75","1347.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","261.18","11.63","","262.01","27.19","426.66","1 through 10","261.18","1908.89","percent of total billed charges",""
"DILATOR BALLOON 12MM DIA 5.5CM 240 40 TO 50 GUIDEWIRE .035IN GUID GASTROINTESTINAL OBLONG FILL SALINE","SUP-ITM-10074025","CDM","C1726","HCPCS","0272","RC","","","","both","","","2245.75","1347.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1738.21","77.4","","1411.46","916.55","1411.46","1 through 10","261.18","1908.89","percent of total billed charges",""
"DILATOR BALLOON 12MM DIA 5.5CM 240 40 TO 50 GUIDEWIRE .035IN GUID GASTROINTESTINAL OBLONG FILL SALINE","SUP-ITM-10074025","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2245.75","1347.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","261.18","11.63","","262.01","27.19","426.66","1 through 10","261.18","1738.21","percent of total billed charges",""
"DILATOR BALLOON 12MM DIA 5.5CM 240 40 TO 50 GUIDEWIRE .035IN GUID GASTROINTESTINAL OBLONG FILL SALINE","SUP-ITM-10074025","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2245.75","1347.45","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","981.84","43.72","","517.05","517.05","517.05","1 through 10","261.18","1738.21","percent of total billed charges",""
"DILATOR BALLOON 12MM DIA 5.5CM 240 40 TO 50 GUIDEWIRE .035IN GUID GASTROINTESTINAL OBLONG FILL SALINE","SUP-ITM-10074025","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2245.75","1347.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1633.11","72.72","","1556.61","860.02","1914.17","1 through 10","261.18","1738.21","percent of total billed charges",""
"DILATOR BALLOON 12MM DIA 5.5CM 240 40 TO 50 GUIDEWIRE .035IN GUID GASTROINTESTINAL OBLONG FILL SALINE","SUP-ITM-10074025","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2245.75","1347.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1412.58","62.9","","1348.55","745.07","1348.55","19","261.18","1738.21","percent of total billed charges",""
"DILATOR BALLOON 12MM DIA 5.5CM 240 40 TO 50 GUIDEWIRE .035IN GUID GASTROINTESTINAL OBLONG FILL SALINE","SUP-ITM-10074025","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2245.75","1347.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1738.21","77.4","","1411.46","916.55","1411.46","1 through 10","261.18","1738.21","percent of total billed charges",""
"DILATOR BALLOON 12MM DIA 5.5CM 240 40 TO 50 GUIDEWIRE .035IN GUID GASTROINTESTINAL OBLONG FILL SALINE","SUP-ITM-10074025","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2245.75","1347.45","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","1633.11","72.72","","860.02","860.02","860.02","1 through 10","261.18","1738.21","percent of total billed charges",""
"DILATOR BALLOON 6MM DIA 5.5CM 240 40 TO 50 .035IN GASTROINTESTINAL OBLONG FILL SALINE WIRE GUIDED GUI","SUP-ITM-10074028","CDM","C1726","HCPCS","0272","RC","","","","both","","","2245.75","1347.45","AETNA [1001]","HB WDH AETNA COMMERCIAL","1567.53","69.8","","166.96","137.81","825.49","1 through 10","261.18","1908.89","percent of total billed charges",""
"DILATOR BALLOON 6MM DIA 5.5CM 240 40 TO 50 .035IN GASTROINTESTINAL OBLONG FILL SALINE WIRE GUIDED GUI","SUP-ITM-10074028","CDM","C1726","HCPCS","0272","RC","","","","both","","","2245.75","1347.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1716.86","1716.86","1716.86","1 through 10","261.18","1908.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DILATOR BALLOON 6MM DIA 5.5CM 240 40 TO 50 .035IN GASTROINTESTINAL OBLONG FILL SALINE WIRE GUIDED GUI","SUP-ITM-10074028","CDM","C1726","HCPCS","0272","RC","","","","both","","","2245.75","1347.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","4281.09","1182.65","4281.09","1 through 10","261.18","1908.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DILATOR BALLOON 6MM DIA 5.5CM 240 40 TO 50 .035IN GASTROINTESTINAL OBLONG FILL SALINE WIRE GUIDED GUI","SUP-ITM-10074028","CDM","C1726","HCPCS","0272","RC","","","","both","","","2245.75","1347.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","261.18","11.63","","262.01","27.19","426.66","1 through 10","261.18","1908.89","percent of total billed charges",""
"DILATOR BALLOON 6MM DIA 5.5CM 240 40 TO 50 .035IN GASTROINTESTINAL OBLONG FILL SALINE WIRE GUIDED GUI","SUP-ITM-10074028","CDM","C1726","HCPCS","0272","RC","","","","both","","","2245.75","1347.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1738.21","77.4","","1411.46","916.55","1411.46","1 through 10","261.18","1908.89","percent of total billed charges",""
"DILATOR BALLOON 6MM DIA 5.5CM 240 40 TO 50 .035IN GASTROINTESTINAL OBLONG FILL SALINE WIRE GUIDED GUI","SUP-ITM-10074028","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2245.75","1347.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","261.18","11.63","","262.01","27.19","426.66","1 through 10","261.18","1738.21","percent of total billed charges",""
"DILATOR BALLOON 6MM DIA 5.5CM 240 40 TO 50 .035IN GASTROINTESTINAL OBLONG FILL SALINE WIRE GUIDED GUI","SUP-ITM-10074028","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2245.75","1347.45","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","981.84","43.72","","517.05","517.05","517.05","1 through 10","261.18","1738.21","percent of total billed charges",""
"DILATOR BALLOON 6MM DIA 5.5CM 240 40 TO 50 .035IN GASTROINTESTINAL OBLONG FILL SALINE WIRE GUIDED GUI","SUP-ITM-10074028","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2245.75","1347.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1633.11","72.72","","1556.61","860.02","1914.17","1 through 10","261.18","1738.21","percent of total billed charges",""
"DILATOR BALLOON 6MM DIA 5.5CM 240 40 TO 50 .035IN GASTROINTESTINAL OBLONG FILL SALINE WIRE GUIDED GUI","SUP-ITM-10074028","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2245.75","1347.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1412.58","62.9","","1348.55","745.07","1348.55","19","261.18","1738.21","percent of total billed charges",""
"DILATOR BALLOON 6MM DIA 5.5CM 240 40 TO 50 .035IN GASTROINTESTINAL OBLONG FILL SALINE WIRE GUIDED GUI","SUP-ITM-10074028","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2245.75","1347.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1738.21","77.4","","1411.46","916.55","1411.46","1 through 10","261.18","1738.21","percent of total billed charges",""
"DILATOR BALLOON 6MM DIA 5.5CM 240 40 TO 50 .035IN GASTROINTESTINAL OBLONG FILL SALINE WIRE GUIDED GUI","SUP-ITM-10074028","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2245.75","1347.45","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","1633.11","72.72","","860.02","860.02","860.02","1 through 10","261.18","1738.21","percent of total billed charges",""
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","both","","","1182.65","709.59","AETNA [1001]","HB WDH AETNA COMMERCIAL","825.49","69.8","","166.96","137.81","825.49","1 through 10","137.54","1005.25","percent of total billed charges",""
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","both","","","1182.65","709.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1716.86","1716.86","1716.86","1 through 10","137.54","1005.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","both","","","1182.65","709.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","4281.09","1182.65","4281.09","1 through 10","137.54","1005.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","both","","","1182.65","709.59","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","137.54","11.63","","262.01","27.19","426.66","1 through 10","137.54","1005.25","percent of total billed charges",""
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","both","","","1182.65","709.59","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","915.37","77.4","","1411.46","916.55","1411.46","1 through 10","137.54","1005.25","percent of total billed charges",""
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1182.65","709.59","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","137.54","11.63","","262.01","27.19","426.66","1 through 10","137.54","915.37","percent of total billed charges",""
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1182.65","709.59","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","517.05","43.72","","517.05","517.05","517.05","1 through 10","137.54","915.37","percent of total billed charges",""
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1182.65","709.59","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","860.02","72.72","","1556.61","860.02","1914.17","1 through 10","137.54","915.37","percent of total billed charges",""
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1182.65","709.59","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","743.89","62.9","","1348.55","745.07","1348.55","19","137.54","915.37","percent of total billed charges",""
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1182.65","709.59","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","915.37","77.4","","1411.46","916.55","1411.46","1 through 10","137.54","915.37","percent of total billed charges",""
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1182.65","709.59","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","860.02","72.72","","860.02","860.02","860.02","1 through 10","137.54","915.37","percent of total billed charges",""
"DILATOR HERCULES 7FR 18-19-20MM 54-57-60FR 8CM .035IN BALLOON ENDOSCOPIC FLUOROSCOPIC GUIDANCE STERILE LF","SUP-ITM-10073888","CDM","C1726","HCPCS","0272","RC","","","","both","","","1547.84","928.70","AETNA [1001]","HB WDH AETNA COMMERCIAL","1080.39","69.8","","166.96","137.81","825.49","1 through 10","180.01","1315.66","percent of total billed charges",""
"DILATOR HERCULES 7FR 18-19-20MM 54-57-60FR 8CM .035IN BALLOON ENDOSCOPIC FLUOROSCOPIC GUIDANCE STERILE LF","SUP-ITM-10073888","CDM","C1726","HCPCS","0272","RC","","","","both","","","1547.84","928.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1716.86","1716.86","1716.86","1 through 10","180.01","1315.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DILATOR HERCULES 7FR 18-19-20MM 54-57-60FR 8CM .035IN BALLOON ENDOSCOPIC FLUOROSCOPIC GUIDANCE STERILE LF","SUP-ITM-10073888","CDM","C1726","HCPCS","0272","RC","","","","both","","","1547.84","928.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","4281.09","1182.65","4281.09","1 through 10","180.01","1315.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DILATOR HERCULES 7FR 18-19-20MM 54-57-60FR 8CM .035IN BALLOON ENDOSCOPIC FLUOROSCOPIC GUIDANCE STERILE LF","SUP-ITM-10073888","CDM","C1726","HCPCS","0272","RC","","","","both","","","1547.84","928.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","180.01","11.63","","262.01","27.19","426.66","1 through 10","180.01","1315.66","percent of total billed charges",""
"DILATOR HERCULES 7FR 18-19-20MM 54-57-60FR 8CM .035IN BALLOON ENDOSCOPIC FLUOROSCOPIC GUIDANCE STERILE LF","SUP-ITM-10073888","CDM","C1726","HCPCS","0272","RC","","","","both","","","1547.84","928.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1198.03","77.4","","1411.46","916.55","1411.46","1 through 10","180.01","1315.66","percent of total billed charges",""
"DILATOR HERCULES 7FR 18-19-20MM 54-57-60FR 8CM .035IN BALLOON ENDOSCOPIC FLUOROSCOPIC GUIDANCE STERILE LF","SUP-ITM-10073888","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1547.84","928.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","180.01","11.63","","262.01","27.19","426.66","1 through 10","180.01","1198.03","percent of total billed charges",""
"DILATOR HERCULES 7FR 18-19-20MM 54-57-60FR 8CM .035IN BALLOON ENDOSCOPIC FLUOROSCOPIC GUIDANCE STERILE LF","SUP-ITM-10073888","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1547.84","928.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","676.72","43.72","","517.05","517.05","517.05","1 through 10","180.01","1198.03","percent of total billed charges",""
"DILATOR HERCULES 7FR 18-19-20MM 54-57-60FR 8CM .035IN BALLOON ENDOSCOPIC FLUOROSCOPIC GUIDANCE STERILE LF","SUP-ITM-10073888","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1547.84","928.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1125.59","72.72","","1556.61","860.02","1914.17","1 through 10","180.01","1198.03","percent of total billed charges",""
"DILATOR HERCULES 7FR 18-19-20MM 54-57-60FR 8CM .035IN BALLOON ENDOSCOPIC FLUOROSCOPIC GUIDANCE STERILE LF","SUP-ITM-10073888","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1547.84","928.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","973.59","62.9","","1348.55","745.07","1348.55","19","180.01","1198.03","percent of total billed charges",""
"DILATOR HERCULES 7FR 18-19-20MM 54-57-60FR 8CM .035IN BALLOON ENDOSCOPIC FLUOROSCOPIC GUIDANCE STERILE LF","SUP-ITM-10073888","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1547.84","928.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1198.03","77.4","","1411.46","916.55","1411.46","1 through 10","180.01","1198.03","percent of total billed charges",""
"DILATOR HERCULES 7FR 18-19-20MM 54-57-60FR 8CM .035IN BALLOON ENDOSCOPIC FLUOROSCOPIC GUIDANCE STERILE LF","SUP-ITM-10073888","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1547.84","928.70","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","1125.59","72.72","","860.02","860.02","860.02","1 through 10","180.01","1198.03","percent of total billed charges",""
"DILATOR RIGIFLEX II 14FR 4.6MM 120FR 40MM 10CM .038IN BALLOON SINGLE-USE ACHALASIA STERILE","SUP-ITM-10138951","CDM","C1726","HCPCS","0272","RC","","","","both","","","2882.51","1729.51","AETNA [1001]","HB WDH AETNA COMMERCIAL","2011.99","69.8","","166.96","137.81","825.49","1 through 10","335.24","2450.13","percent of total billed charges",""
"DILATOR RIGIFLEX II 14FR 4.6MM 120FR 40MM 10CM .038IN BALLOON SINGLE-USE ACHALASIA STERILE","SUP-ITM-10138951","CDM","C1726","HCPCS","0272","RC","","","","both","","","2882.51","1729.51","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1716.86","1716.86","1716.86","1 through 10","335.24","2450.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DILATOR RIGIFLEX II 14FR 4.6MM 120FR 40MM 10CM .038IN BALLOON SINGLE-USE ACHALASIA STERILE","SUP-ITM-10138951","CDM","C1726","HCPCS","0272","RC","","","","both","","","2882.51","1729.51","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","4281.09","1182.65","4281.09","1 through 10","335.24","2450.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DILATOR RIGIFLEX II 14FR 4.6MM 120FR 40MM 10CM .038IN BALLOON SINGLE-USE ACHALASIA STERILE","SUP-ITM-10138951","CDM","C1726","HCPCS","0272","RC","","","","both","","","2882.51","1729.51","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","335.24","11.63","","262.01","27.19","426.66","1 through 10","335.24","2450.13","percent of total billed charges",""
"DILATOR RIGIFLEX II 14FR 4.6MM 120FR 40MM 10CM .038IN BALLOON SINGLE-USE ACHALASIA STERILE","SUP-ITM-10138951","CDM","C1726","HCPCS","0272","RC","","","","both","","","2882.51","1729.51","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2231.06","77.4","","1411.46","916.55","1411.46","1 through 10","335.24","2450.13","percent of total billed charges",""
"DILATOR RIGIFLEX II 14FR 4.6MM 120FR 40MM 10CM .038IN BALLOON SINGLE-USE ACHALASIA STERILE","SUP-ITM-10138951","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2882.51","1729.51","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","335.24","11.63","","262.01","27.19","426.66","1 through 10","335.24","2231.06","percent of total billed charges",""
"DILATOR RIGIFLEX II 14FR 4.6MM 120FR 40MM 10CM .038IN BALLOON SINGLE-USE ACHALASIA STERILE","SUP-ITM-10138951","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2882.51","1729.51","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1260.23","43.72","","517.05","517.05","517.05","1 through 10","335.24","2231.06","percent of total billed charges",""
"DILATOR RIGIFLEX II 14FR 4.6MM 120FR 40MM 10CM .038IN BALLOON SINGLE-USE ACHALASIA STERILE","SUP-ITM-10138951","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2882.51","1729.51","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2096.16","72.72","","1556.61","860.02","1914.17","1 through 10","335.24","2231.06","percent of total billed charges",""
"DILATOR RIGIFLEX II 14FR 4.6MM 120FR 40MM 10CM .038IN BALLOON SINGLE-USE ACHALASIA STERILE","SUP-ITM-10138951","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2882.51","1729.51","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1813.10","62.9","","1348.55","745.07","1348.55","19","335.24","2231.06","percent of total billed charges",""
"DILATOR RIGIFLEX II 14FR 4.6MM 120FR 40MM 10CM .038IN BALLOON SINGLE-USE ACHALASIA STERILE","SUP-ITM-10138951","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2882.51","1729.51","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2231.06","77.4","","1411.46","916.55","1411.46","1 through 10","335.24","2231.06","percent of total billed charges",""
"DILATOR RIGIFLEX II 14FR 4.6MM 120FR 40MM 10CM .038IN BALLOON SINGLE-USE ACHALASIA STERILE","SUP-ITM-10138951","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2882.51","1729.51","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","2096.16","72.72","","860.02","860.02","860.02","1 through 10","335.24","2231.06","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","both","","","518.46","311.08","AETNA [1001]","HB WDH AETNA COMMERCIAL","361.89","69.8","","94.15","94.15","427.63","1 through 10","60.3","440.69","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","both","","","518.46","311.08","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","60.3","440.69","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","both","","","518.46","311.08","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","295.00","56.9","","401.89","65.85","401.89","1 through 10","60.3","440.69","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","both","","","518.46","311.08","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","60.30","11.63","","49.19","10.57","114.40","19","60.3","440.69","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","both","","","518.46","311.08","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","401.29","77.4","","200.75","81.67","643.86","11","60.3","440.69","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","both","","","518.46","311.08","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","60.3","440.69","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","518.46","311.08","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","60.30","11.63","","49.19","10.57","114.40","19","60.3","401.29","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","518.46","311.08","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","325.49","62.78","","93.27","93.27","93.27","1 through 10","60.3","401.29","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","518.46","311.08","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","226.67","43.72","","363.22","363.22","363.22","1 through 10","60.3","401.29","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","518.46","311.08","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","377.02","72.72","","271.85","111.24","551.69","14","60.3","401.29","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","518.46","311.08","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","326.11","62.9","","706.53","93.60","938.00","53","60.3","401.29","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","518.46","311.08","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","401.29","77.4","","200.75","81.67","643.86","11","60.3","401.29","percent of total billed charges",""
"DILATOR VASCULAR 10FR 20CM .038IN STANDARD PUNCTURE SITE CATHETER TRACT","SUP-ITM-10001328","CDM","C1758","HCPCS","0272","RC","","","","both","","","48.99","29.39","AETNA [1001]","HB WDH AETNA COMMERCIAL","34.20","69.8","","50.27","50.27","50.27","1 through 10","5.7","41.64","percent of total billed charges",""
"DILATOR VASCULAR 10FR 20CM .038IN STANDARD PUNCTURE SITE CATHETER TRACT","SUP-ITM-10001328","CDM","C1758","HCPCS","0272","RC","","","","both","","","48.99","29.39","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","64.87","64.87","64.87","1 through 10","5.7","41.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DILATOR VASCULAR 10FR 20CM .038IN STANDARD PUNCTURE SITE CATHETER TRACT","SUP-ITM-10001328","CDM","C1758","HCPCS","0272","RC","","","","both","","","48.99","29.39","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","5.70","11.63","","28.87","11.98","61.67","1 through 10","5.7","41.64","percent of total billed charges",""
"DILATOR VASCULAR 10FR 20CM .038IN STANDARD PUNCTURE SITE CATHETER TRACT","SUP-ITM-10001328","CDM","C1758","HCPCS","0272","RC","","","","both","","","48.99","29.39","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","37.92","77.4","","162.47","162.47","162.47","1 through 10","5.7","41.64","percent of total billed charges",""
"DILATOR VASCULAR 10FR 20CM .038IN STANDARD PUNCTURE SITE CATHETER TRACT","SUP-ITM-10001328","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","48.99","29.39","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","5.70","11.63","","28.87","11.98","61.67","1 through 10","5.7","37.92","percent of total billed charges",""
"DILATOR VASCULAR 10FR 20CM .038IN STANDARD PUNCTURE SITE CATHETER TRACT","SUP-ITM-10001328","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","48.99","29.39","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","30.76","62.78","","40.73","40.73","40.73","1 through 10","5.7","37.92","percent of total billed charges",""
"DILATOR VASCULAR 10FR 20CM .038IN STANDARD PUNCTURE SITE CATHETER TRACT","SUP-ITM-10001328","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","48.99","29.39","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","21.42","43.72","","91.66","74.28","91.66","1 through 10","5.7","37.92","percent of total billed charges",""
"DILATOR VASCULAR 10FR 20CM .038IN STANDARD PUNCTURE SITE CATHETER TRACT","SUP-ITM-10001328","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","48.99","29.39","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","35.63","72.72","","152.45","47.17","239.03","1 through 10","5.7","37.92","percent of total billed charges",""
"DILATOR VASCULAR 10FR 20CM .038IN STANDARD PUNCTURE SITE CATHETER TRACT","SUP-ITM-10001328","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","48.99","29.39","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","35.63","72.72","","152.45","152.45","152.45","1 through 10","5.7","37.92","percent of total billed charges",""
"DILATOR VASCULAR 10FR 20CM .038IN STANDARD PUNCTURE SITE CATHETER TRACT","SUP-ITM-10001328","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","48.99","29.39","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","26.07","53.22","","72.98","72.98","72.98","1 through 10","5.7","37.92","percent of total billed charges",""
"DILATOR VASCULAR 10FR 20CM .038IN STANDARD PUNCTURE SITE CATHETER TRACT","SUP-ITM-10001328","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","48.99","29.39","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","30.81","62.9","","211.13","40.87","215.56","13","5.7","37.92","percent of total billed charges",""
"DILATOR VASCULAR 10FR 20CM .038IN STANDARD PUNCTURE SITE CATHETER TRACT","SUP-ITM-10001328","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","48.99","29.39","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","37.92","77.4","","162.47","162.47","162.47","1 through 10","5.7","37.92","percent of total billed charges",""
"Dipropylacetic Acid (Valproic)","PX-30000182","CDM","80164","CPT","0301","RC","","","","both","","","192.00","115.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","134.02","69.8","","129.83","116.99","129.83","1 through 10","8.8","163.2","percent of total billed charges",""
"Dipropylacetic Acid (Valproic)","PX-30000182","CDM","80164","CPT","0301","RC","","","","both","","","192.00","115.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","163.20","85","","202.00","202.00","202.00","1 through 10","8.8","163.2","percent of total billed charges",""
"Dipropylacetic Acid (Valproic)","PX-30000182","CDM","80164","CPT","0301","RC","","","","outpatient","","","192.00","115.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","139.62","72.72","","135.26","135.26","135.26","1 through 10","12.62","148.61","percent of total billed charges",""
"Dipropylacetic Acid (Valproic)","PX-30000182","CDM","80164","CPT","0301","RC","","","","outpatient","","","192.00","115.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","139.62","72.72","","135.26","135.26","135.26","1 through 10","12.62","148.61","percent of total billed charges",""
"Dipropylacetic Acid (Valproic)","PX-30000182","CDM","80164","CPT","0301","RC","","","","outpatient","","","192.00","115.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","120.77","62.9","","117.18","117.18","117.18","1 through 10","12.62","148.61","percent of total billed charges",""
"Direct Admission of Patient for Hospital Observation Care","PX-76200007","CDM","G0379","HCPCS","0762","RC","","","","both","","","70.00","42.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1762.72","","Case rate ($1,762.72). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5764.25","5764.25","5764.25","1 through 10","10.09","4093.65","other","OPPS APC"
"Direct Admission of Patient for Hospital Observation Care","PX-76200007","CDM","G0379","HCPCS","0762","RC","","","","both","","","70.00","42.00","MEDICARE [2001]","HB WDH MEDICARE","640.54","","APC Price ($640.54). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2766.56","625.83","2766.56","1 through 10","10.09","4093.65","other","OPPS APC"
"DISC CERVICAL 6X18MM PRESTIGE LP","SUP-ITM-10177841","CDM","C1889","HCPCS","0278","RC","","","","both","","","17725.50","10635.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","2061.48","15066.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DISC CERVICAL 6X18MM PRESTIGE LP","SUP-ITM-10177841","CDM","C1889","HCPCS","0278","RC","","","","both","","","17725.50","10635.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","2061.48","15066.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DISC CERVICAL 6X18MM PRESTIGE LP","SUP-ITM-10177841","CDM","C1889","HCPCS","0278","RC","","","","both","","","17725.50","10635.30","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","10085.81","56.9","","0.63","0.63","0.63","1 through 10","2061.48","15066.68","percent of total billed charges",""
"DISC CERVICAL 6X18MM PRESTIGE LP","SUP-ITM-10177841","CDM","C1889","HCPCS","0278","RC","","","","both","","","17725.50","10635.30","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2556.02","14.42","","317.14","317.14","317.14","1 through 10","2061.48","15066.68","percent of total billed charges",""
"DISC CERVICAL 6X18MM PRESTIGE LP","SUP-ITM-10177841","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","17725.50","10635.30","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2556.02","14.42","","317.14","317.14","317.14","1 through 10","2061.48","13719.54","percent of total billed charges",""
"DISC CERVICAL 6X18MM PRESTIGE LP","SUP-ITM-10177841","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","17725.50","10635.30","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","11128.07","62.78","","1125.09","1125.09","1125.09","1 through 10","2061.48","13719.54","percent of total billed charges",""
"DISC CERVICAL 6X18MM PRESTIGE LP","SUP-ITM-10177841","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","17725.50","10635.30","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","12889.98","72.72","","4732.50","1617.43","14180.40","1 through 10","2061.48","13719.54","percent of total billed charges",""
"DISC CERVICAL 6X18MM PRESTIGE LP","SUP-ITM-10177841","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","17725.50","10635.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","11149.34","62.9","","3896.20","3341.38","3896.20","1 through 10","2061.48","13719.54","percent of total billed charges",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","","","","inpatient","","","39355.96","23613.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","29215.07","","Fee schedule rate ($29,215.07). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","28529.08","28529.08","28529.08","1 through 10","3975","36681.5","case rate",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","","","","inpatient","","","39355.96","23613.58","MEDICARE [2001]","HB WDH MEDICARE","7783.50","","Case rate ($7,783.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,218.35, add-ons for qualifying new technology services are included. If operating cost exceeds $11,136.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,341.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,802.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,773.48 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $536.27. The transfer capital threshold is the transfer adjustment factor * $536.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5013.23","0.05","7754.80","1 through 10","3975","36681.5","other","Inpatient DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","","","","inpatient","","","39355.96","23613.58","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7783.50","","Case rate ($7,783.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,218.35, add-ons for qualifying new technology services are included. If operating cost exceeds $11,136.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,341.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $6,802.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,773.48 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $536.27. The transfer capital threshold is the transfer adjustment factor * $536.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7754.30","7754.30","7754.30","1 through 10","3975","36681.5","other","Inpatient DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With McC","441","MS-DRG","","","","","","","","inpatient","","","39637.80","23782.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","68198.78","","Fee schedule rate ($68,198.78). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","40961.53","40961.53","40961.53","1 through 10","3975","68198.78","case rate",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With McC","441","MS-DRG","","","","","","","","inpatient","","","39637.80","23782.68","MEDICARE [2001]","HB WDH MEDICARE","14088.95","","Case rate ($14,088.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,038.21, add-ons for qualifying new technology services are included. If operating cost exceeds $16,956.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,802.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,647.06 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,593.35 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $997.03. The transfer capital threshold is the transfer adjustment factor * $997.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14708.92","9383.10","14708.92","1 through 10","3975","68198.78","other","Inpatient DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With McC","441","MS-DRG","","","","","","","","inpatient","","","39637.80","23782.68","TRICARE [160005]","HB WDH MEDICARE","14088.95","","Case rate ($14,088.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,038.21, add-ons for qualifying new technology services are included. If operating cost exceeds $16,956.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,802.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,647.06 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,593.35 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $997.03. The transfer capital threshold is the transfer adjustment factor * $997.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9431.17","9431.17","9431.17","1 through 10","3975","68198.78","other","Inpatient DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With McC","441","MS-DRG","","","","","","","","inpatient","","","39637.80","23782.68","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","14088.95","","Case rate ($14,088.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,038.21, add-ons for qualifying new technology services are included. If operating cost exceeds $16,956.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,802.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,647.06 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,593.35 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $997.03. The transfer capital threshold is the transfer adjustment factor * $997.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14708.92","14708.92","14708.92","1 through 10","3975","68198.78","other","Inpatient DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With McC","441","MS-DRG","","","","","","","","inpatient","","","39637.80","23782.68","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","36773.40","","Fee schedule rate ($36,773.40). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","38734.30","38734.30","38734.30","1 through 10","3975","68198.78","case rate",""
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","","","","inpatient","","","28260.41","16956.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","31965.68","","Fee schedule rate ($31,965.68). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","31890.42","31890.42","31890.42","1 through 10","3975","31965.68","case rate",""
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","","","","inpatient","","","28260.41","16956.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","12586.77","","Fee schedule rate ($12,586.77). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","12557.13","12557.13","12557.13","1 through 10","3975","31965.68","case rate",""
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","","","","inpatient","","","28260.41","16956.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","25459.15","","Fee schedule rate ($25,459.15). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","25399.21","25399.21","25399.21","1 through 10","3975","31965.68","case rate",""
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","","","","inpatient","","","28260.41","16956.25","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","7045.25","","Case rate ($6,840.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,347.54, add-ons for qualifying new technology services are included. If operating cost exceeds $10,265.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,272.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,927.85 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,902.67 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $467.32. The transfer capital threshold is the transfer adjustment factor * $467.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","5007.60","5007.60","20098.02","1 through 10","3975","31965.68","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","","","","inpatient","","","28260.41","16956.25","MARTIN'S POINT [160007]","HB WDH MEDICARE","6840.05","","Case rate ($6,840.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,347.54, add-ons for qualifying new technology services are included. If operating cost exceeds $10,265.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,272.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,927.85 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,902.67 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $467.32. The transfer capital threshold is the transfer adjustment factor * $467.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6820.83","6820.83","6820.83","1 through 10","3975","31965.68","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","","","","inpatient","","","28260.41","16956.25","MEDICARE [2001]","HB WDH MEDICARE","6840.05","","Case rate ($6,840.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,347.54, add-ons for qualifying new technology services are included. If operating cost exceeds $10,265.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,272.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,927.85 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,902.67 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $467.32. The transfer capital threshold is the transfer adjustment factor * $467.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6952.38","6935.47","6952.83","1 through 10","3975","31965.68","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","","","","inpatient","","","28260.41","16956.25","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6840.05","","Case rate ($6,840.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,347.54, add-ons for qualifying new technology services are included. If operating cost exceeds $10,265.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,272.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,927.85 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,902.67 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $467.32. The transfer capital threshold is the transfer adjustment factor * $467.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6853.14","6853.14","6853.14","1 through 10","3975","31965.68","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With McC","438","MS-DRG","","","","","","","","inpatient","","","49954.65","29972.79","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","13095.14","","Case rate ($12,838.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,883.93, add-ons for qualifying new technology services are included. If operating cost exceeds $15,802.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,710.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,487.84 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,439.06 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.65. The transfer capital threshold is the transfer adjustment factor * $905.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","5689.48","5689.48","5689.48","1 through 10","3975","61947.76","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With McC","438","MS-DRG","","","","","","","","inpatient","","","49954.65","29972.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","61947.76","","Fee schedule rate ($61,947.76). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","61678.79","61678.79","61678.79","1 through 10","3975","61947.76","case rate",""
"Disorders Of Pancreas Except Malignancy With McC","438","MS-DRG","","","","","","","","inpatient","","","49954.65","29972.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","12581.60","","Case rate ($12,838.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,883.93, add-ons for qualifying new technology services are included. If operating cost exceeds $15,802.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,710.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,487.84 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,439.06 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.65. The transfer capital threshold is the transfer adjustment factor * $905.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12770.47","12770.47","12770.47","1 through 10","3975","61947.76","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With McC","438","MS-DRG","","","","","","","","inpatient","","","49954.65","29972.79","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","13223.52","","Case rate ($12,838.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,883.93, add-ons for qualifying new technology services are included. If operating cost exceeds $15,802.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,710.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,487.84 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,439.06 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.65. The transfer capital threshold is the transfer adjustment factor * $905.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","3789.01","3789.01","3789.01","1 through 10","3975","61947.76","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With McC","438","MS-DRG","","","","","","","","inpatient","","","49954.65","29972.79","MEDICARE [2001]","HB WDH MEDICARE","12838.37","","Case rate ($12,838.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,883.93, add-ons for qualifying new technology services are included. If operating cost exceeds $15,802.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,710.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,487.84 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,439.06 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.65. The transfer capital threshold is the transfer adjustment factor * $905.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13031.03","0.05","13031.90","11","3975","61947.76","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With McC","438","MS-DRG","","","","","","","","inpatient","","","49954.65","29972.79","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","12838.37","","Case rate ($12,838.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,883.93, add-ons for qualifying new technology services are included. If operating cost exceeds $15,802.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,710.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,487.84 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,439.06 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $905.65. The transfer capital threshold is the transfer adjustment factor * $905.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12777.86","12777.86","12777.86","1 through 10","3975","61947.76","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With McC","438","MS-DRG","","","","","","","","inpatient","","","49954.65","29972.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","33402.80","","Fee schedule rate ($33,402.80). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","14958.67","14958.67","14958.67","1 through 10","3975","61947.76","case rate",""
"Disorders Of Pancreas Except Malignancy Without Cc/McC","440","MS-DRG","","","","","","","","inpatient","","","22512.12","13507.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","23613.26","","Fee schedule rate ($23,613.26). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","22803.76","22803.76","22803.76","1 through 10","3975","23613.26","case rate",""
"Disorders Of Pancreas Except Malignancy Without Cc/McC","440","MS-DRG","","","","","","","","inpatient","","","22512.12","13507.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","9297.93","","Fee schedule rate ($9,297.93). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","8979.18","8979.18","8979.18","1 through 10","3975","23613.26","case rate",""
"Disorders Of Pancreas Except Malignancy Without Cc/McC","440","MS-DRG","","","","","","","","inpatient","","","22512.12","13507.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","18806.84","","Fee schedule rate ($18,806.84). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","18162.11","18162.11","18162.11","1 through 10","3975","23613.26","case rate",""
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","","","","inpatient","","","59051.62","35430.97","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","8940.28","","Case rate ($8,764.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,124.24, add-ons for qualifying new technology services are included. If operating cost exceeds $12,042.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,413.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,712.12 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,679.37 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.99. The transfer capital threshold is the transfer adjustment factor * $607.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","1335.78","1335.78","1335.78","1 through 10","3975","41587.31","other","Inpatient DRG"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","","","","inpatient","","","59051.62","35430.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","16375.38","","Fee schedule rate ($16,375.38). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","15831.45","15831.45","15831.45","1 through 10","3975","41587.31","case rate",""
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","","","","inpatient","","","59051.62","35430.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","8589.68","","Case rate ($8,764.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,124.24, add-ons for qualifying new technology services are included. If operating cost exceeds $12,042.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,413.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,712.12 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,679.37 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.99. The transfer capital threshold is the transfer adjustment factor * $607.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8649.27","8649.27","8649.27","1 through 10","3975","41587.31","other","Inpatient DRG"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","","","","inpatient","","","59051.62","35430.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","33122.32","","Fee schedule rate ($33,122.32). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","15831.45","15831.45","15831.45","1 through 10","3975","41587.31","case rate",""
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","","","","inpatient","","","59051.62","35430.97","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","9027.93","","Case rate ($8,764.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,124.24, add-ons for qualifying new technology services are included. If operating cost exceeds $12,042.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,413.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,712.12 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,679.37 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.99. The transfer capital threshold is the transfer adjustment factor * $607.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","2397.61","2397.61","2397.61","1 through 10","3975","41587.31","other","Inpatient DRG"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","","","","inpatient","","","59051.62","35430.97","MARTIN'S POINT [160007]","HB WDH MEDICARE","8764.98","","Case rate ($8,764.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,124.24, add-ons for qualifying new technology services are included. If operating cost exceeds $12,042.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,413.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,712.12 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,679.37 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.99. The transfer capital threshold is the transfer adjustment factor * $607.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9301.50","9301.50","9301.50","1 through 10","3975","41587.31","other","Inpatient DRG"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","","","","inpatient","","","59051.62","35430.97","MEDICARE [2001]","HB WDH MEDICARE","8764.98","","Case rate ($8,764.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,124.24, add-ons for qualifying new technology services are included. If operating cost exceeds $12,042.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,413.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,712.12 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,679.37 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.99. The transfer capital threshold is the transfer adjustment factor * $607.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8649.27","8627.95","8649.27","16","3975","41587.31","other","Inpatient DRG"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","","","","inpatient","","","59051.62","35430.97","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8764.98","","Case rate ($8,764.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,124.24, add-ons for qualifying new technology services are included. If operating cost exceeds $12,042.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,413.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,712.12 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,679.37 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $607.99. The transfer capital threshold is the transfer adjustment factor * $607.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8455.40","1358.35","8649.27","1 through 10","3975","41587.31","other","Inpatient DRG"
"Disorders Of The Biliary Tract With McC","444","MS-DRG","","","","","","","","inpatient","","","60261.42","36156.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","50570.26","","Fee schedule rate ($50,570.26). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","49735.44","49735.44","49735.44","1 through 10","3975","63494.37","case rate",""
"Disorders Of The Biliary Tract With McC","444","MS-DRG","","","","","","","","inpatient","","","60261.42","36156.85","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","13542.21","","Case rate ($13,147.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,169.51, add-ons for qualifying new technology services are included. If operating cost exceeds $16,087.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,733.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,774.65 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,724.65 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $928.26. The transfer capital threshold is the transfer adjustment factor * $928.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","19313.78","19313.78","19313.78","1 through 10","3975","63494.37","other","Inpatient DRG"
"Disorders Of The Biliary Tract With McC","444","MS-DRG","","","","","","","","inpatient","","","60261.42","36156.85","MEDICARE [2001]","HB WDH MEDICARE","13147.78","","Case rate ($13,147.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,169.51, add-ons for qualifying new technology services are included. If operating cost exceeds $16,087.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,733.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,774.65 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,724.65 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $928.26. The transfer capital threshold is the transfer adjustment factor * $928.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13154.53","0.05","13187.65","11","3975","63494.37","other","Inpatient DRG"
"Disorders Of The Biliary Tract With McC","444","MS-DRG","","","","","","","","inpatient","","","60261.42","36156.85","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","13147.78","","Case rate ($13,147.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,169.51, add-ons for qualifying new technology services are included. If operating cost exceeds $16,087.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,733.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,774.65 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,724.65 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $928.26. The transfer capital threshold is the transfer adjustment factor * $928.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17185.16","17185.16","17185.16","1 through 10","3975","63494.37","other","Inpatient DRG"
"Disorders Of The Biliary Tract Without Cc/McC","446","MS-DRG","","","","","","","","inpatient","","","47955.31","28773.19","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","6869.05","","Case rate ($6,734.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,250, add-ons for qualifying new technology services are included. If operating cost exceeds $10,168.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,264.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,829.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,805.13 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $459.60. The transfer capital threshold is the transfer adjustment factor * $459.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","6460.86","6460.86","6460.86","1 through 10","3975","31437.48","other","Inpatient DRG"
"Disorders Of The Biliary Tract Without Cc/McC","446","MS-DRG","","","","","","","","inpatient","","","47955.31","28773.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","6599.67","","Case rate ($6,734.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,250, add-ons for qualifying new technology services are included. If operating cost exceeds $10,168.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,264.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,829.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,805.13 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $459.60. The transfer capital threshold is the transfer adjustment factor * $459.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6460.86","6460.86","6460.86","1 through 10","3975","31437.48","other","Inpatient DRG"
"Disorders Of The Biliary Tract Without Cc/McC","446","MS-DRG","","","","","","","","inpatient","","","47955.31","28773.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","25038.47","","Fee schedule rate ($25,038.47). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","23541.95","23541.95","23541.95","1 through 10","3975","31437.48","case rate",""
"Disorders Of The Biliary Tract Without Cc/McC","446","MS-DRG","","","","","","","","inpatient","","","47955.31","28773.19","MEDICARE [2001]","HB WDH MEDICARE","6734.36","","Case rate ($6,734.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,250, add-ons for qualifying new technology services are included. If operating cost exceeds $10,168.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,264.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,829.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,805.13 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $459.60. The transfer capital threshold is the transfer adjustment factor * $459.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6476.54","6476.54","6476.54","1 through 10","3975","31437.48","other","Inpatient DRG"
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","6709.61","4025.77","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","780.33","5703.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","6709.61","4025.77","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","780.33","5703.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","6709.61","4025.77","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3817.77","56.9","","812.12","238.65","1587.46","163","780.33","5703.17","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","6709.61","4025.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","780.33","11.63","","112.68","112.68","146.99","38","780.33","5703.17","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","6709.61","4025.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5193.24","77.4","","303.98","303.98","5854.79","1 through 10","780.33","5703.17","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6709.61","4025.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","780.33","11.63","","112.68","112.68","146.99","38","780.33","5193.24","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6709.61","4025.77","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4212.29","62.78","","780.86","208.94","10480.28","15","780.33","5193.24","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6709.61","4025.77","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2933.44","43.72","","179.76","179.76","179.76","1 through 10","780.33","5193.24","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6709.61","4025.77","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4879.23","72.72","","2355.45","298.99","3965.19","155","780.33","5193.24","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6709.61","4025.77","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4879.23","72.72","","3643.09","3643.09","3643.09","1 through 10","780.33","5193.24","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6709.61","4025.77","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3570.85","53.22","","554.28","554.28","554.28","16","780.33","5193.24","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6709.61","4025.77","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4220.34","62.9","","619.64","173.09","2370.64","150","780.33","5193.24","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6709.61","4025.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5193.24","77.4","","303.98","303.98","5854.79","1 through 10","780.33","5193.24","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","both","","","195.00","117.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","136.11","69.8","","131.92","131.92","131.92","14","8.93","165.75","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","both","","","195.00","117.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","165.75","85","","160.65","160.65","160.65","1 through 10","8.93","165.75","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","outpatient","","","195.00","117.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","85.25","43.72","","82.63","82.63","82.63","1 through 10","12.81","150.93","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","outpatient","","","195.00","117.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","141.80","72.72","","137.44","137.44","137.44","16","12.81","150.93","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","outpatient","","","195.00","117.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","141.80","72.72","","137.44","137.44","137.44","1 through 10","12.81","150.93","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","outpatient","","","195.00","117.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","122.66","62.9","","119.07","119.07","595.35","32","12.81","150.93","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","outpatient","","","195.00","117.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","150.93","77.4","","146.48","146.48","146.48","13","12.81","150.93","percent of total billed charges",""
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1350.00","810.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1044.65","","Case rate ($1,044.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1019.18","989.32","1019.18","12","160.19","1147.5","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1350.00","810.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","449.83","","Case rate ($449.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","438.86","394.98","1741.86","15","160.19","1147.5","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1350.00","810.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","160.19","","APC Price ($163.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","160.86","152.20","258.74","20","160.19","1147.5","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1350.00","810.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","844.38","","Case rate ($844.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","799.65","438.86","823.78","1 through 10","160.19","1147.5","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1350.00","810.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","168.37","","APC Price ($163.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","166.01","165.01","166.01","23","160.19","1147.5","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1350.00","810.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","163.46","","APC Price ($163.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","160.70","160.70","163.48","22","160.19","1147.5","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1350.00","810.00","MEDICARE [2001]","HB WDH MEDICARE","163.46","","APC Price ($163.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","163.48","163.48","163.48","145","160.19","1147.5","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1350.00","810.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","163.46","","APC Price ($163.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","163.22","160.62","163.48","71","160.19","1147.5","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1350.00","810.00","WELLSENSE NH [1050]","HB WDH MEDICARE","163.46","","APC Price ($163.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","168.22","168.22","171.65","1 through 10","160.19","1147.5","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","outpatient","","","1350.00","810.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","194.67","14.42","","187.89","161.05","187.89","1 through 10","157.01","1044.9","percent of total billed charges",""
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","outpatient","","","1350.00","810.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","157.01","11.63","","153.91","134.56","179.42","1 through 10","157.01","1044.9","percent of total billed charges",""
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","outpatient","","","1350.00","810.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","590.22","43.72","","569.67","569.67","569.67","1 through 10","157.01","1044.9","percent of total billed charges",""
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","outpatient","","","1350.00","810.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","981.72","72.72","","947.54","947.54","947.54","1 through 10","157.01","1044.9","percent of total billed charges",""
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","outpatient","","","1350.00","810.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","849.15","62.9","","820.89","820.89","820.89","1 through 10","157.01","1044.9","percent of total billed charges",""
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","outpatient","","","1350.00","810.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1044.90","77.4","","1009.83","1009.83","1009.83","1 through 10","157.01","1044.9","percent of total billed charges",""
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","outpatient","","","1350.00","810.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","157.01","11.63","","153.91","153.91","261.57","1 through 10","157.01","1044.9","percent of total billed charges",""
"Doppler Arterial Extrem Ltd Bilat","PX-92000030","CDM","93922","CPT","0921","RC","","","","both","","","892.00","535.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","860.68","","Case rate ($860.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","839.69","839.69","839.69","1 through 10","131.98","860.68","other","OPPS APC"
"Doppler Arterial Extrem Ltd Bilat","PX-92000030","CDM","93922","CPT","0921","RC","","","","both","","","892.00","535.20","MEDICARE [2001]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","134.69","134.69","134.69","1 through 10","131.98","860.68","other","OPPS APC"
"Doppler Arterial Extrem Ltd Bilat","PX-92000030","CDM","93922","CPT","0921","RC","","","","both","","","892.00","535.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","134.69","134.69","134.69","1 through 10","131.98","860.68","other","OPPS APC"
"Doppler Arterial Extrem Ltd Bilat","PX-92000030","CDM","93922","CPT","0921","RC","","","","outpatient","","","892.00","535.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","690.41","77.4","","667.28","667.28","667.28","1 through 10","103.74","690.41","percent of total billed charges",""
"Doppler Arterial Extrem W/Stress Bi","PX-92000033","CDM","93924","CPT","0921","RC","","","","both","","","1703.00","1021.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1044.65","","Case rate ($1,044.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1019.18","1019.18","1019.18","1 through 10","160.19","1447.55","other","OPPS APC"
"Doppler Arterial Extrem W/Stress Bi","PX-92000033","CDM","93924","CPT","0921","RC","","","","both","","","1703.00","1021.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","449.83","","Case rate ($449.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","426.00","426.00","426.00","1 through 10","160.19","1447.55","other","OPPS APC"
"Doppler Arterial Extrem W/Stress Bi","PX-92000033","CDM","93924","CPT","0921","RC","","","","both","","","1703.00","1021.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","160.19","","APC Price ($163.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","163.48","163.48","163.48","1 through 10","160.19","1447.55","other","OPPS APC"
"Doppler Arterial Extrem W/Stress Bi","PX-92000033","CDM","93924","CPT","0921","RC","","","","both","","","1703.00","1021.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","168.37","","APC Price ($163.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","166.01","166.01","166.01","1 through 10","160.19","1447.55","other","OPPS APC"
"Doppler Arterial Extrem W/Stress Bi","PX-92000033","CDM","93924","CPT","0921","RC","","","","both","","","1703.00","1021.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","163.46","","APC Price ($163.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","160.70","160.70","160.70","1 through 10","160.19","1447.55","other","OPPS APC"
"Doppler Arterial Extrem W/Stress Bi","PX-92000033","CDM","93924","CPT","0921","RC","","","","both","","","1703.00","1021.80","MEDICARE [2001]","HB WDH MEDICARE","163.46","","APC Price ($163.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","163.48","163.48","326.96","15","160.19","1447.55","other","OPPS APC"
"Doppler Arterial Extrem W/Stress Bi","PX-92000033","CDM","93924","CPT","0921","RC","","","","both","","","1703.00","1021.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","163.46","","APC Price ($163.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","163.48","151.96","163.48","1 through 10","160.19","1447.55","other","OPPS APC"
"Doppler Arterial Extrem W/Stress Bi","PX-92000033","CDM","93924","CPT","0921","RC","","","","outpatient","","","1703.00","1021.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","245.57","14.42","","236.92","236.92","236.92","1 through 10","198.06","1318.12","percent of total billed charges",""
"Doppler Arterial Extrem W/Stress Bi","PX-92000033","CDM","93924","CPT","0921","RC","","","","outpatient","","","1703.00","1021.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","198.06","11.63","","194.07","194.07","194.07","1 through 10","198.06","1318.12","percent of total billed charges",""
"Doppler Arterial Extrem W/Stress Bi","PX-92000033","CDM","93924","CPT","0921","RC","","","","outpatient","","","1703.00","1021.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1238.42","72.72","","1194.79","1194.79","1194.79","1 through 10","198.06","1318.12","percent of total billed charges",""
"Doppler Arterial Extrem W/Stress Bi","PX-92000033","CDM","93924","CPT","0921","RC","","","","outpatient","","","1703.00","1021.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1071.19","62.9","","1035.09","1035.09","1035.09","1 through 10","198.06","1318.12","percent of total billed charges",""
"Doppler Echocardio Fetal Cmpl","PX-48000178","CDM","76827","CPT","0483","RC","","","","both","","","475.00","285.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","458.00","309.85","458.00","1 through 10","108.88","710.05","other","OPPS APC"
"Doppler Echocardio Fetal Cmpl","PX-48000178","CDM","76827","CPT","0483","RC","","","","both","","","475.00","285.00","WELLPOINT [1015]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","458.00","458.00","458.00","1 through 10","108.88","710.05","other","OPPS APC"
"Doppler Echocardio Fetal Cmpl","PX-48000178","CDM","76827","CPT","0483","RC","","","","outpatient","","","475.00","285.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","68.50","14.42","","56.61","56.61","66.04","1 through 10","55.24","367.65","percent of total billed charges",""
"Doppler Echocardio Fetal Cmpl","PX-48000178","CDM","76827","CPT","0483","RC","","","","outpatient","","","475.00","285.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","55.24","11.63","","63.07","56.06","63.07","1 through 10","55.24","367.65","percent of total billed charges",""
"Doppler Echocardio Fetal Cmpl","PX-48000178","CDM","76827","CPT","0483","RC","","","","outpatient","","","475.00","285.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","345.42","72.72","","333.06","333.06","333.06","21","55.24","367.65","percent of total billed charges",""
"Doppler Echocardio Fetal Cmpl","PX-48000178","CDM","76827","CPT","0483","RC","","","","outpatient","","","475.00","285.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","298.78","62.9","","288.54","288.54","865.62","11","55.24","367.65","percent of total billed charges",""
"Doppler Echocardio Fetal Cmpl","PX-48000178","CDM","76827","CPT","0483","RC","","","","outpatient","","","475.00","285.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","367.65","77.4","","354.95","354.95","354.95","1 through 10","55.24","367.65","percent of total billed charges",""
"Doppler Echocardio Fetal Cmpl","PX-48000178","CDM","76827","CPT","0483","RC","","","","outpatient","","","475.00","285.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","55.24","11.63","","270.50","54.10","270.50","1 through 10","55.24","367.65","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","856.00","513.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","597.49","69.8","","1729.64","1153.10","2306.19","1 through 10","135.94","886.52","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","856.00","513.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","886.52","","Case rate ($886.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","859.38","826.00","864.90","67","135.94","886.52","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","856.00","513.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","381.73","","Case rate ($381.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","372.43","335.19","372.43","39","135.94","886.52","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","856.00","513.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","135.94","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","136.51","135.96","235.84","143","135.94","886.52","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","856.00","513.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","716.57","","Case rate ($716.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","694.63","629.18","699.09","54","135.94","886.52","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","856.00","513.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","142.87","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","140.61","140.03","140.61","43","135.94","886.52","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","856.00","513.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","136.51","136.51","138.73","118","135.94","886.52","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","856.00","513.60","MEDICARE [2001]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","138.73","132.21","138.73","507","135.94","886.52","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","856.00","513.60","TRICARE [160005]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","277.46","277.46","277.46","1 through 10","135.94","886.52","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","856.00","513.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","136.51","132.21","138.73","197","135.94","886.52","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","both","","","856.00","513.60","WELLSENSE NH [1050]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","143.34","142.75","286.67","21","135.94","886.52","other","OPPS APC"
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","outpatient","","","856.00","513.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","123.44","14.42","","119.11","102.09","119.11","50","99.55","662.54","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","outpatient","","","856.00","513.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","99.55","11.63","","113.74","97.56","208.61","36","99.55","662.54","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","outpatient","","","856.00","513.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","537.40","62.78","","518.56","518.56","518.56","1 through 10","99.55","662.54","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","outpatient","","","856.00","513.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","622.48","72.72","","600.67","543.68","2402.66","51","99.55","662.54","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","outpatient","","","856.00","513.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","538.42","62.9","","520.38","520.38","520.38","41","99.55","662.54","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","outpatient","","","856.00","513.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","662.54","77.4","","600.67","600.67","640.15","11","99.55","662.54","percent of total billed charges",""
"Dosimetry Calculation Basic","PX-33000012","CDM","77300","CPT","0333","RC","","","","outpatient","","","856.00","513.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","99.55","11.63","","217.53","97.56","319.54","31","99.55","662.54","percent of total billed charges",""
"DOWEL CANCELLOUS 15MM IMPLANT HUMAN TISSUE CORTICAL BONE FREEZE DRIED","SUP-ITM-10010251","CDM","C1889","HCPCS","0278","RC","","","","both","","","3903.25","2341.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","453.95","3317.76","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DOWEL CANCELLOUS 15MM IMPLANT HUMAN TISSUE CORTICAL BONE FREEZE DRIED","SUP-ITM-10010251","CDM","C1889","HCPCS","0278","RC","","","","both","","","3903.25","2341.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","453.95","3317.76","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"DOWEL CANCELLOUS 15MM IMPLANT HUMAN TISSUE CORTICAL BONE FREEZE DRIED","SUP-ITM-10010251","CDM","C1889","HCPCS","0278","RC","","","","both","","","3903.25","2341.95","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2220.95","56.9","","0.63","0.63","0.63","1 through 10","453.95","3317.76","percent of total billed charges",""
"DOWEL CANCELLOUS 15MM IMPLANT HUMAN TISSUE CORTICAL BONE FREEZE DRIED","SUP-ITM-10010251","CDM","C1889","HCPCS","0278","RC","","","","both","","","3903.25","2341.95","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","562.85","14.42","","317.14","317.14","317.14","1 through 10","453.95","3317.76","percent of total billed charges",""
"DOWEL CANCELLOUS 15MM IMPLANT HUMAN TISSUE CORTICAL BONE FREEZE DRIED","SUP-ITM-10010251","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3903.25","2341.95","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","562.85","14.42","","317.14","317.14","317.14","1 through 10","453.95","3021.12","percent of total billed charges",""
"DOWEL CANCELLOUS 15MM IMPLANT HUMAN TISSUE CORTICAL BONE FREEZE DRIED","SUP-ITM-10010251","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3903.25","2341.95","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2450.46","62.78","","1125.09","1125.09","1125.09","1 through 10","453.95","3021.12","percent of total billed charges",""
"DOWEL CANCELLOUS 15MM IMPLANT HUMAN TISSUE CORTICAL BONE FREEZE DRIED","SUP-ITM-10010251","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3903.25","2341.95","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2838.44","72.72","","4732.50","1617.43","14180.40","1 through 10","453.95","3021.12","percent of total billed charges",""
"DOWEL CANCELLOUS 15MM IMPLANT HUMAN TISSUE CORTICAL BONE FREEZE DRIED","SUP-ITM-10010251","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3903.25","2341.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2455.14","62.9","","3896.20","3341.38","3896.20","1 through 10","453.95","3021.12","percent of total billed charges",""
"Drain Abscess Finger Simple","PX-76000477","CDM","26010","CPT","0761","RC","","","","both","","","1324.00","794.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","207.59","","APC Price ($207.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.62","207.62","207.62","1 through 10","146.32","1326.74","other","OPPS APC"
"Drain Abscess Scrotal Wall","PX-76001319","CDM","55100","CPT","0761","RC","","","","outpatient","","","1622.00","973.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","","","Payment is accumulated by procedure count. Procedure 1, 62.78% of billed. Procedures 2 - 9999, 31.39% of billed.","20775.78","20775.78","20775.78","1 through 10","191.23","1255.43","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Dress/Debride Burn <5% Total Sm","PX-76000205","CDM","16020","CPT","0761","RC","","","","both","","","592.00","355.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","211.75","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","207.62","207.62","207.62","1 through 10","57.36","1326.74","other","OPPS APC"
"Dress/Debride Burn <5% Total Sm","PX-76000205","CDM","16020","CPT","0761","RC","","","","both","","","592.00","355.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","213.82","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","213.85","213.85","213.85","1 through 10","57.36","1326.74","other","OPPS APC"
"Dress/Debride Burn <5% Total Sm","PX-76000205","CDM","16020","CPT","0761","RC","","","","both","","","592.00","355.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","207.59","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","204.30","204.30","204.30","1 through 10","57.36","1326.74","other","OPPS APC"
"Dress/Debride Burn <5% Total Sm","PX-76000205","CDM","16020","CPT","0761","RC","","","","outpatient","","","592.00","355.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","372.37","62.9","","359.73","359.73","359.73","1 through 10","68.85","458.21","percent of total billed charges",""
"Dress/Debride Burn 5-10% Total Med","PX-76000206","CDM","16025","CPT","0761","RC","","","","both","","","1143.00","685.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","203.44","","APC Price ($207.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","204.37","204.37","204.37","1 through 10","203.44","1326.74","other","OPPS APC"
"Dress/Debride Burn 5-10% Total Med","PX-76000206","CDM","16025","CPT","0761","RC","","","","both","","","1143.00","685.80","MEDICARE [2001]","HB WDH MEDICARE","207.59","","APC Price ($207.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.62","207.62","207.62","1 through 10","203.44","1326.74","other","OPPS APC"
"Drug Assay Acetaminophen","PX-30003719","CDM","80143","CPT","0301","RC","","","","both","","","213.00","127.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","121.20","56.9","","117.21","115.53","117.21","1 through 10","12.12","181.05","percent of total billed charges",""
"Drug Assay Acetaminophen","PX-30003719","CDM","80143","CPT","0301","RC","","","","outpatient","","","213.00","127.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","93.12","43.72","","270.18","270.18","270.18","1 through 10","15.21","164.86","percent of total billed charges",""
"Drug Assay Acetaminophen","PX-30003719","CDM","80143","CPT","0301","RC","","","","outpatient","","","213.00","127.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","154.89","72.72","","149.80","149.80","149.80","1 through 10","15.21","164.86","percent of total billed charges",""
"Drug Assay Acetaminophen","PX-30003719","CDM","80143","CPT","0301","RC","","","","outpatient","","","213.00","127.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","154.89","72.72","","149.80","149.80","149.80","1 through 10","15.21","164.86","percent of total billed charges",""
"Drug Assay Acetaminophen","PX-30003719","CDM","80143","CPT","0301","RC","","","","outpatient","","","213.00","127.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","133.98","62.9","","249.72","129.78","499.44","1 through 10","15.21","164.86","percent of total billed charges",""
"Drug Assay Adalimumab","PX-30003607","CDM","80145","CPT","0300","RC","","","","both","","","443.00","265.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","252.07","56.9","","243.53","243.53","243.53","1 through 10","25.07","376.55","percent of total billed charges",""
"Drug Assay Adalimumab","PX-30003607","CDM","80145","CPT","0300","RC","","","","both","","","443.00","265.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","376.55","85","","363.80","363.80","363.80","1 through 10","25.07","376.55","percent of total billed charges",""
"Drug Assay Adalimumab","PX-30003607","CDM","80145","CPT","0300","RC","","","","outpatient","","","443.00","265.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","51.52","11.63","","107.00","34.03","107.00","1 through 10","51.52","342.88","percent of total billed charges",""
"Drug Assay Adalimumab","PX-30003607","CDM","80145","CPT","0300","RC","","","","outpatient","","","443.00","265.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","193.68","43.72","","187.12","187.12","187.12","1 through 10","51.52","342.88","percent of total billed charges",""
"Drug Assay Adalimumab","PX-30003607","CDM","80145","CPT","0300","RC","","","","outpatient","","","443.00","265.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","322.15","72.72","","311.24","311.24","311.24","1 through 10","51.52","342.88","percent of total billed charges",""
"Drug Assay Infliximab","PX-30003609","CDM","80230","CPT","0300","RC","","","","both","","","443.00","265.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","252.07","56.9","","243.53","243.53","243.53","1 through 10","25.07","376.55","percent of total billed charges",""
"Drug Assay Infliximab","PX-30003609","CDM","80230","CPT","0300","RC","","","","both","","","443.00","265.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","376.55","85","","363.80","363.80","363.80","1 through 10","25.07","376.55","percent of total billed charges",""
"Drug Assay Infliximab","PX-30003609","CDM","80230","CPT","0300","RC","","","","outpatient","","","443.00","265.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","193.68","43.72","","187.12","187.12","187.12","1 through 10","51.52","342.88","percent of total billed charges",""
"Drug Assay Lacosamide","PX-30003610","CDM","80235","CPT","0300","RC","","","","both","","","311.00","186.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","176.96","56.9","","171.27","171.27","513.81","1 through 10","17.62","264.35","percent of total billed charges",""
"Drug Assay Lacosamide","PX-30003610","CDM","80235","CPT","0300","RC","","","","both","","","311.00","186.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","264.35","85","","210.10","210.10","210.10","1 through 10","17.62","264.35","percent of total billed charges",""
"Drug Assay Lacosamide","PX-30003610","CDM","80235","CPT","0300","RC","","","","outpatient","","","311.00","186.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","36.17","11.63","","23.92","23.92","23.92","1 through 10","36.17","240.71","percent of total billed charges",""
"Drug Assay Lacosamide","PX-30003610","CDM","80235","CPT","0300","RC","","","","outpatient","","","311.00","186.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","226.16","72.72","","218.89","218.89","218.89","1 through 10","36.17","240.71","percent of total billed charges",""
"Drug Assay Lacosamide","PX-30003610","CDM","80235","CPT","0300","RC","","","","outpatient","","","311.00","186.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","240.71","77.4","","233.28","233.28","233.28","1 through 10","36.17","240.71","percent of total billed charges",""
"Drug Assay Lacosamide","PX-30003610","CDM","80235","CPT","0300","RC","","","","outpatient","","","311.00","186.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","36.17","11.63","","23.92","23.92","23.92","1 through 10","36.17","240.71","percent of total billed charges",""
"Drug Assay Salicylate","PX-30003723","CDM","80179","CPT","0301","RC","","","","both","","","213.00","127.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","148.67","69.8","","143.79","143.79","143.79","1 through 10","12.12","181.05","percent of total billed charges",""
"Drug Assay Salicylate","PX-30003723","CDM","80179","CPT","0301","RC","","","","both","","","213.00","127.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","121.20","56.9","","117.21","115.53","117.21","1 through 10","12.12","181.05","percent of total billed charges",""
"Drug Assay Salicylate","PX-30003723","CDM","80179","CPT","0301","RC","","","","outpatient","","","213.00","127.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","93.12","43.72","","270.18","90.06","270.18","1 through 10","15.21","164.86","percent of total billed charges",""
"Drug Assay Salicylate","PX-30003723","CDM","80179","CPT","0301","RC","","","","outpatient","","","213.00","127.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","154.89","72.72","","149.80","149.80","149.80","1 through 10","15.21","164.86","percent of total billed charges",""
"Drug Assay Salicylate","PX-30003723","CDM","80179","CPT","0301","RC","","","","outpatient","","","213.00","127.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","133.98","62.9","","249.72","129.78","249.72","1 through 10","15.21","164.86","percent of total billed charges",""
"Drug Assay Vedolizumab","PX-30003611","CDM","80280","CPT","0300","RC","","","","outpatient","","","443.00","265.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","322.15","72.72","","311.24","311.24","311.24","1 through 10","51.52","342.88","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","both","","","71.00","42.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","49.56","69.8","","43.40","43.40","48.16","1 through 10","8.61","67.73","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","both","","","71.00","42.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","60.35","85","","16.56","16.56","16.56","1 through 10","8.61","67.73","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","outpatient","","","71.00","42.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","51.63","72.72","","50.18","50.18","150.54","11","11.77","54.95","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","outpatient","","","71.00","42.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","44.66","62.9","","43.47","43.47","43.47","1 through 10","11.77","54.95","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","outpatient","","","71.00","42.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","54.95","77.4","","53.48","51.22","53.48","1 through 10","11.77","54.95","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","outpatient","","","71.00","42.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","51.63","72.72","","50.18","50.18","50.18","1 through 10","11.77","54.95","percent of total billed charges",""
"Drug Screen Quant Clozapine","PX-30001674","CDM","80159","CPT","0301","RC","","","","both","","","233.00","139.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","162.63","69.8","","141.53","141.53","141.53","1 through 10","13.1","198.05","percent of total billed charges",""
"Drug Screen Quant Dipropylacetic Acid Total","PX-30002957","CDM","80164","CPT","0301","RC","","","","both","","","192.00","115.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","134.02","69.8","","129.83","116.99","129.83","1 through 10","8.8","163.2","percent of total billed charges",""
"Drug Screen Quant Dipropylacetic Acid Total","PX-30002957","CDM","80164","CPT","0301","RC","","","","both","","","192.00","115.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","163.20","85","","202.00","202.00","202.00","1 through 10","8.8","163.2","percent of total billed charges",""
"Drug Screen Quant Dipropylacetic Acid Total","PX-30002957","CDM","80164","CPT","0301","RC","","","","outpatient","","","192.00","115.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","139.62","72.72","","135.26","135.26","135.26","1 through 10","12.62","148.61","percent of total billed charges",""
"Drug Screen Quant Dipropylacetic Acid Total","PX-30002957","CDM","80164","CPT","0301","RC","","","","outpatient","","","192.00","115.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","139.62","72.72","","135.26","135.26","135.26","1 through 10","12.62","148.61","percent of total billed charges",""
"Drug Screen Quant Dipropylacetic Acid Total","PX-30002957","CDM","80164","CPT","0301","RC","","","","outpatient","","","192.00","115.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","120.77","62.9","","117.18","117.18","117.18","1 through 10","12.62","148.61","percent of total billed charges",""
"Drug Screen Quantitative Digoxin Total","PX-30002829","CDM","80162","CPT","0301","RC","","","","outpatient","","","188.00","112.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","118.25","62.9","","213.96","213.96","213.96","1 through 10","12.36","145.51","percent of total billed charges",""
"Drug Scrn Quan Levetiracetam","PX-30001677","CDM","80177","CPT","0301","RC","","","","both","","","71.00","42.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","49.56","69.8","","48.16","48.16","48.16","1 through 10","8.61","67.73","percent of total billed charges",""
"Drug Scrn Quan Levetiracetam","PX-30001677","CDM","80177","CPT","0301","RC","","","","both","","","71.00","42.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","60.35","85","","48.16","48.16","48.16","1 through 10","8.61","67.73","percent of total billed charges",""
"Drug Scrn Quan Levetiracetam","PX-30001677","CDM","80177","CPT","0301","RC","","","","outpatient","","","71.00","42.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","31.04","43.72","","90.51","30.17","90.51","1 through 10","11.77","54.95","percent of total billed charges",""
"Drug Scrn Quan Levetiracetam","PX-30001677","CDM","80177","CPT","0301","RC","","","","outpatient","","","71.00","42.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","51.63","72.72","","50.18","40.73","50.18","15","11.77","54.95","percent of total billed charges",""
"Drug Scrn Quan Levetiracetam","PX-30001677","CDM","80177","CPT","0301","RC","","","","outpatient","","","71.00","42.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","44.66","62.9","","43.47","43.47","43.47","1 through 10","11.77","54.95","percent of total billed charges",""
"Drug Scrn Quan Levetiracetam","PX-30001677","CDM","80177","CPT","0301","RC","","","","outpatient","","","71.00","42.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","54.95","77.4","","53.48","51.22","53.48","1 through 10","11.77","54.95","percent of total billed charges",""
"Drug Susceptability Genotypic/Pheno","PX-30001359","CDM","87900","CPT","0306","RC","","","","outpatient","","","1499.00","899.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","216.16","14.42","","1450.00","1450.00","1450.00","1 through 10","174.33","1160.23","percent of total billed charges",""
"Drug Susceptability Genotypic/Pheno","PX-30001359","CDM","87900","CPT","0306","RC","","","","outpatient","","","1499.00","899.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1090.07","72.72","","1054.44","1054.44","1054.44","1 through 10","174.33","1160.23","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","2675.00","1605.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1613.96","","Case rate ($1,613.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1574.60","1417.15","1574.60","12","247.49","2273.75","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","2675.00","1605.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","694.97","","Case rate ($694.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","678.03","601.45","678.03","19","247.49","2273.75","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","2675.00","1605.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","247.49","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","252.57","248.92","429.37","1 through 10","247.49","2273.75","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","2675.00","1605.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1304.55","","Case rate ($1,304.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1272.72","678.03","2581.00","1 through 10","247.49","2273.75","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","2675.00","1605.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","260.12","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","255.95","255.95","255.99","1 through 10","247.49","2273.75","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","2675.00","1605.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","248.28","238.75","252.57","14","247.49","2273.75","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","2675.00","1605.00","MEDICARE [2001]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","238.75","252.57","41","247.49","2273.75","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","2675.00","1605.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","2273.75","85","","1272.72","1272.72","1272.72","1 through 10","247.49","2273.75","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","2675.00","1605.00","TRICARE [160005]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","1 through 10","247.49","2273.75","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","2675.00","1605.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.52","247.52","252.52","17","247.49","2273.75","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","outpatient","","","2675.00","1605.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","385.74","14.42","","372.18","372.18","372.18","1 through 10","311.1","2070.45","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","outpatient","","","2675.00","1605.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","311.10","11.63","","651.84","355.40","914.58","1 through 10","311.1","2070.45","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","outpatient","","","2675.00","1605.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1679.37","62.78","","1620.35","1620.35","1620.35","1 through 10","311.1","2070.45","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","outpatient","","","2675.00","1605.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1945.26","72.72","","1876.90","1876.90","3753.80","15","311.1","2070.45","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","outpatient","","","2675.00","1605.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1945.26","72.72","","1876.90","1876.90","1876.90","1 through 10","311.1","2070.45","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","outpatient","","","2675.00","1605.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1682.58","62.9","","1626.03","1626.03","1626.03","11","311.1","2070.45","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","outpatient","","","2675.00","1605.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2070.45","77.4","","2000.28","2000.27","2000.28","1 through 10","311.1","2070.45","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","outpatient","","","2675.00","1605.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","311.10","11.63","","304.86","304.86","398.05","1 through 10","311.1","2070.45","percent of total billed charges",""
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","1506.00","903.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","298.29","1 through 10","108.88","1280.1","other","OPPS APC"
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","1506.00","903.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","111.11","107.12","111.11","1 through 10","108.88","1280.1","other","OPPS APC"
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","1506.00","903.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","545.12","559.93","1 through 10","108.88","1280.1","other","OPPS APC"
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","1506.00","903.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","217.17","14.42","","209.52","209.52","209.52","1 through 10","108.88","1280.1","percent of total billed charges",""
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","1506.00","903.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","113.15","113.15","113.15","1 through 10","108.88","1280.1","other","OPPS APC"
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","1506.00","903.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","109.00","111.11","1 through 10","108.88","1280.1","other","OPPS APC"
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","1506.00","903.60","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","107.12","111.11","1 through 10","108.88","1280.1","other","OPPS APC"
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","1506.00","903.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","947.27","62.9","","915.39","915.39","1707.84","1 through 10","108.88","1280.1","percent of total billed charges",""
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","1506.00","903.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","1280.10","85","","321.36","321.36","321.36","1 through 10","108.88","1280.1","percent of total billed charges",""
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","1506.00","903.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","1280.1","other","OPPS APC"
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","1506.00","903.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1165.64","77.4","","1126.08","1126.08","1126.08","1 through 10","108.88","1280.1","percent of total billed charges",""
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","outpatient","","","1506.00","903.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","175.15","11.63","","366.97","171.63","366.97","1 through 10","175.15","1095.16","percent of total billed charges",""
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","outpatient","","","1506.00","903.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1095.16","72.72","","1056.62","1056.62","1767.09","1 through 10","175.15","1095.16","percent of total billed charges",""
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","outpatient","","","1506.00","903.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1095.16","72.72","","1056.62","1056.62","1056.62","1 through 10","175.15","1095.16","percent of total billed charges",""
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","outpatient","","","1506.00","903.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","175.15","11.63","","514.89","514.89","514.89","1 through 10","175.15","1095.16","percent of total billed charges",""
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","1810.00","1086.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1613.96","","Case rate ($1,613.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1574.60","1417.15","1574.60","1 through 10","247.49","1613.96","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","1810.00","1086.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","694.97","","Case rate ($694.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","610.23","601.45","678.03","1 through 10","247.49","1613.96","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","1810.00","1086.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","247.49","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","247.52","247.52","248.03","12","247.49","1613.96","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","1810.00","1086.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1304.55","","Case rate ($1,304.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1254.41","610.23","1272.72","1 through 10","247.49","1613.96","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","1810.00","1086.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","260.12","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","255.95","254.95","255.99","12","247.49","1613.96","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","1810.00","1086.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","248.53","248.28","252.57","23","247.49","1613.96","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","1810.00","1086.00","MEDICARE [2001]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","238.75","252.57","78","247.49","1613.96","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","1810.00","1086.00","TRICARE [160005]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","1 through 10","247.49","1613.96","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","1810.00","1086.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","248.53","247.52","252.57","38","247.49","1613.96","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","1810.00","1086.00","WELLSENSE NH [1050]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","259.90","259.90","265.20","1 through 10","247.49","1613.96","other","OPPS APC"
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","outpatient","","","1810.00","1086.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","210.50","11.63","","240.56","206.35","240.56","1 through 10","210.5","1400.94","percent of total billed charges",""
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","outpatient","","","1810.00","1086.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1316.23","72.72","","1270.42","1270.42","1270.42","1 through 10","210.5","1400.94","percent of total billed charges",""
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","outpatient","","","1810.00","1086.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1316.23","72.72","","1270.42","1270.42","1270.42","1 through 10","210.5","1400.94","percent of total billed charges",""
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","outpatient","","","1810.00","1086.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1138.49","62.9","","1100.61","1100.61","1100.61","1 through 10","210.5","1400.94","percent of total billed charges",""
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","outpatient","","","1810.00","1086.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1400.94","77.4","","1353.93","1353.93","1353.93","1 through 10","210.5","1400.94","percent of total billed charges",""
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","outpatient","","","1810.00","1086.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","210.50","11.63","","206.35","206.35","206.35","1 through 10","210.5","1400.94","percent of total billed charges",""
"Duplex Art Upper Ext Unilat/Lmtd","PX-92000037","CDM","93931","CPT","0921","RC","","","","both","","","1256.00","753.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","108.89","108.89","108.89","1 through 10","108.88","1067.6","other","OPPS APC"
"Duplex Art Upper Ext Unilat/Lmtd","PX-92000037","CDM","93931","CPT","0921","RC","","","","outpatient","","","1256.00","753.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","913.36","72.72","","881.37","881.37","881.37","1 through 10","146.07","972.14","percent of total billed charges",""
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","2626.00","1575.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1613.96","","Case rate ($1,613.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1574.60","1574.60","1574.60","1 through 10","247.49","2232.1","other","OPPS APC"
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","2626.00","1575.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","694.97","","Case rate ($694.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","610.23","610.23","610.23","1 through 10","247.49","2232.1","other","OPPS APC"
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","2626.00","1575.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","247.49","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","247.52","238.75","247.52","1 through 10","247.49","2232.1","other","OPPS APC"
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","2626.00","1575.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","260.12","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","254.95","240.99","254.95","1 through 10","247.49","2232.1","other","OPPS APC"
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","2626.00","1575.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","248.53","238.75","252.57","1 through 10","247.49","2232.1","other","OPPS APC"
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","2626.00","1575.60","MEDICARE [2001]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","22","247.49","2232.1","other","OPPS APC"
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","2626.00","1575.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.52","247.52","252.57","16","247.49","2232.1","other","OPPS APC"
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","outpatient","","","2626.00","1575.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","378.67","14.42","","313.20","313.20","313.20","1 through 10","305.4","2032.52","percent of total billed charges",""
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","outpatient","","","2626.00","1575.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","305.40","11.63","","348.93","348.93","348.93","1 through 10","305.4","2032.52","percent of total billed charges",""
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","outpatient","","","2626.00","1575.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1148.09","43.72","","1107.86","1107.86","1107.86","1 through 10","305.4","2032.52","percent of total billed charges",""
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","outpatient","","","2626.00","1575.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2032.52","77.4","","1963.85","1963.85","1963.85","1 through 10","305.4","2032.52","percent of total billed charges",""
"Duplex Arterial Lower Ext Unilt/Lmt","PX-92000035","CDM","93926","CPT","0921","RC","","","","both","","","1531.00","918.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","108.89","111.11","1 through 10","108.88","1301.35","other","OPPS APC"
"Duplex Arterial Upper Ext Bilat","PX-92000036","CDM","93930","CPT","0921","RC","","","","both","","","2010.00","1206.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","694.97","","Case rate ($694.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","610.23","610.23","610.23","1 through 10","247.49","1708.5","other","OPPS APC"
"Duplex Arterial Upper Ext Bilat","PX-92000036","CDM","93930","CPT","0921","RC","","","","both","","","2010.00","1206.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","247.49","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","252.57","252.57","252.57","1 through 10","247.49","1708.5","other","OPPS APC"
"Duplex Arterial Upper Ext Bilat","PX-92000036","CDM","93930","CPT","0921","RC","","","","both","","","2010.00","1206.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","248.28","248.28","248.28","1 through 10","247.49","1708.5","other","OPPS APC"
"Duplex Arterial Upper Ext Bilat","PX-92000036","CDM","93930","CPT","0921","RC","","","","both","","","2010.00","1206.00","MEDICARE [2001]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","1 through 10","247.49","1708.5","other","OPPS APC"
"Duplex Arterial Upper Ext Bilat","PX-92000036","CDM","93930","CPT","0921","RC","","","","outpatient","","","2010.00","1206.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1555.74","77.4","","1503.50","1503.50","1503.50","1 through 10","233.76","1555.74","percent of total billed charges",""
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","1954.00","1172.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1613.96","","Case rate ($1,613.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1574.60","1417.15","1574.60","24","247.49","1660.9","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","1954.00","1172.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","694.97","","Case rate ($694.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","678.03","610.23","1886.00","24","247.49","1660.9","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","1954.00","1172.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","247.49","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","248.02","247.52","252.57","50","247.49","1660.9","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","1954.00","1172.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1304.55","","Case rate ($1,304.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1145.45","610.23","1254.41","11","247.49","1660.9","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","1954.00","1172.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","260.12","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","255.95","255.65","255.95","26","247.49","1660.9","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","1954.00","1172.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","248.28","248.28","252.57","60","247.49","1660.9","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","1954.00","1172.40","MEDICARE [2001]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","196","247.49","1660.9","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","1954.00","1172.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","1660.90","85","","1886.00","1886.00","1886.00","1 through 10","247.49","1660.9","percent of total billed charges",""
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","1954.00","1172.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.52","247.52","252.57","92","247.49","1660.9","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","1954.00","1172.40","WELLSENSE NH [1050]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","259.90","259.90","259.90","1 through 10","247.49","1660.9","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","outpatient","","","1954.00","1172.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","281.77","14.42","","271.96","271.96","271.96","1 through 10","227.25","1512.4","percent of total billed charges",""
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","outpatient","","","1954.00","1172.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","227.25","11.63","","230.85","222.77","259.70","1 through 10","227.25","1512.4","percent of total billed charges",""
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","outpatient","","","1954.00","1172.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","854.29","43.72","","824.56","824.56","824.56","1 through 10","227.25","1512.4","percent of total billed charges",""
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","outpatient","","","1954.00","1172.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1420.95","72.72","","1371.50","1371.50","1371.50","13","227.25","1512.4","percent of total billed charges",""
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","outpatient","","","1954.00","1172.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1039.92","53.22","","1005.43","1005.43","1005.43","1 through 10","227.25","1512.4","percent of total billed charges",""
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","outpatient","","","1954.00","1172.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1229.07","62.9","","1188.18","1188.18","4563.04","18","227.25","1512.4","percent of total billed charges",""
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","outpatient","","","1954.00","1172.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1512.40","77.4","","1461.65","1461.65","1461.65","1 through 10","227.25","1512.4","percent of total billed charges",""
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","outpatient","","","1954.00","1172.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","227.25","11.63","","222.77","222.77","404.11","1 through 10","227.25","1512.4","percent of total billed charges",""
"Duplex Scan Artl Infl&Ven O/F Hemo Compl Bi Std","PX-92000177","CDM","93985","CPT","0921","RC","","","","both","","","2747.00","1648.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","247.49","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","252.57","233.97","252.57","1 through 10","247.49","2334.95","other","OPPS APC"
"Duplex Scan Artl Infl&Ven O/F Hemo Compl Bi Std","PX-92000177","CDM","93985","CPT","0921","RC","","","","both","","","2747.00","1648.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1563.04","56.9","","1508.42","1508.42","1508.42","1 through 10","247.49","2334.95","percent of total billed charges",""
"Duplex Scan Artl Infl&Ven O/F Hemo Compl Bi Std","PX-92000177","CDM","93985","CPT","0921","RC","","","","both","","","2747.00","1648.20","MEDICARE [2001]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","238.75","252.57","1 through 10","247.49","2334.95","other","OPPS APC"
"Duplex Scan Artl Infl&Ven O/F Hemo Compl Bi Std","PX-92000177","CDM","93985","CPT","0921","RC","","","","both","","","2747.00","1648.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","248.53","252.57","1 through 10","247.49","2334.95","other","OPPS APC"
"Duplex Scan Artl Infl&Ven O/F Hemo Compl Bi Std","PX-92000177","CDM","93985","CPT","0921","RC","","","","outpatient","","","2747.00","1648.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1997.62","72.72","","1927.81","1927.81","1927.81","1 through 10","319.48","2126.18","percent of total billed charges",""
"Duplex Scan Artl Infl&Ven O/F Hemo Compl Bi Std","PX-92000177","CDM","93985","CPT","0921","RC","","","","outpatient","","","2747.00","1648.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1727.86","62.9","","1670.13","1670.13","1670.13","1 through 10","319.48","2126.18","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","1946.00","1167.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","1358.31","69.8","","1310.84","1310.84","1310.84","1 through 10","247.49","1654.1","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","1946.00","1167.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1613.96","","Case rate ($1,613.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1574.60","1417.15","1574.60","13","247.49","1654.1","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","1946.00","1167.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","694.97","","Case rate ($694.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","678.03","610.23","678.03","25","247.49","1654.1","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","1946.00","1167.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","247.49","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","248.53","247.52","405.88","22","247.49","1654.1","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","1946.00","1167.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1304.55","","Case rate ($1,304.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1145.45","610.23","1272.72","18","247.49","1654.1","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","1946.00","1167.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","280.61","14.42","","270.81","232.12","270.81","1 through 10","247.49","1654.1","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","1946.00","1167.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","260.12","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","255.95","254.95","255.95","21","247.49","1654.1","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","1946.00","1167.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","248.28","248.28","252.57","23","247.49","1654.1","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","1946.00","1167.60","MEDICARE [2001]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","82","247.49","1654.1","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","1946.00","1167.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1224.03","62.9","","1183.14","1183.14","4542.84","16","247.49","1654.1","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","1946.00","1167.60","PHCS MULTIPLAN [1022]","HB WDH AMERIHEALTH CARITAS","280.61","14.42","","270.81","270.81","270.81","1 through 10","247.49","1654.1","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","1946.00","1167.60","TRICARE [160005]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","1 through 10","247.49","1654.1","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","1946.00","1167.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","248.53","234.93","252.57","38","247.49","1654.1","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","1946.00","1167.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1506.20","77.4","","1455.45","1455.45","1455.45","1 through 10","247.49","1654.1","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","1946.00","1167.60","WELLPOINT [1015]","HB WDH ANTHEM PPO","1304.55","","Case rate ($1,304.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1272.72","1272.72","1272.72","1 through 10","247.49","1654.1","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","1946.00","1167.60","WELLSENSE NH [1050]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","783.90","259.90","783.90","1 through 10","247.49","1654.1","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","outpatient","","","1946.00","1167.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","226.32","11.63","","258.60","221.82","258.60","16","226.32","1415.13","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","outpatient","","","1946.00","1167.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","850.79","43.72","","821.06","821.06","821.06","1 through 10","226.32","1415.13","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","outpatient","","","1946.00","1167.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1415.13","72.72","","1365.68","1365.68","1365.68","12","226.32","1415.13","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","outpatient","","","1946.00","1167.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1415.13","72.72","","1365.68","1365.68","1365.68","1 through 10","226.32","1415.13","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","outpatient","","","1946.00","1167.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","226.32","11.63","","221.82","221.82","796.90","16","226.32","1415.13","percent of total billed charges",""
"Duplex Venous Extremity Unilat/Lmtd","PX-92000040","CDM","93971","CPT","0921","RC","","","","both","","","1192.00","715.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","832.02","69.8","","802.70","802.70","802.70","1 through 10","108.88","1013.2","percent of total billed charges",""
"Duplex Venous Extremity Unilat/Lmtd","PX-92000040","CDM","93971","CPT","0921","RC","","","","both","","","1192.00","715.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","832.02","69.8","","802.70","802.70","802.70","1 through 10","108.88","1013.2","percent of total billed charges",""
"Duplex Venous Extremity Unilat/Lmtd","PX-92000040","CDM","93971","CPT","0921","RC","","","","both","","","1192.00","715.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","108.89","111.11","55","108.88","1013.2","other","OPPS APC"
"Duplex Venous Extremity Unilat/Lmtd","PX-92000040","CDM","93971","CPT","0921","RC","","","","outpatient","","","1192.00","715.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","866.82","72.72","","836.28","836.28","836.28","1 through 10","138.63","922.61","percent of total billed charges",""
"Duplex Venous Extremity Unilat/Lmtd","PX-92000040","CDM","93971","CPT","0921","RC","","","","outpatient","","","1192.00","715.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","922.61","77.4","","836.28","836.28","836.28","1 through 10","138.63","922.61","percent of total billed charges",""
"Dysequilibrium","149","MS-DRG","","","","","","","","inpatient","","","37533.77","22520.26","MARTIN'S POINT [160007]","HB WDH MEDICARE","6158.87","","Case rate ($6,158.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,718.82, add-ons for qualifying new technology services are included. If operating cost exceeds $9,637.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,222.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,296.44 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,273.95 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.55. The transfer capital threshold is the transfer adjustment factor * $417.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5985.27","5985.27","5985.27","1 through 10","3975","28560.88","other","Inpatient DRG"
"Dysequilibrium","149","MS-DRG","","","","","","","","inpatient","","","37533.77","22520.26","MEDICARE [2001]","HB WDH MEDICARE","6158.87","","Case rate ($6,158.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,718.82, add-ons for qualifying new technology services are included. If operating cost exceeds $9,637.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,222.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,296.44 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,273.95 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.55. The transfer capital threshold is the transfer adjustment factor * $417.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6085.08","0.05","6099.77","1 through 10","3975","28560.88","other","Inpatient DRG"
"Dysequilibrium","149","MS-DRG","","","","","","","","inpatient","","","37533.77","22520.26","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6158.87","","Case rate ($6,158.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,718.82, add-ons for qualifying new technology services are included. If operating cost exceeds $9,637.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,222.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,296.44 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,273.95 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $417.55. The transfer capital threshold is the transfer adjustment factor * $417.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6085.08","6085.08","6085.08","1 through 10","3975","28560.88","other","Inpatient DRG"
"Ecg Event Record/Discon 24 Hr/30 D","PX-73000003","CDM","93270","CPT","0730","RC","","","","both","","","315.00","189.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","38.18","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","43.84","36.15","43.84","1 through 10","38.18","267.75","other","OPPS APC"
"Ecg Event Record/Discon 24 Hr/30 D","PX-73000003","CDM","93270","CPT","0730","RC","","","","both","","","315.00","189.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","179.24","56.9","","172.98","172.98","172.98","1 through 10","38.18","267.75","percent of total billed charges",""
"Ecg Event Record/Discon 24 Hr/30 D","PX-73000003","CDM","93270","CPT","0730","RC","","","","both","","","315.00","189.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.18","38.18","38.96","1 through 10","38.18","267.75","other","OPPS APC"
"Ecg Event Record/Discon 24 Hr/30 D","PX-73000003","CDM","93270","CPT","0730","RC","","","","both","","","315.00","189.00","MEDICARE [2001]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.96","38.96","38.96","1 through 10","38.18","267.75","other","OPPS APC"
"Ecg Event Record/Discon 24 Hr/30 D","PX-73000003","CDM","93270","CPT","0730","RC","","","","both","","","315.00","189.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.69","38.69","38.69","1 through 10","38.18","267.75","other","OPPS APC"
"Ecg Event Record/Discon 24 Hr/30 D","PX-73000003","CDM","93270","CPT","0730","RC","","","","outpatient","","","315.00","189.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","36.63","11.63","","35.90","35.90","35.90","1 through 10","36.63","243.81","percent of total billed charges",""
"Ecg Event Record/Discon 24 Hr/30 D","PX-73000003","CDM","93270","CPT","0730","RC","","","","outpatient","","","315.00","189.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","229.07","72.72","","221.07","221.07","221.07","1 through 10","36.63","243.81","percent of total billed charges",""
"Ecg Event Record/Discon 24 Hr/30 D","PX-73000003","CDM","93270","CPT","0730","RC","","","","outpatient","","","315.00","189.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","198.14","62.9","","191.52","191.52","191.52","1 through 10","36.63","243.81","percent of total billed charges",""
"Ecg Event Record/Discon 24 Hr/30 D","PX-73000003","CDM","93270","CPT","0730","RC","","","","outpatient","","","315.00","189.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","36.63","11.63","","35.90","35.90","35.90","1 through 10","36.63","243.81","percent of total billed charges",""
"Ecg Monitor/Report Up to 48 Hrs Rec","PX-73000007","CDM","93225","CPT","0731","RC","","","","both","","","888.00","532.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","132.50","132.00","133.00","24","131.98","860.68","other","OPPS APC"
"Ecg Monitor/Report Up to 48 Hrs Rec","PX-73000007","CDM","93225","CPT","0731","RC","","","","outpatient","","","888.00","532.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","645.75","72.72","","623.21","599.81","623.21","1 through 10","103.27","687.31","percent of total billed charges",""
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","6932.00","4159.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","841.93","","APC Price ($825.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","825.52","825.52","825.52","19","808.91","5892.2","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","6932.00","4159.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","808.91","","APC Price ($825.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","810.31","809.01","812.31","43","808.91","5892.2","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","6932.00","4159.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","850.19","","APC Price ($825.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","836.86","833.96","846.68","24","808.91","5892.2","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","6932.00","4159.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","825.42","","APC Price ($825.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","811.49","811.49","825.52","69","808.91","5892.2","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","6932.00","4159.20","MEDICARE [2001]","HB WDH MEDICARE","825.42","","APC Price ($825.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","825.52","825.52","825.52","265","808.91","5892.2","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","6932.00","4159.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","825.42","","APC Price ($825.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","809.51","809.01","825.52","134","808.91","5892.2","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","6932.00","4159.20","WELLSENSE NH [1050]","HB WDH MEDICARE","825.42","","APC Price ($825.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","849.46","849.46","2548.38","14","808.91","5892.2","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","outpatient","","","6932.00","4159.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4351.91","62.78","","4199.35","4199.35","4199.35","1 through 10","806.19","5365.37","percent of total billed charges",""
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","outpatient","","","6932.00","4159.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3030.67","43.72","","2924.43","2924.43","2924.43","1 through 10","806.19","5365.37","percent of total billed charges",""
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","outpatient","","","6932.00","4159.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5040.95","72.72","","4864.24","4864.24","9363.52","19","806.19","5365.37","percent of total billed charges",""
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","outpatient","","","6932.00","4159.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5040.95","72.72","","9728.48","9728.48","9728.48","1 through 10","806.19","5365.37","percent of total billed charges",""
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","outpatient","","","6932.00","4159.20","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","5040.95","72.72","","4864.24","4864.24","4864.24","1 through 10","806.19","5365.37","percent of total billed charges",""
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","outpatient","","","6932.00","4159.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5365.37","77.4","","5183.98","5183.97","5183.98","15","806.19","5365.37","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","both","","","465.00","279.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","324.57","69.8","","313.40","53.03","313.40","1 through 10","264.59","395.25","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","both","","","465.00","279.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","257.62","257.62","257.62","1 through 10","264.59","395.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","both","","","465.00","279.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","264.59","56.9","","255.48","255.48","766.44","52","264.59","395.25","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","outpatient","","","465.00","279.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","67.05","14.42","","64.75","55.50","64.75","17","54.08","359.91","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","outpatient","","","465.00","279.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","54.08","11.63","","61.83","54.96","159.09","63","54.08","359.91","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","outpatient","","","465.00","279.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","291.93","62.78","","281.88","281.88","281.88","1 through 10","54.08","359.91","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","outpatient","","","465.00","279.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","203.30","43.72","","196.30","196.30","196.30","1 through 10","54.08","359.91","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","outpatient","","","465.00","279.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","338.15","72.72","","326.51","326.51","326.51","40","54.08","359.91","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","outpatient","","","465.00","279.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","338.15","72.72","","326.51","326.51","326.51","1 through 10","54.08","359.91","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","outpatient","","","465.00","279.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","292.49","62.9","","282.87","282.87","848.61","25","54.08","359.91","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","outpatient","","","465.00","279.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","359.91","77.4","","347.98","347.98","347.98","15","54.08","359.91","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","outpatient","","","465.00","279.00","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","338.15","72.72","","326.51","326.51","326.51","1 through 10","54.08","359.91","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","outpatient","","","465.00","279.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","54.08","11.63","","53.03","53.03","159.09","22","54.08","359.91","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","both","","","700.00","420.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","488.60","69.8","","471.15","79.73","471.15","1 through 10","398.3","595","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","both","","","700.00","420.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","398.30","56.9","","384.08","384.08","2009.17","37","398.3","595","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","outpatient","","","700.00","420.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","100.94","14.42","","97.34","83.43","97.34","13","81.41","541.8","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","outpatient","","","700.00","420.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","81.41","11.63","","92.95","82.62","239.19","36","81.41","541.8","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","outpatient","","","700.00","420.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","439.46","62.78","","423.77","423.77","423.77","1 through 10","81.41","541.8","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","outpatient","","","700.00","420.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","306.04","43.72","","295.11","295.11","295.11","1 through 10","81.41","541.8","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","outpatient","","","700.00","420.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","509.04","72.72","","490.86","490.86","490.86","27","81.41","541.8","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","outpatient","","","700.00","420.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","509.04","72.72","","490.86","490.86","490.86","1 through 10","81.41","541.8","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","outpatient","","","700.00","420.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","440.30","62.9","","425.25","425.25","1275.75","15","81.41","541.8","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","outpatient","","","700.00","420.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","541.80","77.4","","523.13","523.13","523.13","11","81.41","541.8","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","outpatient","","","700.00","420.00","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","509.04","72.72","","490.86","490.86","490.86","1 through 10","81.41","541.8","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","outpatient","","","700.00","420.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","81.41","11.63","","79.73","79.73","239.19","16","81.41","541.8","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","both","","","326.00","195.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","227.55","69.8","","219.87","219.87","219.87","1 through 10","185.49","277.1","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","both","","","326.00","195.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","213.15","213.15","213.15","1 through 10","185.49","277.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","both","","","326.00","195.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","185.49","56.9","","179.24","179.23","179.24","17","185.49","277.1","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","outpatient","","","326.00","195.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","47.01","14.42","","45.42","45.42","45.42","1 through 10","37.91","252.32","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","outpatient","","","326.00","195.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","37.91","11.63","","79.56","37.21","111.63","27","37.91","252.32","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","outpatient","","","326.00","195.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","237.07","72.72","","229.07","229.07","440.74","13","37.91","252.32","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","outpatient","","","326.00","195.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","205.05","62.9","","198.45","198.45","198.45","11","37.91","252.32","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","outpatient","","","326.00","195.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","252.32","77.4","","244.13","244.13","244.13","1 through 10","37.91","252.32","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","outpatient","","","326.00","195.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","237.07","72.72","","229.07","229.07","229.07","1 through 10","37.91","252.32","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","outpatient","","","326.00","195.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","37.91","11.63","","111.63","37.21","111.63","1 through 10","37.91","252.32","percent of total billed charges",""
"Echo Rest & Stress W/Pro Fee W/Cont or W/O Fol W/Cont","PX-48000202","CDM","C8928","HCPCS","0483","RC","","","","both","","","6247.00","3748.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","841.93","","APC Price ($825.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","825.52","825.52","825.52","1 through 10","808.91","5309.95","other","OPPS APC"
"Echo Rest & Stress W/Pro Fee W/Cont or W/O Fol W/Cont","PX-48000202","CDM","C8928","HCPCS","0483","RC","","","","both","","","6247.00","3748.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","808.91","","APC Price ($825.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","809.01","764.54","810.41","1 through 10","808.91","5309.95","other","OPPS APC"
"Echo Rest & Stress W/Pro Fee W/Cont or W/O Fol W/Cont","PX-48000202","CDM","C8928","HCPCS","0483","RC","","","","both","","","6247.00","3748.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","850.19","","APC Price ($825.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","839.66","839.00","839.66","1 through 10","808.91","5309.95","other","OPPS APC"
"Echo Rest & Stress W/Pro Fee W/Cont or W/O Fol W/Cont","PX-48000202","CDM","C8928","HCPCS","0483","RC","","","","both","","","6247.00","3748.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","825.42","","APC Price ($825.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","811.49","811.49","825.52","11","808.91","5309.95","other","OPPS APC"
"Echo Rest & Stress W/Pro Fee W/Cont or W/O Fol W/Cont","PX-48000202","CDM","C8928","HCPCS","0483","RC","","","","both","","","6247.00","3748.20","MEDICARE [2001]","HB WDH MEDICARE","825.42","","APC Price ($825.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","825.52","825.52","825.52","29","808.91","5309.95","other","OPPS APC"
"Echo Rest & Stress W/Pro Fee W/Cont or W/O Fol W/Cont","PX-48000202","CDM","C8928","HCPCS","0483","RC","","","","both","","","6247.00","3748.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","825.42","","APC Price ($825.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","810.01","809.01","825.52","1 through 10","808.91","5309.95","other","OPPS APC"
"Echo Rest & Stress W/Pro Fee W/Cont or W/O Fol W/Cont","PX-48000202","CDM","C8928","HCPCS","0483","RC","","","","both","","","6247.00","3748.20","WELLSENSE NH [1050]","HB WDH MEDICARE","825.42","","APC Price ($825.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","849.46","849.46","849.46","1 through 10","808.91","5309.95","other","OPPS APC"
"Echo Rest & Stress W/Pro Fee W/Cont or W/O Fol W/Cont","PX-48000202","CDM","C8928","HCPCS","0483","RC","","","","outpatient","","","6247.00","3748.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4835.18","77.4","","4671.70","4671.70","4671.70","1 through 10","726.53","4835.18","percent of total billed charges",""
"Echo Tee Cmpl W/Pf W/Cont or W/O Fol W/Cont","PX-48000190","CDM","C8925","HCPCS","0483","RC","","","","both","","","9819.00","5891.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","825.42","","APC Price ($825.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","809.01","764.54","825.52","1 through 10","808.91","8346.15","other","OPPS APC"
"Echo Tee Cmpl W/Pf W/Cont or W/O Fol W/Cont","PX-48000190","CDM","C8925","HCPCS","0483","RC","","","","both","","","9819.00","5891.40","MEDICARE [2001]","HB WDH MEDICARE","825.42","","APC Price ($825.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","825.52","825.52","825.52","1 through 10","808.91","8346.15","other","OPPS APC"
"Echo Tee Cmpl W/Pf W/Cont or W/O Fol W/Cont","PX-48000190","CDM","C8925","HCPCS","0483","RC","","","","both","","","9819.00","5891.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","825.42","","APC Price ($825.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","810.01","810.01","810.01","1 through 10","808.91","8346.15","other","OPPS APC"
"Echo Tee Cmpl W/Pf W/Cont or W/O Fol W/Cont","PX-48000190","CDM","C8925","HCPCS","0483","RC","","","","outpatient","","","9819.00","5891.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7599.91","77.4","","7343.13","7343.13","7343.13","1 through 10","1141.95","7599.91","percent of total billed charges",""
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3234.00","1940.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","2257.33","69.8","","368.64","368.64","368.64","1 through 10","561.39","3660.99","percent of total billed charges",""
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3234.00","1940.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","3660.99","","Case rate ($3,660.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3571.71","3571.71","3571.71","1 through 10","561.39","3660.99","other","OPPS APC"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3234.00","1940.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1576.42","","Case rate ($1,576.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1537.99","1537.99","1537.99","1 through 10","561.39","3660.99","other","OPPS APC"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3234.00","1940.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","561.39","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","561.45","526.77","572.91","1 through 10","561.39","3660.99","other","OPPS APC"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3234.00","1940.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","2959.14","","Case rate ($2,959.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2886.96","1504.55","2886.96","1 through 10","561.39","3660.99","other","OPPS APC"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3234.00","1940.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1840.15","56.9","","1775.85","1775.85","5391.28","12","561.39","3660.99","percent of total billed charges",""
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3234.00","1940.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","590.03","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","578.90","578.30","580.90","1 through 10","561.39","3660.99","other","OPPS APC"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3234.00","1940.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","572.84","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","563.17","561.45","563.74","14","561.39","3660.99","other","OPPS APC"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3234.00","1940.40","MEDICARE [2001]","HB WDH MEDICARE","572.84","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","572.91","572.91","572.91","42","561.39","3660.99","other","OPPS APC"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3234.00","1940.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","572.84","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","564.46","537.52","572.91","13","561.39","3660.99","other","OPPS APC"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","3234.00","1940.40","WELLSENSE NH [1050]","HB WDH MEDICARE","572.84","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","601.56","601.56","601.56","1 through 10","561.39","3660.99","other","OPPS APC"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","outpatient","","","3234.00","1940.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","466.34","14.42","","450.05","450.05","450.05","1 through 10","376.11","2503.12","percent of total billed charges",""
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","outpatient","","","3234.00","1940.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","376.11","11.63","","368.64","368.64","368.64","1 through 10","376.11","2503.12","percent of total billed charges",""
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","outpatient","","","3234.00","1940.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2351.76","72.72","","2269.59","2269.59","2269.59","1 through 10","376.11","2503.12","percent of total billed charges",""
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","outpatient","","","3234.00","1940.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2034.19","62.9","","1966.23","1663.81","1966.23","1 through 10","376.11","2503.12","percent of total billed charges",""
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","outpatient","","","3234.00","1940.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","376.11","11.63","","1805.82","1805.82","1805.82","1 through 10","376.11","2503.12","percent of total billed charges",""
"Echo Transthoracic W/Cont or W/O Fol W/Cont","PX-48000188","CDM","C8924","HCPCS","0483","RC","","","","both","","","3071.00","1842.60","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","380.58","","APC Price ($373.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","373.16","373.16","373.16","1 through 10","365.65","2610.35","other","OPPS APC"
"Echo Transthoracic W/Cont or W/O Fol W/Cont","PX-48000188","CDM","C8924","HCPCS","0483","RC","","","","both","","","3071.00","1842.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","365.65","","APC Price ($373.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","365.70","365.70","367.70","1 through 10","365.65","2610.35","other","OPPS APC"
"Echo Transthoracic W/Cont or W/O Fol W/Cont","PX-48000188","CDM","C8924","HCPCS","0483","RC","","","","both","","","3071.00","1842.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","384.31","","APC Price ($373.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","384.35","376.66","384.35","1 through 10","365.65","2610.35","other","OPPS APC"
"Echo Transthoracic W/Cont or W/O Fol W/Cont","PX-48000188","CDM","C8924","HCPCS","0483","RC","","","","both","","","3071.00","1842.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","373.12","","APC Price ($373.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","366.82","366.82","366.82","1 through 10","365.65","2610.35","other","OPPS APC"
"Echo Transthoracic W/Cont or W/O Fol W/Cont","PX-48000188","CDM","C8924","HCPCS","0483","RC","","","","both","","","3071.00","1842.60","MEDICARE [2001]","HB WDH MEDICARE","373.12","","APC Price ($373.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","373.16","374.71","18","365.65","2610.35","other","OPPS APC"
"Echo Transthoracic W/Cont or W/O Fol W/Cont","PX-48000188","CDM","C8924","HCPCS","0483","RC","","","","both","","","3071.00","1842.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","373.12","","APC Price ($373.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","368.12","366.20","373.16","1 through 10","365.65","2610.35","other","OPPS APC"
"Echo Transthoracic W/Cont or W/O Fol W/Cont","PX-48000188","CDM","C8924","HCPCS","0483","RC","","","","both","","","3071.00","1842.60","WELLSENSE NH [1050]","HB WDH MEDICARE","373.12","","APC Price ($373.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","383.98","383.98","383.98","1 through 10","365.65","2610.35","other","OPPS APC"
"Echo Transthoracic W/Cont or W/O Fol W/Cont","PX-48000188","CDM","C8924","HCPCS","0483","RC","","","","outpatient","","","3071.00","1842.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2233.23","72.72","","2154.69","2154.69","2154.69","1 through 10","357.16","2376.95","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","1248.72","69.8","","1204.75","1204.75","1204.75","1 through 10","247.49","1613.96","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1613.96","","Case rate ($1,613.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1574.60","1168.80","1574.60","1 through 10","247.49","1613.96","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","694.97","","Case rate ($694.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","678.03","668.27","678.03","1 through 10","247.49","1613.96","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","247.49","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","252.57","247.52","252.57","1 through 10","247.49","1613.96","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1304.55","","Case rate ($1,304.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","678.03","678.03","1272.72","1 through 10","247.49","1613.96","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1017.94","56.9","","982.09","982.09","2946.27","13","247.49","1613.96","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","260.12","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","255.99","254.95","255.99","1 through 10","247.49","1613.96","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","248.28","233.97","252.57","1 through 10","247.49","1613.96","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","MEDICARE [2001]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","238.75","252.57","19","247.49","1613.96","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","TRICARE [160005]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","1 through 10","247.49","1613.96","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.52","247.52","252.52","11","247.49","1613.96","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","WELLSENSE NH [1050]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","265.20","259.90","265.20","1 through 10","247.49","1613.96","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","outpatient","","","1789.00","1073.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","257.97","14.42","","213.33","213.33","213.33","1 through 10","208.06","1384.69","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","outpatient","","","1789.00","1073.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","208.06","11.63","","408.01","203.87","790.18","1 through 10","208.06","1384.69","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","outpatient","","","1789.00","1073.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1300.96","72.72","","1255.15","1255.15","1255.15","1 through 10","208.06","1384.69","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","outpatient","","","1789.00","1073.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1125.28","62.9","","1087.38","1087.38","1866.69","1 through 10","208.06","1384.69","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","outpatient","","","1789.00","1073.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1384.69","77.4","","1337.65","1337.65","1337.65","1 through 10","208.06","1384.69","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","outpatient","","","1789.00","1073.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","208.06","11.63","","349.98","203.87","796.90","1 through 10","208.06","1384.69","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","1248.72","69.8","","1204.75","1204.75","1204.75","1 through 10","247.49","1613.96","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1613.96","","Case rate ($1,613.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1574.60","1168.80","1574.60","1 through 10","247.49","1613.96","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","694.97","","Case rate ($694.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","678.03","668.27","678.03","1 through 10","247.49","1613.96","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","247.49","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","252.57","247.52","252.57","1 through 10","247.49","1613.96","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1304.55","","Case rate ($1,304.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","678.03","678.03","1272.72","1 through 10","247.49","1613.96","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1017.94","56.9","","982.09","982.09","2946.27","13","247.49","1613.96","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","260.12","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","255.99","254.95","255.99","1 through 10","247.49","1613.96","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","248.28","233.97","252.57","1 through 10","247.49","1613.96","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","MEDICARE [2001]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","238.75","252.57","19","247.49","1613.96","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","TRICARE [160005]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","1 through 10","247.49","1613.96","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.52","247.52","252.52","11","247.49","1613.96","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","1789.00","1073.40","WELLSENSE NH [1050]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","265.20","259.90","265.20","1 through 10","247.49","1613.96","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","outpatient","","","1789.00","1073.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","257.97","14.42","","213.33","213.33","213.33","1 through 10","208.06","1384.69","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","outpatient","","","1789.00","1073.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","208.06","11.63","","408.01","203.87","790.18","1 through 10","208.06","1384.69","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","outpatient","","","1789.00","1073.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1300.96","72.72","","1255.15","1255.15","1255.15","1 through 10","208.06","1384.69","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","outpatient","","","1789.00","1073.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1125.28","62.9","","1087.38","1087.38","1866.69","1 through 10","208.06","1384.69","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","outpatient","","","1789.00","1073.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1384.69","77.4","","1337.65","1337.65","1337.65","1 through 10","208.06","1384.69","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","outpatient","","","1789.00","1073.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","208.06","11.63","","349.98","203.87","796.90","1 through 10","208.06","1384.69","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","2947.00","1768.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","3660.99","","Case rate ($3,660.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3571.71","3144.68","3571.71","17","561.39","3660.99","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","2947.00","1768.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1576.42","","Case rate ($1,576.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1537.99","1384.20","1537.99","22","561.39","3660.99","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","2947.00","1768.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","561.39","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","563.74","537.52","572.91","20","561.39","3660.99","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","2947.00","1768.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","2959.14","","Case rate ($2,959.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2598.26","1537.99","2886.96","11","561.39","3660.99","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","2947.00","1768.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1676.84","56.9","","1618.24","1618.24","17942.77","30","561.39","3660.99","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","2947.00","1768.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","590.03","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","585.86","578.30","589.80","1 through 10","561.39","3660.99","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","2947.00","1768.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","572.84","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","563.17","562.02","572.91","12","561.39","3660.99","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","2947.00","1768.20","MEDICARE [2001]","HB WDH MEDICARE","572.84","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","572.91","572.91","572.91","28","561.39","3660.99","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","2947.00","1768.20","TRICARE [160005]","HB WDH MEDICARE","572.84","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1145.82","1145.82","1145.82","1 through 10","561.39","3660.99","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","2947.00","1768.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","572.84","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","564.46","561.66","565.16","12","561.39","3660.99","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","outpatient","","","2947.00","1768.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","424.96","14.42","","745.06","351.52","869.24","1 through 10","342.74","2280.98","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","outpatient","","","2947.00","1768.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","342.74","11.63","","718.27","335.93","830.06","1 through 10","342.74","2280.98","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","outpatient","","","2947.00","1768.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1850.13","62.78","","1785.46","1785.46","1785.46","1 through 10","342.74","2280.98","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","outpatient","","","2947.00","1768.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1288.43","43.72","","2635.44","2635.44","2635.44","1 through 10","342.74","2280.98","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","outpatient","","","2947.00","1768.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2143.06","72.72","","2068.16","2068.16","8438.26","19","342.74","2280.98","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","outpatient","","","2947.00","1768.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2143.06","72.72","","4383.56","4383.56","4383.56","1 through 10","342.74","2280.98","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","outpatient","","","2947.00","1768.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1853.66","62.9","","1791.72","1791.72","3797.64","14","342.74","2280.98","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","outpatient","","","2947.00","1768.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2280.98","77.4","","2204.10","2204.10","2204.10","1 through 10","342.74","2280.98","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","outpatient","","","2947.00","1768.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","2143.06","72.72","","2068.16","2068.16","2068.16","1 through 10","342.74","2280.98","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","outpatient","","","2947.00","1768.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","342.74","11.63","","712.00","335.93","712.00","1 through 10","342.74","2280.98","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3249.00","1949.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","2267.80","69.8","","2188.23","370.29","2188.23","18","561.39","3660.99","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3249.00","1949.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","3660.99","","Case rate ($3,660.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3135.00","3135.00","3571.71","139","561.39","3660.99","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3249.00","1949.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1576.42","","Case rate ($1,576.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1537.99","1384.20","1537.99","202","561.39","3660.99","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3249.00","1949.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","561.39","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","563.74","561.45","572.91","238","561.39","3660.99","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3249.00","1949.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","2959.14","","Case rate ($2,959.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2886.96","1537.99","2886.96","112","561.39","3660.99","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3249.00","1949.40","CHAMPVA [160001]","HB WDH MEDICARE","572.84","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","572.91","572.91","572.91","1 through 10","561.39","3660.99","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3249.00","1949.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1848.68","56.9","","1783.82","1783.81","5351.46","249","561.39","3660.99","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3249.00","1949.40","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","2267.80","69.8","","2188.23","2188.23","2188.23","1 through 10","561.39","3660.99","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3249.00","1949.40","HARVARD PILGRIM [120001]","HB WDH MEDICARE","572.84","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","526.97","526.97","526.97","1 through 10","561.39","3660.99","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3249.00","1949.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","590.03","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","580.90","578.30","590.10","83","561.39","3660.99","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3249.00","1949.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","572.84","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","563.17","563.17","572.91","290","561.39","3660.99","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3249.00","1949.40","MEDICARE [2001]","HB WDH MEDICARE","572.84","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","572.91","572.91","572.91","701","561.39","3660.99","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3249.00","1949.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","2761.65","85","","1783.82","752.53","2555.95","1 through 10","561.39","3660.99","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3249.00","1949.40","TRICARE [160005]","HB WDH MEDICARE","572.84","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","572.91","572.91","572.91","31","561.39","3660.99","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3249.00","1949.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","572.84","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","564.46","561.46","572.91","374","561.39","3660.99","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3249.00","1949.40","WELLPOINT [1015]","HB WDH ANTHEM PPO","2959.14","","Case rate ($2,959.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2886.96","2886.96","2886.96","1 through 10","561.39","3660.99","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","3249.00","1949.40","WELLSENSE NH [1050]","HB WDH MEDICARE","572.84","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","589.53","589.53","589.53","39","561.39","3660.99","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","outpatient","","","3249.00","1949.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","468.51","14.42","","452.07","387.49","964.55","76","377.86","2514.73","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","outpatient","","","3249.00","1949.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","377.86","11.63","","791.74","370.29","1580.16","144","377.86","2514.73","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","outpatient","","","3249.00","1949.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2039.72","62.78","","1968.15","1968.15","1968.15","1 through 10","377.86","2514.73","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","outpatient","","","3249.00","1949.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1420.46","43.72","","1370.62","1370.62","1370.62","1 through 10","377.86","2514.73","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","outpatient","","","3249.00","1949.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2362.67","72.72","","2279.77","2279.77","6839.31","103","377.86","2514.73","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","outpatient","","","3249.00","1949.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2362.67","72.72","","2279.77","2279.77","2279.77","1 through 10","377.86","2514.73","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","outpatient","","","3249.00","1949.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1729.12","53.22","","3565.91","3565.91","3565.91","1 through 10","377.86","2514.73","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","outpatient","","","3249.00","1949.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2043.62","62.9","","1975.05","1975.05","12642.21","211","377.86","2514.73","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","outpatient","","","3249.00","1949.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2514.73","77.4","","2429.63","2429.63","2429.63","45","377.86","2514.73","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","outpatient","","","3249.00","1949.40","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","2362.67","72.72","","2279.77","2279.77","2279.77","1 through 10","377.86","2514.73","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","outpatient","","","3249.00","1949.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","377.86","11.63","","790.08","370.29","2370.24","88","377.86","2514.73","percent of total billed charges",""
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","2375.00","1425.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2079.19","","Case rate ($2,079.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2028.48","1987.99","2028.48","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","2375.00","1425.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","895.30","","Case rate ($895.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","873.47","856.04","873.47","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","2375.00","1425.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","318.83","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","325.38","305.82","325.38","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","2375.00","1425.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1680.59","","Case rate ($1,680.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1639.59","873.47","1639.59","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","2375.00","1425.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1351.38","56.9","","1304.15","1304.15","1304.15","1 through 10","318.83","2079.19","percent of total billed charges",""
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","2375.00","1425.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","325.38","325.38","325.38","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","2375.00","1425.00","MEDICARE [2001]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","325.38","325.38","650.76","11","318.83","2079.19","other","OPPS APC"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","2375.00","1425.00","TRICARE [160005]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","325.38","325.38","325.38","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","2375.00","1425.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","319.38","300.71","325.38","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","2375.00","1425.00","WELLPOINT [1015]","HB WDH ANTHEM PPO","1680.59","","Case rate ($1,680.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1639.59","1639.59","1639.59","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","outpatient","","","2375.00","1425.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","342.48","14.42","","330.51","283.29","330.51","1 through 10","276.21","1838.25","percent of total billed charges",""
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","outpatient","","","2375.00","1425.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","276.21","11.63","","315.61","270.72","578.85","16","276.21","1838.25","percent of total billed charges",""
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","outpatient","","","2375.00","1425.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1727.10","72.72","","3333.48","1666.74","3333.48","1 through 10","276.21","1838.25","percent of total billed charges",""
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","outpatient","","","2375.00","1425.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1493.88","62.9","","2887.92","1443.96","2887.92","1 through 10","276.21","1838.25","percent of total billed charges",""
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","outpatient","","","2375.00","1425.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","276.21","11.63","","270.72","270.72","270.72","1 through 10","276.21","1838.25","percent of total billed charges",""
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","1964.00","1178.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","1370.87","69.8","","1322.71","1322.71","1322.71","1 through 10","318.83","2079.19","percent of total billed charges",""
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","1964.00","1178.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2079.19","","Case rate ($2,079.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1895.00","1895.00","1895.00","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","1964.00","1178.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","895.30","","Case rate ($895.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","873.47","873.47","2768.47","14","318.83","2079.19","other","OPPS APC"
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","1964.00","1178.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","318.83","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","320.87","305.82","325.38","16","318.83","2079.19","other","OPPS APC"
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","1964.00","1178.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1680.59","","Case rate ($1,680.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1639.59","856.04","2768.47","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","1964.00","1178.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1117.52","56.9","","1078.26","1078.25","1078.26","15","318.83","2079.19","percent of total billed charges",""
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","1964.00","1178.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","335.10","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","329.78","100.00","335.14","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","1964.00","1178.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","319.85","319.85","325.38","11","318.83","2079.19","other","OPPS APC"
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","1964.00","1178.40","MEDICARE [2001]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","325.38","325.38","325.38","50","318.83","2079.19","other","OPPS APC"
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","1964.00","1178.40","TRICARE [160005]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","325.38","325.38","325.38","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","1964.00","1178.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","319.38","299.91","325.38","19","318.83","2079.19","other","OPPS APC"
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","1964.00","1178.40","WELLSENSE NH [1050]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","334.82","334.82","334.82","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","outpatient","","","1964.00","1178.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","283.21","14.42","","234.22","234.22","273.26","1 through 10","228.41","1520.14","percent of total billed charges",""
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","outpatient","","","1964.00","1178.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","228.41","11.63","","260.94","223.83","671.49","20","228.41","1520.14","percent of total billed charges",""
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","outpatient","","","1964.00","1178.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1428.22","72.72","","1378.04","1378.04","1378.04","1 through 10","228.41","1520.14","percent of total billed charges",""
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","outpatient","","","1964.00","1178.40","INTERNATIONAL COMMERCIAL [140001]","HB WDH UNITED HMO / PPO / INDEM","1520.14","77.4","","1468.63","1468.63","1468.63","1 through 10","228.41","1520.14","percent of total billed charges",""
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","outpatient","","","1964.00","1178.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1235.36","62.9","","1193.85","1193.85","3581.55","12","228.41","1520.14","percent of total billed charges",""
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","outpatient","","","1964.00","1178.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1520.14","77.4","","1468.63","1378.04","1468.63","1 through 10","228.41","1520.14","percent of total billed charges",""
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","outpatient","","","1964.00","1178.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","228.41","11.63","","223.83","223.83","447.66","17","228.41","1520.14","percent of total billed charges",""
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1719.00","1031.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","1199.86","69.8","","1157.98","1157.98","1157.98","1 through 10","160.19","1461.15","percent of total billed charges",""
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1719.00","1031.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1044.65","","Case rate ($1,044.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1019.18","1019.18","1019.18","1 through 10","160.19","1461.15","other","OPPS APC"
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1719.00","1031.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","449.83","","Case rate ($449.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","438.86","438.86","2097.86","1 through 10","160.19","1461.15","other","OPPS APC"
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1719.00","1031.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","160.19","","APC Price ($163.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","160.86","152.20","163.48","1 through 10","160.19","1461.15","other","OPPS APC"
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1719.00","1031.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","844.38","","Case rate ($844.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","823.78","799.65","823.78","1 through 10","160.19","1461.15","other","OPPS APC"
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1719.00","1031.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","978.11","56.9","","943.97","943.97","943.97","1 through 10","160.19","1461.15","percent of total billed charges",""
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1719.00","1031.40","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","978.11","56.9","","943.97","943.97","943.97","1 through 10","160.19","1461.15","percent of total billed charges",""
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1719.00","1031.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","168.37","","APC Price ($163.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","168.38","168.38","168.38","1 through 10","160.19","1461.15","other","OPPS APC"
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1719.00","1031.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","163.46","","APC Price ($163.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","163.48","160.70","163.48","1 through 10","160.19","1461.15","other","OPPS APC"
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1719.00","1031.40","MEDICARE [2001]","HB WDH MEDICARE","163.46","","APC Price ($163.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","163.48","152.20","163.48","12","160.19","1461.15","other","OPPS APC"
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1719.00","1031.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","1461.15","85","","504.36","504.36","504.36","1 through 10","160.19","1461.15","percent of total billed charges",""
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1719.00","1031.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","163.46","","APC Price ($163.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","161.12","160.72","163.48","1 through 10","160.19","1461.15","other","OPPS APC"
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","outpatient","","","1719.00","1031.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","247.88","14.42","","239.23","205.05","239.23","1 through 10","199.92","1330.51","percent of total billed charges",""
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","outpatient","","","1719.00","1031.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","199.92","11.63","","228.44","195.95","418.98","1 through 10","199.92","1330.51","percent of total billed charges",""
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","outpatient","","","1719.00","1031.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1079.19","62.78","","1041.52","1041.52","1041.52","1 through 10","199.92","1330.51","percent of total billed charges",""
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","outpatient","","","1719.00","1031.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","751.55","43.72","","725.31","725.31","725.31","1 through 10","199.92","1330.51","percent of total billed charges",""
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","outpatient","","","1719.00","1031.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1250.06","72.72","","1285.73","1206.42","1285.73","1 through 10","199.92","1330.51","percent of total billed charges",""
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","outpatient","","","1719.00","1031.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1081.25","62.9","","1045.17","1045.17","1045.17","1 through 10","199.92","1330.51","percent of total billed charges",""
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","outpatient","","","1719.00","1031.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","199.92","11.63","","195.95","195.95","257.38","1 through 10","199.92","1330.51","percent of total billed charges",""
"Eeg Monitor > 1 Hr","PX-74000017","CDM","95813","CPT","0740","RC","","","","both","","","2037.00","1222.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","1421.83","69.8","","1372.27","1372.27","1372.27","1 through 10","318.83","2079.19","percent of total billed charges",""
"Eeg Monitor > 1 Hr","PX-74000017","CDM","95813","CPT","0740","RC","","","","both","","","2037.00","1222.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2079.19","","Case rate ($2,079.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1966.00","1966.00","1966.00","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Monitor > 1 Hr","PX-74000017","CDM","95813","CPT","0740","RC","","","","both","","","2037.00","1222.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","895.30","","Case rate ($895.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","873.47","873.47","1966.00","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Monitor > 1 Hr","PX-74000017","CDM","95813","CPT","0740","RC","","","","both","","","2037.00","1222.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","318.83","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","299.70","299.70","299.70","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Monitor > 1 Hr","PX-74000017","CDM","95813","CPT","0740","RC","","","","both","","","2037.00","1222.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1680.59","","Case rate ($1,680.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1639.59","1639.59","1639.59","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Monitor > 1 Hr","PX-74000017","CDM","95813","CPT","0740","RC","","","","both","","","2037.00","1222.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1159.05","56.9","","1118.65","1118.65","1118.65","1 through 10","318.83","2079.19","percent of total billed charges",""
"Eeg Monitor > 1 Hr","PX-74000017","CDM","95813","CPT","0740","RC","","","","both","","","2037.00","1222.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","325.38","325.38","325.38","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Monitor > 1 Hr","PX-74000017","CDM","95813","CPT","0740","RC","","","","both","","","2037.00","1222.20","MEDICARE [2001]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","325.38","305.82","325.38","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Monitor > 1 Hr","PX-74000017","CDM","95813","CPT","0740","RC","","","","both","","","2037.00","1222.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","318.88","300.61","318.88","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Monitor > 1 Hr","PX-74000017","CDM","95813","CPT","0740","RC","","","","outpatient","","","2037.00","1222.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","293.74","14.42","","243.00","243.00","243.00","1 through 10","236.9","1576.64","percent of total billed charges",""
"Eeg Monitor > 1 Hr","PX-74000017","CDM","95813","CPT","0740","RC","","","","outpatient","","","2037.00","1222.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","236.90","11.63","","464.42","232.21","524.20","1 through 10","236.9","1576.64","percent of total billed charges",""
"Eeg Monitor > 1 Hr","PX-74000017","CDM","95813","CPT","0740","RC","","","","outpatient","","","2037.00","1222.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1481.31","72.72","","1429.68","1429.68","1429.68","1 through 10","236.9","1576.64","percent of total billed charges",""
"Eeg Monitor > 1 Hr","PX-74000017","CDM","95813","CPT","0740","RC","","","","outpatient","","","2037.00","1222.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1281.27","62.9","","1238.58","1238.58","1238.58","1 through 10","236.9","1576.64","percent of total billed charges",""
"Eeg Monitor > 1 Hr","PX-74000017","CDM","95813","CPT","0740","RC","","","","outpatient","","","2037.00","1222.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","236.90","11.63","","232.21","232.21","232.21","1 through 10","236.9","1576.64","percent of total billed charges",""
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","both","","","1719.00","1031.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2079.19","","Case rate ($2,079.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1659.00","1659.00","1659.00","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","both","","","1719.00","1031.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","895.30","","Case rate ($895.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","873.47","873.47","873.47","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","both","","","1719.00","1031.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","318.83","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","325.38","325.38","325.38","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","both","","","1719.00","1031.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1680.59","","Case rate ($1,680.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3298.59","1639.59","3298.59","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","both","","","1719.00","1031.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","978.11","56.9","","943.97","943.97","943.97","1 through 10","318.83","2079.19","percent of total billed charges",""
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","both","","","1719.00","1031.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","335.10","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","330.44","330.24","330.44","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","both","","","1719.00","1031.40","MEDICARE [2001]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","325.38","305.82","650.76","1 through 10","318.83","2079.19","other","OPPS APC"
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","outpatient","","","1719.00","1031.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","247.88","14.42","","239.23","239.23","239.23","1 through 10","199.92","1330.51","percent of total billed charges",""
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","outpatient","","","1719.00","1031.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","199.92","11.63","","228.44","228.44","228.44","1 through 10","199.92","1330.51","percent of total billed charges",""
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","outpatient","","","1719.00","1031.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1250.06","72.72","","1206.42","1206.42","1206.42","1 through 10","199.92","1330.51","percent of total billed charges",""
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","outpatient","","","1719.00","1031.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1081.25","62.9","","1045.17","1045.17","1045.17","1 through 10","199.92","1330.51","percent of total billed charges",""
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","outpatient","","","1719.00","1031.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","199.92","11.63","","195.95","195.95","391.90","1 through 10","199.92","1330.51","percent of total billed charges",""
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","both","","","3207.00","1924.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1525.53","","Case rate ($1,525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1488.34","1488.34","1488.34","1 through 10","543.26","3542.81","other","OPPS APC"
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","both","","","3207.00","1924.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","543.26","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","522.23","522.23","522.23","1 through 10","543.26","3542.81","other","OPPS APC"
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","both","","","3207.00","1924.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","2863.62","","Case rate ($2,863.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2793.76","2793.76","2793.76","1 through 10","543.26","3542.81","other","OPPS APC"
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","both","","","3207.00","1924.20","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","1824.78","56.9","","1761.06","1761.06","1761.06","1 through 10","543.26","3542.81","percent of total billed charges",""
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","both","","","3207.00","1924.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","570.98","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","566.05","566.05","566.05","1 through 10","543.26","3542.81","other","OPPS APC"
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","both","","","3207.00","1924.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","554.35","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","554.41","554.41","554.41","1 through 10","543.26","3542.81","other","OPPS APC"
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","both","","","3207.00","1924.20","MEDICARE [2001]","HB WDH MEDICARE","554.35","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","554.41","522.23","554.42","1 through 10","543.26","3542.81","other","OPPS APC"
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","both","","","3207.00","1924.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","554.35","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","543.33","543.33","543.33","1 through 10","543.26","3542.81","other","OPPS APC"
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","outpatient","","","3207.00","1924.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","462.45","14.42","","382.54","382.54","382.54","1 through 10","372.97","2482.22","percent of total billed charges",""
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","outpatient","","","3207.00","1924.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","372.97","11.63","","365.57","365.57","365.57","1 through 10","372.97","2482.22","percent of total billed charges",""
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","outpatient","","","3207.00","1924.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2332.13","72.72","","2250.69","2250.69","2398.62","1 through 10","372.97","2482.22","percent of total billed charges",""
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","outpatient","","","3207.00","1924.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","372.97","11.63","","365.57","365.57","872.86","1 through 10","372.97","2482.22","percent of total billed charges",""
"Eeg W/O Vid Tech Ea Incr 12-26 Hr Cont R-T Mntr","PX-74000063","CDM","95710","CPT","0740","RC","","","","both","","","4123.00","2473.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","2863.62","","Case rate ($2,863.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2793.76","2793.76","2793.76","1 through 10","543.26","3542.81","other","OPPS APC"
"Eeg W/O Vid Tech Ea Incr 12-26 Hr Cont R-T Mntr","PX-74000063","CDM","95710","CPT","0740","RC","","","","both","","","4123.00","2473.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","554.35","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","544.98","544.98","544.98","1 through 10","543.26","3542.81","other","OPPS APC"
"Eeg W/O Video by Tech 2-12 Hr Unmonitored","PX-74000058","CDM","95705","CPT","0740","RC","","","","both","","","2749.00","1649.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1680.59","","Case rate ($1,680.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1639.59","1606.86","1639.59","1 through 10","318.83","2336.65","other","OPPS APC"
"Eeg W/O Video by Tech 2-12 Hr Unmonitored","PX-74000058","CDM","95705","CPT","0740","RC","","","","both","","","2749.00","1649.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1564.18","56.9","","1509.56","1509.56","1509.56","1 through 10","318.83","2336.65","percent of total billed charges",""
"Eeg W/O Video by Tech 2-12 Hr Unmonitored","PX-74000058","CDM","95705","CPT","0740","RC","","","","both","","","2749.00","1649.40","TRICARE [160005]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","305.82","305.82","305.82","1 through 10","318.83","2336.65","other","OPPS APC"
"Eeg W/O Video by Tech 2-12 Hr Unmonitored","PX-74000058","CDM","95705","CPT","0740","RC","","","","outpatient","","","2749.00","1649.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","319.71","11.63","","365.32","365.32","365.32","1 through 10","319.71","2127.73","percent of total billed charges",""
"Egd Endo Mucosal Resection","PX-75000357","CDM","43254","CPT","0750","RC","","","","both","","","7717.00","4630.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1942.26","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1942.49","1942.49","1942.49","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Endoscopic Stent Place","PX-75000358","CDM","43266","CPT","0750","RC","","","","both","","","32290.00","19374.00","MEDICARE [2001]","HB WDH MEDICARE","6219.26","","APC Price ($6,219.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5553.02","5553.02","5553.02","1 through 10","6094.87","39746.79","other","OPPS APC"
"Egd Esophagus Balloon Dilation 30 Mm or Larger","PX-75000390","CDM","43233","CPT","0750","RC","","","","both","","","6546.00","3927.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","2041.36","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2012.36","2012.36","2012.36","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Esophagus Balloon Dilation 30 Mm or Larger","PX-75000390","CDM","43233","CPT","0750","RC","","","","both","","","6546.00","3927.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1982.13","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Esophagus Balloon Dilation 30 Mm or Larger","PX-75000390","CDM","43233","CPT","0750","RC","","","","both","","","6546.00","3927.60","MEDICARE [2001]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1982.13","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","3598.00","2158.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","2511.40","69.8","","2423.46","2423.46","2423.46","1 through 10","959.93","6260.06","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","3598.00","2158.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","999.12","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","979.64","441.61","979.64","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","3598.00","2158.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","6260.06","","Case rate ($6,260.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4455.54","2870.64","4790.90","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","3598.00","2158.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","2695.58","","Case rate ($2,695.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2629.86","1314.93","2629.86","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","3598.00","2158.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","959.93","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","960.05","481.98","979.64","15","959.93","6260.06","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","3598.00","2158.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","5059.95","","Case rate ($5,059.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4461.49","2468.26","4936.51","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","3598.00","2158.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2047.26","56.9","","1975.57","1975.57","4219.70","1 through 10","959.93","6260.06","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","3598.00","2158.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","1008.91","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","989.95","494.42","1000.68","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","3598.00","2158.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","967.55","480.02","979.64","12","959.93","6260.06","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","3598.00","2158.80","MEDICARE [2001]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","979.64","489.82","979.64","68","959.93","6260.06","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","3598.00","2158.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","966.23","489.82","979.64","30","959.93","6260.06","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","3598.00","2158.80","WELLSENSE NH [1050]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1015.35","1015.35","1015.35","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","3598.00","2158.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","518.83","14.42","","500.66","429.14","500.66","1 through 10","418.45","2784.85","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","3598.00","2158.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","418.45","11.63","","478.09","410.10","876.86","1 through 10","418.45","2784.85","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","3598.00","2158.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","2524.84","2524.84","2524.84","1 through 10","418.45","2784.85","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","3598.00","2158.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2263.14","62.9","","2187.36","2187.36","2187.36","1 through 10","418.45","2784.85","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","3598.00","2158.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2784.85","77.4","","2690.80","2690.80","2690.80","1 through 10","418.45","2784.85","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","3598.00","2158.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","418.45","11.63","","410.10","410.10","1567.42","1 through 10","418.45","2784.85","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","5011.00","3006.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","3497.68","69.8","","3374.83","3041.22","4677.30","19","959.93","6260.06","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","5011.00","3006.60","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","999.12","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","489.82","489.82","979.64","12","959.93","6260.06","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","5011.00","3006.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","6260.06","","Case rate ($6,260.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5818.40","3053.70","6107.39","34","959.93","6260.06","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","5011.00","3006.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","2695.58","","Case rate ($2,695.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2629.86","1314.93","2629.86","59","959.93","6260.06","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","5011.00","3006.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","959.93","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","960.05","480.02","979.64","45","959.93","6260.06","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","5011.00","3006.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","5059.95","","Case rate ($5,059.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4936.51","2320.29","4936.51","47","959.93","6260.06","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","5011.00","3006.60","CHAMPVA [160001]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","489.82","489.82","489.82","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","5011.00","3006.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2851.26","56.9","","2751.11","2751.11","7586.11","38","959.93","6260.06","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","5011.00","3006.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","3497.68","69.8","","3374.83","3374.83","3374.83","1 through 10","959.93","6260.06","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","5011.00","3006.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","1008.91","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","999.85","504.51","1977.70","17","959.93","6260.06","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","5011.00","3006.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","967.05","480.02","979.64","52","959.93","6260.06","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","5011.00","3006.60","MEDICARE [2001]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","979.64","489.82","979.64","218","959.93","6260.06","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","5011.00","3006.60","TRICARE [160005]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","979.64","489.82","979.64","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","5011.00","3006.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","963.97","480.03","979.64","85","959.93","6260.06","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","5011.00","3006.60","WELLPOINT [1015]","HB WDH ANTHEM PPO","5059.95","","Case rate ($5,059.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4936.51","4640.58","4936.51","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","5011.00","3006.60","WELLSENSE NH [1050]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1012.93","504.02","1015.65","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","5011.00","3006.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","722.59","14.42","","697.21","597.61","697.21","18","582.78","3878.51","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","5011.00","3006.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","582.78","11.63","","665.78","571.09","1221.09","32","582.78","3878.51","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","5011.00","3006.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","2113.86","2113.86","2113.86","1 through 10","582.78","3878.51","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","5011.00","3006.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3516.01","3516.01","10548.03","25","582.78","3878.51","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","5011.00","3006.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3151.92","62.9","","3046.05","3046.05","3046.05","32","582.78","3878.51","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","5011.00","3006.60","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3516.01","3516.01","3516.01","1 through 10","582.78","3878.51","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","5011.00","3006.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3878.51","77.4","","3747.13","3747.13","3747.13","1 through 10","582.78","3878.51","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","5011.00","3006.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3516.01","3516.01","3516.01","1 through 10","582.78","3878.51","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","5011.00","3006.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","582.78","11.63","","571.09","571.09","2348.58","28","582.78","3878.51","percent of total billed charges",""
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","5643.00","3385.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","3938.81","69.8","","3276.66","3276.66","3276.66","1 through 10","1942.26","12666.17","percent of total billed charges",""
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","5643.00","3385.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","2021.54","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","1982.13","1982.13","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","5643.00","3385.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","12666.17","","Case rate ($12,666.17). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6430.98","6430.98","6430.98","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","5643.00","3385.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1942.26","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1950.42","1942.49","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","5643.00","3385.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","2041.36","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2006.96","2006.96","2006.96","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","5643.00","3385.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1854.00","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","5643.00","3385.80","MEDICARE [2001]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1982.13","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","5643.00","3385.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1947.99","1947.99","1947.99","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","outpatient","","","5643.00","3385.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3959.60","3959.60","3959.60","1 through 10","656.28","4367.68","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Egd Flex Transoral W/Ins Tube/Cath","PX-75000093","CDM","43241","CPT","0750","RC","","","","both","","","4127.00","2476.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","5454.04","","Case rate ($5,454.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5189.46","5189.46","5189.46","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000090","CDM","43238","CPT","0750","RC","","","","both","","","6742.00","4045.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","5454.04","","Case rate ($5,454.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5321.08","5321.08","5321.08","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","7504.00","4502.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","5237.79","69.8","","5054.22","5054.22","5054.22","1 through 10","1942.26","12666.17","percent of total billed charges",""
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","7504.00","4502.40","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","2021.54","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","1982.13","1982.13","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","7504.00","4502.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1942.26","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1950.39","1942.49","1950.39","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","7504.00","4502.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4269.78","56.9","","4120.13","4120.13","4120.13","1 through 10","1942.26","12666.17","percent of total billed charges",""
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","7504.00","4502.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","2041.36","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2011.76","2011.76","2011.76","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","7504.00","4502.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1949.99","1949.99","1949.99","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","7504.00","4502.40","MEDICARE [2001]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1854.00","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","7504.00","4502.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1951.49","1942.49","1951.49","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","outpatient","","","7504.00","4502.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","10531.32","7802.96","10531.32","1 through 10","872.72","5808.1","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","outpatient","","","7504.00","4502.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4720.02","62.9","","4561.83","4561.83","4561.83","1 through 10","872.72","5808.1","percent of total billed charges",""
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","4462.00","2677.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","3114.48","69.8","","3005.59","2708.47","3005.59","1 through 10","1942.26","12666.17","percent of total billed charges",""
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","4462.00","2677.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","2021.54","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","1982.13","1854.00","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","4462.00","2677.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","12666.17","","Case rate ($12,666.17). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","12211.55","6472.05","12357.27","12","1942.26","12666.17","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","4462.00","2677.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","5454.04","","Case rate ($5,454.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5321.08","5189.46","9627.08","26","1942.26","12666.17","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","4462.00","2677.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1942.26","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1950.42","1826.19","1954.38","15","1942.26","12666.17","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","4462.00","2677.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","10237.95","","Case rate ($10,237.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9741.14","5321.08","9988.19","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","4462.00","2677.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2538.88","56.9","","2450.11","2450.11","2450.12","1 through 10","1942.26","12666.17","percent of total billed charges",""
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","4462.00","2677.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","2041.36","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2015.26","2000.76","2019.63","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","4462.00","2677.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1949.99","1942.49","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","4462.00","2677.20","MEDICARE [2001]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1854.00","1982.13","63","1942.26","12666.17","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","4462.00","2677.20","TRICARE [160005]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1982.13","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","4462.00","2677.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1950.42","1942.49","1982.13","30","1942.26","12666.17","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","4462.00","2677.20","WELLSENSE NH [1050]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2047.94","2047.94","2047.94","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","4462.00","2677.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","643.42","14.42","","620.93","532.22","620.93","1 through 10","518.93","3453.59","percent of total billed charges",""
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","4462.00","2677.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","518.93","11.63","","1087.48","508.60","1525.80","20","518.93","3453.59","percent of total billed charges",""
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","4462.00","2677.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","1882.58","1882.58","1882.58","1 through 10","518.93","3453.59","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","4462.00","2677.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3131.32","3131.32","3131.32","1 through 10","518.93","3453.59","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","4462.00","2677.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2806.60","62.9","","2712.78","2712.78","2712.78","1 through 10","518.93","3453.59","percent of total billed charges",""
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","4462.00","2677.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3453.59","77.4","","3337.15","3337.14","3337.15","1 through 10","518.93","3453.59","percent of total billed charges",""
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","4462.00","2677.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3131.32","3131.32","3131.32","1 through 10","518.93","3453.59","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","4462.00","2677.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","518.93","11.63","","508.60","508.60","11606.66","1 through 10","518.93","3453.59","percent of total billed charges",""
"Egd Flex W/Place Gastrostomy Tube","PX-75000098","CDM","43246","CPT","0750","RC","","","","both","","","5766.00","3459.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1942.26","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1854.00","1854.00","1854.00","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex W/Place Gastrostomy Tube","PX-75000098","CDM","43246","CPT","0750","RC","","","","both","","","5766.00","3459.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1942.49","1942.49","1942.49","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex W/Place Gastrostomy Tube","PX-75000098","CDM","43246","CPT","0750","RC","","","","both","","","5766.00","3459.60","MEDICARE [2001]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1982.13","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex W/Place Gastrostomy Tube","PX-75000098","CDM","43246","CPT","0750","RC","","","","both","","","5766.00","3459.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1950.39","1950.39","1950.39","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Flex W/Place Gastrostomy Tube","PX-75000098","CDM","43246","CPT","0750","RC","","","","outpatient","","","5766.00","3459.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","831.46","14.42","","802.33","802.33","802.33","1 through 10","670.59","4462.88","percent of total billed charges",""
"Egd Flex W/Submucosal Injection","PX-75000088","CDM","43236","CPT","0750","RC","","","","both","","","4047.00","2428.20","MEDICARE [2001]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","979.64","979.64","979.64","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd Flex W/Submucosal Injection","PX-75000088","CDM","43236","CPT","0750","RC","","","","both","","","4047.00","2428.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","967.95","967.95","967.95","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","both","","","5120.00","3072.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","959.93","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","979.64","960.05","979.64","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","both","","","5120.00","3072.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","960.05","960.05","960.05","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","both","","","5120.00","3072.00","MEDICARE [2001]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","979.64","979.64","979.64","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","outpatient","","","5120.00","3072.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","595.46","11.63","","1536.07","1536.07","1536.07","1 through 10","595.46","3962.88","percent of total billed charges",""
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","both","","","6441.00","3864.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","5454.04","","Case rate ($5,454.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5321.08","5321.08","5321.08","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","both","","","6441.00","3864.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1942.26","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1942.49","1942.49","1942.49","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","both","","","6441.00","3864.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","2041.36","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2005.76","2005.76","2005.76","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","both","","","6441.00","3864.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1947.99","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","both","","","6441.00","3864.60","MEDICARE [2001]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1854.00","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","both","","","6441.00","3864.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1950.39","1942.49","1954.70","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd Lesion Ablation","PX-75000359","CDM","43270","CPT","0750","RC","","","","outpatient","","","6441.00","3864.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","749.09","11.63","","855.81","855.81","855.81","1 through 10","749.09","4985.33","percent of total billed charges",""
"Egd Partial/Compl Esophagogastric Fundoplasty","PX-75000445","CDM","43210","CPT","0750","RC","","","","both","","","20823.00","12493.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","29933.33","","Case rate ($29,933.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28073.49","20094.00","28073.49","1 through 10","10659.68","69515.56","other","OPPS APC"
"Egd Partial/Compl Esophagogastric Fundoplasty","PX-75000445","CDM","43210","CPT","0750","RC","","","","both","","","20823.00","12493.80","TRICARE [160005]","HB WDH MEDICARE","10877.23","","APC Price ($10,877.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28384.55","28384.55","28384.55","1 through 10","10659.68","69515.56","other","OPPS APC"
"Egd Partial/Compl Esophagogastric Fundoplasty","PX-75000445","CDM","43210","CPT","0750","RC","","","","both","","","20823.00","12493.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","10877.23","","APC Price ($10,877.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","10679.23","10679.23","10679.23","1 through 10","10659.68","69515.56","other","OPPS APC"
"Egd Partial/Compl Esophagogastric Fundoplasty","PX-75000445","CDM","43210","CPT","0750","RC","","","","outpatient","","","20823.00","12493.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2421.71","11.63","","5074.79","5074.79","5074.79","1 through 10","2421.71","16117","percent of total billed charges",""
"Egd Repair Stomach Perforation","PX-75000473","CDM","43999","CPT","0750","RC","","","","both","","","7171.00","4302.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","979.64","979.64","979.64","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","both","","","7011.00","4206.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1942.26","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1982.13","1982.13","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","both","","","7011.00","4206.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1982.13","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","both","","","7011.00","4206.60","MEDICARE [2001]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1982.13","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","both","","","7011.00","4206.60","WELLSENSE NH [1050]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","15299.02","2039.62","15299.02","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","outpatient","","","7011.00","4206.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","815.38","11.63","","799.06","799.06","799.06","1 through 10","815.38","5426.51","percent of total billed charges",""
"Egd W/Control Bleeding","PX-75000104","CDM","43255","CPT","0750","RC","","","","both","","","5774.00","3464.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","12666.17","","Case rate ($12,666.17). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","12357.27","12357.27","12357.27","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Control Bleeding","PX-75000104","CDM","43255","CPT","0750","RC","","","","both","","","5774.00","3464.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","5454.04","","Case rate ($5,454.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5572.00","5321.08","5572.00","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Control Bleeding","PX-75000104","CDM","43255","CPT","0750","RC","","","","both","","","5774.00","3464.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1947.99","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Control Bleeding","PX-75000104","CDM","43255","CPT","0750","RC","","","","both","","","5774.00","3464.40","MEDICARE [2001]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1982.13","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Control Bleeding","PX-75000104","CDM","43255","CPT","0750","RC","","","","both","","","5774.00","3464.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1942.49","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","4816.00","2889.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","3361.57","69.8","","3243.61","2922.96","3243.61","1 through 10","959.93","6260.06","percent of total billed charges",""
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","4816.00","2889.60","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","999.12","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","979.64","979.64","979.64","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","4816.00","2889.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","6260.06","","Case rate ($6,260.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3053.70","3053.70","3053.70","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","4816.00","2889.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","2695.58","","Case rate ($2,695.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2472.21","1236.11","2629.86","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","4816.00","2889.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","5059.95","","Case rate ($5,059.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2468.26","1236.11","2468.26","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","4816.00","2889.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2740.30","56.9","","2644.14","2644.14","3197.78","1 through 10","959.93","6260.06","percent of total billed charges",""
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","4816.00","2889.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","1008.91","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","988.85","494.42","1005.44","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","4816.00","2889.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","966.55","489.82","979.64","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","4816.00","2889.60","MEDICARE [2001]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","979.64","489.82","979.64","31","959.93","6260.06","other","OPPS APC"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","4816.00","2889.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","967.95","489.82","979.64","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","4816.00","2889.60","WELLSENSE NH [1050]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1015.35","1015.35","1015.35","1 through 10","959.93","6260.06","other","OPPS APC"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","outpatient","","","4816.00","2889.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","","","Payment is accumulated by procedure count. Procedure 1, 62.78% of billed. Procedures 2 - 9999, 31.39% of billed.","2917.39","2917.39","2917.39","1 through 10","560.1","3727.58","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","outpatient","","","4816.00","2889.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3379.30","3379.30","3379.30","1 through 10","560.1","3727.58","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","outpatient","","","4816.00","2889.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3029.26","62.9","","2927.61","2927.61","2927.61","1 through 10","560.1","3727.58","percent of total billed charges",""
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","outpatient","","","4816.00","2889.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3727.58","77.4","","3601.43","3601.43","3601.43","1 through 10","560.1","3727.58","percent of total billed charges",""
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","outpatient","","","4816.00","2889.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","560.10","11.63","","10644.19","10644.19","10644.19","1 through 10","560.1","3727.58","percent of total billed charges",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","6487.00","3892.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","4527.93","69.8","","4369.48","3937.54","4369.48","1 through 10","1942.26","12666.17","percent of total billed charges",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","6487.00","3892.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","2021.54","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","1982.13","1982.13","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","6487.00","3892.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","12666.17","","Case rate ($12,666.17). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7276.23","7243.40","12357.27","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","6487.00","3892.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","5454.04","","Case rate ($5,454.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5189.46","5189.46","5189.46","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","6487.00","3892.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1942.26","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1950.42","1942.49","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","6487.00","3892.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","10237.95","","Case rate ($10,237.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7247.73","7243.40","7249.49","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","6487.00","3892.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3691.10","56.9","","3561.94","3561.94","3561.94","1 through 10","1942.26","12666.17","percent of total billed charges",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","6487.00","3892.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1948.99","1948.99","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","6487.00","3892.20","MEDICARE [2001]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1854.00","1982.13","34","1942.26","12666.17","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","6487.00","3892.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1950.39","1942.49","1982.13","11","1942.26","12666.17","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","6487.00","3892.20","WELLSENSE NH [1050]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2046.92","2046.92","2046.92","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","6487.00","3892.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","935.43","14.42","","902.69","773.74","902.69","1 through 10","754.44","5020.94","percent of total billed charges",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","6487.00","3892.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","754.44","11.63","","1580.98","1580.98","1580.98","1 through 10","754.44","5020.94","percent of total billed charges",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","6487.00","3892.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","4552.27","4552.27","5269.37","1 through 10","754.44","5020.94","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","6487.00","3892.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4080.32","62.9","","3943.80","3943.80","3943.80","1 through 10","754.44","5020.94","percent of total billed charges",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","6487.00","3892.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5020.94","77.4","","4851.50","4851.50","4851.50","1 through 10","754.44","5020.94","percent of total billed charges",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","6487.00","3892.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","754.44","11.63","","15507.46","3127.14","15507.46","1 through 10","754.44","5020.94","percent of total billed charges",""
"Egd W/Eus Guided Embolization of Gastric Varices","PX-75000474","CDM","43999","CPT","0750","RC","","","","both","","","22450.00","13470.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","979.64","979.64","979.64","1 through 10","959.93","19082.5","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","5653.00","3391.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","3945.79","69.8","","3807.59","3807.59","3807.59","1 through 10","1942.26","12666.17","percent of total billed charges",""
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","5653.00","3391.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","2021.54","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","1982.13","1982.13","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","5653.00","3391.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","12666.17","","Case rate ($12,666.17). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11285.14","6438.40","11285.14","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","5653.00","3391.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1942.26","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1954.38","1816.92","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","5653.00","3391.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","10237.95","","Case rate ($10,237.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9988.19","5321.08","9988.19","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","5653.00","3391.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3216.56","56.9","","3103.90","3103.89","3103.90","1 through 10","1942.26","12666.17","percent of total billed charges",""
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","5653.00","3391.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","2041.36","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2011.76","2006.66","2011.76","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","5653.00","3391.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1949.99","1942.49","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","5653.00","3391.80","MEDICARE [2001]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1854.00","1982.13","33","1942.26","12666.17","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","5653.00","3391.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1950.42","1822.52","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","5653.00","3391.80","WELLSENSE NH [1050]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2046.82","2046.82","2046.92","1 through 10","1942.26","12666.17","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","outpatient","","","5653.00","3391.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","815.16","14.42","","674.24","674.24","674.24","1 through 10","657.44","4375.42","percent of total billed charges",""
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","outpatient","","","5653.00","3391.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3555.74","62.9","","3436.65","3436.65","3436.65","1 through 10","657.44","4375.42","percent of total billed charges",""
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","outpatient","","","5653.00","3391.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4375.42","77.4","","4227.63","4227.63","4227.63","1 through 10","657.44","4375.42","percent of total billed charges",""
"Ehrlichia Antibody","PX-30000929","CDM","86666","CPT","0302","RC","","","","both","","","56.00","33.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","39.09","69.8","","37.69","11.13","37.69","20","6.62","52.69","percent of total billed charges",""
"Ehrlichia Antibody","PX-30000929","CDM","86666","CPT","0302","RC","","","","outpatient","","","56.00","33.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","40.72","72.72","","39.27","39.27","78.54","17","11.69","43.34","percent of total billed charges",""
"Ehrlichia Antibody","PX-30000929","CDM","86666","CPT","0302","RC","","","","outpatient","","","56.00","33.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","40.72","72.72","","39.27","39.27","39.27","1 through 10","11.69","43.34","percent of total billed charges",""
"Ehrlichia Antibody","PX-30000929","CDM","86666","CPT","0302","RC","","","","outpatient","","","56.00","33.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","35.22","62.9","","34.02","34.02","65.58","41","11.69","43.34","percent of total billed charges",""
"Ehrlichia Antibody","PX-30000929","CDM","86666","CPT","0302","RC","","","","outpatient","","","56.00","33.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","43.34","77.4","","41.85","41.85","41.85","1 through 10","11.69","43.34","percent of total billed charges",""
"Ehrlichia Antibody","PX-30000929","CDM","86666","CPT","0302","RC","","","","outpatient","","","56.00","33.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","40.72","72.72","","39.27","39.27","39.27","1 through 10","11.69","43.34","percent of total billed charges",""
"Eia Ql C Difficile Toxin(S) Antigen","PX-30001233","CDM","87324","CPT","0306","RC","","","","outpatient","","","138.00","82.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","86.80","62.9","","161.44","161.44","161.44","1 through 10","10.68","106.81","percent of total billed charges",""
"Eia Ql C Neoform Antigen","PX-30001234","CDM","87327","CPT","0306","RC","","","","outpatient","","","70.00","42.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","50.90","72.72","","49.45","49.45","49.45","1 through 10","13.73","54.18","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","both","","","115.00","69.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","80.27","69.8","","77.48","13.08","77.48","1 through 10","9.35","97.75","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","outpatient","","","115.00","69.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","83.63","72.72","","80.72","80.72","80.72","16","10.7","89.01","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","outpatient","","","115.00","69.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","83.63","72.72","","80.72","80.72","80.72","1 through 10","10.7","89.01","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","outpatient","","","115.00","69.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","72.34","62.9","","69.93","69.93","69.93","18","10.7","89.01","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","outpatient","","","115.00","69.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","89.01","77.4","","86.03","86.03","86.03","1 through 10","10.7","89.01","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","147.00","88.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","102.61","69.8","","99.12","89.32","99.12","144","6.71","124.95","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","147.00","88.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","102.61","69.8","","99.12","99.12","99.12","1 through 10","6.71","124.95","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","147.00","88.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","124.95","85","","108.71","99.12","108.71","12","6.71","124.95","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","outpatient","","","147.00","88.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","92.29","62.78","","89.15","89.15","89.15","1 through 10","9.61","113.78","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","outpatient","","","147.00","88.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","64.27","43.72","","62.08","62.08","62.08","1 through 10","9.61","113.78","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","outpatient","","","147.00","88.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","106.90","72.72","","103.26","103.26","103.26","195","9.61","113.78","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","outpatient","","","147.00","88.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","106.90","72.72","","103.26","103.26","103.26","1 through 10","9.61","113.78","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","outpatient","","","147.00","88.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","78.23","53.22","","75.70","75.70","151.40","1 through 10","9.61","113.78","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","outpatient","","","147.00","88.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","92.46","62.9","","89.46","89.46","89.46","226","9.61","113.78","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","outpatient","","","147.00","88.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","113.78","77.4","","110.05","110.05","110.05","96","9.61","113.78","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","outpatient","","","147.00","88.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","106.90","72.72","","103.26","103.26","103.26","1 through 10","9.61","113.78","percent of total billed charges",""
"Eia Ql Hepatitis B Surf Ag","PX-30001244","CDM","87341","CPT","0306","RC","","","","outpatient","","","105.00","63.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","66.05","62.9","","64.26","64.26","64.26","1 through 10","12.37","81.27","percent of total billed charges",""
"EIA QL HEPATITIS Be ANTIGEN (HBeAG)","PX-30001245","CDM","87350","CPT","0306","RC","","","","both","","","64.00","38.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","44.67","69.8","","43.28","41.18","43.28","1 through 10","7.49","60.21","percent of total billed charges",""
"EIA QL HEPATITIS Be ANTIGEN (HBeAG)","PX-30001245","CDM","87350","CPT","0306","RC","","","","outpatient","","","64.00","38.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","40.18","62.78","","38.92","38.92","38.92","1 through 10","10.75","49.54","percent of total billed charges",""
"EIA QL HEPATITIS Be ANTIGEN (HBeAG)","PX-30001245","CDM","87350","CPT","0306","RC","","","","outpatient","","","64.00","38.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","46.54","72.72","","45.09","45.09","45.09","17","10.75","49.54","percent of total billed charges",""
"EIA QL HEPATITIS Be ANTIGEN (HBeAG)","PX-30001245","CDM","87350","CPT","0306","RC","","","","outpatient","","","64.00","38.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","40.26","62.9","","39.06","39.06","39.06","19","10.75","49.54","percent of total billed charges",""
"EIA QL HEPATITIS Be ANTIGEN (HBeAG)","PX-30001245","CDM","87350","CPT","0306","RC","","","","outpatient","","","64.00","38.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","49.54","77.4","","48.05","10.99","48.05","1 through 10","10.75","49.54","percent of total billed charges",""
"Eia Ql Histoplasma Antigen","PX-30001247","CDM","87385","CPT","0306","RC","","","","both","","","97.00","58.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","67.71","69.8","","59.13","59.13","59.13","1 through 10","8.61","82.45","percent of total billed charges",""
"Eia Ql Histoplasma Antigen","PX-30001247","CDM","87385","CPT","0306","RC","","","","outpatient","","","97.00","58.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","70.54","72.72","","68.36","68.36","68.36","1 through 10","13.73","75.08","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0300","RC","","","","inpatient","","","341.00","204.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","262.09","76.86","","207.90","207.90","207.90","1 through 10","225.74","262.09","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","341.00","204.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","238.02","69.8","","230.34","207.57","230.34","188","15.65","289.85","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","341.00","204.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","238.02","69.8","","230.34","230.34","230.34","1 through 10","15.65","289.85","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","both","","","341.00","204.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","289.85","85","","143.01","21.68","1669.49","1 through 10","15.65","289.85","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","outpatient","","","341.00","204.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","214.08","62.78","","207.17","207.17","207.17","12","29.06","263.93","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","outpatient","","","341.00","204.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","149.09","43.72","","144.28","144.28","432.84","17","29.06","263.93","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","outpatient","","","341.00","204.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","247.98","72.72","","239.98","239.98","643.58","296","29.06","263.93","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","outpatient","","","341.00","204.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","247.98","72.72","","239.98","239.98","239.98","1 through 10","29.06","263.93","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","outpatient","","","341.00","204.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","181.48","53.22","","175.92","175.92","527.76","26","29.06","263.93","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","outpatient","","","341.00","204.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","214.49","62.9","","207.90","207.90","207.90","351","29.06","263.93","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","outpatient","","","341.00","204.60","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","247.98","72.72","","239.98","239.98","239.98","1 through 10","29.06","263.93","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","outpatient","","","341.00","204.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","263.93","77.4","","255.75","255.73","255.75","146","29.06","263.93","percent of total billed charges",""
"Eia Ql Hiv-1 & Hiv-2 Antibodies","PX-30001248","CDM","87389","CPT","0306","RC","","","","outpatient","","","341.00","204.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","247.98","72.72","","239.98","239.98","239.98","1 through 10","29.06","263.93","percent of total billed charges",""
"Eia Ql Multi Antigen","PX-30001257","CDM","87449","CPT","0300","RC","","","","inpatient","","","103.00","61.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","79.17","76.86","","63.00","63.00","63.00","1 through 10","68.19","79.17","percent of total billed charges",""
"Eia Ql Multi Antigen","PX-30001257","CDM","87449","CPT","0306","RC","","","","both","","","103.00","61.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","71.89","69.8","","62.90","62.90","64.92","1 through 10","7.79","87.55","percent of total billed charges",""
"Eia Ql Multi Antigen","PX-30001257","CDM","87449","CPT","0306","RC","","","","outpatient","","","103.00","61.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","74.90","72.72","","72.72","72.72","72.72","1 through 10","10.68","79.72","percent of total billed charges",""
"Eia Ql Multi Antigen","PX-30001257","CDM","87449","CPT","0306","RC","","","","outpatient","","","103.00","61.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","64.79","62.9","","63.00","63.00","63.00","1 through 10","10.68","79.72","percent of total billed charges",""
"Eia Ql Multi Antigen","PX-30001257","CDM","87449","CPT","0306","RC","","","","outpatient","","","103.00","61.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","79.72","77.4","","77.50","77.50","77.50","1 through 10","10.68","79.72","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","367.00","220.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","256.17","69.8","","247.09","63.98","474.64","1 through 10","60.82","396.58","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","367.00","220.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","396.58","","Case rate ($396.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","354.00","354.00","354.00","56","60.82","396.58","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","367.00","220.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","170.77","","Case rate ($170.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","166.60","166.60","166.81","62","60.82","396.58","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","367.00","220.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","60.82","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","60.83","58.41","62.07","93","60.82","396.58","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","367.00","220.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","320.55","","Case rate ($320.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","312.73","166.60","354.00","42","60.82","396.58","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","367.00","220.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","208.82","56.9","","201.43","82.50","604.28","281","60.82","396.58","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","367.00","220.20","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","208.82","56.9","","386.94","201.43","661.42","1 through 10","60.82","396.58","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","367.00","220.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","256.17","69.8","","300.90","247.03","300.90","1 through 10","60.82","396.58","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","367.00","220.20","HARVARD PILGRIM [120001]","HB WDH MEDICARE","62.06","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","59.01","59.01","59.01","1 through 10","60.82","396.58","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","367.00","220.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","63.92","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","63.93","62.91","63.93","1 through 10","60.82","396.58","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","367.00","220.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","62.06","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","61.01","61.01","62.07","52","60.82","396.58","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","367.00","220.20","MEDICARE [2001]","HB WDH MEDICARE","62.06","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.07","62.07","62.07","204","60.82","396.58","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","367.00","220.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","311.95","85","","201.43","8.83","300.90","1 through 10","60.82","396.58","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","367.00","220.20","TRICARE [160005]","HB WDH MEDICARE","62.06","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.07","31.04","62.07","1 through 10","60.82","396.58","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","367.00","220.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","62.06","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","61.33","60.83","62.07","59","60.82","396.58","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","367.00","220.20","WELLPOINT [1015]","HB WDH ANTHEM PPO","320.55","","Case rate ($320.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","329.00","329.00","329.00","1 through 10","60.82","396.58","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","367.00","220.20","WELLSENSE NH [1050]","HB WDH MEDICARE","62.06","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","195.51","65.17","195.51","1 through 10","60.82","396.58","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","inpatient","","","367.00","220.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","282.08","76.86","","223.02","223.02","428.80","1 through 10","242.95","282.08","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","367.00","220.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","52.92","14.42","","51.05","43.75","51.05","142","42.68","284.06","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","367.00","220.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","42.68","11.63","","48.75","41.81","125.43","329","42.68","284.06","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","367.00","220.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","230.40","62.78","","222.24","222.24","666.72","1 through 10","42.68","284.06","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","367.00","220.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","160.45","43.72","","154.77","154.77","154.77","1 through 10","42.68","284.06","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","367.00","220.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","266.88","72.72","","257.43","257.43","7980.33","227","42.68","284.06","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","367.00","220.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","266.88","72.72","","514.86","257.43","514.86","1 through 10","42.68","284.06","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","367.00","220.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","195.32","53.22","","566.16","566.16","566.16","1 through 10","42.68","284.06","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","367.00","220.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","230.84","62.9","","223.02","223.02","833.04","203","42.68","284.06","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","367.00","220.20","PHCS MULTIPLAN [1022]","HB WDH AMERIHEALTH CARITAS","52.92","14.42","","51.05","51.05","51.05","1 through 10","42.68","284.06","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","367.00","220.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","284.06","77.4","","274.35","274.34","274.35","90","42.68","284.06","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","367.00","220.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","266.88","72.72","","257.43","257.43","257.43","1 through 10","42.68","284.06","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","367.00","220.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","42.68","11.63","","41.81","41.81","125.43","141","42.68","284.06","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","both","","","173.00","103.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","120.75","69.8","","116.57","105.04","116.57","1 through 10","14.93","147.05","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","both","","","173.00","103.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","98.44","56.9","","95.02","95.02","95.02","1 through 10","14.93","147.05","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","173.00","103.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","24.95","14.42","","20.47","20.47","40.00","1 through 10","20.12","133.9","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","173.00","103.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.12","11.63","","20.27","20.27","20.27","1 through 10","20.12","133.9","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","173.00","103.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","125.81","72.72","","121.44","121.44","121.44","1 through 10","20.12","133.9","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","173.00","103.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","125.81","72.72","","121.44","121.44","121.44","1 through 10","20.12","133.9","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","173.00","103.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","108.82","62.9","","105.21","105.21","105.21","1 through 10","20.12","133.9","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","173.00","103.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","133.90","77.4","","129.43","129.43","129.43","1 through 10","20.12","133.9","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","173.00","103.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.12","11.63","","20.27","20.27","20.27","1 through 10","20.12","133.9","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","6940.35","4164.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","807.16","5899.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","6940.35","4164.21","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3949.06","56.9","","2911.53","1863.86","5209.05","65","807.16","5899.3","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","6940.35","4164.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","807.16","11.63","","400.94","400.94","400.94","1 through 10","807.16","5899.3","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","6940.35","4164.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5371.83","77.4","","5214.50","5214.50","16415.28","1 through 10","807.16","5899.3","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6940.35","4164.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","807.16","11.63","","400.94","400.94","400.94","1 through 10","807.16","5371.83","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6940.35","4164.21","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3034.32","43.72","","1543.33","1543.33","1671.61","1 through 10","807.16","5371.83","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6940.35","4164.21","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5047.02","72.72","","3700.21","2382.07","6427.18","53","807.16","5371.83","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6940.35","4164.21","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5047.02","72.72","","12685.80","12685.80","12685.80","1 through 10","807.16","5371.83","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6940.35","4164.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4365.48","62.9","","3408.87","2784.05","9859.40","46","807.16","5371.83","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6940.35","4164.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5371.83","77.4","","5214.50","5214.50","16415.28","1 through 10","807.16","5371.83","percent of total billed charges",""
"ELBOW 20MM IMPLANT HD COMPONENT MODULAR EVOLVE STANDARD 01A","SUP-ITM-10006390","CDM","C1776","HCPCS","0278","RC","","","","both","","","5912.15","3547.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","687.58","5025.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ELBOW 20MM IMPLANT HD COMPONENT MODULAR EVOLVE STANDARD 01A","SUP-ITM-10006390","CDM","C1776","HCPCS","0278","RC","","","","both","","","5912.15","3547.29","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3364.01","56.9","","2911.53","1863.86","5209.05","65","687.58","5025.33","percent of total billed charges",""
"ELBOW 20MM IMPLANT HD COMPONENT MODULAR EVOLVE STANDARD 01A","SUP-ITM-10006390","CDM","C1776","HCPCS","0278","RC","","","","both","","","5912.15","3547.29","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","687.58","11.63","","400.94","400.94","400.94","1 through 10","687.58","5025.33","percent of total billed charges",""
"ELBOW 20MM IMPLANT HD COMPONENT MODULAR EVOLVE STANDARD 01A","SUP-ITM-10006390","CDM","C1776","HCPCS","0278","RC","","","","both","","","5912.15","3547.29","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4576.00","77.4","","5214.50","5214.50","16415.28","1 through 10","687.58","5025.33","percent of total billed charges",""
"ELBOW 20MM IMPLANT HD COMPONENT MODULAR EVOLVE STANDARD 01A","SUP-ITM-10006390","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5912.15","3547.29","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","687.58","11.63","","400.94","400.94","400.94","1 through 10","687.58","4576","percent of total billed charges",""
"ELBOW 20MM IMPLANT HD COMPONENT MODULAR EVOLVE STANDARD 01A","SUP-ITM-10006390","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5912.15","3547.29","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2584.79","43.72","","1543.33","1543.33","1671.61","1 through 10","687.58","4576","percent of total billed charges",""
"ELBOW 20MM IMPLANT HD COMPONENT MODULAR EVOLVE STANDARD 01A","SUP-ITM-10006390","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5912.15","3547.29","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4299.32","72.72","","3700.21","2382.07","6427.18","53","687.58","4576","percent of total billed charges",""
"ELBOW 20MM IMPLANT HD COMPONENT MODULAR EVOLVE STANDARD 01A","SUP-ITM-10006390","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5912.15","3547.29","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4299.32","72.72","","12685.80","12685.80","12685.80","1 through 10","687.58","4576","percent of total billed charges",""
"ELBOW 20MM IMPLANT HD COMPONENT MODULAR EVOLVE STANDARD 01A","SUP-ITM-10006390","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5912.15","3547.29","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3718.74","62.9","","3408.87","2784.05","9859.40","46","687.58","4576","percent of total billed charges",""
"ELBOW 20MM IMPLANT HD COMPONENT MODULAR EVOLVE STANDARD 01A","SUP-ITM-10006390","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5912.15","3547.29","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4576.00","77.4","","5214.50","5214.50","16415.28","1 through 10","687.58","4576","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","19708.00","11824.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","2292.04","16751.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","19708.00","11824.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","11213.85","56.9","","2911.53","1863.86","5209.05","65","2292.04","16751.8","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","19708.00","11824.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2292.04","11.63","","400.94","400.94","400.94","1 through 10","2292.04","16751.8","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","19708.00","11824.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","15253.99","77.4","","5214.50","5214.50","16415.28","1 through 10","2292.04","16751.8","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","19708.00","11824.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2292.04","11.63","","400.94","400.94","400.94","1 through 10","2292.04","15253.99","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","19708.00","11824.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","8616.34","43.72","","1543.33","1543.33","1671.61","1 through 10","2292.04","15253.99","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","19708.00","11824.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","14331.66","72.72","","3700.21","2382.07","6427.18","53","2292.04","15253.99","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","19708.00","11824.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","14331.66","72.72","","12685.80","12685.80","12685.80","1 through 10","2292.04","15253.99","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","19708.00","11824.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","12396.33","62.9","","3408.87","2784.05","9859.40","46","2292.04","15253.99","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","19708.00","11824.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","15253.99","77.4","","5214.50","5214.50","16415.28","1 through 10","2292.04","15253.99","percent of total billed charges",""
"ELBOW HEAD 22MM 4DEG RADIAL COBALT TRANGLED CONTOURED LATERAL SURFACE ANATOMIC RIGHT","SUP-ITM-10045145","CDM","C1776","HCPCS","0278","RC","","","","both","","","14531.88","8719.13","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1690.06","12352.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ELBOW HEAD 22MM 4DEG RADIAL COBALT TRANGLED CONTOURED LATERAL SURFACE ANATOMIC RIGHT","SUP-ITM-10045145","CDM","C1776","HCPCS","0278","RC","","","","both","","","14531.88","8719.13","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","8268.64","56.9","","2911.53","1863.86","5209.05","65","1690.06","12352.1","percent of total billed charges",""
"ELBOW HEAD 22MM 4DEG RADIAL COBALT TRANGLED CONTOURED LATERAL SURFACE ANATOMIC RIGHT","SUP-ITM-10045145","CDM","C1776","HCPCS","0278","RC","","","","both","","","14531.88","8719.13","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1690.06","11.63","","400.94","400.94","400.94","1 through 10","1690.06","12352.1","percent of total billed charges",""
"ELBOW HEAD 22MM 4DEG RADIAL COBALT TRANGLED CONTOURED LATERAL SURFACE ANATOMIC RIGHT","SUP-ITM-10045145","CDM","C1776","HCPCS","0278","RC","","","","both","","","14531.88","8719.13","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","11247.68","77.4","","5214.50","5214.50","16415.28","1 through 10","1690.06","12352.1","percent of total billed charges",""
"ELBOW HEAD 22MM 4DEG RADIAL COBALT TRANGLED CONTOURED LATERAL SURFACE ANATOMIC RIGHT","SUP-ITM-10045145","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14531.88","8719.13","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1690.06","11.63","","400.94","400.94","400.94","1 through 10","1690.06","11247.68","percent of total billed charges",""
"ELBOW HEAD 22MM 4DEG RADIAL COBALT TRANGLED CONTOURED LATERAL SURFACE ANATOMIC RIGHT","SUP-ITM-10045145","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14531.88","8719.13","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","6353.34","43.72","","1543.33","1543.33","1671.61","1 through 10","1690.06","11247.68","percent of total billed charges",""
"ELBOW HEAD 22MM 4DEG RADIAL COBALT TRANGLED CONTOURED LATERAL SURFACE ANATOMIC RIGHT","SUP-ITM-10045145","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14531.88","8719.13","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10567.58","72.72","","3700.21","2382.07","6427.18","53","1690.06","11247.68","percent of total billed charges",""
"ELBOW HEAD 22MM 4DEG RADIAL COBALT TRANGLED CONTOURED LATERAL SURFACE ANATOMIC RIGHT","SUP-ITM-10045145","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14531.88","8719.13","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","10567.58","72.72","","12685.80","12685.80","12685.80","1 through 10","1690.06","11247.68","percent of total billed charges",""
"ELBOW HEAD 22MM 4DEG RADIAL COBALT TRANGLED CONTOURED LATERAL SURFACE ANATOMIC RIGHT","SUP-ITM-10045145","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14531.88","8719.13","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","9140.55","62.9","","3408.87","2784.05","9859.40","46","1690.06","11247.68","percent of total billed charges",""
"ELBOW HEAD 22MM 4DEG RADIAL COBALT TRANGLED CONTOURED LATERAL SURFACE ANATOMIC RIGHT","SUP-ITM-10045145","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14531.88","8719.13","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","11247.68","77.4","","5214.50","5214.50","16415.28","1 through 10","1690.06","11247.68","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","both","","","10257.75","6154.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1192.98","8719.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","both","","","10257.75","6154.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5836.66","56.9","","2911.53","1863.86","5209.05","65","1192.98","8719.09","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","both","","","10257.75","6154.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1192.98","11.63","","400.94","400.94","400.94","1 through 10","1192.98","8719.09","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","both","","","10257.75","6154.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7939.50","77.4","","5214.50","5214.50","16415.28","1 through 10","1192.98","8719.09","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10257.75","6154.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1192.98","11.63","","400.94","400.94","400.94","1 through 10","1192.98","7939.5","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10257.75","6154.65","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4484.69","43.72","","1543.33","1543.33","1671.61","1 through 10","1192.98","7939.5","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10257.75","6154.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7459.44","72.72","","3700.21","2382.07","6427.18","53","1192.98","7939.5","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10257.75","6154.65","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7459.44","72.72","","12685.80","12685.80","12685.80","1 through 10","1192.98","7939.5","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10257.75","6154.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6452.12","62.9","","3408.87","2784.05","9859.40","46","1192.98","7939.5","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10257.75","6154.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7939.50","77.4","","5214.50","5214.50","16415.28","1 through 10","1192.98","7939.5","percent of total billed charges",""
"ELBOW STEM 70MM ULNAR LT LATITUDE EV","SUP-ITM-10123516","CDM","C1776","HCPCS","0278","RC","","","","both","","","14495.52","8697.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1685.83","12321.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ELBOW STEM 70MM ULNAR LT LATITUDE EV","SUP-ITM-10123516","CDM","C1776","HCPCS","0278","RC","","","","both","","","14495.52","8697.31","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","8247.95","56.9","","2911.53","1863.86","5209.05","65","1685.83","12321.19","percent of total billed charges",""
"ELBOW STEM 70MM ULNAR LT LATITUDE EV","SUP-ITM-10123516","CDM","C1776","HCPCS","0278","RC","","","","both","","","14495.52","8697.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1685.83","11.63","","400.94","400.94","400.94","1 through 10","1685.83","12321.19","percent of total billed charges",""
"ELBOW STEM 70MM ULNAR LT LATITUDE EV","SUP-ITM-10123516","CDM","C1776","HCPCS","0278","RC","","","","both","","","14495.52","8697.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","11219.53","77.4","","5214.50","5214.50","16415.28","1 through 10","1685.83","12321.19","percent of total billed charges",""
"ELBOW STEM 70MM ULNAR LT LATITUDE EV","SUP-ITM-10123516","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14495.52","8697.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1685.83","11.63","","400.94","400.94","400.94","1 through 10","1685.83","11219.53","percent of total billed charges",""
"ELBOW STEM 70MM ULNAR LT LATITUDE EV","SUP-ITM-10123516","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14495.52","8697.31","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","6337.44","43.72","","1543.33","1543.33","1671.61","1 through 10","1685.83","11219.53","percent of total billed charges",""
"ELBOW STEM 70MM ULNAR LT LATITUDE EV","SUP-ITM-10123516","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14495.52","8697.31","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10541.14","72.72","","3700.21","2382.07","6427.18","53","1685.83","11219.53","percent of total billed charges",""
"ELBOW STEM 70MM ULNAR LT LATITUDE EV","SUP-ITM-10123516","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14495.52","8697.31","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","10541.14","72.72","","12685.80","12685.80","12685.80","1 through 10","1685.83","11219.53","percent of total billed charges",""
"ELBOW STEM 70MM ULNAR LT LATITUDE EV","SUP-ITM-10123516","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14495.52","8697.31","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","9117.68","62.9","","3408.87","2784.05","9859.40","46","1685.83","11219.53","percent of total billed charges",""
"ELBOW STEM 70MM ULNAR LT LATITUDE EV","SUP-ITM-10123516","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14495.52","8697.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","11219.53","77.4","","5214.50","5214.50","16415.28","1 through 10","1685.83","11219.53","percent of total billed charges",""
"ELBOW STEM 72MM HUMERAL LT LATITUDE EV","SUP-ITM-10123430","CDM","C1776","HCPCS","0278","RC","","","","both","","","17812.36","10687.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","2071.58","15140.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ELBOW STEM 72MM HUMERAL LT LATITUDE EV","SUP-ITM-10123430","CDM","C1776","HCPCS","0278","RC","","","","both","","","17812.36","10687.42","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","10135.23","56.9","","2911.53","1863.86","5209.05","65","2071.58","15140.51","percent of total billed charges",""
"ELBOW STEM 72MM HUMERAL LT LATITUDE EV","SUP-ITM-10123430","CDM","C1776","HCPCS","0278","RC","","","","both","","","17812.36","10687.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2071.58","11.63","","400.94","400.94","400.94","1 through 10","2071.58","15140.51","percent of total billed charges",""
"ELBOW STEM 72MM HUMERAL LT LATITUDE EV","SUP-ITM-10123430","CDM","C1776","HCPCS","0278","RC","","","","both","","","17812.36","10687.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","13786.77","77.4","","5214.50","5214.50","16415.28","1 through 10","2071.58","15140.51","percent of total billed charges",""
"ELBOW STEM 72MM HUMERAL LT LATITUDE EV","SUP-ITM-10123430","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17812.36","10687.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2071.58","11.63","","400.94","400.94","400.94","1 through 10","2071.58","13786.77","percent of total billed charges",""
"ELBOW STEM 72MM HUMERAL LT LATITUDE EV","SUP-ITM-10123430","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17812.36","10687.42","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","7787.56","43.72","","1543.33","1543.33","1671.61","1 through 10","2071.58","13786.77","percent of total billed charges",""
"ELBOW STEM 72MM HUMERAL LT LATITUDE EV","SUP-ITM-10123430","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17812.36","10687.42","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","12953.15","72.72","","3700.21","2382.07","6427.18","53","2071.58","13786.77","percent of total billed charges",""
"ELBOW STEM 72MM HUMERAL LT LATITUDE EV","SUP-ITM-10123430","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17812.36","10687.42","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","12953.15","72.72","","12685.80","12685.80","12685.80","1 through 10","2071.58","13786.77","percent of total billed charges",""
"ELBOW STEM 72MM HUMERAL LT LATITUDE EV","SUP-ITM-10123430","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17812.36","10687.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","11203.97","62.9","","3408.87","2784.05","9859.40","46","2071.58","13786.77","percent of total billed charges",""
"ELBOW STEM 72MM HUMERAL LT LATITUDE EV","SUP-ITM-10123430","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17812.36","10687.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","13786.77","77.4","","5214.50","5214.50","16415.28","1 through 10","2071.58","13786.77","percent of total billed charges",""
"ELBOW STEM 8MMX0 UNIV TAPERED POROUS COATED PRESS FIT OFFSET COBALT TITANIUM","SUP-ITM-10045164","CDM","C1776","HCPCS","0278","RC","","","","both","","","10728.20","6436.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1247.69","9118.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ELBOW STEM 8MMX0 UNIV TAPERED POROUS COATED PRESS FIT OFFSET COBALT TITANIUM","SUP-ITM-10045164","CDM","C1776","HCPCS","0278","RC","","","","both","","","10728.20","6436.92","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6104.35","56.9","","2911.53","1863.86","5209.05","65","1247.69","9118.97","percent of total billed charges",""
"ELBOW STEM 8MMX0 UNIV TAPERED POROUS COATED PRESS FIT OFFSET COBALT TITANIUM","SUP-ITM-10045164","CDM","C1776","HCPCS","0278","RC","","","","both","","","10728.20","6436.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1247.69","11.63","","400.94","400.94","400.94","1 through 10","1247.69","9118.97","percent of total billed charges",""
"ELBOW STEM 8MMX0 UNIV TAPERED POROUS COATED PRESS FIT OFFSET COBALT TITANIUM","SUP-ITM-10045164","CDM","C1776","HCPCS","0278","RC","","","","both","","","10728.20","6436.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8303.63","77.4","","5214.50","5214.50","16415.28","1 through 10","1247.69","9118.97","percent of total billed charges",""
"ELBOW STEM 8MMX0 UNIV TAPERED POROUS COATED PRESS FIT OFFSET COBALT TITANIUM","SUP-ITM-10045164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10728.20","6436.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1247.69","11.63","","400.94","400.94","400.94","1 through 10","1247.69","8303.63","percent of total billed charges",""
"ELBOW STEM 8MMX0 UNIV TAPERED POROUS COATED PRESS FIT OFFSET COBALT TITANIUM","SUP-ITM-10045164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10728.20","6436.92","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4690.37","43.72","","1543.33","1543.33","1671.61","1 through 10","1247.69","8303.63","percent of total billed charges",""
"ELBOW STEM 8MMX0 UNIV TAPERED POROUS COATED PRESS FIT OFFSET COBALT TITANIUM","SUP-ITM-10045164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10728.20","6436.92","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7801.55","72.72","","3700.21","2382.07","6427.18","53","1247.69","8303.63","percent of total billed charges",""
"ELBOW STEM 8MMX0 UNIV TAPERED POROUS COATED PRESS FIT OFFSET COBALT TITANIUM","SUP-ITM-10045164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10728.20","6436.92","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7801.55","72.72","","12685.80","12685.80","12685.80","1 through 10","1247.69","8303.63","percent of total billed charges",""
"ELBOW STEM 8MMX0 UNIV TAPERED POROUS COATED PRESS FIT OFFSET COBALT TITANIUM","SUP-ITM-10045164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10728.20","6436.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6748.04","62.9","","3408.87","2784.05","9859.40","46","1247.69","8303.63","percent of total billed charges",""
"ELBOW STEM 8MMX0 UNIV TAPERED POROUS COATED PRESS FIT OFFSET COBALT TITANIUM","SUP-ITM-10045164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10728.20","6436.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8303.63","77.4","","5214.50","5214.50","16415.28","1 through 10","1247.69","8303.63","percent of total billed charges",""
"ELBOW STEM 8X31MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266644","CDM","C1776","HCPCS","0278","RC","","","","both","","","10039.50","6023.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1167.59","8533.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ELBOW STEM 8X31MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266644","CDM","C1776","HCPCS","0278","RC","","","","both","","","10039.50","6023.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5712.48","56.9","","2911.53","1863.86","5209.05","65","1167.59","8533.58","percent of total billed charges",""
"ELBOW STEM 8X31MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266644","CDM","C1776","HCPCS","0278","RC","","","","both","","","10039.50","6023.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1167.59","11.63","","400.94","400.94","400.94","1 through 10","1167.59","8533.58","percent of total billed charges",""
"ELBOW STEM 8X31MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266644","CDM","C1776","HCPCS","0278","RC","","","","both","","","10039.50","6023.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7770.57","77.4","","5214.50","5214.50","16415.28","1 through 10","1167.59","8533.58","percent of total billed charges",""
"ELBOW STEM 8X31MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266644","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10039.50","6023.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1167.59","11.63","","400.94","400.94","400.94","1 through 10","1167.59","7770.57","percent of total billed charges",""
"ELBOW STEM 8X31MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266644","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10039.50","6023.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4389.27","43.72","","1543.33","1543.33","1671.61","1 through 10","1167.59","7770.57","percent of total billed charges",""
"ELBOW STEM 8X31MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266644","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10039.50","6023.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7300.72","72.72","","3700.21","2382.07","6427.18","53","1167.59","7770.57","percent of total billed charges",""
"ELBOW STEM 8X31MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266644","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10039.50","6023.70","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7300.72","72.72","","12685.80","12685.80","12685.80","1 through 10","1167.59","7770.57","percent of total billed charges",""
"ELBOW STEM 8X31MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266644","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10039.50","6023.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6314.85","62.9","","3408.87","2784.05","9859.40","46","1167.59","7770.57","percent of total billed charges",""
"ELBOW STEM 8X31MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266644","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10039.50","6023.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7770.57","77.4","","5214.50","5214.50","16415.28","1 through 10","1167.59","7770.57","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","both","","","10039.50","6023.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1167.59","8533.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","both","","","10039.50","6023.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5712.48","56.9","","2911.53","1863.86","5209.05","65","1167.59","8533.58","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","both","","","10039.50","6023.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1167.59","11.63","","400.94","400.94","400.94","1 through 10","1167.59","8533.58","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","both","","","10039.50","6023.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7770.57","77.4","","5214.50","5214.50","16415.28","1 through 10","1167.59","8533.58","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10039.50","6023.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1167.59","11.63","","400.94","400.94","400.94","1 through 10","1167.59","7770.57","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10039.50","6023.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4389.27","43.72","","1543.33","1543.33","1671.61","1 through 10","1167.59","7770.57","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10039.50","6023.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7300.72","72.72","","3700.21","2382.07","6427.18","53","1167.59","7770.57","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10039.50","6023.70","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7300.72","72.72","","12685.80","12685.80","12685.80","1 through 10","1167.59","7770.57","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10039.50","6023.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6314.85","62.9","","3408.87","2784.05","9859.40","46","1167.59","7770.57","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10039.50","6023.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7770.57","77.4","","5214.50","5214.50","16415.28","1 through 10","1167.59","7770.57","percent of total billed charges",""
"ELECTRODE DISPERSIVE SONATA PK/10EA","SUP-ITM-10287872","CDM","C1886","HCPCS","0272","RC","","","","both","","","1015.77","609.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","17905.28","17905.28","17905.28","1 through 10","118.13","863.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ELECTRODE DISPERSIVE SONATA PK/10EA","SUP-ITM-10287872","CDM","C1886","HCPCS","0272","RC","","","","both","","","1015.77","609.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","5539.33","5539.33","5539.33","1 through 10","118.13","863.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ELECTRODE DISPERSIVE SONATA PK/10EA","SUP-ITM-10287872","CDM","C1886","HCPCS","0272","RC","","","","both","","","1015.77","609.46","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","118.13","11.63","","1314.65","1314.65","1314.65","1 through 10","118.13","863.4","percent of total billed charges",""
"ELECTRODE DISPERSIVE SONATA PK/10EA","SUP-ITM-10287872","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","1015.77","609.46","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","118.13","11.63","","1314.65","1314.65","1314.65","1 through 10","118.13","786.21","percent of total billed charges",""
"ELECTRODE DISPERSIVE SONATA PK/10EA","SUP-ITM-10287872","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","1015.77","609.46","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","738.67","72.72","","16561.06","16561.06","16561.06","1 through 10","118.13","786.21","percent of total billed charges",""
"Electrolyte Panel","PX-30000008","CDM","80051","CPT","0301","RC","","","","outpatient","","","100.00","60.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","72.72","72.72","","70.54","70.54","70.54","1 through 10","6.54","77.4","percent of total billed charges",""
"Electrolyte Panel","PX-30000008","CDM","80051","CPT","0301","RC","","","","outpatient","","","100.00","60.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","62.90","62.9","","61.11","61.11","61.11","1 through 10","6.54","77.4","percent of total billed charges",""
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3237.00","1942.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","653.35","","APC Price ($640.54). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","2666.98","2666.98","2666.98","1 through 10","627.73","4093.65","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3237.00","1942.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","4093.65","","Case rate ($4,093.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5657.31","3993.82","5657.31","1 through 10","627.73","4093.65","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3237.00","1942.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1762.72","","Case rate ($1,762.72). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7465.06","5403.59","7465.06","1 through 10","627.73","4093.65","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3237.00","1942.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","627.73","","APC Price ($640.54). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2711.23","630.01","2713.43","1 through 10","627.73","4093.65","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3237.00","1942.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","3308.86","","Case rate ($3,308.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7426.91","7426.91","8690.42","1 through 10","627.73","4093.65","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3237.00","1942.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","659.76","","APC Price ($640.54). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2801.47","2793.02","2801.47","1 through 10","627.73","4093.65","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3237.00","1942.20","MEDICARE [2001]","HB WDH MEDICARE","640.54","","APC Price ($640.54). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2766.56","1921.86","8299.68","16","627.73","4093.65","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3237.00","1942.20","TRICARE [160005]","HB WDH MEDICARE","640.54","","APC Price ($640.54). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2766.56","2766.56","2766.56","1 through 10","627.73","4093.65","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3237.00","1942.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","640.54","","APC Price ($640.54). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2713.43","2614.15","2713.73","418","627.73","4093.65","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","outpatient","","","3237.00","1942.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","466.78","14.42","","422.79","422.79","422.79","1 through 10","376.46","2505.44","percent of total billed charges",""
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","outpatient","","","3237.00","1942.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","376.46","11.63","","346.32","346.32","740.49","11","376.46","2505.44","percent of total billed charges",""
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","outpatient","","","3237.00","1942.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2505.44","77.4","","15427.72","1543.03","15427.72","1 through 10","376.46","2505.44","percent of total billed charges",""
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","outpatient","","","3237.00","1942.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","376.46","11.63","","346.32","346.32","346.32","1 through 10","376.46","2505.44","percent of total billed charges",""
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","both","","","3237.00","1942.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","2259.43","69.8","","2046.54","1844.23","2046.54","49","2259.43","2259.43","percent of total billed charges",""
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","outpatient","","","3237.00","1942.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1415.22","43.72","","1281.87","1281.87","1281.87","1 through 10","1415.22","2353.95","percent of total billed charges",""
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","outpatient","","","3237.00","1942.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2353.95","72.72","","2132.15","2132.15","2132.15","30","1415.22","2353.95","percent of total billed charges",""
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","outpatient","","","3237.00","1942.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2353.95","72.72","","2932.00","2132.15","4264.30","1 through 10","1415.22","2353.95","percent of total billed charges",""
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","outpatient","","","3237.00","1942.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","2353.95","72.72","","2132.15","2132.15","2132.15","1 through 10","1415.22","2353.95","percent of total billed charges",""
"Emergency Department Visit Low Mdm","PX-45000003","CDM","99283","CPT","0450","RC","","","","both","","","1220.00","732.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","289.28","","APC Price ($289.28). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2713.43","283.54","2713.73","1 through 10","283.5","3706.98","other","OPPS APC"
"Emergency Department Visit Low Mdm","PX-45000003","CDM","99283","CPT","0450","RC","","","","outpatient","","","1220.00","732.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","175.92","14.42","","159.92","159.92","159.92","1 through 10","141.89","944.28","percent of total billed charges",""
"Emergency Department Visit Low Mdm","PX-45000003","CDM","99283","CPT","0450","RC","","","","outpatient","","","1220.00","732.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","944.28","77.4","","859.48","859.48","859.48","1 through 10","141.89","944.28","percent of total billed charges",""
"Emergency Department Visit Low Mdm","PX-45000003","CDM","99283","CPT","0450","RC","","","","outpatient","","","1220.00","732.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","141.89","11.63","","130.99","130.99","130.99","1 through 10","141.89","944.28","percent of total billed charges",""
"Emergency Department Visit Low Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000003","CDM","99283","CPT","0450","RC","","","25","both","","","1220.00","732.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","851.56","69.8","","774.08","774.08","774.08","1 through 10","851.56","851.56","percent of total billed charges",""
"Emergency Department Visit Low Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000003","CDM","99283","CPT","0450","RC","","","25","outpatient","","","1220.00","732.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","887.18","72.72","","806.46","806.46","806.46","1 through 10","533.38","887.18","percent of total billed charges",""
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","both","","","2190.00","1314.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","1528.62","69.8","","1389.72","1389.72","1389.72","1 through 10","435.98","3706.98","percent of total billed charges",""
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","both","","","2190.00","1314.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","435.98","","APC Price ($444.88). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2713.43","2713.43","2713.43","1 through 10","435.98","3706.98","other","OPPS APC"
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","both","","","2190.00","1314.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","1528.62","69.8","","1389.72","1389.72","1389.72","1 through 10","435.98","3706.98","percent of total billed charges",""
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","both","","","2190.00","1314.00","MEDICARE [2001]","HB WDH MEDICARE","444.88","","APC Price ($444.88). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2766.56","2766.56","2766.56","1 through 10","435.98","3706.98","other","OPPS APC"
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","both","","","2190.00","1314.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","1861.50","85","","1692.35","1692.35","1692.35","1 through 10","435.98","3706.98","percent of total billed charges",""
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","both","","","2190.00","1314.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","444.88","","APC Price ($444.88). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2615.65","436.04","2713.73","14","435.98","3706.98","other","OPPS APC"
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","outpatient","","","2190.00","1314.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1592.57","72.72","","1447.86","1447.86","1447.86","1 through 10","254.7","1695.06","percent of total billed charges",""
"ENDCAP BONE 0MM MULTILOC TI NAIL EXTENSION","SUP-ITM-10097306","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.49","662.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","128.45","938.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ENDCAP BONE 0MM MULTILOC TI NAIL EXTENSION","SUP-ITM-10097306","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.49","662.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","128.45","938.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ENDCAP BONE 0MM MULTILOC TI NAIL EXTENSION","SUP-ITM-10097306","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.49","662.69","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","628.45","56.9","","812.12","238.65","1587.46","163","128.45","938.82","percent of total billed charges",""
"ENDCAP BONE 0MM MULTILOC TI NAIL EXTENSION","SUP-ITM-10097306","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.49","662.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","128.45","11.63","","112.68","112.68","146.99","38","128.45","938.82","percent of total billed charges",""
"ENDCAP BONE 0MM MULTILOC TI NAIL EXTENSION","SUP-ITM-10097306","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.49","662.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","854.88","77.4","","303.98","303.98","5854.79","1 through 10","128.45","938.82","percent of total billed charges",""
"ENDCAP BONE 0MM MULTILOC TI NAIL EXTENSION","SUP-ITM-10097306","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1104.49","662.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","128.45","11.63","","112.68","112.68","146.99","38","128.45","854.88","percent of total billed charges",""
"ENDCAP BONE 0MM MULTILOC TI NAIL EXTENSION","SUP-ITM-10097306","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1104.49","662.69","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","693.40","62.78","","780.86","208.94","10480.28","15","128.45","854.88","percent of total billed charges",""
"ENDCAP BONE 0MM MULTILOC TI NAIL EXTENSION","SUP-ITM-10097306","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1104.49","662.69","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","482.88","43.72","","179.76","179.76","179.76","1 through 10","128.45","854.88","percent of total billed charges",""
"ENDCAP BONE 0MM MULTILOC TI NAIL EXTENSION","SUP-ITM-10097306","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1104.49","662.69","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","803.19","72.72","","2355.45","298.99","3965.19","155","128.45","854.88","percent of total billed charges",""
"ENDCAP BONE 0MM MULTILOC TI NAIL EXTENSION","SUP-ITM-10097306","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1104.49","662.69","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","803.19","72.72","","3643.09","3643.09","3643.09","1 through 10","128.45","854.88","percent of total billed charges",""
"ENDCAP BONE 0MM MULTILOC TI NAIL EXTENSION","SUP-ITM-10097306","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1104.49","662.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","587.81","53.22","","554.28","554.28","554.28","16","128.45","854.88","percent of total billed charges",""
"ENDCAP BONE 0MM MULTILOC TI NAIL EXTENSION","SUP-ITM-10097306","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1104.49","662.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","694.72","62.9","","619.64","173.09","2370.64","150","128.45","854.88","percent of total billed charges",""
"ENDCAP BONE 0MM MULTILOC TI NAIL EXTENSION","SUP-ITM-10097306","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1104.49","662.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","854.88","77.4","","303.98","303.98","5854.79","1 through 10","128.45","854.88","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","both","","","1122.39","673.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","130.53","954.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","both","","","1122.39","673.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","130.53","954.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","both","","","1122.39","673.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","638.64","56.9","","812.12","238.65","1587.46","163","130.53","954.03","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","both","","","1122.39","673.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","130.53","11.63","","112.68","112.68","146.99","38","130.53","954.03","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","both","","","1122.39","673.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","868.73","77.4","","303.98","303.98","5854.79","1 through 10","130.53","954.03","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","130.53","11.63","","112.68","112.68","146.99","38","130.53","868.73","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","704.64","62.78","","780.86","208.94","10480.28","15","130.53","868.73","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","490.71","43.72","","179.76","179.76","179.76","1 through 10","130.53","868.73","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","816.20","72.72","","2355.45","298.99","3965.19","155","130.53","868.73","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","816.20","72.72","","3643.09","3643.09","3643.09","1 through 10","130.53","868.73","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","597.34","53.22","","554.28","554.28","554.28","16","130.53","868.73","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","705.98","62.9","","619.64","173.09","2370.64","150","130.53","868.73","percent of total billed charges",""
"ENDCAP CAP 10MM BONE END NAIL TIBIAL WITH T40 STARDRIVE RECESS EXTENSION TI","SUP-ITM-10018691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","868.73","77.4","","303.98","303.98","5854.79","1 through 10","130.53","868.73","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM T40 STARDRIVE","SUP-ITM-10020981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1311.59","786.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","152.54","1114.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM T40 STARDRIVE","SUP-ITM-10020981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1311.59","786.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","152.54","1114.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM T40 STARDRIVE","SUP-ITM-10020981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1311.59","786.95","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","746.29","56.9","","812.12","238.65","1587.46","163","152.54","1114.85","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM T40 STARDRIVE","SUP-ITM-10020981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1311.59","786.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","152.54","11.63","","112.68","112.68","146.99","38","152.54","1114.85","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM T40 STARDRIVE","SUP-ITM-10020981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1311.59","786.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1015.17","77.4","","303.98","303.98","5854.79","1 through 10","152.54","1114.85","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM T40 STARDRIVE","SUP-ITM-10020981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1311.59","786.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","152.54","11.63","","112.68","112.68","146.99","38","152.54","1015.17","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM T40 STARDRIVE","SUP-ITM-10020981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1311.59","786.95","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","823.42","62.78","","780.86","208.94","10480.28","15","152.54","1015.17","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM T40 STARDRIVE","SUP-ITM-10020981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1311.59","786.95","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","573.43","43.72","","179.76","179.76","179.76","1 through 10","152.54","1015.17","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM T40 STARDRIVE","SUP-ITM-10020981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1311.59","786.95","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","953.79","72.72","","2355.45","298.99","3965.19","155","152.54","1015.17","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM T40 STARDRIVE","SUP-ITM-10020981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1311.59","786.95","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","953.79","72.72","","3643.09","3643.09","3643.09","1 through 10","152.54","1015.17","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM T40 STARDRIVE","SUP-ITM-10020981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1311.59","786.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","698.03","53.22","","554.28","554.28","554.28","16","152.54","1015.17","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM T40 STARDRIVE","SUP-ITM-10020981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1311.59","786.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","824.99","62.9","","619.64","173.09","2370.64","150","152.54","1015.17","percent of total billed charges",""
"ENDCAP FEMORAL 0MM NAIL EX TITANIUM T40 STARDRIVE","SUP-ITM-10020981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1311.59","786.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1015.17","77.4","","303.98","303.98","5854.79","1 through 10","152.54","1015.17","percent of total billed charges",""
"ENDCAP FOR 15MM TFNA TI","SUP-ITM-10163892","CDM","C1713","HCPCS","0278","RC","","","","both","","","1237.44","742.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","143.91","1051.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ENDCAP FOR 15MM TFNA TI","SUP-ITM-10163892","CDM","C1713","HCPCS","0278","RC","","","","both","","","1237.44","742.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","143.91","1051.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ENDCAP FOR 15MM TFNA TI","SUP-ITM-10163892","CDM","C1713","HCPCS","0278","RC","","","","both","","","1237.44","742.46","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","704.10","56.9","","812.12","238.65","1587.46","163","143.91","1051.82","percent of total billed charges",""
"ENDCAP FOR 15MM TFNA TI","SUP-ITM-10163892","CDM","C1713","HCPCS","0278","RC","","","","both","","","1237.44","742.46","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","143.91","11.63","","112.68","112.68","146.99","38","143.91","1051.82","percent of total billed charges",""
"ENDCAP FOR 15MM TFNA TI","SUP-ITM-10163892","CDM","C1713","HCPCS","0278","RC","","","","both","","","1237.44","742.46","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","957.78","77.4","","303.98","303.98","5854.79","1 through 10","143.91","1051.82","percent of total billed charges",""
"ENDCAP FOR 15MM TFNA TI","SUP-ITM-10163892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1237.44","742.46","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","143.91","11.63","","112.68","112.68","146.99","38","143.91","957.78","percent of total billed charges",""
"ENDCAP FOR 15MM TFNA TI","SUP-ITM-10163892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1237.44","742.46","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","776.86","62.78","","780.86","208.94","10480.28","15","143.91","957.78","percent of total billed charges",""
"ENDCAP FOR 15MM TFNA TI","SUP-ITM-10163892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1237.44","742.46","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","541.01","43.72","","179.76","179.76","179.76","1 through 10","143.91","957.78","percent of total billed charges",""
"ENDCAP FOR 15MM TFNA TI","SUP-ITM-10163892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1237.44","742.46","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","899.87","72.72","","2355.45","298.99","3965.19","155","143.91","957.78","percent of total billed charges",""
"ENDCAP FOR 15MM TFNA TI","SUP-ITM-10163892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1237.44","742.46","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","899.87","72.72","","3643.09","3643.09","3643.09","1 through 10","143.91","957.78","percent of total billed charges",""
"ENDCAP FOR 15MM TFNA TI","SUP-ITM-10163892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1237.44","742.46","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","658.57","53.22","","554.28","554.28","554.28","16","143.91","957.78","percent of total billed charges",""
"ENDCAP FOR 15MM TFNA TI","SUP-ITM-10163892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1237.44","742.46","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","778.35","62.9","","619.64","173.09","2370.64","150","143.91","957.78","percent of total billed charges",""
"ENDCAP FOR 15MM TFNA TI","SUP-ITM-10163892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1237.44","742.46","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","957.78","77.4","","303.98","303.98","5854.79","1 through 10","143.91","957.78","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","both","","","1344.82","806.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","156.4","1143.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","both","","","1344.82","806.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","156.4","1143.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","both","","","1344.82","806.89","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","765.20","56.9","","812.12","238.65","1587.46","163","156.4","1143.1","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","both","","","1344.82","806.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","156.40","11.63","","112.68","112.68","146.99","38","156.4","1143.1","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","both","","","1344.82","806.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1040.89","77.4","","303.98","303.98","5854.79","1 through 10","156.4","1143.1","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","156.40","11.63","","112.68","112.68","146.99","38","156.4","1040.89","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","844.28","62.78","","780.86","208.94","10480.28","15","156.4","1040.89","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","587.96","43.72","","179.76","179.76","179.76","1 through 10","156.4","1040.89","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","977.95","72.72","","2355.45","298.99","3965.19","155","156.4","1040.89","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","977.95","72.72","","3643.09","3643.09","3643.09","1 through 10","156.4","1040.89","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","715.71","53.22","","554.28","554.28","554.28","16","156.4","1040.89","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","845.89","62.9","","619.64","173.09","2370.64","150","156.4","1040.89","percent of total billed charges",""
"ENDCAP HINDFOOT ARTHODESIS TI NAIL EX BLADE T25 STARDRIVE RECESS","SUP-ITM-10036886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1344.82","806.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1040.89","77.4","","303.98","303.98","5854.79","1 through 10","156.4","1040.89","percent of total billed charges",""
"ENDCAP NAIL END TITANIUM MULTILOC 2MM EXTENSION","SUP-ITM-10097307","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.49","662.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","128.45","938.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ENDCAP NAIL END TITANIUM MULTILOC 2MM EXTENSION","SUP-ITM-10097307","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.49","662.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","128.45","938.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ENDCAP NAIL END TITANIUM MULTILOC 2MM EXTENSION","SUP-ITM-10097307","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.49","662.69","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","628.45","56.9","","812.12","238.65","1587.46","163","128.45","938.82","percent of total billed charges",""
"ENDCAP NAIL END TITANIUM MULTILOC 2MM EXTENSION","SUP-ITM-10097307","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.49","662.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","128.45","11.63","","112.68","112.68","146.99","38","128.45","938.82","percent of total billed charges",""
"ENDCAP NAIL END TITANIUM MULTILOC 2MM EXTENSION","SUP-ITM-10097307","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.49","662.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","854.88","77.4","","303.98","303.98","5854.79","1 through 10","128.45","938.82","percent of total billed charges",""
"ENDCAP NAIL END TITANIUM MULTILOC 2MM EXTENSION","SUP-ITM-10097307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1104.49","662.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","128.45","11.63","","112.68","112.68","146.99","38","128.45","854.88","percent of total billed charges",""
"ENDCAP NAIL END TITANIUM MULTILOC 2MM EXTENSION","SUP-ITM-10097307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1104.49","662.69","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","693.40","62.78","","780.86","208.94","10480.28","15","128.45","854.88","percent of total billed charges",""
"ENDCAP NAIL END TITANIUM MULTILOC 2MM EXTENSION","SUP-ITM-10097307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1104.49","662.69","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","482.88","43.72","","179.76","179.76","179.76","1 through 10","128.45","854.88","percent of total billed charges",""
"ENDCAP NAIL END TITANIUM MULTILOC 2MM EXTENSION","SUP-ITM-10097307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1104.49","662.69","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","803.19","72.72","","2355.45","298.99","3965.19","155","128.45","854.88","percent of total billed charges",""
"ENDCAP NAIL END TITANIUM MULTILOC 2MM EXTENSION","SUP-ITM-10097307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1104.49","662.69","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","803.19","72.72","","3643.09","3643.09","3643.09","1 through 10","128.45","854.88","percent of total billed charges",""
"ENDCAP NAIL END TITANIUM MULTILOC 2MM EXTENSION","SUP-ITM-10097307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1104.49","662.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","587.81","53.22","","554.28","554.28","554.28","16","128.45","854.88","percent of total billed charges",""
"ENDCAP NAIL END TITANIUM MULTILOC 2MM EXTENSION","SUP-ITM-10097307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1104.49","662.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","694.72","62.9","","619.64","173.09","2370.64","150","128.45","854.88","percent of total billed charges",""
"ENDCAP NAIL END TITANIUM MULTILOC 2MM EXTENSION","SUP-ITM-10097307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1104.49","662.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","854.88","77.4","","303.98","303.98","5854.79","1 through 10","128.45","854.88","percent of total billed charges",""
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","outpatient","","","4529.00","2717.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","526.72","11.63","","10120.51","10120.51","10120.51","1 through 10","526.72","3505.45","percent of total billed charges",""
"Endo Pancreatoscopy Dir Vis Panc","PX-75000120","CDM","43273","CPT","0750","RC","","","","both","","","3507.00","2104.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1995.48","56.9","","1925.50","1925.50","1925.50","1 through 10","1995.48","2980.95","percent of total billed charges",""
"Endo Pancreatoscopy Dir Vis Panc","PX-75000120","CDM","43273","CPT","0750","RC","","","","outpatient","","","3507.00","2104.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","2460.84","2460.84","2460.84","1 through 10","407.86","2714.42","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Endo Small Intest Control Bleed","PX-75000143","CDM","44366","CPT","0750","RC","","","","both","","","6740.00","4044.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1950.30","1947.99","1950.30","1 through 10","1942.26","12666.17","other","OPPS APC"
"Endo Small Intest Control Bleed","PX-75000143","CDM","44366","CPT","0750","RC","","","","both","","","6740.00","4044.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1816.92","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Endo Small Intest W/Biopsy","PX-75000139","CDM","44361","CPT","0750","RC","","","","both","","","8110.00","4866.00","MEDICARE [2001]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1982.13","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Endo Small Intest W/Biopsy","PX-75000139","CDM","44361","CPT","0750","RC","","","","both","","","8110.00","4866.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1942.49","1942.49","1942.49","1 through 10","1942.26","12666.17","other","OPPS APC"
"Endo Small Intestine","PX-75000138","CDM","44360","CPT","0750","RC","","","","both","","","13240.00","7944.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","2041.36","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2003.26","2003.26","2003.26","1 through 10","1942.26","12666.17","other","OPPS APC"
"Endo Small Intestine","PX-75000138","CDM","44360","CPT","0750","RC","","","","both","","","13240.00","7944.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1947.99","1947.99","1947.99","1 through 10","1942.26","12666.17","other","OPPS APC"
"Endo Small Intestine","PX-75000138","CDM","44360","CPT","0750","RC","","","","both","","","13240.00","7944.00","MEDICARE [2001]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1854.00","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","","","","inpatient","","","30842.92","18505.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","31021.91","","Fee schedule rate ($31,021.91). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","30513.30","30513.30","30513.30","1 through 10","3975","38950.1","case rate",""
"Endocrine Disorders With Cc","644","MS-DRG","","","","","","","","inpatient","","","30842.92","18505.75","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","8484.48","","Case rate ($8,237.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,637.26, add-ons for qualifying new technology services are included. If operating cost exceeds $11,555.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,374.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,223.06 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,192.39 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.43. The transfer capital threshold is the transfer adjustment factor * $569.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7815.72","7815.72","11786.75","1 through 10","3975","38950.1","other","Inpatient DRG"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","","","","inpatient","","","30842.92","18505.75","MARTIN'S POINT [160007]","HB WDH MEDICARE","8237.36","","Case rate ($8,237.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,637.26, add-ons for qualifying new technology services are included. If operating cost exceeds $11,555.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,374.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,223.06 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,192.39 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.43. The transfer capital threshold is the transfer adjustment factor * $569.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8112.43","8112.43","8112.43","1 through 10","3975","38950.1","other","Inpatient DRG"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","","","","inpatient","","","30842.92","18505.75","MEDICARE [2001]","HB WDH MEDICARE","8237.36","","Case rate ($8,237.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,637.26, add-ons for qualifying new technology services are included. If operating cost exceeds $11,555.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,374.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,223.06 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,192.39 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.43. The transfer capital threshold is the transfer adjustment factor * $569.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8262.68","5031.31","8262.68","12","3975","38950.1","other","Inpatient DRG"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","","","","inpatient","","","30842.92","18505.75","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8237.36","","Case rate ($8,237.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,637.26, add-ons for qualifying new technology services are included. If operating cost exceeds $11,555.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,374.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,223.06 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,192.39 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.43. The transfer capital threshold is the transfer adjustment factor * $569.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8133.53","8133.53","8133.53","1 through 10","3975","38950.1","other","Inpatient DRG"
"Endocrine Disorders With McC","643","MS-DRG","","","","","","","","inpatient","","","42020.38","25212.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","12700.07","","Case rate ($12,959.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,995.50, add-ons for qualifying new technology services are included. If operating cost exceeds $15,913.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,719.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $11,599.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,550.62 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $914.48. The transfer capital threshold is the transfer adjustment factor * $914.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5446.88","5446.88","5446.88","1 through 10","3975","62551.96","other","Inpatient DRG"
"Endocrine Disorders With McC","643","MS-DRG","","","","","","","","inpatient","","","42020.38","25212.23","MARTIN'S POINT [160007]","HB WDH MEDICARE","12959.25","","Case rate ($12,959.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,995.50, add-ons for qualifying new technology services are included. If operating cost exceeds $15,913.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,719.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $11,599.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,550.62 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $914.48. The transfer capital threshold is the transfer adjustment factor * $914.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10288.06","10288.06","10288.06","1 through 10","3975","62551.96","other","Inpatient DRG"
"Endocrine Disorders With McC","643","MS-DRG","","","","","","","","inpatient","","","42020.38","25212.23","MEDICARE [2001]","HB WDH MEDICARE","12959.25","","Case rate ($12,959.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,995.50, add-ons for qualifying new technology services are included. If operating cost exceeds $15,913.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,719.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $11,599.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,550.62 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $914.48. The transfer capital threshold is the transfer adjustment factor * $914.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12982.62","12950.04","12983.48","1 through 10","3975","62551.96","other","Inpatient DRG"
"Endocrine Disorders With McC","643","MS-DRG","","","","","","","","inpatient","","","42020.38","25212.23","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","12959.25","","Case rate ($12,959.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,995.50, add-ons for qualifying new technology services are included. If operating cost exceeds $15,913.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,719.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $11,599.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,550.62 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $914.48. The transfer capital threshold is the transfer adjustment factor * $914.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12982.62","12982.62","12982.62","1 through 10","3975","62551.96","other","Inpatient DRG"
"Endocrine Disorders Without Cc/McC","645","MS-DRG","","","","","","","","inpatient","","","17741.63","10644.98","MEDICARE [2001]","HB WDH MEDICARE","6285.82","","Case rate ($6,285.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,836, add-ons for qualifying new technology services are included. If operating cost exceeds $9,754.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,231.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,414.13 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,391.13 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $426.82. The transfer capital threshold is the transfer adjustment factor * $426.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1647.23","1647.23","1647.23","1 through 10","3975","29195.48","other","Inpatient DRG"
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","both","","","139.00","83.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","97.02","69.8","","93.53","93.53","93.53","1 through 10","7.86","118.15","percent of total billed charges",""
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","both","","","139.00","83.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","79.09","56.9","","76.25","76.25","76.25","13","7.86","118.15","percent of total billed charges",""
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","outpatient","","","139.00","83.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","20.04","14.42","","10.77","10.77","10.77","1 through 10","16.17","107.59","percent of total billed charges",""
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","outpatient","","","139.00","83.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16.17","11.63","","10.67","10.67","15.83","1 through 10","16.17","107.59","percent of total billed charges",""
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","outpatient","","","139.00","83.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","101.08","72.72","","97.44","97.44","97.44","1 through 10","16.17","107.59","percent of total billed charges",""
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","outpatient","","","139.00","83.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","107.59","77.4","","103.85","103.85","103.85","1 through 10","16.17","107.59","percent of total billed charges",""
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","outpatient","","","139.00","83.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16.17","11.63","","10.67","10.67","18.95","1 through 10","16.17","107.59","percent of total billed charges",""
"ENVELOPE NEURO LARGE TYRX ABSORBABLE ANTIBACTERIAL","SUP-ITM-10166012","CDM","C1889","HCPCS","0278","RC","","","","both","","","6184.45","3710.67","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","719.25","5256.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ENVELOPE NEURO LARGE TYRX ABSORBABLE ANTIBACTERIAL","SUP-ITM-10166012","CDM","C1889","HCPCS","0278","RC","","","","both","","","6184.45","3710.67","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","719.25","5256.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ENVELOPE NEURO LARGE TYRX ABSORBABLE ANTIBACTERIAL","SUP-ITM-10166012","CDM","C1889","HCPCS","0278","RC","","","","both","","","6184.45","3710.67","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3518.95","56.9","","0.63","0.63","0.63","1 through 10","719.25","5256.78","percent of total billed charges",""
"ENVELOPE NEURO LARGE TYRX ABSORBABLE ANTIBACTERIAL","SUP-ITM-10166012","CDM","C1889","HCPCS","0278","RC","","","","both","","","6184.45","3710.67","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","891.80","14.42","","317.14","317.14","317.14","1 through 10","719.25","5256.78","percent of total billed charges",""
"ENVELOPE NEURO LARGE TYRX ABSORBABLE ANTIBACTERIAL","SUP-ITM-10166012","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6184.45","3710.67","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","891.80","14.42","","317.14","317.14","317.14","1 through 10","719.25","4786.76","percent of total billed charges",""
"ENVELOPE NEURO LARGE TYRX ABSORBABLE ANTIBACTERIAL","SUP-ITM-10166012","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6184.45","3710.67","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3882.60","62.78","","1125.09","1125.09","1125.09","1 through 10","719.25","4786.76","percent of total billed charges",""
"ENVELOPE NEURO LARGE TYRX ABSORBABLE ANTIBACTERIAL","SUP-ITM-10166012","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6184.45","3710.67","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4497.33","72.72","","4732.50","1617.43","14180.40","1 through 10","719.25","4786.76","percent of total billed charges",""
"ENVELOPE NEURO LARGE TYRX ABSORBABLE ANTIBACTERIAL","SUP-ITM-10166012","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6184.45","3710.67","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3890.02","62.9","","3896.20","3341.38","3896.20","1 through 10","719.25","4786.76","percent of total billed charges",""
"Enzyme Activity Nonradioact Substr","PX-30000415","CDM","82657","CPT","0301","RC","","","","both","","","255.00","153.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","177.99","69.8","","172.41","172.41","172.41","1 through 10","14.41","216.75","percent of total billed charges",""
"Enzyme Activity Nonradioact Substr","PX-30000415","CDM","82657","CPT","0301","RC","","","","outpatient","","","255.00","153.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","160.40","62.9","","155.61","155.61","155.61","1 through 10","16.24","197.37","percent of total billed charges",""
"Eo W/O Joints Custom T1","PX-27000478","CDM","L3702","HCPCS","0274","RC","","","","outpatient","","","321.00","192.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","201.91","62.9","","202.23","202.23","202.23","1 through 10","140.34","248.45","percent of total billed charges",""
"Ep Comprehensive Left Atrium","PX-48000160","CDM","93621","CPT","0481","RC","","","","both","","","2907.00","1744.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","2805.00","2805.00","2805.00","1 through 10","1654.08","2470.95","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Ep Comprehensive W/Arrhythmia","PX-48000159","CDM","93620","CPT","0480","RC","","","","both","","","25120.00","15072.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","50665.65","","Case rate ($50,665.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","49430.02","49430.02","49430.02","1 through 10","7769.19","50665.65","other","OPPS APC"
"Ep Comprehensive W/Arrhythmia","PX-48000159","CDM","93620","CPT","0480","RC","","","","both","","","25120.00","15072.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","40952.56","","Case rate ($40,952.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","64193.51","21284.71","64193.51","1 through 10","7769.19","50665.65","other","OPPS APC"
"Ep Comprehensive W/Arrhythmia","PX-48000159","CDM","93620","CPT","0480","RC","","","","both","","","25120.00","15072.00","MEDICARE [2001]","HB WDH MEDICARE","7927.74","","APC Price ($7,927.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7928.65","7928.65","7928.65","1 through 10","7769.19","50665.65","other","OPPS APC"
"Ep Comprehensive W/Arrhythmia","PX-48000159","CDM","93620","CPT","0480","RC","","","","both","","","25120.00","15072.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7927.74","","APC Price ($7,927.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7928.65","7928.65","7928.65","1 through 10","7769.19","50665.65","other","OPPS APC"
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","both","","","82026.00","49215.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","57254.15","69.8","","55248.79","55248.79","55248.79","1 through 10","25117.76","163801.78","percent of total billed charges",""
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","both","","","82026.00","49215.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","163801.78","","Case rate ($163,801.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","121883.32","121883.32","121883.32","1 through 10","25117.76","163801.78","other","OPPS APC"
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","both","","","82026.00","49215.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","70532.87","","Case rate ($70,532.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","68813.36","68813.36","68813.36","1 through 10","25117.76","163801.78","other","OPPS APC"
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","both","","","82026.00","49215.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","25117.76","","APC Price ($25,630.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","25633.31","25120.64","25633.31","1 through 10","25117.76","163801.78","other","OPPS APC"
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","both","","","82026.00","49215.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","132399.42","","Case rate ($132,399.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111042.02","111042.02","111042.02","1 through 10","25117.76","163801.78","other","OPPS APC"
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","both","","","82026.00","49215.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","25630.37","","APC Price ($25,630.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","25128.14","22683.74","25633.31","1 through 10","25117.76","163801.78","other","OPPS APC"
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","both","","","82026.00","49215.60","MEDICARE [2001]","HB WDH MEDICARE","25630.37","","APC Price ($25,630.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","25633.31","25633.31","25633.31","1 through 10","25117.76","163801.78","other","OPPS APC"
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","both","","","82026.00","49215.60","WELLSENSE NH [1050]","HB WDH MEDICARE","25630.37","","APC Price ($25,630.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","26376.68","26376.68","26376.68","1 through 10","25117.76","163801.78","other","OPPS APC"
"Ephys Eval W/ Ablation Supravent","PX-48000247","CDM","93653","CPT","0481","RC","","","","outpatient","","","82026.00","49215.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","9539.62","11.63","","9688.33","9688.33","9688.33","1 through 10","9539.62","63488.12","percent of total billed charges",""
"Epifix 16 Sq Cm Tier3","PX-27001033","CDM","Q4186","HCPCS","0636","RC","","","","both","","","1457.00","874.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","938.75","64.43","","1328.70","1328.70","1432.55","45","155.24","1238.45","percent of total billed charges",""
"Epifix 16 Sq Cm Tier3","PX-27001033","CDM","Q4186","HCPCS","0636","RC","","","","both","","","1457.00","874.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","2060.00","2060.00","2060.00","1 through 10","155.24","1238.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Epifix 18mm Disk (3 Sq Cm)","PX-27002066","CDM","Q4186","HCPCS","0636","RC","","","","both","","","2060.00","1236.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","1327.26","64.43","","1328.70","1328.70","1432.55","45","155.24","1751","percent of total billed charges",""
"Epifix 18mm Disk (3 Sq Cm)","PX-27002066","CDM","Q4186","HCPCS","0636","RC","","","","both","","","2060.00","1236.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","2060.00","2060.00","2060.00","1 through 10","155.24","1751","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Epifix 2.0cm X 2.0cm (4 Sq Cm)","PX-27002067","CDM","Q4186","HCPCS","0636","RC","","","","both","","","2221.00","1332.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","1430.99","64.43","","1328.70","1328.70","1432.55","45","155.24","1887.85","percent of total billed charges",""
"Epifix 2.0cm X 2.0cm (4 Sq Cm)","PX-27002067","CDM","Q4186","HCPCS","0636","RC","","","","both","","","2221.00","1332.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","2060.00","2060.00","2060.00","1 through 10","155.24","1887.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Epifix 2.0cm X 4.0cm (8 Sq Cm)","PX-27002068","CDM","Q4186","HCPCS","0636","RC","","","","both","","","1015.00","609.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","653.96","64.43","","1328.70","1328.70","1432.55","45","155.24","862.75","percent of total billed charges",""
"Epifix 2.0cm X 4.0cm (8 Sq Cm)","PX-27002068","CDM","Q4186","HCPCS","0636","RC","","","","both","","","1015.00","609.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","2060.00","2060.00","2060.00","1 through 10","155.24","862.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Epifix 3.5cm X 3.5cm (8 Sq Cm)","PX-27002069","CDM","Q4186","HCPCS","0636","RC","","","","both","","","581.00","348.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","374.34","64.43","","1328.70","1328.70","1432.55","45","155.24","493.85","percent of total billed charges",""
"Epifix 3.5cm X 3.5cm (8 Sq Cm)","PX-27002069","CDM","Q4186","HCPCS","0636","RC","","","","both","","","581.00","348.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","2060.00","2060.00","2060.00","1 through 10","155.24","493.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Epifix 4.0cm X 4.5cm (11 Sq Cm)","PX-27002070","CDM","Q4186","HCPCS","0636","RC","","","","both","","","704.00","422.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","453.59","64.43","","1328.70","1328.70","1432.55","45","155.24","598.4","percent of total billed charges",""
"Epifix 4.0cm X 4.5cm (11 Sq Cm)","PX-27002070","CDM","Q4186","HCPCS","0636","RC","","","","both","","","704.00","422.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","2060.00","2060.00","2060.00","1 through 10","155.24","598.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Epifix 6 Sq Cm Tier1","PX-27001032","CDM","Q4186","HCPCS","0636","RC","","","","both","","","1230.00","738.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","792.49","64.43","","1328.70","1328.70","1432.55","45","155.24","1045.5","percent of total billed charges",""
"Epifix 6 Sq Cm Tier1","PX-27001032","CDM","Q4186","HCPCS","0636","RC","","","","both","","","1230.00","738.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","2060.00","2060.00","2060.00","1 through 10","155.24","1045.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Epifix Mesh 2cm X 3cm (4 Sq Cm)","PX-27002453","CDM","Q4186","HCPCS","0636","RC","","","","both","","","1400.00","840.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","902.02","64.43","","1328.70","1328.70","1432.55","45","155.24","1190","percent of total billed charges",""
"Epifix Mesh 2cm X 3cm (4 Sq Cm)","PX-27002453","CDM","Q4186","HCPCS","0636","RC","","","","both","","","1400.00","840.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","2060.00","2060.00","2060.00","1 through 10","155.24","1190","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Epistaxis With McC","150","MS-DRG","","","","","","","","inpatient","","","31668.94","19001.36","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","10567.52","","Case rate ($10,567.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,787.96, add-ons for qualifying new technology services are included. If operating cost exceeds $13,706.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,544.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,382.94 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,343.09 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $739.71. The transfer capital threshold is the transfer adjustment factor * $739.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10901.43","10901.43","10901.43","1 through 10","3975","50597.13","other","Inpatient DRG"
"Epistaxis Without McC","151","MS-DRG","","","","","","","","inpatient","","","31203.40","18722.04","MEDICARE [2001]","HB WDH MEDICARE","6025.05","","Case rate ($6,025.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,595.32, add-ons for qualifying new technology services are included. If operating cost exceeds $9,513.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,212.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,172.42 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,150.45 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $407.77. The transfer capital threshold is the transfer adjustment factor * $407.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","0.05","1 through 10","3975","27892.07","other","Inpatient DRG"
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","outpatient","","","230.00","138.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","100.56","43.72","","97.06","97.06","97.06","1 through 10","51.91","178.02","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","outpatient","","","230.00","138.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","167.26","72.72","","161.44","161.44","484.32","15","51.91","178.02","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","outpatient","","","230.00","138.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","122.41","53.22","","118.35","118.35","118.35","1 through 10","51.91","178.02","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","outpatient","","","230.00","138.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","144.67","62.9","","139.86","139.86","419.58","44","51.91","178.02","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","outpatient","","","230.00","138.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","178.02","77.4","","172.05","172.05","172.05","1 through 10","51.91","178.02","percent of total billed charges",""
"Epstein-Barr Early Ag Antibody Ea","PX-30000924","CDM","86663","CPT","0302","RC","","","","both","","","71.00","42.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","49.56","69.8","","48.16","48.16","48.16","1 through 10","8.53","67.73","percent of total billed charges",""
"Epstein-Barr Early Ag Antibody Ea","PX-30000924","CDM","86663","CPT","0302","RC","","","","outpatient","","","71.00","42.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","51.63","72.72","","50.18","50.18","50.18","1 through 10","12.23","54.95","percent of total billed charges",""
"Epstein-Barr Early Ag Antibody Ea","PX-30000924","CDM","86663","CPT","0302","RC","","","","outpatient","","","71.00","42.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","44.66","62.9","","43.47","43.47","83.24","18","12.23","54.95","percent of total billed charges",""
"Epstein-Barr Early Ag Antibody Ea","PX-30000924","CDM","86663","CPT","0302","RC","","","","outpatient","","","71.00","42.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","54.95","77.4","","53.48","53.48","53.48","1 through 10","12.23","54.95","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","both","","","81.00","48.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","56.54","69.8","","54.44","54.44","54.44","1 through 10","9.94","78.25","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","outpatient","","","81.00","48.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","58.90","72.72","","56.72","56.72","56.72","1 through 10","13.31","62.69","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","outpatient","","","81.00","48.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","50.95","62.9","","49.14","49.14","94.60","13","13.31","62.69","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","outpatient","","","81.00","48.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","62.69","77.4","","60.45","60.45","60.45","1 through 10","13.31","62.69","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","both","","","98.00","58.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","68.40","69.8","","66.31","66.31","66.31","1 through 10","11.79","93.29","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","outpatient","","","98.00","58.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","71.27","72.72","","69.09","69.08","138.17","1 through 10","13.31","75.85","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","outpatient","","","98.00","58.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","71.27","72.72","","69.09","69.09","69.09","1 through 10","13.31","75.85","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","outpatient","","","98.00","58.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","61.64","62.9","","59.85","59.85","114.77","33","13.31","75.85","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","outpatient","","","98.00","58.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","75.85","77.4","","73.63","73.63","147.24","1 through 10","13.31","75.85","percent of total billed charges",""
"Ercp Destruct Calculi Any Method","PX-75000114","CDM","43265","CPT","0750","RC","","","","both","","","12256.00","7353.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6219.26","","APC Price ($6,219.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9537.16","9537.16","9537.16","1 through 10","6094.87","39746.79","other","OPPS APC"
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","both","","","13083.00","7849.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","9131.93","69.8","","7747.66","7747.66","7747.66","1 through 10","6094.87","39746.79","percent of total billed charges",""
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","both","","","13083.00","7849.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","39746.79","","Case rate ($39,746.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","19388.73","19388.73","19388.73","1 through 10","6094.87","39746.79","other","OPPS APC"
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","both","","","13083.00","7849.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","17114.93","","Case rate ($17,114.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","16697.69","15543.23","16697.69","1 through 10","6094.87","39746.79","other","OPPS APC"
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","both","","","13083.00","7849.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7444.23","56.9","","7183.63","7183.63","7183.63","1 through 10","6094.87","39746.79","percent of total billed charges",""
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","both","","","13083.00","7849.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","6219.26","","APC Price ($6,219.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6103.07","6103.07","6103.07","1 through 10","6094.87","39746.79","other","OPPS APC"
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","both","","","13083.00","7849.80","MEDICARE [2001]","HB WDH MEDICARE","6219.26","","APC Price ($6,219.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6219.97","6219.97","6219.97","1 through 10","6094.87","39746.79","other","OPPS APC"
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","both","","","13083.00","7849.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6219.26","","APC Price ($6,219.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6219.97","6095.58","6219.97","1 through 10","6094.87","39746.79","other","OPPS APC"
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","outpatient","","","13083.00","7849.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","9180.90","9180.90","9180.90","1 through 10","1521.55","10126.24","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","outpatient","","","13083.00","7849.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1521.55","11.63","","9762.53","9752.91","9762.53","1 through 10","1521.55","10126.24","percent of total billed charges",""
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","both","","","10687.00","6412.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1982.13","1982.13","1 through 10","1942.26","12666.17","other","OPPS APC"
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","both","","","10687.00","6412.20","MEDICARE [2001]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1982.13","3975.28","1 through 10","1942.26","12666.17","other","OPPS APC"
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","outpatient","","","10687.00","6412.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","5687.62","53.22","","5497.86","5497.86","5497.86","1 through 10","1242.9","8271.74","percent of total billed charges",""
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","both","","","13615.00","8169.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","6094.87","","APC Price ($6,219.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6219.97","5469.72","6219.97","1 through 10","6094.87","39746.79","other","OPPS APC"
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","both","","","13615.00","8169.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","6405.84","","APC Price ($6,219.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","6289.44","6289.44","6289.44","1 through 10","6094.87","39746.79","other","OPPS APC"
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","both","","","13615.00","8169.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","6219.26","","APC Price ($6,219.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6103.47","6103.47","6103.47","1 through 10","6094.87","39746.79","other","OPPS APC"
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","both","","","13615.00","8169.00","MEDICARE [2001]","HB WDH MEDICARE","6219.26","","APC Price ($6,219.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6219.97","5553.02","6219.97","1 through 10","6094.87","39746.79","other","OPPS APC"
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","both","","","13615.00","8169.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6219.26","","APC Price ($6,219.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6103.28","6103.28","6103.28","1 through 10","6094.87","39746.79","other","OPPS APC"
"Ercp W/Biopsy","PX-75000110","CDM","43261","CPT","0750","RC","","","","both","","","9624.00","5774.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","3895.32","","APC Price ($3,974.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3731.50","3731.50","3731.50","1 through 10","3895.32","25402.78","other","OPPS APC"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","10328.00","6196.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","7208.94","69.8","","6956.27","6091.80","6956.27","1 through 10","3895.32","25402.78","percent of total billed charges",""
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","10328.00","6196.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","25402.78","","Case rate ($25,402.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","12499.15","12499.15","12499.15","1 through 10","3895.32","25402.78","other","OPPS APC"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","10328.00","6196.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","10938.41","","Case rate ($10,938.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","10671.74","9966.00","10671.74","1 through 10","3895.32","25402.78","other","OPPS APC"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","10328.00","6196.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","3895.32","","APC Price ($3,974.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3911.68","3911.68","3911.68","1 through 10","3895.32","25402.78","other","OPPS APC"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","10328.00","6196.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","20532.83","","Case rate ($20,532.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","19605.71","19605.71","19605.71","1 through 10","3895.32","25402.78","other","OPPS APC"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","10328.00","6196.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","4094.07","","APC Price ($3,974.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","4012.65","4012.65","4012.65","1 through 10","3895.32","25402.78","other","OPPS APC"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","10328.00","6196.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","3974.82","","APC Price ($3,974.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3975.28","3975.28","3975.28","1 through 10","3895.32","25402.78","other","OPPS APC"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","10328.00","6196.80","MEDICARE [2001]","HB WDH MEDICARE","3974.82","","APC Price ($3,974.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3975.28","3975.28","3975.28","12","3895.32","25402.78","other","OPPS APC"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","10328.00","6196.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","3974.82","","APC Price ($3,974.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3903.68","3895.78","3975.28","1 through 10","3895.32","25402.78","other","OPPS APC"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","outpatient","","","10328.00","6196.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1201.15","11.63","","2608.94","1372.32","2608.94","1 through 10","1201.15","7993.87","percent of total billed charges",""
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","outpatient","","","10328.00","6196.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6496.31","62.9","","6278.58","6278.58","6278.58","1 through 10","1201.15","7993.87","percent of total billed charges",""
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","both","","","10138.00","6082.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","7076.32","69.8","","6828.53","6828.53","6828.53","1 through 10","3895.32","25402.78","percent of total billed charges",""
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","both","","","10138.00","6082.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","10938.41","","Case rate ($10,938.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","10671.74","9783.00","10671.74","1 through 10","3895.32","25402.78","other","OPPS APC"
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","both","","","10138.00","6082.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","3895.32","","APC Price ($3,974.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3656.87","3656.87","3656.87","1 through 10","3895.32","25402.78","other","OPPS APC"
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","both","","","10138.00","6082.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","3974.82","","APC Price ($3,974.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3903.27","3903.27","3903.27","1 through 10","3895.32","25402.78","other","OPPS APC"
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","both","","","10138.00","6082.80","MEDICARE [2001]","HB WDH MEDICARE","3974.82","","APC Price ($3,974.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3975.28","3975.28","3975.28","1 through 10","3895.32","25402.78","other","OPPS APC"
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","both","","","10138.00","6082.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","3974.82","","APC Price ($3,974.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3903.48","3903.48","3903.48","1 through 10","3895.32","25402.78","other","OPPS APC"
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","both","","","10138.00","6082.80","WELLSENSE NH [1050]","HB WDH MEDICARE","3974.82","","APC Price ($3,974.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4097.76","4097.76","4097.76","1 through 10","3895.32","25402.78","other","OPPS APC"
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","outpatient","","","10138.00","6082.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1179.05","11.63","","2560.38","2560.38","2560.38","1 through 10","1179.05","7846.81","percent of total billed charges",""
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","outpatient","","","10138.00","6082.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1179.05","11.63","","1155.53","1155.53","1155.53","1 through 10","1179.05","7846.81","percent of total billed charges",""
"Erythropoietin","PX-30000421","CDM","82668","CPT","0301","RC","","","","both","","","101.00","60.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","70.50","69.8","","68.40","68.40","68.40","1 through 10","12.21","96.33","percent of total billed charges",""
"Erythropoietin","PX-30000421","CDM","82668","CPT","0301","RC","","","","outpatient","","","101.00","60.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","73.45","72.72","","71.27","71.27","71.27","14","17.52","78.17","percent of total billed charges",""
"Erythropoietin","PX-30000421","CDM","82668","CPT","0301","RC","","","","outpatient","","","101.00","60.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","73.45","72.72","","71.27","71.27","71.27","1 through 10","17.52","78.17","percent of total billed charges",""
"Erythropoietin","PX-30000421","CDM","82668","CPT","0301","RC","","","","outpatient","","","101.00","60.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","53.75","53.22","","156.72","156.72","156.72","1 through 10","17.52","78.17","percent of total billed charges",""
"Erythropoietin","PX-30000421","CDM","82668","CPT","0301","RC","","","","outpatient","","","101.00","60.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","63.53","62.9","","61.74","61.74","61.74","1 through 10","17.52","78.17","percent of total billed charges",""
"Erythropoietin","PX-30000421","CDM","82668","CPT","0301","RC","","","","outpatient","","","101.00","60.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","78.17","77.4","","75.95","75.95","75.95","1 through 10","17.52","78.17","percent of total billed charges",""
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","both","","","12010.00","7206.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","543.26","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","554.41","543.32","554.41","1 through 10","543.26","10208.5","other","OPPS APC"
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","both","","","12010.00","7206.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","2863.62","","Case rate ($2,863.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2793.76","2793.76","2793.76","1 through 10","543.26","10208.5","other","OPPS APC"
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","both","","","12010.00","7206.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","570.98","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","559.62","559.62","559.62","1 through 10","543.26","10208.5","other","OPPS APC"
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","both","","","12010.00","7206.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","554.35","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","543.32","522.23","554.41","1 through 10","543.26","10208.5","other","OPPS APC"
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","both","","","12010.00","7206.00","MEDICARE [2001]","HB WDH MEDICARE","554.35","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","554.41","522.23","554.41","1 through 10","543.26","10208.5","other","OPPS APC"
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","both","","","12010.00","7206.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","554.35","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","545.54","543.33","554.41","1 through 10","543.26","10208.5","other","OPPS APC"
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","both","","","12010.00","7206.00","WELLSENSE NH [1050]","HB WDH MEDICARE","554.35","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1711.47","1711.47","1711.47","1 through 10","543.26","10208.5","other","OPPS APC"
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","outpatient","","","12010.00","7206.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1396.76","11.63","","1595.81","1418.49","1595.81","1 through 10","1396.76","9295.74","percent of total billed charges",""
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","outpatient","","","12010.00","7206.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8733.67","72.72","","19527.32","15482.27","19527.32","1 through 10","1396.76","9295.74","percent of total billed charges",""
"Esophag Balloon Distent Provoc Stud","PX-75000318","CDM","91040","CPT","0750","RC","","","","outpatient","","","12010.00","7206.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1396.76","11.63","","1368.85","1368.85","1368.85","1 through 10","1396.76","9295.74","percent of total billed charges",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","39023.25","23413.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","48195.53","","Fee schedule rate ($48,195.53). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","47620.61","47620.61","47620.61","1 through 10","3975","48195.53","case rate",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","39023.25","23413.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","9885.31","","Case rate ($10,087.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,344.49, add-ons for qualifying new technology services are included. If operating cost exceeds $13,262.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,509.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,937.57 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,899.62 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.60. The transfer capital threshold is the transfer adjustment factor * $704.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9934.33","9934.33","9934.33","1 through 10","3975","48195.53","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","39023.25","23413.95","MARTIN'S POINT [160007]","HB WDH MEDICARE","10087.05","","Case rate ($10,087.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,344.49, add-ons for qualifying new technology services are included. If operating cost exceeds $13,262.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,509.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,937.57 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,899.62 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.60. The transfer capital threshold is the transfer adjustment factor * $704.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10822.77","10822.77","10822.77","1 through 10","3975","48195.53","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","39023.25","23413.95","MEDICARE [2001]","HB WDH MEDICARE","10087.05","","Case rate ($10,087.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,344.49, add-ons for qualifying new technology services are included. If operating cost exceeds $13,262.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,509.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,937.57 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,899.62 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.60. The transfer capital threshold is the transfer adjustment factor * $704.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10137.07","0.05","10162.32","22","3975","48195.53","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","39023.25","23413.95","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","10087.05","","Case rate ($10,087.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,344.49, add-ons for qualifying new technology services are included. If operating cost exceeds $13,262.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,509.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,937.57 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,899.62 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $704.60. The transfer capital threshold is the transfer adjustment factor * $704.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9982.78","9959.74","10162.32","1 through 10","3975","48195.53","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","24070.44","14442.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","29624.88","","Fee schedule rate ($29,624.88). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","21959.70","20740.11","28928.27","1 through 10","3975","29624.88","case rate",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","24070.44","14442.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","11665.06","","Fee schedule rate ($11,665.06). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","11390.76","11390.76","18751.04","1 through 10","3975","29624.88","case rate",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","24070.44","14442.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","6244.31","","Case rate ($6,371.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,915.30, add-ons for qualifying new technology services are included. If operating cost exceeds $9,833.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,238.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $5,493.76 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,470.43 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.10. The transfer capital threshold is the transfer adjustment factor * $433.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6254.48","6254.48","6347.92","1 through 10","3975","29624.88","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","24070.44","14442.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","23594.81","","Fee schedule rate ($23,594.81). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","18243.21","11390.76","23039.99","1 through 10","3975","29624.88","case rate",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","24070.44","14442.26","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","6562.89","","Case rate ($6,371.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,915.30, add-ons for qualifying new technology services are included. If operating cost exceeds $9,833.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,238.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $5,493.76 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,470.43 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.10. The transfer capital threshold is the transfer adjustment factor * $433.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","8363.85","8363.85","8363.85","1 through 10","3975","29624.88","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","24070.44","14442.26","MEDICARE [2001]","HB WDH MEDICARE","6371.74","","Case rate ($6,371.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,915.30, add-ons for qualifying new technology services are included. If operating cost exceeds $9,833.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,238.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $5,493.76 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,470.43 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.10. The transfer capital threshold is the transfer adjustment factor * $433.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6332.58","0.05","6347.92","53","3975","29624.88","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","24070.44","14442.26","TRICARE [160005]","HB WDH MEDICARE","6371.74","","Case rate ($6,371.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,915.30, add-ons for qualifying new technology services are included. If operating cost exceeds $9,833.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,238.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $5,493.76 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,470.43 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.10. The transfer capital threshold is the transfer adjustment factor * $433.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6240.88","6240.88","6240.88","1 through 10","3975","29624.88","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","24070.44","14442.26","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6371.74","","Case rate ($6,371.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,915.30, add-ons for qualifying new technology services are included. If operating cost exceeds $9,833.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,238.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $5,493.76 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,470.43 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.10. The transfer capital threshold is the transfer adjustment factor * $433.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6347.92","6244.67","6347.92","1 through 10","3975","29624.88","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","24070.44","14442.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","15974.00","","Fee schedule rate ($15,974.00). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","15988.35","15988.35","15988.35","1 through 10","3975","29624.88","case rate",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","24070.44","14442.26","WELLSENSE NH [1050]","HB WDH MEDICARE","6371.74","","Case rate ($6,371.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,915.30, add-ons for qualifying new technology services are included. If operating cost exceeds $9,833.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,238.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $5,493.76 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,470.43 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $433.10. The transfer capital threshold is the transfer adjustment factor * $433.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6546.81","6546.81","6546.81","1 through 10","3975","29624.88","other","Inpatient DRG"
"Esrd Emergent Hemodialysis OP","PX-82000033","CDM","G0257","HCPCS","0829","RC","","","","both","","","2563.00","1537.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","752.97","","APC Price ($731.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","687.27","687.27","737.99","1 through 10","716.42","4672.01","other","OPPS APC"
"Esrd Emergent Hemodialysis OP","PX-82000033","CDM","G0257","HCPCS","0829","RC","","","","both","","","2563.00","1537.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","731.04","","APC Price ($731.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","719.43","719.43","719.43","1 through 10","716.42","4672.01","other","OPPS APC"
"Esrd Emergent Hemodialysis OP","PX-82000033","CDM","G0257","HCPCS","0829","RC","","","","both","","","2563.00","1537.80","WELLSENSE NH [1050]","HB WDH MEDICARE","731.04","","APC Price ($731.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1519.46","1504.66","1519.46","1 through 10","716.42","4672.01","other","OPPS APC"
"Esrd Emergent Hemodialysis OP","PX-82000033","CDM","G0257","HCPCS","0829","RC","","","","outpatient","","","2563.00","1537.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","298.08","11.63","","48.78","48.78","48.78","1 through 10","298.08","1983.76","percent of total billed charges",""
"Estrogen Fractionated","PX-30000423","CDM","82671","CPT","0301","RC","","","","both","","","371.00","222.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","258.96","69.8","","250.58","250.58","250.58","1 through 10","21","315.35","percent of total billed charges",""
"Estrogen Fractionated","PX-30000423","CDM","82671","CPT","0301","RC","","","","outpatient","","","371.00","222.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","269.79","72.72","","261.06","261.06","261.06","1 through 10","38.72","287.15","percent of total billed charges",""
"Estrogen Fractionated","PX-30000423","CDM","82671","CPT","0301","RC","","","","outpatient","","","371.00","222.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","233.36","62.9","","226.17","226.17","226.17","1 through 10","38.72","287.15","percent of total billed charges",""
"Estrogen Fractionated","PX-30000423","CDM","82671","CPT","0301","RC","","","","outpatient","","","371.00","222.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","287.15","77.4","","278.23","278.23","278.23","1 through 10","38.72","287.15","percent of total billed charges",""
"Estrone","PX-30000426","CDM","82679","CPT","0301","RC","","","","both","","","135.00","81.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","94.23","69.8","","91.44","91.44","91.44","1 through 10","16.22","129.42","percent of total billed charges",""
"Estrone","PX-30000426","CDM","82679","CPT","0301","RC","","","","outpatient","","","135.00","81.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","84.75","62.78","","82.24","82.24","82.24","1 through 10","23.26","104.49","percent of total billed charges",""
"Ethosuximide","PX-30000024","CDM","80168","CPT","0301","RC","","","","both","","","88.00","52.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","61.42","69.8","","59.33","59.33","59.33","1 through 10","10.62","84.29","percent of total billed charges",""
"Ethosuximide","PX-30000024","CDM","80168","CPT","0301","RC","","","","outpatient","","","88.00","52.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","68.11","77.4","","65.88","65.88","65.88","1 through 10","15.24","68.11","percent of total billed charges",""
"Evac Hematoma Subungal","PX-76000091","CDM","11740","CPT","0761","RC","","","","both","","","335.00","201.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","190.62","56.9","","91.29","91.29","91.29","1 through 10","33.22","860.68","percent of total billed charges",""
"Evac Hematoma Subungal","PX-76000091","CDM","11740","CPT","0761","RC","","","","outpatient","","","335.00","201.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","210.72","62.9","","137.97","137.97","137.97","1 through 10","38.96","259.29","percent of total billed charges",""
"Evac Hematoma Subungal","PX-76000091","CDM","11740","CPT","0761","RC","","","","outpatient","","","335.00","201.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","259.29","77.4","","169.73","169.73","169.73","1 through 10","38.96","259.29","percent of total billed charges",""
"Eval Cervicovag Pamg-1 Pp12 Alpha-F","PX-30000623","CDM","84112","CPT","0301","RC","","","","outpatient","","","687.00","412.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","432.12","62.9","","417.69","417.69","417.69","1 through 10","58.97","531.74","percent of total billed charges",""
"Eval Cervicovag Pamg-1 Pp12 Alpha-F","PX-30000623","CDM","84112","CPT","0301","RC","","","","outpatient","","","687.00","412.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","531.74","77.4","","513.83","513.83","513.83","1 through 10","58.97","531.74","percent of total billed charges",""
"Everolimus","PX-30001866","CDM","80169","CPT","0301","RC","","","","outpatient","","","157.00","94.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","114.17","72.72","","110.53","110.53","110.53","13","6.2","121.52","percent of total billed charges",""
"Everolimus","PX-30001866","CDM","80169","CPT","0301","RC","","","","outpatient","","","157.00","94.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","98.75","62.9","","95.76","95.76","95.76","1 through 10","6.2","121.52","percent of total billed charges",""
"Everolimus","PX-30001866","CDM","80169","CPT","0301","RC","","","","outpatient","","","157.00","94.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","121.52","77.4","","117.80","117.80","117.80","1 through 10","6.2","121.52","percent of total billed charges",""
"Exc Cyst/Tumor Vaginal","PX-76001348","CDM","57135","CPT","0761","RC","","","","both","","","1464.00","878.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","3255.41","","APC Price ($3,321.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3046.15","3046.15","3046.15","1 through 10","833.02","21229.64","other","OPPS APC"
"Exc Cyst/Tumor Vaginal","PX-76001348","CDM","57135","CPT","0761","RC","","","","both","","","1464.00","878.40","MEDICARE [2001]","HB WDH MEDICARE","3321.85","","APC Price ($3,321.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3322.23","3322.23","3322.23","1 through 10","833.02","21229.64","other","OPPS APC"
"Exc Cyst/Tumor Vaginal","PX-76001348","CDM","57135","CPT","0761","RC","","","","outpatient","","","1464.00","878.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","39227.34","39227.34","39227.34","1 through 10","170.26","1133.14","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Exc Lesn Bgn Sclp/Hnd/Gen <0.5cm","PX-76000053","CDM","11420","CPT","0761","RC","","","","both","","","707.00","424.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","493.49","69.8","","7488.14","7488.14","7488.14","1 through 10","402.28","10818.29","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen <0.5cm","PX-76000053","CDM","11420","CPT","0761","RC","","","","both","","","707.00","424.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","4658.35","","Case rate ($4,658.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","12100.78","12100.78","12100.78","1 through 10","402.28","10818.29","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen <0.5cm","PX-76000053","CDM","11420","CPT","0761","RC","","","","both","","","707.00","424.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1659.10","1659.10","1659.10","1 through 10","402.28","10818.29","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000054","CDM","11421","CPT","0761","RC","","","","both","","","954.00","572.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","665.89","69.8","","5274.09","5274.09","5274.09","1 through 10","542.83","4697.85","percent of total billed charges",""
"Exc Lesn Bgn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000054","CDM","11421","CPT","0761","RC","","","","outpatient","","","954.00","572.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","110.95","11.63","","892.48","892.48","892.48","1 through 10","110.95","738.4","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","both","","","1660.00","996.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","4697.85","","Case rate ($4,697.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4583.28","4583.28","4583.28","1 through 10","720.38","4697.85","other","OPPS APC"
"Exc Nail & Matrix","PX-76000092","CDM","11750","CPT","0761","RC","","","","both","","","1054.00","632.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","599.73","56.9","","4299.36","4299.36","4299.36","1 through 10","106.79","2667.66","percent of total billed charges",""
"Exchange Biliary Drg Catheter Prq W/Img Gid Rs&I","PX-36000379","CDM","47536","CPT","0361","RC","","","","both","","","6800.00","4080.00","MEDICARE [2001]","HB WDH MEDICARE","3687.02","","APC Price ($3,687.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3687.44","3687.44","3687.44","1 through 10","3613.28","23563.47","other","OPPS APC"
"Exchange Nephrostomy Catheter Prq W/Img Gid Rs&I","PX-76002187","CDM","50435","CPT","0761","RC","","","","both","","","5481.00","3288.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","2140.20","","APC Price ($2,140.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2105.55","2105.55","2105.55","1 through 10","2097.4","13677.84","other","OPPS APC"
"Exchg Cath Abscess/Cyst Drain","PX-75000293","CDM","49423","CPT","0361","RC","","","","both","","","2083.00","1249.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1942.26","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1982.13","1942.49","1982.13","1 through 10","1185.23","12666.17","other","OPPS APC"
"Exchg Cath Abscess/Cyst Drain","PX-75000293","CDM","49423","CPT","0361","RC","","","","both","","","2083.00","1249.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","10237.95","","Case rate ($10,237.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3703.74","3703.74","3703.74","1 through 10","1185.23","12666.17","other","OPPS APC"
"Exchg Cath Abscess/Cyst Drain","PX-75000293","CDM","49423","CPT","0361","RC","","","","both","","","2083.00","1249.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1982.13","1982.13","1 through 10","1185.23","12666.17","other","OPPS APC"
"Exchg Cath Abscess/Cyst Drain","PX-75000293","CDM","49423","CPT","0361","RC","","","","both","","","2083.00","1249.80","MEDICARE [2001]","HB WDH MEDICARE","1981.90","","APC Price ($1,981.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1982.13","1982.13","1982.13","1 through 10","1185.23","12666.17","other","OPPS APC"
"Exchg Cath Abscess/Cyst Drain","PX-75000293","CDM","49423","CPT","0361","RC","","","","outpatient","","","2083.00","1249.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","242.25","11.63","","237.42","237.42","237.42","1 through 10","242.25","1612.24","percent of total billed charges",""
"Excision Hemorrhoid Thrombosed Ext","PX-75000220","CDM","46320","CPT","0761","RC","","","","both","","","6477.00","3886.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","3389.98","","Case rate ($3,389.98). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3307.34","3307.34","3307.34","1 through 10","933.98","7872.71","other","OPPS APC"
"EXPANDER TISSUE 600CC W14CM H13CM P7.1CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241089","CDM","C1889","HCPCS","0278","RC","","","","both","","","5218.60","3131.16","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","606.92","4435.81","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"EXPANDER TISSUE 600CC W14CM H13CM P7.1CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241089","CDM","C1889","HCPCS","0278","RC","","","","both","","","5218.60","3131.16","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","606.92","4435.81","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"EXPANDER TISSUE 600CC W14CM H13CM P7.1CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241089","CDM","C1889","HCPCS","0278","RC","","","","both","","","5218.60","3131.16","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2969.38","56.9","","0.63","0.63","0.63","1 through 10","606.92","4435.81","percent of total billed charges",""
"EXPANDER TISSUE 600CC W14CM H13CM P7.1CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241089","CDM","C1889","HCPCS","0278","RC","","","","both","","","5218.60","3131.16","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","752.52","14.42","","317.14","317.14","317.14","1 through 10","606.92","4435.81","percent of total billed charges",""
"EXPANDER TISSUE 600CC W14CM H13CM P7.1CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241089","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5218.60","3131.16","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","752.52","14.42","","317.14","317.14","317.14","1 through 10","606.92","4039.2","percent of total billed charges",""
"EXPANDER TISSUE 600CC W14CM H13CM P7.1CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241089","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5218.60","3131.16","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3276.24","62.78","","1125.09","1125.09","1125.09","1 through 10","606.92","4039.2","percent of total billed charges",""
"EXPANDER TISSUE 600CC W14CM H13CM P7.1CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241089","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5218.60","3131.16","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3794.97","72.72","","4732.50","1617.43","14180.40","1 through 10","606.92","4039.2","percent of total billed charges",""
"EXPANDER TISSUE 600CC W14CM H13CM P7.1CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241089","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5218.60","3131.16","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3282.50","62.9","","3896.20","3341.38","3896.20","1 through 10","606.92","4039.2","percent of total billed charges",""
"EXTENSION GRAFTX20 13 70MM ENDOVASCULAR AF ABDOMINAL LIMB ETENSION STRAIGHT","SUP-ITM-10120313","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","14135.96","8481.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10279.67","72.72","","4588.52","4588.52","4588.52","1 through 10","1644.01","10941.23","percent of total billed charges",""
"EXTENSION PERCUTANEOUS","SUP-ITM-10266914","CDM","C1883","HCPCS","0278","RC","","","","outpatient","","","663.36","398.02","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","417.25","62.9","","4897.47","4897.47","4897.47","1 through 10","77.15","513.44","percent of total billed charges",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","","","","inpatient","","","128894.07","77336.44","MARTIN'S POINT [160007]","HB WDH MEDICARE","19135.45","","Case rate ($19,135.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $17,696.08, add-ons for qualifying new technology services are included. If operating cost exceeds $21,614.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,170.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $17,324.78 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,251.21 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,365.80. The transfer capital threshold is the transfer adjustment factor * $1,365.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18634.79","18634.79","18634.79","1 through 10","17557.7","93423.25","other","Inpatient DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","","","","inpatient","","","128894.07","77336.44","MEDICARE [2001]","HB WDH MEDICARE","19135.45","","Case rate ($19,135.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $17,696.08, add-ons for qualifying new technology services are included. If operating cost exceeds $21,614.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,170.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $17,324.78 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,251.21 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,365.80. The transfer capital threshold is the transfer adjustment factor * $1,365.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18966.72","18966.72","18966.72","1 through 10","17557.7","93423.25","other","Inpatient DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","981","MS-DRG","","","","","","","","inpatient","","","142492.18","85495.31","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","37197.40","","Case rate ($36,113.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $33,367.06, add-ons for qualifying new technology services are included. If operating cost exceeds $37,285.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,411.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $33,062.61 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $32,922.19 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,606.50. The transfer capital threshold is the transfer adjustment factor * $2,606.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","14481.24","14481.24","14481.24","1 through 10","33507.1","178288.87","other","Inpatient DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","981","MS-DRG","","","","","","","","inpatient","","","142492.18","85495.31","MEDICARE [2001]","HB WDH MEDICARE","36113.98","","Case rate ($36,113.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $33,367.06, add-ons for qualifying new technology services are included. If operating cost exceeds $37,285.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,411.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $33,062.61 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $32,922.19 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,606.50. The transfer capital threshold is the transfer adjustment factor * $2,606.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","36411.58","36315.64","79025.44","1 through 10","33507.1","178288.87","other","Inpatient DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","981","MS-DRG","","","","","","","","inpatient","","","142492.18","85495.31","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","36113.98","","Case rate ($36,113.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $33,367.06, add-ons for qualifying new technology services are included. If operating cost exceeds $37,285.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,411.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $33,062.61 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $32,922.19 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,606.50. The transfer capital threshold is the transfer adjustment factor * $2,606.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","37541.67","37541.67","37541.67","1 through 10","33507.1","178288.87","other","Inpatient DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC","983","MS-DRG","","","","","","","","inpatient","","","28311.97","16987.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","65132.17","","Fee schedule rate ($65,132.17). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","27244.70","27244.70","27244.70","1 through 10","12240.75","65132.17","case rate",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC","983","MS-DRG","","","","","","","","inpatient","","","28311.97","16987.18","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","13475.44","","Case rate ($13,475.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,471.95, add-ons for qualifying new technology services are included. If operating cost exceeds $16,390.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,757.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,078.37 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,027.08 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $952.20. The transfer capital threshold is the transfer adjustment factor * $952.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12792.15","12792.15","12792.15","1 through 10","12240.75","65132.17","other","Inpatient DRG"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","563.00","337.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","392.97","69.8","","379.01","341.55","379.01","24","40.19","478.55","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","563.00","337.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","41.83","","APC Price ($41.01). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","41.01","39.07","41.01","17","40.19","478.55","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","563.00","337.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","262.09","","Case rate ($262.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","255.69","230.13","798.69","54","40.19","478.55","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","563.00","337.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","112.85","","Case rate ($112.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","110.10","99.09","110.10","66","40.19","478.55","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","563.00","337.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","40.19","","APC Price ($41.01). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","41.01","40.19","66.42","64","40.19","478.55","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","563.00","337.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","211.84","","Case rate ($211.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","206.67","110.10","206.67","40","40.19","478.55","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","563.00","337.80","CHAMPVA [160001]","HB WDH MEDICARE","41.01","","APC Price ($41.01). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","41.01","41.01","543.00","1 through 10","40.19","478.55","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","563.00","337.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","320.35","56.9","","308.97","308.97","308.97","49","40.19","478.55","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","563.00","337.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","42.24","","APC Price ($41.01). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","42.24","42.24","42.24","23","40.19","478.55","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","563.00","337.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","41.01","","APC Price ($41.01). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","40.19","40.19","41.01","65","40.19","478.55","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","563.00","337.80","MEDICARE [2001]","HB WDH MEDICARE","41.01","","APC Price ($41.01). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","41.01","39.07","41.01","162","40.19","478.55","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","563.00","337.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","478.55","85","","352.46","57.41","352.46","1 through 10","40.19","478.55","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","563.00","337.80","TRICARE [160005]","HB WDH MEDICARE","41.01","","APC Price ($41.01). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","41.01","41.01","41.01","1 through 10","40.19","478.55","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","563.00","337.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","41.01","","APC Price ($41.01). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","40.69","39.07","41.01","65","40.19","478.55","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","563.00","337.80","WELLPOINT [1015]","HB WDH ANTHEM PPO","211.84","","Case rate ($211.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","206.67","206.67","206.67","1 through 10","40.19","478.55","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","563.00","337.80","WELLSENSE NH [1050]","HB WDH MEDICARE","41.01","","APC Price ($41.01). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","42.20","42.20","43.06","1 through 10","40.19","478.55","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","outpatient","","","563.00","337.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","81.18","14.42","","78.30","67.11","78.30","22","65.48","435.76","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","outpatient","","","563.00","337.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","65.48","11.63","","74.77","64.14","137.14","35","65.48","435.76","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","outpatient","","","563.00","337.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","353.45","62.78","","340.90","340.90","340.90","1 through 10","65.48","435.76","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","outpatient","","","563.00","337.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","409.41","72.72","","394.87","394.87","394.87","57","65.48","435.76","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","outpatient","","","563.00","337.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","299.63","53.22","","289.47","289.47","289.47","1 through 10","65.48","435.76","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","outpatient","","","563.00","337.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","354.13","62.9","","342.09","342.09","342.09","62","65.48","435.76","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","outpatient","","","563.00","337.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","435.76","77.4","","420.83","420.82","420.83","19","65.48","435.76","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","outpatient","","","563.00","337.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","409.41","72.72","","394.87","394.87","394.87","1 through 10","65.48","435.76","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","outpatient","","","563.00","337.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","65.48","11.63","","64.14","64.14","192.42","21","65.48","435.76","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","563.00","337.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","392.97","69.8","","379.01","341.55","379.01","17","40.19","478.55","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","563.00","337.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","41.83","","APC Price ($41.01). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","41.01","39.07","41.01","13","40.19","478.55","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","563.00","337.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","262.09","","Case rate ($262.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","255.69","230.13","798.69","17","40.19","478.55","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","563.00","337.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","112.85","","Case rate ($112.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.38","99.09","110.10","37","40.19","478.55","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","563.00","337.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","40.19","","APC Price ($41.01). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","40.19","39.07","41.01","45","40.19","478.55","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","563.00","337.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","211.84","","Case rate ($211.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","99.09","206.67","18","40.19","478.55","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","563.00","337.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","320.35","56.9","","308.97","308.97","308.97","37","40.19","478.55","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","563.00","337.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","392.97","69.8","","352.46","352.46","352.46","1 through 10","40.19","478.55","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","563.00","337.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","42.24","","APC Price ($41.01). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","42.24","42.24","42.24","1 through 10","40.19","478.55","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","563.00","337.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","41.01","","APC Price ($41.01). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","40.19","39.07","41.01","37","40.19","478.55","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","563.00","337.80","MEDICARE [2001]","HB WDH MEDICARE","41.01","","APC Price ($41.01). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","41.01","39.07","41.01","99","40.19","478.55","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","563.00","337.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","478.55","85","","352.46","54.70","352.46","1 through 10","40.19","478.55","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","563.00","337.80","TRICARE [160005]","HB WDH MEDICARE","41.01","","APC Price ($41.01). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","41.01","41.01","41.01","1 through 10","40.19","478.55","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","563.00","337.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","41.01","","APC Price ($41.01). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","40.69","39.07","41.01","44","40.19","478.55","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","563.00","337.80","WELLSENSE NH [1050]","HB WDH MEDICARE","41.01","","APC Price ($41.01). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","43.06","42.20","43.06","1 through 10","40.19","478.55","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","outpatient","","","563.00","337.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","81.18","14.42","","78.30","67.11","78.30","1 through 10","65.48","435.76","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","outpatient","","","563.00","337.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","65.48","11.63","","74.77","64.14","137.14","18","65.48","435.76","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","outpatient","","","563.00","337.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","353.45","62.78","","340.90","340.90","340.90","1 through 10","65.48","435.76","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","outpatient","","","563.00","337.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","246.14","43.72","","237.40","237.40","237.40","1 through 10","65.48","435.76","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","outpatient","","","563.00","337.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","409.41","72.72","","394.87","394.87","394.87","28","65.48","435.76","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","outpatient","","","563.00","337.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","354.13","62.9","","342.09","342.09","342.09","22","65.48","435.76","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","outpatient","","","563.00","337.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","435.76","77.4","","420.83","420.83","420.83","1 through 10","65.48","435.76","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","outpatient","","","563.00","337.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","65.48","11.63","","64.14","64.14","64.96","1 through 10","65.48","435.76","percent of total billed charges",""
"Extracranial Procedures With Cc","038","MS-DRG","","","","","","","","inpatient","","","70552.91","42331.75","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","13036.19","","Case rate ($12,780.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,830.59, add-ons for qualifying new technology services are included. If operating cost exceeds $15,748.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,706.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $11,434.29 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,385.73 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $901.43. The transfer capital threshold is the transfer adjustment factor * $901.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","9055.52","9055.52","9055.52","1 through 10","4637","61658.96","other","Inpatient DRG"
"Extracranial Procedures With Cc","038","MS-DRG","","","","","","","","inpatient","","","70552.91","42331.75","MARTIN'S POINT [160007]","HB WDH MEDICARE","12780.58","","Case rate ($12,780.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,830.59, add-ons for qualifying new technology services are included. If operating cost exceeds $15,748.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,706.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $11,434.29 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,385.73 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $901.43. The transfer capital threshold is the transfer adjustment factor * $901.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12389.43","12389.43","12389.43","1 through 10","4637","61658.96","other","Inpatient DRG"
"Extracranial Procedures With Cc","038","MS-DRG","","","","","","","","inpatient","","","70552.91","42331.75","MEDICARE [2001]","HB WDH MEDICARE","12780.58","","Case rate ($12,780.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,830.59, add-ons for qualifying new technology services are included. If operating cost exceeds $15,748.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,706.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $11,434.29 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,385.73 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $901.43. The transfer capital threshold is the transfer adjustment factor * $901.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12602.94","0.05","12635.46","1 through 10","4637","61658.96","other","Inpatient DRG"
"Extracranial Procedures With Cc","038","MS-DRG","","","","","","","","inpatient","","","70552.91","42331.75","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","12780.58","","Case rate ($12,780.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,830.59, add-ons for qualifying new technology services are included. If operating cost exceeds $15,748.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,706.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $11,434.29 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,385.73 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $901.43. The transfer capital threshold is the transfer adjustment factor * $901.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12405.93","12405.93","12405.93","1 through 10","4637","61658.96","other","Inpatient DRG"
"Extracranial Procedures With Cc","038","MS-DRG","","","","","","","","inpatient","","","70552.91","42331.75","WELLSENSE NH [1050]","HB WDH MEDICARE","12780.58","","Case rate ($12,780.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,830.59, add-ons for qualifying new technology services are included. If operating cost exceeds $15,748.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,706.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $11,434.29 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,385.73 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $901.43. The transfer capital threshold is the transfer adjustment factor * $901.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13008.42","13008.42","13008.42","1 through 10","4637","61658.96","other","Inpatient DRG"
"Extracranial Procedures Without Cc/McC","039","MS-DRG","","","","","","","","inpatient","","","55934.94","33560.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","9193.91","","Case rate ($9,381.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,693.32, add-ons for qualifying new technology services are included. If operating cost exceeds $12,611.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,458.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $8,283.62 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,248.44 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $653.04. The transfer capital threshold is the transfer adjustment factor * $653.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9033.14","9033.14","15356.34","1 through 10","4637","44669.12","other","Inpatient DRG"
"Extracranial Procedures Without Cc/McC","039","MS-DRG","","","","","","","","inpatient","","","55934.94","33560.96","MARTIN'S POINT [160007]","HB WDH MEDICARE","9381.54","","Case rate ($9,381.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,693.32, add-ons for qualifying new technology services are included. If operating cost exceeds $12,611.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,458.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $8,283.62 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,248.44 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $653.04. The transfer capital threshold is the transfer adjustment factor * $653.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8882.31","8882.31","8882.31","1 through 10","4637","44669.12","other","Inpatient DRG"
"Extracranial Procedures Without Cc/McC","039","MS-DRG","","","","","","","","inpatient","","","55934.94","33560.96","MEDICARE [2001]","HB WDH MEDICARE","9381.54","","Case rate ($9,381.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,693.32, add-ons for qualifying new technology services are included. If operating cost exceeds $12,611.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,458.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $8,283.62 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,248.44 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $653.04. The transfer capital threshold is the transfer adjustment factor * $653.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9033.14","0.05","9033.14","1 through 10","4637","44669.12","other","Inpatient DRG"
"Extracranial Procedures Without Cc/McC","039","MS-DRG","","","","","","","","inpatient","","","55934.94","33560.96","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","9381.54","","Case rate ($9,381.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,693.32, add-ons for qualifying new technology services are included. If operating cost exceeds $12,611.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,458.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $8,283.62 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,248.44 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $653.04. The transfer capital threshold is the transfer adjustment factor * $653.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9073.48","9073.48","9073.48","1 through 10","4637","44669.12","other","Inpatient DRG"
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","both","","","254.00","152.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","177.29","69.8","","171.71","171.71","171.71","94","11.65","215.9","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","both","","","254.00","152.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","215.90","85","","209.10","209.10","209.10","1 through 10","11.65","215.9","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","outpatient","","","254.00","152.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","184.71","72.72","","178.89","178.89","357.78","49","16.71","196.6","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","outpatient","","","254.00","152.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","184.71","72.72","","178.89","178.89","178.89","1 through 10","16.71","196.6","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","outpatient","","","254.00","152.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","159.77","62.9","","154.98","154.98","464.94","133","16.71","196.6","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","outpatient","","","254.00","152.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","196.60","77.4","","190.65","190.65","190.65","57","16.71","196.6","percent of total billed charges",""
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","","","","inpatient","","","109002.42","65401.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","225853.59","","Fee schedule rate ($225,853.59). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","144091.90","144091.90","144091.90","1 through 10","790.77","225853.59","case rate",""
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","","","","inpatient","","","109002.42","65401.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","88931.88","","Fee schedule rate ($88,931.88). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","86781.77","86781.77","86781.77","1 through 10","790.77","225853.59","case rate",""
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","","","","inpatient","","","109002.42","65401.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","44717.35","","Case rate ($45,629.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $42,150.20, add-ons for qualifying new technology services are included. If operating cost exceeds $46,068.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $51,106.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 17.9. The base transfer operating payment is the transfer adjustment factor * $41,883.20 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $41,705.33 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,301.87. The transfer capital threshold is the transfer adjustment factor * $3,301.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","45418.51","45418.51","45418.51","1 through 10","790.77","225853.59","other","Inpatient DRG"
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","","","","inpatient","","","109002.42","65401.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","179881.69","","Fee schedule rate ($179,881.69). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","114944.55","114944.55","140493.91","1 through 10","790.77","225853.59","case rate",""
"F-Up/Limited Tthrc Echo Congenital Car Anomaly","PX-48000414","CDM","93304","CPT","0480","RC","","","","both","","","1024.00","614.40","MEDICARE [2001]","HB WDH MEDICARE","572.84","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","572.91","572.91","572.91","1 through 10","561.39","590.03","other","OPPS APC"
"F-Up/Limited Tthrc Echo Congenital Car Anomaly","PX-48000414","CDM","93304","CPT","0480","RC","","","","both","","","1024.00","614.40","TRICARE [160005]","HB WDH MEDICARE","572.84","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","572.91","572.91","572.91","1 through 10","561.39","590.03","other","OPPS APC"
"F-Up/Limited Tthrc Echo Congenital Car Anomaly","PX-48000414","CDM","93304","CPT","0483","RC","","","","both","","","1024.00","614.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","3660.99","","Case rate ($3,660.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1752.00","988.00","2106.00","1 through 10","582.66","3660.99","other","OPPS APC"
"F-Up/Limited Tthrc Echo Congenital Car Anomaly","PX-48000414","CDM","93304","CPT","0483","RC","","","","both","","","1024.00","614.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1576.42","","Case rate ($1,576.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1504.55","988.00","1537.99","1 through 10","582.66","3660.99","other","OPPS APC"
"F-Up/Limited Tthrc Echo Congenital Car Anomaly","PX-48000414","CDM","93304","CPT","0483","RC","","","","both","","","1024.00","614.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","2959.14","","Case rate ($2,959.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2106.00","2106.00","2106.00","1 through 10","582.66","3660.99","other","OPPS APC"
"F-Up/Limited Tthrc Echo Congenital Car Anomaly","PX-48000414","CDM","93304","CPT","0483","RC","","","","both","","","1024.00","614.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","582.66","56.9","","562.17","562.17","562.17","1 through 10","582.66","3660.99","percent of total billed charges",""
"F-Up/Limited Tthrc Echo Congenital Car Anomaly","PX-48000414","CDM","93304","CPT","0483","RC","","","","outpatient","","","1024.00","614.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","147.66","14.42","","142.47","142.47","142.47","1 through 10","119.09","792.58","percent of total billed charges",""
"F-Up/Limited Tthrc Echo Congenital Car Anomaly","PX-48000414","CDM","93304","CPT","0483","RC","","","","outpatient","","","1024.00","614.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","119.09","11.63","","249.52","116.70","350.10","18","119.09","792.58","percent of total billed charges",""
"F-Up/Limited Tthrc Echo Congenital Car Anomaly","PX-48000414","CDM","93304","CPT","0483","RC","","","","outpatient","","","1024.00","614.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","744.65","72.72","","718.47","718.47","718.47","1 through 10","119.09","792.58","percent of total billed charges",""
"F-Up/Limited Tthrc Echo Congenital Car Anomaly","PX-48000414","CDM","93304","CPT","0483","RC","","","","outpatient","","","1024.00","614.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","644.10","62.9","","622.44","622.44","622.44","1 through 10","119.09","792.58","percent of total billed charges",""
"F-Up/Limited Tthrc Echo Congenital Car Anomaly","PX-48000414","CDM","93304","CPT","0483","RC","","","","outpatient","","","1024.00","614.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","792.58","77.4","","765.70","765.70","765.70","1 through 10","119.09","792.58","percent of total billed charges",""
"F-Up/Limited Tthrc Echo Congenital Car Anomaly","PX-48000414","CDM","93304","CPT","0483","RC","","","","outpatient","","","1024.00","614.40","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","744.65","72.72","","718.47","718.47","718.47","1 through 10","119.09","792.58","percent of total billed charges",""
"F-Up/Limited Tthrc Echo Congenital Car Anomaly","PX-48000414","CDM","93304","CPT","0483","RC","","","","outpatient","","","1024.00","614.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","119.09","11.63","","350.10","116.70","350.10","1 through 10","119.09","792.58","percent of total billed charges",""
"Factor II","PX-30001052","CDM","85210","CPT","0305","RC","","","","both","","","129.00","77.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","90.04","69.8","","78.63","78.63","78.63","1 through 10","8.44","109.65","percent of total billed charges",""
"Factor II","PX-30001052","CDM","85210","CPT","0305","RC","","","","outpatient","","","129.00","77.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","93.81","72.72","","90.90","90.90","90.90","1 through 10","15.58","99.85","percent of total billed charges",""
"Factor IX (Christmas/Ptc)","PX-30001063","CDM","85250","CPT","0305","RC","","","","both","","","110.00","66.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","76.78","69.8","","66.67","66.67","66.67","1 through 10","12.38","97.81","percent of total billed charges",""
"Factor V (Proaccelerin) Labile","PX-30001053","CDM","85220","CPT","0305","RC","","","","both","","","97.00","58.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","67.71","69.8","","59.13","59.13","59.13","1 through 10","11.47","91.81","percent of total billed charges",""
"Factor VIII Ahg","PX-30001055","CDM","85240","CPT","0305","RC","","","","both","","","97.00","58.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","67.71","69.8","","65.61","59.13","65.61","1 through 10","11.64","91.81","percent of total billed charges",""
"Factor VIII Ahg","PX-30001055","CDM","85240","CPT","0305","RC","","","","outpatient","","","97.00","58.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","42.41","43.72","","41.10","41.10","41.10","1 through 10","16.69","75.08","percent of total billed charges",""
"Factor VIII Ahg","PX-30001055","CDM","85240","CPT","0305","RC","","","","outpatient","","","97.00","58.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","70.54","72.72","","68.36","68.36","68.36","1 through 10","16.69","75.08","percent of total billed charges",""
"Factor VIII Ahg","PX-30001055","CDM","85240","CPT","0305","RC","","","","outpatient","","","97.00","58.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","70.54","72.72","","68.36","68.36","68.36","1 through 10","16.69","75.08","percent of total billed charges",""
"Factor VIII Ahg","PX-30001055","CDM","85240","CPT","0305","RC","","","","outpatient","","","97.00","58.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","61.01","62.9","","59.22","59.22","59.22","1 through 10","16.69","75.08","percent of total billed charges",""
"Factor VIII Ahg","PX-30001055","CDM","85240","CPT","0305","RC","","","","outpatient","","","97.00","58.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","75.08","77.4","","72.85","72.85","72.85","1 through 10","16.69","75.08","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","both","","","124.00","74.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","86.55","69.8","","83.76","75.48","83.76","1 through 10","14.91","118.9","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","outpatient","","","124.00","74.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","90.17","72.72","","87.26","87.26","87.26","1 through 10","21.38","95.98","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","outpatient","","","124.00","74.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","90.17","72.72","","87.26","87.26","87.26","1 through 10","21.38","95.98","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","outpatient","","","124.00","74.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","78.00","62.9","","75.60","75.60","75.60","1 through 10","21.38","95.98","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","outpatient","","","124.00","74.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","95.98","77.4","","93.00","93.00","93.00","1 through 10","21.38","95.98","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","both","","","124.00","74.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","86.55","69.8","","83.76","75.48","83.76","1 through 10","14.91","118.9","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","outpatient","","","124.00","74.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","90.17","72.72","","87.26","87.26","87.26","1 through 10","21.38","95.98","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","outpatient","","","124.00","74.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","90.17","72.72","","87.26","87.26","87.26","1 through 10","21.38","95.98","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","outpatient","","","124.00","74.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","78.00","62.9","","75.60","75.60","75.60","1 through 10","21.38","95.98","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","outpatient","","","124.00","74.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","95.98","77.4","","93.00","93.00","93.00","1 through 10","21.38","95.98","percent of total billed charges",""
"Factor X (Stuart-Prower)","PX-30001064","CDM","85260","CPT","0305","RC","","","","both","","","97.00","58.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","67.71","69.8","","59.13","59.13","59.13","1 through 10","11.64","91.81","percent of total billed charges",""
"Factor XI (Pta)","PX-30001065","CDM","85270","CPT","0305","RC","","","","both","","","144.00","86.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","100.51","69.8","","87.43","87.43","87.43","1 through 10","11.64","122.4","percent of total billed charges",""
"Fat/Lipids Feces Ql","PX-30000430","CDM","82705","CPT","0301","RC","","","","both","","","59.00","35.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","41.18","69.8","","35.85","35.85","35.85","1 through 10","5.1","50.15","percent of total billed charges",""
"Fat/Lipids Feces Ql","PX-30000430","CDM","82705","CPT","0301","RC","","","","outpatient","","","59.00","35.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","37.11","62.9","","35.91","35.91","35.91","1 through 10","4.74","45.67","percent of total billed charges",""
"Fatty Acids Very Long Chain","PX-30000434","CDM","82726","CPT","0301","RC","","","","outpatient","","","227.00","136.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","165.07","72.72","","159.98","159.98","159.98","1 through 10","16.24","175.7","percent of total billed charges",""
"FEMORAL COMPONENT ITOTAL IDENTITY PS","SUP-ITM-10281670","CDM","C1776","HCPCS","0278","RC","","","","both","","","6605.70","3963.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","768.24","5614.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FEMORAL COMPONENT ITOTAL IDENTITY PS","SUP-ITM-10281670","CDM","C1776","HCPCS","0278","RC","","","","both","","","6605.70","3963.42","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3758.64","56.9","","2911.53","1863.86","5209.05","65","768.24","5614.85","percent of total billed charges",""
"FEMORAL COMPONENT ITOTAL IDENTITY PS","SUP-ITM-10281670","CDM","C1776","HCPCS","0278","RC","","","","both","","","6605.70","3963.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","768.24","11.63","","400.94","400.94","400.94","1 through 10","768.24","5614.85","percent of total billed charges",""
"FEMORAL COMPONENT ITOTAL IDENTITY PS","SUP-ITM-10281670","CDM","C1776","HCPCS","0278","RC","","","","both","","","6605.70","3963.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5112.81","77.4","","5214.50","5214.50","16415.28","1 through 10","768.24","5614.85","percent of total billed charges",""
"FEMORAL COMPONENT ITOTAL IDENTITY PS","SUP-ITM-10281670","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6605.70","3963.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","768.24","11.63","","400.94","400.94","400.94","1 through 10","768.24","5112.81","percent of total billed charges",""
"FEMORAL COMPONENT ITOTAL IDENTITY PS","SUP-ITM-10281670","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6605.70","3963.42","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2888.01","43.72","","1543.33","1543.33","1671.61","1 through 10","768.24","5112.81","percent of total billed charges",""
"FEMORAL COMPONENT ITOTAL IDENTITY PS","SUP-ITM-10281670","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6605.70","3963.42","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4803.67","72.72","","3700.21","2382.07","6427.18","53","768.24","5112.81","percent of total billed charges",""
"FEMORAL COMPONENT ITOTAL IDENTITY PS","SUP-ITM-10281670","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6605.70","3963.42","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4803.67","72.72","","12685.80","12685.80","12685.80","1 through 10","768.24","5112.81","percent of total billed charges",""
"FEMORAL COMPONENT ITOTAL IDENTITY PS","SUP-ITM-10281670","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6605.70","3963.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4154.99","62.9","","3408.87","2784.05","9859.40","46","768.24","5112.81","percent of total billed charges",""
"FEMORAL COMPONENT ITOTAL IDENTITY PS","SUP-ITM-10281670","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6605.70","3963.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5112.81","77.4","","5214.50","5214.50","16415.28","1 through 10","768.24","5112.81","percent of total billed charges",""
"FEMORAL COMPONENT SIZE 4N IMPLANT IDENTITY IMPRINT PS","SUP-ITM-10283994","CDM","C1776","HCPCS","0278","RC","","","","both","","","6605.70","3963.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","768.24","5614.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FEMORAL COMPONENT SIZE 4N IMPLANT IDENTITY IMPRINT PS","SUP-ITM-10283994","CDM","C1776","HCPCS","0278","RC","","","","both","","","6605.70","3963.42","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3758.64","56.9","","2911.53","1863.86","5209.05","65","768.24","5614.85","percent of total billed charges",""
"FEMORAL COMPONENT SIZE 4N IMPLANT IDENTITY IMPRINT PS","SUP-ITM-10283994","CDM","C1776","HCPCS","0278","RC","","","","both","","","6605.70","3963.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","768.24","11.63","","400.94","400.94","400.94","1 through 10","768.24","5614.85","percent of total billed charges",""
"FEMORAL COMPONENT SIZE 4N IMPLANT IDENTITY IMPRINT PS","SUP-ITM-10283994","CDM","C1776","HCPCS","0278","RC","","","","both","","","6605.70","3963.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5112.81","77.4","","5214.50","5214.50","16415.28","1 through 10","768.24","5614.85","percent of total billed charges",""
"FEMORAL COMPONENT SIZE 4N IMPLANT IDENTITY IMPRINT PS","SUP-ITM-10283994","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6605.70","3963.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","768.24","11.63","","400.94","400.94","400.94","1 through 10","768.24","5112.81","percent of total billed charges",""
"FEMORAL COMPONENT SIZE 4N IMPLANT IDENTITY IMPRINT PS","SUP-ITM-10283994","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6605.70","3963.42","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2888.01","43.72","","1543.33","1543.33","1671.61","1 through 10","768.24","5112.81","percent of total billed charges",""
"FEMORAL COMPONENT SIZE 4N IMPLANT IDENTITY IMPRINT PS","SUP-ITM-10283994","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6605.70","3963.42","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4803.67","72.72","","3700.21","2382.07","6427.18","53","768.24","5112.81","percent of total billed charges",""
"FEMORAL COMPONENT SIZE 4N IMPLANT IDENTITY IMPRINT PS","SUP-ITM-10283994","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6605.70","3963.42","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4803.67","72.72","","12685.80","12685.80","12685.80","1 through 10","768.24","5112.81","percent of total billed charges",""
"FEMORAL COMPONENT SIZE 4N IMPLANT IDENTITY IMPRINT PS","SUP-ITM-10283994","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6605.70","3963.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4154.99","62.9","","3408.87","2784.05","9859.40","46","768.24","5112.81","percent of total billed charges",""
"FEMORAL COMPONENT SIZE 4N IMPLANT IDENTITY IMPRINT PS","SUP-ITM-10283994","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6605.70","3963.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5112.81","77.4","","5214.50","5214.50","16415.28","1 through 10","768.24","5112.81","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","both","","","10961.00","6576.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1274.76","9316.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","both","","","10961.00","6576.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6236.81","56.9","","2911.53","1863.86","5209.05","65","1274.76","9316.85","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","both","","","10961.00","6576.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1274.76","11.63","","400.94","400.94","400.94","1 through 10","1274.76","9316.85","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","both","","","10961.00","6576.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8483.81","77.4","","5214.50","5214.50","16415.28","1 through 10","1274.76","9316.85","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10961.00","6576.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1274.76","11.63","","400.94","400.94","400.94","1 through 10","1274.76","8483.81","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10961.00","6576.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4792.15","43.72","","1543.33","1543.33","1671.61","1 through 10","1274.76","8483.81","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10961.00","6576.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7970.84","72.72","","3700.21","2382.07","6427.18","53","1274.76","8483.81","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10961.00","6576.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7970.84","72.72","","12685.80","12685.80","12685.80","1 through 10","1274.76","8483.81","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10961.00","6576.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6894.47","62.9","","3408.87","2784.05","9859.40","46","1274.76","8483.81","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10961.00","6576.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8483.81","77.4","","5214.50","5214.50","16415.28","1 through 10","1274.76","8483.81","percent of total billed charges",""
"FEMORAL COMPONENT SZ 3 FEMORAL COMPONENT CRUCIATE SUBSTITUTE NONPOROUS TC3 LT 07","SUP-ITM-10004858","CDM","C1776","HCPCS","0278","RC","","","","both","","","10961.00","6576.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1274.76","9316.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FEMORAL COMPONENT SZ 3 FEMORAL COMPONENT CRUCIATE SUBSTITUTE NONPOROUS TC3 LT 07","SUP-ITM-10004858","CDM","C1776","HCPCS","0278","RC","","","","both","","","10961.00","6576.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6236.81","56.9","","2911.53","1863.86","5209.05","65","1274.76","9316.85","percent of total billed charges",""
"FEMORAL COMPONENT SZ 3 FEMORAL COMPONENT CRUCIATE SUBSTITUTE NONPOROUS TC3 LT 07","SUP-ITM-10004858","CDM","C1776","HCPCS","0278","RC","","","","both","","","10961.00","6576.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1274.76","11.63","","400.94","400.94","400.94","1 through 10","1274.76","9316.85","percent of total billed charges",""
"FEMORAL COMPONENT SZ 3 FEMORAL COMPONENT CRUCIATE SUBSTITUTE NONPOROUS TC3 LT 07","SUP-ITM-10004858","CDM","C1776","HCPCS","0278","RC","","","","both","","","10961.00","6576.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8483.81","77.4","","5214.50","5214.50","16415.28","1 through 10","1274.76","9316.85","percent of total billed charges",""
"FEMORAL COMPONENT SZ 3 FEMORAL COMPONENT CRUCIATE SUBSTITUTE NONPOROUS TC3 LT 07","SUP-ITM-10004858","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10961.00","6576.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1274.76","11.63","","400.94","400.94","400.94","1 through 10","1274.76","8483.81","percent of total billed charges",""
"FEMORAL COMPONENT SZ 3 FEMORAL COMPONENT CRUCIATE SUBSTITUTE NONPOROUS TC3 LT 07","SUP-ITM-10004858","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10961.00","6576.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4792.15","43.72","","1543.33","1543.33","1671.61","1 through 10","1274.76","8483.81","percent of total billed charges",""
"FEMORAL COMPONENT SZ 3 FEMORAL COMPONENT CRUCIATE SUBSTITUTE NONPOROUS TC3 LT 07","SUP-ITM-10004858","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10961.00","6576.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7970.84","72.72","","3700.21","2382.07","6427.18","53","1274.76","8483.81","percent of total billed charges",""
"FEMORAL COMPONENT SZ 3 FEMORAL COMPONENT CRUCIATE SUBSTITUTE NONPOROUS TC3 LT 07","SUP-ITM-10004858","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10961.00","6576.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7970.84","72.72","","12685.80","12685.80","12685.80","1 through 10","1274.76","8483.81","percent of total billed charges",""
"FEMORAL COMPONENT SZ 3 FEMORAL COMPONENT CRUCIATE SUBSTITUTE NONPOROUS TC3 LT 07","SUP-ITM-10004858","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10961.00","6576.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6894.47","62.9","","3408.87","2784.05","9859.40","46","1274.76","8483.81","percent of total billed charges",""
"FEMORAL COMPONENT SZ 3 FEMORAL COMPONENT CRUCIATE SUBSTITUTE NONPOROUS TC3 LT 07","SUP-ITM-10004858","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10961.00","6576.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8483.81","77.4","","5214.50","5214.50","16415.28","1 through 10","1274.76","8483.81","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","987.1","7214.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4829.39","56.9","","2911.53","1863.86","5209.05","65","987.1","7214.38","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","987.10","11.63","","400.94","400.94","400.94","1 through 10","987.1","7214.38","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6569.33","77.4","","5214.50","5214.50","16415.28","1 through 10","987.1","7214.38","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","987.10","11.63","","400.94","400.94","400.94","1 through 10","987.1","6569.33","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3710.74","43.72","","1543.33","1543.33","1671.61","1 through 10","987.1","6569.33","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6172.11","72.72","","3700.21","2382.07","6427.18","53","987.1","6569.33","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6172.11","72.72","","12685.80","12685.80","12685.80","1 through 10","987.1","6569.33","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5338.64","62.9","","3408.87","2784.05","9859.40","46","987.1","6569.33","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6569.33","77.4","","5214.50","5214.50","16415.28","1 through 10","987.1","6569.33","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","4937.30","2962.38","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","574.21","4196.71","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","4937.30","2962.38","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2809.32","56.9","","2911.53","1863.86","5209.05","65","574.21","4196.71","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","4937.30","2962.38","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","574.21","11.63","","400.94","400.94","400.94","1 through 10","574.21","4196.71","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","4937.30","2962.38","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3821.47","77.4","","5214.50","5214.50","16415.28","1 through 10","574.21","4196.71","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4937.30","2962.38","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","574.21","11.63","","400.94","400.94","400.94","1 through 10","574.21","3821.47","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4937.30","2962.38","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2158.59","43.72","","1543.33","1543.33","1671.61","1 through 10","574.21","3821.47","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4937.30","2962.38","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3590.40","72.72","","3700.21","2382.07","6427.18","53","574.21","3821.47","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4937.30","2962.38","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3590.40","72.72","","12685.80","12685.80","12685.80","1 through 10","574.21","3821.47","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4937.30","2962.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3105.56","62.9","","3408.87","2784.05","9859.40","46","574.21","3821.47","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4937.30","2962.38","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3821.47","77.4","","5214.50","5214.50","16415.28","1 through 10","574.21","3821.47","percent of total billed charges",""
"FEMORAL HEAD 36MM 5 ARTICULEZE BIOLOX DELTA TS CEREMIC REVISION 12/14 TAPERED PLUS","SUP-ITM-10117571","CDM","C1776","HCPCS","0278","RC","","","","both","","","4937.30","2962.38","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","574.21","4196.71","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FEMORAL HEAD 36MM 5 ARTICULEZE BIOLOX DELTA TS CEREMIC REVISION 12/14 TAPERED PLUS","SUP-ITM-10117571","CDM","C1776","HCPCS","0278","RC","","","","both","","","4937.30","2962.38","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2809.32","56.9","","2911.53","1863.86","5209.05","65","574.21","4196.71","percent of total billed charges",""
"FEMORAL HEAD 36MM 5 ARTICULEZE BIOLOX DELTA TS CEREMIC REVISION 12/14 TAPERED PLUS","SUP-ITM-10117571","CDM","C1776","HCPCS","0278","RC","","","","both","","","4937.30","2962.38","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","574.21","11.63","","400.94","400.94","400.94","1 through 10","574.21","4196.71","percent of total billed charges",""
"FEMORAL HEAD 36MM 5 ARTICULEZE BIOLOX DELTA TS CEREMIC REVISION 12/14 TAPERED PLUS","SUP-ITM-10117571","CDM","C1776","HCPCS","0278","RC","","","","both","","","4937.30","2962.38","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3821.47","77.4","","5214.50","5214.50","16415.28","1 through 10","574.21","4196.71","percent of total billed charges",""
"FEMORAL HEAD 36MM 5 ARTICULEZE BIOLOX DELTA TS CEREMIC REVISION 12/14 TAPERED PLUS","SUP-ITM-10117571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4937.30","2962.38","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","574.21","11.63","","400.94","400.94","400.94","1 through 10","574.21","3821.47","percent of total billed charges",""
"FEMORAL HEAD 36MM 5 ARTICULEZE BIOLOX DELTA TS CEREMIC REVISION 12/14 TAPERED PLUS","SUP-ITM-10117571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4937.30","2962.38","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2158.59","43.72","","1543.33","1543.33","1671.61","1 through 10","574.21","3821.47","percent of total billed charges",""
"FEMORAL HEAD 36MM 5 ARTICULEZE BIOLOX DELTA TS CEREMIC REVISION 12/14 TAPERED PLUS","SUP-ITM-10117571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4937.30","2962.38","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3590.40","72.72","","3700.21","2382.07","6427.18","53","574.21","3821.47","percent of total billed charges",""
"FEMORAL HEAD 36MM 5 ARTICULEZE BIOLOX DELTA TS CEREMIC REVISION 12/14 TAPERED PLUS","SUP-ITM-10117571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4937.30","2962.38","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3590.40","72.72","","12685.80","12685.80","12685.80","1 through 10","574.21","3821.47","percent of total billed charges",""
"FEMORAL HEAD 36MM 5 ARTICULEZE BIOLOX DELTA TS CEREMIC REVISION 12/14 TAPERED PLUS","SUP-ITM-10117571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4937.30","2962.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3105.56","62.9","","3408.87","2784.05","9859.40","46","574.21","3821.47","percent of total billed charges",""
"FEMORAL HEAD 36MM 5 ARTICULEZE BIOLOX DELTA TS CEREMIC REVISION 12/14 TAPERED PLUS","SUP-ITM-10117571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4937.30","2962.38","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3821.47","77.4","","5214.50","5214.50","16415.28","1 through 10","574.21","3821.47","percent of total billed charges",""
"FEMORAL STEM 16X220MM LEGION TITANIUM PRESS-FIT STRAIGHT","SUP-ITM-10077563","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","482.18","3524.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FEMORAL STEM 16X220MM LEGION TITANIUM PRESS-FIT STRAIGHT","SUP-ITM-10077563","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2359.07","56.9","","2911.53","1863.86","5209.05","65","482.18","3524.1","percent of total billed charges",""
"FEMORAL STEM 16X220MM LEGION TITANIUM PRESS-FIT STRAIGHT","SUP-ITM-10077563","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","482.18","11.63","","400.94","400.94","400.94","1 through 10","482.18","3524.1","percent of total billed charges",""
"FEMORAL STEM 16X220MM LEGION TITANIUM PRESS-FIT STRAIGHT","SUP-ITM-10077563","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3209.00","77.4","","5214.50","5214.50","16415.28","1 through 10","482.18","3524.1","percent of total billed charges",""
"FEMORAL STEM 16X220MM LEGION TITANIUM PRESS-FIT STRAIGHT","SUP-ITM-10077563","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","482.18","11.63","","400.94","400.94","400.94","1 through 10","482.18","3209","percent of total billed charges",""
"FEMORAL STEM 16X220MM LEGION TITANIUM PRESS-FIT STRAIGHT","SUP-ITM-10077563","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1812.63","43.72","","1543.33","1543.33","1671.61","1 through 10","482.18","3209","percent of total billed charges",""
"FEMORAL STEM 16X220MM LEGION TITANIUM PRESS-FIT STRAIGHT","SUP-ITM-10077563","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3014.97","72.72","","3700.21","2382.07","6427.18","53","482.18","3209","percent of total billed charges",""
"FEMORAL STEM 16X220MM LEGION TITANIUM PRESS-FIT STRAIGHT","SUP-ITM-10077563","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3014.97","72.72","","12685.80","12685.80","12685.80","1 through 10","482.18","3209","percent of total billed charges",""
"FEMORAL STEM 16X220MM LEGION TITANIUM PRESS-FIT STRAIGHT","SUP-ITM-10077563","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2607.83","62.9","","3408.87","2784.05","9859.40","46","482.18","3209","percent of total billed charges",""
"FEMORAL STEM 16X220MM LEGION TITANIUM PRESS-FIT STRAIGHT","SUP-ITM-10077563","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3209.00","77.4","","5214.50","5214.50","16415.28","1 through 10","482.18","3209","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","5820.00","3492.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","676.87","4947","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","5820.00","3492.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3311.58","56.9","","2911.53","1863.86","5209.05","65","676.87","4947","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","5820.00","3492.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","676.87","11.63","","400.94","400.94","400.94","1 through 10","676.87","4947","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","5820.00","3492.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4504.68","77.4","","5214.50","5214.50","16415.28","1 through 10","676.87","4947","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","676.87","11.63","","400.94","400.94","400.94","1 through 10","676.87","4504.68","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2544.50","43.72","","1543.33","1543.33","1671.61","1 through 10","676.87","4504.68","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4232.30","72.72","","3700.21","2382.07","6427.18","53","676.87","4504.68","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4232.30","72.72","","12685.80","12685.80","12685.80","1 through 10","676.87","4504.68","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3660.78","62.9","","3408.87","2784.05","9859.40","46","676.87","4504.68","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4504.68","77.4","","5214.50","5214.50","16415.28","1 through 10","676.87","4504.68","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE LOCKING COMPRESSION DISTAL RIGHT TITANIUM","SUP-ITM-10040381","CDM","C1713","HCPCS","0278","RC","","","","both","","","7352.07","4411.24","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","855.05","6249.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FEMUR PLATE 196MM 7 HOLE BONE LOCKING COMPRESSION DISTAL RIGHT TITANIUM","SUP-ITM-10040381","CDM","C1713","HCPCS","0278","RC","","","","both","","","7352.07","4411.24","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","855.05","6249.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FEMUR PLATE 196MM 7 HOLE BONE LOCKING COMPRESSION DISTAL RIGHT TITANIUM","SUP-ITM-10040381","CDM","C1713","HCPCS","0278","RC","","","","both","","","7352.07","4411.24","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4183.33","56.9","","812.12","238.65","1587.46","163","855.05","6249.26","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE LOCKING COMPRESSION DISTAL RIGHT TITANIUM","SUP-ITM-10040381","CDM","C1713","HCPCS","0278","RC","","","","both","","","7352.07","4411.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","855.05","11.63","","112.68","112.68","146.99","38","855.05","6249.26","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE LOCKING COMPRESSION DISTAL RIGHT TITANIUM","SUP-ITM-10040381","CDM","C1713","HCPCS","0278","RC","","","","both","","","7352.07","4411.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5690.50","77.4","","303.98","303.98","5854.79","1 through 10","855.05","6249.26","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE LOCKING COMPRESSION DISTAL RIGHT TITANIUM","SUP-ITM-10040381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7352.07","4411.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","855.05","11.63","","112.68","112.68","146.99","38","855.05","5690.5","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE LOCKING COMPRESSION DISTAL RIGHT TITANIUM","SUP-ITM-10040381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7352.07","4411.24","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4615.63","62.78","","780.86","208.94","10480.28","15","855.05","5690.5","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE LOCKING COMPRESSION DISTAL RIGHT TITANIUM","SUP-ITM-10040381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7352.07","4411.24","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3214.33","43.72","","179.76","179.76","179.76","1 through 10","855.05","5690.5","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE LOCKING COMPRESSION DISTAL RIGHT TITANIUM","SUP-ITM-10040381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7352.07","4411.24","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5346.43","72.72","","2355.45","298.99","3965.19","155","855.05","5690.5","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE LOCKING COMPRESSION DISTAL RIGHT TITANIUM","SUP-ITM-10040381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7352.07","4411.24","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5346.43","72.72","","3643.09","3643.09","3643.09","1 through 10","855.05","5690.5","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE LOCKING COMPRESSION DISTAL RIGHT TITANIUM","SUP-ITM-10040381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7352.07","4411.24","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3912.77","53.22","","554.28","554.28","554.28","16","855.05","5690.5","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE LOCKING COMPRESSION DISTAL RIGHT TITANIUM","SUP-ITM-10040381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7352.07","4411.24","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4624.45","62.9","","619.64","173.09","2370.64","150","855.05","5690.5","percent of total billed charges",""
"FEMUR PLATE 196MM 7 HOLE BONE LOCKING COMPRESSION DISTAL RIGHT TITANIUM","SUP-ITM-10040381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7352.07","4411.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5690.50","77.4","","303.98","303.98","5854.79","1 through 10","855.05","5690.5","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM STERILE","SUP-ITM-10040385","CDM","C1713","HCPCS","0278","RC","","","","both","","","7509.98","4505.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","873.41","6383.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM STERILE","SUP-ITM-10040385","CDM","C1713","HCPCS","0278","RC","","","","both","","","7509.98","4505.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","873.41","6383.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM STERILE","SUP-ITM-10040385","CDM","C1713","HCPCS","0278","RC","","","","both","","","7509.98","4505.99","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4273.18","56.9","","812.12","238.65","1587.46","163","873.41","6383.48","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM STERILE","SUP-ITM-10040385","CDM","C1713","HCPCS","0278","RC","","","","both","","","7509.98","4505.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","873.41","11.63","","112.68","112.68","146.99","38","873.41","6383.48","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM STERILE","SUP-ITM-10040385","CDM","C1713","HCPCS","0278","RC","","","","both","","","7509.98","4505.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5812.72","77.4","","303.98","303.98","5854.79","1 through 10","873.41","6383.48","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM STERILE","SUP-ITM-10040385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7509.98","4505.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","873.41","11.63","","112.68","112.68","146.99","38","873.41","5812.72","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM STERILE","SUP-ITM-10040385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7509.98","4505.99","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4714.77","62.78","","780.86","208.94","10480.28","15","873.41","5812.72","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM STERILE","SUP-ITM-10040385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7509.98","4505.99","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3283.36","43.72","","179.76","179.76","179.76","1 through 10","873.41","5812.72","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM STERILE","SUP-ITM-10040385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7509.98","4505.99","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5461.26","72.72","","2355.45","298.99","3965.19","155","873.41","5812.72","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM STERILE","SUP-ITM-10040385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7509.98","4505.99","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5461.26","72.72","","3643.09","3643.09","3643.09","1 through 10","873.41","5812.72","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM STERILE","SUP-ITM-10040385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7509.98","4505.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3996.81","53.22","","554.28","554.28","554.28","16","873.41","5812.72","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM STERILE","SUP-ITM-10040385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7509.98","4505.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4723.78","62.9","","619.64","173.09","2370.64","150","873.41","5812.72","percent of total billed charges",""
"FEMUR PLATE 236MM 9 HOLE BONE FEMORAL DISTAL LCP RT TITANIUM STERILE","SUP-ITM-10040385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7509.98","4505.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5812.72","77.4","","303.98","303.98","5854.79","1 through 10","873.41","5812.72","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","193.00","115.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","134.71","69.8","","130.53","117.62","130.53","258","8.86","164.05","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","193.00","115.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","134.71","69.8","","130.53","130.53","130.53","1 through 10","8.86","164.05","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","193.00","115.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","164.05","85","","158.95","23.02","158.95","1 through 10","8.86","164.05","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","outpatient","","","193.00","115.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","121.17","62.78","","117.40","117.40","117.40","1 through 10","12.69","149.38","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","outpatient","","","193.00","115.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","84.38","43.72","","81.76","81.76","81.76","22","12.69","149.38","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","outpatient","","","193.00","115.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","140.35","72.72","","135.99","135.99","135.99","461","12.69","149.38","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","outpatient","","","193.00","115.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","140.35","72.72","","135.99","135.99","135.99","23","12.69","149.38","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","outpatient","","","193.00","115.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","102.71","53.22","","99.69","99.69","299.07","21","12.69","149.38","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","outpatient","","","193.00","115.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","121.40","62.9","","117.81","117.81","117.81","570","12.69","149.38","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","outpatient","","","193.00","115.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","149.38","77.4","","144.93","144.93","144.93","175","12.69","149.38","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","outpatient","","","193.00","115.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","140.35","72.72","","135.99","135.99","135.99","1 through 10","12.69","149.38","percent of total billed charges",""
"Fetal Fibronectin","PX-30000437","CDM","82731","CPT","0301","RC","","","","outpatient","","","975.00","585.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","426.27","43.72","","412.28","412.28","412.28","1 through 10","13.54","754.65","percent of total billed charges",""
"Fetal Fibronectin","PX-30000437","CDM","82731","CPT","0301","RC","","","","outpatient","","","975.00","585.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","709.02","72.72","","685.75","685.75","685.75","1 through 10","13.54","754.65","percent of total billed charges",""
"Fetal Heart Doppler Echo F/U","PX-48000179","CDM","76828","CPT","0483","RC","","","","outpatient","","","257.00","154.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","161.65","62.9","","156.24","156.24","156.24","1 through 10","29.89","198.92","percent of total billed charges",""
"Fetal Heart Echo 2d W/ or W/O M-Mod","PX-48000176","CDM","76825","CPT","0483","RC","","","","both","","","1269.00","761.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","3660.99","","Case rate ($3,660.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2912.00","829.32","2912.00","1 through 10","561.39","3660.99","other","OPPS APC"
"Fetal Heart Echo 2d W/ or W/O M-Mod","PX-48000176","CDM","76825","CPT","0483","RC","","","","both","","","1269.00","761.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1576.42","","Case rate ($1,576.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1537.99","1504.55","1537.99","27","561.39","3660.99","other","OPPS APC"
"Fetal Heart Echo 2d W/ or W/O M-Mod","PX-48000176","CDM","76825","CPT","0483","RC","","","","both","","","1269.00","761.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","561.39","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","572.91","572.91","973.95","1 through 10","561.39","3660.99","other","OPPS APC"
"Fetal Heart Echo 2d W/ or W/O M-Mod","PX-48000176","CDM","76825","CPT","0483","RC","","","","both","","","1269.00","761.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","2959.14","","Case rate ($2,959.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2886.96","1537.99","2886.96","1 through 10","561.39","3660.99","other","OPPS APC"
"Fetal Heart Echo 2d W/ or W/O M-Mod","PX-48000176","CDM","76825","CPT","0483","RC","","","","both","","","1269.00","761.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","572.84","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","572.91","572.91","572.91","1 through 10","561.39","3660.99","other","OPPS APC"
"Fetal Heart Echo 2d W/ or W/O M-Mod","PX-48000176","CDM","76825","CPT","0483","RC","","","","both","","","1269.00","761.40","WELLPOINT [1015]","HB WDH ANTHEM PPO","2959.14","","Case rate ($2,959.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1225.00","1225.00","1225.00","1 through 10","561.39","3660.99","other","OPPS APC"
"Fetal Heart Echo 2d W/ or W/O M-Mod","PX-48000176","CDM","76825","CPT","0483","RC","","","","outpatient","","","1269.00","761.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","182.99","14.42","","151.41","151.41","176.65","1 through 10","147.58","982.21","percent of total billed charges",""
"Fetal Heart Echo 2d W/ or W/O M-Mod","PX-48000176","CDM","76825","CPT","0483","RC","","","","outpatient","","","1269.00","761.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","147.58","11.63","","168.68","149.94","168.68","1 through 10","147.58","982.21","percent of total billed charges",""
"Fetal Heart Echo 2d W/ or W/O M-Mod","PX-48000176","CDM","76825","CPT","0483","RC","","","","outpatient","","","1269.00","761.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","922.82","72.72","","890.82","890.82","890.82","20","147.58","982.21","percent of total billed charges",""
"Fetal Heart Echo 2d W/ or W/O M-Mod","PX-48000176","CDM","76825","CPT","0483","RC","","","","outpatient","","","1269.00","761.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","798.20","62.9","","771.75","771.75","2315.25","11","147.58","982.21","percent of total billed charges",""
"Fetal Heart Echo 2d W/ or W/O M-Mod","PX-48000176","CDM","76825","CPT","0483","RC","","","","outpatient","","","1269.00","761.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","982.21","77.4","","949.38","949.38","949.38","1 through 10","147.58","982.21","percent of total billed charges",""
"Fetal Heart Echo 2d W/ or W/O M-Mod","PX-48000176","CDM","76825","CPT","0483","RC","","","","outpatient","","","1269.00","761.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","147.58","11.63","","723.50","144.70","723.50","1 through 10","147.58","982.21","percent of total billed charges",""
"Fetal Heart Echo 2d W/W/O M F/U","PX-48000177","CDM","76826","CPT","0483","RC","","","","both","","","1024.00","614.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1613.96","","Case rate ($1,613.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1551.94","1551.94","1551.94","1 through 10","247.49","1613.96","other","OPPS APC"
"Fetal Heart Echo 2d W/W/O M F/U","PX-48000177","CDM","76826","CPT","0483","RC","","","","both","","","1024.00","614.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","694.97","","Case rate ($694.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","678.03","678.03","678.03","1 through 10","247.49","1613.96","other","OPPS APC"
"Fetal Heart Echo 2d W/W/O M F/U","PX-48000177","CDM","76826","CPT","0483","RC","","","","outpatient","","","1024.00","614.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","119.09","11.63","","136.05","136.05","136.05","1 through 10","119.09","792.58","percent of total billed charges",""
"Fetal Heart Echo 2d W/W/O M F/U","PX-48000177","CDM","76826","CPT","0483","RC","","","","outpatient","","","1024.00","614.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","644.10","62.9","","622.44","622.44","622.44","1 through 10","119.09","792.58","percent of total billed charges",""
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","","","","inpatient","","","39369.62","23621.77","MEDICARE [2001]","HB WDH MEDICARE","7193.56","","Case rate ($7,193.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,673.83, add-ons for qualifying new technology services are included. If operating cost exceeds $10,592.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,298.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,255.53 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,228.96 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $493.16. The transfer capital threshold is the transfer adjustment factor * $493.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7220.70","7238.35","7238.35","1 through 10","3975","33732.69","other","Inpatient DRG"
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","","","","inpatient","","","39369.62","23621.77","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7193.56","","Case rate ($7,193.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,673.83, add-ons for qualifying new technology services are included. If operating cost exceeds $10,592.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,298.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,255.53 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,228.96 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $493.16. The transfer capital threshold is the transfer adjustment factor * $493.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7238.35","7238.35","7238.35","1 through 10","3975","33732.69","other","Inpatient DRG"
"FIBERTAG TIGHTROPE 2","SUP-ITM-10319393","CDM","C1713","HCPCS","0278","RC","","","","both","","","4111.45","2466.87","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","478.16","3494.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FIBERTAG TIGHTROPE 2","SUP-ITM-10319393","CDM","C1713","HCPCS","0278","RC","","","","both","","","4111.45","2466.87","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","478.16","3494.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FIBERTAG TIGHTROPE 2","SUP-ITM-10319393","CDM","C1713","HCPCS","0278","RC","","","","both","","","4111.45","2466.87","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2339.42","56.9","","812.12","238.65","1587.46","163","478.16","3494.73","percent of total billed charges",""
"FIBERTAG TIGHTROPE 2","SUP-ITM-10319393","CDM","C1713","HCPCS","0278","RC","","","","both","","","4111.45","2466.87","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","478.16","11.63","","112.68","112.68","146.99","38","478.16","3494.73","percent of total billed charges",""
"FIBERTAG TIGHTROPE 2","SUP-ITM-10319393","CDM","C1713","HCPCS","0278","RC","","","","both","","","4111.45","2466.87","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3182.26","77.4","","303.98","303.98","5854.79","1 through 10","478.16","3494.73","percent of total billed charges",""
"FIBERTAG TIGHTROPE 2","SUP-ITM-10319393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4111.45","2466.87","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","478.16","11.63","","112.68","112.68","146.99","38","478.16","3182.26","percent of total billed charges",""
"FIBERTAG TIGHTROPE 2","SUP-ITM-10319393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4111.45","2466.87","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2581.17","62.78","","780.86","208.94","10480.28","15","478.16","3182.26","percent of total billed charges",""
"FIBERTAG TIGHTROPE 2","SUP-ITM-10319393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4111.45","2466.87","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1797.53","43.72","","179.76","179.76","179.76","1 through 10","478.16","3182.26","percent of total billed charges",""
"FIBERTAG TIGHTROPE 2","SUP-ITM-10319393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4111.45","2466.87","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2989.85","72.72","","2355.45","298.99","3965.19","155","478.16","3182.26","percent of total billed charges",""
"FIBERTAG TIGHTROPE 2","SUP-ITM-10319393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4111.45","2466.87","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2989.85","72.72","","3643.09","3643.09","3643.09","1 through 10","478.16","3182.26","percent of total billed charges",""
"FIBERTAG TIGHTROPE 2","SUP-ITM-10319393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4111.45","2466.87","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2188.11","53.22","","554.28","554.28","554.28","16","478.16","3182.26","percent of total billed charges",""
"FIBERTAG TIGHTROPE 2","SUP-ITM-10319393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4111.45","2466.87","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2586.10","62.9","","619.64","173.09","2370.64","150","478.16","3182.26","percent of total billed charges",""
"FIBERTAG TIGHTROPE 2","SUP-ITM-10319393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4111.45","2466.87","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3182.26","77.4","","303.98","303.98","5854.79","1 through 10","478.16","3182.26","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","both","","","145.00","87.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","101.21","69.8","","97.72","88.06","97.72","16","6.62","123.25","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","both","","","145.00","87.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","101.21","69.8","","97.72","97.72","97.72","1 through 10","6.62","123.25","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","both","","","145.00","87.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","91.21","62.9","","88.20","88.20","329.16","49","6.62","123.25","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","both","","","145.00","87.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","123.25","85","","119.00","24.82","119.00","1 through 10","6.62","123.25","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","both","","","145.00","87.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","112.23","77.4","","108.50","108.50","108.50","1 through 10","6.62","123.25","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","outpatient","","","145.00","87.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","91.03","62.78","","87.89","87.89","87.89","1 through 10","9.48","105.44","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","outpatient","","","145.00","87.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","63.39","43.72","","61.21","61.21","61.21","1 through 10","9.48","105.44","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","outpatient","","","145.00","87.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","105.44","72.72","","101.81","101.81","101.81","24","9.48","105.44","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","outpatient","","","145.00","87.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","105.44","72.72","","101.81","101.81","101.81","1 through 10","9.48","105.44","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","both","","","129.00","77.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","90.04","69.8","","87.25","78.63","87.25","1 through 10","6.32","109.65","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","outpatient","","","129.00","77.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","56.40","43.72","","54.65","54.65","54.65","1 through 10","7.92","99.85","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","outpatient","","","129.00","77.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","93.81","72.72","","90.90","90.90","90.90","1 through 10","7.92","99.85","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","outpatient","","","129.00","77.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","93.81","72.72","","90.90","90.90","90.90","1 through 10","7.92","99.85","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","outpatient","","","129.00","77.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","81.14","62.9","","78.75","78.75","78.75","1 through 10","7.92","99.85","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","outpatient","","","129.00","77.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","99.85","77.4","","96.88","96.88","96.88","1 through 10","7.92","99.85","percent of total billed charges",""
"FIBULA PLATE 2.7MM 13 HOLE VA LCP SS RT","SUP-ITM-10125035","CDM","C1713","HCPCS","0278","RC","","","","both","","","5016.25","3009.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","583.39","4263.81","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FIBULA PLATE 2.7MM 13 HOLE VA LCP SS RT","SUP-ITM-10125035","CDM","C1713","HCPCS","0278","RC","","","","both","","","5016.25","3009.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","583.39","4263.81","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FIBULA PLATE 2.7MM 13 HOLE VA LCP SS RT","SUP-ITM-10125035","CDM","C1713","HCPCS","0278","RC","","","","both","","","5016.25","3009.75","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2854.25","56.9","","812.12","238.65","1587.46","163","583.39","4263.81","percent of total billed charges",""
"FIBULA PLATE 2.7MM 13 HOLE VA LCP SS RT","SUP-ITM-10125035","CDM","C1713","HCPCS","0278","RC","","","","both","","","5016.25","3009.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","583.39","11.63","","112.68","112.68","146.99","38","583.39","4263.81","percent of total billed charges",""
"FIBULA PLATE 2.7MM 13 HOLE VA LCP SS RT","SUP-ITM-10125035","CDM","C1713","HCPCS","0278","RC","","","","both","","","5016.25","3009.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3882.58","77.4","","303.98","303.98","5854.79","1 through 10","583.39","4263.81","percent of total billed charges",""
"FIBULA PLATE 2.7MM 13 HOLE VA LCP SS RT","SUP-ITM-10125035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5016.25","3009.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","583.39","11.63","","112.68","112.68","146.99","38","583.39","3882.58","percent of total billed charges",""
"FIBULA PLATE 2.7MM 13 HOLE VA LCP SS RT","SUP-ITM-10125035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5016.25","3009.75","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3149.20","62.78","","780.86","208.94","10480.28","15","583.39","3882.58","percent of total billed charges",""
"FIBULA PLATE 2.7MM 13 HOLE VA LCP SS RT","SUP-ITM-10125035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5016.25","3009.75","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2193.10","43.72","","179.76","179.76","179.76","1 through 10","583.39","3882.58","percent of total billed charges",""
"FIBULA PLATE 2.7MM 13 HOLE VA LCP SS RT","SUP-ITM-10125035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5016.25","3009.75","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3647.82","72.72","","2355.45","298.99","3965.19","155","583.39","3882.58","percent of total billed charges",""
"FIBULA PLATE 2.7MM 13 HOLE VA LCP SS RT","SUP-ITM-10125035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5016.25","3009.75","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3647.82","72.72","","3643.09","3643.09","3643.09","1 through 10","583.39","3882.58","percent of total billed charges",""
"FIBULA PLATE 2.7MM 13 HOLE VA LCP SS RT","SUP-ITM-10125035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5016.25","3009.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2669.65","53.22","","554.28","554.28","554.28","16","583.39","3882.58","percent of total billed charges",""
"FIBULA PLATE 2.7MM 13 HOLE VA LCP SS RT","SUP-ITM-10125035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5016.25","3009.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3155.22","62.9","","619.64","173.09","2370.64","150","583.39","3882.58","percent of total billed charges",""
"FIBULA PLATE 2.7MM 13 HOLE VA LCP SS RT","SUP-ITM-10125035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5016.25","3009.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3882.58","77.4","","303.98","303.98","5854.79","1 through 10","583.39","3882.58","percent of total billed charges",""
"FIBULA PLATE 2.7MM 15 HOLE VA LCP SS RT","SUP-ITM-10125037","CDM","C1713","HCPCS","0278","RC","","","","both","","","5233.56","3140.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","608.66","4448.53","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FIBULA PLATE 2.7MM 15 HOLE VA LCP SS RT","SUP-ITM-10125037","CDM","C1713","HCPCS","0278","RC","","","","both","","","5233.56","3140.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","608.66","4448.53","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FIBULA PLATE 2.7MM 15 HOLE VA LCP SS RT","SUP-ITM-10125037","CDM","C1713","HCPCS","0278","RC","","","","both","","","5233.56","3140.14","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2977.90","56.9","","812.12","238.65","1587.46","163","608.66","4448.53","percent of total billed charges",""
"FIBULA PLATE 2.7MM 15 HOLE VA LCP SS RT","SUP-ITM-10125037","CDM","C1713","HCPCS","0278","RC","","","","both","","","5233.56","3140.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","608.66","11.63","","112.68","112.68","146.99","38","608.66","4448.53","percent of total billed charges",""
"FIBULA PLATE 2.7MM 15 HOLE VA LCP SS RT","SUP-ITM-10125037","CDM","C1713","HCPCS","0278","RC","","","","both","","","5233.56","3140.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4050.78","77.4","","303.98","303.98","5854.79","1 through 10","608.66","4448.53","percent of total billed charges",""
"FIBULA PLATE 2.7MM 15 HOLE VA LCP SS RT","SUP-ITM-10125037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5233.56","3140.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","608.66","11.63","","112.68","112.68","146.99","38","608.66","4050.78","percent of total billed charges",""
"FIBULA PLATE 2.7MM 15 HOLE VA LCP SS RT","SUP-ITM-10125037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5233.56","3140.14","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3285.63","62.78","","780.86","208.94","10480.28","15","608.66","4050.78","percent of total billed charges",""
"FIBULA PLATE 2.7MM 15 HOLE VA LCP SS RT","SUP-ITM-10125037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5233.56","3140.14","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2288.11","43.72","","179.76","179.76","179.76","1 through 10","608.66","4050.78","percent of total billed charges",""
"FIBULA PLATE 2.7MM 15 HOLE VA LCP SS RT","SUP-ITM-10125037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5233.56","3140.14","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3805.84","72.72","","2355.45","298.99","3965.19","155","608.66","4050.78","percent of total billed charges",""
"FIBULA PLATE 2.7MM 15 HOLE VA LCP SS RT","SUP-ITM-10125037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5233.56","3140.14","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3805.84","72.72","","3643.09","3643.09","3643.09","1 through 10","608.66","4050.78","percent of total billed charges",""
"FIBULA PLATE 2.7MM 15 HOLE VA LCP SS RT","SUP-ITM-10125037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5233.56","3140.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2785.30","53.22","","554.28","554.28","554.28","16","608.66","4050.78","percent of total billed charges",""
"FIBULA PLATE 2.7MM 15 HOLE VA LCP SS RT","SUP-ITM-10125037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5233.56","3140.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3291.91","62.9","","619.64","173.09","2370.64","150","608.66","4050.78","percent of total billed charges",""
"FIBULA PLATE 2.7MM 15 HOLE VA LCP SS RT","SUP-ITM-10125037","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5233.56","3140.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4050.78","77.4","","303.98","303.98","5854.79","1 through 10","608.66","4050.78","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","both","","","4034.47","2420.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","469.21","3429.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","both","","","4034.47","2420.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","469.21","3429.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","both","","","4034.47","2420.68","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2295.61","56.9","","812.12","238.65","1587.46","163","469.21","3429.3","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","both","","","4034.47","2420.68","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","469.21","11.63","","112.68","112.68","146.99","38","469.21","3429.3","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","both","","","4034.47","2420.68","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3122.68","77.4","","303.98","303.98","5854.79","1 through 10","469.21","3429.3","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4034.47","2420.68","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","469.21","11.63","","112.68","112.68","146.99","38","469.21","3122.68","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4034.47","2420.68","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2532.84","62.78","","780.86","208.94","10480.28","15","469.21","3122.68","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4034.47","2420.68","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1763.87","43.72","","179.76","179.76","179.76","1 through 10","469.21","3122.68","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4034.47","2420.68","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2933.87","72.72","","2355.45","298.99","3965.19","155","469.21","3122.68","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4034.47","2420.68","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2933.87","72.72","","3643.09","3643.09","3643.09","1 through 10","469.21","3122.68","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4034.47","2420.68","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2147.14","53.22","","554.28","554.28","554.28","16","469.21","3122.68","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4034.47","2420.68","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2537.68","62.9","","619.64","173.09","2370.64","150","469.21","3122.68","percent of total billed charges",""
"FIBULA PLATE 2.7X118MM 6 HOLE VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4034.47","2420.68","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3122.68","77.4","","303.98","303.98","5854.79","1 through 10","469.21","3122.68","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","both","","","4440.99","2664.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","516.49","3774.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","both","","","4440.99","2664.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","516.49","3774.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","both","","","4440.99","2664.59","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2526.92","56.9","","812.12","238.65","1587.46","163","516.49","3774.84","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","both","","","4440.99","2664.59","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","516.49","11.63","","112.68","112.68","146.99","38","516.49","3774.84","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","both","","","4440.99","2664.59","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3437.33","77.4","","303.98","303.98","5854.79","1 through 10","516.49","3774.84","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4440.99","2664.59","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","516.49","11.63","","112.68","112.68","146.99","38","516.49","3437.33","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4440.99","2664.59","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2788.05","62.78","","780.86","208.94","10480.28","15","516.49","3437.33","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4440.99","2664.59","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1941.60","43.72","","179.76","179.76","179.76","1 through 10","516.49","3437.33","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4440.99","2664.59","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3229.49","72.72","","2355.45","298.99","3965.19","155","516.49","3437.33","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4440.99","2664.59","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3229.49","72.72","","3643.09","3643.09","3643.09","1 through 10","516.49","3437.33","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4440.99","2664.59","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2363.49","53.22","","554.28","554.28","554.28","16","516.49","3437.33","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4440.99","2664.59","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2793.38","62.9","","619.64","173.09","2370.64","150","516.49","3437.33","percent of total billed charges",""
"FIBULA PLATE 2.7X157MM 9 HOLE VA LCP SS RT","SUP-ITM-10124981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4440.99","2664.59","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3437.33","77.4","","303.98","303.98","5854.79","1 through 10","516.49","3437.33","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.86","2796.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","542.06","3961.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.86","2796.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","542.06","3961.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.86","2796.52","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2652.03","56.9","","812.12","238.65","1587.46","163","542.06","3961.73","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.86","2796.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","542.06","11.63","","112.68","112.68","146.99","38","542.06","3961.73","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.86","2796.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3607.51","77.4","","303.98","303.98","5854.79","1 through 10","542.06","3961.73","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4660.86","2796.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","542.06","11.63","","112.68","112.68","146.99","38","542.06","3607.51","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4660.86","2796.52","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2926.09","62.78","","780.86","208.94","10480.28","15","542.06","3607.51","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4660.86","2796.52","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2037.73","43.72","","179.76","179.76","179.76","1 through 10","542.06","3607.51","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4660.86","2796.52","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3389.38","72.72","","2355.45","298.99","3965.19","155","542.06","3607.51","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4660.86","2796.52","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3389.38","72.72","","3643.09","3643.09","3643.09","1 through 10","542.06","3607.51","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4660.86","2796.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2480.51","53.22","","554.28","554.28","554.28","16","542.06","3607.51","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4660.86","2796.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2931.68","62.9","","619.64","173.09","2370.64","150","542.06","3607.51","percent of total billed charges",""
"FIBULA PLATE 2.7X183MM 11 HOLE VA LCP SS RIGHT","SUP-ITM-10124983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4660.86","2796.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3607.51","77.4","","303.98","303.98","5854.79","1 through 10","542.06","3607.51","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","both","","","3622.84","2173.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","421.34","3079.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","both","","","3622.84","2173.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","421.34","3079.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","both","","","3622.84","2173.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2061.40","56.9","","812.12","238.65","1587.46","163","421.34","3079.41","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","both","","","3622.84","2173.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","421.34","11.63","","112.68","112.68","146.99","38","421.34","3079.41","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","both","","","3622.84","2173.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2804.08","77.4","","303.98","303.98","5854.79","1 through 10","421.34","3079.41","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3622.84","2173.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","421.34","11.63","","112.68","112.68","146.99","38","421.34","2804.08","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3622.84","2173.70","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2274.42","62.78","","780.86","208.94","10480.28","15","421.34","2804.08","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3622.84","2173.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1583.91","43.72","","179.76","179.76","179.76","1 through 10","421.34","2804.08","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3622.84","2173.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2634.53","72.72","","2355.45","298.99","3965.19","155","421.34","2804.08","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3622.84","2173.70","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2634.53","72.72","","3643.09","3643.09","3643.09","1 through 10","421.34","2804.08","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3622.84","2173.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1928.08","53.22","","554.28","554.28","554.28","16","421.34","2804.08","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3622.84","2173.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2278.77","62.9","","619.64","173.09","2370.64","150","421.34","2804.08","percent of total billed charges",""
"FIBULA PLATE 2.7X92MM 4 HOLE VA LCP SS VARIABLE ANGLE LEFT","SUP-ITM-10123422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3622.84","2173.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2804.08","77.4","","303.98","303.98","5854.79","1 through 10","421.34","2804.08","percent of total billed charges",""
"FIBULA PLATE 3.5MM 107 7 HOLE LEG PERI LOC SS LOCKING VARIABLE ANGLE LATERAL DISTAL LEFT","SUP-ITM-10098849","CDM","C1713","HCPCS","0278","RC","","","","both","","","8536.00","5121.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","992.74","7255.6","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FIBULA PLATE 3.5MM 107 7 HOLE LEG PERI LOC SS LOCKING VARIABLE ANGLE LATERAL DISTAL LEFT","SUP-ITM-10098849","CDM","C1713","HCPCS","0278","RC","","","","both","","","8536.00","5121.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","992.74","7255.6","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FIBULA PLATE 3.5MM 107 7 HOLE LEG PERI LOC SS LOCKING VARIABLE ANGLE LATERAL DISTAL LEFT","SUP-ITM-10098849","CDM","C1713","HCPCS","0278","RC","","","","both","","","8536.00","5121.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4856.98","56.9","","812.12","238.65","1587.46","163","992.74","7255.6","percent of total billed charges",""
"FIBULA PLATE 3.5MM 107 7 HOLE LEG PERI LOC SS LOCKING VARIABLE ANGLE LATERAL DISTAL LEFT","SUP-ITM-10098849","CDM","C1713","HCPCS","0278","RC","","","","both","","","8536.00","5121.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","992.74","11.63","","112.68","112.68","146.99","38","992.74","7255.6","percent of total billed charges",""
"FIBULA PLATE 3.5MM 107 7 HOLE LEG PERI LOC SS LOCKING VARIABLE ANGLE LATERAL DISTAL LEFT","SUP-ITM-10098849","CDM","C1713","HCPCS","0278","RC","","","","both","","","8536.00","5121.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6606.86","77.4","","303.98","303.98","5854.79","1 through 10","992.74","7255.6","percent of total billed charges",""
"FIBULA PLATE 3.5MM 107 7 HOLE LEG PERI LOC SS LOCKING VARIABLE ANGLE LATERAL DISTAL LEFT","SUP-ITM-10098849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8536.00","5121.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","992.74","11.63","","112.68","112.68","146.99","38","992.74","6606.86","percent of total billed charges",""
"FIBULA PLATE 3.5MM 107 7 HOLE LEG PERI LOC SS LOCKING VARIABLE ANGLE LATERAL DISTAL LEFT","SUP-ITM-10098849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8536.00","5121.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5358.90","62.78","","780.86","208.94","10480.28","15","992.74","6606.86","percent of total billed charges",""
"FIBULA PLATE 3.5MM 107 7 HOLE LEG PERI LOC SS LOCKING VARIABLE ANGLE LATERAL DISTAL LEFT","SUP-ITM-10098849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8536.00","5121.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3731.94","43.72","","179.76","179.76","179.76","1 through 10","992.74","6606.86","percent of total billed charges",""
"FIBULA PLATE 3.5MM 107 7 HOLE LEG PERI LOC SS LOCKING VARIABLE ANGLE LATERAL DISTAL LEFT","SUP-ITM-10098849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8536.00","5121.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6207.38","72.72","","2355.45","298.99","3965.19","155","992.74","6606.86","percent of total billed charges",""
"FIBULA PLATE 3.5MM 107 7 HOLE LEG PERI LOC SS LOCKING VARIABLE ANGLE LATERAL DISTAL LEFT","SUP-ITM-10098849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8536.00","5121.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6207.38","72.72","","3643.09","3643.09","3643.09","1 through 10","992.74","6606.86","percent of total billed charges",""
"FIBULA PLATE 3.5MM 107 7 HOLE LEG PERI LOC SS LOCKING VARIABLE ANGLE LATERAL DISTAL LEFT","SUP-ITM-10098849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8536.00","5121.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4542.86","53.22","","554.28","554.28","554.28","16","992.74","6606.86","percent of total billed charges",""
"FIBULA PLATE 3.5MM 107 7 HOLE LEG PERI LOC SS LOCKING VARIABLE ANGLE LATERAL DISTAL LEFT","SUP-ITM-10098849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8536.00","5121.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5369.14","62.9","","619.64","173.09","2370.64","150","992.74","6606.86","percent of total billed charges",""
"FIBULA PLATE 3.5MM 107 7 HOLE LEG PERI LOC SS LOCKING VARIABLE ANGLE LATERAL DISTAL LEFT","SUP-ITM-10098849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8536.00","5121.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6606.86","77.4","","303.98","303.98","5854.79","1 through 10","992.74","6606.86","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","both","","","6555.38","3933.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","762.39","5572.07","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","both","","","6555.38","3933.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","762.39","5572.07","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","both","","","6555.38","3933.23","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3730.01","56.9","","812.12","238.65","1587.46","163","762.39","5572.07","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","both","","","6555.38","3933.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","762.39","11.63","","112.68","112.68","146.99","38","762.39","5572.07","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","both","","","6555.38","3933.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5073.86","77.4","","303.98","303.98","5854.79","1 through 10","762.39","5572.07","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6555.38","3933.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","762.39","11.63","","112.68","112.68","146.99","38","762.39","5073.86","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6555.38","3933.23","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4115.47","62.78","","780.86","208.94","10480.28","15","762.39","5073.86","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6555.38","3933.23","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2866.01","43.72","","179.76","179.76","179.76","1 through 10","762.39","5073.86","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6555.38","3933.23","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4767.07","72.72","","2355.45","298.99","3965.19","155","762.39","5073.86","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6555.38","3933.23","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4767.07","72.72","","3643.09","3643.09","3643.09","1 through 10","762.39","5073.86","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6555.38","3933.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3488.77","53.22","","554.28","554.28","554.28","16","762.39","5073.86","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6555.38","3933.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4123.33","62.9","","619.64","173.09","2370.64","150","762.39","5073.86","percent of total billed charges",""
"FIBULA PLATE 3.5X105MM 4 HOLE TIBIAL LCP SS POSTERIOR PROXIMALIMAL MEDIAL","SUP-ITM-10074534","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6555.38","3933.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5073.86","77.4","","303.98","303.98","5854.79","1 through 10","762.39","5073.86","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","both","","","2640.86","1584.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","307.13","2244.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","both","","","2640.86","1584.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","307.13","2244.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","both","","","2640.86","1584.52","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1502.65","56.9","","812.12","238.65","1587.46","163","307.13","2244.73","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","both","","","2640.86","1584.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","307.13","11.63","","112.68","112.68","146.99","38","307.13","2244.73","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","both","","","2640.86","1584.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2044.03","77.4","","303.98","303.98","5854.79","1 through 10","307.13","2244.73","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2640.86","1584.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","307.13","11.63","","112.68","112.68","146.99","38","307.13","2044.03","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2640.86","1584.52","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1657.93","62.78","","780.86","208.94","10480.28","15","307.13","2044.03","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2640.86","1584.52","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1154.58","43.72","","179.76","179.76","179.76","1 through 10","307.13","2044.03","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2640.86","1584.52","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1920.43","72.72","","2355.45","298.99","3965.19","155","307.13","2044.03","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2640.86","1584.52","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1920.43","72.72","","3643.09","3643.09","3643.09","1 through 10","307.13","2044.03","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2640.86","1584.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1405.47","53.22","","554.28","554.28","554.28","16","307.13","2044.03","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2640.86","1584.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1661.10","62.9","","619.64","173.09","2370.64","150","307.13","2044.03","percent of total billed charges",""
"FILLER CEMENT 2.0G BONE EAR OTOMIMIX HYDROXYAPATITE DILUTE CITRIC ACID POWDER LIQUID","SUP-ITM-10092421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2640.86","1584.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2044.03","77.4","","303.98","303.98","5854.79","1 through 10","307.13","2044.03","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","6353.50","3812.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","738.91","5400.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","6353.50","3812.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","738.91","5400.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","6353.50","3812.10","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3615.14","56.9","","812.12","238.65","1587.46","163","738.91","5400.48","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","6353.50","3812.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","738.91","11.63","","112.68","112.68","146.99","38","738.91","5400.48","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","6353.50","3812.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4917.61","77.4","","303.98","303.98","5854.79","1 through 10","738.91","5400.48","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6353.50","3812.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","738.91","11.63","","112.68","112.68","146.99","38","738.91","4917.61","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6353.50","3812.10","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3988.73","62.78","","780.86","208.94","10480.28","15","738.91","4917.61","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6353.50","3812.10","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2777.75","43.72","","179.76","179.76","179.76","1 through 10","738.91","4917.61","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6353.50","3812.10","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4620.27","72.72","","2355.45","298.99","3965.19","155","738.91","4917.61","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6353.50","3812.10","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4620.27","72.72","","3643.09","3643.09","3643.09","1 through 10","738.91","4917.61","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6353.50","3812.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3381.33","53.22","","554.28","554.28","554.28","16","738.91","4917.61","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6353.50","3812.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3996.35","62.9","","619.64","173.09","2370.64","150","738.91","4917.61","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6353.50","3812.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4917.61","77.4","","303.98","303.98","5854.79","1 through 10","738.91","4917.61","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","6831.50","4098.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","794.5","5806.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","6831.50","4098.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","794.5","5806.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","6831.50","4098.90","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3887.12","56.9","","812.12","238.65","1587.46","163","794.5","5806.78","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","6831.50","4098.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","794.50","11.63","","112.68","112.68","146.99","38","794.5","5806.78","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","6831.50","4098.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5287.58","77.4","","303.98","303.98","5854.79","1 through 10","794.5","5806.78","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6831.50","4098.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","794.50","11.63","","112.68","112.68","146.99","38","794.5","5287.58","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6831.50","4098.90","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4288.82","62.78","","780.86","208.94","10480.28","15","794.5","5287.58","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6831.50","4098.90","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2986.73","43.72","","179.76","179.76","179.76","1 through 10","794.5","5287.58","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6831.50","4098.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4967.87","72.72","","2355.45","298.99","3965.19","155","794.5","5287.58","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6831.50","4098.90","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4967.87","72.72","","3643.09","3643.09","3643.09","1 through 10","794.5","5287.58","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6831.50","4098.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3635.72","53.22","","554.28","554.28","554.28","16","794.5","5287.58","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6831.50","4098.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4297.01","62.9","","619.64","173.09","2370.64","150","794.5","5287.58","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6831.50","4098.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5287.58","77.4","","303.98","303.98","5854.79","1 through 10","794.5","5287.58","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","both","","","9644.13","5786.48","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1121.61","8197.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","both","","","9644.13","5786.48","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1121.61","8197.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","both","","","9644.13","5786.48","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5487.51","56.9","","812.12","238.65","1587.46","163","1121.61","8197.51","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","both","","","9644.13","5786.48","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1121.61","11.63","","112.68","112.68","146.99","38","1121.61","8197.51","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","both","","","9644.13","5786.48","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7464.56","77.4","","303.98","303.98","5854.79","1 through 10","1121.61","8197.51","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9644.13","5786.48","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1121.61","11.63","","112.68","112.68","146.99","38","1121.61","7464.56","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9644.13","5786.48","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6054.58","62.78","","780.86","208.94","10480.28","15","1121.61","7464.56","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9644.13","5786.48","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4216.41","43.72","","179.76","179.76","179.76","1 through 10","1121.61","7464.56","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9644.13","5786.48","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7013.21","72.72","","2355.45","298.99","3965.19","155","1121.61","7464.56","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9644.13","5786.48","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7013.21","72.72","","3643.09","3643.09","3643.09","1 through 10","1121.61","7464.56","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9644.13","5786.48","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","5132.61","53.22","","554.28","554.28","554.28","16","1121.61","7464.56","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9644.13","5786.48","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6066.16","62.9","","619.64","173.09","2370.64","150","1121.61","7464.56","percent of total billed charges",""
"FILLER VOID 5ML BONE DRILLABLE CALCIUM","SUP-ITM-10321555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9644.13","5786.48","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7464.56","77.4","","303.98","303.98","5854.79","1 through 10","1121.61","7464.56","percent of total billed charges",""
"FILTER OSTEOSET 4.8MM PELLETS BONE FILLER 8400 0102 OR00000002907004","SUP-ITM-10015875","CDM","C1713","HCPCS","0278","RC","","","","both","","","4512.23","2707.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","524.77","3835.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FILTER OSTEOSET 4.8MM PELLETS BONE FILLER 8400 0102 OR00000002907004","SUP-ITM-10015875","CDM","C1713","HCPCS","0278","RC","","","","both","","","4512.23","2707.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","524.77","3835.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FILTER OSTEOSET 4.8MM PELLETS BONE FILLER 8400 0102 OR00000002907004","SUP-ITM-10015875","CDM","C1713","HCPCS","0278","RC","","","","both","","","4512.23","2707.34","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2567.46","56.9","","812.12","238.65","1587.46","163","524.77","3835.4","percent of total billed charges",""
"FILTER OSTEOSET 4.8MM PELLETS BONE FILLER 8400 0102 OR00000002907004","SUP-ITM-10015875","CDM","C1713","HCPCS","0278","RC","","","","both","","","4512.23","2707.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","524.77","11.63","","112.68","112.68","146.99","38","524.77","3835.4","percent of total billed charges",""
"FILTER OSTEOSET 4.8MM PELLETS BONE FILLER 8400 0102 OR00000002907004","SUP-ITM-10015875","CDM","C1713","HCPCS","0278","RC","","","","both","","","4512.23","2707.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3492.47","77.4","","303.98","303.98","5854.79","1 through 10","524.77","3835.4","percent of total billed charges",""
"FILTER OSTEOSET 4.8MM PELLETS BONE FILLER 8400 0102 OR00000002907004","SUP-ITM-10015875","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4512.23","2707.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","524.77","11.63","","112.68","112.68","146.99","38","524.77","3492.47","percent of total billed charges",""
"FILTER OSTEOSET 4.8MM PELLETS BONE FILLER 8400 0102 OR00000002907004","SUP-ITM-10015875","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4512.23","2707.34","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2832.78","62.78","","780.86","208.94","10480.28","15","524.77","3492.47","percent of total billed charges",""
"FILTER OSTEOSET 4.8MM PELLETS BONE FILLER 8400 0102 OR00000002907004","SUP-ITM-10015875","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4512.23","2707.34","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1972.75","43.72","","179.76","179.76","179.76","1 through 10","524.77","3492.47","percent of total billed charges",""
"FILTER OSTEOSET 4.8MM PELLETS BONE FILLER 8400 0102 OR00000002907004","SUP-ITM-10015875","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4512.23","2707.34","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3281.29","72.72","","2355.45","298.99","3965.19","155","524.77","3492.47","percent of total billed charges",""
"FILTER OSTEOSET 4.8MM PELLETS BONE FILLER 8400 0102 OR00000002907004","SUP-ITM-10015875","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4512.23","2707.34","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3281.29","72.72","","3643.09","3643.09","3643.09","1 through 10","524.77","3492.47","percent of total billed charges",""
"FILTER OSTEOSET 4.8MM PELLETS BONE FILLER 8400 0102 OR00000002907004","SUP-ITM-10015875","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4512.23","2707.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2401.41","53.22","","554.28","554.28","554.28","16","524.77","3492.47","percent of total billed charges",""
"FILTER OSTEOSET 4.8MM PELLETS BONE FILLER 8400 0102 OR00000002907004","SUP-ITM-10015875","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4512.23","2707.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2838.19","62.9","","619.64","173.09","2370.64","150","524.77","3492.47","percent of total billed charges",""
"FILTER OSTEOSET 4.8MM PELLETS BONE FILLER 8400 0102 OR00000002907004","SUP-ITM-10015875","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4512.23","2707.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3492.47","77.4","","303.98","303.98","5854.79","1 through 10","524.77","3492.47","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1064.00","638.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","742.67","69.8","","645.98","645.98","645.98","1 through 10","605.42","4697.85","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1064.00","638.40","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","749.78","","APC Price ($735.08). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","735.17","685.52","735.17","1 through 10","605.42","4697.85","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1064.00","638.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","4697.85","","Case rate ($4,697.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1027.00","695.21","1032.59","1 through 10","605.42","4697.85","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1064.00","638.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","2022.89","","Case rate ($2,022.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2054.00","1027.00","2942.59","1 through 10","605.42","4697.85","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1064.00","638.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","720.38","","APC Price ($735.08). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","721.47","720.47","735.17","14","605.42","4697.85","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1064.00","638.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","3797.22","","Case rate ($3,797.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1032.59","1027.00","1032.59","1 through 10","605.42","4697.85","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1064.00","638.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","605.42","56.9","","2100.75","584.36","2100.75","13","605.42","4697.85","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1064.00","638.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","757.14","","APC Price ($735.08). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","753.69","747.09","757.23","1 through 10","605.42","4697.85","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1064.00","638.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","735.08","","APC Price ($735.08). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","721.37","721.37","735.17","1 through 10","605.42","4697.85","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1064.00","638.40","MEDICARE [2001]","HB WDH MEDICARE","735.08","","APC Price ($735.08). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","735.17","685.52","735.17","53","605.42","4697.85","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1064.00","638.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","735.08","","APC Price ($735.08). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","729.37","728.17","735.17","17","605.42","4697.85","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1064.00","638.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","667.98","62.78","","644.75","644.75","644.75","1 through 10","465.18","823.54","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1064.00","638.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","773.74","72.72","","746.83","746.83","746.83","1 through 10","465.18","823.54","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1064.00","638.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","669.26","62.9","","1941.03","647.01","1941.03","20","465.18","823.54","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1064.00","638.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","823.54","77.4","","795.93","795.93","795.93","1 through 10","465.18","823.54","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn Ea Addl","PX-76002557","CDM","10006","CPT","0761","RC","","","","both","","","915.00","549.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","883.00","883.00","883.00","1 through 10","520.64","777.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Fine Needle Aspiration Bx W/US Gdn Ea Addl","PX-76002557","CDM","10006","CPT","0761","RC","","","","both","","","915.00","549.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","520.64","56.9","","502.43","502.43","502.43","1 through 10","520.64","777.75","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn Ea Addl","PX-76002557","CDM","10006","CPT","0761","RC","","","","outpatient","","","915.00","549.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","665.39","72.72","","642.12","642.12","642.12","1 through 10","400.04","708.21","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn Ea Addl","PX-76002557","CDM","10006","CPT","0761","RC","","","","outpatient","","","915.00","549.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","575.54","62.9","","556.29","556.29","556.29","1 through 10","400.04","708.21","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","451.00","270.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","314.80","69.8","","608.66","608.66","608.66","1 through 10","54.71","383.35","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","451.00","270.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","55.82","","APC Price ($55.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","55.83","51.75","55.83","1 through 10","54.71","383.35","other","OPPS APC"
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","outpatient","","","451.00","270.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","283.14","62.78","","273.72","273.72","273.72","1 through 10","39.04","349.07","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","outpatient","","","451.00","270.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","327.97","72.72","","317.06","317.06","634.12","11","39.04","349.07","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","outpatient","","","451.00","270.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","283.68","62.9","","274.68","274.68","549.36","19","39.04","349.07","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","outpatient","","","451.00","270.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","349.07","77.4","","337.90","337.90","337.90","1 through 10","39.04","349.07","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","329.00","197.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","229.64","69.8","","200.02","200.02","200.02","1 through 10","229.64","2401.82","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","329.00","197.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2401.82","","Case rate ($2,401.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.23","111.23","111.23","1 through 10","229.64","2401.82","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","329.00","197.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1034.22","","Case rate ($1,034.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","113.50","111.23","113.50","1 through 10","229.64","2401.82","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","329.00","197.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","368.30","","APC Price ($375.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","76.88","76.88","76.88","1 through 10","229.64","2401.82","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","329.00","197.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1941.37","","Case rate ($1,941.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","318.00","111.23","318.00","1 through 10","229.64","2401.82","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","329.00","197.40","MEDICARE [2001]","HB WDH MEDICARE","375.82","","APC Price ($375.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.23","350.23","375.86","1 through 10","229.64","2401.82","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","329.00","197.40","TRICARE [160005]","HB WDH MEDICARE","375.82","","APC Price ($375.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","375.86","375.86","375.86","1 through 10","229.64","2401.82","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","329.00","197.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","375.82","","APC Price ($375.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","368.35","368.35","368.35","1 through 10","229.64","2401.82","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","outpatient","","","329.00","197.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","239.25","72.72","","231.25","231.25","231.25","1 through 10","52.31","254.65","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","outpatient","","","329.00","197.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","206.94","62.9","","200.34","200.34","200.34","1 through 10","52.31","254.65","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","outpatient","","","329.00","197.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","254.65","77.4","","246.45","246.45","246.45","1 through 10","52.31","254.65","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","133.00","79.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","92.83","69.8","","81.14","81.14","81.14","25","92.83","127.94","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","133.00","79.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","36.71","36.71","36.71","25","92.83","127.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","133.00","79.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","37.46","37.46","37.46","1 through 10","92.83","127.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","133.00","79.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","36.71","36.71","36.71","30","92.83","127.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","outpatient","","","133.00","79.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","96.72","72.72","","93.81","93.81","93.81","25","16.7","102.94","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","outpatient","","","133.00","79.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","83.66","62.9","","81.27","81.27","81.27","25","16.7","102.94","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","outpatient","","","133.00","79.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","102.94","77.4","","99.98","99.98","99.98","25","16.7","102.94","percent of total billed charges",""
"Flow Cytometry Interp 16+ Marker","PX-31000105","CDM","88189","CPT","0311","RC","","","","outpatient","","","245.00","147.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","178.16","72.72","","172.35","172.35","172.35","1 through 10","66.15","189.63","percent of total billed charges",""
"Flow Cytometry Interp 16+ Marker","PX-31000105","CDM","88189","CPT","0311","RC","","","","outpatient","","","245.00","147.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","154.11","62.9","","149.31","149.31","149.31","1 through 10","66.15","189.63","percent of total billed charges",""
"Flow Cytometry Interp 16+ Marker","PX-31000105","CDM","88189","CPT","0311","RC","","","","outpatient","","","245.00","147.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","189.63","77.4","","183.68","183.68","183.68","1 through 10","66.15","189.63","percent of total billed charges",""
"Fluconazole Level Serum","PX-31000770","CDM","80299","CPT","0310","RC","","","","both","","","271.00","162.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","189.16","69.8","","69.80","62.90","69.80","1 through 10","12.12","230.35","percent of total billed charges",""
"Fluconazole Level Serum","PX-31000770","CDM","80299","CPT","0310","RC","","","","outpatient","","","271.00","162.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","118.48","43.72","","43.72","43.72","43.72","1 through 10","12.76","209.75","percent of total billed charges",""
"Fluconazole Level Serum","PX-31000770","CDM","80299","CPT","0310","RC","","","","outpatient","","","271.00","162.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","197.07","72.72","","72.72","72.72","72.72","1 through 10","12.76","209.75","percent of total billed charges",""
"Fluconazole Level Serum","PX-31000770","CDM","80299","CPT","0310","RC","","","","outpatient","","","271.00","162.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","197.07","72.72","","190.53","190.53","190.53","1 through 10","12.76","209.75","percent of total billed charges",""
"Fluconazole Level Serum","PX-31000770","CDM","80299","CPT","0310","RC","","","","outpatient","","","271.00","162.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","144.23","53.22","","53.31","53.31","53.31","1 through 10","12.76","209.75","percent of total billed charges",""
"Fluconazole Level Serum","PX-31000770","CDM","80299","CPT","0310","RC","","","","outpatient","","","271.00","162.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","170.46","62.9","","63.00","63.00","189.00","13","12.76","209.75","percent of total billed charges",""
"Fluor Antibody Titer","PX-30000813","CDM","86256","CPT","0302","RC","","","","both","","","65.00","39.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","45.37","69.8","","43.97","13.74","43.97","11","7.83","61.69","percent of total billed charges",""
"Fluor Antibody Titer","PX-30000813","CDM","86256","CPT","0302","RC","","","","outpatient","","","65.00","39.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","28.42","43.72","","27.54","27.54","27.54","1 through 10","12.16","50.31","percent of total billed charges",""
"Fluor Antibody Titer","PX-30000813","CDM","86256","CPT","0302","RC","","","","outpatient","","","65.00","39.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","47.27","72.72","","45.81","45.81","45.81","31","12.16","50.31","percent of total billed charges",""
"Fluor Antibody Titer","PX-30000813","CDM","86256","CPT","0302","RC","","","","outpatient","","","65.00","39.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","47.27","72.72","","45.81","45.81","45.81","1 through 10","12.16","50.31","percent of total billed charges",""
"Fluor Antibody Titer","PX-30000813","CDM","86256","CPT","0302","RC","","","","outpatient","","","65.00","39.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","40.89","62.9","","39.69","39.69","151.36","31","12.16","50.31","percent of total billed charges",""
"Fluor Antibody Titer","PX-30000813","CDM","86256","CPT","0302","RC","","","","outpatient","","","65.00","39.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","50.31","77.4","","48.83","11.17","48.83","1 through 10","12.16","50.31","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0300","RC","","","","inpatient","","","65.00","39.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","49.96","76.86","","39.69","39.69","39.69","1 through 10","43.03","49.96","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","both","","","65.00","39.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","45.37","69.8","","43.97","43.97","43.97","1 through 10","7.83","61.69","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","outpatient","","","65.00","39.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","47.27","72.72","","45.81","45.81","87.56","1 through 10","12.16","50.31","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","outpatient","","","65.00","39.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","40.89","62.9","","39.69","39.69","39.69","11","12.16","50.31","percent of total billed charges",""
"Fo Nontorsion Joint Custom T1","PX-27000507","CDM","L3935","HCPCS","0274","RC","","","","outpatient","","","245.00","147.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","154.11","62.9","","154.35","154.35","154.35","1 through 10","130.39","189.63","percent of total billed charges",""
"Fo W/O Joint Custom T1","PX-27000506","CDM","L3933","HCPCS","0274","RC","","","","both","","","237.00","142.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","134.85","56.9","","64.93","47.44","134.85","1 through 10","134.85","235.17","percent of total billed charges",""
"Fo W/O Joint Custom T1","PX-27000506","CDM","L3933","HCPCS","0274","RC","","","","outpatient","","","237.00","142.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","103.62","43.72","","103.62","103.62","103.62","1 through 10","103.62","183.44","percent of total billed charges",""
"Fo W/O Joint Custom T1","PX-27000506","CDM","L3933","HCPCS","0274","RC","","","","outpatient","","","237.00","142.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","172.35","72.72","","172.35","172.35","172.35","1 through 10","103.62","183.44","percent of total billed charges",""
"Fo W/O Joint Custom T1","PX-27000506","CDM","L3933","HCPCS","0274","RC","","","","outpatient","","","237.00","142.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","149.07","62.9","","149.31","149.31","149.31","1 through 10","103.62","183.44","percent of total billed charges",""
"Fo W/O Joint Custom T1","PX-27000506","CDM","L3933","HCPCS","0274","RC","","","","outpatient","","","237.00","142.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","183.44","77.4","","183.68","183.68","183.68","1 through 10","103.62","183.44","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","both","","","79.00","47.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","55.14","69.8","","53.05","16.76","53.05","53","9.56","75.25","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","outpatient","","","79.00","47.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","49.60","62.78","","47.71","47.71","47.71","1 through 10","13.7","61.15","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","outpatient","","","79.00","47.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","34.54","43.72","","33.23","33.23","33.23","1 through 10","13.7","61.15","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","outpatient","","","79.00","47.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","57.45","72.72","","55.27","55.27","55.27","84","13.7","61.15","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","outpatient","","","79.00","47.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","57.45","72.72","","55.27","55.27","55.27","1 through 10","13.7","61.15","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","outpatient","","","79.00","47.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","42.04","53.22","","40.52","40.52","40.52","1 through 10","13.7","61.15","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","outpatient","","","79.00","47.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","49.69","62.9","","47.88","47.88","47.88","128","13.7","61.15","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","outpatient","","","79.00","47.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","61.15","77.4","","58.90","58.90","58.90","32","13.7","61.15","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0300","RC","","","","inpatient","","","263.00","157.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","202.14","76.86","","160.02","160.02","160.02","1 through 10","174.11","202.14","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","both","","","263.00","157.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","183.57","69.8","","177.29","159.77","177.29","70","12.08","223.55","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","both","","","263.00","157.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","183.57","69.8","","177.29","177.29","177.29","1 through 10","12.08","223.55","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","both","","","263.00","157.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","223.55","85","","215.90","16.72","215.90","1 through 10","12.08","223.55","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","outpatient","","","263.00","157.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","165.11","62.78","","159.46","159.46","159.46","1 through 10","17.32","203.56","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","outpatient","","","263.00","157.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","114.98","43.72","","111.05","111.05","111.05","1 through 10","17.32","203.56","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","outpatient","","","263.00","157.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","191.25","72.72","","184.71","184.71","184.71","89","17.32","203.56","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","outpatient","","","263.00","157.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","191.25","72.72","","184.71","184.71","184.71","1 through 10","17.32","203.56","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","outpatient","","","263.00","157.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","139.97","53.22","","135.41","135.41","135.41","1 through 10","17.32","203.56","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","outpatient","","","263.00","157.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","165.43","62.9","","160.02","160.02","160.02","141","17.32","203.56","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","outpatient","","","263.00","157.80","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","191.25","72.72","","196.85","196.85","196.85","1 through 10","17.32","203.56","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","outpatient","","","263.00","157.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","203.56","77.4","","196.85","196.85","196.85","53","17.32","203.56","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","outpatient","","","263.00","157.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","191.25","72.72","","184.71","184.71","184.71","1 through 10","17.32","203.56","percent of total billed charges",""
"FOOT IMPLANT SM CANNULATED PHALINX","SUP-ITM-10193938","CDM","C1776","HCPCS","0278","RC","","","","both","","","5223.96","3134.38","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","607.55","4440.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FOOT IMPLANT SM CANNULATED PHALINX","SUP-ITM-10193938","CDM","C1776","HCPCS","0278","RC","","","","both","","","5223.96","3134.38","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2972.43","56.9","","2911.53","1863.86","5209.05","65","607.55","4440.37","percent of total billed charges",""
"FOOT IMPLANT SM CANNULATED PHALINX","SUP-ITM-10193938","CDM","C1776","HCPCS","0278","RC","","","","both","","","5223.96","3134.38","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","607.55","11.63","","400.94","400.94","400.94","1 through 10","607.55","4440.37","percent of total billed charges",""
"FOOT IMPLANT SM CANNULATED PHALINX","SUP-ITM-10193938","CDM","C1776","HCPCS","0278","RC","","","","both","","","5223.96","3134.38","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4043.35","77.4","","5214.50","5214.50","16415.28","1 through 10","607.55","4440.37","percent of total billed charges",""
"FOOT IMPLANT SM CANNULATED PHALINX","SUP-ITM-10193938","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","607.55","11.63","","400.94","400.94","400.94","1 through 10","607.55","4043.35","percent of total billed charges",""
"FOOT IMPLANT SM CANNULATED PHALINX","SUP-ITM-10193938","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2283.92","43.72","","1543.33","1543.33","1671.61","1 through 10","607.55","4043.35","percent of total billed charges",""
"FOOT IMPLANT SM CANNULATED PHALINX","SUP-ITM-10193938","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3798.86","72.72","","3700.21","2382.07","6427.18","53","607.55","4043.35","percent of total billed charges",""
"FOOT IMPLANT SM CANNULATED PHALINX","SUP-ITM-10193938","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3798.86","72.72","","12685.80","12685.80","12685.80","1 through 10","607.55","4043.35","percent of total billed charges",""
"FOOT IMPLANT SM CANNULATED PHALINX","SUP-ITM-10193938","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3285.87","62.9","","3408.87","2784.05","9859.40","46","607.55","4043.35","percent of total billed charges",""
"FOOT IMPLANT SM CANNULATED PHALINX","SUP-ITM-10193938","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4043.35","77.4","","5214.50","5214.50","16415.28","1 through 10","607.55","4043.35","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","both","","","4251.79","2551.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","494.48","3614.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","both","","","4251.79","2551.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","494.48","3614.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","both","","","4251.79","2551.07","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2419.27","56.9","","812.12","238.65","1587.46","163","494.48","3614.02","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","both","","","4251.79","2551.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","494.48","11.63","","112.68","112.68","146.99","38","494.48","3614.02","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","both","","","4251.79","2551.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3290.89","77.4","","303.98","303.98","5854.79","1 through 10","494.48","3614.02","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4251.79","2551.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","494.48","11.63","","112.68","112.68","146.99","38","494.48","3290.89","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4251.79","2551.07","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2669.27","62.78","","780.86","208.94","10480.28","15","494.48","3290.89","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4251.79","2551.07","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1858.88","43.72","","179.76","179.76","179.76","1 through 10","494.48","3290.89","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4251.79","2551.07","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3091.90","72.72","","2355.45","298.99","3965.19","155","494.48","3290.89","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4251.79","2551.07","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3091.90","72.72","","3643.09","3643.09","3643.09","1 through 10","494.48","3290.89","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4251.79","2551.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2262.80","53.22","","554.28","554.28","554.28","16","494.48","3290.89","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4251.79","2551.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2674.38","62.9","","619.64","173.09","2370.64","150","494.48","3290.89","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X27MM 2 HOLE VA LOCKING STAINLESS VARIABLE ANGLE FUSION STRAIGHT","SUP-ITM-10091981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4251.79","2551.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3290.89","77.4","","303.98","303.98","5854.79","1 through 10","494.48","3290.89","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","both","","","4993.24","2995.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","580.71","4244.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","both","","","4993.24","2995.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","580.71","4244.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","both","","","4993.24","2995.94","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2841.15","56.9","","812.12","238.65","1587.46","163","580.71","4244.25","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","both","","","4993.24","2995.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","580.71","11.63","","112.68","112.68","146.99","38","580.71","4244.25","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","both","","","4993.24","2995.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3864.77","77.4","","303.98","303.98","5854.79","1 through 10","580.71","4244.25","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4993.24","2995.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","580.71","11.63","","112.68","112.68","146.99","38","580.71","3864.77","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4993.24","2995.94","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3134.76","62.78","","780.86","208.94","10480.28","15","580.71","3864.77","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4993.24","2995.94","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2183.04","43.72","","179.76","179.76","179.76","1 through 10","580.71","3864.77","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4993.24","2995.94","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3631.08","72.72","","2355.45","298.99","3965.19","155","580.71","3864.77","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4993.24","2995.94","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3631.08","72.72","","3643.09","3643.09","3643.09","1 through 10","580.71","3864.77","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4993.24","2995.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2657.40","53.22","","554.28","554.28","554.28","16","580.71","3864.77","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4993.24","2995.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3140.75","62.9","","619.64","173.09","2370.64","150","580.71","3864.77","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X43MM VA LCP STAINLESS TMT FUSION MID","SUP-ITM-10090505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4993.24","2995.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3864.77","77.4","","303.98","303.98","5854.79","1 through 10","580.71","3864.77","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","both","","","5011.13","3006.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","582.79","4259.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","both","","","5011.13","3006.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","582.79","4259.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","both","","","5011.13","3006.68","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2851.33","56.9","","812.12","238.65","1587.46","163","582.79","4259.46","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","both","","","5011.13","3006.68","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","582.79","11.63","","112.68","112.68","146.99","38","582.79","4259.46","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","both","","","5011.13","3006.68","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3878.61","77.4","","303.98","303.98","5854.79","1 through 10","582.79","4259.46","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5011.13","3006.68","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","582.79","11.63","","112.68","112.68","146.99","38","582.79","3878.61","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5011.13","3006.68","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3145.99","62.78","","780.86","208.94","10480.28","15","582.79","3878.61","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5011.13","3006.68","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2190.87","43.72","","179.76","179.76","179.76","1 through 10","582.79","3878.61","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5011.13","3006.68","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3644.09","72.72","","2355.45","298.99","3965.19","155","582.79","3878.61","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5011.13","3006.68","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3644.09","72.72","","3643.09","3643.09","3643.09","1 through 10","582.79","3878.61","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5011.13","3006.68","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2666.92","53.22","","554.28","554.28","554.28","16","582.79","3878.61","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5011.13","3006.68","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3152.00","62.9","","619.64","173.09","2370.64","150","582.79","3878.61","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X44MM VA LCP STAINLESS L FUSION RIGHT STANDARD","SUP-ITM-10092001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5011.13","3006.68","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3878.61","77.4","","303.98","303.98","5854.79","1 through 10","582.79","3878.61","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","both","","","6251.13","3750.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","727.01","5313.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","both","","","6251.13","3750.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","727.01","5313.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","both","","","6251.13","3750.68","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3556.89","56.9","","812.12","238.65","1587.46","163","727.01","5313.46","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","both","","","6251.13","3750.68","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","727.01","11.63","","112.68","112.68","146.99","38","727.01","5313.46","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","both","","","6251.13","3750.68","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4838.37","77.4","","303.98","303.98","5854.79","1 through 10","727.01","5313.46","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6251.13","3750.68","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","727.01","11.63","","112.68","112.68","146.99","38","727.01","4838.37","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6251.13","3750.68","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3924.46","62.78","","780.86","208.94","10480.28","15","727.01","4838.37","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6251.13","3750.68","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2732.99","43.72","","179.76","179.76","179.76","1 through 10","727.01","4838.37","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6251.13","3750.68","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4545.82","72.72","","2355.45","298.99","3965.19","155","727.01","4838.37","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6251.13","3750.68","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4545.82","72.72","","3643.09","3643.09","3643.09","1 through 10","727.01","4838.37","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6251.13","3750.68","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3326.85","53.22","","554.28","554.28","554.28","16","727.01","4838.37","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6251.13","3750.68","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3931.96","62.9","","619.64","173.09","2370.64","150","727.01","4838.37","percent of total billed charges",""
"FOOT PLATE 2.4 2.7X57MM LG 5DEG VA LCP STAINLESS FIRST MTP FUSION RIGHT","SUP-ITM-10082255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6251.13","3750.68","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4838.37","77.4","","303.98","303.98","5854.79","1 through 10","727.01","4838.37","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","both","","","4878.18","2926.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","567.33","4146.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","both","","","4878.18","2926.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","567.33","4146.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","both","","","4878.18","2926.91","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2775.68","56.9","","812.12","238.65","1587.46","163","567.33","4146.45","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","both","","","4878.18","2926.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","567.33","11.63","","112.68","112.68","146.99","38","567.33","4146.45","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","both","","","4878.18","2926.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3775.71","77.4","","303.98","303.98","5854.79","1 through 10","567.33","4146.45","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4878.18","2926.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","567.33","11.63","","112.68","112.68","146.99","38","567.33","3775.71","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4878.18","2926.91","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3062.52","62.78","","780.86","208.94","10480.28","15","567.33","3775.71","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4878.18","2926.91","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2132.74","43.72","","179.76","179.76","179.76","1 through 10","567.33","3775.71","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4878.18","2926.91","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3547.41","72.72","","2355.45","298.99","3965.19","155","567.33","3775.71","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4878.18","2926.91","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3547.41","72.72","","3643.09","3643.09","3643.09","1 through 10","567.33","3775.71","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4878.18","2926.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2596.17","53.22","","554.28","554.28","554.28","16","567.33","3775.71","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4878.18","2926.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3068.38","62.9","","619.64","173.09","2370.64","150","567.33","3775.71","percent of total billed charges",""
"FOOT PLATE 2.4/2.7X45MM VA LCP STAINLESS CLOVERLEAF FUSION STANDARD","SUP-ITM-10091978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4878.18","2926.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3775.71","77.4","","303.98","303.98","5854.79","1 through 10","567.33","3775.71","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","4990.65","2994.39","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","580.41","4242.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","4990.65","2994.39","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","580.41","4242.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","4990.65","2994.39","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2839.68","56.9","","812.12","238.65","1587.46","163","580.41","4242.05","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","4990.65","2994.39","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","580.41","11.63","","112.68","112.68","146.99","38","580.41","4242.05","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","4990.65","2994.39","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3862.76","77.4","","303.98","303.98","5854.79","1 through 10","580.41","4242.05","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4990.65","2994.39","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","580.41","11.63","","112.68","112.68","146.99","38","580.41","3862.76","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4990.65","2994.39","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3133.13","62.78","","780.86","208.94","10480.28","15","580.41","3862.76","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4990.65","2994.39","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2181.91","43.72","","179.76","179.76","179.76","1 through 10","580.41","3862.76","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4990.65","2994.39","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3629.20","72.72","","2355.45","298.99","3965.19","155","580.41","3862.76","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4990.65","2994.39","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3629.20","72.72","","3643.09","3643.09","3643.09","1 through 10","580.41","3862.76","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4990.65","2994.39","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2656.02","53.22","","554.28","554.28","554.28","16","580.41","3862.76","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4990.65","2994.39","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3139.12","62.9","","619.64","173.09","2370.64","150","580.41","3862.76","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4990.65","2994.39","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3862.76","77.4","","303.98","303.98","5854.79","1 through 10","580.41","3862.76","percent of total billed charges",""
"Foot Procedures With McC","503","MS-DRG","","","","","","","","inpatient","","","44878.70","26927.22","MEDICARE [2001]","HB WDH MEDICARE","21664.03","","Case rate ($21,664.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $20,029.92, add-ons for qualifying new technology services are included. If operating cost exceeds $23,948.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,355.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $19,668.58 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $19,585.05 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,550.58. The transfer capital threshold is the transfer adjustment factor * $1,550.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20414.87","20414.87","20414.87","1 through 10","3975","106062.08","other","Inpatient DRG"
"Foot Procedures Without Cc/McC","505","MS-DRG","","","","","","","","inpatient","","","46764.93","28058.96","MEDICARE [2001]","HB WDH MEDICARE","14074.53","","Case rate ($14,074.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,024.89, add-ons for qualifying new technology services are included. If operating cost exceeds $16,943.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,801.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $12,633.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,580.01 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $995.98. The transfer capital threshold is the transfer adjustment factor * $995.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13721.75","13721.75","13721.75","1 through 10","3975","68126.58","other","Inpatient DRG"
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","both","","","3612.41","2167.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","420.12","3070.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","both","","","3612.41","2167.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","420.12","3070.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","both","","","3612.41","2167.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2055.46","56.9","","0.63","0.63","0.63","1 through 10","420.12","3070.55","percent of total billed charges",""
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","both","","","3612.41","2167.45","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","520.91","14.42","","317.14","317.14","317.14","1 through 10","420.12","3070.55","percent of total billed charges",""
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3612.41","2167.45","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","520.91","14.42","","317.14","317.14","317.14","1 through 10","420.12","2796.01","percent of total billed charges",""
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3612.41","2167.45","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2267.87","62.78","","1125.09","1125.09","1125.09","1 through 10","420.12","2796.01","percent of total billed charges",""
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3612.41","2167.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2626.94","72.72","","4732.50","1617.43","14180.40","1 through 10","420.12","2796.01","percent of total billed charges",""
"FORCEPS BIOPSY 286 CM 1.2 MM SPYBITE MAX","SUP-ITM-10285476","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3612.41","2167.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2272.21","62.9","","3896.20","3341.38","3896.20","1 through 10","420.12","2796.01","percent of total billed charges",""
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With McC","562","MS-DRG","","","","","","","","inpatient","","","34148.05","20488.83","MARTIN'S POINT [160007]","HB WDH MEDICARE","11276.82","","Case rate ($11,276.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,442.64, add-ons for qualifying new technology services are included. If operating cost exceeds $14,360.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,596.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,040.41 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,997.77 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $791.54. The transfer capital threshold is the transfer adjustment factor * $791.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8957.91","8957.91","8957.91","1 through 10","3975","54142.54","other","Inpatient DRG"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With McC","562","MS-DRG","","","","","","","","inpatient","","","34148.05","20488.83","MEDICARE [2001]","HB WDH MEDICARE","11276.82","","Case rate ($11,276.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,442.64, add-ons for qualifying new technology services are included. If operating cost exceeds $14,360.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,596.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,040.41 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,997.77 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $791.54. The transfer capital threshold is the transfer adjustment factor * $791.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11487.72","11218.27","11487.72","1 through 10","3975","54142.54","other","Inpatient DRG"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With McC","562","MS-DRG","","","","","","","","inpatient","","","34148.05","20488.83","WELLSENSE NH [1050]","HB WDH MEDICARE","11276.82","","Case rate ($11,276.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,442.64, add-ons for qualifying new technology services are included. If operating cost exceeds $14,360.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,596.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $10,040.41 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,997.77 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $791.54. The transfer capital threshold is the transfer adjustment factor * $791.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6015.07","6015.07","6015.07","1 through 10","3975","54142.54","other","Inpatient DRG"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without McC","563","MS-DRG","","","","","","","","inpatient","","","26633.06","15979.84","MARTIN'S POINT [160007]","HB WDH MEDICARE","7252.85","","Case rate ($7,252.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,728.56, add-ons for qualifying new technology services are included. If operating cost exceeds $10,646.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,302.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,310.49 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,283.69 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $497.49. The transfer capital threshold is the transfer adjustment factor * $497.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7917.65","7917.65","7917.65","1 through 10","3975","34029.09","other","Inpatient DRG"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without McC","563","MS-DRG","","","","","","","","inpatient","","","26633.06","15979.84","MEDICARE [2001]","HB WDH MEDICARE","7252.85","","Case rate ($7,252.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,728.56, add-ons for qualifying new technology services are included. If operating cost exceeds $10,646.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,302.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,310.49 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,283.69 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $497.49. The transfer capital threshold is the transfer adjustment factor * $497.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7189.00","407.56","7206.58","1 through 10","3975","34029.09","other","Inpatient DRG"
"Fractures Of Femur Without McC","534","MS-DRG","","","","","","","","inpatient","","","24006.10","14403.66","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","6704.65","","Case rate ($6,573.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,101.24, add-ons for qualifying new technology services are included. If operating cost exceeds $10,019.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,252.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,680.50 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,656.37 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.82. The transfer capital threshold is the transfer adjustment factor * $447.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","6602.87","6602.87","6602.87","1 through 10","3975","30631.88","other","Inpatient DRG"
"Fractures Of Femur Without McC","534","MS-DRG","","","","","","","","inpatient","","","24006.10","14403.66","MEDICARE [2001]","HB WDH MEDICARE","6573.19","","Case rate ($6,573.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,101.24, add-ons for qualifying new technology services are included. If operating cost exceeds $10,019.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,252.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,680.50 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,656.37 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.82. The transfer capital threshold is the transfer adjustment factor * $447.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6586.86","6586.86","6603.29","1 through 10","3975","30631.88","other","Inpatient DRG"
"Fractures Of Hip And Pelvis With McC","535","MS-DRG","","","","","","","","inpatient","","","39760.11","23856.07","MARTIN'S POINT [160007]","HB WDH MEDICARE","10191.19","","Case rate ($10,191.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,440.62, add-ons for qualifying new technology services are included. If operating cost exceeds $13,358.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,517.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,034.12 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,995.75 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $712.21. The transfer capital threshold is the transfer adjustment factor * $712.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Includes an additional $800 of payment.","15085.62","15085.62","15085.62","1 through 10","3975","48716.13","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Fractures Of Hip And Pelvis With McC","535","MS-DRG","","","","","","","","inpatient","","","39760.11","23856.07","MEDICARE [2001]","HB WDH MEDICARE","10191.19","","Case rate ($10,191.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,440.62, add-ons for qualifying new technology services are included. If operating cost exceeds $13,358.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,517.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,034.12 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,995.75 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $712.21. The transfer capital threshold is the transfer adjustment factor * $712.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Includes an additional $800 of payment.","10479.62","5590.65","10505.77","1 through 10","3975","48716.13","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Fractures Of Hip And Pelvis With McC","535","MS-DRG","","","","","","","","inpatient","","","39760.11","23856.07","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","10191.19","","Case rate ($10,191.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,440.62, add-ons for qualifying new technology services are included. If operating cost exceeds $13,358.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,517.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,034.12 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,995.75 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $712.21. The transfer capital threshold is the transfer adjustment factor * $712.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Includes an additional $800 of payment.","8005.31","8005.31","8005.31","1 through 10","3975","48716.13","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Fractures Of Hip And Pelvis Without McC","536","MS-DRG","","","","","","","","inpatient","","","24822.08","14893.25","MEDICARE [2001]","HB WDH MEDICARE","6584.60","","Case rate ($6,584.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,111.77, add-ons for qualifying new technology services are included. If operating cost exceeds $10,029.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,253.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,691.07 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,666.90 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.66. The transfer capital threshold is the transfer adjustment factor * $448.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6563.47","1053.61","6579.41","13","3975","30688.88","other","Inpatient DRG"
"Fractures Of Hip And Pelvis Without McC","536","MS-DRG","","","","","","","","inpatient","","","24822.08","14893.25","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6584.60","","Case rate ($6,584.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,111.77, add-ons for qualifying new technology services are included. If operating cost exceeds $10,029.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,253.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,691.07 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,666.90 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.66. The transfer capital threshold is the transfer adjustment factor * $448.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6563.47","6563.47","6563.47","1 through 10","3975","30688.88","other","Inpatient DRG"
"Francisella Tularensis Antibody","PX-30000931","CDM","86668","CPT","0302","RC","","","","outpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","54.72","62.9","","52.92","52.92","52.92","1 through 10","9.71","67.34","percent of total billed charges",""
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","","","","inpatient","","","9878.57","5927.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","158445.22","","Fee schedule rate ($158,445.22). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","9155.06","9155.06","21578.62","1 through 10","504.5","158445.22","case rate",""
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","","","","inpatient","","","9878.57","5927.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","62389.22","","Fee schedule rate ($62,389.22). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","2916.66","2916.66","24779.49","1 through 10","504.5","158445.22","case rate",""
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","","","","inpatient","","","9878.57","5927.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","31501.10","","Case rate ($32,143.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $29,702.80, add-ons for qualifying new technology services are included. If operating cost exceeds $33,620.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,121.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $29,382.72 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $29,257.93 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,316.39. The transfer capital threshold is the transfer adjustment factor * $2,316.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","1952.39","1952.39","1952.39","1 through 10","504.5","158445.22","other","Inpatient DRG"
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","","","","inpatient","","","9878.57","5927.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","126194.11","","Fee schedule rate ($126,194.11). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","12742.64","5582.92","71667.33","12","504.5","158445.22","case rate",""
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","","","","inpatient","","","9878.57","5927.14","TRICARE [160005]","HB WDH MEDICARE","32143.98","","Case rate ($32,143.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $29,702.80, add-ons for qualifying new technology services are included. If operating cost exceeds $33,620.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,121.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $29,382.72 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $29,257.93 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,316.39. The transfer capital threshold is the transfer adjustment factor * $2,316.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8588.26","8588.26","8588.26","1 through 10","504.5","158445.22","other","Inpatient DRG"
"Fungus Antibody Not Specified","PX-30000932","CDM","86671","CPT","0300","RC","","","","inpatient","","","259.00","155.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","199.07","76.86","","157.50","157.50","157.50","1 through 10","171.46","199.07","percent of total billed charges",""
"Fungus Antibody Not Specified","PX-30000932","CDM","86671","CPT","0302","RC","","","","outpatient","","","259.00","155.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","188.34","72.72","","181.80","181.80","181.80","1 through 10","9.1","200.47","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","10063.75","6038.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1170.41","8554.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","10063.75","6038.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1170.41","8554.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","10063.75","6038.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5726.27","56.9","","812.12","238.65","1587.46","163","1170.41","8554.19","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","10063.75","6038.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1170.41","11.63","","112.68","112.68","146.99","38","1170.41","8554.19","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","10063.75","6038.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7789.34","77.4","","303.98","303.98","5854.79","1 through 10","1170.41","8554.19","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10063.75","6038.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1170.41","11.63","","112.68","112.68","146.99","38","1170.41","7789.34","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10063.75","6038.25","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6318.02","62.78","","780.86","208.94","10480.28","15","1170.41","7789.34","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10063.75","6038.25","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4399.87","43.72","","179.76","179.76","179.76","1 through 10","1170.41","7789.34","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10063.75","6038.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7318.36","72.72","","2355.45","298.99","3965.19","155","1170.41","7789.34","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10063.75","6038.25","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7318.36","72.72","","3643.09","3643.09","3643.09","1 through 10","1170.41","7789.34","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10063.75","6038.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","5355.93","53.22","","554.28","554.28","554.28","16","1170.41","7789.34","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10063.75","6038.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6330.10","62.9","","619.64","173.09","2370.64","150","1170.41","7789.34","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10063.75","6038.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7789.34","77.4","","303.98","303.98","5854.79","1 through 10","1170.41","7789.34","percent of total billed charges",""
"G6pd Enzyme Qn","PX-30000470","CDM","82955","CPT","0301","RC","","","","outpatient","","","52.00","31.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","40.25","77.4","","38.75","38.75","38.75","1 through 10","9.04","40.25","percent of total billed charges",""
"Gabapentin Non-Blood","PX-30002872","CDM","80355","CPT","0301","RC","","","","both","","","95.00","57.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","54.06","56.9","","73.43","73.43","73.43","1 through 10","54.06","117.86","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","both","","","234.00","140.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","163.33","69.8","","142.15","18.78","157.75","1 through 10","10.7","198.9","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","outpatient","","","234.00","140.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","102.30","43.72","","98.81","98.81","98.81","1 through 10","15.34","181.12","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","outpatient","","","234.00","140.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","170.16","72.72","","164.35","164.35","493.05","12","15.34","181.12","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","outpatient","","","234.00","140.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","124.53","53.22","","120.48","120.48","120.48","1 through 10","15.34","181.12","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","outpatient","","","234.00","140.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","147.19","62.9","","142.38","142.38","427.14","11","15.34","181.12","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","outpatient","","","234.00","140.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","181.12","77.4","","175.15","162.45","175.15","1 through 10","15.34","181.12","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0300","RC","","","","inpatient","","","132.00","79.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","101.46","76.86","","80.64","80.64","80.64","1 through 10","87.38","101.46","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","132.00","79.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","92.14","69.8","","89.34","80.51","89.34","132","6.05","112.2","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","outpatient","","","132.00","79.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","82.87","62.78","","80.36","80.36","241.08","1 through 10","8.67","102.17","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","outpatient","","","132.00","79.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","57.71","43.72","","55.96","55.96","55.96","1 through 10","8.67","102.17","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","outpatient","","","132.00","79.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","95.99","72.72","","93.08","93.08","279.24","157","8.67","102.17","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","outpatient","","","132.00","79.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","95.99","72.72","","93.08","93.08","93.08","1 through 10","8.67","102.17","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","outpatient","","","132.00","79.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","70.25","53.22","","68.24","68.24","68.24","1 through 10","8.67","102.17","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","outpatient","","","132.00","79.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","83.03","62.9","","80.64","80.64","155.12","176","8.67","102.17","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","outpatient","","","132.00","79.20","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","95.99","72.72","","99.20","99.20","99.20","1 through 10","8.67","102.17","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","outpatient","","","132.00","79.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","102.17","77.4","","99.20","99.20","99.20","117","8.67","102.17","percent of total billed charges",""
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","both","","","4413.00","2647.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1593.15","","Case rate ($1,593.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1554.28","1554.28","1554.28","1 through 10","302.23","3751.05","other","OPPS APC"
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","both","","","4413.00","2647.80","MEDICARE [2001]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","308.44","308.44","308.44","1 through 10","302.23","3751.05","other","OPPS APC"
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","both","","","4413.00","2647.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","141.99","141.99","141.99","1 through 10","302.23","3751.05","other","OPPS APC"
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","both","","","163.00","97.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","113.77","69.8","","110.28","99.38","110.29","66","7.49","138.55","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","outpatient","","","163.00","97.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","102.33","62.78","","99.19","99.19","99.19","1 through 10","10.68","126.16","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","outpatient","","","163.00","97.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","71.26","43.72","","69.08","69.08","69.08","1 through 10","10.68","126.16","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","outpatient","","","163.00","97.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","118.53","72.72","","114.90","114.90","114.90","125","10.68","126.16","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","outpatient","","","163.00","97.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","118.53","72.72","","114.90","114.90","114.90","1 through 10","10.68","126.16","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","outpatient","","","163.00","97.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","86.75","53.22","","84.23","84.23","84.23","1 through 10","10.68","126.16","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","outpatient","","","163.00","97.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","102.53","62.9","","99.54","99.54","99.54","162","10.68","126.16","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","outpatient","","","163.00","97.80","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","118.53","72.72","","122.45","122.45","122.45","1 through 10","10.68","126.16","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","outpatient","","","163.00","97.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","126.16","77.4","","122.45","122.45","122.45","36","10.68","126.16","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","outpatient","","","163.00","97.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","118.53","72.72","","114.90","114.90","114.90","1 through 10","10.68","126.16","percent of total billed charges",""
"Gas Dilution/Washout Determine Lung","PX-46000044","CDM","94727","CPT","0460","RC","","","","both","","","352.00","211.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","200.29","56.9","","193.46","193.46","193.46","36","160.19","1044.65","percent of total billed charges",""
"Gas Dilution/Washout Determine Lung","PX-46000044","CDM","94727","CPT","0460","RC","","","","both","","","352.00","211.20","MEDICARE [2001]","HB WDH MEDICARE","163.46","","APC Price ($163.46). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","163.48","163.48","163.48","1 through 10","160.19","1044.65","other","OPPS APC"
"Gas Dilution/Washout Determine Lung","PX-46000044","CDM","94727","CPT","0460","RC","","","","outpatient","","","352.00","211.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","50.76","14.42","","49.03","42.02","49.03","17","40.94","272.45","percent of total billed charges",""
"Gas Dilution/Washout Determine Lung","PX-46000044","CDM","94727","CPT","0460","RC","","","","outpatient","","","352.00","211.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.94","11.63","","46.82","40.16","85.87","18","40.94","272.45","percent of total billed charges",""
"Gas Dilution/Washout Determine Lung","PX-46000044","CDM","94727","CPT","0460","RC","","","","outpatient","","","352.00","211.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","153.89","43.72","","148.65","148.65","148.65","1 through 10","40.94","272.45","percent of total billed charges",""
"Gas Dilution/Washout Determine Lung","PX-46000044","CDM","94727","CPT","0460","RC","","","","outpatient","","","352.00","211.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","255.97","72.72","","247.25","247.25","247.25","13","40.94","272.45","percent of total billed charges",""
"Gas Dilution/Washout Determine Lung","PX-46000044","CDM","94727","CPT","0460","RC","","","","outpatient","","","352.00","211.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","255.97","72.72","","247.25","247.25","247.25","1 through 10","40.94","272.45","percent of total billed charges",""
"Gas Dilution/Washout Determine Lung","PX-46000044","CDM","94727","CPT","0460","RC","","","","outpatient","","","352.00","211.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","221.41","62.9","","214.20","214.20","214.20","17","40.94","272.45","percent of total billed charges",""
"Gas Dilution/Washout Determine Lung","PX-46000044","CDM","94727","CPT","0460","RC","","","","outpatient","","","352.00","211.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","272.45","77.4","","263.50","247.25","263.50","1 through 10","40.94","272.45","percent of total billed charges",""
"Gas Dilution/Washout Determine Lung","PX-46000044","CDM","94727","CPT","0460","RC","","","","outpatient","","","352.00","211.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.94","11.63","","40.16","40.16","40.16","11","40.94","272.45","percent of total billed charges",""
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","3434.00","2060.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2683.02","","Case rate ($2,683.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2617.59","2612.24","2617.59","1 through 10","411.42","2918.9","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","3434.00","2060.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1155.31","","Case rate ($1,155.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1127.14","1127.14","1127.14","1 through 10","411.42","2918.9","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","3434.00","2060.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","411.42","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","419.36","393.82","419.86","1 through 10","411.42","2918.9","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","3434.00","2060.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","432.41","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","432.46","432.46","432.46","1 through 10","411.42","2918.9","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","3434.00","2060.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","419.82","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.86","419.86","419.86","1 through 10","411.42","2918.9","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","3434.00","2060.40","MEDICARE [2001]","HB WDH MEDICARE","419.82","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.86","401.86","419.86","17","411.42","2918.9","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","3434.00","2060.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","419.82","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","414.47","393.83","419.86","1 through 10","411.42","2918.9","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","3434.00","2060.40","WELLSENSE NH [1050]","HB WDH MEDICARE","419.82","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","433.63","433.63","433.63","1 through 10","411.42","2918.9","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","outpatient","","","3434.00","2060.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","495.18","14.42","","409.61","409.61","409.61","1 through 10","399.37","2657.92","percent of total billed charges",""
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","outpatient","","","3434.00","2060.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","399.37","11.63","","405.63","391.44","405.63","1 through 10","399.37","2657.92","percent of total billed charges",""
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","outpatient","","","3434.00","2060.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2497.20","72.72","","2409.94","2409.94","2409.94","1 through 10","399.37","2657.92","percent of total billed charges",""
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","outpatient","","","3434.00","2060.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2159.99","62.9","","2087.82","2087.82","2087.82","1 through 10","399.37","2657.92","percent of total billed charges",""
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","outpatient","","","3434.00","2060.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2657.92","77.4","","2568.35","2568.35","2568.35","1 through 10","399.37","2657.92","percent of total billed charges",""
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","outpatient","","","3434.00","2060.40","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","2497.20","72.72","","2409.94","2409.94","2409.94","1 through 10","399.37","2657.92","percent of total billed charges",""
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","outpatient","","","3434.00","2060.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","399.37","11.63","","391.44","391.44","658.34","1 through 10","399.37","2657.92","percent of total billed charges",""
"Gastrin","PX-30000459","CDM","82941","CPT","0301","RC","","","","outpatient","","","95.00","57.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","69.08","72.72","","66.90","66.90","66.90","1 through 10","16.43","73.53","percent of total billed charges",""
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","31370.50","18822.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","14674.10","","Fee schedule rate ($14,674.10). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","14392.09","14392.09","14392.09","1 through 10","7003.8","37266.7","case rate",""
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","31370.50","18822.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","7742.57","","Case rate ($7,900.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,326.41, add-ons for qualifying new technology services are included. If operating cost exceeds $11,244.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,349.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,910.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,881.54 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $544.82. The transfer capital threshold is the transfer adjustment factor * $544.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7745.26","6332.58","7903.33","1 through 10","7003.8","37266.7","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","31370.50","18822.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","29681.16","","Fee schedule rate ($29,681.16). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","39842.17","39842.17","39842.17","1 through 10","7003.8","37266.7","case rate",""
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","31370.50","18822.30","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","8137.60","","Case rate ($7,900.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,326.41, add-ons for qualifying new technology services are included. If operating cost exceeds $11,244.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,349.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,910.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,881.54 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $544.82. The transfer capital threshold is the transfer adjustment factor * $544.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","4995.63","4995.63","4995.63","1 through 10","7003.8","37266.7","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","31370.50","18822.30","MEDICARE [2001]","HB WDH MEDICARE","7900.58","","Case rate ($7,900.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,326.41, add-ons for qualifying new technology services are included. If operating cost exceeds $11,244.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,349.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,910.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,881.54 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $544.82. The transfer capital threshold is the transfer adjustment factor * $544.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7883.95","0.05","7903.33","44","7003.8","37266.7","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","31370.50","18822.30","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7900.58","","Case rate ($7,900.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,326.41, add-ons for qualifying new technology services are included. If operating cost exceeds $11,244.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,349.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,910.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,881.54 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $544.82. The transfer capital threshold is the transfer adjustment factor * $544.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7883.95","7765.78","7903.33","1 through 10","7003.8","37266.7","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With McC","377","MS-DRG","","","","","","","","inpatient","","","45557.39","27334.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","27352.14","","Fee schedule rate ($27,352.14). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","26541.95","26541.95","26541.95","1 through 10","13054.9","69464.18","case rate",""
"Gastrointestinal Hemorrhage With McC","377","MS-DRG","","","","","","","","inpatient","","","45557.39","27334.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","14055.28","","Case rate ($14,342.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,271.88, add-ons for qualifying new technology services are included. If operating cost exceeds $17,190.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,820.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,881.72 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,827.01 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.53. The transfer capital threshold is the transfer adjustment factor * $1,015.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13880.84","13880.84","13880.84","1 through 10","13054.9","69464.18","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With McC","377","MS-DRG","","","","","","","","inpatient","","","45557.39","27334.43","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","14772.38","","Case rate ($14,342.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,271.88, add-ons for qualifying new technology services are included. If operating cost exceeds $17,190.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,820.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,881.72 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,827.01 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.53. The transfer capital threshold is the transfer adjustment factor * $1,015.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","13751.23","5554.18","13751.24","1 through 10","13054.9","69464.18","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With McC","377","MS-DRG","","","","","","","","inpatient","","","45557.39","27334.43","MARTIN'S POINT [160007]","HB WDH MEDICARE","14342.12","","Case rate ($14,342.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,271.88, add-ons for qualifying new technology services are included. If operating cost exceeds $17,190.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,820.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,881.72 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,827.01 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.53. The transfer capital threshold is the transfer adjustment factor * $1,015.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13882.93","13882.93","13882.93","1 through 10","13054.9","69464.18","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With McC","377","MS-DRG","","","","","","","","inpatient","","","45557.39","27334.43","MEDICARE [2001]","HB WDH MEDICARE","14342.12","","Case rate ($14,342.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,271.88, add-ons for qualifying new technology services are included. If operating cost exceeds $17,190.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,820.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,881.72 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,827.01 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.53. The transfer capital threshold is the transfer adjustment factor * $1,015.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12671.69","952.63","14199.86","23","13054.9","69464.18","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With McC","377","MS-DRG","","","","","","","","inpatient","","","45557.39","27334.43","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","14342.12","","Case rate ($14,342.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,271.88, add-ons for qualifying new technology services are included. If operating cost exceeds $17,190.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,820.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,881.72 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,827.01 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.53. The transfer capital threshold is the transfer adjustment factor * $1,015.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13916.84","9848.56","21839.47","1 through 10","13054.9","69464.18","other","Inpatient DRG"
"Gastrointestinal Hemorrhage Without Cc/McC","379","MS-DRG","","","","","","","","inpatient","","","21081.60","12648.96","MEDICARE [2001]","HB WDH MEDICARE","5237.45","","Case rate ($5,237.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $4,868.36, add-ons for qualifying new technology services are included. If operating cost exceeds $8,786.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,155.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,442.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,423.49 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $350.21. The transfer capital threshold is the transfer adjustment factor * $350.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5249.05","5249.05","5249.05","1 through 10","4502.08","23955.26","other","Inpatient DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","24597.36","14758.42","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","6578.26","","Case rate ($6,449.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,986.86, add-ons for qualifying new technology services are included. If operating cost exceeds $9,905.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,243.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,565.64 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,542.00 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $438.77. The transfer capital threshold is the transfer adjustment factor * $438.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","6509.49","6509.49","6509.49","1 through 10","3975","30012.48","other","Inpatient DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","24597.36","14758.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","11817.68","","Fee schedule rate ($11,817.68). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","11701.70","11701.70","11701.70","1 through 10","3975","30012.48","case rate",""
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","24597.36","14758.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","6320.28","","Case rate ($6,449.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,986.86, add-ons for qualifying new technology services are included. If operating cost exceeds $9,905.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,243.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,565.64 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,542.00 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $438.77. The transfer capital threshold is the transfer adjustment factor * $438.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11065.42","11065.42","11065.42","1 through 10","3975","30012.48","other","Inpatient DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","24597.36","14758.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","23903.52","","Fee schedule rate ($23,903.52). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","23668.92","23668.92","23668.92","1 through 10","3975","30012.48","case rate",""
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","24597.36","14758.42","MARTIN'S POINT [160007]","HB WDH MEDICARE","6449.27","","Case rate ($6,449.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,986.86, add-ons for qualifying new technology services are included. If operating cost exceeds $9,905.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,243.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,565.64 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,542.00 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $438.77. The transfer capital threshold is the transfer adjustment factor * $438.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6386.39","6386.39","6388.64","1 through 10","3975","30012.48","other","Inpatient DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","24597.36","14758.42","MEDICARE [2001]","HB WDH MEDICARE","6449.27","","Case rate ($6,449.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,986.86, add-ons for qualifying new technology services are included. If operating cost exceeds $9,905.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,243.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,565.64 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,542.00 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $438.77. The transfer capital threshold is the transfer adjustment factor * $438.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6493.31","0.05","6509.07","20","3975","30012.48","other","Inpatient DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","24597.36","14758.42","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6449.27","","Case rate ($6,449.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,986.86, add-ons for qualifying new technology services are included. If operating cost exceeds $9,905.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,243.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,565.64 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,542.00 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $438.77. The transfer capital threshold is the transfer adjustment factor * $438.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6416.49","4505.94","6509.07","1 through 10","3975","30012.48","other","Inpatient DRG"
"Gastrointestinal Obstruction With McC","388","MS-DRG","","","","","","","","inpatient","","","34821.98","20893.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","22097.18","","Fee schedule rate ($22,097.18). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","4768.33","4768.33","4768.33","1 through 10","3975","56118.55","case rate",""
"Gastrointestinal Obstruction With McC","388","MS-DRG","","","","","","","","inpatient","","","34821.98","20893.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","44695.77","","Fee schedule rate ($44,695.77). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","38484.10","38484.10","38484.10","1 through 10","3975","56118.55","case rate",""
"Gastrointestinal Obstruction With McC","388","MS-DRG","","","","","","","","inpatient","","","34821.98","20893.19","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","12022.30","","Case rate ($11,672.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,807.52, add-ons for qualifying new technology services are included. If operating cost exceeds $14,725.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,625.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,406.85 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,362.65 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $820.43. The transfer capital threshold is the transfer adjustment factor * $820.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11149.50","11149.50","11149.50","1 through 10","3975","56118.55","other","Inpatient DRG"
"Gastrointestinal Obstruction With McC","388","MS-DRG","","","","","","","","inpatient","","","34821.98","20893.19","MARTIN'S POINT [160007]","HB WDH MEDICARE","11672.14","","Case rate ($11,672.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,807.52, add-ons for qualifying new technology services are included. If operating cost exceeds $14,725.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,625.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,406.85 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,362.65 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $820.43. The transfer capital threshold is the transfer adjustment factor * $820.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7216.08","7216.08","7216.08","1 through 10","3975","56118.55","other","Inpatient DRG"
"Gastrointestinal Obstruction With McC","388","MS-DRG","","","","","","","","inpatient","","","34821.98","20893.19","MEDICARE [2001]","HB WDH MEDICARE","11672.14","","Case rate ($11,672.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,807.52, add-ons for qualifying new technology services are included. If operating cost exceeds $14,725.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,625.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,406.85 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,362.65 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $820.43. The transfer capital threshold is the transfer adjustment factor * $820.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11536.00","7839.30","11565.67","1 through 10","3975","56118.55","other","Inpatient DRG"
"Gastrointestinal Obstruction Without Cc/McC","390","MS-DRG","","","","","","","","inpatient","","","22782.67","13669.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","16464.31","","Fee schedule rate ($16,464.31). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","16157.22","16157.22","16157.22","1 through 10","3885.05","20672.05","case rate",""
"Gastrointestinal Obstruction Without Cc/McC","390","MS-DRG","","","","","","","","inpatient","","","22782.67","13669.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","4718.01","","Case rate ($4,580.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $4,262.10, add-ons for qualifying new technology services are included. If operating cost exceeds $8,180.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,107.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,833.51 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $3,817.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $302.22. The transfer capital threshold is the transfer adjustment factor * $302.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","4165.23","4165.23","4165.23","1 through 10","3885.05","20672.05","other","Inpatient DRG"
"Gastrointestinal Obstruction Without Cc/McC","390","MS-DRG","","","","","","","","inpatient","","","22782.67","13669.60","MEDICARE [2001]","HB WDH MEDICARE","4580.59","","Case rate ($4,580.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $4,262.10, add-ons for qualifying new technology services are included. If operating cost exceeds $8,180.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,107.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $3,833.51 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $3,817.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $302.22. The transfer capital threshold is the transfer adjustment factor * $302.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","4573.71","0.05","4584.47","1 through 10","3885.05","20672.05","other","Inpatient DRG"
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","1213.95","728.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","141.18","1031.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","1213.95","728.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","141.18","1031.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","1213.95","728.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","690.74","56.9","","812.12","238.65","1587.46","163","141.18","1031.86","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","1213.95","728.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","141.18","11.63","","112.68","112.68","146.99","38","141.18","1031.86","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","1213.95","728.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","939.60","77.4","","303.98","303.98","5854.79","1 through 10","141.18","1031.86","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1213.95","728.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","141.18","11.63","","112.68","112.68","146.99","38","141.18","939.6","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1213.95","728.37","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","762.12","62.78","","780.86","208.94","10480.28","15","141.18","939.6","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1213.95","728.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","530.74","43.72","","179.76","179.76","179.76","1 through 10","141.18","939.6","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1213.95","728.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","882.78","72.72","","2355.45","298.99","3965.19","155","141.18","939.6","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1213.95","728.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","882.78","72.72","","3643.09","3643.09","3643.09","1 through 10","141.18","939.6","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1213.95","728.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","646.06","53.22","","554.28","554.28","554.28","16","141.18","939.6","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1213.95","728.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","763.57","62.9","","619.64","173.09","2370.64","150","141.18","939.6","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1213.95","728.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","939.60","77.4","","303.98","303.98","5854.79","1 through 10","141.18","939.6","percent of total billed charges",""
"GEL MATRIX 1.0ML GRAFT BONE GRAFTON ALLOGRAFT DEMINERALIZED SYRINGE","SUP-ITM-10118241","CDM","C1889","HCPCS","0278","RC","","","","both","","","1014.94","608.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","118.04","862.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GEL MATRIX 1.0ML GRAFT BONE GRAFTON ALLOGRAFT DEMINERALIZED SYRINGE","SUP-ITM-10118241","CDM","C1889","HCPCS","0278","RC","","","","both","","","1014.94","608.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","118.04","862.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GEL MATRIX 1.0ML GRAFT BONE GRAFTON ALLOGRAFT DEMINERALIZED SYRINGE","SUP-ITM-10118241","CDM","C1889","HCPCS","0278","RC","","","","both","","","1014.94","608.96","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","577.50","56.9","","0.63","0.63","0.63","1 through 10","118.04","862.7","percent of total billed charges",""
"GEL MATRIX 1.0ML GRAFT BONE GRAFTON ALLOGRAFT DEMINERALIZED SYRINGE","SUP-ITM-10118241","CDM","C1889","HCPCS","0278","RC","","","","both","","","1014.94","608.96","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","146.35","14.42","","317.14","317.14","317.14","1 through 10","118.04","862.7","percent of total billed charges",""
"GEL MATRIX 1.0ML GRAFT BONE GRAFTON ALLOGRAFT DEMINERALIZED SYRINGE","SUP-ITM-10118241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1014.94","608.96","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","146.35","14.42","","317.14","317.14","317.14","1 through 10","118.04","785.56","percent of total billed charges",""
"GEL MATRIX 1.0ML GRAFT BONE GRAFTON ALLOGRAFT DEMINERALIZED SYRINGE","SUP-ITM-10118241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1014.94","608.96","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","637.18","62.78","","1125.09","1125.09","1125.09","1 through 10","118.04","785.56","percent of total billed charges",""
"GEL MATRIX 1.0ML GRAFT BONE GRAFTON ALLOGRAFT DEMINERALIZED SYRINGE","SUP-ITM-10118241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1014.94","608.96","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","738.06","72.72","","4732.50","1617.43","14180.40","1 through 10","118.04","785.56","percent of total billed charges",""
"GEL MATRIX 1.0ML GRAFT BONE GRAFTON ALLOGRAFT DEMINERALIZED SYRINGE","SUP-ITM-10118241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1014.94","608.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","638.40","62.9","","3896.20","3341.38","3896.20","1 through 10","118.04","785.56","percent of total billed charges",""
"GENERATOR PULSE PRECISION SPECTRA NEUROSTIMULATOR SPINE IMPLANTABLE","SUP-ITM-10126476","CDM","C1820","HCPCS","0278","RC","","","","both","","","38468.00","23080.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","52982.00","26491.00","52982.00","1 through 10","4473.83","32697.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GENERATOR PULSE PRECISION SPECTRA NEUROSTIMULATOR SPINE IMPLANTABLE","SUP-ITM-10126476","CDM","C1820","HCPCS","0278","RC","","","","both","","","38468.00","23080.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","21888.29","56.9","","45220.14","36256.68","45220.14","1 through 10","4473.83","32697.8","percent of total billed charges",""
"GENERATOR PULSE PRECISION SPECTRA NEUROSTIMULATOR SPINE IMPLANTABLE","SUP-ITM-10126476","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","38468.00","23080.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","27973.93","72.72","","18421.60","18421.60","18421.60","1 through 10","4473.83","29774.23","percent of total billed charges",""
"GENERATOR SPECTRA WAVEWRITER SPINAL CORD","SUP-ITM-10232345","CDM","C1820","HCPCS","0278","RC","","","","both","","","40120.00","24072.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","52982.00","26491.00","52982.00","1 through 10","4665.96","34102","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GENERATOR SPECTRA WAVEWRITER SPINAL CORD","SUP-ITM-10232345","CDM","C1820","HCPCS","0278","RC","","","","both","","","40120.00","24072.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","22828.28","56.9","","45220.14","36256.68","45220.14","1 through 10","4665.96","34102","percent of total billed charges",""
"GENERATOR SPECTRA WAVEWRITER SPINAL CORD","SUP-ITM-10232345","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","40120.00","24072.00","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","29175.26","72.72","","18421.60","18421.60","18421.60","1 through 10","4665.96","31052.88","percent of total billed charges",""
"GENERATOR SPINE PRECISION NOVI PULSE","SUP-ITM-10166128","CDM","C1767","HCPCS","0278","RC","","","","outpatient","","","28320.00","16992.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","17813.28","62.9","","79618.14","79618.14","79618.14","1 through 10","3293.62","21919.68","percent of total billed charges",""
"Genotype Hiv 1 Oth Region","PX-30001366","CDM","87906","CPT","0306","RC","","","","outpatient","","","702.00","421.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","510.49","72.72","","493.77","493.77","493.77","1 through 10","306.91","543.35","percent of total billed charges",""
"Gft Skin Sub F/S/E </=100cm 1st 25","PX-76000180","CDM","15275","CPT","0761","RC","","","","both","","","4638.00","2782.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","3237.32","69.8","","3124.25","3124.25","3124.25","1 through 10","1872.88","12213.74","percent of total billed charges",""
"Gft Skin Sub F/S/E </=100cm 1st 25","PX-76000180","CDM","15275","CPT","0761","RC","","","","both","","","4638.00","2782.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","12213.74","","Case rate ($12,213.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","10772.50","10656.00","15154.70","1 through 10","1872.88","12213.74","other","OPPS APC"
"Gft Skin Sub F/S/E </=100cm 1st 25","PX-76000180","CDM","15275","CPT","0761","RC","","","","both","","","4638.00","2782.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","5259.23","","Case rate ($5,259.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4973.46","4973.46","4973.46","1 through 10","1872.88","12213.74","other","OPPS APC"
"Gft Skin Sub F/S/E </=100cm 1st 25","PX-76000180","CDM","15275","CPT","0761","RC","","","","both","","","4638.00","2782.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","1911.11","","APC Price ($1,911.11). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1873.10","1873.10","1873.10","1 through 10","1872.88","12213.74","other","OPPS APC"
"Gft Skin Sub F/S/E </=100cm 1st 25","PX-76000180","CDM","15275","CPT","0761","RC","","","","both","","","4638.00","2782.80","MEDICARE [2001]","HB WDH MEDICARE","1911.11","","APC Price ($1,911.11). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1911.33","1911.33","3553.66","31","1872.88","12213.74","other","OPPS APC"
"Gft Skin Sub F/S/E </=100cm 1st 25","PX-76000180","CDM","15275","CPT","0761","RC","","","","both","","","4638.00","2782.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1911.11","","APC Price ($1,911.11). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1911.33","1911.33","1911.33","1 through 10","1872.88","12213.74","other","OPPS APC"
"Gft Skin Sub F/S/E </=100cm 1st 25","PX-76000180","CDM","15275","CPT","0761","RC","","","","outpatient","","","4638.00","2782.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","668.80","14.42","","645.44","645.44","645.44","1 through 10","539.4","3589.81","percent of total billed charges",""
"Gft Skin Sub F/S/E </=100cm 1st 25","PX-76000180","CDM","15275","CPT","0761","RC","","","","outpatient","","","4638.00","2782.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","539.40","11.63","","1130.43","1130.43","1130.43","1 through 10","539.4","3589.81","percent of total billed charges",""
"Gft Skin Sub F/S/E </=100cm 1st 25","PX-76000180","CDM","15275","CPT","0761","RC","","","","outpatient","","","4638.00","2782.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","7065.93","7065.93","7065.93","1 through 10","539.4","3589.81","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Gft Skin Sub F/S/E </=100cm 1st 25","PX-76000180","CDM","15275","CPT","0761","RC","","","","outpatient","","","4638.00","2782.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3254.95","3254.95","3254.95","1 through 10","539.4","3589.81","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Gft Skin Sub T/a/L <=100cm 25 Sq Cm","PX-76000176","CDM","15271","CPT","0761","RC","","","","both","","","4115.00","2469.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","2872.27","69.8","","2771.76","2771.76","2771.76","1 through 10","1872.88","12213.74","percent of total billed charges",""
"Gft Skin Sub T/a/L <=100cm 25 Sq Cm","PX-76000176","CDM","15271","CPT","0761","RC","","","","both","","","4115.00","2469.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1872.88","","APC Price ($1,911.11). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1911.33","1873.10","1911.33","1 through 10","1872.88","12213.74","other","OPPS APC"
"Gft Skin Sub T/a/L <=100cm 25 Sq Cm","PX-76000176","CDM","15271","CPT","0761","RC","","","","both","","","4115.00","2469.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","1911.11","","APC Price ($1,911.11). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1911.33","1911.33","1911.33","1 through 10","1872.88","12213.74","other","OPPS APC"
"Gft Skin Sub T/a/L <=100cm 25 Sq Cm","PX-76000176","CDM","15271","CPT","0761","RC","","","","both","","","4115.00","2469.00","MEDICARE [2001]","HB WDH MEDICARE","1911.11","","APC Price ($1,911.11). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1911.33","1911.33","3822.66","157","1872.88","12213.74","other","OPPS APC"
"Gft Skin Sub T/a/L <=100cm 25 Sq Cm","PX-76000176","CDM","15271","CPT","0761","RC","","","","both","","","4115.00","2469.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1911.11","","APC Price ($1,911.11). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1911.33","1911.33","1911.33","15","1872.88","12213.74","other","OPPS APC"
"Gft Skin Sub T/a/L <=100cm 25 Sq Cm","PX-76000176","CDM","15271","CPT","0761","RC","","","","outpatient","","","4115.00","2469.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","593.38","14.42","","572.62","490.82","572.62","29","478.57","3185.01","percent of total billed charges",""
"Gft Skin Sub T/a/L <=100cm 25 Sq Cm","PX-76000176","CDM","15271","CPT","0761","RC","","","","outpatient","","","4115.00","2469.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","478.57","11.63","","486.05","486.05","486.05","1 through 10","478.57","3185.01","percent of total billed charges",""
"Gft Skin Sub T/a/L <=100cm 25 Sq Cm","PX-76000176","CDM","15271","CPT","0761","RC","","","","outpatient","","","4115.00","2469.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","4319.61","4122.58","7110.91","1 through 10","478.57","3185.01","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Gft Skin Sub T/a/L <=100cm 25 Sq Cm","PX-76000176","CDM","15271","CPT","0761","RC","","","","outpatient","","","4115.00","2469.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2588.34","62.9","","2501.73","2501.73","2501.73","1 through 10","478.57","3185.01","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","both","","","102.00","61.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","71.20","69.8","","69.10","62.27","69.10","11","4.68","86.7","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","outpatient","","","102.00","61.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","64.04","62.78","","62.15","62.15","62.15","1 through 10","6.71","78.95","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","outpatient","","","102.00","61.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","74.17","72.72","","71.99","71.99","71.99","27","6.71","78.95","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","outpatient","","","102.00","61.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","74.17","72.72","","71.99","71.99","71.99","1 through 10","6.71","78.95","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","outpatient","","","102.00","61.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","64.16","62.9","","62.37","62.37","62.37","32","6.71","78.95","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","outpatient","","","102.00","61.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","78.95","77.4","","76.73","76.73","76.73","1 through 10","6.71","78.95","percent of total billed charges",""
"GLENOID CAGE LASER M 8 POST AUG RIGHT","SUP-ITM-10321148","CDM","C1776","HCPCS","0278","RC","","","","both","","","9093.75","5456.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1057.6","7729.69","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GLENOID CAGE LASER M 8 POST AUG RIGHT","SUP-ITM-10321148","CDM","C1776","HCPCS","0278","RC","","","","both","","","9093.75","5456.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5174.34","56.9","","2911.53","1863.86","5209.05","65","1057.6","7729.69","percent of total billed charges",""
"GLENOID CAGE LASER M 8 POST AUG RIGHT","SUP-ITM-10321148","CDM","C1776","HCPCS","0278","RC","","","","both","","","9093.75","5456.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1057.60","11.63","","400.94","400.94","400.94","1 through 10","1057.6","7729.69","percent of total billed charges",""
"GLENOID CAGE LASER M 8 POST AUG RIGHT","SUP-ITM-10321148","CDM","C1776","HCPCS","0278","RC","","","","both","","","9093.75","5456.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7038.56","77.4","","5214.50","5214.50","16415.28","1 through 10","1057.6","7729.69","percent of total billed charges",""
"GLENOID CAGE LASER M 8 POST AUG RIGHT","SUP-ITM-10321148","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9093.75","5456.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1057.60","11.63","","400.94","400.94","400.94","1 through 10","1057.6","7038.56","percent of total billed charges",""
"GLENOID CAGE LASER M 8 POST AUG RIGHT","SUP-ITM-10321148","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9093.75","5456.25","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3975.79","43.72","","1543.33","1543.33","1671.61","1 through 10","1057.6","7038.56","percent of total billed charges",""
"GLENOID CAGE LASER M 8 POST AUG RIGHT","SUP-ITM-10321148","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9093.75","5456.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6612.98","72.72","","3700.21","2382.07","6427.18","53","1057.6","7038.56","percent of total billed charges",""
"GLENOID CAGE LASER M 8 POST AUG RIGHT","SUP-ITM-10321148","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9093.75","5456.25","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6612.98","72.72","","12685.80","12685.80","12685.80","1 through 10","1057.6","7038.56","percent of total billed charges",""
"GLENOID CAGE LASER M 8 POST AUG RIGHT","SUP-ITM-10321148","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9093.75","5456.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5719.97","62.9","","3408.87","2784.05","9859.40","46","1057.6","7038.56","percent of total billed charges",""
"GLENOID CAGE LASER M 8 POST AUG RIGHT","SUP-ITM-10321148","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9093.75","5456.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7038.56","77.4","","5214.50","5214.50","16415.28","1 through 10","1057.6","7038.56","percent of total billed charges",""
"GLENOID CAGE LG LASER 8 POST AUG LEFT","SUP-ITM-10317772","CDM","C1776","HCPCS","0278","RC","","","","both","","","9093.75","5456.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1057.6","7729.69","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GLENOID CAGE LG LASER 8 POST AUG LEFT","SUP-ITM-10317772","CDM","C1776","HCPCS","0278","RC","","","","both","","","9093.75","5456.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5174.34","56.9","","2911.53","1863.86","5209.05","65","1057.6","7729.69","percent of total billed charges",""
"GLENOID CAGE LG LASER 8 POST AUG LEFT","SUP-ITM-10317772","CDM","C1776","HCPCS","0278","RC","","","","both","","","9093.75","5456.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1057.60","11.63","","400.94","400.94","400.94","1 through 10","1057.6","7729.69","percent of total billed charges",""
"GLENOID CAGE LG LASER 8 POST AUG LEFT","SUP-ITM-10317772","CDM","C1776","HCPCS","0278","RC","","","","both","","","9093.75","5456.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7038.56","77.4","","5214.50","5214.50","16415.28","1 through 10","1057.6","7729.69","percent of total billed charges",""
"GLENOID CAGE LG LASER 8 POST AUG LEFT","SUP-ITM-10317772","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9093.75","5456.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1057.60","11.63","","400.94","400.94","400.94","1 through 10","1057.6","7038.56","percent of total billed charges",""
"GLENOID CAGE LG LASER 8 POST AUG LEFT","SUP-ITM-10317772","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9093.75","5456.25","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3975.79","43.72","","1543.33","1543.33","1671.61","1 through 10","1057.6","7038.56","percent of total billed charges",""
"GLENOID CAGE LG LASER 8 POST AUG LEFT","SUP-ITM-10317772","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9093.75","5456.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6612.98","72.72","","3700.21","2382.07","6427.18","53","1057.6","7038.56","percent of total billed charges",""
"GLENOID CAGE LG LASER 8 POST AUG LEFT","SUP-ITM-10317772","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9093.75","5456.25","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6612.98","72.72","","12685.80","12685.80","12685.80","1 through 10","1057.6","7038.56","percent of total billed charges",""
"GLENOID CAGE LG LASER 8 POST AUG LEFT","SUP-ITM-10317772","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9093.75","5456.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5719.97","62.9","","3408.87","2784.05","9859.40","46","1057.6","7038.56","percent of total billed charges",""
"GLENOID CAGE LG LASER 8 POST AUG LEFT","SUP-ITM-10317772","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9093.75","5456.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7038.56","77.4","","5214.50","5214.50","16415.28","1 through 10","1057.6","7038.56","percent of total billed charges",""
"GLENOID COMPONENT 15DEG SM CORTILOC RT","SUP-ITM-10205064","CDM","C1776","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1128.11","8245","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GLENOID COMPONENT 15DEG SM CORTILOC RT","SUP-ITM-10205064","CDM","C1776","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5519.30","56.9","","2911.53","1863.86","5209.05","65","1128.11","8245","percent of total billed charges",""
"GLENOID COMPONENT 15DEG SM CORTILOC RT","SUP-ITM-10205064","CDM","C1776","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1128.11","11.63","","400.94","400.94","400.94","1 through 10","1128.11","8245","percent of total billed charges",""
"GLENOID COMPONENT 15DEG SM CORTILOC RT","SUP-ITM-10205064","CDM","C1776","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7507.80","77.4","","5214.50","5214.50","16415.28","1 through 10","1128.11","8245","percent of total billed charges",""
"GLENOID COMPONENT 15DEG SM CORTILOC RT","SUP-ITM-10205064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1128.11","11.63","","400.94","400.94","400.94","1 through 10","1128.11","7507.8","percent of total billed charges",""
"GLENOID COMPONENT 15DEG SM CORTILOC RT","SUP-ITM-10205064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4240.84","43.72","","1543.33","1543.33","1671.61","1 through 10","1128.11","7507.8","percent of total billed charges",""
"GLENOID COMPONENT 15DEG SM CORTILOC RT","SUP-ITM-10205064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7053.84","72.72","","3700.21","2382.07","6427.18","53","1128.11","7507.8","percent of total billed charges",""
"GLENOID COMPONENT 15DEG SM CORTILOC RT","SUP-ITM-10205064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7053.84","72.72","","12685.80","12685.80","12685.80","1 through 10","1128.11","7507.8","percent of total billed charges",""
"GLENOID COMPONENT 15DEG SM CORTILOC RT","SUP-ITM-10205064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6101.30","62.9","","3408.87","2784.05","9859.40","46","1128.11","7507.8","percent of total billed charges",""
"GLENOID COMPONENT 15DEG SM CORTILOC RT","SUP-ITM-10205064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7507.80","77.4","","5214.50","5214.50","16415.28","1 through 10","1128.11","7507.8","percent of total billed charges",""
"GLENOSPHERE CANNULATED 36MM PLUS 2MM INFERIOR OFFSET COCR ECCENTRIC","SUP-ITM-10297481","CDM","C1776","HCPCS","0278","RC","","","","both","","","5820.00","3492.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","676.87","4947","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GLENOSPHERE CANNULATED 36MM PLUS 2MM INFERIOR OFFSET COCR ECCENTRIC","SUP-ITM-10297481","CDM","C1776","HCPCS","0278","RC","","","","both","","","5820.00","3492.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3311.58","56.9","","2911.53","1863.86","5209.05","65","676.87","4947","percent of total billed charges",""
"GLENOSPHERE CANNULATED 36MM PLUS 2MM INFERIOR OFFSET COCR ECCENTRIC","SUP-ITM-10297481","CDM","C1776","HCPCS","0278","RC","","","","both","","","5820.00","3492.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","676.87","11.63","","400.94","400.94","400.94","1 through 10","676.87","4947","percent of total billed charges",""
"GLENOSPHERE CANNULATED 36MM PLUS 2MM INFERIOR OFFSET COCR ECCENTRIC","SUP-ITM-10297481","CDM","C1776","HCPCS","0278","RC","","","","both","","","5820.00","3492.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4504.68","77.4","","5214.50","5214.50","16415.28","1 through 10","676.87","4947","percent of total billed charges",""
"GLENOSPHERE CANNULATED 36MM PLUS 2MM INFERIOR OFFSET COCR ECCENTRIC","SUP-ITM-10297481","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","676.87","11.63","","400.94","400.94","400.94","1 through 10","676.87","4504.68","percent of total billed charges",""
"GLENOSPHERE CANNULATED 36MM PLUS 2MM INFERIOR OFFSET COCR ECCENTRIC","SUP-ITM-10297481","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2544.50","43.72","","1543.33","1543.33","1671.61","1 through 10","676.87","4504.68","percent of total billed charges",""
"GLENOSPHERE CANNULATED 36MM PLUS 2MM INFERIOR OFFSET COCR ECCENTRIC","SUP-ITM-10297481","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4232.30","72.72","","3700.21","2382.07","6427.18","53","676.87","4504.68","percent of total billed charges",""
"GLENOSPHERE CANNULATED 36MM PLUS 2MM INFERIOR OFFSET COCR ECCENTRIC","SUP-ITM-10297481","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4232.30","72.72","","12685.80","12685.80","12685.80","1 through 10","676.87","4504.68","percent of total billed charges",""
"GLENOSPHERE CANNULATED 36MM PLUS 2MM INFERIOR OFFSET COCR ECCENTRIC","SUP-ITM-10297481","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3660.78","62.9","","3408.87","2784.05","9859.40","46","676.87","4504.68","percent of total billed charges",""
"GLENOSPHERE CANNULATED 36MM PLUS 2MM INFERIOR OFFSET COCR ECCENTRIC","SUP-ITM-10297481","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4504.68","77.4","","5214.50","5214.50","16415.28","1 through 10","676.87","4504.68","percent of total billed charges",""
"GLENOSPHERE CANNULATED 39MM TITANIUM STANDARD","SUP-ITM-10297485","CDM","C1776","HCPCS","0278","RC","","","","both","","","13784.48","8270.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1603.14","11716.81","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GLENOSPHERE CANNULATED 39MM TITANIUM STANDARD","SUP-ITM-10297485","CDM","C1776","HCPCS","0278","RC","","","","both","","","13784.48","8270.69","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7843.37","56.9","","2911.53","1863.86","5209.05","65","1603.14","11716.81","percent of total billed charges",""
"GLENOSPHERE CANNULATED 39MM TITANIUM STANDARD","SUP-ITM-10297485","CDM","C1776","HCPCS","0278","RC","","","","both","","","13784.48","8270.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1603.14","11.63","","400.94","400.94","400.94","1 through 10","1603.14","11716.81","percent of total billed charges",""
"GLENOSPHERE CANNULATED 39MM TITANIUM STANDARD","SUP-ITM-10297485","CDM","C1776","HCPCS","0278","RC","","","","both","","","13784.48","8270.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10669.19","77.4","","5214.50","5214.50","16415.28","1 through 10","1603.14","11716.81","percent of total billed charges",""
"GLENOSPHERE CANNULATED 39MM TITANIUM STANDARD","SUP-ITM-10297485","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13784.48","8270.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1603.14","11.63","","400.94","400.94","400.94","1 through 10","1603.14","10669.19","percent of total billed charges",""
"GLENOSPHERE CANNULATED 39MM TITANIUM STANDARD","SUP-ITM-10297485","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13784.48","8270.69","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","6026.57","43.72","","1543.33","1543.33","1671.61","1 through 10","1603.14","10669.19","percent of total billed charges",""
"GLENOSPHERE CANNULATED 39MM TITANIUM STANDARD","SUP-ITM-10297485","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13784.48","8270.69","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10024.07","72.72","","3700.21","2382.07","6427.18","53","1603.14","10669.19","percent of total billed charges",""
"GLENOSPHERE CANNULATED 39MM TITANIUM STANDARD","SUP-ITM-10297485","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13784.48","8270.69","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","10024.07","72.72","","12685.80","12685.80","12685.80","1 through 10","1603.14","10669.19","percent of total billed charges",""
"GLENOSPHERE CANNULATED 39MM TITANIUM STANDARD","SUP-ITM-10297485","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13784.48","8270.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8670.44","62.9","","3408.87","2784.05","9859.40","46","1603.14","10669.19","percent of total billed charges",""
"GLENOSPHERE CANNULATED 39MM TITANIUM STANDARD","SUP-ITM-10297485","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13784.48","8270.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10669.19","77.4","","5214.50","5214.50","16415.28","1 through 10","1603.14","10669.19","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","both","","","132.00","79.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","92.14","69.8","","89.34","80.51","89.35","1 through 10","7.83","112.2","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","both","","","132.00","79.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","75.11","56.9","","72.83","72.83","145.66","1 through 10","7.83","112.2","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","both","","","132.00","79.20","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","75.11","56.9","","59.86","59.86","59.86","1 through 10","7.83","112.2","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","outpatient","","","132.00","79.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","19.03","14.42","","10.73","10.73","10.73","1 through 10","15.35","102.17","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","outpatient","","","132.00","79.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","15.35","11.63","","10.63","10.63","32.00","16","15.35","102.17","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","outpatient","","","132.00","79.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","57.71","43.72","","55.96","55.96","55.96","1 through 10","15.35","102.17","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","outpatient","","","132.00","79.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","95.99","72.72","","93.08","93.08","93.08","12","15.35","102.17","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","outpatient","","","132.00","79.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","70.25","53.22","","68.24","68.24","68.24","1 through 10","15.35","102.17","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","outpatient","","","132.00","79.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","83.03","62.9","","80.64","80.64","80.64","1 through 10","15.35","102.17","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","outpatient","","","132.00","79.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","102.17","77.4","","99.20","99.20","99.20","1 through 10","15.35","102.17","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","outpatient","","","132.00","79.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","15.35","11.63","","10.63","10.63","18.99","1 through 10","15.35","102.17","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","both","","","57.00","34.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","39.79","69.8","","38.39","34.60","38.39","1 through 10","2.55","48.45","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","outpatient","","","57.00","34.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","35.78","62.78","","34.53","34.53","34.53","1 through 10","3.65","44.12","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","outpatient","","","57.00","34.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","24.92","43.72","","24.05","24.05","24.05","1 through 10","3.65","44.12","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","outpatient","","","57.00","34.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","41.45","72.72","","40.00","40.00","40.00","42","3.65","44.12","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","outpatient","","","57.00","34.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","41.45","72.72","","40.00","40.00","40.00","1 through 10","3.65","44.12","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","outpatient","","","57.00","34.20","INTERNATIONAL COMMERCIAL [140001]","HB WDH UNITED HMO / PPO / INDEM","44.12","77.4","","42.63","42.63","42.63","1 through 10","3.65","44.12","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","outpatient","","","57.00","34.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","30.34","53.22","","29.32","29.32","29.32","1 through 10","3.65","44.12","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","outpatient","","","57.00","34.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","35.85","62.9","","34.65","34.65","34.65","47","3.65","44.12","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","outpatient","","","57.00","34.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","44.12","77.4","","42.63","42.63","42.63","24","3.65","44.12","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","outpatient","","","57.00","34.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","41.45","72.72","","40.00","40.00","40.00","1 through 10","3.65","44.12","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","both","","","37.00","22.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","25.83","69.8","","25.13","22.64","25.13","27","2.13","31.45","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","outpatient","","","37.00","22.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","23.23","62.78","","22.60","22.60","22.60","1 through 10","2.17","28.64","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","outpatient","","","37.00","22.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","16.18","43.72","","15.74","15.74","15.74","1 through 10","2.17","28.64","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","outpatient","","","37.00","22.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","26.91","72.72","","26.18","26.18","26.18","46","2.17","28.64","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","outpatient","","","37.00","22.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","26.91","72.72","","26.18","26.18","26.18","1 through 10","2.17","28.64","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","outpatient","","","37.00","22.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","23.27","62.9","","22.68","22.68","22.68","35","2.17","28.64","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","outpatient","","","37.00","22.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","28.64","77.4","","27.90","27.90","27.90","17","2.17","28.64","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","outpatient","","","37.00","22.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","26.91","72.72","","26.18","26.18","26.18","1 through 10","2.17","28.64","percent of total billed charges",""
"Glucose Fluid Not Blood","PX-30000461","CDM","82945","CPT","0300","RC","","","","inpatient","","","57.00","34.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","43.81","76.86","","34.65","34.65","34.65","1 through 10","37.73","43.81","percent of total billed charges",""
"Glucose Fluid Not Blood","PX-30000461","CDM","82945","CPT","0301","RC","","","","both","","","57.00","34.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","39.79","69.8","","38.39","38.39","38.39","1 through 10","2.55","48.45","percent of total billed charges",""
"Glucose Fluid Not Blood","PX-30000461","CDM","82945","CPT","0301","RC","","","","outpatient","","","57.00","34.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","41.45","72.72","","40.00","40.00","40.00","1 through 10","4.7","44.12","percent of total billed charges",""
"Glucose Fluid Not Blood","PX-30000461","CDM","82945","CPT","0301","RC","","","","outpatient","","","57.00","34.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","41.45","72.72","","40.00","40.00","40.00","1 through 10","4.7","44.12","percent of total billed charges",""
"Glucose Fluid Not Blood","PX-30000461","CDM","82945","CPT","0301","RC","","","","outpatient","","","57.00","34.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","35.85","62.9","","103.95","34.65","133.68","18","4.7","44.12","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","both","","","56.00","33.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","39.09","69.8","","37.69","5.41","37.69","58","3.09","47.6","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","outpatient","","","56.00","33.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","35.16","62.78","","33.90","33.90","33.90","1 through 10","4.43","43.34","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","outpatient","","","56.00","33.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","24.48","43.72","","23.61","23.61","23.61","1 through 10","4.43","43.34","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","outpatient","","","56.00","33.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","40.72","72.72","","39.27","39.27","39.27","81","4.43","43.34","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","outpatient","","","56.00","33.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","29.80","53.22","","28.79","28.79","28.79","1 through 10","4.43","43.34","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","outpatient","","","56.00","33.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","35.22","62.9","","34.02","34.02","34.02","83","4.43","43.34","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","outpatient","","","56.00","33.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","43.34","77.4","","41.85","41.85","41.85","55","4.43","43.34","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","outpatient","","","56.00","33.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","40.72","72.72","","39.27","39.27","39.27","1 through 10","4.43","43.34","percent of total billed charges",""
"Glucose Tolerance 1st 3 Specimen","PX-30000466","CDM","82951","CPT","0301","RC","","","","both","","","182.00","109.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","127.04","69.8","","122.85","14.68","122.85","1 through 10","8.37","154.7","percent of total billed charges",""
"Glucose Tolerance 1st 3 Specimen","PX-30000466","CDM","82951","CPT","0301","RC","","","","outpatient","","","182.00","109.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","132.35","72.72","","127.99","40.00","127.99","12","11.99","140.87","percent of total billed charges",""
"Glucose Tolerance 1st 3 Specimen","PX-30000466","CDM","82951","CPT","0301","RC","","","","outpatient","","","182.00","109.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","132.35","72.72","","127.99","127.99","127.99","1 through 10","11.99","140.87","percent of total billed charges",""
"Glucose Tolerance 1st 3 Specimen","PX-30000466","CDM","82951","CPT","0301","RC","","","","outpatient","","","182.00","109.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","114.48","62.9","","110.88","110.88","110.88","1 through 10","11.99","140.87","percent of total billed charges",""
"Glucose Tolerance 1st 3 Specimen","PX-30000466","CDM","82951","CPT","0301","RC","","","","outpatient","","","182.00","109.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","140.87","77.4","","136.40","136.40","136.40","1 through 10","11.99","140.87","percent of total billed charges",""
"Glycated Protein (Fructosamine)","PX-30000480","CDM","82985","CPT","0301","RC","","","","both","","","81.00","48.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","56.54","69.8","","54.44","54.44","54.44","1 through 10","10.89","78.25","percent of total billed charges",""
"Glycated Protein (Fructosamine)","PX-30000480","CDM","82985","CPT","0301","RC","","","","outpatient","","","81.00","48.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","58.90","72.72","","56.72","56.72","56.72","1 through 10","18.06","62.69","percent of total billed charges",""
"Glycated Protein (Fructosamine)","PX-30000480","CDM","82985","CPT","0301","RC","","","","outpatient","","","81.00","48.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","43.11","53.22","","41.58","41.58","41.58","1 through 10","18.06","62.69","percent of total billed charges",""
"Glycated Protein (Fructosamine)","PX-30000480","CDM","82985","CPT","0301","RC","","","","outpatient","","","81.00","48.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","50.95","62.9","","49.14","49.14","49.14","1 through 10","18.06","62.69","percent of total billed charges",""
"Glycated Protein (Fructosamine)","PX-30000480","CDM","82985","CPT","0301","RC","","","","outpatient","","","81.00","48.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","62.69","77.4","","60.45","60.45","60.45","1 through 10","18.06","62.69","percent of total billed charges",""
"GRAFT 0.76 1.24X1.0 40 70CM XW .76TO TISSUE THCK BIOCOMPATIBLE FLEXI DECELLULARIZED DERMIS IMPLANTABLE","SUP-ITM-10129698","CDM","C1889","HCPCS","0278","RC","","","","both","","","9324.90","5594.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","1084.49","7926.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT 0.76 1.24X1.0 40 70CM XW .76TO TISSUE THCK BIOCOMPATIBLE FLEXI DECELLULARIZED DERMIS IMPLANTABLE","SUP-ITM-10129698","CDM","C1889","HCPCS","0278","RC","","","","both","","","9324.90","5594.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","1084.49","7926.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT 0.76 1.24X1.0 40 70CM XW .76TO TISSUE THCK BIOCOMPATIBLE FLEXI DECELLULARIZED DERMIS IMPLANTABLE","SUP-ITM-10129698","CDM","C1889","HCPCS","0278","RC","","","","both","","","9324.90","5594.94","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5305.87","56.9","","0.63","0.63","0.63","1 through 10","1084.49","7926.17","percent of total billed charges",""
"GRAFT 0.76 1.24X1.0 40 70CM XW .76TO TISSUE THCK BIOCOMPATIBLE FLEXI DECELLULARIZED DERMIS IMPLANTABLE","SUP-ITM-10129698","CDM","C1889","HCPCS","0278","RC","","","","both","","","9324.90","5594.94","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1344.65","14.42","","317.14","317.14","317.14","1 through 10","1084.49","7926.17","percent of total billed charges",""
"GRAFT 0.76 1.24X1.0 40 70CM XW .76TO TISSUE THCK BIOCOMPATIBLE FLEXI DECELLULARIZED DERMIS IMPLANTABLE","SUP-ITM-10129698","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9324.90","5594.94","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1344.65","14.42","","317.14","317.14","317.14","1 through 10","1084.49","7217.47","percent of total billed charges",""
"GRAFT 0.76 1.24X1.0 40 70CM XW .76TO TISSUE THCK BIOCOMPATIBLE FLEXI DECELLULARIZED DERMIS IMPLANTABLE","SUP-ITM-10129698","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9324.90","5594.94","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5854.17","62.78","","1125.09","1125.09","1125.09","1 through 10","1084.49","7217.47","percent of total billed charges",""
"GRAFT 0.76 1.24X1.0 40 70CM XW .76TO TISSUE THCK BIOCOMPATIBLE FLEXI DECELLULARIZED DERMIS IMPLANTABLE","SUP-ITM-10129698","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9324.90","5594.94","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6781.07","72.72","","4732.50","1617.43","14180.40","1 through 10","1084.49","7217.47","percent of total billed charges",""
"GRAFT 0.76 1.24X1.0 40 70CM XW .76TO TISSUE THCK BIOCOMPATIBLE FLEXI DECELLULARIZED DERMIS IMPLANTABLE","SUP-ITM-10129698","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9324.90","5594.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5865.36","62.9","","3896.20","3341.38","3896.20","1 through 10","1084.49","7217.47","percent of total billed charges",""
"GRAFT ALLO 20ML DEMINERALIZED MATRIX MIX FREEZE DRIED","SUP-ITM-10048898","CDM","C1889","HCPCS","0278","RC","","","","both","","","10436.04","6261.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","1213.71","8870.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT ALLO 20ML DEMINERALIZED MATRIX MIX FREEZE DRIED","SUP-ITM-10048898","CDM","C1889","HCPCS","0278","RC","","","","both","","","10436.04","6261.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","1213.71","8870.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT ALLO 20ML DEMINERALIZED MATRIX MIX FREEZE DRIED","SUP-ITM-10048898","CDM","C1889","HCPCS","0278","RC","","","","both","","","10436.04","6261.62","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5938.11","56.9","","0.63","0.63","0.63","1 through 10","1213.71","8870.63","percent of total billed charges",""
"GRAFT ALLO 20ML DEMINERALIZED MATRIX MIX FREEZE DRIED","SUP-ITM-10048898","CDM","C1889","HCPCS","0278","RC","","","","both","","","10436.04","6261.62","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1504.88","14.42","","317.14","317.14","317.14","1 through 10","1213.71","8870.63","percent of total billed charges",""
"GRAFT ALLO 20ML DEMINERALIZED MATRIX MIX FREEZE DRIED","SUP-ITM-10048898","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10436.04","6261.62","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1504.88","14.42","","317.14","317.14","317.14","1 through 10","1213.71","8077.49","percent of total billed charges",""
"GRAFT ALLO 20ML DEMINERALIZED MATRIX MIX FREEZE DRIED","SUP-ITM-10048898","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10436.04","6261.62","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6551.75","62.78","","1125.09","1125.09","1125.09","1 through 10","1213.71","8077.49","percent of total billed charges",""
"GRAFT ALLO 20ML DEMINERALIZED MATRIX MIX FREEZE DRIED","SUP-ITM-10048898","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10436.04","6261.62","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7589.09","72.72","","4732.50","1617.43","14180.40","1 through 10","1213.71","8077.49","percent of total billed charges",""
"GRAFT ALLO 20ML DEMINERALIZED MATRIX MIX FREEZE DRIED","SUP-ITM-10048898","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10436.04","6261.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6564.27","62.9","","3896.20","3341.38","3896.20","1 through 10","1213.71","8077.49","percent of total billed charges",""
"GRAFT ALLO 7.0X14 11MM TISSUE CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10028233","CDM","C1889","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","562.54","4111.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT ALLO 7.0X14 11MM TISSUE CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10028233","CDM","C1889","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","562.54","4111.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT ALLO 7.0X14 11MM TISSUE CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10028233","CDM","C1889","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2752.25","56.9","","0.63","0.63","0.63","1 through 10","562.54","4111.45","percent of total billed charges",""
"GRAFT ALLO 7.0X14 11MM TISSUE CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10028233","CDM","C1889","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","697.50","14.42","","317.14","317.14","317.14","1 through 10","562.54","4111.45","percent of total billed charges",""
"GRAFT ALLO 7.0X14 11MM TISSUE CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10028233","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","697.50","14.42","","317.14","317.14","317.14","1 through 10","562.54","3743.84","percent of total billed charges",""
"GRAFT ALLO 7.0X14 11MM TISSUE CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10028233","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3036.67","62.78","","1125.09","1125.09","1125.09","1 through 10","562.54","3743.84","percent of total billed charges",""
"GRAFT ALLO 7.0X14 11MM TISSUE CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10028233","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3517.47","72.72","","4732.50","1617.43","14180.40","1 through 10","562.54","3743.84","percent of total billed charges",""
"GRAFT ALLO 7.0X14 11MM TISSUE CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10028233","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3042.47","62.9","","3896.20","3341.38","3896.20","1 through 10","562.54","3743.84","percent of total billed charges",""
"GRAFT ALLO AVANCE 15X2.0 3.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100507","CDM","C1889","HCPCS","0278","RC","","","","both","","","10282.00","6169.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","1195.8","8739.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT ALLO AVANCE 15X2.0 3.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100507","CDM","C1889","HCPCS","0278","RC","","","","both","","","10282.00","6169.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","1195.8","8739.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT ALLO AVANCE 15X2.0 3.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100507","CDM","C1889","HCPCS","0278","RC","","","","both","","","10282.00","6169.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5850.46","56.9","","0.63","0.63","0.63","1 through 10","1195.8","8739.7","percent of total billed charges",""
"GRAFT ALLO AVANCE 15X2.0 3.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100507","CDM","C1889","HCPCS","0278","RC","","","","both","","","10282.00","6169.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1482.66","14.42","","317.14","317.14","317.14","1 through 10","1195.8","8739.7","percent of total billed charges",""
"GRAFT ALLO AVANCE 15X2.0 3.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100507","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10282.00","6169.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1482.66","14.42","","317.14","317.14","317.14","1 through 10","1195.8","7958.27","percent of total billed charges",""
"GRAFT ALLO AVANCE 15X2.0 3.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100507","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10282.00","6169.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6455.04","62.78","","1125.09","1125.09","1125.09","1 through 10","1195.8","7958.27","percent of total billed charges",""
"GRAFT ALLO AVANCE 15X2.0 3.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100507","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10282.00","6169.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7477.07","72.72","","4732.50","1617.43","14180.40","1 through 10","1195.8","7958.27","percent of total billed charges",""
"GRAFT ALLO AVANCE 15X2.0 3.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100507","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10282.00","6169.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6467.38","62.9","","3896.20","3341.38","3896.20","1 through 10","1195.8","7958.27","percent of total billed charges",""
"GRAFT ALLO XW 8.0X12CM DERMAL L12 AXIS TUTOPLAST IMPLANTABLE URINARY INCONTINENCE","SUP-ITM-10080581","CDM","C1762","HCPCS","0278","RC","","","","outpatient","","","12758.32","7654.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8024.98","62.9","","6599.70","6599.70","6599.70","1 through 10","1483.79","9874.94","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","both","","","832.38","499.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","96.81","707.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","both","","","832.38","499.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","96.81","707.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","both","","","832.38","499.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","473.62","56.9","","0.63","0.63","0.63","1 through 10","96.81","707.52","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","both","","","832.38","499.43","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","120.03","14.42","","317.14","317.14","317.14","1 through 10","96.81","707.52","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","832.38","499.43","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","120.03","14.42","","317.14","317.14","317.14","1 through 10","96.81","644.26","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","832.38","499.43","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","522.57","62.78","","1125.09","1125.09","1125.09","1 through 10","96.81","644.26","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","832.38","499.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","605.31","72.72","","4732.50","1617.43","14180.40","1 through 10","96.81","644.26","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","832.38","499.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","523.57","62.9","","3896.20","3341.38","3896.20","1 through 10","96.81","644.26","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008886","CDM","C1889","HCPCS","0278","RC","","","","both","","","2255.42","1353.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","262.31","1917.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 1 8MM READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008886","CDM","C1889","HCPCS","0278","RC","","","","both","","","2255.42","1353.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","262.31","1917.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 1 8MM READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008886","CDM","C1889","HCPCS","0278","RC","","","","both","","","2255.42","1353.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1283.33","56.9","","0.63","0.63","0.63","1 through 10","262.31","1917.11","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008886","CDM","C1889","HCPCS","0278","RC","","","","both","","","2255.42","1353.25","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","325.23","14.42","","317.14","317.14","317.14","1 through 10","262.31","1917.11","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008886","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2255.42","1353.25","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","325.23","14.42","","317.14","317.14","317.14","1 through 10","262.31","1745.7","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008886","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2255.42","1353.25","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1415.95","62.78","","1125.09","1125.09","1125.09","1 through 10","262.31","1745.7","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008886","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2255.42","1353.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1640.14","72.72","","4732.50","1617.43","14180.40","1 through 10","262.31","1745.7","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008886","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2255.42","1353.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1418.66","62.9","","3896.20","3341.38","3896.20","1 through 10","262.31","1745.7","percent of total billed charges",""
"GRAFT BONE 100MMX15 STRUT FREEZE DRIED MATRI CORTICAL FEMUR IMPLANTABLE","SUP-ITM-10010252","CDM","C1889","HCPCS","0278","RC","","","","both","","","5239.65","3143.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","609.37","4453.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 100MMX15 STRUT FREEZE DRIED MATRI CORTICAL FEMUR IMPLANTABLE","SUP-ITM-10010252","CDM","C1889","HCPCS","0278","RC","","","","both","","","5239.65","3143.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","609.37","4453.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 100MMX15 STRUT FREEZE DRIED MATRI CORTICAL FEMUR IMPLANTABLE","SUP-ITM-10010252","CDM","C1889","HCPCS","0278","RC","","","","both","","","5239.65","3143.79","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2981.36","56.9","","0.63","0.63","0.63","1 through 10","609.37","4453.7","percent of total billed charges",""
"GRAFT BONE 100MMX15 STRUT FREEZE DRIED MATRI CORTICAL FEMUR IMPLANTABLE","SUP-ITM-10010252","CDM","C1889","HCPCS","0278","RC","","","","both","","","5239.65","3143.79","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","755.56","14.42","","317.14","317.14","317.14","1 through 10","609.37","4453.7","percent of total billed charges",""
"GRAFT BONE 100MMX15 STRUT FREEZE DRIED MATRI CORTICAL FEMUR IMPLANTABLE","SUP-ITM-10010252","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5239.65","3143.79","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","755.56","14.42","","317.14","317.14","317.14","1 through 10","609.37","4055.49","percent of total billed charges",""
"GRAFT BONE 100MMX15 STRUT FREEZE DRIED MATRI CORTICAL FEMUR IMPLANTABLE","SUP-ITM-10010252","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5239.65","3143.79","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3289.45","62.78","","1125.09","1125.09","1125.09","1 through 10","609.37","4055.49","percent of total billed charges",""
"GRAFT BONE 100MMX15 STRUT FREEZE DRIED MATRI CORTICAL FEMUR IMPLANTABLE","SUP-ITM-10010252","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5239.65","3143.79","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3810.27","72.72","","4732.50","1617.43","14180.40","1 through 10","609.37","4055.49","percent of total billed charges",""
"GRAFT BONE 100MMX15 STRUT FREEZE DRIED MATRI CORTICAL FEMUR IMPLANTABLE","SUP-ITM-10010252","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5239.65","3143.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3295.74","62.9","","3896.20","3341.38","3896.20","1 through 10","609.37","4055.49","percent of total billed charges",""
"GRAFT BONE 10MM WEDGE FREEZE DRIED MATRI ILIAC CREST TRICORTICAL IMPLANTABLE","SUP-ITM-10010314","CDM","C1889","HCPCS","0278","RC","","","","both","","","4521.14","2712.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","525.81","3842.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 10MM WEDGE FREEZE DRIED MATRI ILIAC CREST TRICORTICAL IMPLANTABLE","SUP-ITM-10010314","CDM","C1889","HCPCS","0278","RC","","","","both","","","4521.14","2712.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","525.81","3842.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 10MM WEDGE FREEZE DRIED MATRI ILIAC CREST TRICORTICAL IMPLANTABLE","SUP-ITM-10010314","CDM","C1889","HCPCS","0278","RC","","","","both","","","4521.14","2712.68","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2572.53","56.9","","0.63","0.63","0.63","1 through 10","525.81","3842.97","percent of total billed charges",""
"GRAFT BONE 10MM WEDGE FREEZE DRIED MATRI ILIAC CREST TRICORTICAL IMPLANTABLE","SUP-ITM-10010314","CDM","C1889","HCPCS","0278","RC","","","","both","","","4521.14","2712.68","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","651.95","14.42","","317.14","317.14","317.14","1 through 10","525.81","3842.97","percent of total billed charges",""
"GRAFT BONE 10MM WEDGE FREEZE DRIED MATRI ILIAC CREST TRICORTICAL IMPLANTABLE","SUP-ITM-10010314","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4521.14","2712.68","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","651.95","14.42","","317.14","317.14","317.14","1 through 10","525.81","3499.36","percent of total billed charges",""
"GRAFT BONE 10MM WEDGE FREEZE DRIED MATRI ILIAC CREST TRICORTICAL IMPLANTABLE","SUP-ITM-10010314","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4521.14","2712.68","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2838.37","62.78","","1125.09","1125.09","1125.09","1 through 10","525.81","3499.36","percent of total billed charges",""
"GRAFT BONE 10MM WEDGE FREEZE DRIED MATRI ILIAC CREST TRICORTICAL IMPLANTABLE","SUP-ITM-10010314","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4521.14","2712.68","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3287.77","72.72","","4732.50","1617.43","14180.40","1 through 10","525.81","3499.36","percent of total billed charges",""
"GRAFT BONE 10MM WEDGE FREEZE DRIED MATRI ILIAC CREST TRICORTICAL IMPLANTABLE","SUP-ITM-10010314","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4521.14","2712.68","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2843.80","62.9","","3896.20","3341.38","3896.20","1 through 10","525.81","3499.36","percent of total billed charges",""
"GRAFT BONE 15ML OSTEOSET XENO SUBSTITUTE RESORBABLE MINIMALLY INVASIVE INJECTABLE MIIG","SUP-ITM-10193686","CDM","C1713","HCPCS","0278","RC","","","","both","","","6353.50","3812.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","738.91","5400.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 15ML OSTEOSET XENO SUBSTITUTE RESORBABLE MINIMALLY INVASIVE INJECTABLE MIIG","SUP-ITM-10193686","CDM","C1713","HCPCS","0278","RC","","","","both","","","6353.50","3812.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","738.91","5400.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 15ML OSTEOSET XENO SUBSTITUTE RESORBABLE MINIMALLY INVASIVE INJECTABLE MIIG","SUP-ITM-10193686","CDM","C1713","HCPCS","0278","RC","","","","both","","","6353.50","3812.10","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3615.14","56.9","","812.12","238.65","1587.46","163","738.91","5400.48","percent of total billed charges",""
"GRAFT BONE 15ML OSTEOSET XENO SUBSTITUTE RESORBABLE MINIMALLY INVASIVE INJECTABLE MIIG","SUP-ITM-10193686","CDM","C1713","HCPCS","0278","RC","","","","both","","","6353.50","3812.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","738.91","11.63","","112.68","112.68","146.99","38","738.91","5400.48","percent of total billed charges",""
"GRAFT BONE 15ML OSTEOSET XENO SUBSTITUTE RESORBABLE MINIMALLY INVASIVE INJECTABLE MIIG","SUP-ITM-10193686","CDM","C1713","HCPCS","0278","RC","","","","both","","","6353.50","3812.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4917.61","77.4","","303.98","303.98","5854.79","1 through 10","738.91","5400.48","percent of total billed charges",""
"GRAFT BONE 15ML OSTEOSET XENO SUBSTITUTE RESORBABLE MINIMALLY INVASIVE INJECTABLE MIIG","SUP-ITM-10193686","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6353.50","3812.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","738.91","11.63","","112.68","112.68","146.99","38","738.91","4917.61","percent of total billed charges",""
"GRAFT BONE 15ML OSTEOSET XENO SUBSTITUTE RESORBABLE MINIMALLY INVASIVE INJECTABLE MIIG","SUP-ITM-10193686","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6353.50","3812.10","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3988.73","62.78","","780.86","208.94","10480.28","15","738.91","4917.61","percent of total billed charges",""
"GRAFT BONE 15ML OSTEOSET XENO SUBSTITUTE RESORBABLE MINIMALLY INVASIVE INJECTABLE MIIG","SUP-ITM-10193686","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6353.50","3812.10","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2777.75","43.72","","179.76","179.76","179.76","1 through 10","738.91","4917.61","percent of total billed charges",""
"GRAFT BONE 15ML OSTEOSET XENO SUBSTITUTE RESORBABLE MINIMALLY INVASIVE INJECTABLE MIIG","SUP-ITM-10193686","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6353.50","3812.10","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4620.27","72.72","","2355.45","298.99","3965.19","155","738.91","4917.61","percent of total billed charges",""
"GRAFT BONE 15ML OSTEOSET XENO SUBSTITUTE RESORBABLE MINIMALLY INVASIVE INJECTABLE MIIG","SUP-ITM-10193686","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6353.50","3812.10","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4620.27","72.72","","3643.09","3643.09","3643.09","1 through 10","738.91","4917.61","percent of total billed charges",""
"GRAFT BONE 15ML OSTEOSET XENO SUBSTITUTE RESORBABLE MINIMALLY INVASIVE INJECTABLE MIIG","SUP-ITM-10193686","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6353.50","3812.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3381.33","53.22","","554.28","554.28","554.28","16","738.91","4917.61","percent of total billed charges",""
"GRAFT BONE 15ML OSTEOSET XENO SUBSTITUTE RESORBABLE MINIMALLY INVASIVE INJECTABLE MIIG","SUP-ITM-10193686","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6353.50","3812.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3996.35","62.9","","619.64","173.09","2370.64","150","738.91","4917.61","percent of total billed charges",""
"GRAFT BONE 15ML OSTEOSET XENO SUBSTITUTE RESORBABLE MINIMALLY INVASIVE INJECTABLE MIIG","SUP-ITM-10193686","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6353.50","3812.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4917.61","77.4","","303.98","303.98","5854.79","1 through 10","738.91","4917.61","percent of total billed charges",""
"GRAFT BONE 15X120MM 200 XW FROZEN STRUT MATRI CORTICAL IMPLANTABLE","SUP-ITM-10010269","CDM","C1889","HCPCS","0278","RC","","","","both","","","2800.35","1680.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","325.68","2380.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 15X120MM 200 XW FROZEN STRUT MATRI CORTICAL IMPLANTABLE","SUP-ITM-10010269","CDM","C1889","HCPCS","0278","RC","","","","both","","","2800.35","1680.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","325.68","2380.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 15X120MM 200 XW FROZEN STRUT MATRI CORTICAL IMPLANTABLE","SUP-ITM-10010269","CDM","C1889","HCPCS","0278","RC","","","","both","","","2800.35","1680.21","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1593.40","56.9","","0.63","0.63","0.63","1 through 10","325.68","2380.3","percent of total billed charges",""
"GRAFT BONE 15X120MM 200 XW FROZEN STRUT MATRI CORTICAL IMPLANTABLE","SUP-ITM-10010269","CDM","C1889","HCPCS","0278","RC","","","","both","","","2800.35","1680.21","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","403.81","14.42","","317.14","317.14","317.14","1 through 10","325.68","2380.3","percent of total billed charges",""
"GRAFT BONE 15X120MM 200 XW FROZEN STRUT MATRI CORTICAL IMPLANTABLE","SUP-ITM-10010269","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2800.35","1680.21","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","403.81","14.42","","317.14","317.14","317.14","1 through 10","325.68","2167.47","percent of total billed charges",""
"GRAFT BONE 15X120MM 200 XW FROZEN STRUT MATRI CORTICAL IMPLANTABLE","SUP-ITM-10010269","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2800.35","1680.21","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1758.06","62.78","","1125.09","1125.09","1125.09","1 through 10","325.68","2167.47","percent of total billed charges",""
"GRAFT BONE 15X120MM 200 XW FROZEN STRUT MATRI CORTICAL IMPLANTABLE","SUP-ITM-10010269","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2800.35","1680.21","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2036.41","72.72","","4732.50","1617.43","14180.40","1 through 10","325.68","2167.47","percent of total billed charges",""
"GRAFT BONE 15X120MM 200 XW FROZEN STRUT MATRI CORTICAL IMPLANTABLE","SUP-ITM-10010269","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2800.35","1680.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1761.42","62.9","","3896.20","3341.38","3896.20","1 through 10","325.68","2167.47","percent of total billed charges",""
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","both","","","995.32","597.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","115.76","846.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","both","","","995.32","597.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","115.76","846.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","both","","","995.32","597.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","566.34","56.9","","0.63","0.63","0.63","1 through 10","115.76","846.02","percent of total billed charges",""
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","both","","","995.32","597.19","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","143.53","14.42","","317.14","317.14","317.14","1 through 10","115.76","846.02","percent of total billed charges",""
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","995.32","597.19","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","143.53","14.42","","317.14","317.14","317.14","1 through 10","115.76","770.38","percent of total billed charges",""
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","995.32","597.19","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","624.86","62.78","","1125.09","1125.09","1125.09","1 through 10","115.76","770.38","percent of total billed charges",""
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","995.32","597.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","723.80","72.72","","4732.50","1617.43","14180.40","1 through 10","115.76","770.38","percent of total billed charges",""
"GRAFT BONE 1CC DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10048894","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","995.32","597.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","626.06","62.9","","3896.20","3341.38","3896.20","1 through 10","115.76","770.38","percent of total billed charges",""
"GRAFT BONE 1CC US ATTRAX PUTTY","SUP-ITM-10252410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.50","621.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","120.54","881.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 1CC US ATTRAX PUTTY","SUP-ITM-10252410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.50","621.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","120.54","881.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 1CC US ATTRAX PUTTY","SUP-ITM-10252410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.50","621.90","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","589.77","56.9","","812.12","238.65","1587.46","163","120.54","881.03","percent of total billed charges",""
"GRAFT BONE 1CC US ATTRAX PUTTY","SUP-ITM-10252410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.50","621.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","120.54","11.63","","112.68","112.68","146.99","38","120.54","881.03","percent of total billed charges",""
"GRAFT BONE 1CC US ATTRAX PUTTY","SUP-ITM-10252410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.50","621.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","802.25","77.4","","303.98","303.98","5854.79","1 through 10","120.54","881.03","percent of total billed charges",""
"GRAFT BONE 1CC US ATTRAX PUTTY","SUP-ITM-10252410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","120.54","11.63","","112.68","112.68","146.99","38","120.54","802.25","percent of total billed charges",""
"GRAFT BONE 1CC US ATTRAX PUTTY","SUP-ITM-10252410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","650.71","62.78","","780.86","208.94","10480.28","15","120.54","802.25","percent of total billed charges",""
"GRAFT BONE 1CC US ATTRAX PUTTY","SUP-ITM-10252410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","453.16","43.72","","179.76","179.76","179.76","1 through 10","120.54","802.25","percent of total billed charges",""
"GRAFT BONE 1CC US ATTRAX PUTTY","SUP-ITM-10252410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","753.74","72.72","","2355.45","298.99","3965.19","155","120.54","802.25","percent of total billed charges",""
"GRAFT BONE 1CC US ATTRAX PUTTY","SUP-ITM-10252410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","753.74","72.72","","3643.09","3643.09","3643.09","1 through 10","120.54","802.25","percent of total billed charges",""
"GRAFT BONE 1CC US ATTRAX PUTTY","SUP-ITM-10252410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","551.63","53.22","","554.28","554.28","554.28","16","120.54","802.25","percent of total billed charges",""
"GRAFT BONE 1CC US ATTRAX PUTTY","SUP-ITM-10252410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","651.96","62.9","","619.64","173.09","2370.64","150","120.54","802.25","percent of total billed charges",""
"GRAFT BONE 1CC US ATTRAX PUTTY","SUP-ITM-10252410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","802.25","77.4","","303.98","303.98","5854.79","1 through 10","120.54","802.25","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","both","","","2224.19","1334.51","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","258.67","1890.56","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","both","","","2224.19","1334.51","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","258.67","1890.56","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","both","","","2224.19","1334.51","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1265.56","56.9","","812.12","238.65","1587.46","163","258.67","1890.56","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","both","","","2224.19","1334.51","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","258.67","11.63","","112.68","112.68","146.99","38","258.67","1890.56","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","both","","","2224.19","1334.51","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1721.52","77.4","","303.98","303.98","5854.79","1 through 10","258.67","1890.56","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2224.19","1334.51","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","258.67","11.63","","112.68","112.68","146.99","38","258.67","1721.52","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2224.19","1334.51","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1396.35","62.78","","780.86","208.94","10480.28","15","258.67","1721.52","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2224.19","1334.51","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","972.42","43.72","","179.76","179.76","179.76","1 through 10","258.67","1721.52","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2224.19","1334.51","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1617.43","72.72","","2355.45","298.99","3965.19","155","258.67","1721.52","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2224.19","1334.51","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1617.43","72.72","","3643.09","3643.09","3643.09","1 through 10","258.67","1721.52","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2224.19","1334.51","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1183.71","53.22","","554.28","554.28","554.28","16","258.67","1721.52","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2224.19","1334.51","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1399.02","62.9","","619.64","173.09","2370.64","150","258.67","1721.52","percent of total billed charges",""
"GRAFT BONE 2.5CC ALLO DEMINERALIZED MATRIX PUTTY SYRINGE FREEZE DRY","SUP-ITM-10048895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2224.19","1334.51","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1721.52","77.4","","303.98","303.98","5854.79","1 through 10","258.67","1721.52","percent of total billed charges",""
"GRAFT BONE 2.5ML MIX FREEZE DRIED DBX DEMINERALISED MATRIX IMPLANTABLE","SUP-ITM-10048896","CDM","C1889","HCPCS","0278","RC","","","","both","","","2666.15","1599.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","310.07","2266.23","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 2.5ML MIX FREEZE DRIED DBX DEMINERALISED MATRIX IMPLANTABLE","SUP-ITM-10048896","CDM","C1889","HCPCS","0278","RC","","","","both","","","2666.15","1599.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","310.07","2266.23","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 2.5ML MIX FREEZE DRIED DBX DEMINERALISED MATRIX IMPLANTABLE","SUP-ITM-10048896","CDM","C1889","HCPCS","0278","RC","","","","both","","","2666.15","1599.69","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1517.04","56.9","","0.63","0.63","0.63","1 through 10","310.07","2266.23","percent of total billed charges",""
"GRAFT BONE 2.5ML MIX FREEZE DRIED DBX DEMINERALISED MATRIX IMPLANTABLE","SUP-ITM-10048896","CDM","C1889","HCPCS","0278","RC","","","","both","","","2666.15","1599.69","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","384.46","14.42","","317.14","317.14","317.14","1 through 10","310.07","2266.23","percent of total billed charges",""
"GRAFT BONE 2.5ML MIX FREEZE DRIED DBX DEMINERALISED MATRIX IMPLANTABLE","SUP-ITM-10048896","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2666.15","1599.69","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","384.46","14.42","","317.14","317.14","317.14","1 through 10","310.07","2063.6","percent of total billed charges",""
"GRAFT BONE 2.5ML MIX FREEZE DRIED DBX DEMINERALISED MATRIX IMPLANTABLE","SUP-ITM-10048896","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2666.15","1599.69","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1673.81","62.78","","1125.09","1125.09","1125.09","1 through 10","310.07","2063.6","percent of total billed charges",""
"GRAFT BONE 2.5ML MIX FREEZE DRIED DBX DEMINERALISED MATRIX IMPLANTABLE","SUP-ITM-10048896","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2666.15","1599.69","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1938.82","72.72","","4732.50","1617.43","14180.40","1 through 10","310.07","2063.6","percent of total billed charges",""
"GRAFT BONE 2.5ML MIX FREEZE DRIED DBX DEMINERALISED MATRIX IMPLANTABLE","SUP-ITM-10048896","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2666.15","1599.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1677.01","62.9","","3896.20","3341.38","3896.20","1 through 10","310.07","2063.6","percent of total billed charges",""
"GRAFT BONE 20CM MASTER STRIP 7800520","SUP-ITM-10168392","CDM","C1713","HCPCS","0278","RC","","","","both","","","13534.00","8120.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1574","11503.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 20CM MASTER STRIP 7800520","SUP-ITM-10168392","CDM","C1713","HCPCS","0278","RC","","","","both","","","13534.00","8120.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1574","11503.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 20CM MASTER STRIP 7800520","SUP-ITM-10168392","CDM","C1713","HCPCS","0278","RC","","","","both","","","13534.00","8120.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7700.85","56.9","","812.12","238.65","1587.46","163","1574","11503.9","percent of total billed charges",""
"GRAFT BONE 20CM MASTER STRIP 7800520","SUP-ITM-10168392","CDM","C1713","HCPCS","0278","RC","","","","both","","","13534.00","8120.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1574.00","11.63","","112.68","112.68","146.99","38","1574","11503.9","percent of total billed charges",""
"GRAFT BONE 20CM MASTER STRIP 7800520","SUP-ITM-10168392","CDM","C1713","HCPCS","0278","RC","","","","both","","","13534.00","8120.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10475.32","77.4","","303.98","303.98","5854.79","1 through 10","1574","11503.9","percent of total billed charges",""
"GRAFT BONE 20CM MASTER STRIP 7800520","SUP-ITM-10168392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13534.00","8120.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1574.00","11.63","","112.68","112.68","146.99","38","1574","10475.32","percent of total billed charges",""
"GRAFT BONE 20CM MASTER STRIP 7800520","SUP-ITM-10168392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13534.00","8120.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","8496.65","62.78","","780.86","208.94","10480.28","15","1574","10475.32","percent of total billed charges",""
"GRAFT BONE 20CM MASTER STRIP 7800520","SUP-ITM-10168392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13534.00","8120.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","5917.06","43.72","","179.76","179.76","179.76","1 through 10","1574","10475.32","percent of total billed charges",""
"GRAFT BONE 20CM MASTER STRIP 7800520","SUP-ITM-10168392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13534.00","8120.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","9841.92","72.72","","2355.45","298.99","3965.19","155","1574","10475.32","percent of total billed charges",""
"GRAFT BONE 20CM MASTER STRIP 7800520","SUP-ITM-10168392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13534.00","8120.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","9841.92","72.72","","3643.09","3643.09","3643.09","1 through 10","1574","10475.32","percent of total billed charges",""
"GRAFT BONE 20CM MASTER STRIP 7800520","SUP-ITM-10168392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13534.00","8120.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","7202.79","53.22","","554.28","554.28","554.28","16","1574","10475.32","percent of total billed charges",""
"GRAFT BONE 20CM MASTER STRIP 7800520","SUP-ITM-10168392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13534.00","8120.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8512.89","62.9","","619.64","173.09","2370.64","150","1574","10475.32","percent of total billed charges",""
"GRAFT BONE 20CM MASTER STRIP 7800520","SUP-ITM-10168392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13534.00","8120.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10475.32","77.4","","303.98","303.98","5854.79","1 through 10","1574","10475.32","percent of total billed charges",""
"GRAFT BONE 20MM ALLOPROCHONDRIX OSTEOCHONDRAL HUMAN TISSUE","SUP-ITM-10212321","CDM","C1889","HCPCS","0278","RC","","","","both","","","17225.00","10335.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","2003.27","14641.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 20MM ALLOPROCHONDRIX OSTEOCHONDRAL HUMAN TISSUE","SUP-ITM-10212321","CDM","C1889","HCPCS","0278","RC","","","","both","","","17225.00","10335.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","2003.27","14641.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 20MM ALLOPROCHONDRIX OSTEOCHONDRAL HUMAN TISSUE","SUP-ITM-10212321","CDM","C1889","HCPCS","0278","RC","","","","both","","","17225.00","10335.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","9801.03","56.9","","0.63","0.63","0.63","1 through 10","2003.27","14641.25","percent of total billed charges",""
"GRAFT BONE 20MM ALLOPROCHONDRIX OSTEOCHONDRAL HUMAN TISSUE","SUP-ITM-10212321","CDM","C1889","HCPCS","0278","RC","","","","both","","","17225.00","10335.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2483.85","14.42","","317.14","317.14","317.14","1 through 10","2003.27","14641.25","percent of total billed charges",""
"GRAFT BONE 20MM ALLOPROCHONDRIX OSTEOCHONDRAL HUMAN TISSUE","SUP-ITM-10212321","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","17225.00","10335.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2483.85","14.42","","317.14","317.14","317.14","1 through 10","2003.27","13332.15","percent of total billed charges",""
"GRAFT BONE 20MM ALLOPROCHONDRIX OSTEOCHONDRAL HUMAN TISSUE","SUP-ITM-10212321","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","17225.00","10335.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","10813.86","62.78","","1125.09","1125.09","1125.09","1 through 10","2003.27","13332.15","percent of total billed charges",""
"GRAFT BONE 20MM ALLOPROCHONDRIX OSTEOCHONDRAL HUMAN TISSUE","SUP-ITM-10212321","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","17225.00","10335.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","12526.02","72.72","","4732.50","1617.43","14180.40","1 through 10","2003.27","13332.15","percent of total billed charges",""
"GRAFT BONE 20MM ALLOPROCHONDRIX OSTEOCHONDRAL HUMAN TISSUE","SUP-ITM-10212321","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","17225.00","10335.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","10834.53","62.9","","3896.20","3341.38","3896.20","1 through 10","2003.27","13332.15","percent of total billed charges",""
"GRAFT BONE 2CC US ATTRAX PUTTY","SUP-ITM-10252409","CDM","C1713","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","241.09","1762.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 2CC US ATTRAX PUTTY","SUP-ITM-10252409","CDM","C1713","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","241.09","1762.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 2CC US ATTRAX PUTTY","SUP-ITM-10252409","CDM","C1713","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1179.54","56.9","","812.12","238.65","1587.46","163","241.09","1762.05","percent of total billed charges",""
"GRAFT BONE 2CC US ATTRAX PUTTY","SUP-ITM-10252409","CDM","C1713","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","241.09","11.63","","112.68","112.68","146.99","38","241.09","1762.05","percent of total billed charges",""
"GRAFT BONE 2CC US ATTRAX PUTTY","SUP-ITM-10252409","CDM","C1713","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1604.50","77.4","","303.98","303.98","5854.79","1 through 10","241.09","1762.05","percent of total billed charges",""
"GRAFT BONE 2CC US ATTRAX PUTTY","SUP-ITM-10252409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","241.09","11.63","","112.68","112.68","146.99","38","241.09","1604.5","percent of total billed charges",""
"GRAFT BONE 2CC US ATTRAX PUTTY","SUP-ITM-10252409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1301.43","62.78","","780.86","208.94","10480.28","15","241.09","1604.5","percent of total billed charges",""
"GRAFT BONE 2CC US ATTRAX PUTTY","SUP-ITM-10252409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","906.32","43.72","","179.76","179.76","179.76","1 through 10","241.09","1604.5","percent of total billed charges",""
"GRAFT BONE 2CC US ATTRAX PUTTY","SUP-ITM-10252409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1507.49","72.72","","2355.45","298.99","3965.19","155","241.09","1604.5","percent of total billed charges",""
"GRAFT BONE 2CC US ATTRAX PUTTY","SUP-ITM-10252409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1507.49","72.72","","3643.09","3643.09","3643.09","1 through 10","241.09","1604.5","percent of total billed charges",""
"GRAFT BONE 2CC US ATTRAX PUTTY","SUP-ITM-10252409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1103.25","53.22","","554.28","554.28","554.28","16","241.09","1604.5","percent of total billed charges",""
"GRAFT BONE 2CC US ATTRAX PUTTY","SUP-ITM-10252409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1303.92","62.9","","619.64","173.09","2370.64","150","241.09","1604.5","percent of total billed charges",""
"GRAFT BONE 2CC US ATTRAX PUTTY","SUP-ITM-10252409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1604.50","77.4","","303.98","303.98","5854.79","1 through 10","241.09","1604.5","percent of total billed charges",""
"GRAFT BONE 4.8MMX5 OSTEOSET PELLET SUBSTITUTE","SUP-ITM-10056978","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.29","1737.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","336.72","2461","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 4.8MMX5 OSTEOSET PELLET SUBSTITUTE","SUP-ITM-10056978","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.29","1737.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","336.72","2461","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 4.8MMX5 OSTEOSET PELLET SUBSTITUTE","SUP-ITM-10056978","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.29","1737.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1647.42","56.9","","812.12","238.65","1587.46","163","336.72","2461","percent of total billed charges",""
"GRAFT BONE 4.8MMX5 OSTEOSET PELLET SUBSTITUTE","SUP-ITM-10056978","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.29","1737.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","336.72","11.63","","112.68","112.68","146.99","38","336.72","2461","percent of total billed charges",""
"GRAFT BONE 4.8MMX5 OSTEOSET PELLET SUBSTITUTE","SUP-ITM-10056978","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.29","1737.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2240.95","77.4","","303.98","303.98","5854.79","1 through 10","336.72","2461","percent of total billed charges",""
"GRAFT BONE 4.8MMX5 OSTEOSET PELLET SUBSTITUTE","SUP-ITM-10056978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2895.29","1737.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","336.72","11.63","","112.68","112.68","146.99","38","336.72","2240.95","percent of total billed charges",""
"GRAFT BONE 4.8MMX5 OSTEOSET PELLET SUBSTITUTE","SUP-ITM-10056978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2895.29","1737.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1817.66","62.78","","780.86","208.94","10480.28","15","336.72","2240.95","percent of total billed charges",""
"GRAFT BONE 4.8MMX5 OSTEOSET PELLET SUBSTITUTE","SUP-ITM-10056978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2895.29","1737.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1265.82","43.72","","179.76","179.76","179.76","1 through 10","336.72","2240.95","percent of total billed charges",""
"GRAFT BONE 4.8MMX5 OSTEOSET PELLET SUBSTITUTE","SUP-ITM-10056978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2895.29","1737.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2105.45","72.72","","2355.45","298.99","3965.19","155","336.72","2240.95","percent of total billed charges",""
"GRAFT BONE 4.8MMX5 OSTEOSET PELLET SUBSTITUTE","SUP-ITM-10056978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2895.29","1737.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2105.45","72.72","","3643.09","3643.09","3643.09","1 through 10","336.72","2240.95","percent of total billed charges",""
"GRAFT BONE 4.8MMX5 OSTEOSET PELLET SUBSTITUTE","SUP-ITM-10056978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2895.29","1737.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1540.87","53.22","","554.28","554.28","554.28","16","336.72","2240.95","percent of total billed charges",""
"GRAFT BONE 4.8MMX5 OSTEOSET PELLET SUBSTITUTE","SUP-ITM-10056978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2895.29","1737.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1821.14","62.9","","619.64","173.09","2370.64","150","336.72","2240.95","percent of total billed charges",""
"GRAFT BONE 4.8MMX5 OSTEOSET PELLET SUBSTITUTE","SUP-ITM-10056978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2895.29","1737.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2240.95","77.4","","303.98","303.98","5854.79","1 through 10","336.72","2240.95","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","both","","","6695.79","4017.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","778.72","5691.42","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","both","","","6695.79","4017.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","778.72","5691.42","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","both","","","6695.79","4017.47","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3809.90","56.9","","0.63","0.63","0.63","1 through 10","778.72","5691.42","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","both","","","6695.79","4017.47","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","965.53","14.42","","317.14","317.14","317.14","1 through 10","778.72","5691.42","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6695.79","4017.47","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","965.53","14.42","","317.14","317.14","317.14","1 through 10","778.72","5182.54","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6695.79","4017.47","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4203.62","62.78","","1125.09","1125.09","1125.09","1 through 10","778.72","5182.54","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6695.79","4017.47","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4869.18","72.72","","4732.50","1617.43","14180.40","1 through 10","778.72","5182.54","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6695.79","4017.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4211.65","62.9","","3896.20","3341.38","3896.20","1 through 10","778.72","5182.54","percent of total billed charges",""
"GRAFT BONE 5CC DBX MIX ALLO DBM PUTTY FREEZE DRIED","SUP-ITM-10008976","CDM","C1713","HCPCS","0278","RC","","","","both","","","4850.82","2910.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","564.15","4123.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 5CC DBX MIX ALLO DBM PUTTY FREEZE DRIED","SUP-ITM-10008976","CDM","C1713","HCPCS","0278","RC","","","","both","","","4850.82","2910.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","564.15","4123.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 5CC DBX MIX ALLO DBM PUTTY FREEZE DRIED","SUP-ITM-10008976","CDM","C1713","HCPCS","0278","RC","","","","both","","","4850.82","2910.49","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2760.12","56.9","","812.12","238.65","1587.46","163","564.15","4123.2","percent of total billed charges",""
"GRAFT BONE 5CC DBX MIX ALLO DBM PUTTY FREEZE DRIED","SUP-ITM-10008976","CDM","C1713","HCPCS","0278","RC","","","","both","","","4850.82","2910.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.15","11.63","","112.68","112.68","146.99","38","564.15","4123.2","percent of total billed charges",""
"GRAFT BONE 5CC DBX MIX ALLO DBM PUTTY FREEZE DRIED","SUP-ITM-10008976","CDM","C1713","HCPCS","0278","RC","","","","both","","","4850.82","2910.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3754.53","77.4","","303.98","303.98","5854.79","1 through 10","564.15","4123.2","percent of total billed charges",""
"GRAFT BONE 5CC DBX MIX ALLO DBM PUTTY FREEZE DRIED","SUP-ITM-10008976","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4850.82","2910.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.15","11.63","","112.68","112.68","146.99","38","564.15","3754.53","percent of total billed charges",""
"GRAFT BONE 5CC DBX MIX ALLO DBM PUTTY FREEZE DRIED","SUP-ITM-10008976","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4850.82","2910.49","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3045.34","62.78","","780.86","208.94","10480.28","15","564.15","3754.53","percent of total billed charges",""
"GRAFT BONE 5CC DBX MIX ALLO DBM PUTTY FREEZE DRIED","SUP-ITM-10008976","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4850.82","2910.49","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2120.78","43.72","","179.76","179.76","179.76","1 through 10","564.15","3754.53","percent of total billed charges",""
"GRAFT BONE 5CC DBX MIX ALLO DBM PUTTY FREEZE DRIED","SUP-ITM-10008976","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4850.82","2910.49","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3527.52","72.72","","2355.45","298.99","3965.19","155","564.15","3754.53","percent of total billed charges",""
"GRAFT BONE 5CC DBX MIX ALLO DBM PUTTY FREEZE DRIED","SUP-ITM-10008976","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4850.82","2910.49","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3527.52","72.72","","3643.09","3643.09","3643.09","1 through 10","564.15","3754.53","percent of total billed charges",""
"GRAFT BONE 5CC DBX MIX ALLO DBM PUTTY FREEZE DRIED","SUP-ITM-10008976","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4850.82","2910.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2581.61","53.22","","554.28","554.28","554.28","16","564.15","3754.53","percent of total billed charges",""
"GRAFT BONE 5CC DBX MIX ALLO DBM PUTTY FREEZE DRIED","SUP-ITM-10008976","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4850.82","2910.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3051.17","62.9","","619.64","173.09","2370.64","150","564.15","3754.53","percent of total billed charges",""
"GRAFT BONE 5CC DBX MIX ALLO DBM PUTTY FREEZE DRIED","SUP-ITM-10008976","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4850.82","2910.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3754.53","77.4","","303.98","303.98","5854.79","1 through 10","564.15","3754.53","percent of total billed charges",""
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","both","","","4099.84","2459.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","476.81","3484.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","both","","","4099.84","2459.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","476.81","3484.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","both","","","4099.84","2459.90","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2332.81","56.9","","0.63","0.63","0.63","1 through 10","476.81","3484.86","percent of total billed charges",""
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","both","","","4099.84","2459.90","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","591.20","14.42","","317.14","317.14","317.14","1 through 10","476.81","3484.86","percent of total billed charges",""
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4099.84","2459.90","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","591.20","14.42","","317.14","317.14","317.14","1 through 10","476.81","3173.28","percent of total billed charges",""
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4099.84","2459.90","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2573.88","62.78","","1125.09","1125.09","1125.09","1 through 10","476.81","3173.28","percent of total billed charges",""
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4099.84","2459.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2981.40","72.72","","4732.50","1617.43","14180.40","1 through 10","476.81","3173.28","percent of total billed charges",""
"GRAFT BONE 5ML DBX ALLO DBM DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008198","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4099.84","2459.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2578.80","62.9","","3896.20","3341.38","3896.20","1 through 10","476.81","3173.28","percent of total billed charges",""
"GRAFT BONE 5X2CM MASTER STRIP","SUP-ITM-10168391","CDM","C1713","HCPCS","0278","RC","","","","both","","","6499.00","3899.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","755.83","5524.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 5X2CM MASTER STRIP","SUP-ITM-10168391","CDM","C1713","HCPCS","0278","RC","","","","both","","","6499.00","3899.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","755.83","5524.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT BONE 5X2CM MASTER STRIP","SUP-ITM-10168391","CDM","C1713","HCPCS","0278","RC","","","","both","","","6499.00","3899.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3697.93","56.9","","812.12","238.65","1587.46","163","755.83","5524.15","percent of total billed charges",""
"GRAFT BONE 5X2CM MASTER STRIP","SUP-ITM-10168391","CDM","C1713","HCPCS","0278","RC","","","","both","","","6499.00","3899.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","755.83","11.63","","112.68","112.68","146.99","38","755.83","5524.15","percent of total billed charges",""
"GRAFT BONE 5X2CM MASTER STRIP","SUP-ITM-10168391","CDM","C1713","HCPCS","0278","RC","","","","both","","","6499.00","3899.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5030.23","77.4","","303.98","303.98","5854.79","1 through 10","755.83","5524.15","percent of total billed charges",""
"GRAFT BONE 5X2CM MASTER STRIP","SUP-ITM-10168391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6499.00","3899.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","755.83","11.63","","112.68","112.68","146.99","38","755.83","5030.23","percent of total billed charges",""
"GRAFT BONE 5X2CM MASTER STRIP","SUP-ITM-10168391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6499.00","3899.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4080.07","62.78","","780.86","208.94","10480.28","15","755.83","5030.23","percent of total billed charges",""
"GRAFT BONE 5X2CM MASTER STRIP","SUP-ITM-10168391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6499.00","3899.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2841.36","43.72","","179.76","179.76","179.76","1 through 10","755.83","5030.23","percent of total billed charges",""
"GRAFT BONE 5X2CM MASTER STRIP","SUP-ITM-10168391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6499.00","3899.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4726.07","72.72","","2355.45","298.99","3965.19","155","755.83","5030.23","percent of total billed charges",""
"GRAFT BONE 5X2CM MASTER STRIP","SUP-ITM-10168391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6499.00","3899.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4726.07","72.72","","3643.09","3643.09","3643.09","1 through 10","755.83","5030.23","percent of total billed charges",""
"GRAFT BONE 5X2CM MASTER STRIP","SUP-ITM-10168391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6499.00","3899.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3458.77","53.22","","554.28","554.28","554.28","16","755.83","5030.23","percent of total billed charges",""
"GRAFT BONE 5X2CM MASTER STRIP","SUP-ITM-10168391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6499.00","3899.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4087.87","62.9","","619.64","173.09","2370.64","150","755.83","5030.23","percent of total billed charges",""
"GRAFT BONE 5X2CM MASTER STRIP","SUP-ITM-10168391","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6499.00","3899.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5030.23","77.4","","303.98","303.98","5854.79","1 through 10","755.83","5030.23","percent of total billed charges",""
"GRAFT CONDYLE FEMORAL LT LATERAL ID","SUP-ITM-10124417","CDM","C1889","HCPCS","0278","RC","","","","both","","","27232.98","16339.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","3167.2","23148.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT CONDYLE FEMORAL LT LATERAL ID","SUP-ITM-10124417","CDM","C1889","HCPCS","0278","RC","","","","both","","","27232.98","16339.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","3167.2","23148.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT CONDYLE FEMORAL LT LATERAL ID","SUP-ITM-10124417","CDM","C1889","HCPCS","0278","RC","","","","both","","","27232.98","16339.79","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","15495.57","56.9","","0.63","0.63","0.63","1 through 10","3167.2","23148.03","percent of total billed charges",""
"GRAFT CONDYLE FEMORAL LT LATERAL ID","SUP-ITM-10124417","CDM","C1889","HCPCS","0278","RC","","","","both","","","27232.98","16339.79","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","3927.00","14.42","","317.14","317.14","317.14","1 through 10","3167.2","23148.03","percent of total billed charges",""
"GRAFT CONDYLE FEMORAL LT LATERAL ID","SUP-ITM-10124417","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","27232.98","16339.79","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","3927.00","14.42","","317.14","317.14","317.14","1 through 10","3167.2","21078.33","percent of total billed charges",""
"GRAFT CONDYLE FEMORAL LT LATERAL ID","SUP-ITM-10124417","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","27232.98","16339.79","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","17096.86","62.78","","1125.09","1125.09","1125.09","1 through 10","3167.2","21078.33","percent of total billed charges",""
"GRAFT CONDYLE FEMORAL LT LATERAL ID","SUP-ITM-10124417","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","27232.98","16339.79","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","19803.82","72.72","","4732.50","1617.43","14180.40","1 through 10","3167.2","21078.33","percent of total billed charges",""
"GRAFT CONDYLE FEMORAL LT LATERAL ID","SUP-ITM-10124417","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","27232.98","16339.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","17129.54","62.9","","3896.20","3341.38","3896.20","1 through 10","3167.2","21078.33","percent of total billed charges",""
"GRAFT DERMAL 16X6CM 0.8TO 1.7MM PLIABLE FOLDING HYDRATED THICK FLEXHD ACELLULAR DERMIS IMPLANTABLE","SUP-ITM-10124528","CDM","C1762","HCPCS","0278","RC","","","","outpatient","","","11360.25","6816.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7145.60","62.9","","6599.70","6599.70","6599.70","1 through 10","1321.2","8792.83","percent of total billed charges",""
"GRAFT DURAL 2X2IN COLLAGEN DURAMATRIX ONLAY","SUP-ITM-10043053","CDM","C1763","HCPCS","0278","RC","","","","both","","","4815.84","2889.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2740.21","56.9","","1156.60","963.29","1156.60","1 through 10","560.08","4093.46","percent of total billed charges",""
"GRAFT DURAL 2X2IN COLLAGEN DURAMATRIX ONLAY","SUP-ITM-10043053","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4815.84","2889.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3502.08","72.72","","8111.92","3502.08","8111.92","1 through 10","560.08","3727.46","percent of total billed charges",""
"GRAFT DURAL 2X2IN COLLAGEN DURAMATRIX ONLAY","SUP-ITM-10043053","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4815.84","2889.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3029.16","62.9","","1066.56","1066.56","1066.56","1 through 10","560.08","3727.46","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 20X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283252","CDM","C1874","HCPCS","0278","RC","","","","both","","","29150.72","17490.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","16586.76","56.9","","4336.72","1572.72","9255.66","15","3390.23","24778.11","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 20X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283252","CDM","C1874","HCPCS","0278","RC","","","","both","","","29150.72","17490.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","22562.66","77.4","","2142.10","2142.10","2142.10","1 through 10","3390.23","24778.11","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 20X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283252","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","29150.72","17490.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","21198.40","72.72","","2261.23","2261.23","2261.23","1 through 10","3390.23","22562.66","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 20X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283252","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","29150.72","17490.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","18335.80","62.9","","4353.04","1741.32","8465.73","1 through 10","3390.23","22562.66","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 20X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283252","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","29150.72","17490.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","22562.66","77.4","","2142.10","2142.10","2142.10","1 through 10","3390.23","22562.66","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 23X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283250","CDM","C1874","HCPCS","0278","RC","","","","both","","","29150.72","17490.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","16586.76","56.9","","4336.72","1572.72","9255.66","15","3390.23","24778.11","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 23X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283250","CDM","C1874","HCPCS","0278","RC","","","","both","","","29150.72","17490.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","22562.66","77.4","","2142.10","2142.10","2142.10","1 through 10","3390.23","24778.11","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 23X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283250","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","29150.72","17490.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","21198.40","72.72","","2261.23","2261.23","2261.23","1 through 10","3390.23","22562.66","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 23X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283250","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","29150.72","17490.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","18335.80","62.9","","4353.04","1741.32","8465.73","1 through 10","3390.23","22562.66","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 23X14.5MMX12CM 15FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283250","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","29150.72","17490.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","22562.66","77.4","","2142.10","2142.10","2142.10","1 through 10","3390.23","22562.66","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 26X14.5MMX12CM 16FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283248","CDM","C1874","HCPCS","0278","RC","","","","both","","","29150.72","17490.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","16586.76","56.9","","4336.72","1572.72","9255.66","15","3390.23","24778.11","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 26X14.5MMX12CM 16FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283248","CDM","C1874","HCPCS","0278","RC","","","","both","","","29150.72","17490.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","22562.66","77.4","","2142.10","2142.10","2142.10","1 through 10","3390.23","24778.11","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 26X14.5MMX12CM 16FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283248","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","29150.72","17490.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","21198.40","72.72","","2261.23","2261.23","2261.23","1 through 10","3390.23","22562.66","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 26X14.5MMX12CM 16FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283248","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","29150.72","17490.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","18335.80","62.9","","4353.04","1741.32","8465.73","1 through 10","3390.23","22562.66","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 26X14.5MMX12CM 16FR EXCLUDER TRUNK CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283248","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","29150.72","17490.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","22562.66","77.4","","2142.10","2142.10","2142.10","1 through 10","3390.23","22562.66","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 28MMX4.5CM 16FR EXCLUDER EXTENDER CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283256","CDM","C1874","HCPCS","0278","RC","","","","both","","","17687.12","10612.27","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","10063.97","56.9","","4336.72","1572.72","9255.66","15","2057.01","15034.05","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 28MMX4.5CM 16FR EXCLUDER EXTENDER CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283256","CDM","C1874","HCPCS","0278","RC","","","","both","","","17687.12","10612.27","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","13689.83","77.4","","2142.10","2142.10","2142.10","1 through 10","2057.01","15034.05","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 28MMX4.5CM 16FR EXCLUDER EXTENDER CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283256","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","17687.12","10612.27","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","12862.07","72.72","","2261.23","2261.23","2261.23","1 through 10","2057.01","13689.83","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 28MMX4.5CM 16FR EXCLUDER EXTENDER CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283256","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","17687.12","10612.27","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","11125.20","62.9","","4353.04","1741.32","8465.73","1 through 10","2057.01","13689.83","percent of total billed charges",""
"GRAFT ENDOPROSTHESIS 28MMX4.5CM 16FR EXCLUDER EXTENDER CONFORMABLE ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10283256","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","17687.12","10612.27","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","13689.83","77.4","","2142.10","2142.10","2142.10","1 through 10","2057.01","13689.83","percent of total billed charges",""
"GRAFT ENDOVASCULAR 16X55MM AFX ABDOMINAL AORTIC ANEURYSM SUPRARENAL EXTENSIONE","SUP-ITM-10120312","CDM","C1874","HCPCS","0278","RC","","","","both","","","14135.96","8481.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","8043.36","56.9","","4336.72","1572.72","9255.66","15","1644.01","12015.57","percent of total billed charges",""
"GRAFT ENDOVASCULAR 16X55MM AFX ABDOMINAL AORTIC ANEURYSM SUPRARENAL EXTENSIONE","SUP-ITM-10120312","CDM","C1874","HCPCS","0278","RC","","","","both","","","14135.96","8481.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10941.23","77.4","","2142.10","2142.10","2142.10","1 through 10","1644.01","12015.57","percent of total billed charges",""
"GRAFT ENDOVASCULAR 16X55MM AFX ABDOMINAL AORTIC ANEURYSM SUPRARENAL EXTENSIONE","SUP-ITM-10120312","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","14135.96","8481.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10279.67","72.72","","2261.23","2261.23","2261.23","1 through 10","1644.01","10941.23","percent of total billed charges",""
"GRAFT ENDOVASCULAR 16X55MM AFX ABDOMINAL AORTIC ANEURYSM SUPRARENAL EXTENSIONE","SUP-ITM-10120312","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","14135.96","8481.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8891.52","62.9","","4353.04","1741.32","8465.73","1 through 10","1644.01","10941.23","percent of total billed charges",""
"GRAFT ENDOVASCULAR 16X55MM AFX ABDOMINAL AORTIC ANEURYSM SUPRARENAL EXTENSIONE","SUP-ITM-10120312","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","14135.96","8481.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10941.23","77.4","","2142.10","2142.10","2142.10","1 through 10","1644.01","10941.23","percent of total billed charges",""
"GRAFT ENDOVASCULAR 28X28X75MM VELA AFX INFRARENAL","SUP-ITM-10213266","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","17221.75","10333.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","12523.66","72.72","","4588.52","4588.52","4588.52","1 through 10","2002.89","13329.63","percent of total billed charges",""
"GRAFT ENDOVASCULAR 34X34X100X100MM AFX ABDOMINAL AORTIC ANEURYSM SUPRARENAL EXTENSION","SUP-ITM-10132524","CDM","C1874","HCPCS","0278","RC","","","","both","","","17221.75","10333.05","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","9799.18","56.9","","4336.72","1572.72","9255.66","15","2002.89","14638.49","percent of total billed charges",""
"GRAFT ENDOVASCULAR 34X34X100X100MM AFX ABDOMINAL AORTIC ANEURYSM SUPRARENAL EXTENSION","SUP-ITM-10132524","CDM","C1874","HCPCS","0278","RC","","","","both","","","17221.75","10333.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","13329.63","77.4","","2142.10","2142.10","2142.10","1 through 10","2002.89","14638.49","percent of total billed charges",""
"GRAFT ENDOVASCULAR 34X34X100X100MM AFX ABDOMINAL AORTIC ANEURYSM SUPRARENAL EXTENSION","SUP-ITM-10132524","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","17221.75","10333.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","12523.66","72.72","","2261.23","2261.23","2261.23","1 through 10","2002.89","13329.63","percent of total billed charges",""
"GRAFT ENDOVASCULAR 34X34X100X100MM AFX ABDOMINAL AORTIC ANEURYSM SUPRARENAL EXTENSION","SUP-ITM-10132524","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","17221.75","10333.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","10832.48","62.9","","4353.04","1741.32","8465.73","1 through 10","2002.89","13329.63","percent of total billed charges",""
"GRAFT ENDOVASCULAR 34X34X100X100MM AFX ABDOMINAL AORTIC ANEURYSM SUPRARENAL EXTENSION","SUP-ITM-10132524","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","17221.75","10333.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","13329.63","77.4","","2142.10","2142.10","2142.10","1 through 10","2002.89","13329.63","percent of total billed charges",""
"GRAFT ENDOVASCULAR 34X34X80MM VELA AFX INFRARENAL","SUP-ITM-10213264","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","17221.75","10333.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","12523.66","72.72","","4588.52","4588.52","4588.52","1 through 10","2002.89","13329.63","percent of total billed charges",""
"GRAFT ENDOVASCULAR 95X28MM COBALT EPTFE ABDOMINAL AORTA SUPRARENAL PROXIMALIMAL EXTENSION AFX","SUP-ITM-10120307","CDM","C1874","HCPCS","0278","RC","","","","both","","","17221.75","10333.05","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","9799.18","56.9","","4336.72","1572.72","9255.66","15","2002.89","14638.49","percent of total billed charges",""
"GRAFT ENDOVASCULAR 95X28MM COBALT EPTFE ABDOMINAL AORTA SUPRARENAL PROXIMALIMAL EXTENSION AFX","SUP-ITM-10120307","CDM","C1874","HCPCS","0278","RC","","","","both","","","17221.75","10333.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","13329.63","77.4","","2142.10","2142.10","2142.10","1 through 10","2002.89","14638.49","percent of total billed charges",""
"GRAFT ENDOVASCULAR 95X28MM COBALT EPTFE ABDOMINAL AORTA SUPRARENAL PROXIMALIMAL EXTENSION AFX","SUP-ITM-10120307","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","17221.75","10333.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","12523.66","72.72","","2261.23","2261.23","2261.23","1 through 10","2002.89","13329.63","percent of total billed charges",""
"GRAFT ENDOVASCULAR 95X28MM COBALT EPTFE ABDOMINAL AORTA SUPRARENAL PROXIMALIMAL EXTENSION AFX","SUP-ITM-10120307","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","17221.75","10333.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","10832.48","62.9","","4353.04","1741.32","8465.73","1 through 10","2002.89","13329.63","percent of total billed charges",""
"GRAFT ENDOVASCULAR 95X28MM COBALT EPTFE ABDOMINAL AORTA SUPRARENAL PROXIMALIMAL EXTENSION AFX","SUP-ITM-10120307","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","17221.75","10333.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","13329.63","77.4","","2142.10","2142.10","2142.10","1 through 10","2002.89","13329.63","percent of total billed charges",""
"GRAFT EXCLUDER 12 13.5X14.5 7 ENDOPROSTHEIS INTERNAL ILIAC BRANCH","SUP-ITM-10166021","CDM","C1874","HCPCS","0278","RC","","","","both","","","12439.16","7463.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7077.88","56.9","","4336.72","1572.72","9255.66","15","1446.67","10573.29","percent of total billed charges",""
"GRAFT EXCLUDER 12 13.5X14.5 7 ENDOPROSTHEIS INTERNAL ILIAC BRANCH","SUP-ITM-10166021","CDM","C1874","HCPCS","0278","RC","","","","both","","","12439.16","7463.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9627.91","77.4","","2142.10","2142.10","2142.10","1 through 10","1446.67","10573.29","percent of total billed charges",""
"GRAFT EXCLUDER 12 13.5X14.5 7 ENDOPROSTHEIS INTERNAL ILIAC BRANCH","SUP-ITM-10166021","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12439.16","7463.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","9045.76","72.72","","2261.23","2261.23","2261.23","1 through 10","1446.67","9627.91","percent of total billed charges",""
"GRAFT EXCLUDER 12 13.5X14.5 7 ENDOPROSTHEIS INTERNAL ILIAC BRANCH","SUP-ITM-10166021","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12439.16","7463.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7824.23","62.9","","4353.04","1741.32","8465.73","1 through 10","1446.67","9627.91","percent of total billed charges",""
"GRAFT EXCLUDER 12 13.5X14.5 7 ENDOPROSTHEIS INTERNAL ILIAC BRANCH","SUP-ITM-10166021","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12439.16","7463.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9627.91","77.4","","2142.10","2142.10","2142.10","1 through 10","1446.67","9627.91","percent of total billed charges",""
"GRAFT ILIC 12MM CRAST WEDGE FREEZE DRIED","SUP-ITM-10010315","CDM","C1889","HCPCS","0278","RC","","","","both","","","4647.60","2788.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","540.52","3950.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT ILIC 12MM CRAST WEDGE FREEZE DRIED","SUP-ITM-10010315","CDM","C1889","HCPCS","0278","RC","","","","both","","","4647.60","2788.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","540.52","3950.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT ILIC 12MM CRAST WEDGE FREEZE DRIED","SUP-ITM-10010315","CDM","C1889","HCPCS","0278","RC","","","","both","","","4647.60","2788.56","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2644.48","56.9","","0.63","0.63","0.63","1 through 10","540.52","3950.46","percent of total billed charges",""
"GRAFT ILIC 12MM CRAST WEDGE FREEZE DRIED","SUP-ITM-10010315","CDM","C1889","HCPCS","0278","RC","","","","both","","","4647.60","2788.56","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","670.18","14.42","","317.14","317.14","317.14","1 through 10","540.52","3950.46","percent of total billed charges",""
"GRAFT ILIC 12MM CRAST WEDGE FREEZE DRIED","SUP-ITM-10010315","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4647.60","2788.56","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","670.18","14.42","","317.14","317.14","317.14","1 through 10","540.52","3597.24","percent of total billed charges",""
"GRAFT ILIC 12MM CRAST WEDGE FREEZE DRIED","SUP-ITM-10010315","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4647.60","2788.56","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2917.76","62.78","","1125.09","1125.09","1125.09","1 through 10","540.52","3597.24","percent of total billed charges",""
"GRAFT ILIC 12MM CRAST WEDGE FREEZE DRIED","SUP-ITM-10010315","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4647.60","2788.56","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3379.73","72.72","","4732.50","1617.43","14180.40","1 through 10","540.52","3597.24","percent of total billed charges",""
"GRAFT ILIC 12MM CRAST WEDGE FREEZE DRIED","SUP-ITM-10010315","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4647.60","2788.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2923.34","62.9","","3896.20","3341.38","3896.20","1 through 10","540.52","3597.24","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","both","","","1796.60","1077.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","208.94","1527.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","both","","","1796.60","1077.96","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1022.27","56.9","","1333.47","776.80","2316.37","34","208.94","1527.11","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","both","","","1796.60","1077.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","208.94","11.63","","348.38","187.99","380.51","1 through 10","208.94","1527.11","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","both","","","1796.60","1077.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1130.06","62.9","","1793.12","860.08","3673.04","20","208.94","1527.11","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","both","","","1796.60","1077.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1390.57","77.4","","1107.52","186.36","4312.65","1 through 10","208.94","1527.11","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1796.60","1077.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","208.94","11.63","","348.38","187.99","380.51","1 through 10","208.94","1306.49","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1796.60","1077.96","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1127.91","62.78","","9719.10","2943.96","9719.10","1 through 10","208.94","1306.49","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1796.60","1077.96","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1306.49","72.72","","2009.48","1217.35","3752.64","17","208.94","1306.49","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","both","","","40348.92","24209.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","4692.58","34296.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","both","","","40348.92","24209.35","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","22958.54","56.9","","1333.47","776.80","2316.37","34","4692.58","34296.58","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","both","","","40348.92","24209.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","4692.58","11.63","","348.38","187.99","380.51","1 through 10","4692.58","34296.58","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","both","","","40348.92","24209.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","25379.47","62.9","","1793.12","860.08","3673.04","20","4692.58","34296.58","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","both","","","40348.92","24209.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","31230.06","77.4","","1107.52","186.36","4312.65","1 through 10","4692.58","34296.58","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","40348.92","24209.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","4692.58","11.63","","348.38","187.99","380.51","1 through 10","4692.58","29341.73","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","40348.92","24209.35","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","25331.05","62.78","","9719.10","2943.96","9719.10","1 through 10","4692.58","29341.73","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","40348.92","24209.35","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","29341.73","72.72","","2009.48","1217.35","3752.64","17","4692.58","29341.73","percent of total billed charges",""
"GRAFT MESH 10X13 VENTRALIGHT POLYPROPYLENE ECHO POSITIONING SYSTEM HYDROGEL BARRIER HERNIA ELLIPSE CS/1EA","SUP-ITM-10157616","CDM","C1781","HCPCS","0278","RC","","","","both","","","13210.80","7926.48","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","1536.42","11229.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT MESH 10X13 VENTRALIGHT POLYPROPYLENE ECHO POSITIONING SYSTEM HYDROGEL BARRIER HERNIA ELLIPSE CS/1EA","SUP-ITM-10157616","CDM","C1781","HCPCS","0278","RC","","","","both","","","13210.80","7926.48","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7516.95","56.9","","1333.47","776.80","2316.37","34","1536.42","11229.18","percent of total billed charges",""
"GRAFT MESH 10X13 VENTRALIGHT POLYPROPYLENE ECHO POSITIONING SYSTEM HYDROGEL BARRIER HERNIA ELLIPSE CS/1EA","SUP-ITM-10157616","CDM","C1781","HCPCS","0278","RC","","","","both","","","13210.80","7926.48","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1536.42","11.63","","348.38","187.99","380.51","1 through 10","1536.42","11229.18","percent of total billed charges",""
"GRAFT MESH 10X13 VENTRALIGHT POLYPROPYLENE ECHO POSITIONING SYSTEM HYDROGEL BARRIER HERNIA ELLIPSE CS/1EA","SUP-ITM-10157616","CDM","C1781","HCPCS","0278","RC","","","","both","","","13210.80","7926.48","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8309.59","62.9","","1793.12","860.08","3673.04","20","1536.42","11229.18","percent of total billed charges",""
"GRAFT MESH 10X13 VENTRALIGHT POLYPROPYLENE ECHO POSITIONING SYSTEM HYDROGEL BARRIER HERNIA ELLIPSE CS/1EA","SUP-ITM-10157616","CDM","C1781","HCPCS","0278","RC","","","","both","","","13210.80","7926.48","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10225.16","77.4","","1107.52","186.36","4312.65","1 through 10","1536.42","11229.18","percent of total billed charges",""
"GRAFT MESH 10X13 VENTRALIGHT POLYPROPYLENE ECHO POSITIONING SYSTEM HYDROGEL BARRIER HERNIA ELLIPSE CS/1EA","SUP-ITM-10157616","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","13210.80","7926.48","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1536.42","11.63","","348.38","187.99","380.51","1 through 10","1536.42","9606.89","percent of total billed charges",""
"GRAFT MESH 10X13 VENTRALIGHT POLYPROPYLENE ECHO POSITIONING SYSTEM HYDROGEL BARRIER HERNIA ELLIPSE CS/1EA","SUP-ITM-10157616","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","13210.80","7926.48","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","8293.74","62.78","","9719.10","2943.96","9719.10","1 through 10","1536.42","9606.89","percent of total billed charges",""
"GRAFT MESH 10X13 VENTRALIGHT POLYPROPYLENE ECHO POSITIONING SYSTEM HYDROGEL BARRIER HERNIA ELLIPSE CS/1EA","SUP-ITM-10157616","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","13210.80","7926.48","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","9606.89","72.72","","2009.48","1217.35","3752.64","17","1536.42","9606.89","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","both","","","19133.04","11479.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","2225.17","16263.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","both","","","19133.04","11479.82","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","10886.70","56.9","","1333.47","776.80","2316.37","34","2225.17","16263.08","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","both","","","19133.04","11479.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2225.17","11.63","","348.38","187.99","380.51","1 through 10","2225.17","16263.08","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","both","","","19133.04","11479.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","12034.68","62.9","","1793.12","860.08","3673.04","20","2225.17","16263.08","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","both","","","19133.04","11479.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","14808.97","77.4","","1107.52","186.36","4312.65","1 through 10","2225.17","16263.08","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","19133.04","11479.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2225.17","11.63","","348.38","187.99","380.51","1 through 10","2225.17","13913.55","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","19133.04","11479.82","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","12011.72","62.78","","9719.10","2943.96","9719.10","1 through 10","2225.17","13913.55","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","19133.04","11479.82","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","13913.55","72.72","","2009.48","1217.35","3752.64","17","2225.17","13913.55","percent of total billed charges",""
"GRAFT MESH 10X15CM PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE BILATERAL CS/2EA","SUP-ITM-10267609","CDM","C1781","HCPCS","0278","RC","","","","both","","","1674.02","1004.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","194.69","1422.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT MESH 10X15CM PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE BILATERAL CS/2EA","SUP-ITM-10267609","CDM","C1781","HCPCS","0278","RC","","","","both","","","1674.02","1004.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","952.52","56.9","","1333.47","776.80","2316.37","34","194.69","1422.92","percent of total billed charges",""
"GRAFT MESH 10X15CM PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE BILATERAL CS/2EA","SUP-ITM-10267609","CDM","C1781","HCPCS","0278","RC","","","","both","","","1674.02","1004.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","194.69","11.63","","348.38","187.99","380.51","1 through 10","194.69","1422.92","percent of total billed charges",""
"GRAFT MESH 10X15CM PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE BILATERAL CS/2EA","SUP-ITM-10267609","CDM","C1781","HCPCS","0278","RC","","","","both","","","1674.02","1004.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1052.96","62.9","","1793.12","860.08","3673.04","20","194.69","1422.92","percent of total billed charges",""
"GRAFT MESH 10X15CM PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE BILATERAL CS/2EA","SUP-ITM-10267609","CDM","C1781","HCPCS","0278","RC","","","","both","","","1674.02","1004.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1295.69","77.4","","1107.52","186.36","4312.65","1 through 10","194.69","1422.92","percent of total billed charges",""
"GRAFT MESH 10X15CM PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE BILATERAL CS/2EA","SUP-ITM-10267609","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1674.02","1004.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","194.69","11.63","","348.38","187.99","380.51","1 through 10","194.69","1217.35","percent of total billed charges",""
"GRAFT MESH 10X15CM PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE BILATERAL CS/2EA","SUP-ITM-10267609","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1674.02","1004.41","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1050.95","62.78","","9719.10","2943.96","9719.10","1 through 10","194.69","1217.35","percent of total billed charges",""
"GRAFT MESH 10X15CM PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE BILATERAL CS/2EA","SUP-ITM-10267609","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1674.02","1004.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1217.35","72.72","","2009.48","1217.35","3752.64","17","194.69","1217.35","percent of total billed charges",""
"GRAFT MESH 12X14 VENTRALIGHT ST POLYPROPYLENE HERNIA SEPRA HYDROGEL BIORESORBABLE ECHO PS POSITIONING SYSTEM RECTANGLE CS/1EA","SUP-ITM-10157615","CDM","C1781","HCPCS","0278","RC","","","","both","","","14443.00","8665.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","1679.72","12276.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT MESH 12X14 VENTRALIGHT ST POLYPROPYLENE HERNIA SEPRA HYDROGEL BIORESORBABLE ECHO PS POSITIONING SYSTEM RECTANGLE CS/1EA","SUP-ITM-10157615","CDM","C1781","HCPCS","0278","RC","","","","both","","","14443.00","8665.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","8218.07","56.9","","1333.47","776.80","2316.37","34","1679.72","12276.55","percent of total billed charges",""
"GRAFT MESH 12X14 VENTRALIGHT ST POLYPROPYLENE HERNIA SEPRA HYDROGEL BIORESORBABLE ECHO PS POSITIONING SYSTEM RECTANGLE CS/1EA","SUP-ITM-10157615","CDM","C1781","HCPCS","0278","RC","","","","both","","","14443.00","8665.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1679.72","11.63","","348.38","187.99","380.51","1 through 10","1679.72","12276.55","percent of total billed charges",""
"GRAFT MESH 12X14 VENTRALIGHT ST POLYPROPYLENE HERNIA SEPRA HYDROGEL BIORESORBABLE ECHO PS POSITIONING SYSTEM RECTANGLE CS/1EA","SUP-ITM-10157615","CDM","C1781","HCPCS","0278","RC","","","","both","","","14443.00","8665.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","9084.65","62.9","","1793.12","860.08","3673.04","20","1679.72","12276.55","percent of total billed charges",""
"GRAFT MESH 12X14 VENTRALIGHT ST POLYPROPYLENE HERNIA SEPRA HYDROGEL BIORESORBABLE ECHO PS POSITIONING SYSTEM RECTANGLE CS/1EA","SUP-ITM-10157615","CDM","C1781","HCPCS","0278","RC","","","","both","","","14443.00","8665.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","11178.88","77.4","","1107.52","186.36","4312.65","1 through 10","1679.72","12276.55","percent of total billed charges",""
"GRAFT MESH 12X14 VENTRALIGHT ST POLYPROPYLENE HERNIA SEPRA HYDROGEL BIORESORBABLE ECHO PS POSITIONING SYSTEM RECTANGLE CS/1EA","SUP-ITM-10157615","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","14443.00","8665.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1679.72","11.63","","348.38","187.99","380.51","1 through 10","1679.72","10502.95","percent of total billed charges",""
"GRAFT MESH 12X14 VENTRALIGHT ST POLYPROPYLENE HERNIA SEPRA HYDROGEL BIORESORBABLE ECHO PS POSITIONING SYSTEM RECTANGLE CS/1EA","SUP-ITM-10157615","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","14443.00","8665.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","9067.32","62.78","","9719.10","2943.96","9719.10","1 through 10","1679.72","10502.95","percent of total billed charges",""
"GRAFT MESH 12X14 VENTRALIGHT ST POLYPROPYLENE HERNIA SEPRA HYDROGEL BIORESORBABLE ECHO PS POSITIONING SYSTEM RECTANGLE CS/1EA","SUP-ITM-10157615","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","14443.00","8665.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10502.95","72.72","","2009.48","1217.35","3752.64","17","1679.72","10502.95","percent of total billed charges",""
"GRAFT MESH 15 XCM PARIETEX PROGRIP POLYESTER MACROPOROUS HERNIA RECTANGULAR BX/1EA","SUP-ITM-10042944","CDM","C1781","HCPCS","0278","RC","","","","both","","","1429.06","857.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","166.2","1214.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT MESH 15 XCM PARIETEX PROGRIP POLYESTER MACROPOROUS HERNIA RECTANGULAR BX/1EA","SUP-ITM-10042944","CDM","C1781","HCPCS","0278","RC","","","","both","","","1429.06","857.44","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","813.14","56.9","","1333.47","776.80","2316.37","34","166.2","1214.7","percent of total billed charges",""
"GRAFT MESH 15 XCM PARIETEX PROGRIP POLYESTER MACROPOROUS HERNIA RECTANGULAR BX/1EA","SUP-ITM-10042944","CDM","C1781","HCPCS","0278","RC","","","","both","","","1429.06","857.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","166.20","11.63","","348.38","187.99","380.51","1 through 10","166.2","1214.7","percent of total billed charges",""
"GRAFT MESH 15 XCM PARIETEX PROGRIP POLYESTER MACROPOROUS HERNIA RECTANGULAR BX/1EA","SUP-ITM-10042944","CDM","C1781","HCPCS","0278","RC","","","","both","","","1429.06","857.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","898.88","62.9","","1793.12","860.08","3673.04","20","166.2","1214.7","percent of total billed charges",""
"GRAFT MESH 15 XCM PARIETEX PROGRIP POLYESTER MACROPOROUS HERNIA RECTANGULAR BX/1EA","SUP-ITM-10042944","CDM","C1781","HCPCS","0278","RC","","","","both","","","1429.06","857.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1106.09","77.4","","1107.52","186.36","4312.65","1 through 10","166.2","1214.7","percent of total billed charges",""
"GRAFT MESH 15 XCM PARIETEX PROGRIP POLYESTER MACROPOROUS HERNIA RECTANGULAR BX/1EA","SUP-ITM-10042944","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1429.06","857.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","166.20","11.63","","348.38","187.99","380.51","1 through 10","166.2","1039.21","percent of total billed charges",""
"GRAFT MESH 15 XCM PARIETEX PROGRIP POLYESTER MACROPOROUS HERNIA RECTANGULAR BX/1EA","SUP-ITM-10042944","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1429.06","857.44","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","897.16","62.78","","9719.10","2943.96","9719.10","1 through 10","166.2","1039.21","percent of total billed charges",""
"GRAFT MESH 15 XCM PARIETEX PROGRIP POLYESTER MACROPOROUS HERNIA RECTANGULAR BX/1EA","SUP-ITM-10042944","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1429.06","857.44","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1039.21","72.72","","2009.48","1217.35","3752.64","17","166.2","1039.21","percent of total billed charges",""
"GRAFT MESH 15X10CM HERNIA MACROPOROUS PARIETENE HERNIATRIC CS/3EA","SUP-ITM-10267098","CDM","C1781","HCPCS","0278","RC","","","","both","","","240.47","144.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","27.97","204.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT MESH 15X10CM HERNIA MACROPOROUS PARIETENE HERNIATRIC CS/3EA","SUP-ITM-10267098","CDM","C1781","HCPCS","0278","RC","","","","both","","","240.47","144.28","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","136.83","56.9","","1333.47","776.80","2316.37","34","27.97","204.4","percent of total billed charges",""
"GRAFT MESH 15X10CM HERNIA MACROPOROUS PARIETENE HERNIATRIC CS/3EA","SUP-ITM-10267098","CDM","C1781","HCPCS","0278","RC","","","","both","","","240.47","144.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","27.97","11.63","","348.38","187.99","380.51","1 through 10","27.97","204.4","percent of total billed charges",""
"GRAFT MESH 15X10CM HERNIA MACROPOROUS PARIETENE HERNIATRIC CS/3EA","SUP-ITM-10267098","CDM","C1781","HCPCS","0278","RC","","","","both","","","240.47","144.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","151.26","62.9","","1793.12","860.08","3673.04","20","27.97","204.4","percent of total billed charges",""
"GRAFT MESH 15X10CM HERNIA MACROPOROUS PARIETENE HERNIATRIC CS/3EA","SUP-ITM-10267098","CDM","C1781","HCPCS","0278","RC","","","","both","","","240.47","144.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","186.12","77.4","","1107.52","186.36","4312.65","1 through 10","27.97","204.4","percent of total billed charges",""
"GRAFT MESH 15X10CM HERNIA MACROPOROUS PARIETENE HERNIATRIC CS/3EA","SUP-ITM-10267098","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","240.47","144.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","27.97","11.63","","348.38","187.99","380.51","1 through 10","27.97","174.87","percent of total billed charges",""
"GRAFT MESH 15X10CM HERNIA MACROPOROUS PARIETENE HERNIATRIC CS/3EA","SUP-ITM-10267098","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","240.47","144.28","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","150.97","62.78","","9719.10","2943.96","9719.10","1 through 10","27.97","174.87","percent of total billed charges",""
"GRAFT MESH 15X10CM HERNIA MACROPOROUS PARIETENE HERNIATRIC CS/3EA","SUP-ITM-10267098","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","240.47","144.28","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","174.87","72.72","","2009.48","1217.35","3752.64","17","27.97","174.87","percent of total billed charges",""
"GRAFT MESH 15X30CM PARIETEX PROGRIP MACROPOROUS POLYESTER RECTANGULAR","SUP-ITM-10267617","CDM","C1781","HCPCS","0278","RC","","","","both","","","2488.64","1493.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","289.43","2115.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT MESH 15X30CM PARIETEX PROGRIP MACROPOROUS POLYESTER RECTANGULAR","SUP-ITM-10267617","CDM","C1781","HCPCS","0278","RC","","","","both","","","2488.64","1493.18","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1416.04","56.9","","1333.47","776.80","2316.37","34","289.43","2115.34","percent of total billed charges",""
"GRAFT MESH 15X30CM PARIETEX PROGRIP MACROPOROUS POLYESTER RECTANGULAR","SUP-ITM-10267617","CDM","C1781","HCPCS","0278","RC","","","","both","","","2488.64","1493.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","289.43","11.63","","348.38","187.99","380.51","1 through 10","289.43","2115.34","percent of total billed charges",""
"GRAFT MESH 15X30CM PARIETEX PROGRIP MACROPOROUS POLYESTER RECTANGULAR","SUP-ITM-10267617","CDM","C1781","HCPCS","0278","RC","","","","both","","","2488.64","1493.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1565.35","62.9","","1793.12","860.08","3673.04","20","289.43","2115.34","percent of total billed charges",""
"GRAFT MESH 15X30CM PARIETEX PROGRIP MACROPOROUS POLYESTER RECTANGULAR","SUP-ITM-10267617","CDM","C1781","HCPCS","0278","RC","","","","both","","","2488.64","1493.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1926.21","77.4","","1107.52","186.36","4312.65","1 through 10","289.43","2115.34","percent of total billed charges",""
"GRAFT MESH 15X30CM PARIETEX PROGRIP MACROPOROUS POLYESTER RECTANGULAR","SUP-ITM-10267617","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2488.64","1493.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","289.43","11.63","","348.38","187.99","380.51","1 through 10","289.43","1809.74","percent of total billed charges",""
"GRAFT MESH 15X30CM PARIETEX PROGRIP MACROPOROUS POLYESTER RECTANGULAR","SUP-ITM-10267617","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2488.64","1493.18","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1562.37","62.78","","9719.10","2943.96","9719.10","1 through 10","289.43","1809.74","percent of total billed charges",""
"GRAFT MESH 15X30CM PARIETEX PROGRIP MACROPOROUS POLYESTER RECTANGULAR","SUP-ITM-10267617","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2488.64","1493.18","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1809.74","72.72","","2009.48","1217.35","3752.64","17","289.43","1809.74","percent of total billed charges",""
"GRAFT MESH 20X20CM HERNIA MACROPOROUS PARIETENE PP","SUP-ITM-10267099","CDM","C1781","HCPCS","0278","RC","","","","both","","","323.53","194.12","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","37.63","275","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT MESH 20X20CM HERNIA MACROPOROUS PARIETENE PP","SUP-ITM-10267099","CDM","C1781","HCPCS","0278","RC","","","","both","","","323.53","194.12","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","184.09","56.9","","1333.47","776.80","2316.37","34","37.63","275","percent of total billed charges",""
"GRAFT MESH 20X20CM HERNIA MACROPOROUS PARIETENE PP","SUP-ITM-10267099","CDM","C1781","HCPCS","0278","RC","","","","both","","","323.53","194.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","37.63","11.63","","348.38","187.99","380.51","1 through 10","37.63","275","percent of total billed charges",""
"GRAFT MESH 20X20CM HERNIA MACROPOROUS PARIETENE PP","SUP-ITM-10267099","CDM","C1781","HCPCS","0278","RC","","","","both","","","323.53","194.12","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","203.50","62.9","","1793.12","860.08","3673.04","20","37.63","275","percent of total billed charges",""
"GRAFT MESH 20X20CM HERNIA MACROPOROUS PARIETENE PP","SUP-ITM-10267099","CDM","C1781","HCPCS","0278","RC","","","","both","","","323.53","194.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","250.41","77.4","","1107.52","186.36","4312.65","1 through 10","37.63","275","percent of total billed charges",""
"GRAFT MESH 20X20CM HERNIA MACROPOROUS PARIETENE PP","SUP-ITM-10267099","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","323.53","194.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","37.63","11.63","","348.38","187.99","380.51","1 through 10","37.63","235.27","percent of total billed charges",""
"GRAFT MESH 20X20CM HERNIA MACROPOROUS PARIETENE PP","SUP-ITM-10267099","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","323.53","194.12","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","203.11","62.78","","9719.10","2943.96","9719.10","1 through 10","37.63","235.27","percent of total billed charges",""
"GRAFT MESH 20X20CM HERNIA MACROPOROUS PARIETENE PP","SUP-ITM-10267099","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","323.53","194.12","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","235.27","72.72","","2009.48","1217.35","3752.64","17","37.63","235.27","percent of total billed charges",""
"GRAFT MESH 30X30CM HERNIA MACROPOROUS PARIETENE PP","SUP-ITM-10267100","CDM","C1781","HCPCS","0278","RC","","","","both","","","644.08","386.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","74.91","547.47","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT MESH 30X30CM HERNIA MACROPOROUS PARIETENE PP","SUP-ITM-10267100","CDM","C1781","HCPCS","0278","RC","","","","both","","","644.08","386.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","366.48","56.9","","1333.47","776.80","2316.37","34","74.91","547.47","percent of total billed charges",""
"GRAFT MESH 30X30CM HERNIA MACROPOROUS PARIETENE PP","SUP-ITM-10267100","CDM","C1781","HCPCS","0278","RC","","","","both","","","644.08","386.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","74.91","11.63","","348.38","187.99","380.51","1 through 10","74.91","547.47","percent of total billed charges",""
"GRAFT MESH 30X30CM HERNIA MACROPOROUS PARIETENE PP","SUP-ITM-10267100","CDM","C1781","HCPCS","0278","RC","","","","both","","","644.08","386.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","405.13","62.9","","1793.12","860.08","3673.04","20","74.91","547.47","percent of total billed charges",""
"GRAFT MESH 30X30CM HERNIA MACROPOROUS PARIETENE PP","SUP-ITM-10267100","CDM","C1781","HCPCS","0278","RC","","","","both","","","644.08","386.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","498.52","77.4","","1107.52","186.36","4312.65","1 through 10","74.91","547.47","percent of total billed charges",""
"GRAFT MESH 30X30CM HERNIA MACROPOROUS PARIETENE PP","SUP-ITM-10267100","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","644.08","386.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","74.91","11.63","","348.38","187.99","380.51","1 through 10","74.91","468.37","percent of total billed charges",""
"GRAFT MESH 30X30CM HERNIA MACROPOROUS PARIETENE PP","SUP-ITM-10267100","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","644.08","386.45","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","404.35","62.78","","9719.10","2943.96","9719.10","1 through 10","74.91","468.37","percent of total billed charges",""
"GRAFT MESH 30X30CM HERNIA MACROPOROUS PARIETENE PP","SUP-ITM-10267100","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","644.08","386.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","468.37","72.72","","2009.48","1217.35","3752.64","17","74.91","468.37","percent of total billed charges",""
"GRAFT MESH 35.5CM 25 W .7MM PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR FLAT SHEET CS/1EA","SUP-ITM-10188645","CDM","C1781","HCPCS","0278","RC","","","","both","","","1485.65","891.39","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","172.78","1262.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT MESH 35.5CM 25 W .7MM PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR FLAT SHEET CS/1EA","SUP-ITM-10188645","CDM","C1781","HCPCS","0278","RC","","","","both","","","1485.65","891.39","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","845.33","56.9","","1333.47","776.80","2316.37","34","172.78","1262.8","percent of total billed charges",""
"GRAFT MESH 35.5CM 25 W .7MM PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR FLAT SHEET CS/1EA","SUP-ITM-10188645","CDM","C1781","HCPCS","0278","RC","","","","both","","","1485.65","891.39","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","172.78","11.63","","348.38","187.99","380.51","1 through 10","172.78","1262.8","percent of total billed charges",""
"GRAFT MESH 35.5CM 25 W .7MM PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR FLAT SHEET CS/1EA","SUP-ITM-10188645","CDM","C1781","HCPCS","0278","RC","","","","both","","","1485.65","891.39","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","934.47","62.9","","1793.12","860.08","3673.04","20","172.78","1262.8","percent of total billed charges",""
"GRAFT MESH 35.5CM 25 W .7MM PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR FLAT SHEET CS/1EA","SUP-ITM-10188645","CDM","C1781","HCPCS","0278","RC","","","","both","","","1485.65","891.39","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1149.89","77.4","","1107.52","186.36","4312.65","1 through 10","172.78","1262.8","percent of total billed charges",""
"GRAFT MESH 35.5CM 25 W .7MM PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR FLAT SHEET CS/1EA","SUP-ITM-10188645","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1485.65","891.39","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","172.78","11.63","","348.38","187.99","380.51","1 through 10","172.78","1080.36","percent of total billed charges",""
"GRAFT MESH 35.5CM 25 W .7MM PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR FLAT SHEET CS/1EA","SUP-ITM-10188645","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1485.65","891.39","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","932.69","62.78","","9719.10","2943.96","9719.10","1 through 10","172.78","1080.36","percent of total billed charges",""
"GRAFT MESH 35.5CM 25 W .7MM PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR FLAT SHEET CS/1EA","SUP-ITM-10188645","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1485.65","891.39","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1080.36","72.72","","2009.48","1217.35","3752.64","17","172.78","1080.36","percent of total billed charges",""
"GRAFT MESH 40X50MM BIOLOGICAL PORCINE COLLAGEN MATRIX EXTREMITY BIO GIDE","SUP-ITM-10011290","CDM","C1762","HCPCS","0278","RC","","","","outpatient","","","4159.82","2495.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2616.53","62.9","","6599.70","6599.70","6599.70","1 through 10","483.79","3219.7","percent of total billed charges",""
"GRAFT MESH 4X6IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159296","CDM","C1781","HCPCS","0278","RC","","","","both","","","13823.67","8294.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","1607.69","11750.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT MESH 4X6IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159296","CDM","C1781","HCPCS","0278","RC","","","","both","","","13823.67","8294.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7865.67","56.9","","1333.47","776.80","2316.37","34","1607.69","11750.12","percent of total billed charges",""
"GRAFT MESH 4X6IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159296","CDM","C1781","HCPCS","0278","RC","","","","both","","","13823.67","8294.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1607.69","11.63","","348.38","187.99","380.51","1 through 10","1607.69","11750.12","percent of total billed charges",""
"GRAFT MESH 4X6IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159296","CDM","C1781","HCPCS","0278","RC","","","","both","","","13823.67","8294.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8695.09","62.9","","1793.12","860.08","3673.04","20","1607.69","11750.12","percent of total billed charges",""
"GRAFT MESH 4X6IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159296","CDM","C1781","HCPCS","0278","RC","","","","both","","","13823.67","8294.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10699.52","77.4","","1107.52","186.36","4312.65","1 through 10","1607.69","11750.12","percent of total billed charges",""
"GRAFT MESH 4X6IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159296","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","13823.67","8294.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1607.69","11.63","","348.38","187.99","380.51","1 through 10","1607.69","10052.57","percent of total billed charges",""
"GRAFT MESH 4X6IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159296","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","13823.67","8294.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","8678.50","62.78","","9719.10","2943.96","9719.10","1 through 10","1607.69","10052.57","percent of total billed charges",""
"GRAFT MESH 4X6IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159296","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","13823.67","8294.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10052.57","72.72","","2009.48","1217.35","3752.64","17","1607.69","10052.57","percent of total billed charges",""
"GRAFT MESH 5IN 7IN XL 3DMAX POLYPROPYLENE MONOFILAMENT PREFORMED PATCH HERNIA LT CS/1EA","SUP-ITM-10018258","CDM","C1781","HCPCS","0278","RC","","","","both","","","2003.90","1202.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","233.05","1703.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT MESH 5IN 7IN XL 3DMAX POLYPROPYLENE MONOFILAMENT PREFORMED PATCH HERNIA LT CS/1EA","SUP-ITM-10018258","CDM","C1781","HCPCS","0278","RC","","","","both","","","2003.90","1202.34","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1140.22","56.9","","1333.47","776.80","2316.37","34","233.05","1703.32","percent of total billed charges",""
"GRAFT MESH 5IN 7IN XL 3DMAX POLYPROPYLENE MONOFILAMENT PREFORMED PATCH HERNIA LT CS/1EA","SUP-ITM-10018258","CDM","C1781","HCPCS","0278","RC","","","","both","","","2003.90","1202.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","233.05","11.63","","348.38","187.99","380.51","1 through 10","233.05","1703.32","percent of total billed charges",""
"GRAFT MESH 5IN 7IN XL 3DMAX POLYPROPYLENE MONOFILAMENT PREFORMED PATCH HERNIA LT CS/1EA","SUP-ITM-10018258","CDM","C1781","HCPCS","0278","RC","","","","both","","","2003.90","1202.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1260.45","62.9","","1793.12","860.08","3673.04","20","233.05","1703.32","percent of total billed charges",""
"GRAFT MESH 5IN 7IN XL 3DMAX POLYPROPYLENE MONOFILAMENT PREFORMED PATCH HERNIA LT CS/1EA","SUP-ITM-10018258","CDM","C1781","HCPCS","0278","RC","","","","both","","","2003.90","1202.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1551.02","77.4","","1107.52","186.36","4312.65","1 through 10","233.05","1703.32","percent of total billed charges",""
"GRAFT MESH 5IN 7IN XL 3DMAX POLYPROPYLENE MONOFILAMENT PREFORMED PATCH HERNIA LT CS/1EA","SUP-ITM-10018258","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2003.90","1202.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","233.05","11.63","","348.38","187.99","380.51","1 through 10","233.05","1457.24","percent of total billed charges",""
"GRAFT MESH 5IN 7IN XL 3DMAX POLYPROPYLENE MONOFILAMENT PREFORMED PATCH HERNIA LT CS/1EA","SUP-ITM-10018258","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2003.90","1202.34","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1258.05","62.78","","9719.10","2943.96","9719.10","1 through 10","233.05","1457.24","percent of total billed charges",""
"GRAFT MESH 5IN 7IN XL 3DMAX POLYPROPYLENE MONOFILAMENT PREFORMED PATCH HERNIA LT CS/1EA","SUP-ITM-10018258","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2003.90","1202.34","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1457.24","72.72","","2009.48","1217.35","3752.64","17","233.05","1457.24","percent of total billed charges",""
"GRAFT MESH 6.0 XIN BARD POLYPROPYLENE MONOFILAMENT SOFT SQUARE BX/3EA","SUP-ITM-10188629","CDM","C1781","HCPCS","0278","RC","","","","both","","","988.13","592.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","114.92","839.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT MESH 6.0 XIN BARD POLYPROPYLENE MONOFILAMENT SOFT SQUARE BX/3EA","SUP-ITM-10188629","CDM","C1781","HCPCS","0278","RC","","","","both","","","988.13","592.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","562.25","56.9","","1333.47","776.80","2316.37","34","114.92","839.91","percent of total billed charges",""
"GRAFT MESH 6.0 XIN BARD POLYPROPYLENE MONOFILAMENT SOFT SQUARE BX/3EA","SUP-ITM-10188629","CDM","C1781","HCPCS","0278","RC","","","","both","","","988.13","592.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","114.92","11.63","","348.38","187.99","380.51","1 through 10","114.92","839.91","percent of total billed charges",""
"GRAFT MESH 6.0 XIN BARD POLYPROPYLENE MONOFILAMENT SOFT SQUARE BX/3EA","SUP-ITM-10188629","CDM","C1781","HCPCS","0278","RC","","","","both","","","988.13","592.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","621.53","62.9","","1793.12","860.08","3673.04","20","114.92","839.91","percent of total billed charges",""
"GRAFT MESH 6.0 XIN BARD POLYPROPYLENE MONOFILAMENT SOFT SQUARE BX/3EA","SUP-ITM-10188629","CDM","C1781","HCPCS","0278","RC","","","","both","","","988.13","592.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","764.81","77.4","","1107.52","186.36","4312.65","1 through 10","114.92","839.91","percent of total billed charges",""
"GRAFT MESH 6.0 XIN BARD POLYPROPYLENE MONOFILAMENT SOFT SQUARE BX/3EA","SUP-ITM-10188629","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","988.13","592.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","114.92","11.63","","348.38","187.99","380.51","1 through 10","114.92","718.57","percent of total billed charges",""
"GRAFT MESH 6.0 XIN BARD POLYPROPYLENE MONOFILAMENT SOFT SQUARE BX/3EA","SUP-ITM-10188629","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","988.13","592.88","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","620.35","62.78","","9719.10","2943.96","9719.10","1 through 10","114.92","718.57","percent of total billed charges",""
"GRAFT MESH 6.0 XIN BARD POLYPROPYLENE MONOFILAMENT SOFT SQUARE BX/3EA","SUP-ITM-10188629","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","988.13","592.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","718.57","72.72","","2009.48","1217.35","3752.64","17","114.92","718.57","percent of total billed charges",""
"GRAFT MESH 6.0X3.5IN ABDOMINAL COLLAGEN COATED RECTANGLE POLYESTER PARIETEX","SUP-ITM-10267569","CDM","C1781","HCPCS","0278","RC","","","","both","","","1365.21","819.13","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","158.77","1160.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT MESH 6.0X3.5IN ABDOMINAL COLLAGEN COATED RECTANGLE POLYESTER PARIETEX","SUP-ITM-10267569","CDM","C1781","HCPCS","0278","RC","","","","both","","","1365.21","819.13","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","776.80","56.9","","1333.47","776.80","2316.37","34","158.77","1160.43","percent of total billed charges",""
"GRAFT MESH 6.0X3.5IN ABDOMINAL COLLAGEN COATED RECTANGLE POLYESTER PARIETEX","SUP-ITM-10267569","CDM","C1781","HCPCS","0278","RC","","","","both","","","1365.21","819.13","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","158.77","11.63","","348.38","187.99","380.51","1 through 10","158.77","1160.43","percent of total billed charges",""
"GRAFT MESH 6.0X3.5IN ABDOMINAL COLLAGEN COATED RECTANGLE POLYESTER PARIETEX","SUP-ITM-10267569","CDM","C1781","HCPCS","0278","RC","","","","both","","","1365.21","819.13","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","858.72","62.9","","1793.12","860.08","3673.04","20","158.77","1160.43","percent of total billed charges",""
"GRAFT MESH 6.0X3.5IN ABDOMINAL COLLAGEN COATED RECTANGLE POLYESTER PARIETEX","SUP-ITM-10267569","CDM","C1781","HCPCS","0278","RC","","","","both","","","1365.21","819.13","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1056.67","77.4","","1107.52","186.36","4312.65","1 through 10","158.77","1160.43","percent of total billed charges",""
"GRAFT MESH 6.0X3.5IN ABDOMINAL COLLAGEN COATED RECTANGLE POLYESTER PARIETEX","SUP-ITM-10267569","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1365.21","819.13","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","158.77","11.63","","348.38","187.99","380.51","1 through 10","158.77","992.78","percent of total billed charges",""
"GRAFT MESH 6.0X3.5IN ABDOMINAL COLLAGEN COATED RECTANGLE POLYESTER PARIETEX","SUP-ITM-10267569","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1365.21","819.13","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","857.08","62.78","","9719.10","2943.96","9719.10","1 through 10","158.77","992.78","percent of total billed charges",""
"GRAFT MESH 6.0X3.5IN ABDOMINAL COLLAGEN COATED RECTANGLE POLYESTER PARIETEX","SUP-ITM-10267569","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1365.21","819.13","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","992.78","72.72","","2009.48","1217.35","3752.64","17","158.77","992.78","percent of total billed charges",""
"GRAFT MESH 6X8IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159297","CDM","C1781","HCPCS","0278","RC","","","","both","","","22130.23","13278.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","2573.75","18810.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT MESH 6X8IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159297","CDM","C1781","HCPCS","0278","RC","","","","both","","","22130.23","13278.14","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","12592.10","56.9","","1333.47","776.80","2316.37","34","2573.75","18810.7","percent of total billed charges",""
"GRAFT MESH 6X8IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159297","CDM","C1781","HCPCS","0278","RC","","","","both","","","22130.23","13278.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2573.75","11.63","","348.38","187.99","380.51","1 through 10","2573.75","18810.7","percent of total billed charges",""
"GRAFT MESH 6X8IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159297","CDM","C1781","HCPCS","0278","RC","","","","both","","","22130.23","13278.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","13919.91","62.9","","1793.12","860.08","3673.04","20","2573.75","18810.7","percent of total billed charges",""
"GRAFT MESH 6X8IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159297","CDM","C1781","HCPCS","0278","RC","","","","both","","","22130.23","13278.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","17128.80","77.4","","1107.52","186.36","4312.65","1 through 10","2573.75","18810.7","percent of total billed charges",""
"GRAFT MESH 6X8IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159297","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","22130.23","13278.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2573.75","11.63","","348.38","187.99","380.51","1 through 10","2573.75","16093.1","percent of total billed charges",""
"GRAFT MESH 6X8IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159297","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","22130.23","13278.14","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","13893.36","62.78","","9719.10","2943.96","9719.10","1 through 10","2573.75","16093.1","percent of total billed charges",""
"GRAFT MESH 6X8IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159297","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","22130.23","13278.14","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","16093.10","72.72","","2009.48","1217.35","3752.64","17","2573.75","16093.1","percent of total billed charges",""
"GRAFT MESH 6X8IN VENTRALIGHT ST POLYPROPYLENE ECHO PS POSITIONING HERNIA MONOFIL HYDROGEL SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10157613","CDM","C1781","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","987.1","7214.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT MESH 6X8IN VENTRALIGHT ST POLYPROPYLENE ECHO PS POSITIONING HERNIA MONOFIL HYDROGEL SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10157613","CDM","C1781","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4829.39","56.9","","1333.47","776.80","2316.37","34","987.1","7214.38","percent of total billed charges",""
"GRAFT MESH 6X8IN VENTRALIGHT ST POLYPROPYLENE ECHO PS POSITIONING HERNIA MONOFIL HYDROGEL SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10157613","CDM","C1781","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","987.10","11.63","","348.38","187.99","380.51","1 through 10","987.1","7214.38","percent of total billed charges",""
"GRAFT MESH 6X8IN VENTRALIGHT ST POLYPROPYLENE ECHO PS POSITIONING HERNIA MONOFIL HYDROGEL SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10157613","CDM","C1781","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5338.64","62.9","","1793.12","860.08","3673.04","20","987.1","7214.38","percent of total billed charges",""
"GRAFT MESH 6X8IN VENTRALIGHT ST POLYPROPYLENE ECHO PS POSITIONING HERNIA MONOFIL HYDROGEL SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10157613","CDM","C1781","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6569.33","77.4","","1107.52","186.36","4312.65","1 through 10","987.1","7214.38","percent of total billed charges",""
"GRAFT MESH 6X8IN VENTRALIGHT ST POLYPROPYLENE ECHO PS POSITIONING HERNIA MONOFIL HYDROGEL SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10157613","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","987.10","11.63","","348.38","187.99","380.51","1 through 10","987.1","6172.11","percent of total billed charges",""
"GRAFT MESH 6X8IN VENTRALIGHT ST POLYPROPYLENE ECHO PS POSITIONING HERNIA MONOFIL HYDROGEL SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10157613","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5328.45","62.78","","9719.10","2943.96","9719.10","1 through 10","987.1","6172.11","percent of total billed charges",""
"GRAFT MESH 6X8IN VENTRALIGHT ST POLYPROPYLENE ECHO PS POSITIONING HERNIA MONOFIL HYDROGEL SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10157613","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6172.11","72.72","","2009.48","1217.35","3752.64","17","987.1","6172.11","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","both","","","1658.40","995.04","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","192.87","1409.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","both","","","1658.40","995.04","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","943.63","56.9","","1333.47","776.80","2316.37","34","192.87","1409.64","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","both","","","1658.40","995.04","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","192.87","11.63","","348.38","187.99","380.51","1 through 10","192.87","1409.64","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","both","","","1658.40","995.04","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1043.13","62.9","","1793.12","860.08","3673.04","20","192.87","1409.64","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","both","","","1658.40","995.04","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1283.60","77.4","","1107.52","186.36","4312.65","1 through 10","192.87","1409.64","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1658.40","995.04","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","192.87","11.63","","348.38","187.99","380.51","1 through 10","192.87","1205.99","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1658.40","995.04","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1041.14","62.78","","9719.10","2943.96","9719.10","1 through 10","192.87","1205.99","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1658.40","995.04","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1205.99","72.72","","2009.48","1217.35","3752.64","17","192.87","1205.99","percent of total billed charges",""
"GRAFT MESH 8CM PARIETEX MACROPOROUS POLYESTER ROUND PLUG KEYHOLE PATCH HERNIA SYSTEM STERILE DISPOSABLE CS/3EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10267610","CDM","C1781","HCPCS","0278","RC","","","","both","","","624.55","374.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","72.64","530.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT MESH 8CM PARIETEX MACROPOROUS POLYESTER ROUND PLUG KEYHOLE PATCH HERNIA SYSTEM STERILE DISPOSABLE CS/3EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10267610","CDM","C1781","HCPCS","0278","RC","","","","both","","","624.55","374.73","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","355.37","56.9","","1333.47","776.80","2316.37","34","72.64","530.87","percent of total billed charges",""
"GRAFT MESH 8CM PARIETEX MACROPOROUS POLYESTER ROUND PLUG KEYHOLE PATCH HERNIA SYSTEM STERILE DISPOSABLE CS/3EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10267610","CDM","C1781","HCPCS","0278","RC","","","","both","","","624.55","374.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","72.64","11.63","","348.38","187.99","380.51","1 through 10","72.64","530.87","percent of total billed charges",""
"GRAFT MESH 8CM PARIETEX MACROPOROUS POLYESTER ROUND PLUG KEYHOLE PATCH HERNIA SYSTEM STERILE DISPOSABLE CS/3EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10267610","CDM","C1781","HCPCS","0278","RC","","","","both","","","624.55","374.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","392.84","62.9","","1793.12","860.08","3673.04","20","72.64","530.87","percent of total billed charges",""
"GRAFT MESH 8CM PARIETEX MACROPOROUS POLYESTER ROUND PLUG KEYHOLE PATCH HERNIA SYSTEM STERILE DISPOSABLE CS/3EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10267610","CDM","C1781","HCPCS","0278","RC","","","","both","","","624.55","374.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","483.40","77.4","","1107.52","186.36","4312.65","1 through 10","72.64","530.87","percent of total billed charges",""
"GRAFT MESH 8CM PARIETEX MACROPOROUS POLYESTER ROUND PLUG KEYHOLE PATCH HERNIA SYSTEM STERILE DISPOSABLE CS/3EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10267610","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","624.55","374.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","72.64","11.63","","348.38","187.99","380.51","1 through 10","72.64","454.17","percent of total billed charges",""
"GRAFT MESH 8CM PARIETEX MACROPOROUS POLYESTER ROUND PLUG KEYHOLE PATCH HERNIA SYSTEM STERILE DISPOSABLE CS/3EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10267610","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","624.55","374.73","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","392.09","62.78","","9719.10","2943.96","9719.10","1 through 10","72.64","454.17","percent of total billed charges",""
"GRAFT MESH 8CM PARIETEX MACROPOROUS POLYESTER ROUND PLUG KEYHOLE PATCH HERNIA SYSTEM STERILE DISPOSABLE CS/3EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10267610","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","624.55","374.73","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","454.17","72.72","","2009.48","1217.35","3752.64","17","72.64","454.17","percent of total billed charges",""
"GRAFT MESH 8X10IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159298","CDM","C1781","HCPCS","0278","RC","","","","both","","","26845.71","16107.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","3122.16","22818.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT MESH 8X10IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159298","CDM","C1781","HCPCS","0278","RC","","","","both","","","26845.71","16107.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","15275.21","56.9","","1333.47","776.80","2316.37","34","3122.16","22818.85","percent of total billed charges",""
"GRAFT MESH 8X10IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159298","CDM","C1781","HCPCS","0278","RC","","","","both","","","26845.71","16107.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","3122.16","11.63","","348.38","187.99","380.51","1 through 10","3122.16","22818.85","percent of total billed charges",""
"GRAFT MESH 8X10IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159298","CDM","C1781","HCPCS","0278","RC","","","","both","","","26845.71","16107.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","16885.95","62.9","","1793.12","860.08","3673.04","20","3122.16","22818.85","percent of total billed charges",""
"GRAFT MESH 8X10IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159298","CDM","C1781","HCPCS","0278","RC","","","","both","","","26845.71","16107.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","20778.58","77.4","","1107.52","186.36","4312.65","1 through 10","3122.16","22818.85","percent of total billed charges",""
"GRAFT MESH 8X10IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159298","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","26845.71","16107.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","3122.16","11.63","","348.38","187.99","380.51","1 through 10","3122.16","19522.2","percent of total billed charges",""
"GRAFT MESH 8X10IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159298","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","26845.71","16107.43","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","16853.74","62.78","","9719.10","2943.96","9719.10","1 through 10","3122.16","19522.2","percent of total billed charges",""
"GRAFT MESH 8X10IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159298","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","26845.71","16107.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","19522.20","72.72","","2009.48","1217.35","3752.64","17","3122.16","19522.2","percent of total billed charges",""
"GRAFT NERVE 30X2.0 3.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124154","CDM","C1889","HCPCS","0278","RC","","","","both","","","13933.96","8360.38","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","1620.52","11843.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT NERVE 30X2.0 3.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124154","CDM","C1889","HCPCS","0278","RC","","","","both","","","13933.96","8360.38","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","1620.52","11843.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT NERVE 30X2.0 3.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124154","CDM","C1889","HCPCS","0278","RC","","","","both","","","13933.96","8360.38","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7928.42","56.9","","0.63","0.63","0.63","1 through 10","1620.52","11843.87","percent of total billed charges",""
"GRAFT NERVE 30X2.0 3.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124154","CDM","C1889","HCPCS","0278","RC","","","","both","","","13933.96","8360.38","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2009.28","14.42","","317.14","317.14","317.14","1 through 10","1620.52","11843.87","percent of total billed charges",""
"GRAFT NERVE 30X2.0 3.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124154","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13933.96","8360.38","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2009.28","14.42","","317.14","317.14","317.14","1 through 10","1620.52","10784.89","percent of total billed charges",""
"GRAFT NERVE 30X2.0 3.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124154","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13933.96","8360.38","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","8747.74","62.78","","1125.09","1125.09","1125.09","1 through 10","1620.52","10784.89","percent of total billed charges",""
"GRAFT NERVE 30X2.0 3.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124154","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13933.96","8360.38","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10132.78","72.72","","4732.50","1617.43","14180.40","1 through 10","1620.52","10784.89","percent of total billed charges",""
"GRAFT NERVE 30X2.0 3.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124154","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13933.96","8360.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8764.46","62.9","","3896.20","3341.38","3896.20","1 through 10","1620.52","10784.89","percent of total billed charges",""
"GRAFT NERVE 50X1.0 2.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124161","CDM","C1889","HCPCS","0278","RC","","","","both","","","17387.50","10432.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","2022.17","14779.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT NERVE 50X1.0 2.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124161","CDM","C1889","HCPCS","0278","RC","","","","both","","","17387.50","10432.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","2022.17","14779.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT NERVE 50X1.0 2.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124161","CDM","C1889","HCPCS","0278","RC","","","","both","","","17387.50","10432.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","9893.49","56.9","","0.63","0.63","0.63","1 through 10","2022.17","14779.38","percent of total billed charges",""
"GRAFT NERVE 50X1.0 2.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124161","CDM","C1889","HCPCS","0278","RC","","","","both","","","17387.50","10432.50","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2507.28","14.42","","317.14","317.14","317.14","1 through 10","2022.17","14779.38","percent of total billed charges",""
"GRAFT NERVE 50X1.0 2.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124161","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","17387.50","10432.50","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2507.28","14.42","","317.14","317.14","317.14","1 through 10","2022.17","13457.93","percent of total billed charges",""
"GRAFT NERVE 50X1.0 2.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124161","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","17387.50","10432.50","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","10915.87","62.78","","1125.09","1125.09","1125.09","1 through 10","2022.17","13457.93","percent of total billed charges",""
"GRAFT NERVE 50X1.0 2.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124161","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","17387.50","10432.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","12644.19","72.72","","4732.50","1617.43","14180.40","1 through 10","2022.17","13457.93","percent of total billed charges",""
"GRAFT NERVE 50X1.0 2.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124161","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","17387.50","10432.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","10936.74","62.9","","3896.20","3341.38","3896.20","1 through 10","2022.17","13457.93","percent of total billed charges",""
"GRAFT STENT 22X16X120MM AFX2 ABDOMINAL AORTIC ANEURYSM BIFURCATED BEA22-90/I16-30","SUP-ITM-10156210","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","25960.00","15576.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","18878.11","72.72","","4588.52","4588.52","4588.52","1 through 10","3019.15","20093.04","percent of total billed charges",""
"GRAFT STENT AFX2 28MM 16MM 140MM BIFURCATED ABDOMINAL AORTIC ANEURYSM","SUP-ITM-10156193","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","25960.00","15576.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","18878.11","72.72","","4588.52","4588.52","4588.52","1 through 10","3019.15","20093.04","percent of total billed charges",""
"GRAFT STENT AFX2 28MM 20MM 120MM BIFURCATED","SUP-ITM-10156183","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","25960.00","15576.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","18878.11","72.72","","4588.52","4588.52","4588.52","1 through 10","3019.15","20093.04","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","both","","","5474.44","3284.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","636.68","4653.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","both","","","5474.44","3284.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","636.68","4653.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","both","","","5474.44","3284.66","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3114.96","56.9","","0.63","0.63","0.63","1 through 10","636.68","4653.27","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","both","","","5474.44","3284.66","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","789.41","14.42","","317.14","317.14","317.14","1 through 10","636.68","4653.27","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5474.44","3284.66","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","789.41","14.42","","317.14","317.14","317.14","1 through 10","636.68","4237.22","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5474.44","3284.66","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3436.85","62.78","","1125.09","1125.09","1125.09","1 through 10","636.68","4237.22","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5474.44","3284.66","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3981.01","72.72","","4732.50","1617.43","14180.40","1 through 10","636.68","4237.22","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5474.44","3284.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3443.42","62.9","","3896.20","3341.38","3896.20","1 through 10","636.68","4237.22","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX15 FREEZE DRIED CANCELLOUS CRUSHED","SUP-ITM-10008885","CDM","C1889","HCPCS","0278","RC","","","","both","","","1414.96","848.98","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","164.56","1202.72","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 1 TO 8MMX15 FREEZE DRIED CANCELLOUS CRUSHED","SUP-ITM-10008885","CDM","C1889","HCPCS","0278","RC","","","","both","","","1414.96","848.98","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","164.56","1202.72","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 1 TO 8MMX15 FREEZE DRIED CANCELLOUS CRUSHED","SUP-ITM-10008885","CDM","C1889","HCPCS","0278","RC","","","","both","","","1414.96","848.98","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","805.11","56.9","","0.63","0.63","0.63","1 through 10","164.56","1202.72","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX15 FREEZE DRIED CANCELLOUS CRUSHED","SUP-ITM-10008885","CDM","C1889","HCPCS","0278","RC","","","","both","","","1414.96","848.98","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","204.04","14.42","","317.14","317.14","317.14","1 through 10","164.56","1202.72","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX15 FREEZE DRIED CANCELLOUS CRUSHED","SUP-ITM-10008885","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1414.96","848.98","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","204.04","14.42","","317.14","317.14","317.14","1 through 10","164.56","1095.18","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX15 FREEZE DRIED CANCELLOUS CRUSHED","SUP-ITM-10008885","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1414.96","848.98","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","888.31","62.78","","1125.09","1125.09","1125.09","1 through 10","164.56","1095.18","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX15 FREEZE DRIED CANCELLOUS CRUSHED","SUP-ITM-10008885","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1414.96","848.98","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1028.96","72.72","","4732.50","1617.43","14180.40","1 through 10","164.56","1095.18","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX15 FREEZE DRIED CANCELLOUS CRUSHED","SUP-ITM-10008885","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1414.96","848.98","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","890.01","62.9","","3896.20","3341.38","3896.20","1 through 10","164.56","1095.18","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MED HUMAN ALLODERM LG PERFORATED REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132978","CDM","Q4116","HCPCS","0636","RC","","","","both","","","19525.32","11715.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","109.46","109.46","109.46","480","80.3","16596.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MED HUMAN ALLODERM LG PERFORATED REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132978","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","19525.32","11715.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","12281.43","62.9","","1012.29","1012.29","1012.29","1008","54.99","15112.6","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MEDIUM CONTOUR NON PERFORATED RTU ALLODERM","SUP-ITM-10132704","CDM","Q4116","HCPCS","0636","RC","","","","both","","","15259.08","9155.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","109.46","109.46","109.46","480","80.3","12970.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MEDIUM CONTOUR NON PERFORATED RTU ALLODERM","SUP-ITM-10132704","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","15259.08","9155.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","9597.96","62.9","","1012.29","1012.29","1012.29","1008","54.99","11810.53","percent of total billed charges",""
"GRAFT TISSUE 1.6 SELECT DUO MED THICK HUMAN ALLODERM CONTOURED MED PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132981","CDM","Q4116","HCPCS","0636","RC","","","","both","","","15715.60","9429.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","109.46","109.46","109.46","480","80.3","13358.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 1.6 SELECT DUO MED THICK HUMAN ALLODERM CONTOURED MED PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132981","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","15715.60","9429.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","9885.11","62.9","","1012.29","1012.29","1012.29","1008","54.99","12163.87","percent of total billed charges",""
"GRAFT TISSUE 1.6X.4MM HUMAN ALLODERM EXTRA LG CONTOURED MED THICKNESS REGENERATIVE MATRIX","SUP-ITM-10190839","CDM","Q4116","HCPCS","0636","RC","","","","both","","","18599.75","11159.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","109.46","109.46","109.46","480","80.3","15809.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 1.6X.4MM HUMAN ALLODERM EXTRA LG CONTOURED MED THICKNESS REGENERATIVE MATRIX","SUP-ITM-10190839","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","18599.75","11159.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","11699.24","62.9","","1012.29","1012.29","1012.29","1008","54.99","14396.21","percent of total billed charges",""
"GRAFT TISSUE 1.6X.4MM XL HUMAN ALLODERM CONTOURED PERFORATED REGENERATIVE MATRIX","SUP-ITM-10190852","CDM","Q4116","HCPCS","0636","RC","","","","both","","","19158.75","11495.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","109.46","109.46","109.46","480","80.3","16284.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 1.6X.4MM XL HUMAN ALLODERM CONTOURED PERFORATED REGENERATIVE MATRIX","SUP-ITM-10190852","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","19158.75","11495.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","12050.85","62.9","","1012.29","1012.29","1012.29","1008","54.99","14828.87","percent of total billed charges",""
"GRAFT TISSUE 10.7X21.5CM LG THIN HUMAN ALLODERM CONTOURED REGENERATIVE MATRIX","SUP-ITM-10174649","CDM","Q4116","HCPCS","0636","RC","","","","both","","","18955.68","11373.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","109.46","109.46","109.46","480","80.3","16112.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 10.7X21.5CM LG THIN HUMAN ALLODERM CONTOURED REGENERATIVE MATRIX","SUP-ITM-10174649","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","18955.68","11373.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","11923.12","62.9","","1012.29","1012.29","1012.29","1008","54.99","14671.7","percent of total billed charges",""
"GRAFT TISSUE 10CMXSURGICAL XENMATRIX COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138497","CDM","C1781","HCPCS","0278","RC","","","","both","","","13029.00","7817.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","1515.27","11074.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 10CMXSURGICAL XENMATRIX COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138497","CDM","C1781","HCPCS","0278","RC","","","","both","","","13029.00","7817.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7413.50","56.9","","1333.47","776.80","2316.37","34","1515.27","11074.65","percent of total billed charges",""
"GRAFT TISSUE 10CMXSURGICAL XENMATRIX COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138497","CDM","C1781","HCPCS","0278","RC","","","","both","","","13029.00","7817.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1515.27","11.63","","348.38","187.99","380.51","1 through 10","1515.27","11074.65","percent of total billed charges",""
"GRAFT TISSUE 10CMXSURGICAL XENMATRIX COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138497","CDM","C1781","HCPCS","0278","RC","","","","both","","","13029.00","7817.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8195.24","62.9","","1793.12","860.08","3673.04","20","1515.27","11074.65","percent of total billed charges",""
"GRAFT TISSUE 10CMXSURGICAL XENMATRIX COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138497","CDM","C1781","HCPCS","0278","RC","","","","both","","","13029.00","7817.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10084.45","77.4","","1107.52","186.36","4312.65","1 through 10","1515.27","11074.65","percent of total billed charges",""
"GRAFT TISSUE 10CMXSURGICAL XENMATRIX COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138497","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","13029.00","7817.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1515.27","11.63","","348.38","187.99","380.51","1 through 10","1515.27","9474.69","percent of total billed charges",""
"GRAFT TISSUE 10CMXSURGICAL XENMATRIX COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138497","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","13029.00","7817.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","8179.61","62.78","","9719.10","2943.96","9719.10","1 through 10","1515.27","9474.69","percent of total billed charges",""
"GRAFT TISSUE 10CMXSURGICAL XENMATRIX COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138497","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","13029.00","7817.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","9474.69","72.72","","2009.48","1217.35","3752.64","17","1515.27","9474.69","percent of total billed charges",""
"GRAFT TISSUE 10X20CM SURGICAL XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10157617","CDM","C1781","HCPCS","0278","RC","","","","both","","","21612.50","12967.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","2513.53","18370.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 10X20CM SURGICAL XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10157617","CDM","C1781","HCPCS","0278","RC","","","","both","","","21612.50","12967.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","12297.51","56.9","","1333.47","776.80","2316.37","34","2513.53","18370.63","percent of total billed charges",""
"GRAFT TISSUE 10X20CM SURGICAL XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10157617","CDM","C1781","HCPCS","0278","RC","","","","both","","","21612.50","12967.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2513.53","11.63","","348.38","187.99","380.51","1 through 10","2513.53","18370.63","percent of total billed charges",""
"GRAFT TISSUE 10X20CM SURGICAL XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10157617","CDM","C1781","HCPCS","0278","RC","","","","both","","","21612.50","12967.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","13594.26","62.9","","1793.12","860.08","3673.04","20","2513.53","18370.63","percent of total billed charges",""
"GRAFT TISSUE 10X20CM SURGICAL XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10157617","CDM","C1781","HCPCS","0278","RC","","","","both","","","21612.50","12967.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","16728.08","77.4","","1107.52","186.36","4312.65","1 through 10","2513.53","18370.63","percent of total billed charges",""
"GRAFT TISSUE 10X20CM SURGICAL XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10157617","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","21612.50","12967.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2513.53","11.63","","348.38","187.99","380.51","1 through 10","2513.53","15716.61","percent of total billed charges",""
"GRAFT TISSUE 10X20CM SURGICAL XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10157617","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","21612.50","12967.50","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","13568.33","62.78","","9719.10","2943.96","9719.10","1 through 10","2513.53","15716.61","percent of total billed charges",""
"GRAFT TISSUE 10X20CM SURGICAL XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10157617","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","21612.50","12967.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","15716.61","72.72","","2009.48","1217.35","3752.64","17","2513.53","15716.61","percent of total billed charges",""
"GRAFT TISSUE 110MG DENOVO NT ALLO CARTILAGE ARTICULAR PARTICULATED NATURAL","SUP-ITM-10029541","CDM","C1889","HCPCS","0278","RC","","","","both","","","20159.60","12095.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","2344.56","17135.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 110MG DENOVO NT ALLO CARTILAGE ARTICULAR PARTICULATED NATURAL","SUP-ITM-10029541","CDM","C1889","HCPCS","0278","RC","","","","both","","","20159.60","12095.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","2344.56","17135.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 110MG DENOVO NT ALLO CARTILAGE ARTICULAR PARTICULATED NATURAL","SUP-ITM-10029541","CDM","C1889","HCPCS","0278","RC","","","","both","","","20159.60","12095.76","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","11470.81","56.9","","0.63","0.63","0.63","1 through 10","2344.56","17135.66","percent of total billed charges",""
"GRAFT TISSUE 110MG DENOVO NT ALLO CARTILAGE ARTICULAR PARTICULATED NATURAL","SUP-ITM-10029541","CDM","C1889","HCPCS","0278","RC","","","","both","","","20159.60","12095.76","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2907.01","14.42","","317.14","317.14","317.14","1 through 10","2344.56","17135.66","percent of total billed charges",""
"GRAFT TISSUE 110MG DENOVO NT ALLO CARTILAGE ARTICULAR PARTICULATED NATURAL","SUP-ITM-10029541","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","20159.60","12095.76","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2907.01","14.42","","317.14","317.14","317.14","1 through 10","2344.56","15603.53","percent of total billed charges",""
"GRAFT TISSUE 110MG DENOVO NT ALLO CARTILAGE ARTICULAR PARTICULATED NATURAL","SUP-ITM-10029541","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","20159.60","12095.76","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","12656.20","62.78","","1125.09","1125.09","1125.09","1 through 10","2344.56","15603.53","percent of total billed charges",""
"GRAFT TISSUE 110MG DENOVO NT ALLO CARTILAGE ARTICULAR PARTICULATED NATURAL","SUP-ITM-10029541","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","20159.60","12095.76","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","14660.06","72.72","","4732.50","1617.43","14180.40","1 through 10","2344.56","15603.53","percent of total billed charges",""
"GRAFT TISSUE 110MG DENOVO NT ALLO CARTILAGE ARTICULAR PARTICULATED NATURAL","SUP-ITM-10029541","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","20159.60","12095.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","12680.39","62.9","","3896.20","3341.38","3896.20","1 through 10","2344.56","15603.53","percent of total billed charges",""
"GRAFT TISSUE 15CMX20 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138493","CDM","C1781","HCPCS","0278","RC","","","","both","","","28320.00","16992.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","3293.62","24072","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 15CMX20 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138493","CDM","C1781","HCPCS","0278","RC","","","","both","","","28320.00","16992.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","16114.08","56.9","","1333.47","776.80","2316.37","34","3293.62","24072","percent of total billed charges",""
"GRAFT TISSUE 15CMX20 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138493","CDM","C1781","HCPCS","0278","RC","","","","both","","","28320.00","16992.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","3293.62","11.63","","348.38","187.99","380.51","1 through 10","3293.62","24072","percent of total billed charges",""
"GRAFT TISSUE 15CMX20 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138493","CDM","C1781","HCPCS","0278","RC","","","","both","","","28320.00","16992.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","17813.28","62.9","","1793.12","860.08","3673.04","20","3293.62","24072","percent of total billed charges",""
"GRAFT TISSUE 15CMX20 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138493","CDM","C1781","HCPCS","0278","RC","","","","both","","","28320.00","16992.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","21919.68","77.4","","1107.52","186.36","4312.65","1 through 10","3293.62","24072","percent of total billed charges",""
"GRAFT TISSUE 15CMX20 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138493","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","28320.00","16992.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","3293.62","11.63","","348.38","187.99","380.51","1 through 10","3293.62","20594.3","percent of total billed charges",""
"GRAFT TISSUE 15CMX20 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138493","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","28320.00","16992.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","17779.30","62.78","","9719.10","2943.96","9719.10","1 through 10","3293.62","20594.3","percent of total billed charges",""
"GRAFT TISSUE 15CMX20 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138493","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","28320.00","16992.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","20594.30","72.72","","2009.48","1217.35","3752.64","17","3293.62","20594.3","percent of total billed charges",""
"GRAFT TISSUE 160MM FLEXI ALLO TENDON ACHILLES BONE BLOCK FROZEN","SUP-ITM-10010256","CDM","C1889","HCPCS","0278","RC","","","","both","","","7507.36","4504.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","873.11","6381.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 160MM FLEXI ALLO TENDON ACHILLES BONE BLOCK FROZEN","SUP-ITM-10010256","CDM","C1889","HCPCS","0278","RC","","","","both","","","7507.36","4504.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","873.11","6381.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 160MM FLEXI ALLO TENDON ACHILLES BONE BLOCK FROZEN","SUP-ITM-10010256","CDM","C1889","HCPCS","0278","RC","","","","both","","","7507.36","4504.42","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4271.69","56.9","","0.63","0.63","0.63","1 through 10","873.11","6381.26","percent of total billed charges",""
"GRAFT TISSUE 160MM FLEXI ALLO TENDON ACHILLES BONE BLOCK FROZEN","SUP-ITM-10010256","CDM","C1889","HCPCS","0278","RC","","","","both","","","7507.36","4504.42","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1082.56","14.42","","317.14","317.14","317.14","1 through 10","873.11","6381.26","percent of total billed charges",""
"GRAFT TISSUE 160MM FLEXI ALLO TENDON ACHILLES BONE BLOCK FROZEN","SUP-ITM-10010256","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7507.36","4504.42","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1082.56","14.42","","317.14","317.14","317.14","1 through 10","873.11","5810.7","percent of total billed charges",""
"GRAFT TISSUE 160MM FLEXI ALLO TENDON ACHILLES BONE BLOCK FROZEN","SUP-ITM-10010256","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7507.36","4504.42","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4713.12","62.78","","1125.09","1125.09","1125.09","1 through 10","873.11","5810.7","percent of total billed charges",""
"GRAFT TISSUE 160MM FLEXI ALLO TENDON ACHILLES BONE BLOCK FROZEN","SUP-ITM-10010256","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7507.36","4504.42","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5459.35","72.72","","4732.50","1617.43","14180.40","1 through 10","873.11","5810.7","percent of total billed charges",""
"GRAFT TISSUE 160MM FLEXI ALLO TENDON ACHILLES BONE BLOCK FROZEN","SUP-ITM-10010256","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7507.36","4504.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4722.13","62.9","","3896.20","3341.38","3896.20","1 through 10","873.11","5810.7","percent of total billed charges",""
"GRAFT TISSUE 16X6CM ALLODERM REHYDRATED REGENERATIVE THIN","SUP-ITM-10100897","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11097.88","6658.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","109.46","109.46","109.46","480","80.3","9433.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 16X6CM ALLODERM REHYDRATED REGENERATIVE THIN","SUP-ITM-10100897","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","11097.88","6658.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6980.57","62.9","","1012.29","1012.29","1012.29","1008","54.99","8589.76","percent of total billed charges",""
"GRAFT TISSUE 16X6CM XTHICK READY TO USE ALLODERM REGENERATIVE MATRIX","SUP-ITM-10126007","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11097.88","6658.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","109.46","109.46","109.46","480","80.3","9433.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 16X6CM XTHICK READY TO USE ALLODERM REGENERATIVE MATRIX","SUP-ITM-10126007","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","11097.88","6658.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6980.57","62.9","","1012.29","1012.29","1012.29","1008","54.99","8589.76","percent of total billed charges",""
"GRAFT TISSUE 19CMX35 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138494","CDM","C1781","HCPCS","0278","RC","","","","both","","","54280.00","32568.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","6312.76","46138","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 19CMX35 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138494","CDM","C1781","HCPCS","0278","RC","","","","both","","","54280.00","32568.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","30885.32","56.9","","1333.47","776.80","2316.37","34","6312.76","46138","percent of total billed charges",""
"GRAFT TISSUE 19CMX35 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138494","CDM","C1781","HCPCS","0278","RC","","","","both","","","54280.00","32568.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","6312.76","11.63","","348.38","187.99","380.51","1 through 10","6312.76","46138","percent of total billed charges",""
"GRAFT TISSUE 19CMX35 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138494","CDM","C1781","HCPCS","0278","RC","","","","both","","","54280.00","32568.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","34142.12","62.9","","1793.12","860.08","3673.04","20","6312.76","46138","percent of total billed charges",""
"GRAFT TISSUE 19CMX35 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138494","CDM","C1781","HCPCS","0278","RC","","","","both","","","54280.00","32568.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","42012.72","77.4","","1107.52","186.36","4312.65","1 through 10","6312.76","46138","percent of total billed charges",""
"GRAFT TISSUE 19CMX35 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138494","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","54280.00","32568.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","6312.76","11.63","","348.38","187.99","380.51","1 through 10","6312.76","39472.42","percent of total billed charges",""
"GRAFT TISSUE 19CMX35 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138494","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","54280.00","32568.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","34076.98","62.78","","9719.10","2943.96","9719.10","1 through 10","6312.76","39472.42","percent of total billed charges",""
"GRAFT TISSUE 19CMX35 XENMATRIX AB COLLAGEN PORCINE ACELLULAR RECTANGLE","SUP-ITM-10138494","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","54280.00","32568.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","39472.42","72.72","","2009.48","1217.35","3752.64","17","6312.76","39472.42","percent of total billed charges",""
"GRAFT TISSUE 1X10CM PERICARDIAL PERI-GUARD BOVINE PERICARDIUM PATCH","SUP-ITM-10139762","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","2214.79","1328.87","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1610.60","72.72","","4588.52","4588.52","4588.52","1 through 10","257.58","1714.25","percent of total billed charges",""
"GRAFT TISSUE 20.1X23.6 RTU ALLODERM RESTORE LARGE MEDTHICK PERFORATED","SUP-ITM-10311449","CDM","Q4116","HCPCS","0636","RC","","","","both","","","26271.52","15762.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","109.46","109.46","109.46","480","80.3","22330.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 20.1X23.6 RTU ALLODERM RESTORE LARGE MEDTHICK PERFORATED","SUP-ITM-10311449","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","26271.52","15762.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","16524.79","62.9","","1012.29","1012.29","1012.29","1008","54.99","20334.16","percent of total billed charges",""
"GRAFT TISSUE 20CMXXENMATRIX AB COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138495","CDM","C1781","HCPCS","0278","RC","","","","both","","","34456.00","20673.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","4007.23","29287.6","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 20CMXXENMATRIX AB COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138495","CDM","C1781","HCPCS","0278","RC","","","","both","","","34456.00","20673.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","19605.46","56.9","","1333.47","776.80","2316.37","34","4007.23","29287.6","percent of total billed charges",""
"GRAFT TISSUE 20CMXXENMATRIX AB COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138495","CDM","C1781","HCPCS","0278","RC","","","","both","","","34456.00","20673.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","4007.23","11.63","","348.38","187.99","380.51","1 through 10","4007.23","29287.6","percent of total billed charges",""
"GRAFT TISSUE 20CMXXENMATRIX AB COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138495","CDM","C1781","HCPCS","0278","RC","","","","both","","","34456.00","20673.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","21672.82","62.9","","1793.12","860.08","3673.04","20","4007.23","29287.6","percent of total billed charges",""
"GRAFT TISSUE 20CMXXENMATRIX AB COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138495","CDM","C1781","HCPCS","0278","RC","","","","both","","","34456.00","20673.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","26668.94","77.4","","1107.52","186.36","4312.65","1 through 10","4007.23","29287.6","percent of total billed charges",""
"GRAFT TISSUE 20CMXXENMATRIX AB COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138495","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","34456.00","20673.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","4007.23","11.63","","348.38","187.99","380.51","1 through 10","4007.23","25056.4","percent of total billed charges",""
"GRAFT TISSUE 20CMXXENMATRIX AB COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138495","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","34456.00","20673.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","21631.48","62.78","","9719.10","2943.96","9719.10","1 through 10","4007.23","25056.4","percent of total billed charges",""
"GRAFT TISSUE 20CMXXENMATRIX AB COLLAGEN PORCINE ACELLULAR SQUARE","SUP-ITM-10138495","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","34456.00","20673.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","25056.40","72.72","","2009.48","1217.35","3752.64","17","4007.23","25056.4","percent of total billed charges",""
"GRAFT TISSUE 20X25CM XENMATRIX AB COLLAGEN PORCINE ACELLULAR STERILE RECTANGLE","SUP-ITM-10138496","CDM","C1781","HCPCS","0278","RC","","","","both","","","41890.00","25134.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","4871.81","35606.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 20X25CM XENMATRIX AB COLLAGEN PORCINE ACELLULAR STERILE RECTANGLE","SUP-ITM-10138496","CDM","C1781","HCPCS","0278","RC","","","","both","","","41890.00","25134.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","23835.41","56.9","","1333.47","776.80","2316.37","34","4871.81","35606.5","percent of total billed charges",""
"GRAFT TISSUE 20X25CM XENMATRIX AB COLLAGEN PORCINE ACELLULAR STERILE RECTANGLE","SUP-ITM-10138496","CDM","C1781","HCPCS","0278","RC","","","","both","","","41890.00","25134.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","4871.81","11.63","","348.38","187.99","380.51","1 through 10","4871.81","35606.5","percent of total billed charges",""
"GRAFT TISSUE 20X25CM XENMATRIX AB COLLAGEN PORCINE ACELLULAR STERILE RECTANGLE","SUP-ITM-10138496","CDM","C1781","HCPCS","0278","RC","","","","both","","","41890.00","25134.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","26348.81","62.9","","1793.12","860.08","3673.04","20","4871.81","35606.5","percent of total billed charges",""
"GRAFT TISSUE 20X25CM XENMATRIX AB COLLAGEN PORCINE ACELLULAR STERILE RECTANGLE","SUP-ITM-10138496","CDM","C1781","HCPCS","0278","RC","","","","both","","","41890.00","25134.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","32422.86","77.4","","1107.52","186.36","4312.65","1 through 10","4871.81","35606.5","percent of total billed charges",""
"GRAFT TISSUE 20X25CM XENMATRIX AB COLLAGEN PORCINE ACELLULAR STERILE RECTANGLE","SUP-ITM-10138496","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","41890.00","25134.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","4871.81","11.63","","348.38","187.99","380.51","1 through 10","4871.81","30462.41","percent of total billed charges",""
"GRAFT TISSUE 20X25CM XENMATRIX AB COLLAGEN PORCINE ACELLULAR STERILE RECTANGLE","SUP-ITM-10138496","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","41890.00","25134.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","26298.54","62.78","","9719.10","2943.96","9719.10","1 through 10","4871.81","30462.41","percent of total billed charges",""
"GRAFT TISSUE 20X25CM XENMATRIX AB COLLAGEN PORCINE ACELLULAR STERILE RECTANGLE","SUP-ITM-10138496","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","41890.00","25134.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","30462.41","72.72","","2009.48","1217.35","3752.64","17","4871.81","30462.41","percent of total billed charges",""
"GRAFT TISSUE 230X10MM ACHILLES TENDON TIBIALIS PRE SHAPED","SUP-ITM-10212050","CDM","C1889","HCPCS","0278","RC","","","","both","","","10984.96","6590.98","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","1277.55","9337.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 230X10MM ACHILLES TENDON TIBIALIS PRE SHAPED","SUP-ITM-10212050","CDM","C1889","HCPCS","0278","RC","","","","both","","","10984.96","6590.98","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","1277.55","9337.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 230X10MM ACHILLES TENDON TIBIALIS PRE SHAPED","SUP-ITM-10212050","CDM","C1889","HCPCS","0278","RC","","","","both","","","10984.96","6590.98","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6250.44","56.9","","0.63","0.63","0.63","1 through 10","1277.55","9337.22","percent of total billed charges",""
"GRAFT TISSUE 230X10MM ACHILLES TENDON TIBIALIS PRE SHAPED","SUP-ITM-10212050","CDM","C1889","HCPCS","0278","RC","","","","both","","","10984.96","6590.98","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1584.03","14.42","","317.14","317.14","317.14","1 through 10","1277.55","9337.22","percent of total billed charges",""
"GRAFT TISSUE 230X10MM ACHILLES TENDON TIBIALIS PRE SHAPED","SUP-ITM-10212050","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10984.96","6590.98","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1584.03","14.42","","317.14","317.14","317.14","1 through 10","1277.55","8502.36","percent of total billed charges",""
"GRAFT TISSUE 230X10MM ACHILLES TENDON TIBIALIS PRE SHAPED","SUP-ITM-10212050","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10984.96","6590.98","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6896.36","62.78","","1125.09","1125.09","1125.09","1 through 10","1277.55","8502.36","percent of total billed charges",""
"GRAFT TISSUE 230X10MM ACHILLES TENDON TIBIALIS PRE SHAPED","SUP-ITM-10212050","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10984.96","6590.98","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7988.26","72.72","","4732.50","1617.43","14180.40","1 through 10","1277.55","8502.36","percent of total billed charges",""
"GRAFT TISSUE 230X10MM ACHILLES TENDON TIBIALIS PRE SHAPED","SUP-ITM-10212050","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10984.96","6590.98","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6909.54","62.9","","3896.20","3341.38","3896.20","1 through 10","1277.55","8502.36","percent of total billed charges",""
"GRAFT TISSUE 6X14X11MM CORNERSTONE LACSR CORTICAL BONE","SUP-ITM-10088961","CDM","C1889","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","562.54","4111.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 6X14X11MM CORNERSTONE LACSR CORTICAL BONE","SUP-ITM-10088961","CDM","C1889","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","562.54","4111.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 6X14X11MM CORNERSTONE LACSR CORTICAL BONE","SUP-ITM-10088961","CDM","C1889","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2752.25","56.9","","0.63","0.63","0.63","1 through 10","562.54","4111.45","percent of total billed charges",""
"GRAFT TISSUE 6X14X11MM CORNERSTONE LACSR CORTICAL BONE","SUP-ITM-10088961","CDM","C1889","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","697.50","14.42","","317.14","317.14","317.14","1 through 10","562.54","4111.45","percent of total billed charges",""
"GRAFT TISSUE 6X14X11MM CORNERSTONE LACSR CORTICAL BONE","SUP-ITM-10088961","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","697.50","14.42","","317.14","317.14","317.14","1 through 10","562.54","3743.84","percent of total billed charges",""
"GRAFT TISSUE 6X14X11MM CORNERSTONE LACSR CORTICAL BONE","SUP-ITM-10088961","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3036.67","62.78","","1125.09","1125.09","1125.09","1 through 10","562.54","3743.84","percent of total billed charges",""
"GRAFT TISSUE 6X14X11MM CORNERSTONE LACSR CORTICAL BONE","SUP-ITM-10088961","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3517.47","72.72","","4732.50","1617.43","14180.40","1 through 10","562.54","3743.84","percent of total billed charges",""
"GRAFT TISSUE 6X14X11MM CORNERSTONE LACSR CORTICAL BONE","SUP-ITM-10088961","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3042.47","62.9","","3896.20","3341.38","3896.20","1 through 10","562.54","3743.84","percent of total billed charges",""
"GRAFT TISSUE 7.3X14.7CM SM THIN HUMAN ALLODERM CONTOURED REGENERATIVE MATRIX","SUP-ITM-10174645","CDM","Q4116","HCPCS","0636","RC","","","","both","","","10689.40","6413.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","109.46","109.46","109.46","480","80.3","9085.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 7.3X14.7CM SM THIN HUMAN ALLODERM CONTOURED REGENERATIVE MATRIX","SUP-ITM-10174645","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","10689.40","6413.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6723.63","62.9","","1012.29","1012.29","1012.29","1008","54.99","8273.6","percent of total billed charges",""
"GRAFT TISSUE 8.0X14 11MM CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10081794","CDM","C1889","HCPCS","0278","RC","","","","both","","","5182.50","3109.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","602.72","4405.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 8.0X14 11MM CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10081794","CDM","C1889","HCPCS","0278","RC","","","","both","","","5182.50","3109.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","602.72","4405.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 8.0X14 11MM CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10081794","CDM","C1889","HCPCS","0278","RC","","","","both","","","5182.50","3109.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2948.84","56.9","","0.63","0.63","0.63","1 through 10","602.72","4405.13","percent of total billed charges",""
"GRAFT TISSUE 8.0X14 11MM CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10081794","CDM","C1889","HCPCS","0278","RC","","","","both","","","5182.50","3109.50","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","747.32","14.42","","317.14","317.14","317.14","1 through 10","602.72","4405.13","percent of total billed charges",""
"GRAFT TISSUE 8.0X14 11MM CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10081794","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5182.50","3109.50","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","747.32","14.42","","317.14","317.14","317.14","1 through 10","602.72","4011.26","percent of total billed charges",""
"GRAFT TISSUE 8.0X14 11MM CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10081794","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5182.50","3109.50","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3253.57","62.78","","1125.09","1125.09","1125.09","1 through 10","602.72","4011.26","percent of total billed charges",""
"GRAFT TISSUE 8.0X14 11MM CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10081794","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5182.50","3109.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3768.71","72.72","","4732.50","1617.43","14180.40","1 through 10","602.72","4011.26","percent of total billed charges",""
"GRAFT TISSUE 8.0X14 11MM CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10081794","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5182.50","3109.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3259.79","62.9","","3896.20","3341.38","3896.20","1 through 10","602.72","4011.26","percent of total billed charges",""
"GRAFT TISSUE 8X16CM ALLODERM READY TO USE REGENERATIVE MATRIX XTHICK","SUP-ITM-10100954","CDM","Q4116","HCPCS","0636","RC","","","","both","","","14798.52","8879.11","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","109.46","109.46","109.46","480","80.3","12578.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE 8X16CM ALLODERM READY TO USE REGENERATIVE MATRIX XTHICK","SUP-ITM-10100954","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","14798.52","8879.11","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","9308.27","62.9","","1012.29","1012.29","1012.29","1008","54.99","11454.05","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS DISTAL LT STRUCTURAL ALLO","SUP-ITM-10010808","CDM","C1889","HCPCS","0278","RC","","","","both","","","11552.51","6931.51","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","1343.56","9819.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE FROZEN HUMERUS DISTAL LT STRUCTURAL ALLO","SUP-ITM-10010808","CDM","C1889","HCPCS","0278","RC","","","","both","","","11552.51","6931.51","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","1343.56","9819.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE FROZEN HUMERUS DISTAL LT STRUCTURAL ALLO","SUP-ITM-10010808","CDM","C1889","HCPCS","0278","RC","","","","both","","","11552.51","6931.51","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6573.38","56.9","","0.63","0.63","0.63","1 through 10","1343.56","9819.63","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS DISTAL LT STRUCTURAL ALLO","SUP-ITM-10010808","CDM","C1889","HCPCS","0278","RC","","","","both","","","11552.51","6931.51","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1665.87","14.42","","317.14","317.14","317.14","1 through 10","1343.56","9819.63","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS DISTAL LT STRUCTURAL ALLO","SUP-ITM-10010808","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11552.51","6931.51","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1665.87","14.42","","317.14","317.14","317.14","1 through 10","1343.56","8941.64","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS DISTAL LT STRUCTURAL ALLO","SUP-ITM-10010808","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11552.51","6931.51","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","7252.67","62.78","","1125.09","1125.09","1125.09","1 through 10","1343.56","8941.64","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS DISTAL LT STRUCTURAL ALLO","SUP-ITM-10010808","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11552.51","6931.51","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8400.99","72.72","","4732.50","1617.43","14180.40","1 through 10","1343.56","8941.64","percent of total billed charges",""
"GRAFT TISSUE FROZEN HUMERUS DISTAL LT STRUCTURAL ALLO","SUP-ITM-10010808","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11552.51","6931.51","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7266.53","62.9","","3896.20","3341.38","3896.20","1 through 10","1343.56","8941.64","percent of total billed charges",""
"GRAFT TISSUE LG TISSUE CONTOUR NON PERFORATED MEDIUM RTU ALLODERM REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132705","CDM","Q4116","HCPCS","0636","RC","","","","both","","","18955.68","11373.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","109.46","109.46","109.46","480","80.3","16112.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE LG TISSUE CONTOUR NON PERFORATED MEDIUM RTU ALLODERM REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132705","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","18955.68","11373.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","11923.12","62.9","","1012.29","1012.29","1012.29","1008","54.99","14671.7","percent of total billed charges",""
"GRAFT TISSUE XL-THICK 2.4+/-0.4MM HUMAN ALLODERM EXTRA THICK CONTOUR REGENERATIVE MATRIX","SUP-ITM-10190853","CDM","Q4116","HCPCS","0636","RC","","","","both","","","19158.75","11495.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","109.46","109.46","109.46","480","80.3","16284.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT TISSUE XL-THICK 2.4+/-0.4MM HUMAN ALLODERM EXTRA THICK CONTOUR REGENERATIVE MATRIX","SUP-ITM-10190853","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","19158.75","11495.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","12050.85","62.9","","1012.29","1012.29","1012.29","1008","54.99","14828.87","percent of total billed charges",""
"GRAFT VASCULAR 10MMX70CM GORETEX THIN WALL REMOVABLE RING LINED","SUP-ITM-10074689","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","6469.90","3881.94","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4704.91","72.72","","4588.52","4588.52","4588.52","1 through 10","752.45","5007.7","percent of total billed charges",""
"GRAFT VASCULAR 40CM 6MM FLEXIBLE KINK RESISTANT ACUSEAL","SUP-ITM-10238530","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","6513.55","3908.13","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4736.65","72.72","","4588.52","4588.52","4588.52","1 through 10","757.53","5041.49","percent of total billed charges",""
"GRAFT VASCULAR 40CMX8.0 16MM BIFURCATED KNITTED DOUBLE VELOUR HEMASHIELD","SUP-ITM-10005027","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","3390.05","2034.03","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2465.24","72.72","","4588.52","4588.52","4588.52","1 through 10","394.26","2623.9","percent of total billed charges",""
"GRAFT VASCULAR 45CM 4 TO 7MM FLEXIBLE KINK RESISTANT TAPERED ACUSEAL","SUP-ITM-10238527","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","7478.70","4487.22","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5438.51","72.72","","4588.52","4588.52","4588.52","1 through 10","869.77","5788.51","percent of total billed charges",""
"GRAFT VASCULAR 45CM 4.0 7.0MM PROPATEN STRETCH TAPERED WALLED STANDARD","SUP-ITM-10022970","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","6309.85","3785.91","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4588.52","72.72","","4588.52","4588.52","4588.52","1 through 10","733.84","4883.82","percent of total billed charges",""
"GRAFT VASCULAR 6.0MMX40 50CM PROPATEN HEPARIN CARMEDA BIOACTIVE SURFACE THIN WALL STRETCH REMOVABLE RING","SUP-ITM-10022965","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","9122.85","5473.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6634.14","72.72","","4588.52","4588.52","4588.52","1 through 10","1060.99","7061.09","percent of total billed charges",""
"GRAFT VASCULAR 6.0MMX80CM SM STRAIGHT STD WALL NON RINGED PTFE CENTERFLEX","SUP-ITM-10012363","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","16988.30","10192.98","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","12353.89","72.72","","4588.52","4588.52","4588.52","1 through 10","1975.74","13148.94","percent of total billed charges",""
"GRAFT VASCULAR 6MMX30CM BOVINE COLLAGEN CAROTID ARTERY","SUP-ITM-10008753","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","10398.40","6239.04","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7561.72","72.72","","4588.52","4588.52","4588.52","1 through 10","1209.33","8048.36","percent of total billed charges",""
"GRAFT VASCULAR 6MMX40CM PROPATEN HEPARIN CARMEDA BIOACTIVE SURFACE THIN WALL STRETCH","SUP-ITM-10021551","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","6198.30","3718.98","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4507.40","72.72","","4588.52","4588.52","4588.52","1 through 10","720.86","4797.48","percent of total billed charges",""
"GRAFT VASCULAR 6MMX60 80CM PROPATEN HEPARIN CARMEDA BIOACTIVE SURFACE THIN WALL STRETCH REMOVABLE RING","SUP-ITM-10022949","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","11687.72","7012.63","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8499.31","72.72","","4588.52","4588.52","4588.52","1 through 10","1359.28","9046.3","percent of total billed charges",""
"GRAFT VASCULAR 7.0MMX60 80CM PROPATEN HEPARIN SURFACE THIN WALL STRETCH REMOVABLE RING","SUP-ITM-10074780","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","11687.72","7012.63","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8499.31","72.72","","4588.52","4588.52","4588.52","1 through 10","1359.28","9046.3","percent of total billed charges",""
"GRAFT VASCULAR 70 TO 79CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134476","CDM","C1889","HCPCS","0278","RC","","","","both","","","21204.60","12722.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","2466.09","18023.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT VASCULAR 70 TO 79CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134476","CDM","C1889","HCPCS","0278","RC","","","","both","","","21204.60","12722.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","2466.09","18023.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GRAFT VASCULAR 70 TO 79CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134476","CDM","C1889","HCPCS","0278","RC","","","","both","","","21204.60","12722.76","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","12065.42","56.9","","0.63","0.63","0.63","1 through 10","2466.09","18023.91","percent of total billed charges",""
"GRAFT VASCULAR 70 TO 79CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134476","CDM","C1889","HCPCS","0278","RC","","","","both","","","21204.60","12722.76","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","3057.70","14.42","","317.14","317.14","317.14","1 through 10","2466.09","18023.91","percent of total billed charges",""
"GRAFT VASCULAR 70 TO 79CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134476","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","21204.60","12722.76","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","3057.70","14.42","","317.14","317.14","317.14","1 through 10","2466.09","16412.36","percent of total billed charges",""
"GRAFT VASCULAR 70 TO 79CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134476","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","21204.60","12722.76","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","13312.25","62.78","","1125.09","1125.09","1125.09","1 through 10","2466.09","16412.36","percent of total billed charges",""
"GRAFT VASCULAR 70 TO 79CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134476","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","21204.60","12722.76","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","15419.99","72.72","","4732.50","1617.43","14180.40","1 through 10","2466.09","16412.36","percent of total billed charges",""
"GRAFT VASCULAR 70 TO 79CM CRYOVEIN ALLO SAPHENOUS VEIN","SUP-ITM-10134476","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","21204.60","12722.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","13337.69","62.9","","3896.20","3341.38","3896.20","1 through 10","2466.09","16412.36","percent of total billed charges",""
"GRAFT VASCULAR 70X40CM PROPATEN AXILLOBIFEMORAL STD WALL REMOVABLE RINGS","SUP-ITM-10233908","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","15655.00","9393.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","11384.32","72.72","","4588.52","4588.52","4588.52","1 through 10","1820.68","12116.97","percent of total billed charges",""
"GRAFT VASCULAR 7MM 40CM RSX50 PROPATEN HEPARIN CARMEDA BIOACTIVE SURFACE THIN WALL STRETCH REMOVABLE RING","SUP-ITM-10074779","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","9122.85","5473.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6634.14","72.72","","4588.52","4588.52","4588.52","1 through 10","1060.99","7061.09","percent of total billed charges",""
"GRAFT VASCULAR 8.0MMX40CM PROPATEN HEPARIN CARMEDA BIOACTIVE SURFACE THIN WALL REMOVABLE RING STRETCH","SUP-ITM-10023013","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","6198.30","3718.98","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4507.40","72.72","","4588.52","4588.52","4588.52","1 through 10","720.86","4797.48","percent of total billed charges",""
"GRAFT VASCULAR 80CMX6.0MM PROPATEN HEPARIN CARMEDA BIOACTIVE SURFACE THIN WALL STRETCH","SUP-ITM-10023011","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","11989.20","7193.52","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8718.55","72.72","","4588.52","4588.52","4588.52","1 through 10","1394.34","9279.64","percent of total billed charges",""
"GRAFT VASCULAR 80X70CM 8.0MM PROPATEN CONFIGURATION STRETCH THIN WALLED REMOVABLE RINGED","SUP-ITM-10021034","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","12039.20","7223.52","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8754.91","72.72","","4588.52","4588.52","4588.52","1 through 10","1400.16","9318.34","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","both","","","209.00","125.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","145.88","69.8","","141.00","141.00","141.00","1 through 10","40.19","262.09","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","both","","","209.00","125.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","262.09","","Case rate ($262.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","108.93","108.93","108.93","1 through 10","40.19","262.09","other","OPPS APC"
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","outpatient","","","209.00","125.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","151.98","72.72","","146.89","146.89","146.89","1 through 10","24.31","161.77","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","outpatient","","","209.00","125.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","111.23","53.22","","107.69","107.69","107.69","1 through 10","24.31","161.77","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","outpatient","","","209.00","125.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","131.46","62.9","","127.26","127.26","127.26","11","24.31","161.77","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","outpatient","","","209.00","125.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","161.77","77.4","","321.52","156.55","321.52","1 through 10","24.31","161.77","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","451.00","270.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","314.80","69.8","","304.33","304.33","304.33","1 through 10","54.71","383.35","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","451.00","270.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","153.62","","Case rate ($153.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","436.00","436.00","436.00","1 through 10","54.71","383.35","other","OPPS APC"
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","451.00","270.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","54.71","","APC Price ($55.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","436.00","436.00","436.00","1 through 10","54.71","383.35","other","OPPS APC"
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","451.00","270.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","288.36","","Case rate ($288.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","436.00","436.00","436.00","1 through 10","54.71","383.35","other","OPPS APC"
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","451.00","270.60","MEDICARE [2001]","HB WDH MEDICARE","55.82","","APC Price ($55.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","167.49","55.83","167.49","1 through 10","54.71","383.35","other","OPPS APC"
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","451.00","270.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","55.82","","APC Price ($55.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.72","51.75","55.83","1 through 10","54.71","383.35","other","OPPS APC"
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","outpatient","","","451.00","270.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","65.03","14.42","","27.07","27.07","27.07","1 through 10","52.45","349.07","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","outpatient","","","451.00","270.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","52.45","11.63","","80.43","80.43","80.43","1 through 10","52.45","349.07","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","outpatient","","","451.00","270.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","283.14","62.78","","273.72","273.72","273.72","1 through 10","52.45","349.07","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","outpatient","","","451.00","270.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","197.18","43.72","","190.62","190.62","190.62","1 through 10","52.45","349.07","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","outpatient","","","451.00","270.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","327.97","72.72","","317.06","317.06","1585.30","61","52.45","349.07","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","outpatient","","","451.00","270.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","327.97","72.72","","317.06","317.06","317.06","1 through 10","52.45","349.07","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","outpatient","","","451.00","270.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","240.02","53.22","","232.43","232.43","232.43","1 through 10","52.45","349.07","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","outpatient","","","451.00","270.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","283.68","62.9","","274.68","274.68","824.04","42","52.45","349.07","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","outpatient","","","451.00","270.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","349.07","77.4","","337.90","337.90","675.80","16","52.45","349.07","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0310","RC","","","","inpatient","","","451.00","270.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","346.64","76.86","","274.68","274.68","274.68","1 through 10","298.56","346.64","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","451.00","270.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","314.80","69.8","","608.66","304.33","608.66","18","54.71","383.35","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","451.00","270.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","288.36","","Case rate ($288.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.95","53.95","53.95","1 through 10","54.71","383.35","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","451.00","270.60","CHAMPVA [160001]","HB WDH MEDICARE","55.82","","APC Price ($55.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","55.83","55.83","55.83","1 through 10","54.71","383.35","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","451.00","270.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","314.80","69.8","","608.66","304.33","608.66","1 through 10","54.71","383.35","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","451.00","270.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","57.50","","APC Price ($55.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.35","56.35","56.35","1 through 10","54.71","383.35","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","451.00","270.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","55.82","","APC Price ($55.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.81","54.81","54.81","1 through 10","54.71","383.35","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","451.00","270.60","MEDICARE [2001]","HB WDH MEDICARE","55.82","","APC Price ($55.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","55.83","55.83","55.83","17","54.71","383.35","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","451.00","270.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","383.35","85","","637.50","71.28","637.50","1 through 10","54.71","383.35","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","451.00","270.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","55.82","","APC Price ($55.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.72","51.85","54.92","59","54.71","383.35","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","451.00","270.60","WELLSENSE NH [1050]","HB WDH MEDICARE","55.82","","APC Price ($55.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","114.90","114.90","114.90","1 through 10","54.71","383.35","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","451.00","270.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","65.03","14.42","","144.32","36.08","144.32","1 through 10","52.45","349.07","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","451.00","270.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","52.45","11.63","","69.38","34.69","69.38","1 through 10","52.45","349.07","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","451.00","270.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","283.14","62.78","","273.72","273.72","821.16","21","52.45","349.07","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","451.00","270.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","197.18","43.72","","190.62","190.62","571.86","14","52.45","349.07","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","451.00","270.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","327.97","72.72","","317.06","317.06","1268.24","593","52.45","349.07","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","451.00","270.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","327.97","72.72","","634.12","317.06","1268.24","38","52.45","349.07","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","451.00","270.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","240.02","53.22","","697.29","232.43","1162.15","45","52.45","349.07","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","451.00","270.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","283.68","62.9","","549.36","274.68","1373.40","704","52.45","349.07","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","451.00","270.60","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","327.97","72.72","","951.18","951.18","951.18","1 through 10","52.45","349.07","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","451.00","270.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","349.07","77.4","","675.80","337.90","1689.50","238","52.45","349.07","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","451.00","270.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","327.97","72.72","","634.12","317.06","951.18","18","52.45","349.07","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0310","RC","","","","inpatient","","","796.00","477.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","611.81","76.86","","485.10","485.10","485.10","1 through 10","526.95","611.81","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","796.00","477.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","555.61","69.8","","4299.68","537.46","4299.68","1 through 10","368.3","2401.82","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","796.00","477.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","676.60","85","","761.55","761.55","761.55","1 through 10","368.3","2401.82","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","796.00","477.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","375.82","","APC Price ($375.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","368.35","368.35","369.85","1 through 10","368.3","2401.82","other","OPPS APC"
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","outpatient","","","796.00","477.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","114.78","14.42","","108.24","108.24","108.24","1 through 10","92.57","616.1","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","outpatient","","","796.00","477.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","92.57","11.63","","277.52","277.52","277.52","1 through 10","92.57","616.1","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","outpatient","","","796.00","477.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","499.73","62.78","","483.41","483.41","483.41","1 through 10","92.57","616.1","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","outpatient","","","796.00","477.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","348.01","43.72","","1009.92","1009.92","1009.92","1 through 10","92.57","616.1","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","outpatient","","","796.00","477.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","578.85","72.72","","1119.88","559.94","1679.84","52","92.57","616.1","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","outpatient","","","796.00","477.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","578.85","72.72","","559.94","559.94","559.94","1 through 10","92.57","616.1","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","outpatient","","","796.00","477.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","423.63","53.22","","2052.45","410.49","2052.45","1 through 10","92.57","616.1","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","outpatient","","","796.00","477.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","500.68","62.9","","1455.30","485.10","7276.50","70","92.57","616.1","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","outpatient","","","796.00","477.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","616.10","77.4","","596.75","596.75","596.75","11","92.57","616.1","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","outpatient","","","796.00","477.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","578.85","72.72","","1883.32","1006.23","1883.32","1 through 10","92.57","616.1","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","outpatient","","","1112.00","667.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","160.35","14.42","","41.50","41.50","41.50","1 through 10","129.33","860.69","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","outpatient","","","1112.00","667.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","808.65","72.72","","781.74","781.74","781.74","1 through 10","129.33","860.69","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","outpatient","","","1112.00","667.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","699.45","62.9","","2031.75","677.25","2031.75","1 through 10","129.33","860.69","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","outpatient","","","1112.00","667.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","860.69","77.4","","833.13","833.13","833.13","1 through 10","129.33","860.69","percent of total billed charges",""
"Gross Only Level I","PX-31000147","CDM","88300","CPT","0310","RC","","","","inpatient","","","209.00","125.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","160.64","76.86","","127.26","127.26","127.26","1 through 10","138.36","160.64","percent of total billed charges",""
"Gross Only Level I","PX-31000147","CDM","88300","CPT","0312","RC","","","","outpatient","","","209.00","125.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","131.46","62.9","","127.26","127.26","127.26","1 through 10","24.31","161.77","percent of total billed charges",""
"Gross Only Level I","PX-31000147","CDM","88300","CPT","0312","RC","","","","outpatient","","","209.00","125.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","161.77","77.4","","156.55","156.55","156.55","1 through 10","24.31","161.77","percent of total billed charges",""
"Growth Hormone (Hgh)","PX-30000483","CDM","83003","CPT","0301","RC","","","","outpatient","","","91.00","54.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","39.79","43.72","","38.47","38.47","38.47","1 through 10","15.53","70.43","percent of total billed charges",""
"Growth Hormone (Hgh)","PX-30000483","CDM","83003","CPT","0301","RC","","","","outpatient","","","91.00","54.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","57.24","62.9","","55.44","55.44","55.44","1 through 10","15.53","70.43","percent of total billed charges",""
"Growth Hormone (Hgh)","PX-30000483","CDM","83003","CPT","0301","RC","","","","outpatient","","","91.00","54.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","70.43","77.4","","68.20","68.20","68.20","1 through 10","15.53","70.43","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 1","PX-33000109","CDM","77387","CPT","0333","RC","","","","both","","","1790.00","1074.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","1249.42","69.8","","1205.45","1205.45","1205.45","22","319.39","1521.5","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 1","PX-33000109","CDM","77387","CPT","0333","RC","","","","both","","","1790.00","1074.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","1727.00","1727.00","1727.00","1 through 10","319.39","1521.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 1","PX-33000109","CDM","77387","CPT","0333","RC","","","","outpatient","","","1790.00","1074.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","258.12","14.42","","249.03","249.03","249.03","60","208.18","1385.46","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 1","PX-33000109","CDM","77387","CPT","0333","RC","","","","outpatient","","","1790.00","1074.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","208.18","11.63","","237.81","237.81","237.81","36","208.18","1385.46","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 1","PX-33000109","CDM","77387","CPT","0333","RC","","","","outpatient","","","1790.00","1074.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1123.76","62.78","","1084.21","1084.21","1084.21","16","208.18","1385.46","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 1","PX-33000109","CDM","77387","CPT","0333","RC","","","","outpatient","","","1790.00","1074.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1301.69","72.72","","1255.87","1136.71","1255.87","102","208.18","1385.46","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 1","PX-33000109","CDM","77387","CPT","0333","RC","","","","outpatient","","","1790.00","1074.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1125.91","62.9","","1088.01","1088.01","1088.01","53","208.18","1385.46","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 1","PX-33000109","CDM","77387","CPT","0333","RC","","","","outpatient","","","1790.00","1074.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1385.46","77.4","","1255.87","1255.87","1255.87","25","208.18","1385.46","percent of total billed charges",""
"Guidance for Loc of Target Vol Radiaj Tx Dlvr - 1","PX-33000109","CDM","77387","CPT","0333","RC","","","","outpatient","","","1790.00","1074.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","208.18","11.63","","203.99","203.99","203.99","16","208.18","1385.46","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","both","","","912.12","547.27","AETNA [1001]","HB WDH AETNA COMMERCIAL","636.66","69.8","","279.80","225.71","279.80","16","106.08","775.3","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","both","","","912.12","547.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","106.08","775.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","both","","","912.12","547.27","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","519.00","56.9","","18.95","9.41","1260.18","1 through 10","106.08","775.3","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","both","","","912.12","547.27","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","106.08","11.63","","37.78","11.63","183.64","21","106.08","775.3","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","both","","","912.12","547.27","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","705.98","77.4","","225.79","68.39","1154.35","11","106.08","775.3","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","both","","","912.12","547.27","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","106.08","775.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","912.12","547.27","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","106.08","11.63","","37.78","11.63","183.64","21","106.08","705.98","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","912.12","547.27","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","572.63","62.78","","123.83","114.55","572.63","1 through 10","106.08","705.98","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","912.12","547.27","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","398.78","43.72","","127.38","127.38","148.03","1 through 10","106.08","705.98","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","912.12","547.27","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","663.29","72.72","","196.34","62.16","1727.00","33","106.08","705.98","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","912.12","547.27","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","663.29","72.72","","173.00","173.00","173.00","1 through 10","106.08","705.98","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","912.12","547.27","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","485.43","53.22","","205.24","190.08","205.24","1 through 10","106.08","705.98","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","912.12","547.27","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","573.72","62.9","","305.08","81.02","4529.24","103","106.08","705.98","percent of total billed charges",""
"GUIDEWIRE 200CM SAVARY-GILLIARD SS","SUP-ITM-10239802","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","912.12","547.27","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","705.98","77.4","","225.79","68.39","1154.35","11","106.08","705.98","percent of total billed charges",""
"GUIDEWIRE ACROBAT2 4CM 450CM .025IN STRAIGHT TIP HYDROPHILIC COATING STERILE DISP","SUP-ITM-10191324","CDM","C1769","HCPCS","0272","RC","","","","both","","","1679.13","1007.48","AETNA [1001]","HB WDH AETNA COMMERCIAL","1172.03","69.8","","279.80","225.71","279.80","16","195.28","1427.26","percent of total billed charges",""
"GUIDEWIRE ACROBAT2 4CM 450CM .025IN STRAIGHT TIP HYDROPHILIC COATING STERILE DISP","SUP-ITM-10191324","CDM","C1769","HCPCS","0272","RC","","","","both","","","1679.13","1007.48","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","195.28","1427.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ACROBAT2 4CM 450CM .025IN STRAIGHT TIP HYDROPHILIC COATING STERILE DISP","SUP-ITM-10191324","CDM","C1769","HCPCS","0272","RC","","","","both","","","1679.13","1007.48","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","955.42","56.9","","18.95","9.41","1260.18","1 through 10","195.28","1427.26","percent of total billed charges",""
"GUIDEWIRE ACROBAT2 4CM 450CM .025IN STRAIGHT TIP HYDROPHILIC COATING STERILE DISP","SUP-ITM-10191324","CDM","C1769","HCPCS","0272","RC","","","","both","","","1679.13","1007.48","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","195.28","11.63","","37.78","11.63","183.64","21","195.28","1427.26","percent of total billed charges",""
"GUIDEWIRE ACROBAT2 4CM 450CM .025IN STRAIGHT TIP HYDROPHILIC COATING STERILE DISP","SUP-ITM-10191324","CDM","C1769","HCPCS","0272","RC","","","","both","","","1679.13","1007.48","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1299.65","77.4","","225.79","68.39","1154.35","11","195.28","1427.26","percent of total billed charges",""
"GUIDEWIRE ACROBAT2 4CM 450CM .025IN STRAIGHT TIP HYDROPHILIC COATING STERILE DISP","SUP-ITM-10191324","CDM","C1769","HCPCS","0272","RC","","","","both","","","1679.13","1007.48","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","195.28","1427.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ACROBAT2 4CM 450CM .025IN STRAIGHT TIP HYDROPHILIC COATING STERILE DISP","SUP-ITM-10191324","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1679.13","1007.48","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","195.28","11.63","","37.78","11.63","183.64","21","195.28","1299.65","percent of total billed charges",""
"GUIDEWIRE ACROBAT2 4CM 450CM .025IN STRAIGHT TIP HYDROPHILIC COATING STERILE DISP","SUP-ITM-10191324","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1679.13","1007.48","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1054.16","62.78","","123.83","114.55","572.63","1 through 10","195.28","1299.65","percent of total billed charges",""
"GUIDEWIRE ACROBAT2 4CM 450CM .025IN STRAIGHT TIP HYDROPHILIC COATING STERILE DISP","SUP-ITM-10191324","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1679.13","1007.48","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","734.12","43.72","","127.38","127.38","148.03","1 through 10","195.28","1299.65","percent of total billed charges",""
"GUIDEWIRE ACROBAT2 4CM 450CM .025IN STRAIGHT TIP HYDROPHILIC COATING STERILE DISP","SUP-ITM-10191324","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1679.13","1007.48","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1221.06","72.72","","196.34","62.16","1727.00","33","195.28","1299.65","percent of total billed charges",""
"GUIDEWIRE ACROBAT2 4CM 450CM .025IN STRAIGHT TIP HYDROPHILIC COATING STERILE DISP","SUP-ITM-10191324","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1679.13","1007.48","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1221.06","72.72","","173.00","173.00","173.00","1 through 10","195.28","1299.65","percent of total billed charges",""
"GUIDEWIRE ACROBAT2 4CM 450CM .025IN STRAIGHT TIP HYDROPHILIC COATING STERILE DISP","SUP-ITM-10191324","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1679.13","1007.48","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","893.63","53.22","","205.24","190.08","205.24","1 through 10","195.28","1299.65","percent of total billed charges",""
"GUIDEWIRE ACROBAT2 4CM 450CM .025IN STRAIGHT TIP HYDROPHILIC COATING STERILE DISP","SUP-ITM-10191324","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1679.13","1007.48","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1056.17","62.9","","305.08","81.02","4529.24","103","195.28","1299.65","percent of total billed charges",""
"GUIDEWIRE ACROBAT2 4CM 450CM .025IN STRAIGHT TIP HYDROPHILIC COATING STERILE DISP","SUP-ITM-10191324","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1679.13","1007.48","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1299.65","77.4","","225.79","68.39","1154.35","11","195.28","1299.65","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","both","","","240.61","144.37","AETNA [1001]","HB WDH AETNA COMMERCIAL","167.95","69.8","","279.80","225.71","279.80","16","27.98","204.52","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","both","","","240.61","144.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","27.98","204.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","both","","","240.61","144.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","136.91","56.9","","18.95","9.41","1260.18","1 through 10","27.98","204.52","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","both","","","240.61","144.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","27.98","11.63","","37.78","11.63","183.64","21","27.98","204.52","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","both","","","240.61","144.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","186.23","77.4","","225.79","68.39","1154.35","11","27.98","204.52","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","both","","","240.61","144.37","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","27.98","204.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","240.61","144.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","27.98","11.63","","37.78","11.63","183.64","21","27.98","186.23","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","240.61","144.37","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","151.05","62.78","","123.83","114.55","572.63","1 through 10","27.98","186.23","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","240.61","144.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","105.19","43.72","","127.38","127.38","148.03","1 through 10","27.98","186.23","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","240.61","144.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","174.97","72.72","","196.34","62.16","1727.00","33","27.98","186.23","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","240.61","144.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","174.97","72.72","","173.00","173.00","173.00","1 through 10","27.98","186.23","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","240.61","144.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","128.05","53.22","","205.24","190.08","205.24","1 through 10","27.98","186.23","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","240.61","144.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","151.34","62.9","","305.08","81.02","4529.24","103","27.98","186.23","percent of total billed charges",""
"GUIDEWIRE AMPLATZ 7CM 145CM .035IN SUPER STIFF BENTSON UROLOGICAL STRAIGHT STIFF FIXED FLEX TIP PTFE COATED BX/5EA","SUP-ITM-10064985","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","240.61","144.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","186.23","77.4","","225.79","68.39","1154.35","11","27.98","186.23","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN 3MM J TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009538","CDM","C1769","HCPCS","0272","RC","","","","both","","","179.66","107.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","125.40","69.8","","279.80","225.71","279.80","16","20.89","152.71","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN 3MM J TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009538","CDM","C1769","HCPCS","0272","RC","","","","both","","","179.66","107.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","20.89","152.71","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN 3MM J TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009538","CDM","C1769","HCPCS","0272","RC","","","","both","","","179.66","107.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","102.23","56.9","","18.95","9.41","1260.18","1 through 10","20.89","152.71","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN 3MM J TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009538","CDM","C1769","HCPCS","0272","RC","","","","both","","","179.66","107.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.89","11.63","","37.78","11.63","183.64","21","20.89","152.71","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN 3MM J TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009538","CDM","C1769","HCPCS","0272","RC","","","","both","","","179.66","107.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","139.06","77.4","","225.79","68.39","1154.35","11","20.89","152.71","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN 3MM J TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009538","CDM","C1769","HCPCS","0272","RC","","","","both","","","179.66","107.80","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","20.89","152.71","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN 3MM J TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009538","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","179.66","107.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.89","11.63","","37.78","11.63","183.64","21","20.89","139.06","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN 3MM J TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009538","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","179.66","107.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","112.79","62.78","","123.83","114.55","572.63","1 through 10","20.89","139.06","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN 3MM J TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009538","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","179.66","107.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","78.55","43.72","","127.38","127.38","148.03","1 through 10","20.89","139.06","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN 3MM J TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009538","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","179.66","107.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","130.65","72.72","","196.34","62.16","1727.00","33","20.89","139.06","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN 3MM J TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009538","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","179.66","107.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","130.65","72.72","","173.00","173.00","173.00","1 through 10","20.89","139.06","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN 3MM J TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009538","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","179.66","107.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","95.62","53.22","","205.24","190.08","205.24","1 through 10","20.89","139.06","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN 3MM J TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009538","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","179.66","107.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","113.01","62.9","","305.08","81.02","4529.24","103","20.89","139.06","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN 3MM J TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10009538","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","179.66","107.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","139.06","77.4","","225.79","68.39","1154.35","11","20.89","139.06","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","both","","","172.75","103.65","AETNA [1001]","HB WDH AETNA COMMERCIAL","120.58","69.8","","279.80","225.71","279.80","16","20.09","146.84","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","both","","","172.75","103.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","20.09","146.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","both","","","172.75","103.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","98.29","56.9","","18.95","9.41","1260.18","1 through 10","20.09","146.84","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","both","","","172.75","103.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.09","11.63","","37.78","11.63","183.64","21","20.09","146.84","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","both","","","172.75","103.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","133.71","77.4","","225.79","68.39","1154.35","11","20.09","146.84","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","both","","","172.75","103.65","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","20.09","146.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","172.75","103.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.09","11.63","","37.78","11.63","183.64","21","20.09","133.71","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","108.45","62.78","","123.83","114.55","572.63","1 through 10","20.09","133.71","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","75.53","43.72","","127.38","127.38","148.03","1 through 10","20.09","133.71","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","125.62","72.72","","196.34","62.16","1727.00","33","20.09","133.71","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","125.62","72.72","","173.00","173.00","173.00","1 through 10","20.09","133.71","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","172.75","103.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","91.94","53.22","","205.24","190.08","205.24","1 through 10","20.09","133.71","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","172.75","103.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","108.66","62.9","","305.08","81.02","4529.24","103","20.09","133.71","percent of total billed charges",""
"GUIDEWIRE AMPLATZ SUPER STIFF 7CM 260CM .035IN STRAIGHT TIP PTFE COATED VASCULAR BX/5EA","SUP-ITM-10000374","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","172.75","103.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","133.71","77.4","","225.79","68.39","1154.35","11","20.09","133.71","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","both","","","1008.86","605.32","AETNA [1001]","HB WDH AETNA COMMERCIAL","704.18","69.8","","279.80","225.71","279.80","16","117.33","857.53","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","both","","","1008.86","605.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","117.33","857.53","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","both","","","1008.86","605.32","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","574.04","56.9","","18.95","9.41","1260.18","1 through 10","117.33","857.53","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","both","","","1008.86","605.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","117.33","11.63","","37.78","11.63","183.64","21","117.33","857.53","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","both","","","1008.86","605.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","780.86","77.4","","225.79","68.39","1154.35","11","117.33","857.53","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","both","","","1008.86","605.32","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","117.33","857.53","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1008.86","605.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","117.33","11.63","","37.78","11.63","183.64","21","117.33","780.86","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1008.86","605.32","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","633.36","62.78","","123.83","114.55","572.63","1 through 10","117.33","780.86","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1008.86","605.32","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","441.07","43.72","","127.38","127.38","148.03","1 through 10","117.33","780.86","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1008.86","605.32","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","733.64","72.72","","196.34","62.16","1727.00","33","117.33","780.86","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1008.86","605.32","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","733.64","72.72","","173.00","173.00","173.00","1 through 10","117.33","780.86","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1008.86","605.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","536.92","53.22","","205.24","190.08","205.24","1 through 10","117.33","780.86","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1008.86","605.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","634.57","62.9","","305.08","81.02","4529.24","103","117.33","780.86","percent of total billed charges",""
"GUIDEWIRE BARRX 260CM .038IN RFA ENDOSCOPIC HALO ABLATION","SUP-ITM-10026959","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1008.86","605.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","780.86","77.4","","225.79","68.39","1154.35","11","117.33","780.86","percent of total billed charges",""
"GUIDEWIRE BILIARY .025INX450CM JAGWIRE REVOLUTION HIGH PERFORMANCE ANGLED BX/2EA","SUP-ITM-10287223","CDM","C1769","HCPCS","0272","RC","","","","both","","","1209.94","725.96","AETNA [1001]","HB WDH AETNA COMMERCIAL","844.54","69.8","","279.80","225.71","279.80","16","140.72","1028.45","percent of total billed charges",""
"GUIDEWIRE BILIARY .025INX450CM JAGWIRE REVOLUTION HIGH PERFORMANCE ANGLED BX/2EA","SUP-ITM-10287223","CDM","C1769","HCPCS","0272","RC","","","","both","","","1209.94","725.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","140.72","1028.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE BILIARY .025INX450CM JAGWIRE REVOLUTION HIGH PERFORMANCE ANGLED BX/2EA","SUP-ITM-10287223","CDM","C1769","HCPCS","0272","RC","","","","both","","","1209.94","725.96","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","688.46","56.9","","18.95","9.41","1260.18","1 through 10","140.72","1028.45","percent of total billed charges",""
"GUIDEWIRE BILIARY .025INX450CM JAGWIRE REVOLUTION HIGH PERFORMANCE ANGLED BX/2EA","SUP-ITM-10287223","CDM","C1769","HCPCS","0272","RC","","","","both","","","1209.94","725.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","140.72","11.63","","37.78","11.63","183.64","21","140.72","1028.45","percent of total billed charges",""
"GUIDEWIRE BILIARY .025INX450CM JAGWIRE REVOLUTION HIGH PERFORMANCE ANGLED BX/2EA","SUP-ITM-10287223","CDM","C1769","HCPCS","0272","RC","","","","both","","","1209.94","725.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","936.49","77.4","","225.79","68.39","1154.35","11","140.72","1028.45","percent of total billed charges",""
"GUIDEWIRE BILIARY .025INX450CM JAGWIRE REVOLUTION HIGH PERFORMANCE ANGLED BX/2EA","SUP-ITM-10287223","CDM","C1769","HCPCS","0272","RC","","","","both","","","1209.94","725.96","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","140.72","1028.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE BILIARY .025INX450CM JAGWIRE REVOLUTION HIGH PERFORMANCE ANGLED BX/2EA","SUP-ITM-10287223","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.94","725.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","140.72","11.63","","37.78","11.63","183.64","21","140.72","936.49","percent of total billed charges",""
"GUIDEWIRE BILIARY .025INX450CM JAGWIRE REVOLUTION HIGH PERFORMANCE ANGLED BX/2EA","SUP-ITM-10287223","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.94","725.96","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","759.60","62.78","","123.83","114.55","572.63","1 through 10","140.72","936.49","percent of total billed charges",""
"GUIDEWIRE BILIARY .025INX450CM JAGWIRE REVOLUTION HIGH PERFORMANCE ANGLED BX/2EA","SUP-ITM-10287223","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.94","725.96","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","528.99","43.72","","127.38","127.38","148.03","1 through 10","140.72","936.49","percent of total billed charges",""
"GUIDEWIRE BILIARY .025INX450CM JAGWIRE REVOLUTION HIGH PERFORMANCE ANGLED BX/2EA","SUP-ITM-10287223","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.94","725.96","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","879.87","72.72","","196.34","62.16","1727.00","33","140.72","936.49","percent of total billed charges",""
"GUIDEWIRE BILIARY .025INX450CM JAGWIRE REVOLUTION HIGH PERFORMANCE ANGLED BX/2EA","SUP-ITM-10287223","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.94","725.96","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","879.87","72.72","","173.00","173.00","173.00","1 through 10","140.72","936.49","percent of total billed charges",""
"GUIDEWIRE BILIARY .025INX450CM JAGWIRE REVOLUTION HIGH PERFORMANCE ANGLED BX/2EA","SUP-ITM-10287223","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.94","725.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","643.93","53.22","","205.24","190.08","205.24","1 through 10","140.72","936.49","percent of total billed charges",""
"GUIDEWIRE BILIARY .025INX450CM JAGWIRE REVOLUTION HIGH PERFORMANCE ANGLED BX/2EA","SUP-ITM-10287223","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.94","725.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","761.05","62.9","","305.08","81.02","4529.24","103","140.72","936.49","percent of total billed charges",""
"GUIDEWIRE BILIARY .025INX450CM JAGWIRE REVOLUTION HIGH PERFORMANCE ANGLED BX/2EA","SUP-ITM-10287223","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.94","725.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","936.49","77.4","","225.79","68.39","1154.35","11","140.72","936.49","percent of total billed charges",""
"GUIDEWIRE BILIARY .035INX480CM 5 OR PANCREATIC ANGLED RADPQ TIP COAT KINK RESISTANT CORE CONNECTION TRA","SUP-ITM-10073940","CDM","C1769","HCPCS","0272","RC","","","","both","","","1278.35","767.01","AETNA [1001]","HB WDH AETNA COMMERCIAL","892.29","69.8","","279.80","225.71","279.80","16","148.67","1086.6","percent of total billed charges",""
"GUIDEWIRE BILIARY .035INX480CM 5 OR PANCREATIC ANGLED RADPQ TIP COAT KINK RESISTANT CORE CONNECTION TRA","SUP-ITM-10073940","CDM","C1769","HCPCS","0272","RC","","","","both","","","1278.35","767.01","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","148.67","1086.6","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE BILIARY .035INX480CM 5 OR PANCREATIC ANGLED RADPQ TIP COAT KINK RESISTANT CORE CONNECTION TRA","SUP-ITM-10073940","CDM","C1769","HCPCS","0272","RC","","","","both","","","1278.35","767.01","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","727.38","56.9","","18.95","9.41","1260.18","1 through 10","148.67","1086.6","percent of total billed charges",""
"GUIDEWIRE BILIARY .035INX480CM 5 OR PANCREATIC ANGLED RADPQ TIP COAT KINK RESISTANT CORE CONNECTION TRA","SUP-ITM-10073940","CDM","C1769","HCPCS","0272","RC","","","","both","","","1278.35","767.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","148.67","11.63","","37.78","11.63","183.64","21","148.67","1086.6","percent of total billed charges",""
"GUIDEWIRE BILIARY .035INX480CM 5 OR PANCREATIC ANGLED RADPQ TIP COAT KINK RESISTANT CORE CONNECTION TRA","SUP-ITM-10073940","CDM","C1769","HCPCS","0272","RC","","","","both","","","1278.35","767.01","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","989.44","77.4","","225.79","68.39","1154.35","11","148.67","1086.6","percent of total billed charges",""
"GUIDEWIRE BILIARY .035INX480CM 5 OR PANCREATIC ANGLED RADPQ TIP COAT KINK RESISTANT CORE CONNECTION TRA","SUP-ITM-10073940","CDM","C1769","HCPCS","0272","RC","","","","both","","","1278.35","767.01","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","148.67","1086.6","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE BILIARY .035INX480CM 5 OR PANCREATIC ANGLED RADPQ TIP COAT KINK RESISTANT CORE CONNECTION TRA","SUP-ITM-10073940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1278.35","767.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","148.67","11.63","","37.78","11.63","183.64","21","148.67","989.44","percent of total billed charges",""
"GUIDEWIRE BILIARY .035INX480CM 5 OR PANCREATIC ANGLED RADPQ TIP COAT KINK RESISTANT CORE CONNECTION TRA","SUP-ITM-10073940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1278.35","767.01","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","802.55","62.78","","123.83","114.55","572.63","1 through 10","148.67","989.44","percent of total billed charges",""
"GUIDEWIRE BILIARY .035INX480CM 5 OR PANCREATIC ANGLED RADPQ TIP COAT KINK RESISTANT CORE CONNECTION TRA","SUP-ITM-10073940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1278.35","767.01","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","558.89","43.72","","127.38","127.38","148.03","1 through 10","148.67","989.44","percent of total billed charges",""
"GUIDEWIRE BILIARY .035INX480CM 5 OR PANCREATIC ANGLED RADPQ TIP COAT KINK RESISTANT CORE CONNECTION TRA","SUP-ITM-10073940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1278.35","767.01","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","929.62","72.72","","196.34","62.16","1727.00","33","148.67","989.44","percent of total billed charges",""
"GUIDEWIRE BILIARY .035INX480CM 5 OR PANCREATIC ANGLED RADPQ TIP COAT KINK RESISTANT CORE CONNECTION TRA","SUP-ITM-10073940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1278.35","767.01","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","929.62","72.72","","173.00","173.00","173.00","1 through 10","148.67","989.44","percent of total billed charges",""
"GUIDEWIRE BILIARY .035INX480CM 5 OR PANCREATIC ANGLED RADPQ TIP COAT KINK RESISTANT CORE CONNECTION TRA","SUP-ITM-10073940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1278.35","767.01","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","680.34","53.22","","205.24","190.08","205.24","1 through 10","148.67","989.44","percent of total billed charges",""
"GUIDEWIRE BILIARY .035INX480CM 5 OR PANCREATIC ANGLED RADPQ TIP COAT KINK RESISTANT CORE CONNECTION TRA","SUP-ITM-10073940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1278.35","767.01","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","804.08","62.9","","305.08","81.02","4529.24","103","148.67","989.44","percent of total billed charges",""
"GUIDEWIRE BILIARY .035INX480CM 5 OR PANCREATIC ANGLED RADPQ TIP COAT KINK RESISTANT CORE CONNECTION TRA","SUP-ITM-10073940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1278.35","767.01","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","989.44","77.4","","225.79","68.39","1154.35","11","148.67","989.44","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","138.20","82.92","AETNA [1001]","HB WDH AETNA COMMERCIAL","96.46","69.8","","279.80","225.71","279.80","16","16.07","117.47","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","138.20","82.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","16.07","117.47","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","138.20","82.92","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","78.64","56.9","","18.95","9.41","1260.18","1 through 10","16.07","117.47","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","138.20","82.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16.07","11.63","","37.78","11.63","183.64","21","16.07","117.47","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","138.20","82.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","106.97","77.4","","225.79","68.39","1154.35","11","16.07","117.47","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","138.20","82.92","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","16.07","117.47","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","138.20","82.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16.07","11.63","","37.78","11.63","183.64","21","16.07","106.97","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","138.20","82.92","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","86.76","62.78","","123.83","114.55","572.63","1 through 10","16.07","106.97","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","138.20","82.92","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","60.42","43.72","","127.38","127.38","148.03","1 through 10","16.07","106.97","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","138.20","82.92","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","100.50","72.72","","196.34","62.16","1727.00","33","16.07","106.97","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","138.20","82.92","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","100.50","72.72","","173.00","173.00","173.00","1 through 10","16.07","106.97","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","138.20","82.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","73.55","53.22","","205.24","190.08","205.24","1 through 10","16.07","106.97","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","138.20","82.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","86.93","62.9","","305.08","81.02","4529.24","103","16.07","106.97","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","138.20","82.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","106.97","77.4","","225.79","68.39","1154.35","11","16.07","106.97","percent of total billed charges",""
"GUIDEWIRE BONE 1MMX14IN NITINOL BX/1EA","SUP-ITM-10191489","CDM","C1769","HCPCS","0272","RC","","","","both","","","1271.58","762.95","AETNA [1001]","HB WDH AETNA COMMERCIAL","887.56","69.8","","279.80","225.71","279.80","16","147.88","1080.84","percent of total billed charges",""
"GUIDEWIRE BONE 1MMX14IN NITINOL BX/1EA","SUP-ITM-10191489","CDM","C1769","HCPCS","0272","RC","","","","both","","","1271.58","762.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","147.88","1080.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE BONE 1MMX14IN NITINOL BX/1EA","SUP-ITM-10191489","CDM","C1769","HCPCS","0272","RC","","","","both","","","1271.58","762.95","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","723.53","56.9","","18.95","9.41","1260.18","1 through 10","147.88","1080.84","percent of total billed charges",""
"GUIDEWIRE BONE 1MMX14IN NITINOL BX/1EA","SUP-ITM-10191489","CDM","C1769","HCPCS","0272","RC","","","","both","","","1271.58","762.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","147.88","11.63","","37.78","11.63","183.64","21","147.88","1080.84","percent of total billed charges",""
"GUIDEWIRE BONE 1MMX14IN NITINOL BX/1EA","SUP-ITM-10191489","CDM","C1769","HCPCS","0272","RC","","","","both","","","1271.58","762.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","984.20","77.4","","225.79","68.39","1154.35","11","147.88","1080.84","percent of total billed charges",""
"GUIDEWIRE BONE 1MMX14IN NITINOL BX/1EA","SUP-ITM-10191489","CDM","C1769","HCPCS","0272","RC","","","","both","","","1271.58","762.95","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","147.88","1080.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE BONE 1MMX14IN NITINOL BX/1EA","SUP-ITM-10191489","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1271.58","762.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","147.88","11.63","","37.78","11.63","183.64","21","147.88","984.2","percent of total billed charges",""
"GUIDEWIRE BONE 1MMX14IN NITINOL BX/1EA","SUP-ITM-10191489","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1271.58","762.95","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","798.30","62.78","","123.83","114.55","572.63","1 through 10","147.88","984.2","percent of total billed charges",""
"GUIDEWIRE BONE 1MMX14IN NITINOL BX/1EA","SUP-ITM-10191489","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1271.58","762.95","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","555.93","43.72","","127.38","127.38","148.03","1 through 10","147.88","984.2","percent of total billed charges",""
"GUIDEWIRE BONE 1MMX14IN NITINOL BX/1EA","SUP-ITM-10191489","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1271.58","762.95","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","924.69","72.72","","196.34","62.16","1727.00","33","147.88","984.2","percent of total billed charges",""
"GUIDEWIRE BONE 1MMX14IN NITINOL BX/1EA","SUP-ITM-10191489","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1271.58","762.95","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","924.69","72.72","","173.00","173.00","173.00","1 through 10","147.88","984.2","percent of total billed charges",""
"GUIDEWIRE BONE 1MMX14IN NITINOL BX/1EA","SUP-ITM-10191489","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1271.58","762.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","676.73","53.22","","205.24","190.08","205.24","1 through 10","147.88","984.2","percent of total billed charges",""
"GUIDEWIRE BONE 1MMX14IN NITINOL BX/1EA","SUP-ITM-10191489","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1271.58","762.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","799.82","62.9","","305.08","81.02","4529.24","103","147.88","984.2","percent of total billed charges",""
"GUIDEWIRE BONE 1MMX14IN NITINOL BX/1EA","SUP-ITM-10191489","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1271.58","762.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","984.20","77.4","","225.79","68.39","1154.35","11","147.88","984.2","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","both","","","210.06","126.04","AETNA [1001]","HB WDH AETNA COMMERCIAL","146.62","69.8","","279.80","225.71","279.80","16","24.43","178.55","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","both","","","210.06","126.04","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","24.43","178.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","both","","","210.06","126.04","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","119.52","56.9","","18.95","9.41","1260.18","1 through 10","24.43","178.55","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","both","","","210.06","126.04","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","24.43","11.63","","37.78","11.63","183.64","21","24.43","178.55","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","both","","","210.06","126.04","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","162.59","77.4","","225.79","68.39","1154.35","11","24.43","178.55","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","both","","","210.06","126.04","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","24.43","178.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","210.06","126.04","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","24.43","11.63","","37.78","11.63","183.64","21","24.43","162.59","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","210.06","126.04","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","131.88","62.78","","123.83","114.55","572.63","1 through 10","24.43","162.59","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","210.06","126.04","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","91.84","43.72","","127.38","127.38","148.03","1 through 10","24.43","162.59","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","210.06","126.04","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","152.76","72.72","","196.34","62.16","1727.00","33","24.43","162.59","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","210.06","126.04","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","152.76","72.72","","173.00","173.00","173.00","1 through 10","24.43","162.59","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","210.06","126.04","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","111.79","53.22","","205.24","190.08","205.24","1 through 10","24.43","162.59","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","210.06","126.04","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","132.13","62.9","","305.08","81.02","4529.24","103","24.43","162.59","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","210.06","126.04","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","162.59","77.4","","225.79","68.39","1154.35","11","24.43","162.59","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","248.00","148.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","173.10","69.8","","279.80","225.71","279.80","16","28.84","210.8","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","248.00","148.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","28.84","210.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","248.00","148.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","141.11","56.9","","18.95","9.41","1260.18","1 through 10","28.84","210.8","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","248.00","148.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","28.84","11.63","","37.78","11.63","183.64","21","28.84","210.8","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","248.00","148.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","191.95","77.4","","225.79","68.39","1154.35","11","28.84","210.8","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","248.00","148.80","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","28.84","210.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","248.00","148.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","28.84","11.63","","37.78","11.63","183.64","21","28.84","191.95","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","248.00","148.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","155.69","62.78","","123.83","114.55","572.63","1 through 10","28.84","191.95","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","248.00","148.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","108.43","43.72","","127.38","127.38","148.03","1 through 10","28.84","191.95","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","248.00","148.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","180.35","72.72","","196.34","62.16","1727.00","33","28.84","191.95","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","248.00","148.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","180.35","72.72","","173.00","173.00","173.00","1 through 10","28.84","191.95","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","248.00","148.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","131.99","53.22","","205.24","190.08","205.24","1 through 10","28.84","191.95","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","248.00","148.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","155.99","62.9","","305.08","81.02","4529.24","103","28.84","191.95","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","248.00","148.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","191.95","77.4","","225.79","68.39","1154.35","11","28.84","191.95","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.035 ACUTRAK 2 SS SINGLE TROCAR TIP","SUP-ITM-10189370","CDM","C1769","HCPCS","0272","RC","","","","both","","","124.38","74.63","AETNA [1001]","HB WDH AETNA COMMERCIAL","86.82","69.8","","279.80","225.71","279.80","16","14.47","105.72","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.035 ACUTRAK 2 SS SINGLE TROCAR TIP","SUP-ITM-10189370","CDM","C1769","HCPCS","0272","RC","","","","both","","","124.38","74.63","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","14.47","105.72","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE BONE 6.0IN 0.035 ACUTRAK 2 SS SINGLE TROCAR TIP","SUP-ITM-10189370","CDM","C1769","HCPCS","0272","RC","","","","both","","","124.38","74.63","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","70.77","56.9","","18.95","9.41","1260.18","1 through 10","14.47","105.72","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.035 ACUTRAK 2 SS SINGLE TROCAR TIP","SUP-ITM-10189370","CDM","C1769","HCPCS","0272","RC","","","","both","","","124.38","74.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","14.47","11.63","","37.78","11.63","183.64","21","14.47","105.72","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.035 ACUTRAK 2 SS SINGLE TROCAR TIP","SUP-ITM-10189370","CDM","C1769","HCPCS","0272","RC","","","","both","","","124.38","74.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","96.27","77.4","","225.79","68.39","1154.35","11","14.47","105.72","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.035 ACUTRAK 2 SS SINGLE TROCAR TIP","SUP-ITM-10189370","CDM","C1769","HCPCS","0272","RC","","","","both","","","124.38","74.63","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","14.47","105.72","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE BONE 6.0IN 0.035 ACUTRAK 2 SS SINGLE TROCAR TIP","SUP-ITM-10189370","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","124.38","74.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","14.47","11.63","","37.78","11.63","183.64","21","14.47","96.27","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.035 ACUTRAK 2 SS SINGLE TROCAR TIP","SUP-ITM-10189370","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","124.38","74.63","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","78.09","62.78","","123.83","114.55","572.63","1 through 10","14.47","96.27","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.035 ACUTRAK 2 SS SINGLE TROCAR TIP","SUP-ITM-10189370","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","124.38","74.63","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","54.38","43.72","","127.38","127.38","148.03","1 through 10","14.47","96.27","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.035 ACUTRAK 2 SS SINGLE TROCAR TIP","SUP-ITM-10189370","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","124.38","74.63","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","90.45","72.72","","196.34","62.16","1727.00","33","14.47","96.27","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.035 ACUTRAK 2 SS SINGLE TROCAR TIP","SUP-ITM-10189370","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","124.38","74.63","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","90.45","72.72","","173.00","173.00","173.00","1 through 10","14.47","96.27","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.035 ACUTRAK 2 SS SINGLE TROCAR TIP","SUP-ITM-10189370","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","124.38","74.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","66.20","53.22","","205.24","190.08","205.24","1 through 10","14.47","96.27","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.035 ACUTRAK 2 SS SINGLE TROCAR TIP","SUP-ITM-10189370","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","124.38","74.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","78.24","62.9","","305.08","81.02","4529.24","103","14.47","96.27","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.035 ACUTRAK 2 SS SINGLE TROCAR TIP","SUP-ITM-10189370","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","124.38","74.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","96.27","77.4","","225.79","68.39","1154.35","11","14.47","96.27","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","110.56","66.34","AETNA [1001]","HB WDH AETNA COMMERCIAL","77.17","69.8","","279.80","225.71","279.80","16","12.86","93.98","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","110.56","66.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","12.86","93.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","110.56","66.34","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","62.91","56.9","","18.95","9.41","1260.18","1 through 10","12.86","93.98","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","110.56","66.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","12.86","11.63","","37.78","11.63","183.64","21","12.86","93.98","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","110.56","66.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","85.57","77.4","","225.79","68.39","1154.35","11","12.86","93.98","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","110.56","66.34","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","12.86","93.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","110.56","66.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","12.86","11.63","","37.78","11.63","183.64","21","12.86","85.57","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","110.56","66.34","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","69.41","62.78","","123.83","114.55","572.63","1 through 10","12.86","85.57","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","110.56","66.34","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","48.34","43.72","","127.38","127.38","148.03","1 through 10","12.86","85.57","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","110.56","66.34","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","80.40","72.72","","196.34","62.16","1727.00","33","12.86","85.57","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","110.56","66.34","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","80.40","72.72","","173.00","173.00","173.00","1 through 10","12.86","85.57","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","110.56","66.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","58.84","53.22","","205.24","190.08","205.24","1 through 10","12.86","85.57","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","110.56","66.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","69.54","62.9","","305.08","81.02","4529.24","103","12.86","85.57","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","110.56","66.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","85.57","77.4","","225.79","68.39","1154.35","11","12.86","85.57","percent of total billed charges",""
"GUIDEWIRE CALIBRATED .025IN 260CM TIP ACROBAT LONG","SUP-ITM-10191322","CDM","C1769","HCPCS","0272","RC","","","","both","","","1679.13","1007.48","AETNA [1001]","HB WDH AETNA COMMERCIAL","1172.03","69.8","","279.80","225.71","279.80","16","195.28","1427.26","percent of total billed charges",""
"GUIDEWIRE CALIBRATED .025IN 260CM TIP ACROBAT LONG","SUP-ITM-10191322","CDM","C1769","HCPCS","0272","RC","","","","both","","","1679.13","1007.48","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","195.28","1427.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE CALIBRATED .025IN 260CM TIP ACROBAT LONG","SUP-ITM-10191322","CDM","C1769","HCPCS","0272","RC","","","","both","","","1679.13","1007.48","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","955.42","56.9","","18.95","9.41","1260.18","1 through 10","195.28","1427.26","percent of total billed charges",""
"GUIDEWIRE CALIBRATED .025IN 260CM TIP ACROBAT LONG","SUP-ITM-10191322","CDM","C1769","HCPCS","0272","RC","","","","both","","","1679.13","1007.48","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","195.28","11.63","","37.78","11.63","183.64","21","195.28","1427.26","percent of total billed charges",""
"GUIDEWIRE CALIBRATED .025IN 260CM TIP ACROBAT LONG","SUP-ITM-10191322","CDM","C1769","HCPCS","0272","RC","","","","both","","","1679.13","1007.48","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1299.65","77.4","","225.79","68.39","1154.35","11","195.28","1427.26","percent of total billed charges",""
"GUIDEWIRE CALIBRATED .025IN 260CM TIP ACROBAT LONG","SUP-ITM-10191322","CDM","C1769","HCPCS","0272","RC","","","","both","","","1679.13","1007.48","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","195.28","1427.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE CALIBRATED .025IN 260CM TIP ACROBAT LONG","SUP-ITM-10191322","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1679.13","1007.48","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","195.28","11.63","","37.78","11.63","183.64","21","195.28","1299.65","percent of total billed charges",""
"GUIDEWIRE CALIBRATED .025IN 260CM TIP ACROBAT LONG","SUP-ITM-10191322","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1679.13","1007.48","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1054.16","62.78","","123.83","114.55","572.63","1 through 10","195.28","1299.65","percent of total billed charges",""
"GUIDEWIRE CALIBRATED .025IN 260CM TIP ACROBAT LONG","SUP-ITM-10191322","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1679.13","1007.48","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","734.12","43.72","","127.38","127.38","148.03","1 through 10","195.28","1299.65","percent of total billed charges",""
"GUIDEWIRE CALIBRATED .025IN 260CM TIP ACROBAT LONG","SUP-ITM-10191322","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1679.13","1007.48","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1221.06","72.72","","196.34","62.16","1727.00","33","195.28","1299.65","percent of total billed charges",""
"GUIDEWIRE CALIBRATED .025IN 260CM TIP ACROBAT LONG","SUP-ITM-10191322","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1679.13","1007.48","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1221.06","72.72","","173.00","173.00","173.00","1 through 10","195.28","1299.65","percent of total billed charges",""
"GUIDEWIRE CALIBRATED .025IN 260CM TIP ACROBAT LONG","SUP-ITM-10191322","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1679.13","1007.48","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","893.63","53.22","","205.24","190.08","205.24","1 through 10","195.28","1299.65","percent of total billed charges",""
"GUIDEWIRE CALIBRATED .025IN 260CM TIP ACROBAT LONG","SUP-ITM-10191322","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1679.13","1007.48","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1056.17","62.9","","305.08","81.02","4529.24","103","195.28","1299.65","percent of total billed charges",""
"GUIDEWIRE CALIBRATED .025IN 260CM TIP ACROBAT LONG","SUP-ITM-10191322","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1679.13","1007.48","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1299.65","77.4","","225.79","68.39","1154.35","11","195.28","1299.65","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","both","","","292.85","175.71","AETNA [1001]","HB WDH AETNA COMMERCIAL","204.41","69.8","","279.80","225.71","279.80","16","34.06","248.92","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","both","","","292.85","175.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","34.06","248.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","both","","","292.85","175.71","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","166.63","56.9","","18.95","9.41","1260.18","1 through 10","34.06","248.92","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","both","","","292.85","175.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","34.06","11.63","","37.78","11.63","183.64","21","34.06","248.92","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","both","","","292.85","175.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","226.67","77.4","","225.79","68.39","1154.35","11","34.06","248.92","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","both","","","292.85","175.71","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","34.06","248.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","292.85","175.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","34.06","11.63","","37.78","11.63","183.64","21","34.06","226.67","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","292.85","175.71","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","183.85","62.78","","123.83","114.55","572.63","1 through 10","34.06","226.67","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","292.85","175.71","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","128.03","43.72","","127.38","127.38","148.03","1 through 10","34.06","226.67","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","292.85","175.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","212.96","72.72","","196.34","62.16","1727.00","33","34.06","226.67","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","292.85","175.71","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","212.96","72.72","","173.00","173.00","173.00","1 through 10","34.06","226.67","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","292.85","175.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","155.85","53.22","","205.24","190.08","205.24","1 through 10","34.06","226.67","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","292.85","175.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","184.20","62.9","","305.08","81.02","4529.24","103","34.06","226.67","percent of total billed charges",""
"GUIDEWIRE COPE 7CM 60CM .018IN MANDRIL NITINOL PLATINUM TIP VASCULAR","SUP-ITM-10087284","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","292.85","175.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","226.67","77.4","","225.79","68.39","1154.35","11","34.06","226.67","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","100.68","60.41","AETNA [1001]","HB WDH AETNA COMMERCIAL","70.27","69.8","","279.80","225.71","279.80","16","11.71","85.58","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","100.68","60.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","11.71","85.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","100.68","60.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","57.29","56.9","","18.95","9.41","1260.18","1 through 10","11.71","85.58","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","100.68","60.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","11.71","11.63","","37.78","11.63","183.64","21","11.71","85.58","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","100.68","60.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","77.93","77.4","","225.79","68.39","1154.35","11","11.71","85.58","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","100.68","60.41","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","11.71","85.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","100.68","60.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","11.71","11.63","","37.78","11.63","183.64","21","11.71","77.93","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","100.68","60.41","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","63.21","62.78","","123.83","114.55","572.63","1 through 10","11.71","77.93","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","100.68","60.41","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","44.02","43.72","","127.38","127.38","148.03","1 through 10","11.71","77.93","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","100.68","60.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","73.21","72.72","","196.34","62.16","1727.00","33","11.71","77.93","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","100.68","60.41","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","73.21","72.72","","173.00","173.00","173.00","1 through 10","11.71","77.93","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","100.68","60.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","53.58","53.22","","205.24","190.08","205.24","1 through 10","11.71","77.93","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","100.68","60.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","63.33","62.9","","305.08","81.02","4529.24","103","11.71","77.93","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","100.68","60.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","77.93","77.4","","225.79","68.39","1154.35","11","11.71","77.93","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","both","","","57.08","34.25","AETNA [1001]","HB WDH AETNA COMMERCIAL","39.84","69.8","","279.80","225.71","279.80","16","6.64","48.52","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","both","","","57.08","34.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","6.64","48.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","both","","","57.08","34.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","32.48","56.9","","18.95","9.41","1260.18","1 through 10","6.64","48.52","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","both","","","57.08","34.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","6.64","11.63","","37.78","11.63","183.64","21","6.64","48.52","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","both","","","57.08","34.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","44.18","77.4","","225.79","68.39","1154.35","11","6.64","48.52","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","both","","","57.08","34.25","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","6.64","48.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","57.08","34.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","6.64","11.63","","37.78","11.63","183.64","21","6.64","44.18","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","57.08","34.25","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","35.83","62.78","","123.83","114.55","572.63","1 through 10","6.64","44.18","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","57.08","34.25","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","24.96","43.72","","127.38","127.38","148.03","1 through 10","6.64","44.18","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","57.08","34.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","41.51","72.72","","196.34","62.16","1727.00","33","6.64","44.18","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","57.08","34.25","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","41.51","72.72","","173.00","173.00","173.00","1 through 10","6.64","44.18","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","57.08","34.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","30.38","53.22","","205.24","190.08","205.24","1 through 10","6.64","44.18","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","57.08","34.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","35.90","62.9","","305.08","81.02","4529.24","103","6.64","44.18","percent of total billed charges",""
"GUIDEWIRE DIAGNOSTIC 1.5MM .035X180CM INQWIRE FIXED CORE PTFE COATED J TIP BX/10EA","SUP-ITM-10216561","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","57.08","34.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","44.18","77.4","","225.79","68.39","1154.35","11","6.64","44.18","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 260CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10087783","CDM","C1769","HCPCS","0272","RC","","","","both","","","1140.15","684.09","AETNA [1001]","HB WDH AETNA COMMERCIAL","795.82","69.8","","279.80","225.71","279.80","16","132.6","969.13","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 260CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10087783","CDM","C1769","HCPCS","0272","RC","","","","both","","","1140.15","684.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","132.6","969.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE DREAMWIRE 260CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10087783","CDM","C1769","HCPCS","0272","RC","","","","both","","","1140.15","684.09","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","648.75","56.9","","18.95","9.41","1260.18","1 through 10","132.6","969.13","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 260CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10087783","CDM","C1769","HCPCS","0272","RC","","","","both","","","1140.15","684.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","132.60","11.63","","37.78","11.63","183.64","21","132.6","969.13","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 260CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10087783","CDM","C1769","HCPCS","0272","RC","","","","both","","","1140.15","684.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","882.48","77.4","","225.79","68.39","1154.35","11","132.6","969.13","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 260CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10087783","CDM","C1769","HCPCS","0272","RC","","","","both","","","1140.15","684.09","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","132.6","969.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE DREAMWIRE 260CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10087783","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1140.15","684.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","132.60","11.63","","37.78","11.63","183.64","21","132.6","882.48","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 260CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10087783","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1140.15","684.09","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","715.79","62.78","","123.83","114.55","572.63","1 through 10","132.6","882.48","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 260CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10087783","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1140.15","684.09","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","498.47","43.72","","127.38","127.38","148.03","1 through 10","132.6","882.48","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 260CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10087783","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1140.15","684.09","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","829.12","72.72","","196.34","62.16","1727.00","33","132.6","882.48","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 260CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10087783","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1140.15","684.09","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","829.12","72.72","","173.00","173.00","173.00","1 through 10","132.6","882.48","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 260CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10087783","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1140.15","684.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","606.79","53.22","","205.24","190.08","205.24","1 through 10","132.6","882.48","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 260CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10087783","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1140.15","684.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","717.15","62.9","","305.08","81.02","4529.24","103","132.6","882.48","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 260CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10087783","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1140.15","684.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","882.48","77.4","","225.79","68.39","1154.35","11","132.6","882.48","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 260CM 0.035IN WIREX STRAIGHT TIP TORQUABLE HYDROPHILIC RADIOPAQUE JAGWIRE BX/2EA","SUP-ITM-10008908","CDM","C1769","HCPCS","0272","RC","","","","both","","","646.09","387.65","AETNA [1001]","HB WDH AETNA COMMERCIAL","450.97","69.8","","279.80","225.71","279.80","16","75.14","549.18","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 260CM 0.035IN WIREX STRAIGHT TIP TORQUABLE HYDROPHILIC RADIOPAQUE JAGWIRE BX/2EA","SUP-ITM-10008908","CDM","C1769","HCPCS","0272","RC","","","","both","","","646.09","387.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","75.14","549.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ENDOSCOPIC 260CM 0.035IN WIREX STRAIGHT TIP TORQUABLE HYDROPHILIC RADIOPAQUE JAGWIRE BX/2EA","SUP-ITM-10008908","CDM","C1769","HCPCS","0272","RC","","","","both","","","646.09","387.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","367.63","56.9","","18.95","9.41","1260.18","1 through 10","75.14","549.18","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 260CM 0.035IN WIREX STRAIGHT TIP TORQUABLE HYDROPHILIC RADIOPAQUE JAGWIRE BX/2EA","SUP-ITM-10008908","CDM","C1769","HCPCS","0272","RC","","","","both","","","646.09","387.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","75.14","11.63","","37.78","11.63","183.64","21","75.14","549.18","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 260CM 0.035IN WIREX STRAIGHT TIP TORQUABLE HYDROPHILIC RADIOPAQUE JAGWIRE BX/2EA","SUP-ITM-10008908","CDM","C1769","HCPCS","0272","RC","","","","both","","","646.09","387.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","500.07","77.4","","225.79","68.39","1154.35","11","75.14","549.18","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 260CM 0.035IN WIREX STRAIGHT TIP TORQUABLE HYDROPHILIC RADIOPAQUE JAGWIRE BX/2EA","SUP-ITM-10008908","CDM","C1769","HCPCS","0272","RC","","","","both","","","646.09","387.65","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","75.14","549.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ENDOSCOPIC 260CM 0.035IN WIREX STRAIGHT TIP TORQUABLE HYDROPHILIC RADIOPAQUE JAGWIRE BX/2EA","SUP-ITM-10008908","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","646.09","387.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","75.14","11.63","","37.78","11.63","183.64","21","75.14","500.07","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 260CM 0.035IN WIREX STRAIGHT TIP TORQUABLE HYDROPHILIC RADIOPAQUE JAGWIRE BX/2EA","SUP-ITM-10008908","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","646.09","387.65","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","405.62","62.78","","123.83","114.55","572.63","1 through 10","75.14","500.07","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 260CM 0.035IN WIREX STRAIGHT TIP TORQUABLE HYDROPHILIC RADIOPAQUE JAGWIRE BX/2EA","SUP-ITM-10008908","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","646.09","387.65","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","282.47","43.72","","127.38","127.38","148.03","1 through 10","75.14","500.07","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 260CM 0.035IN WIREX STRAIGHT TIP TORQUABLE HYDROPHILIC RADIOPAQUE JAGWIRE BX/2EA","SUP-ITM-10008908","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","646.09","387.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","469.84","72.72","","196.34","62.16","1727.00","33","75.14","500.07","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 260CM 0.035IN WIREX STRAIGHT TIP TORQUABLE HYDROPHILIC RADIOPAQUE JAGWIRE BX/2EA","SUP-ITM-10008908","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","646.09","387.65","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","469.84","72.72","","173.00","173.00","173.00","1 through 10","75.14","500.07","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 260CM 0.035IN WIREX STRAIGHT TIP TORQUABLE HYDROPHILIC RADIOPAQUE JAGWIRE BX/2EA","SUP-ITM-10008908","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","646.09","387.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","343.85","53.22","","205.24","190.08","205.24","1 through 10","75.14","500.07","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 260CM 0.035IN WIREX STRAIGHT TIP TORQUABLE HYDROPHILIC RADIOPAQUE JAGWIRE BX/2EA","SUP-ITM-10008908","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","646.09","387.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","406.39","62.9","","305.08","81.02","4529.24","103","75.14","500.07","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 260CM 0.035IN WIREX STRAIGHT TIP TORQUABLE HYDROPHILIC RADIOPAQUE JAGWIRE BX/2EA","SUP-ITM-10008908","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","646.09","387.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","500.07","77.4","","225.79","68.39","1154.35","11","75.14","500.07","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3.0CM 145X0.038IN WIRE FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE S/S","SUP-ITM-10000057","CDM","C1769","HCPCS","0272","RC","","","","both","","","122.31","73.39","AETNA [1001]","HB WDH AETNA COMMERCIAL","85.37","69.8","","279.80","225.71","279.80","16","14.22","103.96","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3.0CM 145X0.038IN WIRE FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE S/S","SUP-ITM-10000057","CDM","C1769","HCPCS","0272","RC","","","","both","","","122.31","73.39","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","14.22","103.96","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ENDOSCOPIC 3.0CM 145X0.038IN WIRE FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE S/S","SUP-ITM-10000057","CDM","C1769","HCPCS","0272","RC","","","","both","","","122.31","73.39","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","69.59","56.9","","18.95","9.41","1260.18","1 through 10","14.22","103.96","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3.0CM 145X0.038IN WIRE FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE S/S","SUP-ITM-10000057","CDM","C1769","HCPCS","0272","RC","","","","both","","","122.31","73.39","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","14.22","11.63","","37.78","11.63","183.64","21","14.22","103.96","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3.0CM 145X0.038IN WIRE FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE S/S","SUP-ITM-10000057","CDM","C1769","HCPCS","0272","RC","","","","both","","","122.31","73.39","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","94.67","77.4","","225.79","68.39","1154.35","11","14.22","103.96","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3.0CM 145X0.038IN WIRE FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE S/S","SUP-ITM-10000057","CDM","C1769","HCPCS","0272","RC","","","","both","","","122.31","73.39","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","14.22","103.96","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ENDOSCOPIC 3.0CM 145X0.038IN WIRE FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE S/S","SUP-ITM-10000057","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","122.31","73.39","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","14.22","11.63","","37.78","11.63","183.64","21","14.22","94.67","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3.0CM 145X0.038IN WIRE FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE S/S","SUP-ITM-10000057","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","122.31","73.39","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","76.79","62.78","","123.83","114.55","572.63","1 through 10","14.22","94.67","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3.0CM 145X0.038IN WIRE FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE S/S","SUP-ITM-10000057","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","122.31","73.39","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","53.47","43.72","","127.38","127.38","148.03","1 through 10","14.22","94.67","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3.0CM 145X0.038IN WIRE FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE S/S","SUP-ITM-10000057","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","122.31","73.39","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","88.94","72.72","","196.34","62.16","1727.00","33","14.22","94.67","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3.0CM 145X0.038IN WIRE FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE S/S","SUP-ITM-10000057","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","122.31","73.39","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","88.94","72.72","","173.00","173.00","173.00","1 through 10","14.22","94.67","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3.0CM 145X0.038IN WIRE FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE S/S","SUP-ITM-10000057","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","122.31","73.39","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","65.09","53.22","","205.24","190.08","205.24","1 through 10","14.22","94.67","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3.0CM 145X0.038IN WIRE FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE S/S","SUP-ITM-10000057","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","122.31","73.39","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","76.93","62.9","","305.08","81.02","4529.24","103","14.22","94.67","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3.0CM 145X0.038IN WIRE FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE S/S","SUP-ITM-10000057","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","122.31","73.39","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","94.67","77.4","","225.79","68.39","1154.35","11","14.22","94.67","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3CM 150 0.038IN WIREX FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE","SUP-ITM-10016049","CDM","C1769","HCPCS","0272","RC","","","","both","","","100.68","60.41","AETNA [1001]","HB WDH AETNA COMMERCIAL","70.27","69.8","","279.80","225.71","279.80","16","11.71","85.58","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3CM 150 0.038IN WIREX FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE","SUP-ITM-10016049","CDM","C1769","HCPCS","0272","RC","","","","both","","","100.68","60.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","11.71","85.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ENDOSCOPIC 3CM 150 0.038IN WIREX FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE","SUP-ITM-10016049","CDM","C1769","HCPCS","0272","RC","","","","both","","","100.68","60.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","57.29","56.9","","18.95","9.41","1260.18","1 through 10","11.71","85.58","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3CM 150 0.038IN WIREX FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE","SUP-ITM-10016049","CDM","C1769","HCPCS","0272","RC","","","","both","","","100.68","60.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","11.71","11.63","","37.78","11.63","183.64","21","11.71","85.58","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3CM 150 0.038IN WIREX FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE","SUP-ITM-10016049","CDM","C1769","HCPCS","0272","RC","","","","both","","","100.68","60.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","77.93","77.4","","225.79","68.39","1154.35","11","11.71","85.58","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3CM 150 0.038IN WIREX FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE","SUP-ITM-10016049","CDM","C1769","HCPCS","0272","RC","","","","both","","","100.68","60.41","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","11.71","85.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ENDOSCOPIC 3CM 150 0.038IN WIREX FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE","SUP-ITM-10016049","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","100.68","60.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","11.71","11.63","","37.78","11.63","183.64","21","11.71","77.93","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3CM 150 0.038IN WIREX FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE","SUP-ITM-10016049","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","100.68","60.41","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","63.21","62.78","","123.83","114.55","572.63","1 through 10","11.71","77.93","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3CM 150 0.038IN WIREX FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE","SUP-ITM-10016049","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","100.68","60.41","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","44.02","43.72","","127.38","127.38","148.03","1 through 10","11.71","77.93","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3CM 150 0.038IN WIREX FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE","SUP-ITM-10016049","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","100.68","60.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","73.21","72.72","","196.34","62.16","1727.00","33","11.71","77.93","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3CM 150 0.038IN WIREX FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE","SUP-ITM-10016049","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","100.68","60.41","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","73.21","72.72","","173.00","173.00","173.00","1 through 10","11.71","77.93","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3CM 150 0.038IN WIREX FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE","SUP-ITM-10016049","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","100.68","60.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","53.58","53.22","","205.24","190.08","205.24","1 through 10","11.71","77.93","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3CM 150 0.038IN WIREX FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE","SUP-ITM-10016049","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","100.68","60.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","63.33","62.9","","305.08","81.02","4529.24","103","11.71","77.93","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3CM 150 0.038IN WIREX FLEX TIP FIXED CORE NON HYDROPHILIC RADIOPAQUE","SUP-ITM-10016049","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","100.68","60.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","77.93","77.4","","225.79","68.39","1154.35","11","11.71","77.93","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 0.038IN 230CM BARRX STAINLESS STEEL FLEXIBLE STRAIGHT DISTAL TIP STERILE DISPOSABLE","SUP-ITM-10266273","CDM","C1769","HCPCS","0272","RC","","","","both","","","1333.63","800.18","AETNA [1001]","HB WDH AETNA COMMERCIAL","930.87","69.8","","279.80","225.71","279.80","16","155.1","1133.59","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 0.038IN 230CM BARRX STAINLESS STEEL FLEXIBLE STRAIGHT DISTAL TIP STERILE DISPOSABLE","SUP-ITM-10266273","CDM","C1769","HCPCS","0272","RC","","","","both","","","1333.63","800.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","155.1","1133.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ENDOSCOPY 0.038IN 230CM BARRX STAINLESS STEEL FLEXIBLE STRAIGHT DISTAL TIP STERILE DISPOSABLE","SUP-ITM-10266273","CDM","C1769","HCPCS","0272","RC","","","","both","","","1333.63","800.18","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","758.84","56.9","","18.95","9.41","1260.18","1 through 10","155.1","1133.59","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 0.038IN 230CM BARRX STAINLESS STEEL FLEXIBLE STRAIGHT DISTAL TIP STERILE DISPOSABLE","SUP-ITM-10266273","CDM","C1769","HCPCS","0272","RC","","","","both","","","1333.63","800.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","155.10","11.63","","37.78","11.63","183.64","21","155.1","1133.59","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 0.038IN 230CM BARRX STAINLESS STEEL FLEXIBLE STRAIGHT DISTAL TIP STERILE DISPOSABLE","SUP-ITM-10266273","CDM","C1769","HCPCS","0272","RC","","","","both","","","1333.63","800.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1032.23","77.4","","225.79","68.39","1154.35","11","155.1","1133.59","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 0.038IN 230CM BARRX STAINLESS STEEL FLEXIBLE STRAIGHT DISTAL TIP STERILE DISPOSABLE","SUP-ITM-10266273","CDM","C1769","HCPCS","0272","RC","","","","both","","","1333.63","800.18","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","155.1","1133.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ENDOSCOPY 0.038IN 230CM BARRX STAINLESS STEEL FLEXIBLE STRAIGHT DISTAL TIP STERILE DISPOSABLE","SUP-ITM-10266273","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1333.63","800.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","155.10","11.63","","37.78","11.63","183.64","21","155.1","1032.23","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 0.038IN 230CM BARRX STAINLESS STEEL FLEXIBLE STRAIGHT DISTAL TIP STERILE DISPOSABLE","SUP-ITM-10266273","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1333.63","800.18","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","837.25","62.78","","123.83","114.55","572.63","1 through 10","155.1","1032.23","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 0.038IN 230CM BARRX STAINLESS STEEL FLEXIBLE STRAIGHT DISTAL TIP STERILE DISPOSABLE","SUP-ITM-10266273","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1333.63","800.18","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","583.06","43.72","","127.38","127.38","148.03","1 through 10","155.1","1032.23","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 0.038IN 230CM BARRX STAINLESS STEEL FLEXIBLE STRAIGHT DISTAL TIP STERILE DISPOSABLE","SUP-ITM-10266273","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1333.63","800.18","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","969.82","72.72","","196.34","62.16","1727.00","33","155.1","1032.23","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 0.038IN 230CM BARRX STAINLESS STEEL FLEXIBLE STRAIGHT DISTAL TIP STERILE DISPOSABLE","SUP-ITM-10266273","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1333.63","800.18","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","969.82","72.72","","173.00","173.00","173.00","1 through 10","155.1","1032.23","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 0.038IN 230CM BARRX STAINLESS STEEL FLEXIBLE STRAIGHT DISTAL TIP STERILE DISPOSABLE","SUP-ITM-10266273","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1333.63","800.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","709.76","53.22","","205.24","190.08","205.24","1 through 10","155.1","1032.23","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 0.038IN 230CM BARRX STAINLESS STEEL FLEXIBLE STRAIGHT DISTAL TIP STERILE DISPOSABLE","SUP-ITM-10266273","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1333.63","800.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","838.85","62.9","","305.08","81.02","4529.24","103","155.1","1032.23","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 0.038IN 230CM BARRX STAINLESS STEEL FLEXIBLE STRAIGHT DISTAL TIP STERILE DISPOSABLE","SUP-ITM-10266273","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1333.63","800.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1032.23","77.4","","225.79","68.39","1154.35","11","155.1","1032.23","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 15MM .035X180CM FIXED CORE HEAVY DUTY SS FLEXIBLE CURVED TIP TAPERED SAFE TJ PTFE COATED","SUP-ITM-10087244","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.67","58.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","67.48","69.8","","279.80","225.71","279.80","16","11.24","82.17","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 15MM .035X180CM FIXED CORE HEAVY DUTY SS FLEXIBLE CURVED TIP TAPERED SAFE TJ PTFE COATED","SUP-ITM-10087244","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.67","58.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","11.24","82.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ENDOSCOPY 15MM .035X180CM FIXED CORE HEAVY DUTY SS FLEXIBLE CURVED TIP TAPERED SAFE TJ PTFE COATED","SUP-ITM-10087244","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.67","58.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","55.01","56.9","","18.95","9.41","1260.18","1 through 10","11.24","82.17","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 15MM .035X180CM FIXED CORE HEAVY DUTY SS FLEXIBLE CURVED TIP TAPERED SAFE TJ PTFE COATED","SUP-ITM-10087244","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.67","58.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","11.24","11.63","","37.78","11.63","183.64","21","11.24","82.17","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 15MM .035X180CM FIXED CORE HEAVY DUTY SS FLEXIBLE CURVED TIP TAPERED SAFE TJ PTFE COATED","SUP-ITM-10087244","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.67","58.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","74.82","77.4","","225.79","68.39","1154.35","11","11.24","82.17","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 15MM .035X180CM FIXED CORE HEAVY DUTY SS FLEXIBLE CURVED TIP TAPERED SAFE TJ PTFE COATED","SUP-ITM-10087244","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.67","58.00","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","11.24","82.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ENDOSCOPY 15MM .035X180CM FIXED CORE HEAVY DUTY SS FLEXIBLE CURVED TIP TAPERED SAFE TJ PTFE COATED","SUP-ITM-10087244","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","96.67","58.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","11.24","11.63","","37.78","11.63","183.64","21","11.24","74.82","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 15MM .035X180CM FIXED CORE HEAVY DUTY SS FLEXIBLE CURVED TIP TAPERED SAFE TJ PTFE COATED","SUP-ITM-10087244","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","96.67","58.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","60.69","62.78","","123.83","114.55","572.63","1 through 10","11.24","74.82","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 15MM .035X180CM FIXED CORE HEAVY DUTY SS FLEXIBLE CURVED TIP TAPERED SAFE TJ PTFE COATED","SUP-ITM-10087244","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","96.67","58.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","42.26","43.72","","127.38","127.38","148.03","1 through 10","11.24","74.82","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 15MM .035X180CM FIXED CORE HEAVY DUTY SS FLEXIBLE CURVED TIP TAPERED SAFE TJ PTFE COATED","SUP-ITM-10087244","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","96.67","58.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","70.30","72.72","","196.34","62.16","1727.00","33","11.24","74.82","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 15MM .035X180CM FIXED CORE HEAVY DUTY SS FLEXIBLE CURVED TIP TAPERED SAFE TJ PTFE COATED","SUP-ITM-10087244","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","96.67","58.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","70.30","72.72","","173.00","173.00","173.00","1 through 10","11.24","74.82","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 15MM .035X180CM FIXED CORE HEAVY DUTY SS FLEXIBLE CURVED TIP TAPERED SAFE TJ PTFE COATED","SUP-ITM-10087244","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","96.67","58.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","51.45","53.22","","205.24","190.08","205.24","1 through 10","11.24","74.82","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 15MM .035X180CM FIXED CORE HEAVY DUTY SS FLEXIBLE CURVED TIP TAPERED SAFE TJ PTFE COATED","SUP-ITM-10087244","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","96.67","58.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","60.81","62.9","","305.08","81.02","4529.24","103","11.24","74.82","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 15MM .035X180CM FIXED CORE HEAVY DUTY SS FLEXIBLE CURVED TIP TAPERED SAFE TJ PTFE COATED","SUP-ITM-10087244","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","96.67","58.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","74.82","77.4","","225.79","68.39","1154.35","11","11.24","74.82","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","1245.53","747.32","AETNA [1001]","HB WDH AETNA COMMERCIAL","869.38","69.8","","279.80","225.71","279.80","16","144.86","1058.7","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","1245.53","747.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","144.86","1058.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","1245.53","747.32","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","708.71","56.9","","18.95","9.41","1260.18","1 through 10","144.86","1058.7","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","1245.53","747.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","144.86","11.63","","37.78","11.63","183.64","21","144.86","1058.7","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","1245.53","747.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","964.04","77.4","","225.79","68.39","1154.35","11","144.86","1058.7","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","1245.53","747.32","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","144.86","1058.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1245.53","747.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","144.86","11.63","","37.78","11.63","183.64","21","144.86","964.04","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1245.53","747.32","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","781.94","62.78","","123.83","114.55","572.63","1 through 10","144.86","964.04","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1245.53","747.32","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","544.55","43.72","","127.38","127.38","148.03","1 through 10","144.86","964.04","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1245.53","747.32","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","905.75","72.72","","196.34","62.16","1727.00","33","144.86","964.04","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1245.53","747.32","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","905.75","72.72","","173.00","173.00","173.00","1 through 10","144.86","964.04","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1245.53","747.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","662.87","53.22","","205.24","190.08","205.24","1 through 10","144.86","964.04","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1245.53","747.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","783.44","62.9","","305.08","81.02","4529.24","103","144.86","964.04","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1245.53","747.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","964.04","77.4","","225.79","68.39","1154.35","11","144.86","964.04","percent of total billed charges",""
"GUIDEWIRE EXTENSION 200CM 0.035IN BILIARY JAGTAIL HYDROPHILIC TIP BX/5EA","SUP-ITM-10138931","CDM","C1769","HCPCS","0272","RC","","","","both","","","587.35","352.41","AETNA [1001]","HB WDH AETNA COMMERCIAL","409.97","69.8","","279.80","225.71","279.80","16","68.31","499.25","percent of total billed charges",""
"GUIDEWIRE EXTENSION 200CM 0.035IN BILIARY JAGTAIL HYDROPHILIC TIP BX/5EA","SUP-ITM-10138931","CDM","C1769","HCPCS","0272","RC","","","","both","","","587.35","352.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","68.31","499.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE EXTENSION 200CM 0.035IN BILIARY JAGTAIL HYDROPHILIC TIP BX/5EA","SUP-ITM-10138931","CDM","C1769","HCPCS","0272","RC","","","","both","","","587.35","352.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","334.20","56.9","","18.95","9.41","1260.18","1 through 10","68.31","499.25","percent of total billed charges",""
"GUIDEWIRE EXTENSION 200CM 0.035IN BILIARY JAGTAIL HYDROPHILIC TIP BX/5EA","SUP-ITM-10138931","CDM","C1769","HCPCS","0272","RC","","","","both","","","587.35","352.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","68.31","11.63","","37.78","11.63","183.64","21","68.31","499.25","percent of total billed charges",""
"GUIDEWIRE EXTENSION 200CM 0.035IN BILIARY JAGTAIL HYDROPHILIC TIP BX/5EA","SUP-ITM-10138931","CDM","C1769","HCPCS","0272","RC","","","","both","","","587.35","352.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","454.61","77.4","","225.79","68.39","1154.35","11","68.31","499.25","percent of total billed charges",""
"GUIDEWIRE EXTENSION 200CM 0.035IN BILIARY JAGTAIL HYDROPHILIC TIP BX/5EA","SUP-ITM-10138931","CDM","C1769","HCPCS","0272","RC","","","","both","","","587.35","352.41","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","68.31","499.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE EXTENSION 200CM 0.035IN BILIARY JAGTAIL HYDROPHILIC TIP BX/5EA","SUP-ITM-10138931","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","587.35","352.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","68.31","11.63","","37.78","11.63","183.64","21","68.31","454.61","percent of total billed charges",""
"GUIDEWIRE EXTENSION 200CM 0.035IN BILIARY JAGTAIL HYDROPHILIC TIP BX/5EA","SUP-ITM-10138931","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","587.35","352.41","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","368.74","62.78","","123.83","114.55","572.63","1 through 10","68.31","454.61","percent of total billed charges",""
"GUIDEWIRE EXTENSION 200CM 0.035IN BILIARY JAGTAIL HYDROPHILIC TIP BX/5EA","SUP-ITM-10138931","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","587.35","352.41","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","256.79","43.72","","127.38","127.38","148.03","1 through 10","68.31","454.61","percent of total billed charges",""
"GUIDEWIRE EXTENSION 200CM 0.035IN BILIARY JAGTAIL HYDROPHILIC TIP BX/5EA","SUP-ITM-10138931","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","587.35","352.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","427.12","72.72","","196.34","62.16","1727.00","33","68.31","454.61","percent of total billed charges",""
"GUIDEWIRE EXTENSION 200CM 0.035IN BILIARY JAGTAIL HYDROPHILIC TIP BX/5EA","SUP-ITM-10138931","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","587.35","352.41","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","427.12","72.72","","173.00","173.00","173.00","1 through 10","68.31","454.61","percent of total billed charges",""
"GUIDEWIRE EXTENSION 200CM 0.035IN BILIARY JAGTAIL HYDROPHILIC TIP BX/5EA","SUP-ITM-10138931","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","587.35","352.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","312.59","53.22","","205.24","190.08","205.24","1 through 10","68.31","454.61","percent of total billed charges",""
"GUIDEWIRE EXTENSION 200CM 0.035IN BILIARY JAGTAIL HYDROPHILIC TIP BX/5EA","SUP-ITM-10138931","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","587.35","352.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","369.44","62.9","","305.08","81.02","4529.24","103","68.31","454.61","percent of total billed charges",""
"GUIDEWIRE EXTENSION 200CM 0.035IN BILIARY JAGTAIL HYDROPHILIC TIP BX/5EA","SUP-ITM-10138931","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","587.35","352.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","454.61","77.4","","225.79","68.39","1154.35","11","68.31","454.61","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 200CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10076811","CDM","C1769","HCPCS","0272","RC","","","","both","","","1883.60","1130.16","AETNA [1001]","HB WDH AETNA COMMERCIAL","1314.75","69.8","","279.80","225.71","279.80","16","219.06","1601.06","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 200CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10076811","CDM","C1769","HCPCS","0272","RC","","","","both","","","1883.60","1130.16","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","219.06","1601.06","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE FATHOM-16 10CM 200CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10076811","CDM","C1769","HCPCS","0272","RC","","","","both","","","1883.60","1130.16","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1071.77","56.9","","18.95","9.41","1260.18","1 through 10","219.06","1601.06","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 200CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10076811","CDM","C1769","HCPCS","0272","RC","","","","both","","","1883.60","1130.16","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","219.06","11.63","","37.78","11.63","183.64","21","219.06","1601.06","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 200CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10076811","CDM","C1769","HCPCS","0272","RC","","","","both","","","1883.60","1130.16","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1457.91","77.4","","225.79","68.39","1154.35","11","219.06","1601.06","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 200CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10076811","CDM","C1769","HCPCS","0272","RC","","","","both","","","1883.60","1130.16","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","219.06","1601.06","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE FATHOM-16 10CM 200CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10076811","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1883.60","1130.16","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","219.06","11.63","","37.78","11.63","183.64","21","219.06","1457.91","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 200CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10076811","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1883.60","1130.16","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1182.52","62.78","","123.83","114.55","572.63","1 through 10","219.06","1457.91","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 200CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10076811","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1883.60","1130.16","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","823.51","43.72","","127.38","127.38","148.03","1 through 10","219.06","1457.91","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 200CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10076811","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1883.60","1130.16","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1369.75","72.72","","196.34","62.16","1727.00","33","219.06","1457.91","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 200CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10076811","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1883.60","1130.16","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1369.75","72.72","","173.00","173.00","173.00","1 through 10","219.06","1457.91","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 200CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10076811","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1883.60","1130.16","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1002.45","53.22","","205.24","190.08","205.24","1 through 10","219.06","1457.91","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 200CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10076811","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1883.60","1130.16","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1184.78","62.9","","305.08","81.02","4529.24","103","219.06","1457.91","percent of total billed charges",""
"GUIDEWIRE FATHOM-16 10CM 200CM .016IN EMBOLIZATION STRAIGHT TIP NITINOL PERIPHERAL","SUP-ITM-10076811","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1883.60","1130.16","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1457.91","77.4","","225.79","68.39","1154.35","11","219.06","1457.91","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","both","","","210.76","126.46","AETNA [1001]","HB WDH AETNA COMMERCIAL","147.11","69.8","","279.80","225.71","279.80","16","24.51","179.15","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","both","","","210.76","126.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","24.51","179.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","both","","","210.76","126.46","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","119.92","56.9","","18.95","9.41","1260.18","1 through 10","24.51","179.15","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","both","","","210.76","126.46","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","24.51","11.63","","37.78","11.63","183.64","21","24.51","179.15","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","both","","","210.76","126.46","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","163.13","77.4","","225.79","68.39","1154.35","11","24.51","179.15","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","both","","","210.76","126.46","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","24.51","179.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","210.76","126.46","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","24.51","11.63","","37.78","11.63","183.64","21","24.51","163.13","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","210.76","126.46","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","132.32","62.78","","123.83","114.55","572.63","1 through 10","24.51","163.13","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","210.76","126.46","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","92.14","43.72","","127.38","127.38","148.03","1 through 10","24.51","163.13","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","210.76","126.46","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","153.26","72.72","","196.34","62.16","1727.00","33","24.51","163.13","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","210.76","126.46","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","153.26","72.72","","173.00","173.00","173.00","1 through 10","24.51","163.13","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","210.76","126.46","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","112.17","53.22","","205.24","190.08","205.24","1 through 10","24.51","163.13","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","210.76","126.46","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","132.57","62.9","","305.08","81.02","4529.24","103","24.51","163.13","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000100","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","210.76","126.46","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","163.13","77.4","","225.79","68.39","1154.35","11","24.51","163.13","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000125","CDM","C1769","HCPCS","0272","RC","","","","both","","","328.23","196.94","AETNA [1001]","HB WDH AETNA COMMERCIAL","229.10","69.8","","279.80","225.71","279.80","16","38.17","279","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000125","CDM","C1769","HCPCS","0272","RC","","","","both","","","328.23","196.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","38.17","279","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000125","CDM","C1769","HCPCS","0272","RC","","","","both","","","328.23","196.94","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","186.76","56.9","","18.95","9.41","1260.18","1 through 10","38.17","279","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000125","CDM","C1769","HCPCS","0272","RC","","","","both","","","328.23","196.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","38.17","11.63","","37.78","11.63","183.64","21","38.17","279","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000125","CDM","C1769","HCPCS","0272","RC","","","","both","","","328.23","196.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","254.05","77.4","","225.79","68.39","1154.35","11","38.17","279","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000125","CDM","C1769","HCPCS","0272","RC","","","","both","","","328.23","196.94","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","38.17","279","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000125","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","328.23","196.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","38.17","11.63","","37.78","11.63","183.64","21","38.17","254.05","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000125","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","328.23","196.94","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","206.06","62.78","","123.83","114.55","572.63","1 through 10","38.17","254.05","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000125","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","328.23","196.94","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","143.50","43.72","","127.38","127.38","148.03","1 through 10","38.17","254.05","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000125","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","328.23","196.94","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","238.69","72.72","","196.34","62.16","1727.00","33","38.17","254.05","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000125","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","328.23","196.94","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","238.69","72.72","","173.00","173.00","173.00","1 through 10","38.17","254.05","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000125","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","328.23","196.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","174.68","53.22","","205.24","190.08","205.24","1 through 10","38.17","254.05","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000125","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","328.23","196.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","206.46","62.9","","305.08","81.02","4529.24","103","38.17","254.05","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000125","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","328.23","196.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","254.05","77.4","","225.79","68.39","1154.35","11","38.17","254.05","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","286.77","172.06","AETNA [1001]","HB WDH AETNA COMMERCIAL","200.17","69.8","","279.80","225.71","279.80","16","33.35","243.75","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","286.77","172.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","33.35","243.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","286.77","172.06","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","163.17","56.9","","18.95","9.41","1260.18","1 through 10","33.35","243.75","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","286.77","172.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","33.35","11.63","","37.78","11.63","183.64","21","33.35","243.75","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","286.77","172.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","221.96","77.4","","225.79","68.39","1154.35","11","33.35","243.75","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","286.77","172.06","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","33.35","243.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","286.77","172.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","33.35","11.63","","37.78","11.63","183.64","21","33.35","221.96","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","286.77","172.06","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","180.03","62.78","","123.83","114.55","572.63","1 through 10","33.35","221.96","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","286.77","172.06","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","125.38","43.72","","127.38","127.38","148.03","1 through 10","33.35","221.96","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","286.77","172.06","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","208.54","72.72","","196.34","62.16","1727.00","33","33.35","221.96","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","286.77","172.06","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","208.54","72.72","","173.00","173.00","173.00","1 through 10","33.35","221.96","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","286.77","172.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","152.62","53.22","","205.24","190.08","205.24","1 through 10","33.35","221.96","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","286.77","172.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","180.38","62.9","","305.08","81.02","4529.24","103","33.35","221.96","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","286.77","172.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","221.96","77.4","","225.79","68.39","1154.35","11","33.35","221.96","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","both","","","338.59","203.15","AETNA [1001]","HB WDH AETNA COMMERCIAL","236.34","69.8","","279.80","225.71","279.80","16","39.38","287.8","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","both","","","338.59","203.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","39.38","287.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","both","","","338.59","203.15","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","192.66","56.9","","18.95","9.41","1260.18","1 through 10","39.38","287.8","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","both","","","338.59","203.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","39.38","11.63","","37.78","11.63","183.64","21","39.38","287.8","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","both","","","338.59","203.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","262.07","77.4","","225.79","68.39","1154.35","11","39.38","287.8","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","both","","","338.59","203.15","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","39.38","287.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","338.59","203.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","39.38","11.63","","37.78","11.63","183.64","21","39.38","262.07","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","338.59","203.15","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","212.57","62.78","","123.83","114.55","572.63","1 through 10","39.38","262.07","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","338.59","203.15","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","148.03","43.72","","127.38","127.38","148.03","1 through 10","39.38","262.07","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","338.59","203.15","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","246.22","72.72","","196.34","62.16","1727.00","33","39.38","262.07","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","338.59","203.15","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","246.22","72.72","","173.00","173.00","173.00","1 through 10","39.38","262.07","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","338.59","203.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","180.20","53.22","","205.24","190.08","205.24","1 through 10","39.38","262.07","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","338.59","203.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","212.97","62.9","","305.08","81.02","4529.24","103","39.38","262.07","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000172","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","338.59","203.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","262.07","77.4","","225.79","68.39","1154.35","11","39.38","262.07","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10116082","CDM","C1769","HCPCS","0272","RC","","","","both","","","566.62","339.97","AETNA [1001]","HB WDH AETNA COMMERCIAL","395.50","69.8","","279.80","225.71","279.80","16","65.9","481.63","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10116082","CDM","C1769","HCPCS","0272","RC","","","","both","","","566.62","339.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","65.9","481.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE GLIDEWIRE 260CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10116082","CDM","C1769","HCPCS","0272","RC","","","","both","","","566.62","339.97","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","322.41","56.9","","18.95","9.41","1260.18","1 through 10","65.9","481.63","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10116082","CDM","C1769","HCPCS","0272","RC","","","","both","","","566.62","339.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","65.90","11.63","","37.78","11.63","183.64","21","65.9","481.63","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10116082","CDM","C1769","HCPCS","0272","RC","","","","both","","","566.62","339.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","438.56","77.4","","225.79","68.39","1154.35","11","65.9","481.63","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10116082","CDM","C1769","HCPCS","0272","RC","","","","both","","","566.62","339.97","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","65.9","481.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE GLIDEWIRE 260CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10116082","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","566.62","339.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","65.90","11.63","","37.78","11.63","183.64","21","65.9","438.56","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10116082","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","566.62","339.97","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","355.72","62.78","","123.83","114.55","572.63","1 through 10","65.9","438.56","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10116082","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","566.62","339.97","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","247.73","43.72","","127.38","127.38","148.03","1 through 10","65.9","438.56","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10116082","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","566.62","339.97","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","412.05","72.72","","196.34","62.16","1727.00","33","65.9","438.56","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10116082","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","566.62","339.97","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","412.05","72.72","","173.00","173.00","173.00","1 through 10","65.9","438.56","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10116082","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","566.62","339.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","301.56","53.22","","205.24","190.08","205.24","1 through 10","65.9","438.56","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10116082","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","566.62","339.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","356.40","62.9","","305.08","81.02","4529.24","103","65.9","438.56","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .018IN 3CM STANDARD ANGLED FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10116082","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","566.62","339.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","438.56","77.4","","225.79","68.39","1154.35","11","65.9","438.56","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","both","","","324.77","194.86","AETNA [1001]","HB WDH AETNA COMMERCIAL","226.69","69.8","","279.80","225.71","279.80","16","37.77","276.05","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","both","","","324.77","194.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","37.77","276.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","both","","","324.77","194.86","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","184.79","56.9","","18.95","9.41","1260.18","1 through 10","37.77","276.05","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","both","","","324.77","194.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","37.77","11.63","","37.78","11.63","183.64","21","37.77","276.05","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","both","","","324.77","194.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","251.37","77.4","","225.79","68.39","1154.35","11","37.77","276.05","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","both","","","324.77","194.86","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","37.77","276.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","324.77","194.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","37.77","11.63","","37.78","11.63","183.64","21","37.77","251.37","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","324.77","194.86","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","203.89","62.78","","123.83","114.55","572.63","1 through 10","37.77","251.37","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","324.77","194.86","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","141.99","43.72","","127.38","127.38","148.03","1 through 10","37.77","251.37","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","324.77","194.86","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","236.17","72.72","","196.34","62.16","1727.00","33","37.77","251.37","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","324.77","194.86","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","236.17","72.72","","173.00","173.00","173.00","1 through 10","37.77","251.37","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","324.77","194.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","172.84","53.22","","205.24","190.08","205.24","1 through 10","37.77","251.37","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","324.77","194.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","204.28","62.9","","305.08","81.02","4529.24","103","37.77","251.37","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000105","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","324.77","194.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","251.37","77.4","","225.79","68.39","1154.35","11","37.77","251.37","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000375","CDM","C1769","HCPCS","0272","RC","","","","both","","","362.78","217.67","AETNA [1001]","HB WDH AETNA COMMERCIAL","253.22","69.8","","279.80","225.71","279.80","16","42.19","308.36","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000375","CDM","C1769","HCPCS","0272","RC","","","","both","","","362.78","217.67","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","42.19","308.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000375","CDM","C1769","HCPCS","0272","RC","","","","both","","","362.78","217.67","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","206.42","56.9","","18.95","9.41","1260.18","1 through 10","42.19","308.36","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000375","CDM","C1769","HCPCS","0272","RC","","","","both","","","362.78","217.67","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","42.19","11.63","","37.78","11.63","183.64","21","42.19","308.36","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000375","CDM","C1769","HCPCS","0272","RC","","","","both","","","362.78","217.67","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","280.79","77.4","","225.79","68.39","1154.35","11","42.19","308.36","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000375","CDM","C1769","HCPCS","0272","RC","","","","both","","","362.78","217.67","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","42.19","308.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000375","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","362.78","217.67","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","42.19","11.63","","37.78","11.63","183.64","21","42.19","280.79","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000375","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","362.78","217.67","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","227.75","62.78","","123.83","114.55","572.63","1 through 10","42.19","280.79","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000375","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","362.78","217.67","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","158.61","43.72","","127.38","127.38","148.03","1 through 10","42.19","280.79","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000375","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","362.78","217.67","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","263.81","72.72","","196.34","62.16","1727.00","33","42.19","280.79","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000375","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","362.78","217.67","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","263.81","72.72","","173.00","173.00","173.00","1 through 10","42.19","280.79","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000375","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","362.78","217.67","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","193.07","53.22","","205.24","190.08","205.24","1 through 10","42.19","280.79","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000375","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","362.78","217.67","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","228.19","62.9","","305.08","81.02","4529.24","103","42.19","280.79","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 260CM .035IN 3CM STIFF ANGLED FLEXIBLE TIP HYDROPHILIC COATED PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000375","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","362.78","217.67","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","280.79","77.4","","225.79","68.39","1154.35","11","42.19","280.79","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","both","","","1147.06","688.24","AETNA [1001]","HB WDH AETNA COMMERCIAL","800.65","69.8","","279.80","225.71","279.80","16","133.4","975","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","both","","","1147.06","688.24","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","133.4","975","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","both","","","1147.06","688.24","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","652.68","56.9","","18.95","9.41","1260.18","1 through 10","133.4","975","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","both","","","1147.06","688.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","133.40","11.63","","37.78","11.63","183.64","21","133.4","975","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","both","","","1147.06","688.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","887.82","77.4","","225.79","68.39","1154.35","11","133.4","975","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","both","","","1147.06","688.24","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","133.4","975","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1147.06","688.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","133.40","11.63","","37.78","11.63","183.64","21","133.4","887.82","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1147.06","688.24","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","720.12","62.78","","123.83","114.55","572.63","1 through 10","133.4","887.82","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1147.06","688.24","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","501.49","43.72","","127.38","127.38","148.03","1 through 10","133.4","887.82","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1147.06","688.24","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","834.14","72.72","","196.34","62.16","1727.00","33","133.4","887.82","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1147.06","688.24","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","834.14","72.72","","173.00","173.00","173.00","1 through 10","133.4","887.82","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1147.06","688.24","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","610.47","53.22","","205.24","190.08","205.24","1 through 10","133.4","887.82","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1147.06","688.24","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","721.50","62.9","","305.08","81.02","4529.24","103","133.4","887.82","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 180CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065083","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1147.06","688.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","887.82","77.4","","225.79","68.39","1154.35","11","133.4","887.82","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","both","","","1288.72","773.23","AETNA [1001]","HB WDH AETNA COMMERCIAL","899.53","69.8","","279.80","225.71","279.80","16","149.88","1095.41","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","both","","","1288.72","773.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","149.88","1095.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","both","","","1288.72","773.23","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","733.28","56.9","","18.95","9.41","1260.18","1 through 10","149.88","1095.41","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","both","","","1288.72","773.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","149.88","11.63","","37.78","11.63","183.64","21","149.88","1095.41","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","both","","","1288.72","773.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","997.47","77.4","","225.79","68.39","1154.35","11","149.88","1095.41","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","both","","","1288.72","773.23","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","149.88","1095.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1288.72","773.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","149.88","11.63","","37.78","11.63","183.64","21","149.88","997.47","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1288.72","773.23","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","809.06","62.78","","123.83","114.55","572.63","1 through 10","149.88","997.47","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1288.72","773.23","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","563.43","43.72","","127.38","127.38","148.03","1 through 10","149.88","997.47","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1288.72","773.23","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","937.16","72.72","","196.34","62.16","1727.00","33","149.88","997.47","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1288.72","773.23","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","937.16","72.72","","173.00","173.00","173.00","1 through 10","149.88","997.47","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1288.72","773.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","685.86","53.22","","205.24","190.08","205.24","1 through 10","149.88","997.47","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1288.72","773.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","810.60","62.9","","305.08","81.02","4529.24","103","149.88","997.47","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE ADVANTAGE 25CM 260CM .035IN 5CM FLEXIBLE ANGLE TIP BX/1EA","SUP-ITM-10065084","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1288.72","773.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","997.47","77.4","","225.79","68.39","1154.35","11","149.88","997.47","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 190CM .014IN STRAIGHT TIP PERIPHERAL MIDDLEWEIGHT W/HYDROCOAT","SUP-ITM-10172940","CDM","C1769","HCPCS","0272","RC","","","","both","","","518.25","310.95","AETNA [1001]","HB WDH AETNA COMMERCIAL","361.74","69.8","","279.80","225.71","279.80","16","60.27","440.51","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 190CM .014IN STRAIGHT TIP PERIPHERAL MIDDLEWEIGHT W/HYDROCOAT","SUP-ITM-10172940","CDM","C1769","HCPCS","0272","RC","","","","both","","","518.25","310.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","60.27","440.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE HI TORQUE 190CM .014IN STRAIGHT TIP PERIPHERAL MIDDLEWEIGHT W/HYDROCOAT","SUP-ITM-10172940","CDM","C1769","HCPCS","0272","RC","","","","both","","","518.25","310.95","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","294.88","56.9","","18.95","9.41","1260.18","1 through 10","60.27","440.51","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 190CM .014IN STRAIGHT TIP PERIPHERAL MIDDLEWEIGHT W/HYDROCOAT","SUP-ITM-10172940","CDM","C1769","HCPCS","0272","RC","","","","both","","","518.25","310.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","60.27","11.63","","37.78","11.63","183.64","21","60.27","440.51","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 190CM .014IN STRAIGHT TIP PERIPHERAL MIDDLEWEIGHT W/HYDROCOAT","SUP-ITM-10172940","CDM","C1769","HCPCS","0272","RC","","","","both","","","518.25","310.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","401.13","77.4","","225.79","68.39","1154.35","11","60.27","440.51","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 190CM .014IN STRAIGHT TIP PERIPHERAL MIDDLEWEIGHT W/HYDROCOAT","SUP-ITM-10172940","CDM","C1769","HCPCS","0272","RC","","","","both","","","518.25","310.95","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","60.27","440.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE HI TORQUE 190CM .014IN STRAIGHT TIP PERIPHERAL MIDDLEWEIGHT W/HYDROCOAT","SUP-ITM-10172940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","518.25","310.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","60.27","11.63","","37.78","11.63","183.64","21","60.27","401.13","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 190CM .014IN STRAIGHT TIP PERIPHERAL MIDDLEWEIGHT W/HYDROCOAT","SUP-ITM-10172940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","518.25","310.95","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","325.36","62.78","","123.83","114.55","572.63","1 through 10","60.27","401.13","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 190CM .014IN STRAIGHT TIP PERIPHERAL MIDDLEWEIGHT W/HYDROCOAT","SUP-ITM-10172940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","518.25","310.95","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","226.58","43.72","","127.38","127.38","148.03","1 through 10","60.27","401.13","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 190CM .014IN STRAIGHT TIP PERIPHERAL MIDDLEWEIGHT W/HYDROCOAT","SUP-ITM-10172940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","518.25","310.95","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","376.87","72.72","","196.34","62.16","1727.00","33","60.27","401.13","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 190CM .014IN STRAIGHT TIP PERIPHERAL MIDDLEWEIGHT W/HYDROCOAT","SUP-ITM-10172940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","518.25","310.95","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","376.87","72.72","","173.00","173.00","173.00","1 through 10","60.27","401.13","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 190CM .014IN STRAIGHT TIP PERIPHERAL MIDDLEWEIGHT W/HYDROCOAT","SUP-ITM-10172940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","518.25","310.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","275.81","53.22","","205.24","190.08","205.24","1 through 10","60.27","401.13","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 190CM .014IN STRAIGHT TIP PERIPHERAL MIDDLEWEIGHT W/HYDROCOAT","SUP-ITM-10172940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","518.25","310.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","325.98","62.9","","305.08","81.02","4529.24","103","60.27","401.13","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 190CM .014IN STRAIGHT TIP PERIPHERAL MIDDLEWEIGHT W/HYDROCOAT","SUP-ITM-10172940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","518.25","310.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","401.13","77.4","","225.79","68.39","1154.35","11","60.27","401.13","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 260CM .035IN PERIPHERAL VERSACORE S/S PTFE STEERABLE FLOPPY","SUP-ITM-10049208","CDM","C1769","HCPCS","0272","RC","","","","both","","","317.86","190.72","AETNA [1001]","HB WDH AETNA COMMERCIAL","221.87","69.8","","279.80","225.71","279.80","16","36.97","270.18","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 260CM .035IN PERIPHERAL VERSACORE S/S PTFE STEERABLE FLOPPY","SUP-ITM-10049208","CDM","C1769","HCPCS","0272","RC","","","","both","","","317.86","190.72","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","36.97","270.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE HI TORQUE 260CM .035IN PERIPHERAL VERSACORE S/S PTFE STEERABLE FLOPPY","SUP-ITM-10049208","CDM","C1769","HCPCS","0272","RC","","","","both","","","317.86","190.72","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","180.86","56.9","","18.95","9.41","1260.18","1 through 10","36.97","270.18","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 260CM .035IN PERIPHERAL VERSACORE S/S PTFE STEERABLE FLOPPY","SUP-ITM-10049208","CDM","C1769","HCPCS","0272","RC","","","","both","","","317.86","190.72","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","36.97","11.63","","37.78","11.63","183.64","21","36.97","270.18","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 260CM .035IN PERIPHERAL VERSACORE S/S PTFE STEERABLE FLOPPY","SUP-ITM-10049208","CDM","C1769","HCPCS","0272","RC","","","","both","","","317.86","190.72","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","246.02","77.4","","225.79","68.39","1154.35","11","36.97","270.18","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 260CM .035IN PERIPHERAL VERSACORE S/S PTFE STEERABLE FLOPPY","SUP-ITM-10049208","CDM","C1769","HCPCS","0272","RC","","","","both","","","317.86","190.72","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","36.97","270.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE HI TORQUE 260CM .035IN PERIPHERAL VERSACORE S/S PTFE STEERABLE FLOPPY","SUP-ITM-10049208","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","317.86","190.72","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","36.97","11.63","","37.78","11.63","183.64","21","36.97","246.02","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 260CM .035IN PERIPHERAL VERSACORE S/S PTFE STEERABLE FLOPPY","SUP-ITM-10049208","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","317.86","190.72","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","199.55","62.78","","123.83","114.55","572.63","1 through 10","36.97","246.02","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 260CM .035IN PERIPHERAL VERSACORE S/S PTFE STEERABLE FLOPPY","SUP-ITM-10049208","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","317.86","190.72","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","138.97","43.72","","127.38","127.38","148.03","1 through 10","36.97","246.02","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 260CM .035IN PERIPHERAL VERSACORE S/S PTFE STEERABLE FLOPPY","SUP-ITM-10049208","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","317.86","190.72","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","231.15","72.72","","196.34","62.16","1727.00","33","36.97","246.02","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 260CM .035IN PERIPHERAL VERSACORE S/S PTFE STEERABLE FLOPPY","SUP-ITM-10049208","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","317.86","190.72","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","231.15","72.72","","173.00","173.00","173.00","1 through 10","36.97","246.02","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 260CM .035IN PERIPHERAL VERSACORE S/S PTFE STEERABLE FLOPPY","SUP-ITM-10049208","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","317.86","190.72","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","169.17","53.22","","205.24","190.08","205.24","1 through 10","36.97","246.02","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 260CM .035IN PERIPHERAL VERSACORE S/S PTFE STEERABLE FLOPPY","SUP-ITM-10049208","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","317.86","190.72","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","199.93","62.9","","305.08","81.02","4529.24","103","36.97","246.02","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 260CM .035IN PERIPHERAL VERSACORE S/S PTFE STEERABLE FLOPPY","SUP-ITM-10049208","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","317.86","190.72","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","246.02","77.4","","225.79","68.39","1154.35","11","36.97","246.02","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .014IN NITINOL TIP PERIPHERAL COMMAND ES STEERABLE S/S HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10114943","CDM","C1769","HCPCS","0272","RC","","","","both","","","898.30","538.98","AETNA [1001]","HB WDH AETNA COMMERCIAL","627.01","69.8","","279.80","225.71","279.80","16","104.47","763.56","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .014IN NITINOL TIP PERIPHERAL COMMAND ES STEERABLE S/S HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10114943","CDM","C1769","HCPCS","0272","RC","","","","both","","","898.30","538.98","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","104.47","763.56","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE HI TORQUE 300CM .014IN NITINOL TIP PERIPHERAL COMMAND ES STEERABLE S/S HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10114943","CDM","C1769","HCPCS","0272","RC","","","","both","","","898.30","538.98","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","511.13","56.9","","18.95","9.41","1260.18","1 through 10","104.47","763.56","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .014IN NITINOL TIP PERIPHERAL COMMAND ES STEERABLE S/S HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10114943","CDM","C1769","HCPCS","0272","RC","","","","both","","","898.30","538.98","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","104.47","11.63","","37.78","11.63","183.64","21","104.47","763.56","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .014IN NITINOL TIP PERIPHERAL COMMAND ES STEERABLE S/S HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10114943","CDM","C1769","HCPCS","0272","RC","","","","both","","","898.30","538.98","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","695.28","77.4","","225.79","68.39","1154.35","11","104.47","763.56","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .014IN NITINOL TIP PERIPHERAL COMMAND ES STEERABLE S/S HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10114943","CDM","C1769","HCPCS","0272","RC","","","","both","","","898.30","538.98","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","104.47","763.56","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE HI TORQUE 300CM .014IN NITINOL TIP PERIPHERAL COMMAND ES STEERABLE S/S HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10114943","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","898.30","538.98","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","104.47","11.63","","37.78","11.63","183.64","21","104.47","695.28","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .014IN NITINOL TIP PERIPHERAL COMMAND ES STEERABLE S/S HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10114943","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","898.30","538.98","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","563.95","62.78","","123.83","114.55","572.63","1 through 10","104.47","695.28","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .014IN NITINOL TIP PERIPHERAL COMMAND ES STEERABLE S/S HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10114943","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","898.30","538.98","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","392.74","43.72","","127.38","127.38","148.03","1 through 10","104.47","695.28","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .014IN NITINOL TIP PERIPHERAL COMMAND ES STEERABLE S/S HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10114943","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","898.30","538.98","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","653.24","72.72","","196.34","62.16","1727.00","33","104.47","695.28","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .014IN NITINOL TIP PERIPHERAL COMMAND ES STEERABLE S/S HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10114943","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","898.30","538.98","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","653.24","72.72","","173.00","173.00","173.00","1 through 10","104.47","695.28","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .014IN NITINOL TIP PERIPHERAL COMMAND ES STEERABLE S/S HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10114943","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","898.30","538.98","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","478.08","53.22","","205.24","190.08","205.24","1 through 10","104.47","695.28","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .014IN NITINOL TIP PERIPHERAL COMMAND ES STEERABLE S/S HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10114943","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","898.30","538.98","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","565.03","62.9","","305.08","81.02","4529.24","103","104.47","695.28","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .014IN NITINOL TIP PERIPHERAL COMMAND ES STEERABLE S/S HYDROPHILIC COATED PERIPHERAL BX/5EA","SUP-ITM-10114943","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","898.30","538.98","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","695.28","77.4","","225.79","68.39","1154.35","11","104.47","695.28","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .018IN PERIPHERAL CONNECT 250T","SUP-ITM-10168896","CDM","C1769","HCPCS","0272","RC","","","","both","","","829.20","497.52","AETNA [1001]","HB WDH AETNA COMMERCIAL","578.78","69.8","","279.80","225.71","279.80","16","96.44","704.82","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .018IN PERIPHERAL CONNECT 250T","SUP-ITM-10168896","CDM","C1769","HCPCS","0272","RC","","","","both","","","829.20","497.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","96.44","704.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE HI TORQUE 300CM .018IN PERIPHERAL CONNECT 250T","SUP-ITM-10168896","CDM","C1769","HCPCS","0272","RC","","","","both","","","829.20","497.52","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","471.81","56.9","","18.95","9.41","1260.18","1 through 10","96.44","704.82","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .018IN PERIPHERAL CONNECT 250T","SUP-ITM-10168896","CDM","C1769","HCPCS","0272","RC","","","","both","","","829.20","497.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","96.44","11.63","","37.78","11.63","183.64","21","96.44","704.82","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .018IN PERIPHERAL CONNECT 250T","SUP-ITM-10168896","CDM","C1769","HCPCS","0272","RC","","","","both","","","829.20","497.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","641.80","77.4","","225.79","68.39","1154.35","11","96.44","704.82","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .018IN PERIPHERAL CONNECT 250T","SUP-ITM-10168896","CDM","C1769","HCPCS","0272","RC","","","","both","","","829.20","497.52","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","96.44","704.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE HI TORQUE 300CM .018IN PERIPHERAL CONNECT 250T","SUP-ITM-10168896","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","829.20","497.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","96.44","11.63","","37.78","11.63","183.64","21","96.44","641.8","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .018IN PERIPHERAL CONNECT 250T","SUP-ITM-10168896","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","829.20","497.52","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","520.57","62.78","","123.83","114.55","572.63","1 through 10","96.44","641.8","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .018IN PERIPHERAL CONNECT 250T","SUP-ITM-10168896","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","829.20","497.52","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","362.53","43.72","","127.38","127.38","148.03","1 through 10","96.44","641.8","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .018IN PERIPHERAL CONNECT 250T","SUP-ITM-10168896","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","829.20","497.52","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","602.99","72.72","","196.34","62.16","1727.00","33","96.44","641.8","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .018IN PERIPHERAL CONNECT 250T","SUP-ITM-10168896","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","829.20","497.52","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","602.99","72.72","","173.00","173.00","173.00","1 through 10","96.44","641.8","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .018IN PERIPHERAL CONNECT 250T","SUP-ITM-10168896","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","829.20","497.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","441.30","53.22","","205.24","190.08","205.24","1 through 10","96.44","641.8","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .018IN PERIPHERAL CONNECT 250T","SUP-ITM-10168896","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","829.20","497.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","521.57","62.9","","305.08","81.02","4529.24","103","96.44","641.8","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 300CM .018IN PERIPHERAL CONNECT 250T","SUP-ITM-10168896","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","829.20","497.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","641.80","77.4","","225.79","68.39","1154.35","11","96.44","641.8","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 5CM 190CM .014IN PERIPHERAL SPARTACORE S/S SHAFT STEERABLE","SUP-ITM-10006994","CDM","C1769","HCPCS","0272","RC","","","","both","","","393.87","236.32","AETNA [1001]","HB WDH AETNA COMMERCIAL","274.92","69.8","","279.80","225.71","279.80","16","45.81","334.79","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 5CM 190CM .014IN PERIPHERAL SPARTACORE S/S SHAFT STEERABLE","SUP-ITM-10006994","CDM","C1769","HCPCS","0272","RC","","","","both","","","393.87","236.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","45.81","334.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE HI TORQUE 5CM 190CM .014IN PERIPHERAL SPARTACORE S/S SHAFT STEERABLE","SUP-ITM-10006994","CDM","C1769","HCPCS","0272","RC","","","","both","","","393.87","236.32","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","224.11","56.9","","18.95","9.41","1260.18","1 through 10","45.81","334.79","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 5CM 190CM .014IN PERIPHERAL SPARTACORE S/S SHAFT STEERABLE","SUP-ITM-10006994","CDM","C1769","HCPCS","0272","RC","","","","both","","","393.87","236.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","45.81","11.63","","37.78","11.63","183.64","21","45.81","334.79","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 5CM 190CM .014IN PERIPHERAL SPARTACORE S/S SHAFT STEERABLE","SUP-ITM-10006994","CDM","C1769","HCPCS","0272","RC","","","","both","","","393.87","236.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","304.86","77.4","","225.79","68.39","1154.35","11","45.81","334.79","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 5CM 190CM .014IN PERIPHERAL SPARTACORE S/S SHAFT STEERABLE","SUP-ITM-10006994","CDM","C1769","HCPCS","0272","RC","","","","both","","","393.87","236.32","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","45.81","334.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE HI TORQUE 5CM 190CM .014IN PERIPHERAL SPARTACORE S/S SHAFT STEERABLE","SUP-ITM-10006994","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","393.87","236.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","45.81","11.63","","37.78","11.63","183.64","21","45.81","304.86","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 5CM 190CM .014IN PERIPHERAL SPARTACORE S/S SHAFT STEERABLE","SUP-ITM-10006994","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","393.87","236.32","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","247.27","62.78","","123.83","114.55","572.63","1 through 10","45.81","304.86","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 5CM 190CM .014IN PERIPHERAL SPARTACORE S/S SHAFT STEERABLE","SUP-ITM-10006994","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","393.87","236.32","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","172.20","43.72","","127.38","127.38","148.03","1 through 10","45.81","304.86","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 5CM 190CM .014IN PERIPHERAL SPARTACORE S/S SHAFT STEERABLE","SUP-ITM-10006994","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","393.87","236.32","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","286.42","72.72","","196.34","62.16","1727.00","33","45.81","304.86","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 5CM 190CM .014IN PERIPHERAL SPARTACORE S/S SHAFT STEERABLE","SUP-ITM-10006994","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","393.87","236.32","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","286.42","72.72","","173.00","173.00","173.00","1 through 10","45.81","304.86","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 5CM 190CM .014IN PERIPHERAL SPARTACORE S/S SHAFT STEERABLE","SUP-ITM-10006994","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","393.87","236.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","209.62","53.22","","205.24","190.08","205.24","1 through 10","45.81","304.86","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 5CM 190CM .014IN PERIPHERAL SPARTACORE S/S SHAFT STEERABLE","SUP-ITM-10006994","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","393.87","236.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","247.74","62.9","","305.08","81.02","4529.24","103","45.81","304.86","percent of total billed charges",""
"GUIDEWIRE HI TORQUE 5CM 190CM .014IN PERIPHERAL SPARTACORE S/S SHAFT STEERABLE","SUP-ITM-10006994","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","393.87","236.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","304.86","77.4","","225.79","68.39","1154.35","11","45.81","304.86","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 180CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10169931","CDM","C1769","HCPCS","0272","RC","","","","both","","","80.85","48.51","AETNA [1001]","HB WDH AETNA COMMERCIAL","56.43","69.8","","279.80","225.71","279.80","16","9.4","68.72","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 180CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10169931","CDM","C1769","HCPCS","0272","RC","","","","both","","","80.85","48.51","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","9.4","68.72","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE INQWIRE 1.5MM 180CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10169931","CDM","C1769","HCPCS","0272","RC","","","","both","","","80.85","48.51","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","46.00","56.9","","18.95","9.41","1260.18","1 through 10","9.4","68.72","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 180CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10169931","CDM","C1769","HCPCS","0272","RC","","","","both","","","80.85","48.51","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","9.40","11.63","","37.78","11.63","183.64","21","9.4","68.72","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 180CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10169931","CDM","C1769","HCPCS","0272","RC","","","","both","","","80.85","48.51","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","62.58","77.4","","225.79","68.39","1154.35","11","9.4","68.72","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 180CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10169931","CDM","C1769","HCPCS","0272","RC","","","","both","","","80.85","48.51","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","9.4","68.72","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE INQWIRE 1.5MM 180CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10169931","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","80.85","48.51","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","9.40","11.63","","37.78","11.63","183.64","21","9.4","62.58","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 180CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10169931","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","80.85","48.51","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","50.76","62.78","","123.83","114.55","572.63","1 through 10","9.4","62.58","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 180CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10169931","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","80.85","48.51","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","35.35","43.72","","127.38","127.38","148.03","1 through 10","9.4","62.58","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 180CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10169931","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","80.85","48.51","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","58.79","72.72","","196.34","62.16","1727.00","33","9.4","62.58","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 180CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10169931","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","80.85","48.51","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","58.79","72.72","","173.00","173.00","173.00","1 through 10","9.4","62.58","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 180CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10169931","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","80.85","48.51","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","43.03","53.22","","205.24","190.08","205.24","1 through 10","9.4","62.58","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 180CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10169931","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","80.85","48.51","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","50.85","62.9","","305.08","81.02","4529.24","103","9.4","62.58","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 180CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10169931","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","80.85","48.51","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","62.58","77.4","","225.79","68.39","1154.35","11","9.4","62.58","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10188613","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.32","43.99","AETNA [1001]","HB WDH AETNA COMMERCIAL","51.18","69.8","","279.80","225.71","279.80","16","8.53","62.32","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10188613","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.32","43.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","8.53","62.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE INQWIRE 1.5MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10188613","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.32","43.99","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","41.72","56.9","","18.95","9.41","1260.18","1 through 10","8.53","62.32","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10188613","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.32","43.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","8.53","11.63","","37.78","11.63","183.64","21","8.53","62.32","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10188613","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.32","43.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","56.75","77.4","","225.79","68.39","1154.35","11","8.53","62.32","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10188613","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.32","43.99","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","8.53","62.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE INQWIRE 1.5MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10188613","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","73.32","43.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","8.53","11.63","","37.78","11.63","183.64","21","8.53","56.75","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10188613","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","73.32","43.99","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","46.03","62.78","","123.83","114.55","572.63","1 through 10","8.53","56.75","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10188613","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","73.32","43.99","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","32.06","43.72","","127.38","127.38","148.03","1 through 10","8.53","56.75","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10188613","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","73.32","43.99","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","53.32","72.72","","196.34","62.16","1727.00","33","8.53","56.75","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10188613","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","73.32","43.99","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","53.32","72.72","","173.00","173.00","173.00","1 through 10","8.53","56.75","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10188613","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","73.32","43.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","39.02","53.22","","205.24","190.08","205.24","1 through 10","8.53","56.75","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10188613","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","73.32","43.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","46.12","62.9","","305.08","81.02","4529.24","103","8.53","56.75","percent of total billed charges",""
"GUIDEWIRE INQWIRE 1.5MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10188613","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","73.32","43.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","56.75","77.4","","225.79","68.39","1154.35","11","8.53","56.75","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","both","","","85.48","51.29","AETNA [1001]","HB WDH AETNA COMMERCIAL","59.67","69.8","","279.80","225.71","279.80","16","9.94","72.66","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","both","","","85.48","51.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","9.94","72.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","both","","","85.48","51.29","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","48.64","56.9","","18.95","9.41","1260.18","1 through 10","9.94","72.66","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","both","","","85.48","51.29","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","9.94","11.63","","37.78","11.63","183.64","21","9.94","72.66","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","both","","","85.48","51.29","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","66.16","77.4","","225.79","68.39","1154.35","11","9.94","72.66","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","both","","","85.48","51.29","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","9.94","72.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","85.48","51.29","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","9.94","11.63","","37.78","11.63","183.64","21","9.94","66.16","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","85.48","51.29","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","53.66","62.78","","123.83","114.55","572.63","1 through 10","9.94","66.16","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","85.48","51.29","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","37.37","43.72","","127.38","127.38","148.03","1 through 10","9.94","66.16","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","85.48","51.29","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","62.16","72.72","","196.34","62.16","1727.00","33","9.94","66.16","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","85.48","51.29","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","62.16","72.72","","173.00","173.00","173.00","1 through 10","9.94","66.16","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","85.48","51.29","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","45.49","53.22","","205.24","190.08","205.24","1 through 10","9.94","66.16","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","85.48","51.29","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","53.77","62.9","","305.08","81.02","4529.24","103","9.94","66.16","percent of total billed charges",""
"GUIDEWIRE INQWIRE 3MM 260CM .035IN J-TIP DIAGNOSTIC VASCULAR BX/10EA","SUP-ITM-10024881","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","85.48","51.29","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","66.16","77.4","","225.79","68.39","1154.35","11","9.94","66.16","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","both","","","1209.94","725.96","AETNA [1001]","HB WDH AETNA COMMERCIAL","844.54","69.8","","279.80","225.71","279.80","16","140.72","1028.45","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","both","","","1209.94","725.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","140.72","1028.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","both","","","1209.94","725.96","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","688.46","56.9","","18.95","9.41","1260.18","1 through 10","140.72","1028.45","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","both","","","1209.94","725.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","140.72","11.63","","37.78","11.63","183.64","21","140.72","1028.45","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","both","","","1209.94","725.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","936.49","77.4","","225.79","68.39","1154.35","11","140.72","1028.45","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","both","","","1209.94","725.96","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","140.72","1028.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.94","725.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","140.72","11.63","","37.78","11.63","183.64","21","140.72","936.49","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.94","725.96","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","759.60","62.78","","123.83","114.55","572.63","1 through 10","140.72","936.49","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.94","725.96","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","528.99","43.72","","127.38","127.38","148.03","1 through 10","140.72","936.49","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.94","725.96","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","879.87","72.72","","196.34","62.16","1727.00","33","140.72","936.49","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.94","725.96","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","879.87","72.72","","173.00","173.00","173.00","1 through 10","140.72","936.49","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.94","725.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","643.93","53.22","","205.24","190.08","205.24","1 through 10","140.72","936.49","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.94","725.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","761.05","62.9","","305.08","81.02","4529.24","103","140.72","936.49","percent of total billed charges",""
"GUIDEWIRE JAGWIRE .025INX260CM REVOLUTION ANGLED BX/2EA","SUP-ITM-10282335","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.94","725.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","936.49","77.4","","225.79","68.39","1154.35","11","140.72","936.49","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 260CM .025IN STIFF SHAFT STRAIGHT BX/2EA","SUP-ITM-10012120","CDM","C1769","HCPCS","0272","RC","","","","both","","","646.09","387.65","AETNA [1001]","HB WDH AETNA COMMERCIAL","450.97","69.8","","279.80","225.71","279.80","16","75.14","549.18","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 260CM .025IN STIFF SHAFT STRAIGHT BX/2EA","SUP-ITM-10012120","CDM","C1769","HCPCS","0272","RC","","","","both","","","646.09","387.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","75.14","549.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE JAGWIRE 260CM .025IN STIFF SHAFT STRAIGHT BX/2EA","SUP-ITM-10012120","CDM","C1769","HCPCS","0272","RC","","","","both","","","646.09","387.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","367.63","56.9","","18.95","9.41","1260.18","1 through 10","75.14","549.18","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 260CM .025IN STIFF SHAFT STRAIGHT BX/2EA","SUP-ITM-10012120","CDM","C1769","HCPCS","0272","RC","","","","both","","","646.09","387.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","75.14","11.63","","37.78","11.63","183.64","21","75.14","549.18","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 260CM .025IN STIFF SHAFT STRAIGHT BX/2EA","SUP-ITM-10012120","CDM","C1769","HCPCS","0272","RC","","","","both","","","646.09","387.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","500.07","77.4","","225.79","68.39","1154.35","11","75.14","549.18","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 260CM .025IN STIFF SHAFT STRAIGHT BX/2EA","SUP-ITM-10012120","CDM","C1769","HCPCS","0272","RC","","","","both","","","646.09","387.65","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","75.14","549.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE JAGWIRE 260CM .025IN STIFF SHAFT STRAIGHT BX/2EA","SUP-ITM-10012120","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","646.09","387.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","75.14","11.63","","37.78","11.63","183.64","21","75.14","500.07","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 260CM .025IN STIFF SHAFT STRAIGHT BX/2EA","SUP-ITM-10012120","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","646.09","387.65","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","405.62","62.78","","123.83","114.55","572.63","1 through 10","75.14","500.07","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 260CM .025IN STIFF SHAFT STRAIGHT BX/2EA","SUP-ITM-10012120","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","646.09","387.65","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","282.47","43.72","","127.38","127.38","148.03","1 through 10","75.14","500.07","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 260CM .025IN STIFF SHAFT STRAIGHT BX/2EA","SUP-ITM-10012120","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","646.09","387.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","469.84","72.72","","196.34","62.16","1727.00","33","75.14","500.07","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 260CM .025IN STIFF SHAFT STRAIGHT BX/2EA","SUP-ITM-10012120","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","646.09","387.65","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","469.84","72.72","","173.00","173.00","173.00","1 through 10","75.14","500.07","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 260CM .025IN STIFF SHAFT STRAIGHT BX/2EA","SUP-ITM-10012120","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","646.09","387.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","343.85","53.22","","205.24","190.08","205.24","1 through 10","75.14","500.07","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 260CM .025IN STIFF SHAFT STRAIGHT BX/2EA","SUP-ITM-10012120","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","646.09","387.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","406.39","62.9","","305.08","81.02","4529.24","103","75.14","500.07","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 260CM .025IN STIFF SHAFT STRAIGHT BX/2EA","SUP-ITM-10012120","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","646.09","387.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","500.07","77.4","","225.79","68.39","1154.35","11","75.14","500.07","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 450CM .035IN TIP BILIARY STRAIGHT TRIM HIGH PERFORMANCE BX/2EA","SUP-ITM-10000498","CDM","C1769","HCPCS","0272","RC","","","","both","","","718.64","431.18","AETNA [1001]","HB WDH AETNA COMMERCIAL","501.61","69.8","","279.80","225.71","279.80","16","83.58","610.84","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 450CM .035IN TIP BILIARY STRAIGHT TRIM HIGH PERFORMANCE BX/2EA","SUP-ITM-10000498","CDM","C1769","HCPCS","0272","RC","","","","both","","","718.64","431.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","83.58","610.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE JAGWIRE 450CM .035IN TIP BILIARY STRAIGHT TRIM HIGH PERFORMANCE BX/2EA","SUP-ITM-10000498","CDM","C1769","HCPCS","0272","RC","","","","both","","","718.64","431.18","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","408.91","56.9","","18.95","9.41","1260.18","1 through 10","83.58","610.84","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 450CM .035IN TIP BILIARY STRAIGHT TRIM HIGH PERFORMANCE BX/2EA","SUP-ITM-10000498","CDM","C1769","HCPCS","0272","RC","","","","both","","","718.64","431.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","83.58","11.63","","37.78","11.63","183.64","21","83.58","610.84","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 450CM .035IN TIP BILIARY STRAIGHT TRIM HIGH PERFORMANCE BX/2EA","SUP-ITM-10000498","CDM","C1769","HCPCS","0272","RC","","","","both","","","718.64","431.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","556.23","77.4","","225.79","68.39","1154.35","11","83.58","610.84","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 450CM .035IN TIP BILIARY STRAIGHT TRIM HIGH PERFORMANCE BX/2EA","SUP-ITM-10000498","CDM","C1769","HCPCS","0272","RC","","","","both","","","718.64","431.18","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","83.58","610.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE JAGWIRE 450CM .035IN TIP BILIARY STRAIGHT TRIM HIGH PERFORMANCE BX/2EA","SUP-ITM-10000498","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","718.64","431.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","83.58","11.63","","37.78","11.63","183.64","21","83.58","556.23","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 450CM .035IN TIP BILIARY STRAIGHT TRIM HIGH PERFORMANCE BX/2EA","SUP-ITM-10000498","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","718.64","431.18","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","451.16","62.78","","123.83","114.55","572.63","1 through 10","83.58","556.23","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 450CM .035IN TIP BILIARY STRAIGHT TRIM HIGH PERFORMANCE BX/2EA","SUP-ITM-10000498","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","718.64","431.18","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","314.19","43.72","","127.38","127.38","148.03","1 through 10","83.58","556.23","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 450CM .035IN TIP BILIARY STRAIGHT TRIM HIGH PERFORMANCE BX/2EA","SUP-ITM-10000498","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","718.64","431.18","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","522.60","72.72","","196.34","62.16","1727.00","33","83.58","556.23","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 450CM .035IN TIP BILIARY STRAIGHT TRIM HIGH PERFORMANCE BX/2EA","SUP-ITM-10000498","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","718.64","431.18","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","522.60","72.72","","173.00","173.00","173.00","1 through 10","83.58","556.23","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 450CM .035IN TIP BILIARY STRAIGHT TRIM HIGH PERFORMANCE BX/2EA","SUP-ITM-10000498","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","718.64","431.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","382.46","53.22","","205.24","190.08","205.24","1 through 10","83.58","556.23","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 450CM .035IN TIP BILIARY STRAIGHT TRIM HIGH PERFORMANCE BX/2EA","SUP-ITM-10000498","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","718.64","431.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","452.02","62.9","","305.08","81.02","4529.24","103","83.58","556.23","percent of total billed charges",""
"GUIDEWIRE JAGWIRE 450CM .035IN TIP BILIARY STRAIGHT TRIM HIGH PERFORMANCE BX/2EA","SUP-ITM-10000498","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","718.64","431.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","556.23","77.4","","225.79","68.39","1154.35","11","83.58","556.23","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","123.83","74.30","AETNA [1001]","HB WDH AETNA COMMERCIAL","86.43","69.8","","279.80","225.71","279.80","16","14.4","105.26","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","123.83","74.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","14.4","105.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","123.83","74.30","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","70.46","56.9","","18.95","9.41","1260.18","1 through 10","14.4","105.26","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","123.83","74.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","14.40","11.63","","37.78","11.63","183.64","21","14.4","105.26","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","123.83","74.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","95.84","77.4","","225.79","68.39","1154.35","11","14.4","105.26","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","123.83","74.30","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","14.4","105.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","123.83","74.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","14.40","11.63","","37.78","11.63","183.64","21","14.4","95.84","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","123.83","74.30","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","77.74","62.78","","123.83","114.55","572.63","1 through 10","14.4","95.84","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","123.83","74.30","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","54.14","43.72","","127.38","127.38","148.03","1 through 10","14.4","95.84","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","123.83","74.30","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","90.05","72.72","","196.34","62.16","1727.00","33","14.4","95.84","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","123.83","74.30","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","90.05","72.72","","173.00","173.00","173.00","1 through 10","14.4","95.84","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","123.83","74.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","65.90","53.22","","205.24","190.08","205.24","1 through 10","14.4","95.84","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","123.83","74.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","77.89","62.9","","305.08","81.02","4529.24","103","14.4","95.84","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","123.83","74.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","95.84","77.4","","225.79","68.39","1154.35","11","14.4","95.84","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","both","","","864.44","518.66","AETNA [1001]","HB WDH AETNA COMMERCIAL","603.38","69.8","","279.80","225.71","279.80","16","100.53","734.77","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","both","","","864.44","518.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","100.53","734.77","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","both","","","864.44","518.66","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","491.87","56.9","","18.95","9.41","1260.18","1 through 10","100.53","734.77","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","both","","","864.44","518.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","100.53","11.63","","37.78","11.63","183.64","21","100.53","734.77","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","both","","","864.44","518.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","669.08","77.4","","225.79","68.39","1154.35","11","100.53","734.77","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","both","","","864.44","518.66","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","100.53","734.77","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","864.44","518.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","100.53","11.63","","37.78","11.63","183.64","21","100.53","669.08","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","864.44","518.66","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","542.70","62.78","","123.83","114.55","572.63","1 through 10","100.53","669.08","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","864.44","518.66","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","377.93","43.72","","127.38","127.38","148.03","1 through 10","100.53","669.08","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","864.44","518.66","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","628.62","72.72","","196.34","62.16","1727.00","33","100.53","669.08","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","864.44","518.66","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","628.62","72.72","","173.00","173.00","173.00","1 through 10","100.53","669.08","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","864.44","518.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","460.05","53.22","","205.24","190.08","205.24","1 through 10","100.53","669.08","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","864.44","518.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","543.73","62.9","","305.08","81.02","4529.24","103","100.53","669.08","percent of total billed charges",""
"GUIDEWIRE LUNDERQUIST 11MM 260CM .035IN EXTRA STIFF PTFE COATED S/S DOUBLE CURVED TSMG-35-260-LES BX/5EA","SUP-ITM-10135483","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","864.44","518.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","669.08","77.4","","225.79","68.39","1154.35","11","100.53","669.08","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 180CM .035IN STRAIGHT TIP S/S BX/5EA","SUP-ITM-10025772","CDM","C1769","HCPCS","0272","RC","","","","both","","","186.57","111.94","AETNA [1001]","HB WDH AETNA COMMERCIAL","130.23","69.8","","279.80","225.71","279.80","16","21.7","158.58","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 180CM .035IN STRAIGHT TIP S/S BX/5EA","SUP-ITM-10025772","CDM","C1769","HCPCS","0272","RC","","","","both","","","186.57","111.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","21.7","158.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE MAGIC TORQUE 5CM 180CM .035IN STRAIGHT TIP S/S BX/5EA","SUP-ITM-10025772","CDM","C1769","HCPCS","0272","RC","","","","both","","","186.57","111.94","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","106.16","56.9","","18.95","9.41","1260.18","1 through 10","21.7","158.58","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 180CM .035IN STRAIGHT TIP S/S BX/5EA","SUP-ITM-10025772","CDM","C1769","HCPCS","0272","RC","","","","both","","","186.57","111.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","21.70","11.63","","37.78","11.63","183.64","21","21.7","158.58","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 180CM .035IN STRAIGHT TIP S/S BX/5EA","SUP-ITM-10025772","CDM","C1769","HCPCS","0272","RC","","","","both","","","186.57","111.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","144.41","77.4","","225.79","68.39","1154.35","11","21.7","158.58","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 180CM .035IN STRAIGHT TIP S/S BX/5EA","SUP-ITM-10025772","CDM","C1769","HCPCS","0272","RC","","","","both","","","186.57","111.94","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","21.7","158.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE MAGIC TORQUE 5CM 180CM .035IN STRAIGHT TIP S/S BX/5EA","SUP-ITM-10025772","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","186.57","111.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","21.70","11.63","","37.78","11.63","183.64","21","21.7","144.41","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 180CM .035IN STRAIGHT TIP S/S BX/5EA","SUP-ITM-10025772","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","186.57","111.94","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","117.13","62.78","","123.83","114.55","572.63","1 through 10","21.7","144.41","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 180CM .035IN STRAIGHT TIP S/S BX/5EA","SUP-ITM-10025772","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","186.57","111.94","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","81.57","43.72","","127.38","127.38","148.03","1 through 10","21.7","144.41","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 180CM .035IN STRAIGHT TIP S/S BX/5EA","SUP-ITM-10025772","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","186.57","111.94","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","135.67","72.72","","196.34","62.16","1727.00","33","21.7","144.41","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 180CM .035IN STRAIGHT TIP S/S BX/5EA","SUP-ITM-10025772","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","186.57","111.94","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","135.67","72.72","","173.00","173.00","173.00","1 through 10","21.7","144.41","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 180CM .035IN STRAIGHT TIP S/S BX/5EA","SUP-ITM-10025772","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","186.57","111.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","99.29","53.22","","205.24","190.08","205.24","1 through 10","21.7","144.41","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 180CM .035IN STRAIGHT TIP S/S BX/5EA","SUP-ITM-10025772","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","186.57","111.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","117.35","62.9","","305.08","81.02","4529.24","103","21.7","144.41","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 180CM .035IN STRAIGHT TIP S/S BX/5EA","SUP-ITM-10025772","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","186.57","111.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","144.41","77.4","","225.79","68.39","1154.35","11","21.7","144.41","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 260CM .035IN STRAIGHT TIP S/S BX/3EA","SUP-ITM-10025773","CDM","C1769","HCPCS","0272","RC","","","","both","","","310.95","186.57","AETNA [1001]","HB WDH AETNA COMMERCIAL","217.04","69.8","","279.80","225.71","279.80","16","36.16","264.31","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 260CM .035IN STRAIGHT TIP S/S BX/3EA","SUP-ITM-10025773","CDM","C1769","HCPCS","0272","RC","","","","both","","","310.95","186.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","36.16","264.31","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE MAGIC TORQUE 5CM 260CM .035IN STRAIGHT TIP S/S BX/3EA","SUP-ITM-10025773","CDM","C1769","HCPCS","0272","RC","","","","both","","","310.95","186.57","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","176.93","56.9","","18.95","9.41","1260.18","1 through 10","36.16","264.31","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 260CM .035IN STRAIGHT TIP S/S BX/3EA","SUP-ITM-10025773","CDM","C1769","HCPCS","0272","RC","","","","both","","","310.95","186.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","36.16","11.63","","37.78","11.63","183.64","21","36.16","264.31","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 260CM .035IN STRAIGHT TIP S/S BX/3EA","SUP-ITM-10025773","CDM","C1769","HCPCS","0272","RC","","","","both","","","310.95","186.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","240.68","77.4","","225.79","68.39","1154.35","11","36.16","264.31","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 260CM .035IN STRAIGHT TIP S/S BX/3EA","SUP-ITM-10025773","CDM","C1769","HCPCS","0272","RC","","","","both","","","310.95","186.57","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","36.16","264.31","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE MAGIC TORQUE 5CM 260CM .035IN STRAIGHT TIP S/S BX/3EA","SUP-ITM-10025773","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","310.95","186.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","36.16","11.63","","37.78","11.63","183.64","21","36.16","240.68","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 260CM .035IN STRAIGHT TIP S/S BX/3EA","SUP-ITM-10025773","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","310.95","186.57","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","195.21","62.78","","123.83","114.55","572.63","1 through 10","36.16","240.68","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 260CM .035IN STRAIGHT TIP S/S BX/3EA","SUP-ITM-10025773","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","310.95","186.57","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","135.95","43.72","","127.38","127.38","148.03","1 through 10","36.16","240.68","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 260CM .035IN STRAIGHT TIP S/S BX/3EA","SUP-ITM-10025773","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","310.95","186.57","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","226.12","72.72","","196.34","62.16","1727.00","33","36.16","240.68","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 260CM .035IN STRAIGHT TIP S/S BX/3EA","SUP-ITM-10025773","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","310.95","186.57","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","226.12","72.72","","173.00","173.00","173.00","1 through 10","36.16","240.68","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 260CM .035IN STRAIGHT TIP S/S BX/3EA","SUP-ITM-10025773","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","310.95","186.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","165.49","53.22","","205.24","190.08","205.24","1 through 10","36.16","240.68","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 260CM .035IN STRAIGHT TIP S/S BX/3EA","SUP-ITM-10025773","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","310.95","186.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","195.59","62.9","","305.08","81.02","4529.24","103","36.16","240.68","percent of total billed charges",""
"GUIDEWIRE MAGIC TORQUE 5CM 260CM .035IN STRAIGHT TIP S/S BX/3EA","SUP-ITM-10025773","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","310.95","186.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","240.68","77.4","","225.79","68.39","1154.35","11","36.16","240.68","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.2X45CM SURGICAL NITINOL","SUP-ITM-10216317","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.61","294.37","AETNA [1001]","HB WDH AETNA COMMERCIAL","342.45","69.8","","279.80","225.71","279.80","16","57.06","417.02","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.2X45CM SURGICAL NITINOL","SUP-ITM-10216317","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.61","294.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","57.06","417.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ORTHOPEDIC 1.2X45CM SURGICAL NITINOL","SUP-ITM-10216317","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.61","294.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","279.16","56.9","","18.95","9.41","1260.18","1 through 10","57.06","417.02","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.2X45CM SURGICAL NITINOL","SUP-ITM-10216317","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.61","294.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","57.06","11.63","","37.78","11.63","183.64","21","57.06","417.02","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.2X45CM SURGICAL NITINOL","SUP-ITM-10216317","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.61","294.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","379.73","77.4","","225.79","68.39","1154.35","11","57.06","417.02","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.2X45CM SURGICAL NITINOL","SUP-ITM-10216317","CDM","C1769","HCPCS","0272","RC","","","","both","","","490.61","294.37","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","57.06","417.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ORTHOPEDIC 1.2X45CM SURGICAL NITINOL","SUP-ITM-10216317","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","490.61","294.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","57.06","11.63","","37.78","11.63","183.64","21","57.06","379.73","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.2X45CM SURGICAL NITINOL","SUP-ITM-10216317","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","490.61","294.37","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","308.00","62.78","","123.83","114.55","572.63","1 through 10","57.06","379.73","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.2X45CM SURGICAL NITINOL","SUP-ITM-10216317","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","490.61","294.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","214.49","43.72","","127.38","127.38","148.03","1 through 10","57.06","379.73","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.2X45CM SURGICAL NITINOL","SUP-ITM-10216317","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","490.61","294.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","356.77","72.72","","196.34","62.16","1727.00","33","57.06","379.73","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.2X45CM SURGICAL NITINOL","SUP-ITM-10216317","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","490.61","294.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","356.77","72.72","","173.00","173.00","173.00","1 through 10","57.06","379.73","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.2X45CM SURGICAL NITINOL","SUP-ITM-10216317","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","490.61","294.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","261.10","53.22","","205.24","190.08","205.24","1 through 10","57.06","379.73","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.2X45CM SURGICAL NITINOL","SUP-ITM-10216317","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","490.61","294.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","308.59","62.9","","305.08","81.02","4529.24","103","57.06","379.73","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.2X45CM SURGICAL NITINOL","SUP-ITM-10216317","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","490.61","294.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","379.73","77.4","","225.79","68.39","1154.35","11","57.06","379.73","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.83","74.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","14.4","105.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.83","74.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","14.4","105.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.83","74.30","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","70.46","56.9","","812.12","238.65","1587.46","163","14.4","105.26","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.83","74.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","14.40","11.63","","112.68","112.68","146.99","38","14.4","105.26","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.83","74.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","95.84","77.4","","303.98","303.98","5854.79","1 through 10","14.4","105.26","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.83","74.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","14.40","11.63","","112.68","112.68","146.99","38","14.4","95.84","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.83","74.30","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","77.74","62.78","","780.86","208.94","10480.28","15","14.4","95.84","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.83","74.30","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","54.14","43.72","","179.76","179.76","179.76","1 through 10","14.4","95.84","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.83","74.30","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","90.05","72.72","","2355.45","298.99","3965.19","155","14.4","95.84","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.83","74.30","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","90.05","72.72","","3643.09","3643.09","3643.09","1 through 10","14.4","95.84","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.83","74.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","65.90","53.22","","554.28","554.28","554.28","16","14.4","95.84","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.83","74.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","77.89","62.9","","619.64","173.09","2370.64","150","14.4","95.84","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6MM 150CM SS THREADED POINT SPADE","SUP-ITM-10038572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.83","74.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","95.84","77.4","","303.98","303.98","5854.79","1 through 10","14.4","95.84","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","448.67","269.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","313.17","69.8","","279.80","225.71","279.80","16","52.18","381.37","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","448.67","269.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","52.18","381.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","448.67","269.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","255.29","56.9","","18.95","9.41","1260.18","1 through 10","52.18","381.37","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","448.67","269.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","52.18","11.63","","37.78","11.63","183.64","21","52.18","381.37","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","448.67","269.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","347.27","77.4","","225.79","68.39","1154.35","11","52.18","381.37","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","448.67","269.20","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","52.18","381.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","448.67","269.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","52.18","11.63","","37.78","11.63","183.64","21","52.18","347.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","448.67","269.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","281.68","62.78","","123.83","114.55","572.63","1 through 10","52.18","347.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","448.67","269.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","196.16","43.72","","127.38","127.38","148.03","1 through 10","52.18","347.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","448.67","269.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","326.27","72.72","","196.34","62.16","1727.00","33","52.18","347.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","448.67","269.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","326.27","72.72","","173.00","173.00","173.00","1 through 10","52.18","347.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","448.67","269.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","238.78","53.22","","205.24","190.08","205.24","1 through 10","52.18","347.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","448.67","269.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","282.21","62.9","","305.08","81.02","4529.24","103","52.18","347.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","448.67","269.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","347.27","77.4","","225.79","68.39","1154.35","11","52.18","347.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","398.02","238.81","AETNA [1001]","HB WDH AETNA COMMERCIAL","277.82","69.8","","279.80","225.71","279.80","16","46.29","338.32","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","398.02","238.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","46.29","338.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","398.02","238.81","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","226.47","56.9","","18.95","9.41","1260.18","1 through 10","46.29","338.32","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","398.02","238.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","46.29","11.63","","37.78","11.63","183.64","21","46.29","338.32","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","398.02","238.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","308.07","77.4","","225.79","68.39","1154.35","11","46.29","338.32","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","398.02","238.81","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","46.29","338.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","398.02","238.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","46.29","11.63","","37.78","11.63","183.64","21","46.29","308.07","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","398.02","238.81","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","249.88","62.78","","123.83","114.55","572.63","1 through 10","46.29","308.07","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","398.02","238.81","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","174.01","43.72","","127.38","127.38","148.03","1 through 10","46.29","308.07","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","398.02","238.81","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","289.44","72.72","","196.34","62.16","1727.00","33","46.29","308.07","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","398.02","238.81","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","289.44","72.72","","173.00","173.00","173.00","1 through 10","46.29","308.07","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","398.02","238.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","211.83","53.22","","205.24","190.08","205.24","1 through 10","46.29","308.07","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","398.02","238.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","250.35","62.9","","305.08","81.02","4529.24","103","46.29","308.07","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","398.02","238.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","308.07","77.4","","225.79","68.39","1154.35","11","46.29","308.07","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","329.81","197.89","AETNA [1001]","HB WDH AETNA COMMERCIAL","230.21","69.8","","279.80","225.71","279.80","16","38.36","280.34","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","329.81","197.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","38.36","280.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","329.81","197.89","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","187.66","56.9","","18.95","9.41","1260.18","1 through 10","38.36","280.34","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","329.81","197.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","38.36","11.63","","37.78","11.63","183.64","21","38.36","280.34","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","329.81","197.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","255.27","77.4","","225.79","68.39","1154.35","11","38.36","280.34","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","329.81","197.89","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","38.36","280.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","329.81","197.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","38.36","11.63","","37.78","11.63","183.64","21","38.36","255.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","329.81","197.89","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","207.05","62.78","","123.83","114.55","572.63","1 through 10","38.36","255.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","329.81","197.89","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","144.19","43.72","","127.38","127.38","148.03","1 through 10","38.36","255.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","329.81","197.89","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","239.84","72.72","","196.34","62.16","1727.00","33","38.36","255.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","329.81","197.89","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","239.84","72.72","","173.00","173.00","173.00","1 through 10","38.36","255.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","329.81","197.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","175.52","53.22","","205.24","190.08","205.24","1 through 10","38.36","255.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","329.81","197.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","207.45","62.9","","305.08","81.02","4529.24","103","38.36","255.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","329.81","197.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","255.27","77.4","","225.79","68.39","1154.35","11","38.36","255.27","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","2041.84","1225.10","AETNA [1001]","HB WDH AETNA COMMERCIAL","1425.20","69.8","","279.80","225.71","279.80","16","237.47","1735.56","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","2041.84","1225.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","237.47","1735.56","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","2041.84","1225.10","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1161.81","56.9","","18.95","9.41","1260.18","1 through 10","237.47","1735.56","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","2041.84","1225.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","237.47","11.63","","37.78","11.63","183.64","21","237.47","1735.56","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","2041.84","1225.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1580.38","77.4","","225.79","68.39","1154.35","11","237.47","1735.56","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","2041.84","1225.10","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","237.47","1735.56","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2041.84","1225.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","237.47","11.63","","37.78","11.63","183.64","21","237.47","1580.38","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2041.84","1225.10","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1281.87","62.78","","123.83","114.55","572.63","1 through 10","237.47","1580.38","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2041.84","1225.10","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","892.69","43.72","","127.38","127.38","148.03","1 through 10","237.47","1580.38","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2041.84","1225.10","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1484.83","72.72","","196.34","62.16","1727.00","33","237.47","1580.38","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2041.84","1225.10","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1484.83","72.72","","173.00","173.00","173.00","1 through 10","237.47","1580.38","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2041.84","1225.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1086.67","53.22","","205.24","190.08","205.24","1 through 10","237.47","1580.38","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2041.84","1225.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1284.32","62.9","","305.08","81.02","4529.24","103","237.47","1580.38","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2041.84","1225.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1580.38","77.4","","225.79","68.39","1154.35","11","237.47","1580.38","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","both","","","457.65","274.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","53.22","389","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","both","","","457.65","274.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","53.22","389","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","both","","","457.65","274.59","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","260.40","56.9","","812.12","238.65","1587.46","163","53.22","389","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","both","","","457.65","274.59","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","53.22","11.63","","112.68","112.68","146.99","38","53.22","389","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","both","","","457.65","274.59","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","354.22","77.4","","303.98","303.98","5854.79","1 through 10","53.22","389","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","457.65","274.59","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","53.22","11.63","","112.68","112.68","146.99","38","53.22","354.22","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","457.65","274.59","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","287.31","62.78","","780.86","208.94","10480.28","15","53.22","354.22","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","457.65","274.59","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","200.08","43.72","","179.76","179.76","179.76","1 through 10","53.22","354.22","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","457.65","274.59","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","332.80","72.72","","2355.45","298.99","3965.19","155","53.22","354.22","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","457.65","274.59","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","332.80","72.72","","3643.09","3643.09","3643.09","1 through 10","53.22","354.22","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","457.65","274.59","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","243.56","53.22","","554.28","554.28","554.28","16","53.22","354.22","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","457.65","274.59","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","287.86","62.9","","619.64","173.09","2370.64","150","53.22","354.22","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8MM 450 SS FLUTED","SUP-ITM-10073028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","457.65","274.59","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","354.22","77.4","","303.98","303.98","5854.79","1 through 10","53.22","354.22","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8X220MM FLUTED TIP","SUP-ITM-10276385","CDM","C1769","HCPCS","0272","RC","","","","both","","","594.26","356.56","AETNA [1001]","HB WDH AETNA COMMERCIAL","414.79","69.8","","279.80","225.71","279.80","16","69.11","505.12","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8X220MM FLUTED TIP","SUP-ITM-10276385","CDM","C1769","HCPCS","0272","RC","","","","both","","","594.26","356.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","69.11","505.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ORTHOPEDIC 2.8X220MM FLUTED TIP","SUP-ITM-10276385","CDM","C1769","HCPCS","0272","RC","","","","both","","","594.26","356.56","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","338.13","56.9","","18.95","9.41","1260.18","1 through 10","69.11","505.12","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8X220MM FLUTED TIP","SUP-ITM-10276385","CDM","C1769","HCPCS","0272","RC","","","","both","","","594.26","356.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","69.11","11.63","","37.78","11.63","183.64","21","69.11","505.12","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8X220MM FLUTED TIP","SUP-ITM-10276385","CDM","C1769","HCPCS","0272","RC","","","","both","","","594.26","356.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","459.96","77.4","","225.79","68.39","1154.35","11","69.11","505.12","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8X220MM FLUTED TIP","SUP-ITM-10276385","CDM","C1769","HCPCS","0272","RC","","","","both","","","594.26","356.56","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","69.11","505.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ORTHOPEDIC 2.8X220MM FLUTED TIP","SUP-ITM-10276385","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","594.26","356.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","69.11","11.63","","37.78","11.63","183.64","21","69.11","459.96","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8X220MM FLUTED TIP","SUP-ITM-10276385","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","594.26","356.56","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","373.08","62.78","","123.83","114.55","572.63","1 through 10","69.11","459.96","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8X220MM FLUTED TIP","SUP-ITM-10276385","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","594.26","356.56","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","259.81","43.72","","127.38","127.38","148.03","1 through 10","69.11","459.96","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8X220MM FLUTED TIP","SUP-ITM-10276385","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","594.26","356.56","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","432.15","72.72","","196.34","62.16","1727.00","33","69.11","459.96","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8X220MM FLUTED TIP","SUP-ITM-10276385","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","594.26","356.56","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","432.15","72.72","","173.00","173.00","173.00","1 through 10","69.11","459.96","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8X220MM FLUTED TIP","SUP-ITM-10276385","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","594.26","356.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","316.27","53.22","","205.24","190.08","205.24","1 through 10","69.11","459.96","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8X220MM FLUTED TIP","SUP-ITM-10276385","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","594.26","356.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","373.79","62.9","","305.08","81.02","4529.24","103","69.11","459.96","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8X220MM FLUTED TIP","SUP-ITM-10276385","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","594.26","356.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","459.96","77.4","","225.79","68.39","1154.35","11","69.11","459.96","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","both","","","483.22","289.93","AETNA [1001]","HB WDH AETNA COMMERCIAL","337.29","69.8","","279.80","225.71","279.80","16","56.2","410.74","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","both","","","483.22","289.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","56.2","410.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","both","","","483.22","289.93","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","274.95","56.9","","18.95","9.41","1260.18","1 through 10","56.2","410.74","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","both","","","483.22","289.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","56.20","11.63","","37.78","11.63","183.64","21","56.2","410.74","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","both","","","483.22","289.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","374.01","77.4","","225.79","68.39","1154.35","11","56.2","410.74","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","both","","","483.22","289.93","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","56.2","410.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","483.22","289.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","56.20","11.63","","37.78","11.63","183.64","21","56.2","374.01","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","483.22","289.93","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","303.37","62.78","","123.83","114.55","572.63","1 through 10","56.2","374.01","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","483.22","289.93","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","211.26","43.72","","127.38","127.38","148.03","1 through 10","56.2","374.01","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","483.22","289.93","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","351.40","72.72","","196.34","62.16","1727.00","33","56.2","374.01","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","483.22","289.93","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","351.40","72.72","","173.00","173.00","173.00","1 through 10","56.2","374.01","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","483.22","289.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","257.17","53.22","","205.24","190.08","205.24","1 through 10","56.2","374.01","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","483.22","289.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","303.95","62.9","","305.08","81.02","4529.24","103","56.2","374.01","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X290MM SS","SUP-ITM-10022092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","483.22","289.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","374.01","77.4","","225.79","68.39","1154.35","11","56.2","374.01","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","2197.17","1318.30","AETNA [1001]","HB WDH AETNA COMMERCIAL","1533.62","69.8","","279.80","225.71","279.80","16","255.53","1867.59","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","2197.17","1318.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","255.53","1867.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","2197.17","1318.30","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1250.19","56.9","","18.95","9.41","1260.18","1 through 10","255.53","1867.59","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","2197.17","1318.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","255.53","11.63","","37.78","11.63","183.64","21","255.53","1867.59","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","2197.17","1318.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1700.61","77.4","","225.79","68.39","1154.35","11","255.53","1867.59","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","2197.17","1318.30","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","255.53","1867.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2197.17","1318.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","255.53","11.63","","37.78","11.63","183.64","21","255.53","1700.61","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2197.17","1318.30","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1379.38","62.78","","123.83","114.55","572.63","1 through 10","255.53","1700.61","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2197.17","1318.30","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","960.60","43.72","","127.38","127.38","148.03","1 through 10","255.53","1700.61","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2197.17","1318.30","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1597.78","72.72","","196.34","62.16","1727.00","33","255.53","1700.61","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2197.17","1318.30","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1597.78","72.72","","173.00","173.00","173.00","1 through 10","255.53","1700.61","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2197.17","1318.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1169.33","53.22","","205.24","190.08","205.24","1 through 10","255.53","1700.61","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2197.17","1318.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1382.02","62.9","","305.08","81.02","4529.24","103","255.53","1700.61","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","2197.17","1318.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1700.61","77.4","","225.79","68.39","1154.35","11","255.53","1700.61","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","493.44","296.06","AETNA [1001]","HB WDH AETNA COMMERCIAL","344.42","69.8","","279.80","225.71","279.80","16","57.39","419.42","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","493.44","296.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","57.39","419.42","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","493.44","296.06","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","280.77","56.9","","18.95","9.41","1260.18","1 through 10","57.39","419.42","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","493.44","296.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","57.39","11.63","","37.78","11.63","183.64","21","57.39","419.42","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","493.44","296.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","381.92","77.4","","225.79","68.39","1154.35","11","57.39","419.42","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","493.44","296.06","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","57.39","419.42","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","493.44","296.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","57.39","11.63","","37.78","11.63","183.64","21","57.39","381.92","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","493.44","296.06","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","309.78","62.78","","123.83","114.55","572.63","1 through 10","57.39","381.92","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","493.44","296.06","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","215.73","43.72","","127.38","127.38","148.03","1 through 10","57.39","381.92","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","493.44","296.06","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","358.83","72.72","","196.34","62.16","1727.00","33","57.39","381.92","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","493.44","296.06","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","358.83","72.72","","173.00","173.00","173.00","1 through 10","57.39","381.92","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","493.44","296.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","262.61","53.22","","205.24","190.08","205.24","1 through 10","57.39","381.92","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","493.44","296.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","310.37","62.9","","305.08","81.02","4529.24","103","57.39","381.92","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","493.44","296.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","381.92","77.4","","225.79","68.39","1154.35","11","57.39","381.92","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.00","414.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","80.36","587.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.00","414.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","80.36","587.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.00","414.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","393.18","56.9","","812.12","238.65","1587.46","163","80.36","587.35","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.00","414.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","80.36","11.63","","112.68","112.68","146.99","38","80.36","587.35","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.00","414.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","534.83","77.4","","303.98","303.98","5854.79","1 through 10","80.36","587.35","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","80.36","11.63","","112.68","112.68","146.99","38","80.36","534.83","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","433.81","62.78","","780.86","208.94","10480.28","15","80.36","534.83","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","302.11","43.72","","179.76","179.76","179.76","1 through 10","80.36","534.83","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","502.50","72.72","","2355.45","298.99","3965.19","155","80.36","534.83","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","502.50","72.72","","3643.09","3643.09","3643.09","1 through 10","80.36","534.83","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","367.75","53.22","","554.28","554.28","554.28","16","80.36","534.83","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","434.64","62.9","","619.64","173.09","2370.64","150","80.36","534.83","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","534.83","77.4","","303.98","303.98","5854.79","1 through 10","80.36","534.83","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS 300CM .014IN VASCULAR ANGIOGRAPHY SILICONE COATED STRAIGHT BX/3EA","SUP-ITM-10000292","CDM","C1769","HCPCS","0272","RC","","","","both","","","575.07","345.04","AETNA [1001]","HB WDH AETNA COMMERCIAL","401.40","69.8","","279.80","225.71","279.80","16","66.88","488.81","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS 300CM .014IN VASCULAR ANGIOGRAPHY SILICONE COATED STRAIGHT BX/3EA","SUP-ITM-10000292","CDM","C1769","HCPCS","0272","RC","","","","both","","","575.07","345.04","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","66.88","488.81","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE PLATINUM PLUS 300CM .014IN VASCULAR ANGIOGRAPHY SILICONE COATED STRAIGHT BX/3EA","SUP-ITM-10000292","CDM","C1769","HCPCS","0272","RC","","","","both","","","575.07","345.04","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","327.21","56.9","","18.95","9.41","1260.18","1 through 10","66.88","488.81","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS 300CM .014IN VASCULAR ANGIOGRAPHY SILICONE COATED STRAIGHT BX/3EA","SUP-ITM-10000292","CDM","C1769","HCPCS","0272","RC","","","","both","","","575.07","345.04","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","66.88","11.63","","37.78","11.63","183.64","21","66.88","488.81","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS 300CM .014IN VASCULAR ANGIOGRAPHY SILICONE COATED STRAIGHT BX/3EA","SUP-ITM-10000292","CDM","C1769","HCPCS","0272","RC","","","","both","","","575.07","345.04","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","445.10","77.4","","225.79","68.39","1154.35","11","66.88","488.81","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS 300CM .014IN VASCULAR ANGIOGRAPHY SILICONE COATED STRAIGHT BX/3EA","SUP-ITM-10000292","CDM","C1769","HCPCS","0272","RC","","","","both","","","575.07","345.04","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","66.88","488.81","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE PLATINUM PLUS 300CM .014IN VASCULAR ANGIOGRAPHY SILICONE COATED STRAIGHT BX/3EA","SUP-ITM-10000292","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","575.07","345.04","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","66.88","11.63","","37.78","11.63","183.64","21","66.88","445.1","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS 300CM .014IN VASCULAR ANGIOGRAPHY SILICONE COATED STRAIGHT BX/3EA","SUP-ITM-10000292","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","575.07","345.04","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","361.03","62.78","","123.83","114.55","572.63","1 through 10","66.88","445.1","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS 300CM .014IN VASCULAR ANGIOGRAPHY SILICONE COATED STRAIGHT BX/3EA","SUP-ITM-10000292","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","575.07","345.04","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","251.42","43.72","","127.38","127.38","148.03","1 through 10","66.88","445.1","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS 300CM .014IN VASCULAR ANGIOGRAPHY SILICONE COATED STRAIGHT BX/3EA","SUP-ITM-10000292","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","575.07","345.04","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","418.19","72.72","","196.34","62.16","1727.00","33","66.88","445.1","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS 300CM .014IN VASCULAR ANGIOGRAPHY SILICONE COATED STRAIGHT BX/3EA","SUP-ITM-10000292","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","575.07","345.04","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","418.19","72.72","","173.00","173.00","173.00","1 through 10","66.88","445.1","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS 300CM .014IN VASCULAR ANGIOGRAPHY SILICONE COATED STRAIGHT BX/3EA","SUP-ITM-10000292","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","575.07","345.04","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","306.05","53.22","","205.24","190.08","205.24","1 through 10","66.88","445.1","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS 300CM .014IN VASCULAR ANGIOGRAPHY SILICONE COATED STRAIGHT BX/3EA","SUP-ITM-10000292","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","575.07","345.04","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","361.72","62.9","","305.08","81.02","4529.24","103","66.88","445.1","percent of total billed charges",""
"GUIDEWIRE PLATINUM PLUS 300CM .014IN VASCULAR ANGIOGRAPHY SILICONE COATED STRAIGHT BX/3EA","SUP-ITM-10000292","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","575.07","345.04","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","445.10","77.4","","225.79","68.39","1154.35","11","66.88","445.1","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","both","","","621.90","373.14","AETNA [1001]","HB WDH AETNA COMMERCIAL","434.09","69.8","","279.80","225.71","279.80","16","72.33","528.62","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","both","","","621.90","373.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","72.33","528.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","both","","","621.90","373.14","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","353.86","56.9","","18.95","9.41","1260.18","1 through 10","72.33","528.62","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","both","","","621.90","373.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","72.33","11.63","","37.78","11.63","183.64","21","72.33","528.62","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","both","","","621.90","373.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","481.35","77.4","","225.79","68.39","1154.35","11","72.33","528.62","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","both","","","621.90","373.14","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","72.33","528.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","621.90","373.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","72.33","11.63","","37.78","11.63","183.64","21","72.33","481.35","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","621.90","373.14","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","390.43","62.78","","123.83","114.55","572.63","1 through 10","72.33","481.35","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","621.90","373.14","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","271.89","43.72","","127.38","127.38","148.03","1 through 10","72.33","481.35","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","621.90","373.14","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","452.25","72.72","","196.34","62.16","1727.00","33","72.33","481.35","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","621.90","373.14","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","452.25","72.72","","173.00","173.00","173.00","1 through 10","72.33","481.35","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","621.90","373.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","330.98","53.22","","205.24","190.08","205.24","1 through 10","72.33","481.35","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","621.90","373.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","391.18","62.9","","305.08","81.02","4529.24","103","72.33","481.35","percent of total billed charges",""
"GUIDEWIRE PT GRAPHIX 3CM 300CM .014IN VASCULAR STRAIGHT TIP MODERATE SUPPORT ICE HYDROPHILIC COATED POLYMER INTERMEDIATE BX/5EA","SUP-ITM-10008428","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","621.90","373.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","481.35","77.4","","225.79","68.39","1154.35","11","72.33","481.35","percent of total billed charges",""
"GUIDEWIRE PTFE 260CM SHORT .035IN COATED FIXED CORE STRAIGHT BENSTON TAPER BX/1EA","SUP-ITM-10156176","CDM","C1769","HCPCS","0272","RC","","","","both","","","75.46","45.28","AETNA [1001]","HB WDH AETNA COMMERCIAL","52.67","69.8","","279.80","225.71","279.80","16","8.78","64.14","percent of total billed charges",""
"GUIDEWIRE PTFE 260CM SHORT .035IN COATED FIXED CORE STRAIGHT BENSTON TAPER BX/1EA","SUP-ITM-10156176","CDM","C1769","HCPCS","0272","RC","","","","both","","","75.46","45.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","8.78","64.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE PTFE 260CM SHORT .035IN COATED FIXED CORE STRAIGHT BENSTON TAPER BX/1EA","SUP-ITM-10156176","CDM","C1769","HCPCS","0272","RC","","","","both","","","75.46","45.28","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","42.94","56.9","","18.95","9.41","1260.18","1 through 10","8.78","64.14","percent of total billed charges",""
"GUIDEWIRE PTFE 260CM SHORT .035IN COATED FIXED CORE STRAIGHT BENSTON TAPER BX/1EA","SUP-ITM-10156176","CDM","C1769","HCPCS","0272","RC","","","","both","","","75.46","45.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","8.78","11.63","","37.78","11.63","183.64","21","8.78","64.14","percent of total billed charges",""
"GUIDEWIRE PTFE 260CM SHORT .035IN COATED FIXED CORE STRAIGHT BENSTON TAPER BX/1EA","SUP-ITM-10156176","CDM","C1769","HCPCS","0272","RC","","","","both","","","75.46","45.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","58.41","77.4","","225.79","68.39","1154.35","11","8.78","64.14","percent of total billed charges",""
"GUIDEWIRE PTFE 260CM SHORT .035IN COATED FIXED CORE STRAIGHT BENSTON TAPER BX/1EA","SUP-ITM-10156176","CDM","C1769","HCPCS","0272","RC","","","","both","","","75.46","45.28","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","8.78","64.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE PTFE 260CM SHORT .035IN COATED FIXED CORE STRAIGHT BENSTON TAPER BX/1EA","SUP-ITM-10156176","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","75.46","45.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","8.78","11.63","","37.78","11.63","183.64","21","8.78","58.41","percent of total billed charges",""
"GUIDEWIRE PTFE 260CM SHORT .035IN COATED FIXED CORE STRAIGHT BENSTON TAPER BX/1EA","SUP-ITM-10156176","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","75.46","45.28","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","47.37","62.78","","123.83","114.55","572.63","1 through 10","8.78","58.41","percent of total billed charges",""
"GUIDEWIRE PTFE 260CM SHORT .035IN COATED FIXED CORE STRAIGHT BENSTON TAPER BX/1EA","SUP-ITM-10156176","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","75.46","45.28","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","32.99","43.72","","127.38","127.38","148.03","1 through 10","8.78","58.41","percent of total billed charges",""
"GUIDEWIRE PTFE 260CM SHORT .035IN COATED FIXED CORE STRAIGHT BENSTON TAPER BX/1EA","SUP-ITM-10156176","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","75.46","45.28","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","54.87","72.72","","196.34","62.16","1727.00","33","8.78","58.41","percent of total billed charges",""
"GUIDEWIRE PTFE 260CM SHORT .035IN COATED FIXED CORE STRAIGHT BENSTON TAPER BX/1EA","SUP-ITM-10156176","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","75.46","45.28","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","54.87","72.72","","173.00","173.00","173.00","1 through 10","8.78","58.41","percent of total billed charges",""
"GUIDEWIRE PTFE 260CM SHORT .035IN COATED FIXED CORE STRAIGHT BENSTON TAPER BX/1EA","SUP-ITM-10156176","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","75.46","45.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","40.16","53.22","","205.24","190.08","205.24","1 through 10","8.78","58.41","percent of total billed charges",""
"GUIDEWIRE PTFE 260CM SHORT .035IN COATED FIXED CORE STRAIGHT BENSTON TAPER BX/1EA","SUP-ITM-10156176","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","75.46","45.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","47.46","62.9","","305.08","81.02","4529.24","103","8.78","58.41","percent of total billed charges",""
"GUIDEWIRE PTFE 260CM SHORT .035IN COATED FIXED CORE STRAIGHT BENSTON TAPER BX/1EA","SUP-ITM-10156176","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","75.46","45.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","58.41","77.4","","225.79","68.39","1154.35","11","8.78","58.41","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 3CM 480CM .018IN EXTRA SUPPORT STRAIGHT TIP","SUP-ITM-10000308","CDM","C1769","HCPCS","0272","RC","","","","both","","","1209.25","725.55","AETNA [1001]","HB WDH AETNA COMMERCIAL","844.06","69.8","","279.80","225.71","279.80","16","140.64","1027.86","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 3CM 480CM .018IN EXTRA SUPPORT STRAIGHT TIP","SUP-ITM-10000308","CDM","C1769","HCPCS","0272","RC","","","","both","","","1209.25","725.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","140.64","1027.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ROADRUNNER 3CM 480CM .018IN EXTRA SUPPORT STRAIGHT TIP","SUP-ITM-10000308","CDM","C1769","HCPCS","0272","RC","","","","both","","","1209.25","725.55","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","688.06","56.9","","18.95","9.41","1260.18","1 through 10","140.64","1027.86","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 3CM 480CM .018IN EXTRA SUPPORT STRAIGHT TIP","SUP-ITM-10000308","CDM","C1769","HCPCS","0272","RC","","","","both","","","1209.25","725.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","140.64","11.63","","37.78","11.63","183.64","21","140.64","1027.86","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 3CM 480CM .018IN EXTRA SUPPORT STRAIGHT TIP","SUP-ITM-10000308","CDM","C1769","HCPCS","0272","RC","","","","both","","","1209.25","725.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","935.96","77.4","","225.79","68.39","1154.35","11","140.64","1027.86","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 3CM 480CM .018IN EXTRA SUPPORT STRAIGHT TIP","SUP-ITM-10000308","CDM","C1769","HCPCS","0272","RC","","","","both","","","1209.25","725.55","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","140.64","1027.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE ROADRUNNER 3CM 480CM .018IN EXTRA SUPPORT STRAIGHT TIP","SUP-ITM-10000308","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.25","725.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","140.64","11.63","","37.78","11.63","183.64","21","140.64","935.96","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 3CM 480CM .018IN EXTRA SUPPORT STRAIGHT TIP","SUP-ITM-10000308","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.25","725.55","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","759.17","62.78","","123.83","114.55","572.63","1 through 10","140.64","935.96","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 3CM 480CM .018IN EXTRA SUPPORT STRAIGHT TIP","SUP-ITM-10000308","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.25","725.55","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","528.68","43.72","","127.38","127.38","148.03","1 through 10","140.64","935.96","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 3CM 480CM .018IN EXTRA SUPPORT STRAIGHT TIP","SUP-ITM-10000308","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.25","725.55","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","879.37","72.72","","196.34","62.16","1727.00","33","140.64","935.96","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 3CM 480CM .018IN EXTRA SUPPORT STRAIGHT TIP","SUP-ITM-10000308","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.25","725.55","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","879.37","72.72","","173.00","173.00","173.00","1 through 10","140.64","935.96","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 3CM 480CM .018IN EXTRA SUPPORT STRAIGHT TIP","SUP-ITM-10000308","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.25","725.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","643.56","53.22","","205.24","190.08","205.24","1 through 10","140.64","935.96","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 3CM 480CM .018IN EXTRA SUPPORT STRAIGHT TIP","SUP-ITM-10000308","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.25","725.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","760.62","62.9","","305.08","81.02","4529.24","103","140.64","935.96","percent of total billed charges",""
"GUIDEWIRE ROADRUNNER 3CM 480CM .018IN EXTRA SUPPORT STRAIGHT TIP","SUP-ITM-10000308","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1209.25","725.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","935.96","77.4","","225.79","68.39","1154.35","11","140.64","935.96","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","441.66","265.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","308.28","69.8","","279.80","225.71","279.80","16","51.37","375.41","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","441.66","265.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","51.37","375.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","441.66","265.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","251.30","56.9","","18.95","9.41","1260.18","1 through 10","51.37","375.41","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","441.66","265.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","51.37","11.63","","37.78","11.63","183.64","21","51.37","375.41","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","441.66","265.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","341.84","77.4","","225.79","68.39","1154.35","11","51.37","375.41","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","441.66","265.00","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","51.37","375.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","441.66","265.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","51.37","11.63","","37.78","11.63","183.64","21","51.37","341.84","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","441.66","265.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","277.27","62.78","","123.83","114.55","572.63","1 through 10","51.37","341.84","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","441.66","265.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","193.09","43.72","","127.38","127.38","148.03","1 through 10","51.37","341.84","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","441.66","265.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","321.18","72.72","","196.34","62.16","1727.00","33","51.37","341.84","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","441.66","265.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","321.18","72.72","","173.00","173.00","173.00","1 through 10","51.37","341.84","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","441.66","265.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","235.05","53.22","","205.24","190.08","205.24","1 through 10","51.37","341.84","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","441.66","265.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","277.80","62.9","","305.08","81.02","4529.24","103","51.37","341.84","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","441.66","265.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","341.84","77.4","","225.79","68.39","1154.35","11","51.37","341.84","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 260CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10152906","CDM","C1769","HCPCS","0272","RC","","","","both","","","128.33","77.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","89.57","69.8","","279.80","225.71","279.80","16","14.92","109.08","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 260CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10152906","CDM","C1769","HCPCS","0272","RC","","","","both","","","128.33","77.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","14.92","109.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE STARTER 15CM 260CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10152906","CDM","C1769","HCPCS","0272","RC","","","","both","","","128.33","77.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","73.02","56.9","","18.95","9.41","1260.18","1 through 10","14.92","109.08","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 260CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10152906","CDM","C1769","HCPCS","0272","RC","","","","both","","","128.33","77.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","14.92","11.63","","37.78","11.63","183.64","21","14.92","109.08","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 260CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10152906","CDM","C1769","HCPCS","0272","RC","","","","both","","","128.33","77.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","99.33","77.4","","225.79","68.39","1154.35","11","14.92","109.08","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 260CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10152906","CDM","C1769","HCPCS","0272","RC","","","","both","","","128.33","77.00","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","14.92","109.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE STARTER 15CM 260CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10152906","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","128.33","77.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","14.92","11.63","","37.78","11.63","183.64","21","14.92","99.33","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 260CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10152906","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","128.33","77.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","80.57","62.78","","123.83","114.55","572.63","1 through 10","14.92","99.33","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 260CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10152906","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","128.33","77.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","56.11","43.72","","127.38","127.38","148.03","1 through 10","14.92","99.33","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 260CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10152906","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","128.33","77.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","93.32","72.72","","196.34","62.16","1727.00","33","14.92","99.33","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 260CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10152906","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","128.33","77.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","93.32","72.72","","173.00","173.00","173.00","1 through 10","14.92","99.33","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 260CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10152906","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","128.33","77.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","68.30","53.22","","205.24","190.08","205.24","1 through 10","14.92","99.33","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 260CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10152906","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","128.33","77.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","80.72","62.9","","305.08","81.02","4529.24","103","14.92","99.33","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 260CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10152906","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","128.33","77.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","99.33","77.4","","225.79","68.39","1154.35","11","14.92","99.33","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 480CM .035IN 5CM STRAIGHT TIP DIRECT RADIOPAQUE AQUACOAT BLACK","SUP-ITM-10009155","CDM","C1769","HCPCS","0272","RC","","","","both","","","1278.35","767.01","AETNA [1001]","HB WDH AETNA COMMERCIAL","892.29","69.8","","279.80","225.71","279.80","16","148.67","1086.6","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 480CM .035IN 5CM STRAIGHT TIP DIRECT RADIOPAQUE AQUACOAT BLACK","SUP-ITM-10009155","CDM","C1769","HCPCS","0272","RC","","","","both","","","1278.35","767.01","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","148.67","1086.6","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE TRACER METROII 480CM .035IN 5CM STRAIGHT TIP DIRECT RADIOPAQUE AQUACOAT BLACK","SUP-ITM-10009155","CDM","C1769","HCPCS","0272","RC","","","","both","","","1278.35","767.01","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","727.38","56.9","","18.95","9.41","1260.18","1 through 10","148.67","1086.6","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 480CM .035IN 5CM STRAIGHT TIP DIRECT RADIOPAQUE AQUACOAT BLACK","SUP-ITM-10009155","CDM","C1769","HCPCS","0272","RC","","","","both","","","1278.35","767.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","148.67","11.63","","37.78","11.63","183.64","21","148.67","1086.6","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 480CM .035IN 5CM STRAIGHT TIP DIRECT RADIOPAQUE AQUACOAT BLACK","SUP-ITM-10009155","CDM","C1769","HCPCS","0272","RC","","","","both","","","1278.35","767.01","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","989.44","77.4","","225.79","68.39","1154.35","11","148.67","1086.6","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 480CM .035IN 5CM STRAIGHT TIP DIRECT RADIOPAQUE AQUACOAT BLACK","SUP-ITM-10009155","CDM","C1769","HCPCS","0272","RC","","","","both","","","1278.35","767.01","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","148.67","1086.6","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE TRACER METROII 480CM .035IN 5CM STRAIGHT TIP DIRECT RADIOPAQUE AQUACOAT BLACK","SUP-ITM-10009155","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1278.35","767.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","148.67","11.63","","37.78","11.63","183.64","21","148.67","989.44","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 480CM .035IN 5CM STRAIGHT TIP DIRECT RADIOPAQUE AQUACOAT BLACK","SUP-ITM-10009155","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1278.35","767.01","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","802.55","62.78","","123.83","114.55","572.63","1 through 10","148.67","989.44","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 480CM .035IN 5CM STRAIGHT TIP DIRECT RADIOPAQUE AQUACOAT BLACK","SUP-ITM-10009155","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1278.35","767.01","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","558.89","43.72","","127.38","127.38","148.03","1 through 10","148.67","989.44","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 480CM .035IN 5CM STRAIGHT TIP DIRECT RADIOPAQUE AQUACOAT BLACK","SUP-ITM-10009155","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1278.35","767.01","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","929.62","72.72","","196.34","62.16","1727.00","33","148.67","989.44","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 480CM .035IN 5CM STRAIGHT TIP DIRECT RADIOPAQUE AQUACOAT BLACK","SUP-ITM-10009155","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1278.35","767.01","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","929.62","72.72","","173.00","173.00","173.00","1 through 10","148.67","989.44","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 480CM .035IN 5CM STRAIGHT TIP DIRECT RADIOPAQUE AQUACOAT BLACK","SUP-ITM-10009155","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1278.35","767.01","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","680.34","53.22","","205.24","190.08","205.24","1 through 10","148.67","989.44","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 480CM .035IN 5CM STRAIGHT TIP DIRECT RADIOPAQUE AQUACOAT BLACK","SUP-ITM-10009155","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1278.35","767.01","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","804.08","62.9","","305.08","81.02","4529.24","103","148.67","989.44","percent of total billed charges",""
"GUIDEWIRE TRACER METROII 480CM .035IN 5CM STRAIGHT TIP DIRECT RADIOPAQUE AQUACOAT BLACK","SUP-ITM-10009155","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1278.35","767.01","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","989.44","77.4","","225.79","68.39","1154.35","11","148.67","989.44","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","356.56","213.94","AETNA [1001]","HB WDH AETNA COMMERCIAL","248.88","69.8","","279.80","225.71","279.80","16","41.47","303.08","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","356.56","213.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","41.47","303.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","356.56","213.94","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","202.88","56.9","","18.95","9.41","1260.18","1 through 10","41.47","303.08","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","356.56","213.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","41.47","11.63","","37.78","11.63","183.64","21","41.47","303.08","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","356.56","213.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","275.98","77.4","","225.79","68.39","1154.35","11","41.47","303.08","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","356.56","213.94","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","41.47","303.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","356.56","213.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","41.47","11.63","","37.78","11.63","183.64","21","41.47","275.98","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","356.56","213.94","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","223.85","62.78","","123.83","114.55","572.63","1 through 10","41.47","275.98","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","356.56","213.94","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","155.89","43.72","","127.38","127.38","148.03","1 through 10","41.47","275.98","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","356.56","213.94","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","259.29","72.72","","196.34","62.16","1727.00","33","41.47","275.98","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","356.56","213.94","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","259.29","72.72","","173.00","173.00","173.00","1 through 10","41.47","275.98","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","356.56","213.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","189.76","53.22","","205.24","190.08","205.24","1 through 10","41.47","275.98","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","356.56","213.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","224.28","62.9","","305.08","81.02","4529.24","103","41.47","275.98","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","356.56","213.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","275.98","77.4","","225.79","68.39","1154.35","11","41.47","275.98","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","both","","","345.86","207.52","AETNA [1001]","HB WDH AETNA COMMERCIAL","241.41","69.8","","279.80","225.71","279.80","16","40.22","293.98","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","both","","","345.86","207.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","40.22","293.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","both","","","345.86","207.52","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","196.79","56.9","","18.95","9.41","1260.18","1 through 10","40.22","293.98","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","both","","","345.86","207.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.22","11.63","","37.78","11.63","183.64","21","40.22","293.98","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","both","","","345.86","207.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","267.70","77.4","","225.79","68.39","1154.35","11","40.22","293.98","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","both","","","345.86","207.52","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","40.22","293.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","345.86","207.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.22","11.63","","37.78","11.63","183.64","21","40.22","267.7","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","345.86","207.52","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","217.13","62.78","","123.83","114.55","572.63","1 through 10","40.22","267.7","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","345.86","207.52","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","151.21","43.72","","127.38","127.38","148.03","1 through 10","40.22","267.7","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","345.86","207.52","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","251.51","72.72","","196.34","62.16","1727.00","33","40.22","267.7","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","345.86","207.52","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","251.51","72.72","","173.00","173.00","173.00","1 through 10","40.22","267.7","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","345.86","207.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","184.07","53.22","","205.24","190.08","205.24","1 through 10","40.22","267.7","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","345.86","207.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","217.55","62.9","","305.08","81.02","4529.24","103","40.22","267.7","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .025INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116061","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","345.86","207.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","267.70","77.4","","225.79","68.39","1154.35","11","40.22","267.7","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","240.61","144.37","AETNA [1001]","HB WDH AETNA COMMERCIAL","167.95","69.8","","279.80","225.71","279.80","16","27.98","204.52","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","240.61","144.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","27.98","204.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","240.61","144.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","136.91","56.9","","18.95","9.41","1260.18","1 through 10","27.98","204.52","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","240.61","144.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","27.98","11.63","","37.78","11.63","183.64","21","27.98","204.52","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","240.61","144.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","186.23","77.4","","225.79","68.39","1154.35","11","27.98","204.52","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","240.61","144.37","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","27.98","204.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","240.61","144.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","27.98","11.63","","37.78","11.63","183.64","21","27.98","186.23","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","240.61","144.37","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","151.05","62.78","","123.83","114.55","572.63","1 through 10","27.98","186.23","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","240.61","144.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","105.19","43.72","","127.38","127.38","148.03","1 through 10","27.98","186.23","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","240.61","144.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","174.97","72.72","","196.34","62.16","1727.00","33","27.98","186.23","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","240.61","144.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","174.97","72.72","","173.00","173.00","173.00","1 through 10","27.98","186.23","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","240.61","144.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","128.05","53.22","","205.24","190.08","205.24","1 through 10","27.98","186.23","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","240.61","144.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","151.34","62.9","","305.08","81.02","4529.24","103","27.98","186.23","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","240.61","144.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","186.23","77.4","","225.79","68.39","1154.35","11","27.98","186.23","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","both","","","580.44","348.26","AETNA [1001]","HB WDH AETNA COMMERCIAL","405.15","69.8","","279.80","225.71","279.80","16","67.51","493.37","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","both","","","580.44","348.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","67.51","493.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","both","","","580.44","348.26","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","330.27","56.9","","18.95","9.41","1260.18","1 through 10","67.51","493.37","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","both","","","580.44","348.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","67.51","11.63","","37.78","11.63","183.64","21","67.51","493.37","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","both","","","580.44","348.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","449.26","77.4","","225.79","68.39","1154.35","11","67.51","493.37","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","both","","","580.44","348.26","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","67.51","493.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","580.44","348.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","67.51","11.63","","37.78","11.63","183.64","21","67.51","449.26","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","580.44","348.26","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","364.40","62.78","","123.83","114.55","572.63","1 through 10","67.51","449.26","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","580.44","348.26","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","253.77","43.72","","127.38","127.38","148.03","1 through 10","67.51","449.26","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","580.44","348.26","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","422.10","72.72","","196.34","62.16","1727.00","33","67.51","449.26","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","580.44","348.26","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","422.10","72.72","","173.00","173.00","173.00","1 through 10","67.51","449.26","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","580.44","348.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","308.91","53.22","","205.24","190.08","205.24","1 through 10","67.51","449.26","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","580.44","348.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","365.10","62.9","","305.08","81.02","4529.24","103","67.51","449.26","percent of total billed charges",""
"GUIDEWIRE V-18 CONTROLWIRE 8CM 150CM .018IN ICE HYDROPHILIC COATING STEERABLE VASCULAR","SUP-ITM-10008804","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","580.44","348.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","449.26","77.4","","225.79","68.39","1154.35","11","67.51","449.26","percent of total billed charges",""
"GUIDEWIRE VASCULAR .014INX300CM PERIPHERAL V-14 CONTROL WIRE SCITANIUM HYDROPHILIC COATING SHORT TAPER ANGLED","SUP-ITM-10216577","CDM","C1769","HCPCS","0272","RC","","","","both","","","1103.18","661.91","AETNA [1001]","HB WDH AETNA COMMERCIAL","770.02","69.8","","279.80","225.71","279.80","16","128.3","937.7","percent of total billed charges",""
"GUIDEWIRE VASCULAR .014INX300CM PERIPHERAL V-14 CONTROL WIRE SCITANIUM HYDROPHILIC COATING SHORT TAPER ANGLED","SUP-ITM-10216577","CDM","C1769","HCPCS","0272","RC","","","","both","","","1103.18","661.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","128.3","937.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VASCULAR .014INX300CM PERIPHERAL V-14 CONTROL WIRE SCITANIUM HYDROPHILIC COATING SHORT TAPER ANGLED","SUP-ITM-10216577","CDM","C1769","HCPCS","0272","RC","","","","both","","","1103.18","661.91","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","627.71","56.9","","18.95","9.41","1260.18","1 through 10","128.3","937.7","percent of total billed charges",""
"GUIDEWIRE VASCULAR .014INX300CM PERIPHERAL V-14 CONTROL WIRE SCITANIUM HYDROPHILIC COATING SHORT TAPER ANGLED","SUP-ITM-10216577","CDM","C1769","HCPCS","0272","RC","","","","both","","","1103.18","661.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","128.30","11.63","","37.78","11.63","183.64","21","128.3","937.7","percent of total billed charges",""
"GUIDEWIRE VASCULAR .014INX300CM PERIPHERAL V-14 CONTROL WIRE SCITANIUM HYDROPHILIC COATING SHORT TAPER ANGLED","SUP-ITM-10216577","CDM","C1769","HCPCS","0272","RC","","","","both","","","1103.18","661.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","853.86","77.4","","225.79","68.39","1154.35","11","128.3","937.7","percent of total billed charges",""
"GUIDEWIRE VASCULAR .014INX300CM PERIPHERAL V-14 CONTROL WIRE SCITANIUM HYDROPHILIC COATING SHORT TAPER ANGLED","SUP-ITM-10216577","CDM","C1769","HCPCS","0272","RC","","","","both","","","1103.18","661.91","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","128.3","937.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VASCULAR .014INX300CM PERIPHERAL V-14 CONTROL WIRE SCITANIUM HYDROPHILIC COATING SHORT TAPER ANGLED","SUP-ITM-10216577","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1103.18","661.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","128.30","11.63","","37.78","11.63","183.64","21","128.3","853.86","percent of total billed charges",""
"GUIDEWIRE VASCULAR .014INX300CM PERIPHERAL V-14 CONTROL WIRE SCITANIUM HYDROPHILIC COATING SHORT TAPER ANGLED","SUP-ITM-10216577","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1103.18","661.91","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","692.58","62.78","","123.83","114.55","572.63","1 through 10","128.3","853.86","percent of total billed charges",""
"GUIDEWIRE VASCULAR .014INX300CM PERIPHERAL V-14 CONTROL WIRE SCITANIUM HYDROPHILIC COATING SHORT TAPER ANGLED","SUP-ITM-10216577","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1103.18","661.91","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","482.31","43.72","","127.38","127.38","148.03","1 through 10","128.3","853.86","percent of total billed charges",""
"GUIDEWIRE VASCULAR .014INX300CM PERIPHERAL V-14 CONTROL WIRE SCITANIUM HYDROPHILIC COATING SHORT TAPER ANGLED","SUP-ITM-10216577","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1103.18","661.91","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","802.23","72.72","","196.34","62.16","1727.00","33","128.3","853.86","percent of total billed charges",""
"GUIDEWIRE VASCULAR .014INX300CM PERIPHERAL V-14 CONTROL WIRE SCITANIUM HYDROPHILIC COATING SHORT TAPER ANGLED","SUP-ITM-10216577","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1103.18","661.91","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","802.23","72.72","","173.00","173.00","173.00","1 through 10","128.3","853.86","percent of total billed charges",""
"GUIDEWIRE VASCULAR .014INX300CM PERIPHERAL V-14 CONTROL WIRE SCITANIUM HYDROPHILIC COATING SHORT TAPER ANGLED","SUP-ITM-10216577","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1103.18","661.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","587.11","53.22","","205.24","190.08","205.24","1 through 10","128.3","853.86","percent of total billed charges",""
"GUIDEWIRE VASCULAR .014INX300CM PERIPHERAL V-14 CONTROL WIRE SCITANIUM HYDROPHILIC COATING SHORT TAPER ANGLED","SUP-ITM-10216577","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1103.18","661.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","693.90","62.9","","305.08","81.02","4529.24","103","128.3","853.86","percent of total billed charges",""
"GUIDEWIRE VASCULAR .014INX300CM PERIPHERAL V-14 CONTROL WIRE SCITANIUM HYDROPHILIC COATING SHORT TAPER ANGLED","SUP-ITM-10216577","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1103.18","661.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","853.86","77.4","","225.79","68.39","1154.35","11","128.3","853.86","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 180CM PTFE COATED FIXED CORE BENSTON BX/10EA","SUP-ITM-10237313","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.66","44.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","51.41","69.8","","279.80","225.71","279.80","16","8.57","62.61","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 180CM PTFE COATED FIXED CORE BENSTON BX/10EA","SUP-ITM-10237313","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.66","44.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","8.57","62.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VASCULAR .035IN 180CM PTFE COATED FIXED CORE BENSTON BX/10EA","SUP-ITM-10237313","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.66","44.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","41.91","56.9","","18.95","9.41","1260.18","1 through 10","8.57","62.61","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 180CM PTFE COATED FIXED CORE BENSTON BX/10EA","SUP-ITM-10237313","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.66","44.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","8.57","11.63","","37.78","11.63","183.64","21","8.57","62.61","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 180CM PTFE COATED FIXED CORE BENSTON BX/10EA","SUP-ITM-10237313","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.66","44.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","57.01","77.4","","225.79","68.39","1154.35","11","8.57","62.61","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 180CM PTFE COATED FIXED CORE BENSTON BX/10EA","SUP-ITM-10237313","CDM","C1769","HCPCS","0272","RC","","","","both","","","73.66","44.20","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","8.57","62.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VASCULAR .035IN 180CM PTFE COATED FIXED CORE BENSTON BX/10EA","SUP-ITM-10237313","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","73.66","44.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","8.57","11.63","","37.78","11.63","183.64","21","8.57","57.01","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 180CM PTFE COATED FIXED CORE BENSTON BX/10EA","SUP-ITM-10237313","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","73.66","44.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","46.24","62.78","","123.83","114.55","572.63","1 through 10","8.57","57.01","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 180CM PTFE COATED FIXED CORE BENSTON BX/10EA","SUP-ITM-10237313","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","73.66","44.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","32.20","43.72","","127.38","127.38","148.03","1 through 10","8.57","57.01","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 180CM PTFE COATED FIXED CORE BENSTON BX/10EA","SUP-ITM-10237313","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","73.66","44.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","53.57","72.72","","196.34","62.16","1727.00","33","8.57","57.01","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 180CM PTFE COATED FIXED CORE BENSTON BX/10EA","SUP-ITM-10237313","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","73.66","44.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","53.57","72.72","","173.00","173.00","173.00","1 through 10","8.57","57.01","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 180CM PTFE COATED FIXED CORE BENSTON BX/10EA","SUP-ITM-10237313","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","73.66","44.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","39.20","53.22","","205.24","190.08","205.24","1 through 10","8.57","57.01","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 180CM PTFE COATED FIXED CORE BENSTON BX/10EA","SUP-ITM-10237313","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","73.66","44.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","46.33","62.9","","305.08","81.02","4529.24","103","8.57","57.01","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035IN 180CM PTFE COATED FIXED CORE BENSTON BX/10EA","SUP-ITM-10237313","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","73.66","44.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","57.01","77.4","","225.79","68.39","1154.35","11","8.57","57.01","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035X102IN INQWIRE PTFE COATED FIXED CORE STRAIGHT TIP SS BX/10EA","SUP-ITM-10274224","CDM","C1769","HCPCS","0272","RC","","","","both","","","84.44","50.66","AETNA [1001]","HB WDH AETNA COMMERCIAL","58.94","69.8","","279.80","225.71","279.80","16","9.82","71.77","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035X102IN INQWIRE PTFE COATED FIXED CORE STRAIGHT TIP SS BX/10EA","SUP-ITM-10274224","CDM","C1769","HCPCS","0272","RC","","","","both","","","84.44","50.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","9.82","71.77","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VASCULAR .035X102IN INQWIRE PTFE COATED FIXED CORE STRAIGHT TIP SS BX/10EA","SUP-ITM-10274224","CDM","C1769","HCPCS","0272","RC","","","","both","","","84.44","50.66","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","48.05","56.9","","18.95","9.41","1260.18","1 through 10","9.82","71.77","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035X102IN INQWIRE PTFE COATED FIXED CORE STRAIGHT TIP SS BX/10EA","SUP-ITM-10274224","CDM","C1769","HCPCS","0272","RC","","","","both","","","84.44","50.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","9.82","11.63","","37.78","11.63","183.64","21","9.82","71.77","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035X102IN INQWIRE PTFE COATED FIXED CORE STRAIGHT TIP SS BX/10EA","SUP-ITM-10274224","CDM","C1769","HCPCS","0272","RC","","","","both","","","84.44","50.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","65.36","77.4","","225.79","68.39","1154.35","11","9.82","71.77","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035X102IN INQWIRE PTFE COATED FIXED CORE STRAIGHT TIP SS BX/10EA","SUP-ITM-10274224","CDM","C1769","HCPCS","0272","RC","","","","both","","","84.44","50.66","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","9.82","71.77","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VASCULAR .035X102IN INQWIRE PTFE COATED FIXED CORE STRAIGHT TIP SS BX/10EA","SUP-ITM-10274224","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","84.44","50.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","9.82","11.63","","37.78","11.63","183.64","21","9.82","65.36","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035X102IN INQWIRE PTFE COATED FIXED CORE STRAIGHT TIP SS BX/10EA","SUP-ITM-10274224","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","84.44","50.66","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","53.01","62.78","","123.83","114.55","572.63","1 through 10","9.82","65.36","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035X102IN INQWIRE PTFE COATED FIXED CORE STRAIGHT TIP SS BX/10EA","SUP-ITM-10274224","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","84.44","50.66","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","36.92","43.72","","127.38","127.38","148.03","1 through 10","9.82","65.36","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035X102IN INQWIRE PTFE COATED FIXED CORE STRAIGHT TIP SS BX/10EA","SUP-ITM-10274224","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","84.44","50.66","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","61.40","72.72","","196.34","62.16","1727.00","33","9.82","65.36","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035X102IN INQWIRE PTFE COATED FIXED CORE STRAIGHT TIP SS BX/10EA","SUP-ITM-10274224","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","84.44","50.66","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","61.40","72.72","","173.00","173.00","173.00","1 through 10","9.82","65.36","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035X102IN INQWIRE PTFE COATED FIXED CORE STRAIGHT TIP SS BX/10EA","SUP-ITM-10274224","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","84.44","50.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","44.94","53.22","","205.24","190.08","205.24","1 through 10","9.82","65.36","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035X102IN INQWIRE PTFE COATED FIXED CORE STRAIGHT TIP SS BX/10EA","SUP-ITM-10274224","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","84.44","50.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","53.11","62.9","","305.08","81.02","4529.24","103","9.82","65.36","percent of total billed charges",""
"GUIDEWIRE VASCULAR .035X102IN INQWIRE PTFE COATED FIXED CORE STRAIGHT TIP SS BX/10EA","SUP-ITM-10274224","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","84.44","50.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","65.36","77.4","","225.79","68.39","1154.35","11","9.82","65.36","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 180CM .035IN J TIP ROSEN CURVED TIP S/S PTFE COATED HEAVY DUTY FIXED CORE","SUP-ITM-10009377","CDM","C1769","HCPCS","0272","RC","","","","both","","","95.29","57.17","AETNA [1001]","HB WDH AETNA COMMERCIAL","66.51","69.8","","279.80","225.71","279.80","16","11.08","81","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 180CM .035IN J TIP ROSEN CURVED TIP S/S PTFE COATED HEAVY DUTY FIXED CORE","SUP-ITM-10009377","CDM","C1769","HCPCS","0272","RC","","","","both","","","95.29","57.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","11.08","81","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VASCULAR 1.5MM 180CM .035IN J TIP ROSEN CURVED TIP S/S PTFE COATED HEAVY DUTY FIXED CORE","SUP-ITM-10009377","CDM","C1769","HCPCS","0272","RC","","","","both","","","95.29","57.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","54.22","56.9","","18.95","9.41","1260.18","1 through 10","11.08","81","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 180CM .035IN J TIP ROSEN CURVED TIP S/S PTFE COATED HEAVY DUTY FIXED CORE","SUP-ITM-10009377","CDM","C1769","HCPCS","0272","RC","","","","both","","","95.29","57.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","11.08","11.63","","37.78","11.63","183.64","21","11.08","81","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 180CM .035IN J TIP ROSEN CURVED TIP S/S PTFE COATED HEAVY DUTY FIXED CORE","SUP-ITM-10009377","CDM","C1769","HCPCS","0272","RC","","","","both","","","95.29","57.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","73.75","77.4","","225.79","68.39","1154.35","11","11.08","81","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 180CM .035IN J TIP ROSEN CURVED TIP S/S PTFE COATED HEAVY DUTY FIXED CORE","SUP-ITM-10009377","CDM","C1769","HCPCS","0272","RC","","","","both","","","95.29","57.17","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","11.08","81","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VASCULAR 1.5MM 180CM .035IN J TIP ROSEN CURVED TIP S/S PTFE COATED HEAVY DUTY FIXED CORE","SUP-ITM-10009377","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","95.29","57.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","11.08","11.63","","37.78","11.63","183.64","21","11.08","73.75","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 180CM .035IN J TIP ROSEN CURVED TIP S/S PTFE COATED HEAVY DUTY FIXED CORE","SUP-ITM-10009377","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","95.29","57.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","59.82","62.78","","123.83","114.55","572.63","1 through 10","11.08","73.75","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 180CM .035IN J TIP ROSEN CURVED TIP S/S PTFE COATED HEAVY DUTY FIXED CORE","SUP-ITM-10009377","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","95.29","57.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","41.66","43.72","","127.38","127.38","148.03","1 through 10","11.08","73.75","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 180CM .035IN J TIP ROSEN CURVED TIP S/S PTFE COATED HEAVY DUTY FIXED CORE","SUP-ITM-10009377","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","95.29","57.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","69.29","72.72","","196.34","62.16","1727.00","33","11.08","73.75","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 180CM .035IN J TIP ROSEN CURVED TIP S/S PTFE COATED HEAVY DUTY FIXED CORE","SUP-ITM-10009377","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","95.29","57.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","69.29","72.72","","173.00","173.00","173.00","1 through 10","11.08","73.75","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 180CM .035IN J TIP ROSEN CURVED TIP S/S PTFE COATED HEAVY DUTY FIXED CORE","SUP-ITM-10009377","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","95.29","57.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","50.71","53.22","","205.24","190.08","205.24","1 through 10","11.08","73.75","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 180CM .035IN J TIP ROSEN CURVED TIP S/S PTFE COATED HEAVY DUTY FIXED CORE","SUP-ITM-10009377","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","95.29","57.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","59.94","62.9","","305.08","81.02","4529.24","103","11.08","73.75","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 180CM .035IN J TIP ROSEN CURVED TIP S/S PTFE COATED HEAVY DUTY FIXED CORE","SUP-ITM-10009377","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","95.29","57.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","73.75","77.4","","225.79","68.39","1154.35","11","11.08","73.75","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 260CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10028564","CDM","C1769","HCPCS","0272","RC","","","","both","","","200.32","120.19","AETNA [1001]","HB WDH AETNA COMMERCIAL","139.82","69.8","","279.80","225.71","279.80","16","23.3","170.27","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 260CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10028564","CDM","C1769","HCPCS","0272","RC","","","","both","","","200.32","120.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","23.3","170.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VASCULAR 1.5MM 260CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10028564","CDM","C1769","HCPCS","0272","RC","","","","both","","","200.32","120.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","113.98","56.9","","18.95","9.41","1260.18","1 through 10","23.3","170.27","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 260CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10028564","CDM","C1769","HCPCS","0272","RC","","","","both","","","200.32","120.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","23.30","11.63","","37.78","11.63","183.64","21","23.3","170.27","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 260CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10028564","CDM","C1769","HCPCS","0272","RC","","","","both","","","200.32","120.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","155.05","77.4","","225.79","68.39","1154.35","11","23.3","170.27","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 260CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10028564","CDM","C1769","HCPCS","0272","RC","","","","both","","","200.32","120.19","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","23.3","170.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VASCULAR 1.5MM 260CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10028564","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","200.32","120.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","23.30","11.63","","37.78","11.63","183.64","21","23.3","155.05","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 260CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10028564","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","200.32","120.19","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","125.76","62.78","","123.83","114.55","572.63","1 through 10","23.3","155.05","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 260CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10028564","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","200.32","120.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","87.58","43.72","","127.38","127.38","148.03","1 through 10","23.3","155.05","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 260CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10028564","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","200.32","120.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","145.67","72.72","","196.34","62.16","1727.00","33","23.3","155.05","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 260CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10028564","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","200.32","120.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","145.67","72.72","","173.00","173.00","173.00","1 through 10","23.3","155.05","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 260CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10028564","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","200.32","120.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","106.61","53.22","","205.24","190.08","205.24","1 through 10","23.3","155.05","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 260CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10028564","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","200.32","120.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","126.00","62.9","","305.08","81.02","4529.24","103","23.3","155.05","percent of total billed charges",""
"GUIDEWIRE VASCULAR 1.5MM 260CM .035IN ROSEN PTFE COATED S/S","SUP-ITM-10028564","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","200.32","120.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","155.05","77.4","","225.79","68.39","1154.35","11","23.3","155.05","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .3 3MM ADULT .038 SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10008216","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.67","58.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","67.48","69.8","","279.80","225.71","279.80","16","11.24","82.17","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .3 3MM ADULT .038 SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10008216","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.67","58.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","11.24","82.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VASCULAR 145CM .3 3MM ADULT .038 SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10008216","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.67","58.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","55.01","56.9","","18.95","9.41","1260.18","1 through 10","11.24","82.17","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .3 3MM ADULT .038 SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10008216","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.67","58.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","11.24","11.63","","37.78","11.63","183.64","21","11.24","82.17","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .3 3MM ADULT .038 SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10008216","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.67","58.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","74.82","77.4","","225.79","68.39","1154.35","11","11.24","82.17","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .3 3MM ADULT .038 SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10008216","CDM","C1769","HCPCS","0272","RC","","","","both","","","96.67","58.00","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","11.24","82.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VASCULAR 145CM .3 3MM ADULT .038 SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10008216","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","96.67","58.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","11.24","11.63","","37.78","11.63","183.64","21","11.24","74.82","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .3 3MM ADULT .038 SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10008216","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","96.67","58.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","60.69","62.78","","123.83","114.55","572.63","1 through 10","11.24","74.82","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .3 3MM ADULT .038 SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10008216","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","96.67","58.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","42.26","43.72","","127.38","127.38","148.03","1 through 10","11.24","74.82","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .3 3MM ADULT .038 SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10008216","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","96.67","58.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","70.30","72.72","","196.34","62.16","1727.00","33","11.24","74.82","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .3 3MM ADULT .038 SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10008216","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","96.67","58.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","70.30","72.72","","173.00","173.00","173.00","1 through 10","11.24","74.82","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .3 3MM ADULT .038 SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10008216","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","96.67","58.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","51.45","53.22","","205.24","190.08","205.24","1 through 10","11.24","74.82","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .3 3MM ADULT .038 SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10008216","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","96.67","58.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","60.81","62.9","","305.08","81.02","4529.24","103","11.24","74.82","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .3 3MM ADULT .038 SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10008216","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","96.67","58.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","74.82","77.4","","225.79","68.39","1154.35","11","11.24","74.82","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM 0.035IN WHOLEY SS HI TORQUE STIFF SHAPEABLE STRAIGHT TIP PK/3EA","SUP-ITM-10175808","CDM","C1769","HCPCS","0272","RC","","","","both","","","301.97","181.18","AETNA [1001]","HB WDH AETNA COMMERCIAL","210.78","69.8","","279.80","225.71","279.80","16","35.12","256.67","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM 0.035IN WHOLEY SS HI TORQUE STIFF SHAPEABLE STRAIGHT TIP PK/3EA","SUP-ITM-10175808","CDM","C1769","HCPCS","0272","RC","","","","both","","","301.97","181.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","35.12","256.67","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VASCULAR 145CM 0.035IN WHOLEY SS HI TORQUE STIFF SHAPEABLE STRAIGHT TIP PK/3EA","SUP-ITM-10175808","CDM","C1769","HCPCS","0272","RC","","","","both","","","301.97","181.18","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","171.82","56.9","","18.95","9.41","1260.18","1 through 10","35.12","256.67","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM 0.035IN WHOLEY SS HI TORQUE STIFF SHAPEABLE STRAIGHT TIP PK/3EA","SUP-ITM-10175808","CDM","C1769","HCPCS","0272","RC","","","","both","","","301.97","181.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","35.12","11.63","","37.78","11.63","183.64","21","35.12","256.67","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM 0.035IN WHOLEY SS HI TORQUE STIFF SHAPEABLE STRAIGHT TIP PK/3EA","SUP-ITM-10175808","CDM","C1769","HCPCS","0272","RC","","","","both","","","301.97","181.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","233.72","77.4","","225.79","68.39","1154.35","11","35.12","256.67","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM 0.035IN WHOLEY SS HI TORQUE STIFF SHAPEABLE STRAIGHT TIP PK/3EA","SUP-ITM-10175808","CDM","C1769","HCPCS","0272","RC","","","","both","","","301.97","181.18","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","35.12","256.67","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VASCULAR 145CM 0.035IN WHOLEY SS HI TORQUE STIFF SHAPEABLE STRAIGHT TIP PK/3EA","SUP-ITM-10175808","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","301.97","181.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","35.12","11.63","","37.78","11.63","183.64","21","35.12","233.72","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM 0.035IN WHOLEY SS HI TORQUE STIFF SHAPEABLE STRAIGHT TIP PK/3EA","SUP-ITM-10175808","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","301.97","181.18","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","189.58","62.78","","123.83","114.55","572.63","1 through 10","35.12","233.72","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM 0.035IN WHOLEY SS HI TORQUE STIFF SHAPEABLE STRAIGHT TIP PK/3EA","SUP-ITM-10175808","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","301.97","181.18","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","132.02","43.72","","127.38","127.38","148.03","1 through 10","35.12","233.72","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM 0.035IN WHOLEY SS HI TORQUE STIFF SHAPEABLE STRAIGHT TIP PK/3EA","SUP-ITM-10175808","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","301.97","181.18","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","219.59","72.72","","196.34","62.16","1727.00","33","35.12","233.72","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM 0.035IN WHOLEY SS HI TORQUE STIFF SHAPEABLE STRAIGHT TIP PK/3EA","SUP-ITM-10175808","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","301.97","181.18","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","219.59","72.72","","173.00","173.00","173.00","1 through 10","35.12","233.72","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM 0.035IN WHOLEY SS HI TORQUE STIFF SHAPEABLE STRAIGHT TIP PK/3EA","SUP-ITM-10175808","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","301.97","181.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","160.71","53.22","","205.24","190.08","205.24","1 through 10","35.12","233.72","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM 0.035IN WHOLEY SS HI TORQUE STIFF SHAPEABLE STRAIGHT TIP PK/3EA","SUP-ITM-10175808","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","301.97","181.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","189.94","62.9","","305.08","81.02","4529.24","103","35.12","233.72","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM 0.035IN WHOLEY SS HI TORQUE STIFF SHAPEABLE STRAIGHT TIP PK/3EA","SUP-ITM-10175808","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","301.97","181.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","233.72","77.4","","225.79","68.39","1154.35","11","35.12","233.72","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM 3 .035 STARTER PTFE STRAIGHT FIXED CORE BX/10EA","SUP-ITM-10071379","CDM","C1769","HCPCS","0272","RC","","","","both","","","57.35","34.41","AETNA [1001]","HB WDH AETNA COMMERCIAL","40.03","69.8","","279.80","225.71","279.80","16","6.67","48.75","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM 3 .035 STARTER PTFE STRAIGHT FIXED CORE BX/10EA","SUP-ITM-10071379","CDM","C1769","HCPCS","0272","RC","","","","both","","","57.35","34.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","6.67","48.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VASCULAR 150CM 3 .035 STARTER PTFE STRAIGHT FIXED CORE BX/10EA","SUP-ITM-10071379","CDM","C1769","HCPCS","0272","RC","","","","both","","","57.35","34.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","32.63","56.9","","18.95","9.41","1260.18","1 through 10","6.67","48.75","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM 3 .035 STARTER PTFE STRAIGHT FIXED CORE BX/10EA","SUP-ITM-10071379","CDM","C1769","HCPCS","0272","RC","","","","both","","","57.35","34.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","6.67","11.63","","37.78","11.63","183.64","21","6.67","48.75","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM 3 .035 STARTER PTFE STRAIGHT FIXED CORE BX/10EA","SUP-ITM-10071379","CDM","C1769","HCPCS","0272","RC","","","","both","","","57.35","34.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","44.39","77.4","","225.79","68.39","1154.35","11","6.67","48.75","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM 3 .035 STARTER PTFE STRAIGHT FIXED CORE BX/10EA","SUP-ITM-10071379","CDM","C1769","HCPCS","0272","RC","","","","both","","","57.35","34.41","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","6.67","48.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VASCULAR 150CM 3 .035 STARTER PTFE STRAIGHT FIXED CORE BX/10EA","SUP-ITM-10071379","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","57.35","34.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","6.67","11.63","","37.78","11.63","183.64","21","6.67","44.39","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM 3 .035 STARTER PTFE STRAIGHT FIXED CORE BX/10EA","SUP-ITM-10071379","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","57.35","34.41","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","36.00","62.78","","123.83","114.55","572.63","1 through 10","6.67","44.39","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM 3 .035 STARTER PTFE STRAIGHT FIXED CORE BX/10EA","SUP-ITM-10071379","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","57.35","34.41","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","25.07","43.72","","127.38","127.38","148.03","1 through 10","6.67","44.39","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM 3 .035 STARTER PTFE STRAIGHT FIXED CORE BX/10EA","SUP-ITM-10071379","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","57.35","34.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","41.70","72.72","","196.34","62.16","1727.00","33","6.67","44.39","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM 3 .035 STARTER PTFE STRAIGHT FIXED CORE BX/10EA","SUP-ITM-10071379","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","57.35","34.41","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","41.70","72.72","","173.00","173.00","173.00","1 through 10","6.67","44.39","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM 3 .035 STARTER PTFE STRAIGHT FIXED CORE BX/10EA","SUP-ITM-10071379","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","57.35","34.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","30.52","53.22","","205.24","190.08","205.24","1 through 10","6.67","44.39","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM 3 .035 STARTER PTFE STRAIGHT FIXED CORE BX/10EA","SUP-ITM-10071379","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","57.35","34.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","36.07","62.9","","305.08","81.02","4529.24","103","6.67","44.39","percent of total billed charges",""
"GUIDEWIRE VASCULAR 150CM 3 .035 STARTER PTFE STRAIGHT FIXED CORE BX/10EA","SUP-ITM-10071379","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","57.35","34.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","44.39","77.4","","225.79","68.39","1154.35","11","6.67","44.39","percent of total billed charges",""
"GUIDEWIRE VASCULAR 195CM .018IN HI TORQUE CONNECET T PK/5EA --ORDER IN MULT OF 5--","SUP-ITM-10168894","CDM","C1769","HCPCS","0272","RC","","","","both","","","829.20","497.52","AETNA [1001]","HB WDH AETNA COMMERCIAL","578.78","69.8","","279.80","225.71","279.80","16","96.44","704.82","percent of total billed charges",""
"GUIDEWIRE VASCULAR 195CM .018IN HI TORQUE CONNECET T PK/5EA --ORDER IN MULT OF 5--","SUP-ITM-10168894","CDM","C1769","HCPCS","0272","RC","","","","both","","","829.20","497.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","96.44","704.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VASCULAR 195CM .018IN HI TORQUE CONNECET T PK/5EA --ORDER IN MULT OF 5--","SUP-ITM-10168894","CDM","C1769","HCPCS","0272","RC","","","","both","","","829.20","497.52","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","471.81","56.9","","18.95","9.41","1260.18","1 through 10","96.44","704.82","percent of total billed charges",""
"GUIDEWIRE VASCULAR 195CM .018IN HI TORQUE CONNECET T PK/5EA --ORDER IN MULT OF 5--","SUP-ITM-10168894","CDM","C1769","HCPCS","0272","RC","","","","both","","","829.20","497.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","96.44","11.63","","37.78","11.63","183.64","21","96.44","704.82","percent of total billed charges",""
"GUIDEWIRE VASCULAR 195CM .018IN HI TORQUE CONNECET T PK/5EA --ORDER IN MULT OF 5--","SUP-ITM-10168894","CDM","C1769","HCPCS","0272","RC","","","","both","","","829.20","497.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","641.80","77.4","","225.79","68.39","1154.35","11","96.44","704.82","percent of total billed charges",""
"GUIDEWIRE VASCULAR 195CM .018IN HI TORQUE CONNECET T PK/5EA --ORDER IN MULT OF 5--","SUP-ITM-10168894","CDM","C1769","HCPCS","0272","RC","","","","both","","","829.20","497.52","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","96.44","704.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VASCULAR 195CM .018IN HI TORQUE CONNECET T PK/5EA --ORDER IN MULT OF 5--","SUP-ITM-10168894","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","829.20","497.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","96.44","11.63","","37.78","11.63","183.64","21","96.44","641.8","percent of total billed charges",""
"GUIDEWIRE VASCULAR 195CM .018IN HI TORQUE CONNECET T PK/5EA --ORDER IN MULT OF 5--","SUP-ITM-10168894","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","829.20","497.52","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","520.57","62.78","","123.83","114.55","572.63","1 through 10","96.44","641.8","percent of total billed charges",""
"GUIDEWIRE VASCULAR 195CM .018IN HI TORQUE CONNECET T PK/5EA --ORDER IN MULT OF 5--","SUP-ITM-10168894","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","829.20","497.52","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","362.53","43.72","","127.38","127.38","148.03","1 through 10","96.44","641.8","percent of total billed charges",""
"GUIDEWIRE VASCULAR 195CM .018IN HI TORQUE CONNECET T PK/5EA --ORDER IN MULT OF 5--","SUP-ITM-10168894","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","829.20","497.52","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","602.99","72.72","","196.34","62.16","1727.00","33","96.44","641.8","percent of total billed charges",""
"GUIDEWIRE VASCULAR 195CM .018IN HI TORQUE CONNECET T PK/5EA --ORDER IN MULT OF 5--","SUP-ITM-10168894","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","829.20","497.52","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","602.99","72.72","","173.00","173.00","173.00","1 through 10","96.44","641.8","percent of total billed charges",""
"GUIDEWIRE VASCULAR 195CM .018IN HI TORQUE CONNECET T PK/5EA --ORDER IN MULT OF 5--","SUP-ITM-10168894","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","829.20","497.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","441.30","53.22","","205.24","190.08","205.24","1 through 10","96.44","641.8","percent of total billed charges",""
"GUIDEWIRE VASCULAR 195CM .018IN HI TORQUE CONNECET T PK/5EA --ORDER IN MULT OF 5--","SUP-ITM-10168894","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","829.20","497.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","521.57","62.9","","305.08","81.02","4529.24","103","96.44","641.8","percent of total billed charges",""
"GUIDEWIRE VASCULAR 195CM .018IN HI TORQUE CONNECET T PK/5EA --ORDER IN MULT OF 5--","SUP-ITM-10168894","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","829.20","497.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","641.80","77.4","","225.79","68.39","1154.35","11","96.44","641.8","percent of total billed charges",""
"GUIDEWIRE VASCULAR 300CM 0.014IN FATHOM 14 NITINOL HYPOTUBE PTFE HYDROPHILIC COATED STEERABLE DISTAL STRAIGHT TIP","SUP-ITM-10191068","CDM","C1769","HCPCS","0272","RC","","","","both","","","1932.38","1159.43","AETNA [1001]","HB WDH AETNA COMMERCIAL","1348.80","69.8","","279.80","225.71","279.80","16","224.74","1642.52","percent of total billed charges",""
"GUIDEWIRE VASCULAR 300CM 0.014IN FATHOM 14 NITINOL HYPOTUBE PTFE HYDROPHILIC COATED STEERABLE DISTAL STRAIGHT TIP","SUP-ITM-10191068","CDM","C1769","HCPCS","0272","RC","","","","both","","","1932.38","1159.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","224.74","1642.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VASCULAR 300CM 0.014IN FATHOM 14 NITINOL HYPOTUBE PTFE HYDROPHILIC COATED STEERABLE DISTAL STRAIGHT TIP","SUP-ITM-10191068","CDM","C1769","HCPCS","0272","RC","","","","both","","","1932.38","1159.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1099.52","56.9","","18.95","9.41","1260.18","1 through 10","224.74","1642.52","percent of total billed charges",""
"GUIDEWIRE VASCULAR 300CM 0.014IN FATHOM 14 NITINOL HYPOTUBE PTFE HYDROPHILIC COATED STEERABLE DISTAL STRAIGHT TIP","SUP-ITM-10191068","CDM","C1769","HCPCS","0272","RC","","","","both","","","1932.38","1159.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","224.74","11.63","","37.78","11.63","183.64","21","224.74","1642.52","percent of total billed charges",""
"GUIDEWIRE VASCULAR 300CM 0.014IN FATHOM 14 NITINOL HYPOTUBE PTFE HYDROPHILIC COATED STEERABLE DISTAL STRAIGHT TIP","SUP-ITM-10191068","CDM","C1769","HCPCS","0272","RC","","","","both","","","1932.38","1159.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1495.66","77.4","","225.79","68.39","1154.35","11","224.74","1642.52","percent of total billed charges",""
"GUIDEWIRE VASCULAR 300CM 0.014IN FATHOM 14 NITINOL HYPOTUBE PTFE HYDROPHILIC COATED STEERABLE DISTAL STRAIGHT TIP","SUP-ITM-10191068","CDM","C1769","HCPCS","0272","RC","","","","both","","","1932.38","1159.43","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","224.74","1642.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VASCULAR 300CM 0.014IN FATHOM 14 NITINOL HYPOTUBE PTFE HYDROPHILIC COATED STEERABLE DISTAL STRAIGHT TIP","SUP-ITM-10191068","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1932.38","1159.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","224.74","11.63","","37.78","11.63","183.64","21","224.74","1495.66","percent of total billed charges",""
"GUIDEWIRE VASCULAR 300CM 0.014IN FATHOM 14 NITINOL HYPOTUBE PTFE HYDROPHILIC COATED STEERABLE DISTAL STRAIGHT TIP","SUP-ITM-10191068","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1932.38","1159.43","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1213.15","62.78","","123.83","114.55","572.63","1 through 10","224.74","1495.66","percent of total billed charges",""
"GUIDEWIRE VASCULAR 300CM 0.014IN FATHOM 14 NITINOL HYPOTUBE PTFE HYDROPHILIC COATED STEERABLE DISTAL STRAIGHT TIP","SUP-ITM-10191068","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1932.38","1159.43","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","844.84","43.72","","127.38","127.38","148.03","1 through 10","224.74","1495.66","percent of total billed charges",""
"GUIDEWIRE VASCULAR 300CM 0.014IN FATHOM 14 NITINOL HYPOTUBE PTFE HYDROPHILIC COATED STEERABLE DISTAL STRAIGHT TIP","SUP-ITM-10191068","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1932.38","1159.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1405.23","72.72","","196.34","62.16","1727.00","33","224.74","1495.66","percent of total billed charges",""
"GUIDEWIRE VASCULAR 300CM 0.014IN FATHOM 14 NITINOL HYPOTUBE PTFE HYDROPHILIC COATED STEERABLE DISTAL STRAIGHT TIP","SUP-ITM-10191068","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1932.38","1159.43","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1405.23","72.72","","173.00","173.00","173.00","1 through 10","224.74","1495.66","percent of total billed charges",""
"GUIDEWIRE VASCULAR 300CM 0.014IN FATHOM 14 NITINOL HYPOTUBE PTFE HYDROPHILIC COATED STEERABLE DISTAL STRAIGHT TIP","SUP-ITM-10191068","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1932.38","1159.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1028.41","53.22","","205.24","190.08","205.24","1 through 10","224.74","1495.66","percent of total billed charges",""
"GUIDEWIRE VASCULAR 300CM 0.014IN FATHOM 14 NITINOL HYPOTUBE PTFE HYDROPHILIC COATED STEERABLE DISTAL STRAIGHT TIP","SUP-ITM-10191068","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1932.38","1159.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1215.47","62.9","","305.08","81.02","4529.24","103","224.74","1495.66","percent of total billed charges",""
"GUIDEWIRE VASCULAR 300CM 0.014IN FATHOM 14 NITINOL HYPOTUBE PTFE HYDROPHILIC COATED STEERABLE DISTAL STRAIGHT TIP","SUP-ITM-10191068","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1932.38","1159.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1495.66","77.4","","225.79","68.39","1154.35","11","224.74","1495.66","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MMX180CM 0.021IN SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10087259","CDM","C1769","HCPCS","0272","RC","","","","both","","","124.31","74.59","AETNA [1001]","HB WDH AETNA COMMERCIAL","86.77","69.8","","279.80","225.71","279.80","16","14.46","105.66","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MMX180CM 0.021IN SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10087259","CDM","C1769","HCPCS","0272","RC","","","","both","","","124.31","74.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","14.46","105.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VASCULAR 3MMX180CM 0.021IN SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10087259","CDM","C1769","HCPCS","0272","RC","","","","both","","","124.31","74.59","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","70.73","56.9","","18.95","9.41","1260.18","1 through 10","14.46","105.66","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MMX180CM 0.021IN SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10087259","CDM","C1769","HCPCS","0272","RC","","","","both","","","124.31","74.59","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","14.46","11.63","","37.78","11.63","183.64","21","14.46","105.66","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MMX180CM 0.021IN SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10087259","CDM","C1769","HCPCS","0272","RC","","","","both","","","124.31","74.59","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","96.22","77.4","","225.79","68.39","1154.35","11","14.46","105.66","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MMX180CM 0.021IN SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10087259","CDM","C1769","HCPCS","0272","RC","","","","both","","","124.31","74.59","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","14.46","105.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VASCULAR 3MMX180CM 0.021IN SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10087259","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","124.31","74.59","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","14.46","11.63","","37.78","11.63","183.64","21","14.46","96.22","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MMX180CM 0.021IN SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10087259","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","124.31","74.59","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","78.04","62.78","","123.83","114.55","572.63","1 through 10","14.46","96.22","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MMX180CM 0.021IN SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10087259","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","124.31","74.59","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","54.35","43.72","","127.38","127.38","148.03","1 through 10","14.46","96.22","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MMX180CM 0.021IN SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10087259","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","124.31","74.59","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","90.40","72.72","","196.34","62.16","1727.00","33","14.46","96.22","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MMX180CM 0.021IN SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10087259","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","124.31","74.59","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","90.40","72.72","","173.00","173.00","173.00","1 through 10","14.46","96.22","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MMX180CM 0.021IN SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10087259","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","124.31","74.59","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","66.16","53.22","","205.24","190.08","205.24","1 through 10","14.46","96.22","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MMX180CM 0.021IN SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10087259","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","124.31","74.59","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","78.19","62.9","","305.08","81.02","4529.24","103","14.46","96.22","percent of total billed charges",""
"GUIDEWIRE VASCULAR 3MMX180CM 0.021IN SS PTFE COATED SAFE T J CURVED TIP FIXED CORE","SUP-ITM-10087259","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","124.31","74.59","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","96.22","77.4","","225.79","68.39","1154.35","11","14.46","96.22","percent of total billed charges",""
"GUIDEWIRE VIPERWIRE ADVANCE 335CM .014IN FLEX TIP PERIPHERAL BX/5EA","SUP-ITM-10157550","CDM","C1769","HCPCS","0272","RC","","","","both","","","1036.50","621.90","AETNA [1001]","HB WDH AETNA COMMERCIAL","723.48","69.8","","279.80","225.71","279.80","16","120.54","881.03","percent of total billed charges",""
"GUIDEWIRE VIPERWIRE ADVANCE 335CM .014IN FLEX TIP PERIPHERAL BX/5EA","SUP-ITM-10157550","CDM","C1769","HCPCS","0272","RC","","","","both","","","1036.50","621.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","120.54","881.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VIPERWIRE ADVANCE 335CM .014IN FLEX TIP PERIPHERAL BX/5EA","SUP-ITM-10157550","CDM","C1769","HCPCS","0272","RC","","","","both","","","1036.50","621.90","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","589.77","56.9","","18.95","9.41","1260.18","1 through 10","120.54","881.03","percent of total billed charges",""
"GUIDEWIRE VIPERWIRE ADVANCE 335CM .014IN FLEX TIP PERIPHERAL BX/5EA","SUP-ITM-10157550","CDM","C1769","HCPCS","0272","RC","","","","both","","","1036.50","621.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","120.54","11.63","","37.78","11.63","183.64","21","120.54","881.03","percent of total billed charges",""
"GUIDEWIRE VIPERWIRE ADVANCE 335CM .014IN FLEX TIP PERIPHERAL BX/5EA","SUP-ITM-10157550","CDM","C1769","HCPCS","0272","RC","","","","both","","","1036.50","621.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","802.25","77.4","","225.79","68.39","1154.35","11","120.54","881.03","percent of total billed charges",""
"GUIDEWIRE VIPERWIRE ADVANCE 335CM .014IN FLEX TIP PERIPHERAL BX/5EA","SUP-ITM-10157550","CDM","C1769","HCPCS","0272","RC","","","","both","","","1036.50","621.90","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","120.54","881.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"GUIDEWIRE VIPERWIRE ADVANCE 335CM .014IN FLEX TIP PERIPHERAL BX/5EA","SUP-ITM-10157550","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1036.50","621.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","120.54","11.63","","37.78","11.63","183.64","21","120.54","802.25","percent of total billed charges",""
"GUIDEWIRE VIPERWIRE ADVANCE 335CM .014IN FLEX TIP PERIPHERAL BX/5EA","SUP-ITM-10157550","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","650.71","62.78","","123.83","114.55","572.63","1 through 10","120.54","802.25","percent of total billed charges",""
"GUIDEWIRE VIPERWIRE ADVANCE 335CM .014IN FLEX TIP PERIPHERAL BX/5EA","SUP-ITM-10157550","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","453.16","43.72","","127.38","127.38","148.03","1 through 10","120.54","802.25","percent of total billed charges",""
"GUIDEWIRE VIPERWIRE ADVANCE 335CM .014IN FLEX TIP PERIPHERAL BX/5EA","SUP-ITM-10157550","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","753.74","72.72","","196.34","62.16","1727.00","33","120.54","802.25","percent of total billed charges",""
"GUIDEWIRE VIPERWIRE ADVANCE 335CM .014IN FLEX TIP PERIPHERAL BX/5EA","SUP-ITM-10157550","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","753.74","72.72","","173.00","173.00","173.00","1 through 10","120.54","802.25","percent of total billed charges",""
"GUIDEWIRE VIPERWIRE ADVANCE 335CM .014IN FLEX TIP PERIPHERAL BX/5EA","SUP-ITM-10157550","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1036.50","621.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","551.63","53.22","","205.24","190.08","205.24","1 through 10","120.54","802.25","percent of total billed charges",""
"GUIDEWIRE VIPERWIRE ADVANCE 335CM .014IN FLEX TIP PERIPHERAL BX/5EA","SUP-ITM-10157550","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1036.50","621.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","651.96","62.9","","305.08","81.02","4529.24","103","120.54","802.25","percent of total billed charges",""
"GUIDEWIRE VIPERWIRE ADVANCE 335CM .014IN FLEX TIP PERIPHERAL BX/5EA","SUP-ITM-10157550","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1036.50","621.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","802.25","77.4","","225.79","68.39","1154.35","11","120.54","802.25","percent of total billed charges",""
"HAND L 2.3MM 6 HOLE PATE BONE PROFYE COMPRESSION","SUP-ITM-10143786","CDM","C1713","HCPCS","0278","RC","","","","both","","","3410.43","2046.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","396.63","2898.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HAND L 2.3MM 6 HOLE PATE BONE PROFYE COMPRESSION","SUP-ITM-10143786","CDM","C1713","HCPCS","0278","RC","","","","both","","","3410.43","2046.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","396.63","2898.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HAND L 2.3MM 6 HOLE PATE BONE PROFYE COMPRESSION","SUP-ITM-10143786","CDM","C1713","HCPCS","0278","RC","","","","both","","","3410.43","2046.26","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1940.53","56.9","","812.12","238.65","1587.46","163","396.63","2898.87","percent of total billed charges",""
"HAND L 2.3MM 6 HOLE PATE BONE PROFYE COMPRESSION","SUP-ITM-10143786","CDM","C1713","HCPCS","0278","RC","","","","both","","","3410.43","2046.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","396.63","11.63","","112.68","112.68","146.99","38","396.63","2898.87","percent of total billed charges",""
"HAND L 2.3MM 6 HOLE PATE BONE PROFYE COMPRESSION","SUP-ITM-10143786","CDM","C1713","HCPCS","0278","RC","","","","both","","","3410.43","2046.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2639.67","77.4","","303.98","303.98","5854.79","1 through 10","396.63","2898.87","percent of total billed charges",""
"HAND L 2.3MM 6 HOLE PATE BONE PROFYE COMPRESSION","SUP-ITM-10143786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3410.43","2046.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","396.63","11.63","","112.68","112.68","146.99","38","396.63","2639.67","percent of total billed charges",""
"HAND L 2.3MM 6 HOLE PATE BONE PROFYE COMPRESSION","SUP-ITM-10143786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3410.43","2046.26","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2141.07","62.78","","780.86","208.94","10480.28","15","396.63","2639.67","percent of total billed charges",""
"HAND L 2.3MM 6 HOLE PATE BONE PROFYE COMPRESSION","SUP-ITM-10143786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3410.43","2046.26","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1491.04","43.72","","179.76","179.76","179.76","1 through 10","396.63","2639.67","percent of total billed charges",""
"HAND L 2.3MM 6 HOLE PATE BONE PROFYE COMPRESSION","SUP-ITM-10143786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3410.43","2046.26","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2480.06","72.72","","2355.45","298.99","3965.19","155","396.63","2639.67","percent of total billed charges",""
"HAND L 2.3MM 6 HOLE PATE BONE PROFYE COMPRESSION","SUP-ITM-10143786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3410.43","2046.26","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2480.06","72.72","","3643.09","3643.09","3643.09","1 through 10","396.63","2639.67","percent of total billed charges",""
"HAND L 2.3MM 6 HOLE PATE BONE PROFYE COMPRESSION","SUP-ITM-10143786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3410.43","2046.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1815.03","53.22","","554.28","554.28","554.28","16","396.63","2639.67","percent of total billed charges",""
"HAND L 2.3MM 6 HOLE PATE BONE PROFYE COMPRESSION","SUP-ITM-10143786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3410.43","2046.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2145.16","62.9","","619.64","173.09","2370.64","150","396.63","2639.67","percent of total billed charges",""
"HAND L 2.3MM 6 HOLE PATE BONE PROFYE COMPRESSION","SUP-ITM-10143786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3410.43","2046.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2639.67","77.4","","303.98","303.98","5854.79","1 through 10","396.63","2639.67","percent of total billed charges",""
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/McC","513","MS-DRG","","","","","","","","inpatient","","","46828.55","28097.13","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","12785.78","","Case rate ($12,413.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,491.68, add-ons for qualifying new technology services are included. If operating cost exceeds $15,409.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,679.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,093.92 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,046.81 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.59. The transfer capital threshold is the transfer adjustment factor * $874.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","5836.31","5836.31","5836.31","1 through 10","3975","59823.56","other","Inpatient DRG"
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/McC","513","MS-DRG","","","","","","","","inpatient","","","46828.55","28097.13","MEDICARE [2001]","HB WDH MEDICARE","12413.38","","Case rate ($12,413.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,491.68, add-ons for qualifying new technology services are included. If operating cost exceeds $15,409.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,679.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,093.92 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,046.81 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $874.59. The transfer capital threshold is the transfer adjustment factor * $874.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11834.98","11834.98","11835.77","1 through 10","3975","59823.56","other","Inpatient DRG"
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/McC","514","MS-DRG","","","","","","","","inpatient","","","71724.29","43034.57","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8216.84","","Case rate ($8,216.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,618.31, add-ons for qualifying new technology services are included. If operating cost exceeds $11,536.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,372.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $7,204.04 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,173.44 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $567.93. The transfer capital threshold is the transfer adjustment factor * $567.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8158.27","8158.27","8158.27","1 through 10","3975","38847.5","other","Inpatient DRG"
"HAND PLATE 2.3MM 16 HOLE PROFYLE","SUP-ITM-10143710","CDM","C1713","HCPCS","0278","RC","","","","both","","","4579.26","2747.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","532.57","3892.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HAND PLATE 2.3MM 16 HOLE PROFYLE","SUP-ITM-10143710","CDM","C1713","HCPCS","0278","RC","","","","both","","","4579.26","2747.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","532.57","3892.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HAND PLATE 2.3MM 16 HOLE PROFYLE","SUP-ITM-10143710","CDM","C1713","HCPCS","0278","RC","","","","both","","","4579.26","2747.56","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2605.60","56.9","","812.12","238.65","1587.46","163","532.57","3892.37","percent of total billed charges",""
"HAND PLATE 2.3MM 16 HOLE PROFYLE","SUP-ITM-10143710","CDM","C1713","HCPCS","0278","RC","","","","both","","","4579.26","2747.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","532.57","11.63","","112.68","112.68","146.99","38","532.57","3892.37","percent of total billed charges",""
"HAND PLATE 2.3MM 16 HOLE PROFYLE","SUP-ITM-10143710","CDM","C1713","HCPCS","0278","RC","","","","both","","","4579.26","2747.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3544.35","77.4","","303.98","303.98","5854.79","1 through 10","532.57","3892.37","percent of total billed charges",""
"HAND PLATE 2.3MM 16 HOLE PROFYLE","SUP-ITM-10143710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4579.26","2747.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","532.57","11.63","","112.68","112.68","146.99","38","532.57","3544.35","percent of total billed charges",""
"HAND PLATE 2.3MM 16 HOLE PROFYLE","SUP-ITM-10143710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4579.26","2747.56","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2874.86","62.78","","780.86","208.94","10480.28","15","532.57","3544.35","percent of total billed charges",""
"HAND PLATE 2.3MM 16 HOLE PROFYLE","SUP-ITM-10143710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4579.26","2747.56","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2002.05","43.72","","179.76","179.76","179.76","1 through 10","532.57","3544.35","percent of total billed charges",""
"HAND PLATE 2.3MM 16 HOLE PROFYLE","SUP-ITM-10143710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4579.26","2747.56","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3330.04","72.72","","2355.45","298.99","3965.19","155","532.57","3544.35","percent of total billed charges",""
"HAND PLATE 2.3MM 16 HOLE PROFYLE","SUP-ITM-10143710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4579.26","2747.56","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3330.04","72.72","","3643.09","3643.09","3643.09","1 through 10","532.57","3544.35","percent of total billed charges",""
"HAND PLATE 2.3MM 16 HOLE PROFYLE","SUP-ITM-10143710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4579.26","2747.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2437.08","53.22","","554.28","554.28","554.28","16","532.57","3544.35","percent of total billed charges",""
"HAND PLATE 2.3MM 16 HOLE PROFYLE","SUP-ITM-10143710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4579.26","2747.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2880.35","62.9","","619.64","173.09","2370.64","150","532.57","3544.35","percent of total billed charges",""
"HAND PLATE 2.3MM 16 HOLE PROFYLE","SUP-ITM-10143710","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4579.26","2747.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3544.35","77.4","","303.98","303.98","5854.79","1 through 10","532.57","3544.35","percent of total billed charges",""
"HAND PLATE 2.3MM 4 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT BAR","SUP-ITM-10143796","CDM","C1713","HCPCS","0278","RC","","","","both","","","4475.68","2685.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","520.52","3804.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HAND PLATE 2.3MM 4 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT BAR","SUP-ITM-10143796","CDM","C1713","HCPCS","0278","RC","","","","both","","","4475.68","2685.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","520.52","3804.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HAND PLATE 2.3MM 4 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT BAR","SUP-ITM-10143796","CDM","C1713","HCPCS","0278","RC","","","","both","","","4475.68","2685.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2546.66","56.9","","812.12","238.65","1587.46","163","520.52","3804.33","percent of total billed charges",""
"HAND PLATE 2.3MM 4 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT BAR","SUP-ITM-10143796","CDM","C1713","HCPCS","0278","RC","","","","both","","","4475.68","2685.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","520.52","11.63","","112.68","112.68","146.99","38","520.52","3804.33","percent of total billed charges",""
"HAND PLATE 2.3MM 4 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT BAR","SUP-ITM-10143796","CDM","C1713","HCPCS","0278","RC","","","","both","","","4475.68","2685.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3464.18","77.4","","303.98","303.98","5854.79","1 through 10","520.52","3804.33","percent of total billed charges",""
"HAND PLATE 2.3MM 4 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT BAR","SUP-ITM-10143796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4475.68","2685.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","520.52","11.63","","112.68","112.68","146.99","38","520.52","3464.18","percent of total billed charges",""
"HAND PLATE 2.3MM 4 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT BAR","SUP-ITM-10143796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4475.68","2685.41","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2809.83","62.78","","780.86","208.94","10480.28","15","520.52","3464.18","percent of total billed charges",""
"HAND PLATE 2.3MM 4 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT BAR","SUP-ITM-10143796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4475.68","2685.41","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1956.77","43.72","","179.76","179.76","179.76","1 through 10","520.52","3464.18","percent of total billed charges",""
"HAND PLATE 2.3MM 4 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT BAR","SUP-ITM-10143796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4475.68","2685.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3254.71","72.72","","2355.45","298.99","3965.19","155","520.52","3464.18","percent of total billed charges",""
"HAND PLATE 2.3MM 4 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT BAR","SUP-ITM-10143796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4475.68","2685.41","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3254.71","72.72","","3643.09","3643.09","3643.09","1 through 10","520.52","3464.18","percent of total billed charges",""
"HAND PLATE 2.3MM 4 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT BAR","SUP-ITM-10143796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4475.68","2685.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2381.96","53.22","","554.28","554.28","554.28","16","520.52","3464.18","percent of total billed charges",""
"HAND PLATE 2.3MM 4 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT BAR","SUP-ITM-10143796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4475.68","2685.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2815.20","62.9","","619.64","173.09","2370.64","150","520.52","3464.18","percent of total billed charges",""
"HAND PLATE 2.3MM 4 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING STRAIGHT BAR","SUP-ITM-10143796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4475.68","2685.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3464.18","77.4","","303.98","303.98","5854.79","1 through 10","520.52","3464.18","percent of total billed charges",""
"HANDPIECE RFA SONATA - ORDER IN MULTIPLES OF 5EA","SUP-ITM-10287871","CDM","C1886","HCPCS","0272","RC","","","","both","","","13938.00","8362.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","17905.28","17905.28","17905.28","1 through 10","1620.99","11847.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HANDPIECE RFA SONATA - ORDER IN MULTIPLES OF 5EA","SUP-ITM-10287871","CDM","C1886","HCPCS","0272","RC","","","","both","","","13938.00","8362.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","5539.33","5539.33","5539.33","1 through 10","1620.99","11847.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HANDPIECE RFA SONATA - ORDER IN MULTIPLES OF 5EA","SUP-ITM-10287871","CDM","C1886","HCPCS","0272","RC","","","","both","","","13938.00","8362.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1620.99","11.63","","1314.65","1314.65","1314.65","1 through 10","1620.99","11847.3","percent of total billed charges",""
"HANDPIECE RFA SONATA - ORDER IN MULTIPLES OF 5EA","SUP-ITM-10287871","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","13938.00","8362.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1620.99","11.63","","1314.65","1314.65","1314.65","1 through 10","1620.99","10788.01","percent of total billed charges",""
"HANDPIECE RFA SONATA - ORDER IN MULTIPLES OF 5EA","SUP-ITM-10287871","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","13938.00","8362.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10135.71","72.72","","16561.06","16561.06","16561.06","1 through 10","1620.99","10788.01","percent of total billed charges",""
"Haptoglobin Qn","PX-30000486","CDM","83010","CPT","0301","RC","","","","both","","","68.00","40.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","47.46","69.8","","46.07","46.07","46.07","1 through 10","8.18","64.73","percent of total billed charges",""
"Haptoglobin Qn","PX-30000486","CDM","83010","CPT","0301","RC","","","","outpatient","","","68.00","40.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","29.73","43.72","","28.86","28.86","28.86","1 through 10","11.73","52.63","percent of total billed charges",""
"Haptoglobin Qn","PX-30000486","CDM","83010","CPT","0301","RC","","","","outpatient","","","68.00","40.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","49.45","72.72","","48.00","48.00","96.00","1 through 10","11.73","52.63","percent of total billed charges",""
"Haptoglobin Qn","PX-30000486","CDM","83010","CPT","0301","RC","","","","outpatient","","","68.00","40.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","42.77","62.9","","41.58","41.58","41.58","1 through 10","11.73","52.63","percent of total billed charges",""
"HC Amb Surgical Boot Eac","PX-27001963","CDM","L3260","HCPCS","0274","RC","","","","outpatient","","","52.00","31.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","6.05","11.63","","7.16","7.16","7.16","1 through 10","6.05","40.25","percent of total billed charges",""
"HC Amphetamine or Methamphetamine (Quant Amphetamines 5 or More)","PX-30002843","CDM","80326","CPT","0301","RC","","","","both","","","58.00","34.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","33.00","56.9","","22.59","22.59","22.59","1 through 10","33","117.86","percent of total billed charges",""
"HC Benzodiazepines (Benzodiazepines 13 or More)","PX-30002864","CDM","80347","CPT","0301","RC","","","","both","","","549.00","329.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","312.38","56.9","","214.24","214.24","214.24","1 through 10","74.38","466.65","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0300","RC","","","","inpatient","","","49.00","29.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","37.66","76.86","","29.61","29.61","29.61","1 through 10","32.44","37.66","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","49.00","29.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","34.20","69.8","","32.81","29.56","32.81","106","15.04","262.09","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","49.00","29.40","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","41.83","","APC Price ($41.01). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","39.07","39.07","39.07","1 through 10","15.04","262.09","other","OPPS APC"
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","49.00","29.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","262.09","","Case rate ($262.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1.94","1.94","1.94","119","15.04","262.09","other","OPPS APC"
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","49.00","29.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","112.85","","Case rate ($112.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1.94","1.94","1.94","248","15.04","262.09","other","OPPS APC"
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","49.00","29.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","40.19","","APC Price ($41.01). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2.99","2.97","4.07","109","15.04","262.09","other","OPPS APC"
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","49.00","29.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","211.84","","Case rate ($211.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1.94","1.94","1.94","269","15.04","262.09","other","OPPS APC"
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","49.00","29.40","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","34.20","69.8","","32.81","32.81","32.81","1 through 10","15.04","262.09","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","49.00","29.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","41.65","85","","32.81","32.81","32.81","1 through 10","15.04","262.09","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","49.00","29.40","TRICARE [160005]","HB WDH MEDICARE","41.01","","APC Price ($41.01). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","134.69","134.69","134.69","1 through 10","15.04","262.09","other","OPPS APC"
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","49.00","29.40","WELLPOINT [1015]","HB WDH ANTHEM PPO","211.84","","Case rate ($211.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6.15","6.15","6.15","1 through 10","15.04","262.09","other","OPPS APC"
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","outpatient","","","49.00","29.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","30.76","62.78","","29.51","29.51","88.53","1 through 10","2.77","37.93","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","outpatient","","","49.00","29.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","21.42","43.72","","20.55","20.55","41.10","12","2.77","37.93","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","outpatient","","","49.00","29.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","35.63","72.72","","34.18","34.18","34.18","134","2.77","37.93","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","outpatient","","","49.00","29.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","35.63","72.72","","34.18","34.18","34.18","1 through 10","2.77","37.93","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","outpatient","","","49.00","29.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","26.08","53.22","","25.06","25.06","25.06","1 through 10","2.77","37.93","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","outpatient","","","49.00","29.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","30.82","62.9","","29.61","29.61","29.61","150","2.77","37.93","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","outpatient","","","49.00","29.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","37.93","77.4","","36.43","36.43","36.43","73","2.77","37.93","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","outpatient","","","49.00","29.40","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","35.63","72.72","","34.18","34.18","34.18","1 through 10","2.77","37.93","percent of total billed charges",""
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","both","","","1437.00","862.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","349.24","","APC Price ($342.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","342.39","342.39","342.39","1 through 10","335.54","2286.14","other","OPPS APC"
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","both","","","1437.00","862.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2286.14","","Case rate ($2,286.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2230.39","2230.39","2230.39","1 through 10","335.54","2286.14","other","OPPS APC"
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","both","","","1437.00","862.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","335.54","","APC Price ($342.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","340.04","340.04","340.04","1 through 10","335.54","2286.14","other","OPPS APC"
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","both","","","1437.00","862.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","817.65","56.9","","2452.95","817.65","5449.53","1 through 10","335.54","2286.14","percent of total billed charges",""
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","both","","","1437.00","862.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","342.39","","APC Price ($342.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","341.43","336.91","341.43","1 through 10","335.54","2286.14","other","OPPS APC"
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","both","","","1437.00","862.20","MEDICARE [2001]","HB WDH MEDICARE","342.39","","APC Price ($342.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","342.39","342.39","346.98","1 through 10","335.54","2286.14","other","OPPS APC"
"HC Brachy Nonstranded IR-192 Hdr per Source Tier1","PX-27000031","CDM","C1717","HCPCS","0278","RC","","","","outpatient","","","1437.00","862.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1112.24","77.4","","1113.68","1113.68","1113.68","1 through 10","167.12","1112.24","percent of total billed charges",""
"HC Bwh Kappa Free Light Chain","PX-30002821","CDM","83520","CPT","0301","RC","","","","both","","","200.00","120.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","139.60","69.8","","134.71","14.76","134.71","17","11.23","170","percent of total billed charges",""
"HC Bwh Kappa Free Light Chain","PX-30002821","CDM","83520","CPT","0301","RC","","","","inpatient","","","200.00","120.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","153.72","76.86","","121.59","121.59","121.59","1 through 10","132.4","153.72","percent of total billed charges",""
"HC Bwh Kappa Free Light Chain","PX-30002821","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","145.44","72.72","","140.35","140.35","140.35","16","12.06","154.8","percent of total billed charges",""
"HC Bwh Kappa Free Light Chain","PX-30002821","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","145.44","72.72","","140.35","140.35","140.35","1 through 10","12.06","154.8","percent of total billed charges",""
"HC Bwh Kappa Free Light Chain","PX-30002821","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","106.44","53.22","","102.89","102.89","102.89","1 through 10","12.06","154.8","percent of total billed charges",""
"HC Bwh Kappa Free Light Chain","PX-30002821","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","125.80","62.9","","243.18","121.59","364.77","19","12.06","154.8","percent of total billed charges",""
"HC Bwh Kappa Free Light Chain","PX-30002821","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","154.80","77.4","","149.58","138.91","149.58","12","12.06","154.8","percent of total billed charges",""
"HC Catheter Inf per/Cent/Midline O/Than Hem Tier1","PX-27000057","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","1561.00","936.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","181.54","11.63","","214.95","191.07","214.95","1 through 10","181.54","1208.21","percent of total billed charges",""
"HC Catheter Inf per/Cent/Midline O/Than Hem Tier1","PX-27000057","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","1561.00","936.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1135.16","72.72","","3405.48","1135.16","3405.48","1 through 10","181.54","1208.21","percent of total billed charges",""
"HC Catheter Inf per/Cent/Midline O/Than Hem Tier1","PX-27000057","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","1561.00","936.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","981.87","62.9","","3937.48","3937.48","3937.48","1 through 10","181.54","1208.21","percent of total billed charges",""
"HC Collect Blood From Catheter Venous","PX-76001108","CDM","36592","CPT","0761","RC","","","","both","","","238.00","142.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","695.68","","Case rate ($695.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","230.00","230.00","230.00","1 through 10","131.98","860.68","other","OPPS APC"
"HC Collect Blood From Catheter Venous","PX-76001108","CDM","36592","CPT","0761","RC","","","","both","","","238.00","142.80","MEDICARE [2001]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","134.69","134.69","134.69","1 through 10","131.98","860.68","other","OPPS APC"
"HC Collect Blood From Catheter Venous","PX-76001108","CDM","36592","CPT","0761","RC","","","","both","","","238.00","142.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","132.00","132.00","132.00","1 through 10","131.98","860.68","other","OPPS APC"
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","both","","","5774.00","3464.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","6363.44","","Case rate ($6,363.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3307.34","3307.34","3307.34","1 through 10","1207.22","7872.71","other","OPPS APC"
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","both","","","5774.00","3464.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3285.41","56.9","","3170.47","3170.47","3170.47","1 through 10","1207.22","7872.71","percent of total billed charges",""
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","both","","","5774.00","3464.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","603.68","603.68","603.68","1 through 10","1207.22","7872.71","other","OPPS APC"
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","both","","","5774.00","3464.40","MEDICARE [2001]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1232.00","1232.00","1232.00","1 through 10","1207.22","7872.71","other","OPPS APC"
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","both","","","5774.00","3464.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1207.36","603.68","1207.36","1 through 10","1207.22","7872.71","other","OPPS APC"
"HC Critical Care; First 30-74 Minutes","PX-45000006","CDM","99291","CPT","0450","RC","","","","both","","","4152.00","2491.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","880.33","","APC Price ($880.33). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2713.43","2711.23","2713.73","50","862.72","5626.1","other","OPPS APC"
"HC Critical Care; First 30-74 Minutes","PX-45000006","CDM","99291","CPT","0450","RC","","","","outpatient","","","4152.00","2491.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","482.88","11.63","","445.65","445.65","445.65","1 through 10","482.88","3213.65","percent of total billed charges",""
"HC Hzv Zoster Vacc Recombinant Adjuvanted Im Njx","PX-63601284","CDM","90750","CPT","0636","RC","","","","both","","","289.00","173.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","186.20","64.43","","221.95","221.95","221.95","1 through 10","186.2","572.15","percent of total billed charges",""
"HC Hzv Zoster Vacc Recombinant Adjuvanted Im Njx","PX-63601284","CDM","90750","CPT","0636","RC","","","","outpatient","","","289.00","173.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","223.69","77.4","","252.70","252.70","252.70","1 through 10","33.61","223.69","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","both","","","482.00","289.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","336.44","69.8","","299.44","269.84","299.44","1 through 10","22.81","409.7","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","both","","","482.00","289.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","274.26","56.9","","244.10","244.10","244.10","22","22.81","409.7","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","both","","","482.00","289.20","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","274.26","56.9","","244.10","244.10","244.10","1 through 10","22.81","409.7","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","outpatient","","","482.00","289.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","69.50","14.42","","31.26","31.26","31.26","1 through 10","56.06","373.07","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","outpatient","","","482.00","289.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","56.06","11.63","","30.96","30.96","30.96","1 through 10","56.06","373.07","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","outpatient","","","482.00","289.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","302.60","62.78","","269.33","269.33","269.33","1 through 10","56.06","373.07","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","outpatient","","","482.00","289.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","350.51","72.72","","311.97","311.97","311.97","11","56.06","373.07","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","outpatient","","","482.00","289.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","303.18","62.9","","270.27","270.27","270.27","35","56.06","373.07","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","outpatient","","","482.00","289.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","373.07","77.4","","332.48","332.48","332.48","12","56.06","373.07","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","outpatient","","","482.00","289.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","350.51","72.72","","311.97","311.97","311.97","1 through 10","56.06","373.07","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","outpatient","","","482.00","289.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","56.06","11.63","","30.96","30.96","30.96","1 through 10","56.06","373.07","percent of total billed charges",""
"HC Immunoassay Infectious Agent Antibody Quan","PX-30000827","CDM","86317","CPT","0302","RC","","","","both","","","80.00","48.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","55.84","69.8","","53.75","53.75","53.75","1 through 10","9.74","76.77","percent of total billed charges",""
"HC Immunoassay Infectious Agent Antibody Quan","PX-30000827","CDM","86317","CPT","0302","RC","","","","outpatient","","","80.00","48.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","58.18","72.72","","55.99","55.99","55.99","1 through 10","13.96","61.92","percent of total billed charges",""
"HC Immunoassay Infectious Agent Antibody Quan","PX-30000827","CDM","86317","CPT","0302","RC","","","","outpatient","","","80.00","48.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","50.32","62.9","","145.53","48.51","182.32","11","13.96","61.92","percent of total billed charges",""
"HC Immunoassay Infectious Agent Antibody Quan","PX-30000827","CDM","86317","CPT","0302","RC","","","","outpatient","","","80.00","48.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","61.92","77.4","","59.68","59.68","59.68","1 through 10","13.96","61.92","percent of total billed charges",""
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","both","","","144737.00","86842.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","34166.59","","APC Price ($33,496.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","34956.01","33500.50","34956.01","1 through 10","32826.72","214074.65","other","OPPS APC"
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","both","","","144737.00","86842.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","92180.32","","Case rate ($92,180.32). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","89933.07","89933.07","89933.07","1 through 10","32826.72","214074.65","other","OPPS APC"
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","both","","","144737.00","86842.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","32826.72","","APC Price ($33,496.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","32957.83","32957.83","32957.83","1 through 10","32826.72","214074.65","other","OPPS APC"
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","both","","","144737.00","86842.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","34501.56","","APC Price ($33,496.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","33826.41","33826.41","33826.41","1 through 10","32826.72","214074.65","other","OPPS APC"
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","both","","","144737.00","86842.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","33496.66","","APC Price ($33,496.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","32838.39","32838.39","32838.39","1 through 10","32826.72","214074.65","other","OPPS APC"
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","both","","","144737.00","86842.20","MEDICARE [2001]","HB WDH MEDICARE","33496.66","","APC Price ($33,496.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","64110.06","64110.06","96165.09","23","32826.72","214074.65","other","OPPS APC"
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","both","","","144737.00","86842.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","33496.66","","APC Price ($33,496.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","32838.39","32838.39","32838.39","1 through 10","32826.72","214074.65","other","OPPS APC"
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","outpatient","","","144737.00","86842.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16832.91","11.63","","35845.20","35845.20","35845.20","1 through 10","16832.91","112026.44","percent of total billed charges",""
"HC Insj/Rplcmt Perm Dfb W/Trnsvns Lds 1/Dual Chmbr","PX-48000074","CDM","33249","CPT","0361","RC","","","","outpatient","","","144737.00","86842.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","91039.57","62.9","","87990.21","87990.21","87990.21","1 through 10","16832.91","112026.44","percent of total billed charges",""
"HC Njx Dx/Ther Agt Pvrt Facet Jt Crv/Thrc 1 Level (Lt)","PX-76001531","CDM","64490","CPT","0761","RC","","","","both","","","4999.00","2999.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2844.43","56.9","","12161.81","12161.81","12161.81","1 through 10","911.54","5944.45","percent of total billed charges",""
"HC Njx Dx/Ther Agt Pvrt Facet Jt Crv/Thrc 1 Level (Lt)","PX-76001531","CDM","64490","CPT","0761","RC","","","","both","","","4999.00","2999.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1373.06","915.37","1376.48","24","911.54","5944.45","other","OPPS APC"
"HC Njx Dx/Ther Agt Pvrt Facet Jt Crv/Thrc 1 Level (Lt)","PX-76001531","CDM","64490","CPT","0761","RC","","","","outpatient","","","4999.00","2999.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3635.27","3635.27","3635.27","1 through 10","581.38","3869.23","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"HC Open/Perq Placement Intravascular Stent Initial","PX-76001940","CDM","37236","CPT","0761","RC","","","","both","","","40925.00","24555.00","MEDICARE [2001]","HB WDH MEDICARE","11848.17","","APC Price ($11,848.17). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","21437.82","21437.82","21437.82","1 through 10","11611.21","75720.79","other","OPPS APC"
"HC Opiate(S), Drug and Metab, Ea Proc (Opioids & Opiate Analogs 5+)","PX-30002881","CDM","80364","CPT","0301","RC","","","","both","","","52.00","31.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","29.59","56.9","","20.17","20.17","20.17","1 through 10","29.59","117.86","percent of total billed charges",""
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","both","","","236.00","141.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","164.73","69.8","","159.14","159.14","159.14","1 through 10","38.18","248.99","percent of total billed charges",""
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","both","","","236.00","141.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","248.99","","Case rate ($248.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","228.00","228.00","228.00","1 through 10","38.18","248.99","other","OPPS APC"
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","both","","","236.00","141.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","107.21","","Case rate ($107.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","92.57","92.57","92.57","1 through 10","38.18","248.99","other","OPPS APC"
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","both","","","236.00","141.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","38.18","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","38.18","36.01","38.41","1 through 10","38.18","248.99","other","OPPS APC"
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","both","","","236.00","141.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","201.25","","Case rate ($201.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","196.34","196.34","196.34","1 through 10","38.18","248.99","other","OPPS APC"
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","both","","","236.00","141.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","134.28","56.9","","129.73","129.73","129.73","1 through 10","38.18","248.99","percent of total billed charges",""
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","both","","","236.00","141.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","40.13","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","40.13","39.33","40.13","1 through 10","38.18","248.99","other","OPPS APC"
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","both","","","236.00","141.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.30","36.12","38.96","1 through 10","38.18","248.99","other","OPPS APC"
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","both","","","236.00","141.60","MEDICARE [2001]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.96","38.96","38.96","39","38.18","248.99","other","OPPS APC"
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","both","","","236.00","141.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.69","38.19","38.96","35","38.18","248.99","other","OPPS APC"
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","outpatient","","","236.00","141.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","27.45","11.63","","31.40","31.40","31.40","1 through 10","27.45","182.66","percent of total billed charges",""
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","outpatient","","","236.00","141.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","171.62","72.72","","165.80","165.80","165.80","1 through 10","27.45","182.66","percent of total billed charges",""
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","outpatient","","","236.00","141.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","148.44","62.9","","143.64","143.64","143.64","1 through 10","27.45","182.66","percent of total billed charges",""
"HC Prgrmg Eval Implantable in Prsn Dual Lead Dfb","PX-48000009","CDM","93283","CPT","0480","RC","","","","outpatient","","","236.00","141.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","182.66","77.4","","176.70","176.70","176.70","1 through 10","27.45","182.66","percent of total billed charges",""
"HC Rmvl Impltbl Dfb Pls Gen W/Rplcmt Pls Gen Mlt Ld","PX-48000077","CDM","33264","CPT","0361","RC","","","","both","","","144737.00","86842.20","MEDICARE [2001]","HB WDH MEDICARE","33496.66","","APC Price ($33,496.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","33500.50","32055.03","33500.50","1 through 10","32826.72","214074.65","other","OPPS APC"
"HC Rmvl Impltbl Dfb Pls Gen W/Rplcmt Pls Gen Mlt Ld","PX-48000077","CDM","33264","CPT","0361","RC","","","","outpatient","","","144737.00","86842.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16832.91","11.63","","16496.91","16496.91","16496.91","1 through 10","16832.91","112026.44","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","both","","","468.00","280.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","326.66","69.8","","326.66","294.37","468.00","1 through 10","266.29","532.67","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","both","","","468.00","280.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","266.29","56.9","","61.75","61.73","61.75","1 through 10","266.29","532.67","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","outpatient","","","468.00","280.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","67.49","14.42","","67.49","67.49","67.49","1 through 10","54.43","362.23","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","outpatient","","","468.00","280.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","54.43","11.63","","64.44","55.27","118.18","1 through 10","54.43","362.23","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","outpatient","","","468.00","280.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","340.33","72.72","","340.33","340.33","340.33","1 through 10","54.43","362.23","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","outpatient","","","468.00","280.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","340.33","72.72","","340.33","340.33","340.33","1 through 10","54.43","362.23","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","outpatient","","","468.00","280.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","294.37","62.9","","294.84","294.84","294.84","1 through 10","54.43","362.23","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","outpatient","","","468.00","280.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","362.23","77.4","","362.70","362.70","362.70","1 through 10","54.43","362.23","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","outpatient","","","468.00","280.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","54.43","11.63","","55.27","55.27","55.27","1 through 10","54.43","362.23","percent of total billed charges",""
"Hcg Ql","PX-30000743","CDM","84703","CPT","0300","RC","","","","inpatient","","","113.00","67.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","86.85","76.86","","68.67","66.21","68.67","1 through 10","74.81","86.85","percent of total billed charges",""
"Hcg Ql","PX-30000743","CDM","84703","CPT","0301","RC","","","","both","","","113.00","67.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","78.87","69.8","","76.08","76.08","76.08","1 through 10","4.89","96.05","percent of total billed charges",""
"Hcg Ql","PX-30000743","CDM","84703","CPT","0301","RC","","","","outpatient","","","113.00","67.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","70.94","62.78","","68.43","68.43","68.43","1 through 10","7.01","87.46","percent of total billed charges",""
"Hcg Ql","PX-30000743","CDM","84703","CPT","0301","RC","","","","outpatient","","","113.00","67.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","49.40","43.72","","47.65","47.65","47.65","1 through 10","7.01","87.46","percent of total billed charges",""
"Hcg Ql","PX-30000743","CDM","84703","CPT","0301","RC","","","","outpatient","","","113.00","67.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","82.17","72.72","","79.26","79.26","79.26","19","7.01","87.46","percent of total billed charges",""
"Hcg Ql","PX-30000743","CDM","84703","CPT","0301","RC","","","","outpatient","","","113.00","67.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","60.14","53.22","","58.11","58.11","58.11","1 through 10","7.01","87.46","percent of total billed charges",""
"Hcg Ql","PX-30000743","CDM","84703","CPT","0301","RC","","","","outpatient","","","113.00","67.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","71.08","62.9","","68.67","68.67","258.28","31","7.01","87.46","percent of total billed charges",""
"Hcg Ql","PX-30000743","CDM","84703","CPT","0301","RC","","","","outpatient","","","113.00","67.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","87.46","77.4","","84.48","79.26","84.48","1 through 10","7.01","87.46","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0300","RC","","","","inpatient","","","213.00","127.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","163.71","76.86","","129.78","129.78","129.78","1 through 10","141.01","163.71","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","both","","","213.00","127.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","148.67","69.8","","143.79","129.57","143.79","138","9.78","181.05","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","both","","","213.00","127.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","181.05","85","","83.73","13.55","206.00","1 through 10","9.78","181.05","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","outpatient","","","213.00","127.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","133.72","62.78","","258.66","129.33","258.66","1 through 10","14.03","164.86","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","outpatient","","","213.00","127.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","93.12","43.72","","90.06","90.06","90.06","1 through 10","14.03","164.86","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","outpatient","","","213.00","127.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","154.89","72.72","","149.80","139.00","149.80","160","14.03","164.86","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","outpatient","","","213.00","127.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","154.89","72.72","","149.80","149.80","149.80","1 through 10","14.03","164.86","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","outpatient","","","213.00","127.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","113.36","53.22","","109.82","26.54","109.82","1 through 10","14.03","164.86","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","outpatient","","","213.00","127.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","133.98","62.9","","129.78","129.78","129.78","212","14.03","164.86","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","outpatient","","","213.00","127.80","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","154.89","72.72","","159.65","149.80","159.65","1 through 10","14.03","164.86","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","outpatient","","","213.00","127.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","164.86","77.4","","159.65","159.65","159.65","111","14.03","164.86","percent of total billed charges",""
"Hdr Rdncl Ntrstl/Intrcav Brachytx 1 Channel","PX-33000124","CDM","77770","CPT","0333","RC","","","","both","","","7864.00","4718.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","4632.53","","Case rate ($4,632.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4519.56","4519.56","4519.56","1 through 10","710.37","6684.4","other","OPPS APC"
"Hdr Rdncl Ntrstl/Intrcav Brachytx 1 Channel","PX-33000124","CDM","77770","CPT","0333","RC","","","","both","","","7864.00","4718.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","710.37","","APC Price ($724.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","684.61","684.61","684.61","1 through 10","710.37","6684.4","other","OPPS APC"
"Hdr Rdncl Ntrstl/Intrcav Brachytx 1 Channel","PX-33000124","CDM","77770","CPT","0333","RC","","","","both","","","7864.00","4718.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","724.86","","APC Price ($724.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","713.35","687.40","713.35","1 through 10","710.37","6684.4","other","OPPS APC"
"Hdr Rdncl Ntrstl/Intrcav Brachytx 1 Channel","PX-33000124","CDM","77770","CPT","0333","RC","","","","both","","","7864.00","4718.40","MEDICARE [2001]","HB WDH MEDICARE","724.86","","APC Price ($724.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","724.95","698.58","724.95","1 through 10","710.37","6684.4","other","OPPS APC"
"Hdr Rdncl Ntrstl/Intrcav Brachytx 1 Channel","PX-33000124","CDM","77770","CPT","0333","RC","","","","outpatient","","","7864.00","4718.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6086.74","77.4","","5881.48","5881.48","5881.48","1 through 10","914.58","6086.74","percent of total billed charges",""
"HEAD BIOLOX 36MM 12/14 DELTA FEMORAL SHORT","SUP-ITM-10269632","CDM","C1776","HCPCS","0278","RC","","","","both","","","3752.13","2251.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","436.37","3189.31","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HEAD BIOLOX 36MM 12/14 DELTA FEMORAL SHORT","SUP-ITM-10269632","CDM","C1776","HCPCS","0278","RC","","","","both","","","3752.13","2251.28","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2134.96","56.9","","2911.53","1863.86","5209.05","65","436.37","3189.31","percent of total billed charges",""
"HEAD BIOLOX 36MM 12/14 DELTA FEMORAL SHORT","SUP-ITM-10269632","CDM","C1776","HCPCS","0278","RC","","","","both","","","3752.13","2251.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","436.37","11.63","","400.94","400.94","400.94","1 through 10","436.37","3189.31","percent of total billed charges",""
"HEAD BIOLOX 36MM 12/14 DELTA FEMORAL SHORT","SUP-ITM-10269632","CDM","C1776","HCPCS","0278","RC","","","","both","","","3752.13","2251.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2904.15","77.4","","5214.50","5214.50","16415.28","1 through 10","436.37","3189.31","percent of total billed charges",""
"HEAD BIOLOX 36MM 12/14 DELTA FEMORAL SHORT","SUP-ITM-10269632","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3752.13","2251.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","436.37","11.63","","400.94","400.94","400.94","1 through 10","436.37","2904.15","percent of total billed charges",""
"HEAD BIOLOX 36MM 12/14 DELTA FEMORAL SHORT","SUP-ITM-10269632","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3752.13","2251.28","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1640.43","43.72","","1543.33","1543.33","1671.61","1 through 10","436.37","2904.15","percent of total billed charges",""
"HEAD BIOLOX 36MM 12/14 DELTA FEMORAL SHORT","SUP-ITM-10269632","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3752.13","2251.28","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2728.55","72.72","","3700.21","2382.07","6427.18","53","436.37","2904.15","percent of total billed charges",""
"HEAD BIOLOX 36MM 12/14 DELTA FEMORAL SHORT","SUP-ITM-10269632","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3752.13","2251.28","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2728.55","72.72","","12685.80","12685.80","12685.80","1 through 10","436.37","2904.15","percent of total billed charges",""
"HEAD BIOLOX 36MM 12/14 DELTA FEMORAL SHORT","SUP-ITM-10269632","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3752.13","2251.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2360.09","62.9","","3408.87","2784.05","9859.40","46","436.37","2904.15","percent of total billed charges",""
"HEAD BIOLOX 36MM 12/14 DELTA FEMORAL SHORT","SUP-ITM-10269632","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3752.13","2251.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2904.15","77.4","","5214.50","5214.50","16415.28","1 through 10","436.37","2904.15","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","482.18","3524.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2359.07","56.9","","2911.53","1863.86","5209.05","65","482.18","3524.1","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","482.18","11.63","","400.94","400.94","400.94","1 through 10","482.18","3524.1","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3209.00","77.4","","5214.50","5214.50","16415.28","1 through 10","482.18","3524.1","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","482.18","11.63","","400.94","400.94","400.94","1 through 10","482.18","3209","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1812.63","43.72","","1543.33","1543.33","1671.61","1 through 10","482.18","3209","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3014.97","72.72","","3700.21","2382.07","6427.18","53","482.18","3209","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3014.97","72.72","","12685.80","12685.80","12685.80","1 through 10","482.18","3209","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2607.83","62.9","","3408.87","2784.05","9859.40","46","482.18","3209","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3209.00","77.4","","5214.50","5214.50","16415.28","1 through 10","482.18","3209","percent of total billed charges",""
"HEAD RADIAL 10X22MM PLUS 0 ELBOW 5.5MM STEM","SUP-ITM-10286314","CDM","C1776","HCPCS","0278","RC","","","","both","","","12431.40","7458.84","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1445.77","10566.69","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HEAD RADIAL 10X22MM PLUS 0 ELBOW 5.5MM STEM","SUP-ITM-10286314","CDM","C1776","HCPCS","0278","RC","","","","both","","","12431.40","7458.84","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7073.47","56.9","","2911.53","1863.86","5209.05","65","1445.77","10566.69","percent of total billed charges",""
"HEAD RADIAL 10X22MM PLUS 0 ELBOW 5.5MM STEM","SUP-ITM-10286314","CDM","C1776","HCPCS","0278","RC","","","","both","","","12431.40","7458.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1445.77","11.63","","400.94","400.94","400.94","1 through 10","1445.77","10566.69","percent of total billed charges",""
"HEAD RADIAL 10X22MM PLUS 0 ELBOW 5.5MM STEM","SUP-ITM-10286314","CDM","C1776","HCPCS","0278","RC","","","","both","","","12431.40","7458.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9621.90","77.4","","5214.50","5214.50","16415.28","1 through 10","1445.77","10566.69","percent of total billed charges",""
"HEAD RADIAL 10X22MM PLUS 0 ELBOW 5.5MM STEM","SUP-ITM-10286314","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12431.40","7458.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1445.77","11.63","","400.94","400.94","400.94","1 through 10","1445.77","9621.9","percent of total billed charges",""
"HEAD RADIAL 10X22MM PLUS 0 ELBOW 5.5MM STEM","SUP-ITM-10286314","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12431.40","7458.84","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","5435.01","43.72","","1543.33","1543.33","1671.61","1 through 10","1445.77","9621.9","percent of total billed charges",""
"HEAD RADIAL 10X22MM PLUS 0 ELBOW 5.5MM STEM","SUP-ITM-10286314","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12431.40","7458.84","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","9040.11","72.72","","3700.21","2382.07","6427.18","53","1445.77","9621.9","percent of total billed charges",""
"HEAD RADIAL 10X22MM PLUS 0 ELBOW 5.5MM STEM","SUP-ITM-10286314","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12431.40","7458.84","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","9040.11","72.72","","12685.80","12685.80","12685.80","1 through 10","1445.77","9621.9","percent of total billed charges",""
"HEAD RADIAL 10X22MM PLUS 0 ELBOW 5.5MM STEM","SUP-ITM-10286314","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12431.40","7458.84","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7819.35","62.9","","3408.87","2784.05","9859.40","46","1445.77","9621.9","percent of total billed charges",""
"HEAD RADIAL 10X22MM PLUS 0 ELBOW 5.5MM STEM","SUP-ITM-10286314","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12431.40","7458.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9621.90","77.4","","5214.50","5214.50","16415.28","1 through 10","1445.77","9621.9","percent of total billed charges",""
"HEAD RADIAL 22MM LEFT ARH SOLUTIONS 2","SUP-ITM-10276307","CDM","C1776","HCPCS","0278","RC","","","","both","","","15986.28","9591.77","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1859.2","13588.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HEAD RADIAL 22MM LEFT ARH SOLUTIONS 2","SUP-ITM-10276307","CDM","C1776","HCPCS","0278","RC","","","","both","","","15986.28","9591.77","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","9096.19","56.9","","2911.53","1863.86","5209.05","65","1859.2","13588.34","percent of total billed charges",""
"HEAD RADIAL 22MM LEFT ARH SOLUTIONS 2","SUP-ITM-10276307","CDM","C1776","HCPCS","0278","RC","","","","both","","","15986.28","9591.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1859.20","11.63","","400.94","400.94","400.94","1 through 10","1859.2","13588.34","percent of total billed charges",""
"HEAD RADIAL 22MM LEFT ARH SOLUTIONS 2","SUP-ITM-10276307","CDM","C1776","HCPCS","0278","RC","","","","both","","","15986.28","9591.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12373.38","77.4","","5214.50","5214.50","16415.28","1 through 10","1859.2","13588.34","percent of total billed charges",""
"HEAD RADIAL 22MM LEFT ARH SOLUTIONS 2","SUP-ITM-10276307","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15986.28","9591.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1859.20","11.63","","400.94","400.94","400.94","1 through 10","1859.2","12373.38","percent of total billed charges",""
"HEAD RADIAL 22MM LEFT ARH SOLUTIONS 2","SUP-ITM-10276307","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15986.28","9591.77","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","6989.20","43.72","","1543.33","1543.33","1671.61","1 through 10","1859.2","12373.38","percent of total billed charges",""
"HEAD RADIAL 22MM LEFT ARH SOLUTIONS 2","SUP-ITM-10276307","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15986.28","9591.77","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","11625.22","72.72","","3700.21","2382.07","6427.18","53","1859.2","12373.38","percent of total billed charges",""
"HEAD RADIAL 22MM LEFT ARH SOLUTIONS 2","SUP-ITM-10276307","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15986.28","9591.77","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","11625.22","72.72","","12685.80","12685.80","12685.80","1 through 10","1859.2","12373.38","percent of total billed charges",""
"HEAD RADIAL 22MM LEFT ARH SOLUTIONS 2","SUP-ITM-10276307","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15986.28","9591.77","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","10055.37","62.9","","3408.87","2784.05","9859.40","46","1859.2","12373.38","percent of total billed charges",""
"HEAD RADIAL 22MM LEFT ARH SOLUTIONS 2","SUP-ITM-10276307","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15986.28","9591.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12373.38","77.4","","5214.50","5214.50","16415.28","1 through 10","1859.2","12373.38","percent of total billed charges",""
"HEAD RADIAL 22MM RIGHT ARH SOLUTIONS 2","SUP-ITM-10282059","CDM","C1776","HCPCS","0278","RC","","","","both","","","15986.28","9591.77","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1859.2","13588.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HEAD RADIAL 22MM RIGHT ARH SOLUTIONS 2","SUP-ITM-10282059","CDM","C1776","HCPCS","0278","RC","","","","both","","","15986.28","9591.77","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","9096.19","56.9","","2911.53","1863.86","5209.05","65","1859.2","13588.34","percent of total billed charges",""
"HEAD RADIAL 22MM RIGHT ARH SOLUTIONS 2","SUP-ITM-10282059","CDM","C1776","HCPCS","0278","RC","","","","both","","","15986.28","9591.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1859.20","11.63","","400.94","400.94","400.94","1 through 10","1859.2","13588.34","percent of total billed charges",""
"HEAD RADIAL 22MM RIGHT ARH SOLUTIONS 2","SUP-ITM-10282059","CDM","C1776","HCPCS","0278","RC","","","","both","","","15986.28","9591.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12373.38","77.4","","5214.50","5214.50","16415.28","1 through 10","1859.2","13588.34","percent of total billed charges",""
"HEAD RADIAL 22MM RIGHT ARH SOLUTIONS 2","SUP-ITM-10282059","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15986.28","9591.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1859.20","11.63","","400.94","400.94","400.94","1 through 10","1859.2","12373.38","percent of total billed charges",""
"HEAD RADIAL 22MM RIGHT ARH SOLUTIONS 2","SUP-ITM-10282059","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15986.28","9591.77","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","6989.20","43.72","","1543.33","1543.33","1671.61","1 through 10","1859.2","12373.38","percent of total billed charges",""
"HEAD RADIAL 22MM RIGHT ARH SOLUTIONS 2","SUP-ITM-10282059","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15986.28","9591.77","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","11625.22","72.72","","3700.21","2382.07","6427.18","53","1859.2","12373.38","percent of total billed charges",""
"HEAD RADIAL 22MM RIGHT ARH SOLUTIONS 2","SUP-ITM-10282059","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15986.28","9591.77","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","11625.22","72.72","","12685.80","12685.80","12685.80","1 through 10","1859.2","12373.38","percent of total billed charges",""
"HEAD RADIAL 22MM RIGHT ARH SOLUTIONS 2","SUP-ITM-10282059","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15986.28","9591.77","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","10055.37","62.9","","3408.87","2784.05","9859.40","46","1859.2","12373.38","percent of total billed charges",""
"HEAD RADIAL 22MM RIGHT ARH SOLUTIONS 2","SUP-ITM-10282059","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15986.28","9591.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12373.38","77.4","","5214.50","5214.50","16415.28","1 through 10","1859.2","12373.38","percent of total billed charges",""
"Headaches Without McC","103","MS-DRG","","","","","","","","inpatient","","","40311.99","24187.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","31779.48","","Fee schedule rate ($31,779.48). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","19927.39","19927.39","19927.39","1 through 10","3975","31779.48","case rate",""
"Headaches Without McC","103","MS-DRG","","","","","","","","inpatient","","","40311.99","24187.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","6666.73","","Case rate ($6,802.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,313.16, add-ons for qualifying new technology services are included. If operating cost exceeds $10,231.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,269.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,893.32 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,868.29 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $464.60. The transfer capital threshold is the transfer adjustment factor * $464.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6860.02","6860.02","6860.02","1 through 10","3975","31779.48","other","Inpatient DRG"
"Headaches Without McC","103","MS-DRG","","","","","","","","inpatient","","","40311.99","24187.19","MEDICARE [2001]","HB WDH MEDICARE","6802.79","","Case rate ($6,802.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,313.16, add-ons for qualifying new technology services are included. If operating cost exceeds $10,231.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,269.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,893.32 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,868.29 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $464.60. The transfer capital threshold is the transfer adjustment factor * $464.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6876.73","6876.73","6877.18","1 through 10","3975","31779.48","other","Inpatient DRG"
"Headaches Without McC","103","MS-DRG","","","","","","","","inpatient","","","40311.99","24187.19","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6802.79","","Case rate ($6,802.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,313.16, add-ons for qualifying new technology services are included. If operating cost exceeds $10,231.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,269.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,893.32 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,868.29 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $464.60. The transfer capital threshold is the transfer adjustment factor * $464.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6754.42","6754.42","6754.42","1 through 10","3975","31779.48","other","Inpatient DRG"
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","","","","inpatient","","","28830.73","17298.44","MEDICARE [2001]","HB WDH MEDICARE","6899.34","","Case rate ($6,899.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,402.27, add-ons for qualifying new technology services are included. If operating cost exceeds $10,320.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,276.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,982.81 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,957.40 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $471.66. The transfer capital threshold is the transfer adjustment factor * $471.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6943.01","0.05","6959.94","1 through 10","3975","32262.08","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","31338.34","18803.00","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","10408.98","","Case rate ($10,204.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,453.25, add-ons for qualifying new technology services are included. If operating cost exceeds $13,371.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,518.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,046.80 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,008.38 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.21. The transfer capital threshold is the transfer adjustment factor * $713.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","10290.23","1112.09","10315.88","11","3975","48784.53","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","31338.34","18803.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","19209.35","","Fee schedule rate ($19,209.35). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","19047.37","19047.37","19047.37","1 through 10","3975","48784.53","case rate",""
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","31338.34","18803.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","10000.78","","Case rate ($10,204.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,453.25, add-ons for qualifying new technology services are included. If operating cost exceeds $13,371.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,518.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,046.80 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,008.38 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.21. The transfer capital threshold is the transfer adjustment factor * $713.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10109.56","2789.83","10143.08","17","3975","48784.53","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","31338.34","18803.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","38854.57","","Fee schedule rate ($38,854.57). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","20933.25","20933.25","38526.96","1 through 10","3975","48784.53","case rate",""
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","31338.34","18803.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","10511.03","","Case rate ($10,204.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,453.25, add-ons for qualifying new technology services are included. If operating cost exceeds $13,371.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,518.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,046.80 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,008.38 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.21. The transfer capital threshold is the transfer adjustment factor * $713.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","9897.59","5840.61","9921.74","11","3975","48784.53","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","31338.34","18803.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","10204.88","","Case rate ($10,204.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,453.25, add-ons for qualifying new technology services are included. If operating cost exceeds $13,371.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,518.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,046.80 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,008.38 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.21. The transfer capital threshold is the transfer adjustment factor * $713.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10114.43","10022.52","11241.80","17","3975","48784.53","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","31338.34","18803.00","MEDICARE [2001]","HB WDH MEDICARE","10204.88","","Case rate ($10,204.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,453.25, add-ons for qualifying new technology services are included. If operating cost exceeds $13,371.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,518.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,046.80 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,008.38 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.21. The transfer capital threshold is the transfer adjustment factor * $713.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10290.23","0.05","10315.88","180","3975","48784.53","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","31338.34","18803.00","TRICARE [160005]","HB WDH MEDICARE","10204.88","","Case rate ($10,204.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,453.25, add-ons for qualifying new technology services are included. If operating cost exceeds $13,371.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,518.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,046.80 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,008.38 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.21. The transfer capital threshold is the transfer adjustment factor * $713.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10363.86","10363.86","10363.86","1 through 10","3975","48784.53","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","31338.34","18803.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","10204.88","","Case rate ($10,204.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,453.25, add-ons for qualifying new technology services are included. If operating cost exceeds $13,371.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,518.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,046.80 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,008.38 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $713.21. The transfer capital threshold is the transfer adjustment factor * $713.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10123.93","7895.15","10290.23","54","3975","48784.53","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","31338.34","18803.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","26305.06","","Fee schedule rate ($26,305.06). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","26735.35","26735.35","26735.35","1 through 10","3975","48784.53","case rate",""
"Heart Failure And Shock Without Cc/McC","293","MS-DRG","","","","","","","","inpatient","","","22871.75","13723.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","4652.90","","Case rate ($4,747.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $4,416.48, add-ons for qualifying new technology services are included. If operating cost exceeds $8,334.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,119.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,988.54 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $3,971.60 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.44. The transfer capital threshold is the transfer adjustment factor * $314.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","4537.43","4537.43","4537.43","1 through 10","3975","21508.06","other","Inpatient DRG"
"Heart Failure And Shock Without Cc/McC","293","MS-DRG","","","","","","","","inpatient","","","22871.75","13723.05","MEDICARE [2001]","HB WDH MEDICARE","4747.86","","Case rate ($4,747.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $4,416.48, add-ons for qualifying new technology services are included. If operating cost exceeds $8,334.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,119.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $3,988.54 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $3,971.60 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $314.44. The transfer capital threshold is the transfer adjustment factor * $314.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","4595.83","4595.83","4595.83","1 through 10","3975","21508.06","other","Inpatient DRG"
"Heavy Metal Qn Ea","PX-30000491","CDM","83018","CPT","0301","RC","","","","outpatient","","","119.00","71.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","74.85","62.9","","72.45","72.45","72.45","1 through 10","26.33","92.11","percent of total billed charges",""
"Helicobacter Pylori With Clarithromycin","PX-30003739","CDM","87798","CPT","0306","RC","","","","both","","","188.00","112.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","131.22","69.8","","127.04","114.48","508.14","20","22.81","180.59","percent of total billed charges",""
"Helicobacter Pylori With Clarithromycin","PX-30003739","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","118.03","62.78","","114.26","114.26","114.26","1 through 10","24.28","145.51","percent of total billed charges",""
"Helicobacter Pylori With Clarithromycin","PX-30003739","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","82.19","43.72","","79.57","79.57","79.57","1 through 10","24.28","145.51","percent of total billed charges",""
"Helicobacter Pylori With Clarithromycin","PX-30003739","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","529.40","79","24.28","145.51","percent of total billed charges",""
"Helicobacter Pylori With Clarithromycin","PX-30003739","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Helicobacter Pylori With Clarithromycin","PX-30003739","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","118.25","62.9","","114.66","114.66","114.66","231","24.28","145.51","percent of total billed charges",""
"Helicobacter Pylori With Clarithromycin","PX-30003739","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","145.51","77.4","","141.05","141.05","564.20","57","24.28","145.51","percent of total billed charges",""
"Helicobacter Pylori With Clarithromycin","PX-30003739","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30000937","CDM","86682","CPT","0302","RC","","","","outpatient","","","71.00","42.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","51.63","72.72","","50.18","50.18","50.18","1 through 10","9.1","54.95","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30000937","CDM","86682","CPT","0302","RC","","","","outpatient","","","71.00","42.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","44.66","62.9","","43.47","43.47","43.47","1 through 10","9.1","54.95","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","both","","","96.00","57.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","67.01","69.8","","64.91","64.91","64.91","1 through 10","8.37","81.6","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","both","","","96.00","57.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","81.60","85","","66.22","66.22","66.22","1 through 10","8.37","81.6","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","outpatient","","","96.00","57.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","69.81","72.72","","67.63","67.63","67.63","1 through 10","12.16","74.3","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","outpatient","","","96.00","57.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","60.38","62.9","","58.59","58.59","58.59","1 through 10","12.16","74.3","percent of total billed charges",""
"Hemoglobin Fetal Kleihauer-Betke","PX-30001102","CDM","85460","CPT","0305","RC","","","","outpatient","","","105.00","63.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","76.36","72.72","","74.17","74.17","74.17","1 through 10","9.27","81.27","percent of total billed charges",""
"Hemoglobin Fract Qn","PX-30000493","CDM","83021","CPT","0301","RC","","","","both","","","124.00","74.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","86.55","69.8","","83.76","75.48","83.76","1 through 10","11.74","105.4","percent of total billed charges",""
"Hemoglobin Fract Qn","PX-30000493","CDM","83021","CPT","0301","RC","","","","both","","","124.00","74.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","105.40","85","","93.31","93.31","93.31","1 through 10","11.74","105.4","percent of total billed charges",""
"Hemoglobin Fract Qn","PX-30000493","CDM","83021","CPT","0301","RC","","","","outpatient","","","124.00","74.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","90.17","72.72","","87.26","87.26","87.26","1 through 10","16.24","95.98","percent of total billed charges",""
"Hemoglobin Fract Qn","PX-30000493","CDM","83021","CPT","0301","RC","","","","outpatient","","","124.00","74.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","90.17","72.72","","87.26","87.26","87.26","1 through 10","16.24","95.98","percent of total billed charges",""
"Hemoglobin Fract Qn","PX-30000493","CDM","83021","CPT","0301","RC","","","","outpatient","","","124.00","74.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","78.00","62.9","","75.60","75.60","120.00","1 through 10","16.24","95.98","percent of total billed charges",""
"Hemoglobin Fract Qn","PX-30000493","CDM","83021","CPT","0301","RC","","","","outpatient","","","124.00","74.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","95.98","77.4","","93.00","93.00","93.00","1 through 10","16.24","95.98","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","138.00","82.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","96.32","69.8","","92.83","83.66","92.83","592","6.31","117.3","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","138.00","82.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","96.32","69.8","","92.83","92.83","92.83","1 through 10","6.31","117.3","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","138.00","82.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","117.30","85","","86.33","16.49","113.05","20","6.31","117.3","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","138.00","82.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","86.64","62.78","","83.50","83.50","83.50","25","9.05","106.81","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","138.00","82.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","60.33","43.72","","58.15","58.15","58.15","35","9.05","106.81","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","138.00","82.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","100.35","72.72","","96.72","96.72","96.72","1021","9.05","106.81","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","138.00","82.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","100.35","72.72","","96.72","96.72","96.72","38","9.05","106.81","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","138.00","82.80","INTERNATIONAL COMMERCIAL [140001]","HB WDH UNITED HMO / PPO / INDEM","106.81","77.4","","103.07","103.07","103.07","1 through 10","9.05","106.81","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","138.00","82.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","73.44","53.22","","70.90","70.90","141.80","80","9.05","106.81","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","138.00","82.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","86.80","62.9","","83.79","83.79","83.79","1185","9.05","106.81","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","138.00","82.80","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","100.35","72.72","","103.08","103.08","103.08","1 through 10","9.05","106.81","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","138.00","82.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","106.81","77.4","","103.08","103.08","103.08","440","9.05","106.81","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","138.00","82.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","100.35","72.72","","96.72","96.72","96.72","11","9.05","106.81","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0300","RC","","","","inpatient","","","116.00","69.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","89.16","76.86","","70.56","67.47","134.94","1 through 10","76.79","89.16","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","116.00","69.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","80.97","69.8","","78.18","70.45","78.18","203","5.31","98.6","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","116.00","69.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","80.97","69.8","","78.18","78.18","78.18","1 through 10","5.31","98.6","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","116.00","69.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","98.60","85","","95.20","95.20","95.20","1 through 10","5.31","98.6","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","116.00","69.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","72.82","62.78","","70.31","70.31","70.31","1 through 10","7.61","89.78","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","116.00","69.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","50.72","43.72","","48.97","48.97","146.91","14","7.61","89.78","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","116.00","69.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","84.36","72.72","","81.45","81.45","81.45","319","7.61","89.78","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","116.00","69.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","84.36","72.72","","81.45","81.45","162.90","16","7.61","89.78","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","116.00","69.60","INTERNATIONAL COMMERCIAL [140001]","HB WDH UNITED HMO / PPO / INDEM","89.78","77.4","","86.80","86.80","86.80","1 through 10","7.61","89.78","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","116.00","69.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","61.74","53.22","","59.71","59.71","119.42","19","7.61","89.78","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","116.00","69.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","72.96","62.9","","70.56","70.56","269.88","474","7.61","89.78","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","116.00","69.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","89.78","77.4","","86.80","86.80","86.80","137","7.61","89.78","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","116.00","69.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","84.36","72.72","","81.45","81.45","81.45","1 through 10","7.61","89.78","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) IGM","PX-30000960","CDM","86709","CPT","0302","RC","","","","both","","","159.00","95.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","110.98","69.8","","107.49","12.83","107.49","1 through 10","7.32","135.15","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) IGM","PX-30000960","CDM","86709","CPT","0302","RC","","","","outpatient","","","159.00","95.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","115.62","72.72","","111.99","111.99","111.99","12","10.49","123.07","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) IGM","PX-30000960","CDM","86709","CPT","0302","RC","","","","outpatient","","","159.00","95.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","100.01","62.9","","97.02","97.02","97.02","14","10.49","123.07","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) IGM","PX-30000960","CDM","86709","CPT","0302","RC","","","","outpatient","","","159.00","95.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","123.07","77.4","","119.35","27.31","119.35","1 through 10","10.49","123.07","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","both","","","176.00","105.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","122.85","69.8","","118.66","14.12","118.66","12","8.05","149.6","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","outpatient","","","176.00","105.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","110.49","62.78","","106.73","106.73","106.73","1 through 10","11.55","136.22","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","outpatient","","","176.00","105.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","76.95","43.72","","74.32","74.32","74.32","1 through 10","11.55","136.22","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","outpatient","","","176.00","105.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","127.99","72.72","","123.62","123.62","123.62","13","11.55","136.22","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","outpatient","","","176.00","105.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","110.70","62.9","","107.10","107.10","411.16","30","11.55","136.22","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","outpatient","","","176.00","105.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","136.22","77.4","","131.75","131.75","131.75","1 through 10","11.55","136.22","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","outpatient","","","176.00","105.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","127.99","72.72","","123.62","123.62","123.62","1 through 10","11.55","136.22","percent of total billed charges",""
"Hepatitis B Core Antibody Igm","PX-30000956","CDM","86705","CPT","0302","RC","","","","both","","","168.00","100.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","117.26","69.8","","113.08","113.08","113.08","1 through 10","7.65","142.8","percent of total billed charges",""
"Hepatitis B Core Antibody Igm","PX-30000956","CDM","86705","CPT","0302","RC","","","","outpatient","","","168.00","100.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","122.17","72.72","","117.81","117.81","353.43","1 through 10","10.97","130.03","percent of total billed charges",""
"Hepatitis B Core Antibody Igm","PX-30000956","CDM","86705","CPT","0302","RC","","","","outpatient","","","168.00","100.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","105.67","62.9","","306.18","102.06","306.18","1 through 10","10.97","130.03","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","both","","","172.00","103.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","120.06","69.8","","115.87","104.41","115.87","43","7.83","146.2","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","outpatient","","","172.00","103.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","107.98","62.78","","104.21","104.21","104.21","1 through 10","11.23","133.13","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","outpatient","","","172.00","103.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","75.20","43.72","","72.58","72.58","72.58","1 through 10","11.23","133.13","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","outpatient","","","172.00","103.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","125.08","72.72","","120.72","120.72","120.72","76","11.23","133.13","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","outpatient","","","172.00","103.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","125.08","72.72","","120.72","120.72","120.72","1 through 10","11.23","133.13","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","outpatient","","","172.00","103.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","91.54","53.22","","88.49","88.49","88.49","1 through 10","11.23","133.13","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","outpatient","","","172.00","103.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","108.19","62.9","","104.58","104.58","313.74","108","11.23","133.13","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","outpatient","","","172.00","103.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","133.13","77.4","","128.65","128.65","128.65","25","11.23","133.13","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","outpatient","","","172.00","103.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","125.08","72.72","","120.72","120.72","120.72","1 through 10","11.23","133.13","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","153.00","91.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","106.79","69.8","","103.30","93.09","103.30","55","6.98","130.05","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","outpatient","","","153.00","91.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","96.05","62.78","","92.91","92.91","92.91","1 through 10","10.02","118.42","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","outpatient","","","153.00","91.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","66.89","43.72","","64.71","64.71","64.71","1 through 10","10.02","118.42","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","outpatient","","","153.00","91.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","111.26","72.72","","107.63","107.63","107.63","102","10.02","118.42","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","outpatient","","","153.00","91.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","111.26","72.72","","107.63","107.63","107.63","1 through 10","10.02","118.42","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","outpatient","","","153.00","91.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","81.43","53.22","","78.90","78.90","78.90","1 through 10","10.02","118.42","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","outpatient","","","153.00","91.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","96.24","62.9","","93.24","93.24","93.24","141","10.02","118.42","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","outpatient","","","153.00","91.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","118.42","77.4","","114.70","114.70","114.70","42","10.02","118.42","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","outpatient","","","153.00","91.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","111.26","72.72","","107.63","107.63","107.63","1 through 10","10.02","118.42","percent of total billed charges",""
"HEPATITIS Be ANTIBODY (HBeAb)","PX-30000958","CDM","86707","CPT","0302","RC","","","","both","","","64.00","38.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","44.67","69.8","","43.28","41.18","43.28","1 through 10","7.52","60.21","percent of total billed charges",""
"HEPATITIS Be ANTIBODY (HBeAb)","PX-30000958","CDM","86707","CPT","0302","RC","","","","outpatient","","","64.00","38.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","40.18","62.78","","38.92","38.92","38.92","1 through 10","10.78","49.54","percent of total billed charges",""
"HEPATITIS Be ANTIBODY (HBeAb)","PX-30000958","CDM","86707","CPT","0302","RC","","","","outpatient","","","64.00","38.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","46.54","72.72","","45.09","45.09","45.09","15","10.78","49.54","percent of total billed charges",""
"HEPATITIS Be ANTIBODY (HBeAb)","PX-30000958","CDM","86707","CPT","0302","RC","","","","outpatient","","","64.00","38.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","40.26","62.9","","39.06","39.06","39.06","17","10.78","49.54","percent of total billed charges",""
"HEPATITIS Be ANTIBODY (HBeAb)","PX-30000958","CDM","86707","CPT","0302","RC","","","","outpatient","","","64.00","38.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","49.54","77.4","","48.05","48.05","48.05","1 through 10","10.78","49.54","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","203.00","121.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","141.69","69.8","","136.81","123.28","136.81","212","9.28","172.55","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","203.00","121.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","141.69","69.8","","136.81","136.81","136.81","1 through 10","9.28","172.55","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","203.00","121.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","172.55","85","","136.81","12.85","166.60","1 through 10","9.28","172.55","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","outpatient","","","203.00","121.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","127.44","62.78","","123.05","123.05","123.05","13","12.4","157.12","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","outpatient","","","203.00","121.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","88.75","43.72","","85.69","85.69","257.07","15","12.4","157.12","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","outpatient","","","203.00","121.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","147.62","72.72","","142.53","142.53","142.53","314","12.4","157.12","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","outpatient","","","203.00","121.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","147.62","72.72","","142.53","142.53","142.53","13","12.4","157.12","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","outpatient","","","203.00","121.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","108.04","53.22","","104.49","104.49","313.47","30","12.4","157.12","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","outpatient","","","203.00","121.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","127.69","62.9","","123.48","123.48","123.48","373","12.4","157.12","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","outpatient","","","203.00","121.80","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","147.62","72.72","","151.89","142.53","151.89","1 through 10","12.4","157.12","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","outpatient","","","203.00","121.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","157.12","77.4","","151.90","151.90","151.90","153","12.4","157.12","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","outpatient","","","203.00","121.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","147.62","72.72","","142.53","142.53","142.53","1 through 10","12.4","157.12","percent of total billed charges",""
"Hepatitis E Virus (Hev) Antibody, Igg","PX-30003658","CDM","86790","CPT","0301","RC","","","","both","","","69.00","41.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","48.16","69.8","","46.77","46.77","46.77","1 through 10","8.37","66.21","percent of total billed charges",""
"Hepatitis E Virus (Hev) Antibody, Igm","PX-30003657","CDM","86790","CPT","0301","RC","","","","both","","","69.00","41.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","48.16","69.8","","46.77","46.77","46.77","1 through 10","8.37","66.21","percent of total billed charges",""
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","","","","inpatient","","","68399.43","41039.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","52585.92","","Fee schedule rate ($52,585.92). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","48353.57","48353.57","48353.57","1 through 10","3975","66025.17","case rate",""
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","","","","inpatient","","","75028.11","45016.87","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","12970.51","","Case rate ($13,235.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,250.21, add-ons for qualifying new technology services are included. If operating cost exceeds $16,168.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,739.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $11,855.69 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,805.34 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.65. The transfer capital threshold is the transfer adjustment factor * $934.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13047.70","13047.70","13047.70","1 through 10","3975","63931.37","other","Inpatient DRG"
"Hernia Procedures Except Inguinal And Femoral With McC","353","MS-DRG","","","","","","","","inpatient","","","184782.34","110869.40","MEDICARE [2001]","HB WDH MEDICARE","22507.14","","Case rate ($22,507.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $20,808.10, add-ons for qualifying new technology services are included. If operating cost exceeds $24,726.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,417.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $20,450.08 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $20,363.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,612.19. The transfer capital threshold is the transfer adjustment factor * $1,612.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22633.57","22633.57","22633.57","1 through 10","3975","110276.29","other","Inpatient DRG"
"Hernia Procedures Except Inguinal And Femoral Without Cc/McC","355","MS-DRG","","","","","","","","inpatient","","","77306.31","46383.79","MEDICARE [2001]","HB WDH MEDICARE","10670.15","","Case rate ($10,670.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,882.69, add-ons for qualifying new technology services are included. If operating cost exceeds $13,800.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,552.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $9,478.07 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,437.82 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.21. The transfer capital threshold is the transfer adjustment factor * $747.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10530.75","10530.75","10530.75","1 through 10","3975","51110.13","other","Inpatient DRG"
"Herpes Simplex Antibody","PX-30000944","CDM","86694","CPT","0300","RC","","","","inpatient","","","77.00","46.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","59.18","76.86","","46.62","46.62","46.62","1 through 10","50.97","59.18","percent of total billed charges",""
"Herpes Simplex Antibody","PX-30000944","CDM","86694","CPT","0302","RC","","","","both","","","77.00","46.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","53.75","69.8","","51.65","51.65","51.65","1 through 10","9.35","73.73","percent of total billed charges",""
"Herpes Simplex Antibody","PX-30000944","CDM","86694","CPT","0302","RC","","","","outpatient","","","77.00","46.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","48.34","62.78","","46.46","46.46","46.46","1 through 10","13.41","59.6","percent of total billed charges",""
"Herpes Simplex Antibody","PX-30000944","CDM","86694","CPT","0302","RC","","","","outpatient","","","77.00","46.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","55.99","72.72","","53.81","53.81","53.81","1 through 10","13.41","59.6","percent of total billed charges",""
"Herpes Simplex Antibody","PX-30000944","CDM","86694","CPT","0302","RC","","","","outpatient","","","77.00","46.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","48.43","62.9","","89.54","89.54","89.54","1 through 10","13.41","59.6","percent of total billed charges",""
"Herpes Simplex Antibody","PX-30000944","CDM","86694","CPT","0302","RC","","","","outpatient","","","77.00","46.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","59.60","77.4","","57.35","57.35","57.35","1 through 10","13.41","59.6","percent of total billed charges",""
"Herpes Simplex Type I Antibody","PX-30000946","CDM","86695","CPT","0302","RC","","","","both","","","71.00","42.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","49.56","69.8","","48.16","15.03","48.16","1 through 10","8.57","67.73","percent of total billed charges",""
"Herpes Simplex Type I Antibody","PX-30000946","CDM","86695","CPT","0302","RC","","","","outpatient","","","71.00","42.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","51.63","72.72","","50.18","50.18","50.18","1 through 10","12.28","54.95","percent of total billed charges",""
"Herpes Simplex Type I Antibody","PX-30000946","CDM","86695","CPT","0302","RC","","","","outpatient","","","71.00","42.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","37.79","53.22","","36.78","36.78","36.78","1 through 10","12.28","54.95","percent of total billed charges",""
"Herpes Simplex Type I Antibody","PX-30000946","CDM","86695","CPT","0302","RC","","","","outpatient","","","71.00","42.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","44.66","62.9","","43.47","43.47","43.47","1 through 10","12.28","54.95","percent of total billed charges",""
"Herpes Simplex Type I Antibody","PX-30000946","CDM","86695","CPT","0302","RC","","","","outpatient","","","71.00","42.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","54.95","77.4","","53.48","53.48","53.48","1 through 10","12.28","54.95","percent of total billed charges",""
"Herpes Simplex Type II Antibody","PX-30000948","CDM","86696","CPT","0302","RC","","","","both","","","103.00","61.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","71.89","69.8","","69.80","22.06","69.80","1 through 10","12.58","99.33","percent of total billed charges",""
"Herpes Simplex Type II Antibody","PX-30000948","CDM","86696","CPT","0302","RC","","","","outpatient","","","103.00","61.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","74.90","72.72","","72.72","72.72","72.72","1 through 10","18.03","79.72","percent of total billed charges",""
"Herpes Simplex Type II Antibody","PX-30000948","CDM","86696","CPT","0302","RC","","","","outpatient","","","103.00","61.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","54.82","53.22","","53.31","53.31","53.31","1 through 10","18.03","79.72","percent of total billed charges",""
"Herpes Simplex Type II Antibody","PX-30000948","CDM","86696","CPT","0302","RC","","","","outpatient","","","103.00","61.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","64.79","62.9","","63.00","63.00","63.00","14","18.03","79.72","percent of total billed charges",""
"Herpes Simplex Type II Antibody","PX-30000948","CDM","86696","CPT","0302","RC","","","","outpatient","","","103.00","61.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","79.72","77.4","","77.50","77.50","77.50","1 through 10","18.03","79.72","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","both","","","85.00","51.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","59.33","69.8","","57.24","57.24","57.24","1 through 10","3.37","72.25","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","outpatient","","","85.00","51.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","61.81","72.72","","59.63","59.63","178.89","25","4.82","65.79","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","outpatient","","","85.00","51.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","61.81","72.72","","59.63","59.63","59.63","1 through 10","4.82","65.79","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","outpatient","","","85.00","51.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","45.24","53.22","","43.71","43.71","43.71","1 through 10","4.82","65.79","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","outpatient","","","85.00","51.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","53.47","62.9","","51.66","51.66","199.28","33","4.82","65.79","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","outpatient","","","85.00","51.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","65.79","77.4","","63.55","63.55","63.55","11","4.82","65.79","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","both","","","301.00","180.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","210.10","69.8","","210.10","189.33","210.10","1 through 10","171.27","298.56","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","both","","","301.00","180.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","171.27","56.9","","171.27","46.17","171.27","1 through 10","171.27","298.56","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","outpatient","","","301.00","180.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","218.89","72.72","","218.89","218.89","218.89","1 through 10","131.6","232.97","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","outpatient","","","301.00","180.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","189.33","62.9","","189.63","189.63","189.63","1 through 10","131.6","232.97","percent of total billed charges",""
"HGB QUANT TRANSCUt","PX-30000108","CDM","88738","CPT","0300","RC","","","","both","","","39.00","23.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","27.22","69.8","","26.52","23.90","26.52","1 through 10","3.26","33.15","percent of total billed charges",""
"HGB QUANT TRANSCUt","PX-30000108","CDM","88738","CPT","0300","RC","","","","outpatient","","","39.00","23.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","17.05","43.72","","16.61","16.61","16.61","1 through 10","4.67","30.19","percent of total billed charges",""
"HGB QUANT TRANSCUt","PX-30000108","CDM","88738","CPT","0300","RC","","","","outpatient","","","39.00","23.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","28.36","72.72","","27.63","27.63","27.63","1 through 10","4.67","30.19","percent of total billed charges",""
"HGB QUANT TRANSCUt","PX-30000108","CDM","88738","CPT","0300","RC","","","","outpatient","","","39.00","23.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","28.36","72.72","","27.63","27.63","27.63","1 through 10","4.67","30.19","percent of total billed charges",""
"HGB QUANT TRANSCUt","PX-30000108","CDM","88738","CPT","0300","RC","","","","outpatient","","","39.00","23.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","24.53","62.9","","23.94","23.94","23.94","22","4.67","30.19","percent of total billed charges",""
"HGB QUANT TRANSCUt","PX-30000108","CDM","88738","CPT","0300","RC","","","","outpatient","","","39.00","23.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","30.19","77.4","","29.45","27.63","29.45","1 through 10","4.67","30.19","percent of total billed charges",""
"HINGE FLEX 0 45.4X14MM SIZE 2 PROSTHESIS TOE SWANSON","SUP-ITM-10056823","CDM","C1776","HCPCS","0278","RC","","","","both","","","6336.47","3801.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","736.93","5386","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HINGE FLEX 0 45.4X14MM SIZE 2 PROSTHESIS TOE SWANSON","SUP-ITM-10056823","CDM","C1776","HCPCS","0278","RC","","","","both","","","6336.47","3801.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3605.45","56.9","","2911.53","1863.86","5209.05","65","736.93","5386","percent of total billed charges",""
"HINGE FLEX 0 45.4X14MM SIZE 2 PROSTHESIS TOE SWANSON","SUP-ITM-10056823","CDM","C1776","HCPCS","0278","RC","","","","both","","","6336.47","3801.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","736.93","11.63","","400.94","400.94","400.94","1 through 10","736.93","5386","percent of total billed charges",""
"HINGE FLEX 0 45.4X14MM SIZE 2 PROSTHESIS TOE SWANSON","SUP-ITM-10056823","CDM","C1776","HCPCS","0278","RC","","","","both","","","6336.47","3801.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4904.43","77.4","","5214.50","5214.50","16415.28","1 through 10","736.93","5386","percent of total billed charges",""
"HINGE FLEX 0 45.4X14MM SIZE 2 PROSTHESIS TOE SWANSON","SUP-ITM-10056823","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6336.47","3801.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","736.93","11.63","","400.94","400.94","400.94","1 through 10","736.93","4904.43","percent of total billed charges",""
"HINGE FLEX 0 45.4X14MM SIZE 2 PROSTHESIS TOE SWANSON","SUP-ITM-10056823","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6336.47","3801.88","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2770.30","43.72","","1543.33","1543.33","1671.61","1 through 10","736.93","4904.43","percent of total billed charges",""
"HINGE FLEX 0 45.4X14MM SIZE 2 PROSTHESIS TOE SWANSON","SUP-ITM-10056823","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6336.47","3801.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4607.88","72.72","","3700.21","2382.07","6427.18","53","736.93","4904.43","percent of total billed charges",""
"HINGE FLEX 0 45.4X14MM SIZE 2 PROSTHESIS TOE SWANSON","SUP-ITM-10056823","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6336.47","3801.88","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4607.88","72.72","","12685.80","12685.80","12685.80","1 through 10","736.93","4904.43","percent of total billed charges",""
"HINGE FLEX 0 45.4X14MM SIZE 2 PROSTHESIS TOE SWANSON","SUP-ITM-10056823","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6336.47","3801.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3985.64","62.9","","3408.87","2784.05","9859.40","46","736.93","4904.43","percent of total billed charges",""
"HINGE FLEX 0 45.4X14MM SIZE 2 PROSTHESIS TOE SWANSON","SUP-ITM-10056823","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6336.47","3801.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4904.43","77.4","","5214.50","5214.50","16415.28","1 through 10","736.93","4904.43","percent of total billed charges",""
"HINGE SWANSON 18X58.9MM SIZE 3 TO 0 PROSTHESIS TOE LATERAL FLEXIBLE REGULAR STEM","SUP-ITM-10005010","CDM","C1776","HCPCS","0278","RC","","","","both","","","6336.47","3801.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","736.93","5386","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HINGE SWANSON 18X58.9MM SIZE 3 TO 0 PROSTHESIS TOE LATERAL FLEXIBLE REGULAR STEM","SUP-ITM-10005010","CDM","C1776","HCPCS","0278","RC","","","","both","","","6336.47","3801.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3605.45","56.9","","2911.53","1863.86","5209.05","65","736.93","5386","percent of total billed charges",""
"HINGE SWANSON 18X58.9MM SIZE 3 TO 0 PROSTHESIS TOE LATERAL FLEXIBLE REGULAR STEM","SUP-ITM-10005010","CDM","C1776","HCPCS","0278","RC","","","","both","","","6336.47","3801.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","736.93","11.63","","400.94","400.94","400.94","1 through 10","736.93","5386","percent of total billed charges",""
"HINGE SWANSON 18X58.9MM SIZE 3 TO 0 PROSTHESIS TOE LATERAL FLEXIBLE REGULAR STEM","SUP-ITM-10005010","CDM","C1776","HCPCS","0278","RC","","","","both","","","6336.47","3801.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4904.43","77.4","","5214.50","5214.50","16415.28","1 through 10","736.93","5386","percent of total billed charges",""
"HINGE SWANSON 18X58.9MM SIZE 3 TO 0 PROSTHESIS TOE LATERAL FLEXIBLE REGULAR STEM","SUP-ITM-10005010","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6336.47","3801.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","736.93","11.63","","400.94","400.94","400.94","1 through 10","736.93","4904.43","percent of total billed charges",""
"HINGE SWANSON 18X58.9MM SIZE 3 TO 0 PROSTHESIS TOE LATERAL FLEXIBLE REGULAR STEM","SUP-ITM-10005010","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6336.47","3801.88","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2770.30","43.72","","1543.33","1543.33","1671.61","1 through 10","736.93","4904.43","percent of total billed charges",""
"HINGE SWANSON 18X58.9MM SIZE 3 TO 0 PROSTHESIS TOE LATERAL FLEXIBLE REGULAR STEM","SUP-ITM-10005010","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6336.47","3801.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4607.88","72.72","","3700.21","2382.07","6427.18","53","736.93","4904.43","percent of total billed charges",""
"HINGE SWANSON 18X58.9MM SIZE 3 TO 0 PROSTHESIS TOE LATERAL FLEXIBLE REGULAR STEM","SUP-ITM-10005010","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6336.47","3801.88","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4607.88","72.72","","12685.80","12685.80","12685.80","1 through 10","736.93","4904.43","percent of total billed charges",""
"HINGE SWANSON 18X58.9MM SIZE 3 TO 0 PROSTHESIS TOE LATERAL FLEXIBLE REGULAR STEM","SUP-ITM-10005010","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6336.47","3801.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3985.64","62.9","","3408.87","2784.05","9859.40","46","736.93","4904.43","percent of total billed charges",""
"HINGE SWANSON 18X58.9MM SIZE 3 TO 0 PROSTHESIS TOE LATERAL FLEXIBLE REGULAR STEM","SUP-ITM-10005010","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6336.47","3801.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4904.43","77.4","","5214.50","5214.50","16415.28","1 through 10","736.93","4904.43","percent of total billed charges",""
"HIP 12/14 32MM PLUS 0 MD BIOLOX OPTION CERAMIC TITANIUM TAPER ADAPTER","SUP-ITM-10120537","CDM","C1776","HCPCS","0278","RC","","","","both","","","2902.20","1741.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","337.53","2466.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP 12/14 32MM PLUS 0 MD BIOLOX OPTION CERAMIC TITANIUM TAPER ADAPTER","SUP-ITM-10120537","CDM","C1776","HCPCS","0278","RC","","","","both","","","2902.20","1741.32","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1651.35","56.9","","2911.53","1863.86","5209.05","65","337.53","2466.87","percent of total billed charges",""
"HIP 12/14 32MM PLUS 0 MD BIOLOX OPTION CERAMIC TITANIUM TAPER ADAPTER","SUP-ITM-10120537","CDM","C1776","HCPCS","0278","RC","","","","both","","","2902.20","1741.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","337.53","11.63","","400.94","400.94","400.94","1 through 10","337.53","2466.87","percent of total billed charges",""
"HIP 12/14 32MM PLUS 0 MD BIOLOX OPTION CERAMIC TITANIUM TAPER ADAPTER","SUP-ITM-10120537","CDM","C1776","HCPCS","0278","RC","","","","both","","","2902.20","1741.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2246.30","77.4","","5214.50","5214.50","16415.28","1 through 10","337.53","2466.87","percent of total billed charges",""
"HIP 12/14 32MM PLUS 0 MD BIOLOX OPTION CERAMIC TITANIUM TAPER ADAPTER","SUP-ITM-10120537","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2902.20","1741.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","337.53","11.63","","400.94","400.94","400.94","1 through 10","337.53","2246.3","percent of total billed charges",""
"HIP 12/14 32MM PLUS 0 MD BIOLOX OPTION CERAMIC TITANIUM TAPER ADAPTER","SUP-ITM-10120537","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2902.20","1741.32","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1268.84","43.72","","1543.33","1543.33","1671.61","1 through 10","337.53","2246.3","percent of total billed charges",""
"HIP 12/14 32MM PLUS 0 MD BIOLOX OPTION CERAMIC TITANIUM TAPER ADAPTER","SUP-ITM-10120537","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2902.20","1741.32","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2110.48","72.72","","3700.21","2382.07","6427.18","53","337.53","2246.3","percent of total billed charges",""
"HIP 12/14 32MM PLUS 0 MD BIOLOX OPTION CERAMIC TITANIUM TAPER ADAPTER","SUP-ITM-10120537","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2902.20","1741.32","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2110.48","72.72","","12685.80","12685.80","12685.80","1 through 10","337.53","2246.3","percent of total billed charges",""
"HIP 12/14 32MM PLUS 0 MD BIOLOX OPTION CERAMIC TITANIUM TAPER ADAPTER","SUP-ITM-10120537","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2902.20","1741.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1825.48","62.9","","3408.87","2784.05","9859.40","46","337.53","2246.3","percent of total billed charges",""
"HIP 12/14 32MM PLUS 0 MD BIOLOX OPTION CERAMIC TITANIUM TAPER ADAPTER","SUP-ITM-10120537","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2902.20","1741.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2246.30","77.4","","5214.50","5214.50","16415.28","1 through 10","337.53","2246.3","percent of total billed charges",""
"HIP 26MM LFIT COBALT CHROMIUM C TAPERED 0 OFFSET","SUP-ITM-10015200","CDM","C1776","HCPCS","0278","RC","","","","both","","","3648.48","2189.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","424.32","3101.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP 26MM LFIT COBALT CHROMIUM C TAPERED 0 OFFSET","SUP-ITM-10015200","CDM","C1776","HCPCS","0278","RC","","","","both","","","3648.48","2189.09","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2075.99","56.9","","2911.53","1863.86","5209.05","65","424.32","3101.21","percent of total billed charges",""
"HIP 26MM LFIT COBALT CHROMIUM C TAPERED 0 OFFSET","SUP-ITM-10015200","CDM","C1776","HCPCS","0278","RC","","","","both","","","3648.48","2189.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","424.32","11.63","","400.94","400.94","400.94","1 through 10","424.32","3101.21","percent of total billed charges",""
"HIP 26MM LFIT COBALT CHROMIUM C TAPERED 0 OFFSET","SUP-ITM-10015200","CDM","C1776","HCPCS","0278","RC","","","","both","","","3648.48","2189.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2823.92","77.4","","5214.50","5214.50","16415.28","1 through 10","424.32","3101.21","percent of total billed charges",""
"HIP 26MM LFIT COBALT CHROMIUM C TAPERED 0 OFFSET","SUP-ITM-10015200","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3648.48","2189.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","424.32","11.63","","400.94","400.94","400.94","1 through 10","424.32","2823.92","percent of total billed charges",""
"HIP 26MM LFIT COBALT CHROMIUM C TAPERED 0 OFFSET","SUP-ITM-10015200","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3648.48","2189.09","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1595.12","43.72","","1543.33","1543.33","1671.61","1 through 10","424.32","2823.92","percent of total billed charges",""
"HIP 26MM LFIT COBALT CHROMIUM C TAPERED 0 OFFSET","SUP-ITM-10015200","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3648.48","2189.09","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2653.17","72.72","","3700.21","2382.07","6427.18","53","424.32","2823.92","percent of total billed charges",""
"HIP 26MM LFIT COBALT CHROMIUM C TAPERED 0 OFFSET","SUP-ITM-10015200","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3648.48","2189.09","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2653.17","72.72","","12685.80","12685.80","12685.80","1 through 10","424.32","2823.92","percent of total billed charges",""
"HIP 26MM LFIT COBALT CHROMIUM C TAPERED 0 OFFSET","SUP-ITM-10015200","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3648.48","2189.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2294.89","62.9","","3408.87","2784.05","9859.40","46","424.32","2823.92","percent of total billed charges",""
"HIP 26MM LFIT COBALT CHROMIUM C TAPERED 0 OFFSET","SUP-ITM-10015200","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3648.48","2189.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2823.92","77.4","","5214.50","5214.50","16415.28","1 through 10","424.32","2823.92","percent of total billed charges",""
"HIP 28MM 0.0 LFIT V40 COBALT LOW FRICTION ION TREATMENT PLUS","SUP-ITM-10017462","CDM","C1776","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","241.09","1762.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP 28MM 0.0 LFIT V40 COBALT LOW FRICTION ION TREATMENT PLUS","SUP-ITM-10017462","CDM","C1776","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1179.54","56.9","","2911.53","1863.86","5209.05","65","241.09","1762.05","percent of total billed charges",""
"HIP 28MM 0.0 LFIT V40 COBALT LOW FRICTION ION TREATMENT PLUS","SUP-ITM-10017462","CDM","C1776","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","241.09","11.63","","400.94","400.94","400.94","1 through 10","241.09","1762.05","percent of total billed charges",""
"HIP 28MM 0.0 LFIT V40 COBALT LOW FRICTION ION TREATMENT PLUS","SUP-ITM-10017462","CDM","C1776","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1604.50","77.4","","5214.50","5214.50","16415.28","1 through 10","241.09","1762.05","percent of total billed charges",""
"HIP 28MM 0.0 LFIT V40 COBALT LOW FRICTION ION TREATMENT PLUS","SUP-ITM-10017462","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","241.09","11.63","","400.94","400.94","400.94","1 through 10","241.09","1604.5","percent of total billed charges",""
"HIP 28MM 0.0 LFIT V40 COBALT LOW FRICTION ION TREATMENT PLUS","SUP-ITM-10017462","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","906.32","43.72","","1543.33","1543.33","1671.61","1 through 10","241.09","1604.5","percent of total billed charges",""
"HIP 28MM 0.0 LFIT V40 COBALT LOW FRICTION ION TREATMENT PLUS","SUP-ITM-10017462","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1507.49","72.72","","3700.21","2382.07","6427.18","53","241.09","1604.5","percent of total billed charges",""
"HIP 28MM 0.0 LFIT V40 COBALT LOW FRICTION ION TREATMENT PLUS","SUP-ITM-10017462","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1507.49","72.72","","12685.80","12685.80","12685.80","1 through 10","241.09","1604.5","percent of total billed charges",""
"HIP 28MM 0.0 LFIT V40 COBALT LOW FRICTION ION TREATMENT PLUS","SUP-ITM-10017462","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1303.92","62.9","","3408.87","2784.05","9859.40","46","241.09","1604.5","percent of total billed charges",""
"HIP 28MM 0.0 LFIT V40 COBALT LOW FRICTION ION TREATMENT PLUS","SUP-ITM-10017462","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1604.50","77.4","","5214.50","5214.50","16415.28","1 through 10","241.09","1604.5","percent of total billed charges",""
"HIP 28MM CERAMIC BIOLOXDELTA OPTION","SUP-ITM-10122600","CDM","C1776","HCPCS","0278","RC","","","","both","","","2902.20","1741.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","337.53","2466.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP 28MM CERAMIC BIOLOXDELTA OPTION","SUP-ITM-10122600","CDM","C1776","HCPCS","0278","RC","","","","both","","","2902.20","1741.32","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1651.35","56.9","","2911.53","1863.86","5209.05","65","337.53","2466.87","percent of total billed charges",""
"HIP 28MM CERAMIC BIOLOXDELTA OPTION","SUP-ITM-10122600","CDM","C1776","HCPCS","0278","RC","","","","both","","","2902.20","1741.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","337.53","11.63","","400.94","400.94","400.94","1 through 10","337.53","2466.87","percent of total billed charges",""
"HIP 28MM CERAMIC BIOLOXDELTA OPTION","SUP-ITM-10122600","CDM","C1776","HCPCS","0278","RC","","","","both","","","2902.20","1741.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2246.30","77.4","","5214.50","5214.50","16415.28","1 through 10","337.53","2466.87","percent of total billed charges",""
"HIP 28MM CERAMIC BIOLOXDELTA OPTION","SUP-ITM-10122600","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2902.20","1741.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","337.53","11.63","","400.94","400.94","400.94","1 through 10","337.53","2246.3","percent of total billed charges",""
"HIP 28MM CERAMIC BIOLOXDELTA OPTION","SUP-ITM-10122600","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2902.20","1741.32","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1268.84","43.72","","1543.33","1543.33","1671.61","1 through 10","337.53","2246.3","percent of total billed charges",""
"HIP 28MM CERAMIC BIOLOXDELTA OPTION","SUP-ITM-10122600","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2902.20","1741.32","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2110.48","72.72","","3700.21","2382.07","6427.18","53","337.53","2246.3","percent of total billed charges",""
"HIP 28MM CERAMIC BIOLOXDELTA OPTION","SUP-ITM-10122600","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2902.20","1741.32","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2110.48","72.72","","12685.80","12685.80","12685.80","1 through 10","337.53","2246.3","percent of total billed charges",""
"HIP 28MM CERAMIC BIOLOXDELTA OPTION","SUP-ITM-10122600","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2902.20","1741.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1825.48","62.9","","3408.87","2784.05","9859.40","46","337.53","2246.3","percent of total billed charges",""
"HIP 28MM CERAMIC BIOLOXDELTA OPTION","SUP-ITM-10122600","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2902.20","1741.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2246.30","77.4","","5214.50","5214.50","16415.28","1 through 10","337.53","2246.3","percent of total billed charges",""
"HIP 28MM TAPERED LOW FRICTION MORSE PLUS","SUP-ITM-10007371","CDM","C1776","HCPCS","0278","RC","","","","both","","","2079.91","1247.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","241.89","1767.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP 28MM TAPERED LOW FRICTION MORSE PLUS","SUP-ITM-10007371","CDM","C1776","HCPCS","0278","RC","","","","both","","","2079.91","1247.95","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1183.47","56.9","","2911.53","1863.86","5209.05","65","241.89","1767.92","percent of total billed charges",""
"HIP 28MM TAPERED LOW FRICTION MORSE PLUS","SUP-ITM-10007371","CDM","C1776","HCPCS","0278","RC","","","","both","","","2079.91","1247.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","241.89","11.63","","400.94","400.94","400.94","1 through 10","241.89","1767.92","percent of total billed charges",""
"HIP 28MM TAPERED LOW FRICTION MORSE PLUS","SUP-ITM-10007371","CDM","C1776","HCPCS","0278","RC","","","","both","","","2079.91","1247.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1609.85","77.4","","5214.50","5214.50","16415.28","1 through 10","241.89","1767.92","percent of total billed charges",""
"HIP 28MM TAPERED LOW FRICTION MORSE PLUS","SUP-ITM-10007371","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2079.91","1247.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","241.89","11.63","","400.94","400.94","400.94","1 through 10","241.89","1609.85","percent of total billed charges",""
"HIP 28MM TAPERED LOW FRICTION MORSE PLUS","SUP-ITM-10007371","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2079.91","1247.95","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","909.34","43.72","","1543.33","1543.33","1671.61","1 through 10","241.89","1609.85","percent of total billed charges",""
"HIP 28MM TAPERED LOW FRICTION MORSE PLUS","SUP-ITM-10007371","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2079.91","1247.95","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1512.51","72.72","","3700.21","2382.07","6427.18","53","241.89","1609.85","percent of total billed charges",""
"HIP 28MM TAPERED LOW FRICTION MORSE PLUS","SUP-ITM-10007371","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2079.91","1247.95","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1512.51","72.72","","12685.80","12685.80","12685.80","1 through 10","241.89","1609.85","percent of total billed charges",""
"HIP 28MM TAPERED LOW FRICTION MORSE PLUS","SUP-ITM-10007371","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2079.91","1247.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1308.26","62.9","","3408.87","2784.05","9859.40","46","241.89","1609.85","percent of total billed charges",""
"HIP 28MM TAPERED LOW FRICTION MORSE PLUS","SUP-ITM-10007371","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2079.91","1247.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1609.85","77.4","","5214.50","5214.50","16415.28","1 through 10","241.89","1609.85","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","321.45","2349.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1572.72","56.9","","2911.53","1863.86","5209.05","65","321.45","2349.4","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.45","11.63","","400.94","400.94","400.94","1 through 10","321.45","2349.4","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2139.34","77.4","","5214.50","5214.50","16415.28","1 through 10","321.45","2349.4","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.45","11.63","","400.94","400.94","400.94","1 through 10","321.45","2139.34","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1208.42","43.72","","1543.33","1543.33","1671.61","1 through 10","321.45","2139.34","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2009.98","72.72","","3700.21","2382.07","6427.18","53","321.45","2139.34","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2009.98","72.72","","12685.80","12685.80","12685.80","1 through 10","321.45","2139.34","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1738.56","62.9","","3408.87","2784.05","9859.40","46","321.45","2139.34","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2139.34","77.4","","5214.50","5214.50","16415.28","1 through 10","321.45","2139.34","percent of total billed charges",""
"HIP 4.0MM PROSTHESIS LFIT V40 COBALT LOW FRICTION ION TREATMENT 28 MINUS","SUP-ITM-10035003","CDM","C1776","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","241.09","1762.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP 4.0MM PROSTHESIS LFIT V40 COBALT LOW FRICTION ION TREATMENT 28 MINUS","SUP-ITM-10035003","CDM","C1776","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1179.54","56.9","","2911.53","1863.86","5209.05","65","241.09","1762.05","percent of total billed charges",""
"HIP 4.0MM PROSTHESIS LFIT V40 COBALT LOW FRICTION ION TREATMENT 28 MINUS","SUP-ITM-10035003","CDM","C1776","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","241.09","11.63","","400.94","400.94","400.94","1 through 10","241.09","1762.05","percent of total billed charges",""
"HIP 4.0MM PROSTHESIS LFIT V40 COBALT LOW FRICTION ION TREATMENT 28 MINUS","SUP-ITM-10035003","CDM","C1776","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1604.50","77.4","","5214.50","5214.50","16415.28","1 through 10","241.09","1762.05","percent of total billed charges",""
"HIP 4.0MM PROSTHESIS LFIT V40 COBALT LOW FRICTION ION TREATMENT 28 MINUS","SUP-ITM-10035003","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","241.09","11.63","","400.94","400.94","400.94","1 through 10","241.09","1604.5","percent of total billed charges",""
"HIP 4.0MM PROSTHESIS LFIT V40 COBALT LOW FRICTION ION TREATMENT 28 MINUS","SUP-ITM-10035003","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","906.32","43.72","","1543.33","1543.33","1671.61","1 through 10","241.09","1604.5","percent of total billed charges",""
"HIP 4.0MM PROSTHESIS LFIT V40 COBALT LOW FRICTION ION TREATMENT 28 MINUS","SUP-ITM-10035003","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1507.49","72.72","","3700.21","2382.07","6427.18","53","241.09","1604.5","percent of total billed charges",""
"HIP 4.0MM PROSTHESIS LFIT V40 COBALT LOW FRICTION ION TREATMENT 28 MINUS","SUP-ITM-10035003","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1507.49","72.72","","12685.80","12685.80","12685.80","1 through 10","241.09","1604.5","percent of total billed charges",""
"HIP 4.0MM PROSTHESIS LFIT V40 COBALT LOW FRICTION ION TREATMENT 28 MINUS","SUP-ITM-10035003","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1303.92","62.9","","3408.87","2784.05","9859.40","46","241.09","1604.5","percent of total billed charges",""
"HIP 4.0MM PROSTHESIS LFIT V40 COBALT LOW FRICTION ION TREATMENT 28 MINUS","SUP-ITM-10035003","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1604.50","77.4","","5214.50","5214.50","16415.28","1 through 10","241.09","1604.5","percent of total billed charges",""
"HIP 44MM TANDEM COBALT CHROMIUM UNIPOLAR","SUP-ITM-10004718","CDM","C1776","HCPCS","0278","RC","","","","both","","","1540.93","924.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","179.21","1309.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP 44MM TANDEM COBALT CHROMIUM UNIPOLAR","SUP-ITM-10004718","CDM","C1776","HCPCS","0278","RC","","","","both","","","1540.93","924.56","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","876.79","56.9","","2911.53","1863.86","5209.05","65","179.21","1309.79","percent of total billed charges",""
"HIP 44MM TANDEM COBALT CHROMIUM UNIPOLAR","SUP-ITM-10004718","CDM","C1776","HCPCS","0278","RC","","","","both","","","1540.93","924.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","179.21","11.63","","400.94","400.94","400.94","1 through 10","179.21","1309.79","percent of total billed charges",""
"HIP 44MM TANDEM COBALT CHROMIUM UNIPOLAR","SUP-ITM-10004718","CDM","C1776","HCPCS","0278","RC","","","","both","","","1540.93","924.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1192.68","77.4","","5214.50","5214.50","16415.28","1 through 10","179.21","1309.79","percent of total billed charges",""
"HIP 44MM TANDEM COBALT CHROMIUM UNIPOLAR","SUP-ITM-10004718","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1540.93","924.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","179.21","11.63","","400.94","400.94","400.94","1 through 10","179.21","1192.68","percent of total billed charges",""
"HIP 44MM TANDEM COBALT CHROMIUM UNIPOLAR","SUP-ITM-10004718","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1540.93","924.56","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","673.69","43.72","","1543.33","1543.33","1671.61","1 through 10","179.21","1192.68","percent of total billed charges",""
"HIP 44MM TANDEM COBALT CHROMIUM UNIPOLAR","SUP-ITM-10004718","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1540.93","924.56","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1120.56","72.72","","3700.21","2382.07","6427.18","53","179.21","1192.68","percent of total billed charges",""
"HIP 44MM TANDEM COBALT CHROMIUM UNIPOLAR","SUP-ITM-10004718","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1540.93","924.56","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1120.56","72.72","","12685.80","12685.80","12685.80","1 through 10","179.21","1192.68","percent of total billed charges",""
"HIP 44MM TANDEM COBALT CHROMIUM UNIPOLAR","SUP-ITM-10004718","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1540.93","924.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","969.24","62.9","","3408.87","2784.05","9859.40","46","179.21","1192.68","percent of total billed charges",""
"HIP 44MM TANDEM COBALT CHROMIUM UNIPOLAR","SUP-ITM-10004718","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1540.93","924.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1192.68","77.4","","5214.50","5214.50","16415.28","1 through 10","179.21","1192.68","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","321.45","2349.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1572.72","56.9","","2911.53","1863.86","5209.05","65","321.45","2349.4","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.45","11.63","","400.94","400.94","400.94","1 through 10","321.45","2349.4","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2139.34","77.4","","5214.50","5214.50","16415.28","1 through 10","321.45","2349.4","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.45","11.63","","400.94","400.94","400.94","1 through 10","321.45","2139.34","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1208.42","43.72","","1543.33","1543.33","1671.61","1 through 10","321.45","2139.34","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2009.98","72.72","","3700.21","2382.07","6427.18","53","321.45","2139.34","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2009.98","72.72","","12685.80","12685.80","12685.80","1 through 10","321.45","2139.34","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1738.56","62.9","","3408.87","2784.05","9859.40","46","321.45","2139.34","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2139.34","77.4","","5214.50","5214.50","16415.28","1 through 10","321.45","2139.34","percent of total billed charges",""
"HIP 51MM TANDEM COBALT CHROMIUM UNIPOLAR","SUP-ITM-10001972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1540.93","924.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","179.21","1309.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP 51MM TANDEM COBALT CHROMIUM UNIPOLAR","SUP-ITM-10001972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1540.93","924.56","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","876.79","56.9","","2911.53","1863.86","5209.05","65","179.21","1309.79","percent of total billed charges",""
"HIP 51MM TANDEM COBALT CHROMIUM UNIPOLAR","SUP-ITM-10001972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1540.93","924.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","179.21","11.63","","400.94","400.94","400.94","1 through 10","179.21","1309.79","percent of total billed charges",""
"HIP 51MM TANDEM COBALT CHROMIUM UNIPOLAR","SUP-ITM-10001972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1540.93","924.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1192.68","77.4","","5214.50","5214.50","16415.28","1 through 10","179.21","1309.79","percent of total billed charges",""
"HIP 51MM TANDEM COBALT CHROMIUM UNIPOLAR","SUP-ITM-10001972","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1540.93","924.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","179.21","11.63","","400.94","400.94","400.94","1 through 10","179.21","1192.68","percent of total billed charges",""
"HIP 51MM TANDEM COBALT CHROMIUM UNIPOLAR","SUP-ITM-10001972","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1540.93","924.56","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","673.69","43.72","","1543.33","1543.33","1671.61","1 through 10","179.21","1192.68","percent of total billed charges",""
"HIP 51MM TANDEM COBALT CHROMIUM UNIPOLAR","SUP-ITM-10001972","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1540.93","924.56","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1120.56","72.72","","3700.21","2382.07","6427.18","53","179.21","1192.68","percent of total billed charges",""
"HIP 51MM TANDEM COBALT CHROMIUM UNIPOLAR","SUP-ITM-10001972","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1540.93","924.56","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1120.56","72.72","","12685.80","12685.80","12685.80","1 through 10","179.21","1192.68","percent of total billed charges",""
"HIP 51MM TANDEM COBALT CHROMIUM UNIPOLAR","SUP-ITM-10001972","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1540.93","924.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","969.24","62.9","","3408.87","2784.05","9859.40","46","179.21","1192.68","percent of total billed charges",""
"HIP 51MM TANDEM COBALT CHROMIUM UNIPOLAR","SUP-ITM-10001972","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1540.93","924.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1192.68","77.4","","5214.50","5214.50","16415.28","1 through 10","179.21","1192.68","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","564.06","4122.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2759.65","56.9","","2911.53","1863.86","5209.05","65","564.06","4122.5","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.06","11.63","","400.94","400.94","400.94","1 through 10","564.06","4122.5","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3753.90","77.4","","5214.50","5214.50","16415.28","1 through 10","564.06","4122.5","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.06","11.63","","400.94","400.94","400.94","1 through 10","564.06","3753.9","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2120.42","43.72","","1543.33","1543.33","1671.61","1 through 10","564.06","3753.9","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3526.92","72.72","","3700.21","2382.07","6427.18","53","564.06","3753.9","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3526.92","72.72","","12685.80","12685.80","12685.80","1 through 10","564.06","3753.9","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3050.65","62.9","","3408.87","2784.05","9859.40","46","564.06","3753.9","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3753.90","77.4","","5214.50","5214.50","16415.28","1 through 10","564.06","3753.9","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","564.06","4122.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2759.65","56.9","","2911.53","1863.86","5209.05","65","564.06","4122.5","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.06","11.63","","400.94","400.94","400.94","1 through 10","564.06","4122.5","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3753.90","77.4","","5214.50","5214.50","16415.28","1 through 10","564.06","4122.5","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.06","11.63","","400.94","400.94","400.94","1 through 10","564.06","3753.9","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2120.42","43.72","","1543.33","1543.33","1671.61","1 through 10","564.06","3753.9","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3526.92","72.72","","3700.21","2382.07","6427.18","53","564.06","3753.9","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3526.92","72.72","","12685.80","12685.80","12685.80","1 through 10","564.06","3753.9","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3050.65","62.9","","3408.87","2784.05","9859.40","46","564.06","3753.9","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3753.90","77.4","","5214.50","5214.50","16415.28","1 through 10","564.06","3753.9","percent of total billed charges",""
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","74158.61","44495.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","79591.21","","Fee schedule rate ($79,591.21). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","54325.09","54325.09","54325.09","1 through 10","3975","79591.21","case rate",""
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","74158.61","44495.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","31339.75","","Fee schedule rate ($31,339.75). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","30289.24","30289.24","30289.24","1 through 10","3975","79591.21","case rate",""
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","74158.61","44495.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","16040.82","","Case rate ($16,368.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,141.91, add-ons for qualifying new technology services are included. If operating cost exceeds $19,060.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,968.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,759.71 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,697.03 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,163.59. The transfer capital threshold is the transfer adjustment factor * $1,163.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15113.57","15113.57","15113.57","1 through 10","3975","79591.21","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","74158.61","44495.17","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","16859.23","","Case rate ($16,368.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,141.91, add-ons for qualifying new technology services are included. If operating cost exceeds $19,060.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,968.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,759.71 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,697.03 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,163.59. The transfer capital threshold is the transfer adjustment factor * $1,163.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","15731.68","15731.68","117142.25","1 through 10","3975","79591.21","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","74158.61","44495.17","MARTIN'S POINT [160007]","HB WDH MEDICARE","16368.18","","Case rate ($16,368.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,141.91, add-ons for qualifying new technology services are included. If operating cost exceeds $19,060.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,968.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,759.71 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,697.03 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,163.59. The transfer capital threshold is the transfer adjustment factor * $1,163.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15808.04","13382.62","15856.52","1 through 10","3975","79591.21","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","74158.61","44495.17","MEDICARE [2001]","HB WDH MEDICARE","16368.18","","Case rate ($16,368.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,141.91, add-ons for qualifying new technology services are included. If operating cost exceeds $19,060.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,968.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,759.71 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,697.03 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,163.59. The transfer capital threshold is the transfer adjustment factor * $1,163.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15388.70","0.05","16141.86","22","3975","79591.21","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","74158.61","44495.17","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","16368.18","","Case rate ($16,368.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,141.91, add-ons for qualifying new technology services are included. If operating cost exceeds $19,060.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,968.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,759.71 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,697.03 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,163.59. The transfer capital threshold is the transfer adjustment factor * $1,163.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15819.04","15779.24","15842.13","1 through 10","3975","79591.21","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","74158.61","44495.17","WELLSENSE NH [1050]","HB WDH MEDICARE","16368.18","","Case rate ($16,368.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,141.91, add-ons for qualifying new technology services are included. If operating cost exceeds $19,060.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,968.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,759.71 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,697.03 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,163.59. The transfer capital threshold is the transfer adjustment factor * $1,163.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16654.37","16654.37","16654.37","1 through 10","3975","79591.21","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With McC","480","MS-DRG","","","","","","","","inpatient","","","91040.50","54624.30","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","23037.14","","Case rate ($22,585.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $20,880.37, add-ons for qualifying new technology services are included. If operating cost exceeds $24,798.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,422.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,522.66 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $20,435.50 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,617.91. The transfer capital threshold is the transfer adjustment factor * $1,617.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","16101.01","16101.01","16101.01","1 through 10","3975","110667.69","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With McC","480","MS-DRG","","","","","","","","inpatient","","","91040.50","54624.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","22133.72","","Case rate ($22,585.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $20,880.37, add-ons for qualifying new technology services are included. If operating cost exceeds $24,798.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,422.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,522.66 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $20,435.50 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,617.91. The transfer capital threshold is the transfer adjustment factor * $1,617.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","22240.22","22240.22","22240.22","1 through 10","3975","110667.69","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With McC","480","MS-DRG","","","","","","","","inpatient","","","91040.50","54624.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","88141.57","","Fee schedule rate ($88,141.57). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","86839.20","86839.20","86839.20","1 through 10","3975","110667.69","case rate",""
"Hip And Femur Procedures Except Major Joint With McC","480","MS-DRG","","","","","","","","inpatient","","","91040.50","54624.30","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","23262.99","","Case rate ($22,585.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $20,880.37, add-ons for qualifying new technology services are included. If operating cost exceeds $24,798.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,422.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,522.66 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $20,435.50 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,617.91. The transfer capital threshold is the transfer adjustment factor * $1,617.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","14989.46","14989.46","14989.46","1 through 10","3975","110667.69","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With McC","480","MS-DRG","","","","","","","","inpatient","","","91040.50","54624.30","MEDICARE [2001]","HB WDH MEDICARE","22585.43","","Case rate ($22,585.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $20,880.37, add-ons for qualifying new technology services are included. If operating cost exceeds $24,798.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,422.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,522.66 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $20,435.50 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,617.91. The transfer capital threshold is the transfer adjustment factor * $1,617.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20346.12","0.05","22695.64","1 through 10","3975","110667.69","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With McC","480","MS-DRG","","","","","","","","inpatient","","","91040.50","54624.30","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","22585.43","","Case rate ($22,585.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $20,880.37, add-ons for qualifying new technology services are included. If operating cost exceeds $24,798.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,422.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,522.66 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $20,435.50 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,617.91. The transfer capital threshold is the transfer adjustment factor * $1,617.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22108.11","21748.77","22694.10","1 through 10","3975","110667.69","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint Without Cc/McC","482","MS-DRG","","","","","","","","inpatient","","","66721.51","40032.91","MARTIN'S POINT [160007]","HB WDH MEDICARE","12844.45","","Case rate ($12,844.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,889.54, add-ons for qualifying new technology services are included. If operating cost exceeds $15,807.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,711.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,493.48 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,444.67 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.09. The transfer capital threshold is the transfer adjustment factor * $906.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10118.35","10118.35","10118.35","1 through 10","3975","61978.16","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint Without Cc/McC","482","MS-DRG","","","","","","","","inpatient","","","66721.51","40032.91","MEDICARE [2001]","HB WDH MEDICARE","12844.45","","Case rate ($12,844.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,889.54, add-ons for qualifying new technology services are included. If operating cost exceeds $15,807.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,711.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,493.48 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,444.67 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.09. The transfer capital threshold is the transfer adjustment factor * $906.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12415.06","12253.03","12446.25","1 through 10","3975","61978.16","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint Without Cc/McC","482","MS-DRG","","","","","","","","inpatient","","","66721.51","40032.91","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","12844.45","","Case rate ($12,844.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,889.54, add-ons for qualifying new technology services are included. If operating cost exceeds $15,807.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,711.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,493.48 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,444.67 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.09. The transfer capital threshold is the transfer adjustment factor * $906.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12235.73","12235.73","12235.73","1 through 10","3975","61978.16","other","Inpatient DRG"
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","345.50","207.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","40.18","293.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","345.50","207.30","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","196.59","56.9","","2911.53","1863.86","5209.05","65","40.18","293.68","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","345.50","207.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.18","11.63","","400.94","400.94","400.94","1 through 10","40.18","293.68","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","345.50","207.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","267.42","77.4","","5214.50","5214.50","16415.28","1 through 10","40.18","293.68","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.18","11.63","","400.94","400.94","400.94","1 through 10","40.18","267.42","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","151.05","43.72","","1543.33","1543.33","1671.61","1 through 10","40.18","267.42","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","251.25","72.72","","3700.21","2382.07","6427.18","53","40.18","267.42","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","251.25","72.72","","12685.80","12685.80","12685.80","1 through 10","40.18","267.42","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","217.32","62.9","","3408.87","2784.05","9859.40","46","40.18","267.42","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","267.42","77.4","","5214.50","5214.50","16415.28","1 through 10","40.18","267.42","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","482.18","3524.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2359.07","56.9","","2911.53","1863.86","5209.05","65","482.18","3524.1","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","482.18","11.63","","400.94","400.94","400.94","1 through 10","482.18","3524.1","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3209.00","77.4","","5214.50","5214.50","16415.28","1 through 10","482.18","3524.1","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","482.18","11.63","","400.94","400.94","400.94","1 through 10","482.18","3209","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1812.63","43.72","","1543.33","1543.33","1671.61","1 through 10","482.18","3209","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3014.97","72.72","","3700.21","2382.07","6427.18","53","482.18","3209","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3014.97","72.72","","12685.80","12685.80","12685.80","1 through 10","482.18","3209","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2607.83","62.9","","3408.87","2784.05","9859.40","46","482.18","3209","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3209.00","77.4","","5214.50","5214.50","16415.28","1 through 10","482.18","3209","percent of total billed charges",""
"HIP H 40MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10019219","CDM","C1776","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","321.45","2349.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP H 40MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10019219","CDM","C1776","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1572.72","56.9","","2911.53","1863.86","5209.05","65","321.45","2349.4","percent of total billed charges",""
"HIP H 40MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10019219","CDM","C1776","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.45","11.63","","400.94","400.94","400.94","1 through 10","321.45","2349.4","percent of total billed charges",""
"HIP H 40MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10019219","CDM","C1776","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2139.34","77.4","","5214.50","5214.50","16415.28","1 through 10","321.45","2349.4","percent of total billed charges",""
"HIP H 40MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10019219","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.45","11.63","","400.94","400.94","400.94","1 through 10","321.45","2139.34","percent of total billed charges",""
"HIP H 40MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10019219","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1208.42","43.72","","1543.33","1543.33","1671.61","1 through 10","321.45","2139.34","percent of total billed charges",""
"HIP H 40MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10019219","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2009.98","72.72","","3700.21","2382.07","6427.18","53","321.45","2139.34","percent of total billed charges",""
"HIP H 40MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10019219","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2009.98","72.72","","12685.80","12685.80","12685.80","1 through 10","321.45","2139.34","percent of total billed charges",""
"HIP H 40MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10019219","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1738.56","62.9","","3408.87","2784.05","9859.40","46","321.45","2139.34","percent of total billed charges",""
"HIP H 40MM UNITRAX COBALT UNIPOLAR SIZE","SUP-ITM-10019219","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2139.34","77.4","","5214.50","5214.50","16415.28","1 through 10","321.45","2139.34","percent of total billed charges",""
"HIP IMPLANT 28X42MM COBALT SELF CENTERING BIPOLAR","SUP-ITM-10006416","CDM","C1776","HCPCS","0278","RC","","","","both","","","2411.59","1446.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","280.47","2049.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP IMPLANT 28X42MM COBALT SELF CENTERING BIPOLAR","SUP-ITM-10006416","CDM","C1776","HCPCS","0278","RC","","","","both","","","2411.59","1446.95","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1372.19","56.9","","2911.53","1863.86","5209.05","65","280.47","2049.85","percent of total billed charges",""
"HIP IMPLANT 28X42MM COBALT SELF CENTERING BIPOLAR","SUP-ITM-10006416","CDM","C1776","HCPCS","0278","RC","","","","both","","","2411.59","1446.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","280.47","11.63","","400.94","400.94","400.94","1 through 10","280.47","2049.85","percent of total billed charges",""
"HIP IMPLANT 28X42MM COBALT SELF CENTERING BIPOLAR","SUP-ITM-10006416","CDM","C1776","HCPCS","0278","RC","","","","both","","","2411.59","1446.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1866.57","77.4","","5214.50","5214.50","16415.28","1 through 10","280.47","2049.85","percent of total billed charges",""
"HIP IMPLANT 28X42MM COBALT SELF CENTERING BIPOLAR","SUP-ITM-10006416","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2411.59","1446.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","280.47","11.63","","400.94","400.94","400.94","1 through 10","280.47","1866.57","percent of total billed charges",""
"HIP IMPLANT 28X42MM COBALT SELF CENTERING BIPOLAR","SUP-ITM-10006416","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2411.59","1446.95","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1054.35","43.72","","1543.33","1543.33","1671.61","1 through 10","280.47","1866.57","percent of total billed charges",""
"HIP IMPLANT 28X42MM COBALT SELF CENTERING BIPOLAR","SUP-ITM-10006416","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2411.59","1446.95","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1753.71","72.72","","3700.21","2382.07","6427.18","53","280.47","1866.57","percent of total billed charges",""
"HIP IMPLANT 28X42MM COBALT SELF CENTERING BIPOLAR","SUP-ITM-10006416","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2411.59","1446.95","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1753.71","72.72","","12685.80","12685.80","12685.80","1 through 10","280.47","1866.57","percent of total billed charges",""
"HIP IMPLANT 28X42MM COBALT SELF CENTERING BIPOLAR","SUP-ITM-10006416","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2411.59","1446.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1516.89","62.9","","3408.87","2784.05","9859.40","46","280.47","1866.57","percent of total billed charges",""
"HIP IMPLANT 28X42MM COBALT SELF CENTERING BIPOLAR","SUP-ITM-10006416","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2411.59","1446.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1866.57","77.4","","5214.50","5214.50","16415.28","1 through 10","280.47","1866.57","percent of total billed charges",""
"HIP LINER 36MM F ACETABULAR NEUTRAL G7 VIT E","SUP-ITM-10268812","CDM","C1776","HCPCS","0278","RC","","","","both","","","5296.52","3177.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","615.99","4502.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP LINER 36MM F ACETABULAR NEUTRAL G7 VIT E","SUP-ITM-10268812","CDM","C1776","HCPCS","0278","RC","","","","both","","","5296.52","3177.91","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3013.72","56.9","","2911.53","1863.86","5209.05","65","615.99","4502.04","percent of total billed charges",""
"HIP LINER 36MM F ACETABULAR NEUTRAL G7 VIT E","SUP-ITM-10268812","CDM","C1776","HCPCS","0278","RC","","","","both","","","5296.52","3177.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","615.99","11.63","","400.94","400.94","400.94","1 through 10","615.99","4502.04","percent of total billed charges",""
"HIP LINER 36MM F ACETABULAR NEUTRAL G7 VIT E","SUP-ITM-10268812","CDM","C1776","HCPCS","0278","RC","","","","both","","","5296.52","3177.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4099.51","77.4","","5214.50","5214.50","16415.28","1 through 10","615.99","4502.04","percent of total billed charges",""
"HIP LINER 36MM F ACETABULAR NEUTRAL G7 VIT E","SUP-ITM-10268812","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5296.52","3177.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","615.99","11.63","","400.94","400.94","400.94","1 through 10","615.99","4099.51","percent of total billed charges",""
"HIP LINER 36MM F ACETABULAR NEUTRAL G7 VIT E","SUP-ITM-10268812","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5296.52","3177.91","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2315.64","43.72","","1543.33","1543.33","1671.61","1 through 10","615.99","4099.51","percent of total billed charges",""
"HIP LINER 36MM F ACETABULAR NEUTRAL G7 VIT E","SUP-ITM-10268812","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5296.52","3177.91","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3851.63","72.72","","3700.21","2382.07","6427.18","53","615.99","4099.51","percent of total billed charges",""
"HIP LINER 36MM F ACETABULAR NEUTRAL G7 VIT E","SUP-ITM-10268812","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5296.52","3177.91","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3851.63","72.72","","12685.80","12685.80","12685.80","1 through 10","615.99","4099.51","percent of total billed charges",""
"HIP LINER 36MM F ACETABULAR NEUTRAL G7 VIT E","SUP-ITM-10268812","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5296.52","3177.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3331.51","62.9","","3408.87","2784.05","9859.40","46","615.99","4099.51","percent of total billed charges",""
"HIP LINER 36MM F ACETABULAR NEUTRAL G7 VIT E","SUP-ITM-10268812","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5296.52","3177.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4099.51","77.4","","5214.50","5214.50","16415.28","1 through 10","615.99","4099.51","percent of total billed charges",""
"HIP PLATE 47MM 2 HOLE 135DEG OMEGA3 KEYLESS SS STANDARD BARREL","SUP-ITM-10034677","CDM","C1713","HCPCS","0278","RC","","","","both","","","6569.27","3941.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","764.01","5583.88","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP PLATE 47MM 2 HOLE 135DEG OMEGA3 KEYLESS SS STANDARD BARREL","SUP-ITM-10034677","CDM","C1713","HCPCS","0278","RC","","","","both","","","6569.27","3941.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","764.01","5583.88","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP PLATE 47MM 2 HOLE 135DEG OMEGA3 KEYLESS SS STANDARD BARREL","SUP-ITM-10034677","CDM","C1713","HCPCS","0278","RC","","","","both","","","6569.27","3941.56","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3737.91","56.9","","812.12","238.65","1587.46","163","764.01","5583.88","percent of total billed charges",""
"HIP PLATE 47MM 2 HOLE 135DEG OMEGA3 KEYLESS SS STANDARD BARREL","SUP-ITM-10034677","CDM","C1713","HCPCS","0278","RC","","","","both","","","6569.27","3941.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","764.01","11.63","","112.68","112.68","146.99","38","764.01","5583.88","percent of total billed charges",""
"HIP PLATE 47MM 2 HOLE 135DEG OMEGA3 KEYLESS SS STANDARD BARREL","SUP-ITM-10034677","CDM","C1713","HCPCS","0278","RC","","","","both","","","6569.27","3941.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5084.61","77.4","","303.98","303.98","5854.79","1 through 10","764.01","5583.88","percent of total billed charges",""
"HIP PLATE 47MM 2 HOLE 135DEG OMEGA3 KEYLESS SS STANDARD BARREL","SUP-ITM-10034677","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6569.27","3941.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","764.01","11.63","","112.68","112.68","146.99","38","764.01","5084.61","percent of total billed charges",""
"HIP PLATE 47MM 2 HOLE 135DEG OMEGA3 KEYLESS SS STANDARD BARREL","SUP-ITM-10034677","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6569.27","3941.56","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4124.19","62.78","","780.86","208.94","10480.28","15","764.01","5084.61","percent of total billed charges",""
"HIP PLATE 47MM 2 HOLE 135DEG OMEGA3 KEYLESS SS STANDARD BARREL","SUP-ITM-10034677","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6569.27","3941.56","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2872.08","43.72","","179.76","179.76","179.76","1 through 10","764.01","5084.61","percent of total billed charges",""
"HIP PLATE 47MM 2 HOLE 135DEG OMEGA3 KEYLESS SS STANDARD BARREL","SUP-ITM-10034677","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6569.27","3941.56","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4777.17","72.72","","2355.45","298.99","3965.19","155","764.01","5084.61","percent of total billed charges",""
"HIP PLATE 47MM 2 HOLE 135DEG OMEGA3 KEYLESS SS STANDARD BARREL","SUP-ITM-10034677","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6569.27","3941.56","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4777.17","72.72","","3643.09","3643.09","3643.09","1 through 10","764.01","5084.61","percent of total billed charges",""
"HIP PLATE 47MM 2 HOLE 135DEG OMEGA3 KEYLESS SS STANDARD BARREL","SUP-ITM-10034677","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6569.27","3941.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3496.17","53.22","","554.28","554.28","554.28","16","764.01","5084.61","percent of total billed charges",""
"HIP PLATE 47MM 2 HOLE 135DEG OMEGA3 KEYLESS SS STANDARD BARREL","SUP-ITM-10034677","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6569.27","3941.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4132.07","62.9","","619.64","173.09","2370.64","150","764.01","5084.61","percent of total billed charges",""
"HIP PLATE 47MM 2 HOLE 135DEG OMEGA3 KEYLESS SS STANDARD BARREL","SUP-ITM-10034677","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6569.27","3941.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5084.61","77.4","","303.98","303.98","5854.79","1 through 10","764.01","5084.61","percent of total billed charges",""
"Hip Replacement With Principal Diagnosis Of Hip Fracture With McC","521","MS-DRG","","","","","","","","inpatient","","","93230.30","55938.18","MARTIN'S POINT [160007]","HB WDH MEDICARE","22265.38","","Case rate ($22,265.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $20,584.96, add-ons for qualifying new technology services are included. If operating cost exceeds $24,503.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,399.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,225.99 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $20,140.09 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,594.52. The transfer capital threshold is the transfer adjustment factor * $1,594.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","22100.54","22100.54","22100.54","1 through 10","20497.91","109067.89","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture With McC","521","MS-DRG","","","","","","","","inpatient","","","93230.30","55938.18","MEDICARE [2001]","HB WDH MEDICARE","22265.38","","Case rate ($22,265.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $20,584.96, add-ons for qualifying new technology services are included. If operating cost exceeds $24,503.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,399.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,225.99 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $20,140.09 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,594.52. The transfer capital threshold is the transfer adjustment factor * $1,594.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","22437.83","0.05","22495.14","1 through 10","20497.91","109067.89","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture With McC","521","MS-DRG","","","","","","","","inpatient","","","93230.30","55938.18","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","22265.38","","Case rate ($22,265.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $20,584.96, add-ons for qualifying new technology services are included. If operating cost exceeds $24,503.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,399.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,225.99 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $20,140.09 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,594.52. The transfer capital threshold is the transfer adjustment factor * $1,594.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","22069.73","22069.73","22069.73","1 through 10","20497.91","109067.89","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","83442.93","50065.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","16213.66","","Case rate ($16,544.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,304.70, add-ons for qualifying new technology services are included. If operating cost exceeds $19,222.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,981.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,923.20 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,859.83 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,176.47. The transfer capital threshold is the transfer adjustment factor * $1,176.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","16065.17","16065.17","16065.17","1 through 10","15123.83","80472.81","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","83442.93","50065.76","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","17040.89","","Case rate ($16,544.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,304.70, add-ons for qualifying new technology services are included. If operating cost exceeds $19,222.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,981.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,923.20 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,859.83 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,176.47. The transfer capital threshold is the transfer adjustment factor * $1,176.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","11812.02","11812.02","11812.02","1 through 10","15123.83","80472.81","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","83442.93","50065.76","MARTIN'S POINT [160007]","HB WDH MEDICARE","16544.55","","Case rate ($16,544.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,304.70, add-ons for qualifying new technology services are included. If operating cost exceeds $19,222.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,981.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,923.20 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,859.83 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,176.47. The transfer capital threshold is the transfer adjustment factor * $1,176.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","16077.05","16077.05","23228.10","1 through 10","15123.83","80472.81","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","83442.93","50065.76","MEDICARE [2001]","HB WDH MEDICARE","16544.55","","Case rate ($16,544.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,304.70, add-ons for qualifying new technology services are included. If operating cost exceeds $19,222.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,981.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,923.20 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,859.83 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,176.47. The transfer capital threshold is the transfer adjustment factor * $1,176.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","16351.58","0.05","16393.03","14","15123.83","80472.81","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","83442.93","50065.76","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","16544.55","","Case rate ($16,544.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,304.70, add-ons for qualifying new technology services are included. If operating cost exceeds $19,222.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,981.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,923.20 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,859.83 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,176.47. The transfer capital threshold is the transfer adjustment factor * $1,176.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","16034.55","16034.55","16089.17","1 through 10","15123.83","80472.81","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","83442.93","50065.76","WELLSENSE NH [1050]","HB WDH MEDICARE","16544.55","","Case rate ($16,544.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,304.70, add-ons for qualifying new technology services are included. If operating cost exceeds $19,222.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,981.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,923.20 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,859.83 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,176.47. The transfer capital threshold is the transfer adjustment factor * $1,176.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","16912.23","16912.23","16912.23","1 through 10","15123.83","80472.81","other","Inpatient DRG"
"HIP SHELL 46C ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10237366","CDM","C1776","HCPCS","0278","RC","","","","both","","","5601.75","3361.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","651.48","4761.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP SHELL 46C ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10237366","CDM","C1776","HCPCS","0278","RC","","","","both","","","5601.75","3361.05","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3187.40","56.9","","2911.53","1863.86","5209.05","65","651.48","4761.49","percent of total billed charges",""
"HIP SHELL 46C ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10237366","CDM","C1776","HCPCS","0278","RC","","","","both","","","5601.75","3361.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","651.48","11.63","","400.94","400.94","400.94","1 through 10","651.48","4761.49","percent of total billed charges",""
"HIP SHELL 46C ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10237366","CDM","C1776","HCPCS","0278","RC","","","","both","","","5601.75","3361.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4335.75","77.4","","5214.50","5214.50","16415.28","1 through 10","651.48","4761.49","percent of total billed charges",""
"HIP SHELL 46C ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10237366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5601.75","3361.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","651.48","11.63","","400.94","400.94","400.94","1 through 10","651.48","4335.75","percent of total billed charges",""
"HIP SHELL 46C ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10237366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5601.75","3361.05","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2449.09","43.72","","1543.33","1543.33","1671.61","1 through 10","651.48","4335.75","percent of total billed charges",""
"HIP SHELL 46C ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10237366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5601.75","3361.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4073.59","72.72","","3700.21","2382.07","6427.18","53","651.48","4335.75","percent of total billed charges",""
"HIP SHELL 46C ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10237366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5601.75","3361.05","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4073.59","72.72","","12685.80","12685.80","12685.80","1 through 10","651.48","4335.75","percent of total billed charges",""
"HIP SHELL 46C ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10237366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5601.75","3361.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3523.50","62.9","","3408.87","2784.05","9859.40","46","651.48","4335.75","percent of total billed charges",""
"HIP SHELL 46C ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10237366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5601.75","3361.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4335.75","77.4","","5214.50","5214.50","16415.28","1 through 10","651.48","4335.75","percent of total billed charges",""
"HIP SHELL SZ 52E ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10240791","CDM","C1776","HCPCS","0278","RC","","","","both","","","5601.75","3361.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","651.48","4761.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP SHELL SZ 52E ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10240791","CDM","C1776","HCPCS","0278","RC","","","","both","","","5601.75","3361.05","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3187.40","56.9","","2911.53","1863.86","5209.05","65","651.48","4761.49","percent of total billed charges",""
"HIP SHELL SZ 52E ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10240791","CDM","C1776","HCPCS","0278","RC","","","","both","","","5601.75","3361.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","651.48","11.63","","400.94","400.94","400.94","1 through 10","651.48","4761.49","percent of total billed charges",""
"HIP SHELL SZ 52E ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10240791","CDM","C1776","HCPCS","0278","RC","","","","both","","","5601.75","3361.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4335.75","77.4","","5214.50","5214.50","16415.28","1 through 10","651.48","4761.49","percent of total billed charges",""
"HIP SHELL SZ 52E ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10240791","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5601.75","3361.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","651.48","11.63","","400.94","400.94","400.94","1 through 10","651.48","4335.75","percent of total billed charges",""
"HIP SHELL SZ 52E ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10240791","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5601.75","3361.05","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2449.09","43.72","","1543.33","1543.33","1671.61","1 through 10","651.48","4335.75","percent of total billed charges",""
"HIP SHELL SZ 52E ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10240791","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5601.75","3361.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4073.59","72.72","","3700.21","2382.07","6427.18","53","651.48","4335.75","percent of total billed charges",""
"HIP SHELL SZ 52E ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10240791","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5601.75","3361.05","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4073.59","72.72","","12685.80","12685.80","12685.80","1 through 10","651.48","4335.75","percent of total billed charges",""
"HIP SHELL SZ 52E ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10240791","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5601.75","3361.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3523.50","62.9","","3408.87","2784.05","9859.40","46","651.48","4335.75","percent of total billed charges",""
"HIP SHELL SZ 52E ACETABULAR MULTIHOLE TRITANIUM TRIDENT II","SUP-ITM-10240791","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5601.75","3361.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4335.75","77.4","","5214.50","5214.50","16415.28","1 through 10","651.48","4335.75","percent of total billed charges",""
"HIP SPACER 14MM UNIVERSAL CEMENTED 16B","SUP-ITM-10004554","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.75","103.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","20.09","146.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP SPACER 14MM UNIVERSAL CEMENTED 16B","SUP-ITM-10004554","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.75","103.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","98.29","56.9","","2911.53","1863.86","5209.05","65","20.09","146.84","percent of total billed charges",""
"HIP SPACER 14MM UNIVERSAL CEMENTED 16B","SUP-ITM-10004554","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.75","103.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.09","11.63","","400.94","400.94","400.94","1 through 10","20.09","146.84","percent of total billed charges",""
"HIP SPACER 14MM UNIVERSAL CEMENTED 16B","SUP-ITM-10004554","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.75","103.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","133.71","77.4","","5214.50","5214.50","16415.28","1 through 10","20.09","146.84","percent of total billed charges",""
"HIP SPACER 14MM UNIVERSAL CEMENTED 16B","SUP-ITM-10004554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.09","11.63","","400.94","400.94","400.94","1 through 10","20.09","133.71","percent of total billed charges",""
"HIP SPACER 14MM UNIVERSAL CEMENTED 16B","SUP-ITM-10004554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","75.53","43.72","","1543.33","1543.33","1671.61","1 through 10","20.09","133.71","percent of total billed charges",""
"HIP SPACER 14MM UNIVERSAL CEMENTED 16B","SUP-ITM-10004554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","125.62","72.72","","3700.21","2382.07","6427.18","53","20.09","133.71","percent of total billed charges",""
"HIP SPACER 14MM UNIVERSAL CEMENTED 16B","SUP-ITM-10004554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","125.62","72.72","","12685.80","12685.80","12685.80","1 through 10","20.09","133.71","percent of total billed charges",""
"HIP SPACER 14MM UNIVERSAL CEMENTED 16B","SUP-ITM-10004554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","108.66","62.9","","3408.87","2784.05","9859.40","46","20.09","133.71","percent of total billed charges",""
"HIP SPACER 14MM UNIVERSAL CEMENTED 16B","SUP-ITM-10004554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","133.71","77.4","","5214.50","5214.50","16415.28","1 through 10","20.09","133.71","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","both","","","172.75","103.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","20.09","146.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","both","","","172.75","103.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","20.09","146.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","both","","","172.75","103.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","98.29","56.9","","812.12","238.65","1587.46","163","20.09","146.84","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","both","","","172.75","103.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.09","11.63","","112.68","112.68","146.99","38","20.09","146.84","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","both","","","172.75","103.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","133.71","77.4","","303.98","303.98","5854.79","1 through 10","20.09","146.84","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.09","11.63","","112.68","112.68","146.99","38","20.09","133.71","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","108.45","62.78","","780.86","208.94","10480.28","15","20.09","133.71","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","75.53","43.72","","179.76","179.76","179.76","1 through 10","20.09","133.71","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","125.62","72.72","","2355.45","298.99","3965.19","155","20.09","133.71","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","125.62","72.72","","3643.09","3643.09","3643.09","1 through 10","20.09","133.71","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","91.94","53.22","","554.28","554.28","554.28","16","20.09","133.71","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","108.66","62.9","","619.64","173.09","2370.64","150","20.09","133.71","percent of total billed charges",""
"HIP SPACER 8MM UNIVERSAL ACCOLADE OMNIFIT COBALT CEMENTED","SUP-ITM-10004548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","133.71","77.4","","303.98","303.98","5854.79","1 through 10","20.09","133.71","percent of total billed charges",""
"HIP STEM 103MM SZ 4 TRI LOCK GRIPTON PRESERVATION CEMENTLESS STANDARD OFFSET","SUP-ITM-10088697","CDM","C1776","HCPCS","0278","RC","","","","both","","","5820.00","3492.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","676.87","4947","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP STEM 103MM SZ 4 TRI LOCK GRIPTON PRESERVATION CEMENTLESS STANDARD OFFSET","SUP-ITM-10088697","CDM","C1776","HCPCS","0278","RC","","","","both","","","5820.00","3492.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3311.58","56.9","","2911.53","1863.86","5209.05","65","676.87","4947","percent of total billed charges",""
"HIP STEM 103MM SZ 4 TRI LOCK GRIPTON PRESERVATION CEMENTLESS STANDARD OFFSET","SUP-ITM-10088697","CDM","C1776","HCPCS","0278","RC","","","","both","","","5820.00","3492.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","676.87","11.63","","400.94","400.94","400.94","1 through 10","676.87","4947","percent of total billed charges",""
"HIP STEM 103MM SZ 4 TRI LOCK GRIPTON PRESERVATION CEMENTLESS STANDARD OFFSET","SUP-ITM-10088697","CDM","C1776","HCPCS","0278","RC","","","","both","","","5820.00","3492.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4504.68","77.4","","5214.50","5214.50","16415.28","1 through 10","676.87","4947","percent of total billed charges",""
"HIP STEM 103MM SZ 4 TRI LOCK GRIPTON PRESERVATION CEMENTLESS STANDARD OFFSET","SUP-ITM-10088697","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","676.87","11.63","","400.94","400.94","400.94","1 through 10","676.87","4504.68","percent of total billed charges",""
"HIP STEM 103MM SZ 4 TRI LOCK GRIPTON PRESERVATION CEMENTLESS STANDARD OFFSET","SUP-ITM-10088697","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2544.50","43.72","","1543.33","1543.33","1671.61","1 through 10","676.87","4504.68","percent of total billed charges",""
"HIP STEM 103MM SZ 4 TRI LOCK GRIPTON PRESERVATION CEMENTLESS STANDARD OFFSET","SUP-ITM-10088697","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4232.30","72.72","","3700.21","2382.07","6427.18","53","676.87","4504.68","percent of total billed charges",""
"HIP STEM 103MM SZ 4 TRI LOCK GRIPTON PRESERVATION CEMENTLESS STANDARD OFFSET","SUP-ITM-10088697","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4232.30","72.72","","12685.80","12685.80","12685.80","1 through 10","676.87","4504.68","percent of total billed charges",""
"HIP STEM 103MM SZ 4 TRI LOCK GRIPTON PRESERVATION CEMENTLESS STANDARD OFFSET","SUP-ITM-10088697","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3660.78","62.9","","3408.87","2784.05","9859.40","46","676.87","4504.68","percent of total billed charges",""
"HIP STEM 103MM SZ 4 TRI LOCK GRIPTON PRESERVATION CEMENTLESS STANDARD OFFSET","SUP-ITM-10088697","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4504.68","77.4","","5214.50","5214.50","16415.28","1 through 10","676.87","4504.68","percent of total billed charges",""
"HIP STEM 15X20X165MM 36MM PLUS 8 LATERAL NECK 11/13 TAPER FEMORAL S-ROM STANDARD","SUP-ITM-10004641","CDM","C1776","HCPCS","0278","RC","","","","both","","","8002.50","4801.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","930.69","6802.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP STEM 15X20X165MM 36MM PLUS 8 LATERAL NECK 11/13 TAPER FEMORAL S-ROM STANDARD","SUP-ITM-10004641","CDM","C1776","HCPCS","0278","RC","","","","both","","","8002.50","4801.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4553.42","56.9","","2911.53","1863.86","5209.05","65","930.69","6802.13","percent of total billed charges",""
"HIP STEM 15X20X165MM 36MM PLUS 8 LATERAL NECK 11/13 TAPER FEMORAL S-ROM STANDARD","SUP-ITM-10004641","CDM","C1776","HCPCS","0278","RC","","","","both","","","8002.50","4801.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","930.69","11.63","","400.94","400.94","400.94","1 through 10","930.69","6802.13","percent of total billed charges",""
"HIP STEM 15X20X165MM 36MM PLUS 8 LATERAL NECK 11/13 TAPER FEMORAL S-ROM STANDARD","SUP-ITM-10004641","CDM","C1776","HCPCS","0278","RC","","","","both","","","8002.50","4801.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6193.94","77.4","","5214.50","5214.50","16415.28","1 through 10","930.69","6802.13","percent of total billed charges",""
"HIP STEM 15X20X165MM 36MM PLUS 8 LATERAL NECK 11/13 TAPER FEMORAL S-ROM STANDARD","SUP-ITM-10004641","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","930.69","11.63","","400.94","400.94","400.94","1 through 10","930.69","6193.94","percent of total billed charges",""
"HIP STEM 15X20X165MM 36MM PLUS 8 LATERAL NECK 11/13 TAPER FEMORAL S-ROM STANDARD","SUP-ITM-10004641","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3498.69","43.72","","1543.33","1543.33","1671.61","1 through 10","930.69","6193.94","percent of total billed charges",""
"HIP STEM 15X20X165MM 36MM PLUS 8 LATERAL NECK 11/13 TAPER FEMORAL S-ROM STANDARD","SUP-ITM-10004641","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5819.42","72.72","","3700.21","2382.07","6427.18","53","930.69","6193.94","percent of total billed charges",""
"HIP STEM 15X20X165MM 36MM PLUS 8 LATERAL NECK 11/13 TAPER FEMORAL S-ROM STANDARD","SUP-ITM-10004641","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5819.42","72.72","","12685.80","12685.80","12685.80","1 through 10","930.69","6193.94","percent of total billed charges",""
"HIP STEM 15X20X165MM 36MM PLUS 8 LATERAL NECK 11/13 TAPER FEMORAL S-ROM STANDARD","SUP-ITM-10004641","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5033.57","62.9","","3408.87","2784.05","9859.40","46","930.69","6193.94","percent of total billed charges",""
"HIP STEM 15X20X165MM 36MM PLUS 8 LATERAL NECK 11/13 TAPER FEMORAL S-ROM STANDARD","SUP-ITM-10004641","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6193.94","77.4","","5214.50","5214.50","16415.28","1 through 10","930.69","6193.94","percent of total billed charges",""
"HIP STEM 21MM X 115MM CONICAL DISTAL","SUP-ITM-10303387","CDM","C1776","HCPCS","0278","RC","","","","both","","","11344.15","6806.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1319.32","9642.53","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP STEM 21MM X 115MM CONICAL DISTAL","SUP-ITM-10303387","CDM","C1776","HCPCS","0278","RC","","","","both","","","11344.15","6806.49","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6454.82","56.9","","2911.53","1863.86","5209.05","65","1319.32","9642.53","percent of total billed charges",""
"HIP STEM 21MM X 115MM CONICAL DISTAL","SUP-ITM-10303387","CDM","C1776","HCPCS","0278","RC","","","","both","","","11344.15","6806.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1319.32","11.63","","400.94","400.94","400.94","1 through 10","1319.32","9642.53","percent of total billed charges",""
"HIP STEM 21MM X 115MM CONICAL DISTAL","SUP-ITM-10303387","CDM","C1776","HCPCS","0278","RC","","","","both","","","11344.15","6806.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8780.37","77.4","","5214.50","5214.50","16415.28","1 through 10","1319.32","9642.53","percent of total billed charges",""
"HIP STEM 21MM X 115MM CONICAL DISTAL","SUP-ITM-10303387","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11344.15","6806.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1319.32","11.63","","400.94","400.94","400.94","1 through 10","1319.32","8780.37","percent of total billed charges",""
"HIP STEM 21MM X 115MM CONICAL DISTAL","SUP-ITM-10303387","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11344.15","6806.49","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4959.66","43.72","","1543.33","1543.33","1671.61","1 through 10","1319.32","8780.37","percent of total billed charges",""
"HIP STEM 21MM X 115MM CONICAL DISTAL","SUP-ITM-10303387","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11344.15","6806.49","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8249.47","72.72","","3700.21","2382.07","6427.18","53","1319.32","8780.37","percent of total billed charges",""
"HIP STEM 21MM X 115MM CONICAL DISTAL","SUP-ITM-10303387","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11344.15","6806.49","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","8249.47","72.72","","12685.80","12685.80","12685.80","1 through 10","1319.32","8780.37","percent of total billed charges",""
"HIP STEM 21MM X 115MM CONICAL DISTAL","SUP-ITM-10303387","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11344.15","6806.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7135.47","62.9","","3408.87","2784.05","9859.40","46","1319.32","8780.37","percent of total billed charges",""
"HIP STEM 21MM X 115MM CONICAL DISTAL","SUP-ITM-10303387","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11344.15","6806.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8780.37","77.4","","5214.50","5214.50","16415.28","1 through 10","1319.32","8780.37","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","both","","","11344.15","6806.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1319.32","9642.53","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","both","","","11344.15","6806.49","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6454.82","56.9","","2911.53","1863.86","5209.05","65","1319.32","9642.53","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","both","","","11344.15","6806.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1319.32","11.63","","400.94","400.94","400.94","1 through 10","1319.32","9642.53","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","both","","","11344.15","6806.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8780.37","77.4","","5214.50","5214.50","16415.28","1 through 10","1319.32","9642.53","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11344.15","6806.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1319.32","11.63","","400.94","400.94","400.94","1 through 10","1319.32","8780.37","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11344.15","6806.49","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4959.66","43.72","","1543.33","1543.33","1671.61","1 through 10","1319.32","8780.37","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11344.15","6806.49","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8249.47","72.72","","3700.21","2382.07","6427.18","53","1319.32","8780.37","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11344.15","6806.49","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","8249.47","72.72","","12685.80","12685.80","12685.80","1 through 10","1319.32","8780.37","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11344.15","6806.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7135.47","62.9","","3408.87","2784.05","9859.40","46","1319.32","8780.37","percent of total billed charges",""
"HIP STEM 23MM 0.0 PROSTHESIS TITANIUM MODULAR REVISION CONE STANDARD PLUS","SUP-ITM-10017448","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11344.15","6806.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8780.37","77.4","","5214.50","5214.50","16415.28","1 through 10","1319.32","8780.37","percent of total billed charges",""
"HIP STEM 25X33 120 9.6MM SIZE 6 127DEG IMPLANT FEMORAL SECUR FIT MAX ANGLED NECK 01","SUP-ITM-10018490","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","789.68","5771.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP STEM 25X33 120 9.6MM SIZE 6 127DEG IMPLANT FEMORAL SECUR FIT MAX ANGLED NECK 01","SUP-ITM-10018490","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3863.51","56.9","","2911.53","1863.86","5209.05","65","789.68","5771.5","percent of total billed charges",""
"HIP STEM 25X33 120 9.6MM SIZE 6 127DEG IMPLANT FEMORAL SECUR FIT MAX ANGLED NECK 01","SUP-ITM-10018490","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","789.68","11.63","","400.94","400.94","400.94","1 through 10","789.68","5771.5","percent of total billed charges",""
"HIP STEM 25X33 120 9.6MM SIZE 6 127DEG IMPLANT FEMORAL SECUR FIT MAX ANGLED NECK 01","SUP-ITM-10018490","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5255.46","77.4","","5214.50","5214.50","16415.28","1 through 10","789.68","5771.5","percent of total billed charges",""
"HIP STEM 25X33 120 9.6MM SIZE 6 127DEG IMPLANT FEMORAL SECUR FIT MAX ANGLED NECK 01","SUP-ITM-10018490","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","789.68","11.63","","400.94","400.94","400.94","1 through 10","789.68","5255.46","percent of total billed charges",""
"HIP STEM 25X33 120 9.6MM SIZE 6 127DEG IMPLANT FEMORAL SECUR FIT MAX ANGLED NECK 01","SUP-ITM-10018490","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2968.59","43.72","","1543.33","1543.33","1671.61","1 through 10","789.68","5255.46","percent of total billed charges",""
"HIP STEM 25X33 120 9.6MM SIZE 6 127DEG IMPLANT FEMORAL SECUR FIT MAX ANGLED NECK 01","SUP-ITM-10018490","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4937.69","72.72","","3700.21","2382.07","6427.18","53","789.68","5255.46","percent of total billed charges",""
"HIP STEM 25X33 120 9.6MM SIZE 6 127DEG IMPLANT FEMORAL SECUR FIT MAX ANGLED NECK 01","SUP-ITM-10018490","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4937.69","72.72","","12685.80","12685.80","12685.80","1 through 10","789.68","5255.46","percent of total billed charges",""
"HIP STEM 25X33 120 9.6MM SIZE 6 127DEG IMPLANT FEMORAL SECUR FIT MAX ANGLED NECK 01","SUP-ITM-10018490","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4270.91","62.9","","3408.87","2784.05","9859.40","46","789.68","5255.46","percent of total billed charges",""
"HIP STEM 25X33 120 9.6MM SIZE 6 127DEG IMPLANT FEMORAL SECUR FIT MAX ANGLED NECK 01","SUP-ITM-10018490","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5255.46","77.4","","5214.50","5214.50","16415.28","1 through 10","789.68","5255.46","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","both","","","8730.00","5238.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1015.3","7420.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","both","","","8730.00","5238.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4967.37","56.9","","2911.53","1863.86","5209.05","65","1015.3","7420.5","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","both","","","8730.00","5238.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1015.30","11.63","","400.94","400.94","400.94","1 through 10","1015.3","7420.5","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","both","","","8730.00","5238.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6757.02","77.4","","5214.50","5214.50","16415.28","1 through 10","1015.3","7420.5","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8730.00","5238.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1015.30","11.63","","400.94","400.94","400.94","1 through 10","1015.3","6757.02","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8730.00","5238.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3816.76","43.72","","1543.33","1543.33","1671.61","1 through 10","1015.3","6757.02","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8730.00","5238.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6348.46","72.72","","3700.21","2382.07","6427.18","53","1015.3","6757.02","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8730.00","5238.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6348.46","72.72","","12685.80","12685.80","12685.80","1 through 10","1015.3","6757.02","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8730.00","5238.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5491.17","62.9","","3408.87","2784.05","9859.40","46","1015.3","6757.02","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8730.00","5238.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6757.02","77.4","","5214.50","5214.50","16415.28","1 through 10","1015.3","6757.02","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","789.68","5771.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3863.51","56.9","","2911.53","1863.86","5209.05","65","789.68","5771.5","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","789.68","11.63","","400.94","400.94","400.94","1 through 10","789.68","5771.5","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5255.46","77.4","","5214.50","5214.50","16415.28","1 through 10","789.68","5771.5","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","789.68","11.63","","400.94","400.94","400.94","1 through 10","789.68","5255.46","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2968.59","43.72","","1543.33","1543.33","1671.61","1 through 10","789.68","5255.46","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4937.69","72.72","","3700.21","2382.07","6427.18","53","789.68","5255.46","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4937.69","72.72","","12685.80","12685.80","12685.80","1 through 10","789.68","5255.46","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4270.91","62.9","","3408.87","2784.05","9859.40","46","789.68","5255.46","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5255.46","77.4","","5214.50","5214.50","16415.28","1 through 10","789.68","5255.46","percent of total billed charges",""
"HIP STEM 35MM SZ 1 ALLOCLASSIC SL PROTASUL 100 TI POROUS TAPER STRAIGHT OFFSET","SUP-ITM-10202591","CDM","C1776","HCPCS","0278","RC","","","","both","","","8402.63","5041.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","977.23","7142.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP STEM 35MM SZ 1 ALLOCLASSIC SL PROTASUL 100 TI POROUS TAPER STRAIGHT OFFSET","SUP-ITM-10202591","CDM","C1776","HCPCS","0278","RC","","","","both","","","8402.63","5041.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4781.10","56.9","","2911.53","1863.86","5209.05","65","977.23","7142.24","percent of total billed charges",""
"HIP STEM 35MM SZ 1 ALLOCLASSIC SL PROTASUL 100 TI POROUS TAPER STRAIGHT OFFSET","SUP-ITM-10202591","CDM","C1776","HCPCS","0278","RC","","","","both","","","8402.63","5041.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","977.23","11.63","","400.94","400.94","400.94","1 through 10","977.23","7142.24","percent of total billed charges",""
"HIP STEM 35MM SZ 1 ALLOCLASSIC SL PROTASUL 100 TI POROUS TAPER STRAIGHT OFFSET","SUP-ITM-10202591","CDM","C1776","HCPCS","0278","RC","","","","both","","","8402.63","5041.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6503.64","77.4","","5214.50","5214.50","16415.28","1 through 10","977.23","7142.24","percent of total billed charges",""
"HIP STEM 35MM SZ 1 ALLOCLASSIC SL PROTASUL 100 TI POROUS TAPER STRAIGHT OFFSET","SUP-ITM-10202591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8402.63","5041.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","977.23","11.63","","400.94","400.94","400.94","1 through 10","977.23","6503.64","percent of total billed charges",""
"HIP STEM 35MM SZ 1 ALLOCLASSIC SL PROTASUL 100 TI POROUS TAPER STRAIGHT OFFSET","SUP-ITM-10202591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8402.63","5041.58","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3673.63","43.72","","1543.33","1543.33","1671.61","1 through 10","977.23","6503.64","percent of total billed charges",""
"HIP STEM 35MM SZ 1 ALLOCLASSIC SL PROTASUL 100 TI POROUS TAPER STRAIGHT OFFSET","SUP-ITM-10202591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8402.63","5041.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6110.39","72.72","","3700.21","2382.07","6427.18","53","977.23","6503.64","percent of total billed charges",""
"HIP STEM 35MM SZ 1 ALLOCLASSIC SL PROTASUL 100 TI POROUS TAPER STRAIGHT OFFSET","SUP-ITM-10202591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8402.63","5041.58","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6110.39","72.72","","12685.80","12685.80","12685.80","1 through 10","977.23","6503.64","percent of total billed charges",""
"HIP STEM 35MM SZ 1 ALLOCLASSIC SL PROTASUL 100 TI POROUS TAPER STRAIGHT OFFSET","SUP-ITM-10202591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8402.63","5041.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5285.25","62.9","","3408.87","2784.05","9859.40","46","977.23","6503.64","percent of total billed charges",""
"HIP STEM 35MM SZ 1 ALLOCLASSIC SL PROTASUL 100 TI POROUS TAPER STRAIGHT OFFSET","SUP-ITM-10202591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8402.63","5041.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6503.64","77.4","","5214.50","5214.50","16415.28","1 through 10","977.23","6503.64","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","789.68","5771.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3863.51","56.9","","2911.53","1863.86","5209.05","65","789.68","5771.5","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","789.68","11.63","","400.94","400.94","400.94","1 through 10","789.68","5771.5","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5255.46","77.4","","5214.50","5214.50","16415.28","1 through 10","789.68","5771.5","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","789.68","11.63","","400.94","400.94","400.94","1 through 10","789.68","5255.46","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2968.59","43.72","","1543.33","1543.33","1671.61","1 through 10","789.68","5255.46","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4937.69","72.72","","3700.21","2382.07","6427.18","53","789.68","5255.46","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4937.69","72.72","","12685.80","12685.80","12685.80","1 through 10","789.68","5255.46","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4270.91","62.9","","3408.87","2784.05","9859.40","46","789.68","5255.46","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5255.46","77.4","","5214.50","5214.50","16415.28","1 through 10","789.68","5255.46","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","789.68","5771.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3863.51","56.9","","2911.53","1863.86","5209.05","65","789.68","5771.5","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","789.68","11.63","","400.94","400.94","400.94","1 through 10","789.68","5771.5","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5255.46","77.4","","5214.50","5214.50","16415.28","1 through 10","789.68","5771.5","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","789.68","11.63","","400.94","400.94","400.94","1 through 10","789.68","5255.46","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2968.59","43.72","","1543.33","1543.33","1671.61","1 through 10","789.68","5255.46","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4937.69","72.72","","3700.21","2382.07","6427.18","53","789.68","5255.46","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4937.69","72.72","","12685.80","12685.80","12685.80","1 through 10","789.68","5255.46","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4270.91","62.9","","3408.87","2784.05","9859.40","46","789.68","5255.46","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5255.46","77.4","","5214.50","5214.50","16415.28","1 through 10","789.68","5255.46","percent of total billed charges",""
"HIP STEM SIZE 8 CLASSIC PROFEMUR GLADIATOR TITANIUM IMAL PLASMA COAT TAPERED WEDGE EXTENDED","SUP-ITM-10123984","CDM","C1713","HCPCS","0278","RC","","","","both","","","9840.65","5904.39","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1144.47","8364.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP STEM SIZE 8 CLASSIC PROFEMUR GLADIATOR TITANIUM IMAL PLASMA COAT TAPERED WEDGE EXTENDED","SUP-ITM-10123984","CDM","C1713","HCPCS","0278","RC","","","","both","","","9840.65","5904.39","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1144.47","8364.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP STEM SIZE 8 CLASSIC PROFEMUR GLADIATOR TITANIUM IMAL PLASMA COAT TAPERED WEDGE EXTENDED","SUP-ITM-10123984","CDM","C1713","HCPCS","0278","RC","","","","both","","","9840.65","5904.39","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5599.33","56.9","","812.12","238.65","1587.46","163","1144.47","8364.55","percent of total billed charges",""
"HIP STEM SIZE 8 CLASSIC PROFEMUR GLADIATOR TITANIUM IMAL PLASMA COAT TAPERED WEDGE EXTENDED","SUP-ITM-10123984","CDM","C1713","HCPCS","0278","RC","","","","both","","","9840.65","5904.39","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1144.47","11.63","","112.68","112.68","146.99","38","1144.47","8364.55","percent of total billed charges",""
"HIP STEM SIZE 8 CLASSIC PROFEMUR GLADIATOR TITANIUM IMAL PLASMA COAT TAPERED WEDGE EXTENDED","SUP-ITM-10123984","CDM","C1713","HCPCS","0278","RC","","","","both","","","9840.65","5904.39","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7616.66","77.4","","303.98","303.98","5854.79","1 through 10","1144.47","8364.55","percent of total billed charges",""
"HIP STEM SIZE 8 CLASSIC PROFEMUR GLADIATOR TITANIUM IMAL PLASMA COAT TAPERED WEDGE EXTENDED","SUP-ITM-10123984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9840.65","5904.39","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1144.47","11.63","","112.68","112.68","146.99","38","1144.47","7616.66","percent of total billed charges",""
"HIP STEM SIZE 8 CLASSIC PROFEMUR GLADIATOR TITANIUM IMAL PLASMA COAT TAPERED WEDGE EXTENDED","SUP-ITM-10123984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9840.65","5904.39","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6177.96","62.78","","780.86","208.94","10480.28","15","1144.47","7616.66","percent of total billed charges",""
"HIP STEM SIZE 8 CLASSIC PROFEMUR GLADIATOR TITANIUM IMAL PLASMA COAT TAPERED WEDGE EXTENDED","SUP-ITM-10123984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9840.65","5904.39","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4302.33","43.72","","179.76","179.76","179.76","1 through 10","1144.47","7616.66","percent of total billed charges",""
"HIP STEM SIZE 8 CLASSIC PROFEMUR GLADIATOR TITANIUM IMAL PLASMA COAT TAPERED WEDGE EXTENDED","SUP-ITM-10123984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9840.65","5904.39","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7156.12","72.72","","2355.45","298.99","3965.19","155","1144.47","7616.66","percent of total billed charges",""
"HIP STEM SIZE 8 CLASSIC PROFEMUR GLADIATOR TITANIUM IMAL PLASMA COAT TAPERED WEDGE EXTENDED","SUP-ITM-10123984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9840.65","5904.39","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7156.12","72.72","","3643.09","3643.09","3643.09","1 through 10","1144.47","7616.66","percent of total billed charges",""
"HIP STEM SIZE 8 CLASSIC PROFEMUR GLADIATOR TITANIUM IMAL PLASMA COAT TAPERED WEDGE EXTENDED","SUP-ITM-10123984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9840.65","5904.39","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","5237.19","53.22","","554.28","554.28","554.28","16","1144.47","7616.66","percent of total billed charges",""
"HIP STEM SIZE 8 CLASSIC PROFEMUR GLADIATOR TITANIUM IMAL PLASMA COAT TAPERED WEDGE EXTENDED","SUP-ITM-10123984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9840.65","5904.39","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6189.77","62.9","","619.64","173.09","2370.64","150","1144.47","7616.66","percent of total billed charges",""
"HIP STEM SIZE 8 CLASSIC PROFEMUR GLADIATOR TITANIUM IMAL PLASMA COAT TAPERED WEDGE EXTENDED","SUP-ITM-10123984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9840.65","5904.39","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7616.66","77.4","","303.98","303.98","5854.79","1 through 10","1144.47","7616.66","percent of total billed charges",""
"HIP STEM SZ 2 130X32MM 130DEG FEMORAL SUMMIT DUOFIX TITANIUM HYDROXYAPATITE TAPERED STANDARD OFFSET CEMENTLESS","SUP-ITM-10012987","CDM","C1776","HCPCS","0278","RC","","","","both","","","5820.00","3492.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","676.87","4947","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP STEM SZ 2 130X32MM 130DEG FEMORAL SUMMIT DUOFIX TITANIUM HYDROXYAPATITE TAPERED STANDARD OFFSET CEMENTLESS","SUP-ITM-10012987","CDM","C1776","HCPCS","0278","RC","","","","both","","","5820.00","3492.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3311.58","56.9","","2911.53","1863.86","5209.05","65","676.87","4947","percent of total billed charges",""
"HIP STEM SZ 2 130X32MM 130DEG FEMORAL SUMMIT DUOFIX TITANIUM HYDROXYAPATITE TAPERED STANDARD OFFSET CEMENTLESS","SUP-ITM-10012987","CDM","C1776","HCPCS","0278","RC","","","","both","","","5820.00","3492.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","676.87","11.63","","400.94","400.94","400.94","1 through 10","676.87","4947","percent of total billed charges",""
"HIP STEM SZ 2 130X32MM 130DEG FEMORAL SUMMIT DUOFIX TITANIUM HYDROXYAPATITE TAPERED STANDARD OFFSET CEMENTLESS","SUP-ITM-10012987","CDM","C1776","HCPCS","0278","RC","","","","both","","","5820.00","3492.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4504.68","77.4","","5214.50","5214.50","16415.28","1 through 10","676.87","4947","percent of total billed charges",""
"HIP STEM SZ 2 130X32MM 130DEG FEMORAL SUMMIT DUOFIX TITANIUM HYDROXYAPATITE TAPERED STANDARD OFFSET CEMENTLESS","SUP-ITM-10012987","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","676.87","11.63","","400.94","400.94","400.94","1 through 10","676.87","4504.68","percent of total billed charges",""
"HIP STEM SZ 2 130X32MM 130DEG FEMORAL SUMMIT DUOFIX TITANIUM HYDROXYAPATITE TAPERED STANDARD OFFSET CEMENTLESS","SUP-ITM-10012987","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2544.50","43.72","","1543.33","1543.33","1671.61","1 through 10","676.87","4504.68","percent of total billed charges",""
"HIP STEM SZ 2 130X32MM 130DEG FEMORAL SUMMIT DUOFIX TITANIUM HYDROXYAPATITE TAPERED STANDARD OFFSET CEMENTLESS","SUP-ITM-10012987","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4232.30","72.72","","3700.21","2382.07","6427.18","53","676.87","4504.68","percent of total billed charges",""
"HIP STEM SZ 2 130X32MM 130DEG FEMORAL SUMMIT DUOFIX TITANIUM HYDROXYAPATITE TAPERED STANDARD OFFSET CEMENTLESS","SUP-ITM-10012987","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4232.30","72.72","","12685.80","12685.80","12685.80","1 through 10","676.87","4504.68","percent of total billed charges",""
"HIP STEM SZ 2 130X32MM 130DEG FEMORAL SUMMIT DUOFIX TITANIUM HYDROXYAPATITE TAPERED STANDARD OFFSET CEMENTLESS","SUP-ITM-10012987","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3660.78","62.9","","3408.87","2784.05","9859.40","46","676.87","4504.68","percent of total billed charges",""
"HIP STEM SZ 2 130X32MM 130DEG FEMORAL SUMMIT DUOFIX TITANIUM HYDROXYAPATITE TAPERED STANDARD OFFSET CEMENTLESS","SUP-ITM-10012987","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4504.68","77.4","","5214.50","5214.50","16415.28","1 through 10","676.87","4504.68","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","both","","","5475.65","3285.39","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","636.82","4654.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","both","","","5475.65","3285.39","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3115.64","56.9","","2911.53","1863.86","5209.05","65","636.82","4654.3","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","both","","","5475.65","3285.39","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","636.82","11.63","","400.94","400.94","400.94","1 through 10","636.82","4654.3","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","both","","","5475.65","3285.39","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4238.15","77.4","","5214.50","5214.50","16415.28","1 through 10","636.82","4654.3","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5475.65","3285.39","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","636.82","11.63","","400.94","400.94","400.94","1 through 10","636.82","4238.15","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5475.65","3285.39","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2393.95","43.72","","1543.33","1543.33","1671.61","1 through 10","636.82","4238.15","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5475.65","3285.39","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3981.89","72.72","","3700.21","2382.07","6427.18","53","636.82","4238.15","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5475.65","3285.39","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3981.89","72.72","","12685.80","12685.80","12685.80","1 through 10","636.82","4238.15","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5475.65","3285.39","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3444.18","62.9","","3408.87","2784.05","9859.40","46","636.82","4238.15","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5475.65","3285.39","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4238.15","77.4","","5214.50","5214.50","16415.28","1 through 10","636.82","4238.15","percent of total billed charges",""
"HIP STEM SZ 4 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197789","CDM","C1776","HCPCS","0278","RC","","","","both","","","6305.00","3783.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","733.27","5359.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP STEM SZ 4 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197789","CDM","C1776","HCPCS","0278","RC","","","","both","","","6305.00","3783.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3587.55","56.9","","2911.53","1863.86","5209.05","65","733.27","5359.25","percent of total billed charges",""
"HIP STEM SZ 4 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197789","CDM","C1776","HCPCS","0278","RC","","","","both","","","6305.00","3783.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","733.27","11.63","","400.94","400.94","400.94","1 through 10","733.27","5359.25","percent of total billed charges",""
"HIP STEM SZ 4 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197789","CDM","C1776","HCPCS","0278","RC","","","","both","","","6305.00","3783.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4880.07","77.4","","5214.50","5214.50","16415.28","1 through 10","733.27","5359.25","percent of total billed charges",""
"HIP STEM SZ 4 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197789","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6305.00","3783.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","733.27","11.63","","400.94","400.94","400.94","1 through 10","733.27","4880.07","percent of total billed charges",""
"HIP STEM SZ 4 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197789","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6305.00","3783.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2756.55","43.72","","1543.33","1543.33","1671.61","1 through 10","733.27","4880.07","percent of total billed charges",""
"HIP STEM SZ 4 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197789","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6305.00","3783.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4585.00","72.72","","3700.21","2382.07","6427.18","53","733.27","4880.07","percent of total billed charges",""
"HIP STEM SZ 4 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197789","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6305.00","3783.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4585.00","72.72","","12685.80","12685.80","12685.80","1 through 10","733.27","4880.07","percent of total billed charges",""
"HIP STEM SZ 4 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197789","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6305.00","3783.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3965.85","62.9","","3408.87","2784.05","9859.40","46","733.27","4880.07","percent of total billed charges",""
"HIP STEM SZ 4 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197789","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6305.00","3783.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4880.07","77.4","","5214.50","5214.50","16415.28","1 through 10","733.27","4880.07","percent of total billed charges",""
"HIP STEM SZ 5 FEMORAL COLLAR POLAR TITANIUM HYDROXYAPATITE LM/RL","SUP-ITM-10198484","CDM","C1776","HCPCS","0278","RC","","","","both","","","8002.50","4801.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","930.69","6802.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP STEM SZ 5 FEMORAL COLLAR POLAR TITANIUM HYDROXYAPATITE LM/RL","SUP-ITM-10198484","CDM","C1776","HCPCS","0278","RC","","","","both","","","8002.50","4801.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4553.42","56.9","","2911.53","1863.86","5209.05","65","930.69","6802.13","percent of total billed charges",""
"HIP STEM SZ 5 FEMORAL COLLAR POLAR TITANIUM HYDROXYAPATITE LM/RL","SUP-ITM-10198484","CDM","C1776","HCPCS","0278","RC","","","","both","","","8002.50","4801.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","930.69","11.63","","400.94","400.94","400.94","1 through 10","930.69","6802.13","percent of total billed charges",""
"HIP STEM SZ 5 FEMORAL COLLAR POLAR TITANIUM HYDROXYAPATITE LM/RL","SUP-ITM-10198484","CDM","C1776","HCPCS","0278","RC","","","","both","","","8002.50","4801.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6193.94","77.4","","5214.50","5214.50","16415.28","1 through 10","930.69","6802.13","percent of total billed charges",""
"HIP STEM SZ 5 FEMORAL COLLAR POLAR TITANIUM HYDROXYAPATITE LM/RL","SUP-ITM-10198484","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","930.69","11.63","","400.94","400.94","400.94","1 through 10","930.69","6193.94","percent of total billed charges",""
"HIP STEM SZ 5 FEMORAL COLLAR POLAR TITANIUM HYDROXYAPATITE LM/RL","SUP-ITM-10198484","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3498.69","43.72","","1543.33","1543.33","1671.61","1 through 10","930.69","6193.94","percent of total billed charges",""
"HIP STEM SZ 5 FEMORAL COLLAR POLAR TITANIUM HYDROXYAPATITE LM/RL","SUP-ITM-10198484","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5819.42","72.72","","3700.21","2382.07","6427.18","53","930.69","6193.94","percent of total billed charges",""
"HIP STEM SZ 5 FEMORAL COLLAR POLAR TITANIUM HYDROXYAPATITE LM/RL","SUP-ITM-10198484","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5819.42","72.72","","12685.80","12685.80","12685.80","1 through 10","930.69","6193.94","percent of total billed charges",""
"HIP STEM SZ 5 FEMORAL COLLAR POLAR TITANIUM HYDROXYAPATITE LM/RL","SUP-ITM-10198484","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5033.57","62.9","","3408.87","2784.05","9859.40","46","930.69","6193.94","percent of total billed charges",""
"HIP STEM SZ 5 FEMORAL COLLAR POLAR TITANIUM HYDROXYAPATITE LM/RL","SUP-ITM-10198484","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6193.94","77.4","","5214.50","5214.50","16415.28","1 through 10","930.69","6193.94","percent of total billed charges",""
"HIP STEM SZ 6 FEMORAL COLLAR POLAR TITANIUM HYDROXYAPATITE LM/RL","SUP-ITM-10198482","CDM","C1776","HCPCS","0278","RC","","","","both","","","8002.50","4801.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","930.69","6802.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HIP STEM SZ 6 FEMORAL COLLAR POLAR TITANIUM HYDROXYAPATITE LM/RL","SUP-ITM-10198482","CDM","C1776","HCPCS","0278","RC","","","","both","","","8002.50","4801.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4553.42","56.9","","2911.53","1863.86","5209.05","65","930.69","6802.13","percent of total billed charges",""
"HIP STEM SZ 6 FEMORAL COLLAR POLAR TITANIUM HYDROXYAPATITE LM/RL","SUP-ITM-10198482","CDM","C1776","HCPCS","0278","RC","","","","both","","","8002.50","4801.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","930.69","11.63","","400.94","400.94","400.94","1 through 10","930.69","6802.13","percent of total billed charges",""
"HIP STEM SZ 6 FEMORAL COLLAR POLAR TITANIUM HYDROXYAPATITE LM/RL","SUP-ITM-10198482","CDM","C1776","HCPCS","0278","RC","","","","both","","","8002.50","4801.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6193.94","77.4","","5214.50","5214.50","16415.28","1 through 10","930.69","6802.13","percent of total billed charges",""
"HIP STEM SZ 6 FEMORAL COLLAR POLAR TITANIUM HYDROXYAPATITE LM/RL","SUP-ITM-10198482","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","930.69","11.63","","400.94","400.94","400.94","1 through 10","930.69","6193.94","percent of total billed charges",""
"HIP STEM SZ 6 FEMORAL COLLAR POLAR TITANIUM HYDROXYAPATITE LM/RL","SUP-ITM-10198482","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3498.69","43.72","","1543.33","1543.33","1671.61","1 through 10","930.69","6193.94","percent of total billed charges",""
"HIP STEM SZ 6 FEMORAL COLLAR POLAR TITANIUM HYDROXYAPATITE LM/RL","SUP-ITM-10198482","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5819.42","72.72","","3700.21","2382.07","6427.18","53","930.69","6193.94","percent of total billed charges",""
"HIP STEM SZ 6 FEMORAL COLLAR POLAR TITANIUM HYDROXYAPATITE LM/RL","SUP-ITM-10198482","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5819.42","72.72","","12685.80","12685.80","12685.80","1 through 10","930.69","6193.94","percent of total billed charges",""
"HIP STEM SZ 6 FEMORAL COLLAR POLAR TITANIUM HYDROXYAPATITE LM/RL","SUP-ITM-10198482","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5033.57","62.9","","3408.87","2784.05","9859.40","46","930.69","6193.94","percent of total billed charges",""
"HIP STEM SZ 6 FEMORAL COLLAR POLAR TITANIUM HYDROXYAPATITE LM/RL","SUP-ITM-10198482","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6193.94","77.4","","5214.50","5214.50","16415.28","1 through 10","930.69","6193.94","percent of total billed charges",""
"Histamine","PX-30000511","CDM","83088","CPT","0301","RC","","","","outpatient","","","158.00","94.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","99.38","62.9","","96.39","96.39","96.39","1 through 10","35.39","122.29","percent of total billed charges",""
"Histoplasma Antibody","PX-30000950","CDM","86698","CPT","0302","RC","","","","both","","","97.00","58.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","67.71","69.8","","59.13","59.13","59.13","1 through 10","8.96","82.45","percent of total billed charges",""
"Histoplasma Antibody","PX-30000950","CDM","86698","CPT","0302","RC","","","","outpatient","","","97.00","58.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","70.54","72.72","","68.36","68.36","68.36","1 through 10","14.98","75.08","percent of total billed charges",""
"Hla Typing II High Res 1 Locus Ea","PX-30000770","CDM","81382","CPT","0310","RC","","","","outpatient","","","1297.00","778.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","943.18","72.72","","911.91","911.91","911.91","1 through 10","150.84","1003.88","percent of total billed charges",""
"Hla Typing II High Res 1 Locus Ea","PX-30000770","CDM","81382","CPT","0310","RC","","","","outpatient","","","1297.00","778.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","815.81","62.9","","790.02","790.02","790.02","1 through 10","150.84","1003.88","percent of total billed charges",""
"Hla Typing II High Res 1 Locus Ea","PX-30000770","CDM","81382","CPT","0310","RC","","","","outpatient","","","1297.00","778.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","150.84","11.63","","148.12","148.12","148.12","1 through 10","150.84","1003.88","percent of total billed charges",""
"Hla Typing Single Antigen a/B/C","PX-30001020","CDM","86812","CPT","0300","RC","","","","inpatient","","","141.00","84.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","108.37","76.86","","81.98","81.98","81.98","1 through 10","93.34","108.37","percent of total billed charges",""
"Hla Typing Single Antigen a/B/C","PX-30001020","CDM","86812","CPT","0302","RC","","","","both","","","141.00","84.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","98.42","69.8","","94.93","29.42","94.93","11","16.78","133.94","percent of total billed charges",""
"Hla Typing Single Antigen a/B/C","PX-30001020","CDM","86812","CPT","0302","RC","","","","outpatient","","","141.00","84.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","102.54","72.72","","98.90","98.90","98.90","1 through 10","24.05","109.13","percent of total billed charges",""
"Hla Typing Single Antigen a/B/C","PX-30001020","CDM","86812","CPT","0302","RC","","","","outpatient","","","141.00","84.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","88.69","62.9","","85.68","85.68","85.68","17","24.05","109.13","percent of total billed charges",""
"Hla Typing Single Antigen a/B/C","PX-30001020","CDM","86812","CPT","0302","RC","","","","outpatient","","","141.00","84.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","109.13","77.4","","105.40","105.40","105.40","1 through 10","24.05","109.13","percent of total billed charges",""
"Ho W/O Joints Custom T1","PX-27000499","CDM","L3919","HCPCS","0274","RC","","","","both","","","301.00","180.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","171.27","56.9","","46.17","46.17","46.17","1 through 10","171.27","298.56","percent of total billed charges",""
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","both","","","946.00","567.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","660.31","69.8","","637.27","637.27","637.27","1 through 10","160.19","844.38","percent of total billed charges",""
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","both","","","946.00","567.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","160.19","","APC Price ($163.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","163.48","152.20","163.48","82","160.19","844.38","other","OPPS APC"
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","both","","","946.00","567.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","844.38","","Case rate ($844.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","823.78","438.86","823.78","71","160.19","844.38","other","OPPS APC"
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","both","","","946.00","567.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","538.27","56.9","","519.50","519.50","519.50","113","160.19","844.38","percent of total billed charges",""
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","both","","","946.00","567.60","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","538.27","56.9","","519.50","519.50","519.50","1 through 10","160.19","844.38","percent of total billed charges",""
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","both","","","946.00","567.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","168.37","","APC Price ($163.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","165.01","156.48","168.38","13","160.19","844.38","other","OPPS APC"
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","both","","","946.00","567.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","163.46","","APC Price ($163.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","160.86","152.20","163.48","58","160.19","844.38","other","OPPS APC"
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","both","","","946.00","567.60","MEDICARE [2001]","HB WDH MEDICARE","163.46","","APC Price ($163.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","163.48","152.20","163.48","204","160.19","844.38","other","OPPS APC"
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","both","","","946.00","567.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","804.10","85","","295.67","272.56","295.67","1 through 10","160.19","844.38","percent of total billed charges",""
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","both","","","946.00","567.60","TRICARE [160005]","HB WDH MEDICARE","163.46","","APC Price ($163.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","163.48","152.20","163.48","11","160.19","844.38","other","OPPS APC"
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","both","","","946.00","567.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","163.46","","APC Price ($163.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","160.87","150.16","163.48","38","160.19","844.38","other","OPPS APC"
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","both","","","946.00","567.60","WELLPOINT [1015]","HB WDH ANTHEM PPO","844.38","","Case rate ($844.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","799.65","799.65","799.65","1 through 10","160.19","844.38","other","OPPS APC"
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","both","","","946.00","567.60","WELLSENSE NH [1050]","HB WDH MEDICARE","163.46","","APC Price ($163.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","98.28","98.28","98.69","1 through 10","160.19","844.38","other","OPPS APC"
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","outpatient","","","946.00","567.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","110.02","11.63","","58.46","58.46","58.46","1 through 10","110.02","732.2","percent of total billed charges",""
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","outpatient","","","946.00","567.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","732.20","77.4","","707.58","707.58","707.58","33","110.02","732.2","percent of total billed charges",""
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","","outpatient","","","946.00","567.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","110.02","11.63","","58.46","58.46","257.91","21","110.02","732.2","percent of total billed charges",""
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0929","RC","","","","both","","","946.00","567.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1044.65","","Case rate ($1,044.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","913.00","913.00","913.00","65","449.83","1044.65","other","OPPS APC"
"Home Sleep Test/Type III Portable","PX-74000048","CDM","G0399","HCPCS","0929","RC","","","","both","","","946.00","567.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","449.83","","Case rate ($449.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","438.86","426.00","438.86","143","449.83","1044.65","other","OPPS APC"
"Home Sleep Test/Type III Portable|REDUCED SERVICES","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","52","both","","","946.00","567.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","168.37","","APC Price ($163.46). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","76.81","76.81","76.81","1 through 10","160.19","168.37","other","OPPS APC"
"Home Sleep Test/Type III Portable|REDUCED SERVICES","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","52","both","","","946.00","567.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","163.46","","APC Price ($163.46). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","80.35","80.35","80.35","1 through 10","160.19","168.37","other","OPPS APC"
"Home Sleep Test/Type III Portable|REDUCED SERVICES","PX-74000048","CDM","G0399","HCPCS","0740","RC","","","52","both","","","946.00","567.60","MEDICARE [2001]","HB WDH MEDICARE","163.46","","APC Price ($163.46). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","81.74","76.10","81.74","1 through 10","160.19","168.37","other","OPPS APC"
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","both","","","92.00","55.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","64.22","69.8","","62.12","62.12","62.12","1 through 10","11.65","87.29","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","outpatient","","","92.00","55.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","57.76","62.78","","55.87","55.87","55.87","1 through 10","12.82","71.21","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","outpatient","","","92.00","55.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","40.22","43.72","","38.91","38.91","38.91","1 through 10","12.82","71.21","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","outpatient","","","92.00","55.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","66.90","72.72","","64.72","64.72","64.72","15","12.82","71.21","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","outpatient","","","92.00","55.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","48.96","53.22","","47.45","47.45","47.45","1 through 10","12.82","71.21","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","outpatient","","","92.00","55.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","57.87","62.9","","56.07","56.07","56.07","1 through 10","12.82","71.21","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","outpatient","","","92.00","55.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","71.21","77.4","","68.98","68.98","68.98","1 through 10","12.82","71.21","percent of total billed charges",""
"Hospital OP Specimen Collection for Covid-19, Any Specimen Source","PX-30003651","CDM","C9803","HCPCS","0300","RC","","","","both","","","63.00","37.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","43.97","69.8","","5699.69","5699.69","5699.69","1 through 10","35.85","53.55","percent of total billed charges",""
"Hospital OP Specimen Collection for Covid-19, Any Specimen Source","PX-30003651","CDM","C9803","HCPCS","0300","RC","","","","outpatient","","","63.00","37.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","39.63","62.9","","159.52","159.52","159.52","1 through 10","7.33","48.76","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE PLUS","SUP-ITM-10123215","CDM","C1776","HCPCS","0278","RC","","","","both","","","3946.99","2368.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","459.03","3354.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE PLUS","SUP-ITM-10123215","CDM","C1776","HCPCS","0278","RC","","","","both","","","3946.99","2368.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2245.84","56.9","","2911.53","1863.86","5209.05","65","459.03","3354.94","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE PLUS","SUP-ITM-10123215","CDM","C1776","HCPCS","0278","RC","","","","both","","","3946.99","2368.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","459.03","11.63","","400.94","400.94","400.94","1 through 10","459.03","3354.94","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE PLUS","SUP-ITM-10123215","CDM","C1776","HCPCS","0278","RC","","","","both","","","3946.99","2368.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3054.97","77.4","","5214.50","5214.50","16415.28","1 through 10","459.03","3354.94","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE PLUS","SUP-ITM-10123215","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3946.99","2368.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","459.03","11.63","","400.94","400.94","400.94","1 through 10","459.03","3054.97","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE PLUS","SUP-ITM-10123215","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3946.99","2368.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1725.62","43.72","","1543.33","1543.33","1671.61","1 through 10","459.03","3054.97","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE PLUS","SUP-ITM-10123215","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3946.99","2368.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2870.25","72.72","","3700.21","2382.07","6427.18","53","459.03","3054.97","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE PLUS","SUP-ITM-10123215","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3946.99","2368.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2870.25","72.72","","12685.80","12685.80","12685.80","1 through 10","459.03","3054.97","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE PLUS","SUP-ITM-10123215","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3946.99","2368.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2482.66","62.9","","3408.87","2784.05","9859.40","46","459.03","3054.97","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE PLUS","SUP-ITM-10123215","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3946.99","2368.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3054.97","77.4","","5214.50","5214.50","16415.28","1 through 10","459.03","3054.97","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","3946.99","2368.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","459.03","3354.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","3946.99","2368.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2245.84","56.9","","2911.53","1863.86","5209.05","65","459.03","3354.94","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","3946.99","2368.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","459.03","11.63","","400.94","400.94","400.94","1 through 10","459.03","3354.94","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","3946.99","2368.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3054.97","77.4","","5214.50","5214.50","16415.28","1 through 10","459.03","3354.94","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3946.99","2368.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","459.03","11.63","","400.94","400.94","400.94","1 through 10","459.03","3054.97","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3946.99","2368.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1725.62","43.72","","1543.33","1543.33","1671.61","1 through 10","459.03","3054.97","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3946.99","2368.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2870.25","72.72","","3700.21","2382.07","6427.18","53","459.03","3054.97","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3946.99","2368.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2870.25","72.72","","12685.80","12685.80","12685.80","1 through 10","459.03","3054.97","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3946.99","2368.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2482.66","62.9","","3408.87","2784.05","9859.40","46","459.03","3054.97","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3946.99","2368.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3054.97","77.4","","5214.50","5214.50","16415.28","1 through 10","459.03","3054.97","percent of total billed charges",""
"HUMERAL HEAD 18X52MM GLOBAL ADVANTAGE ECC CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10029605","CDM","C1776","HCPCS","0278","RC","","","","both","","","3593.20","2155.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","417.89","3054.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERAL HEAD 18X52MM GLOBAL ADVANTAGE ECC CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10029605","CDM","C1776","HCPCS","0278","RC","","","","both","","","3593.20","2155.92","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2044.53","56.9","","2911.53","1863.86","5209.05","65","417.89","3054.22","percent of total billed charges",""
"HUMERAL HEAD 18X52MM GLOBAL ADVANTAGE ECC CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10029605","CDM","C1776","HCPCS","0278","RC","","","","both","","","3593.20","2155.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","417.89","11.63","","400.94","400.94","400.94","1 through 10","417.89","3054.22","percent of total billed charges",""
"HUMERAL HEAD 18X52MM GLOBAL ADVANTAGE ECC CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10029605","CDM","C1776","HCPCS","0278","RC","","","","both","","","3593.20","2155.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2781.14","77.4","","5214.50","5214.50","16415.28","1 through 10","417.89","3054.22","percent of total billed charges",""
"HUMERAL HEAD 18X52MM GLOBAL ADVANTAGE ECC CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10029605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3593.20","2155.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","417.89","11.63","","400.94","400.94","400.94","1 through 10","417.89","2781.14","percent of total billed charges",""
"HUMERAL HEAD 18X52MM GLOBAL ADVANTAGE ECC CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10029605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3593.20","2155.92","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1570.95","43.72","","1543.33","1543.33","1671.61","1 through 10","417.89","2781.14","percent of total billed charges",""
"HUMERAL HEAD 18X52MM GLOBAL ADVANTAGE ECC CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10029605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3593.20","2155.92","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2612.98","72.72","","3700.21","2382.07","6427.18","53","417.89","2781.14","percent of total billed charges",""
"HUMERAL HEAD 18X52MM GLOBAL ADVANTAGE ECC CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10029605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3593.20","2155.92","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2612.98","72.72","","12685.80","12685.80","12685.80","1 through 10","417.89","2781.14","percent of total billed charges",""
"HUMERAL HEAD 18X52MM GLOBAL ADVANTAGE ECC CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10029605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3593.20","2155.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2260.12","62.9","","3408.87","2784.05","9859.40","46","417.89","2781.14","percent of total billed charges",""
"HUMERAL HEAD 18X52MM GLOBAL ADVANTAGE ECC CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10029605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3593.20","2155.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2781.14","77.4","","5214.50","5214.50","16415.28","1 through 10","417.89","2781.14","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","482.18","3524.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2359.07","56.9","","2911.53","1863.86","5209.05","65","482.18","3524.1","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","482.18","11.63","","400.94","400.94","400.94","1 through 10","482.18","3524.1","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3209.00","77.4","","5214.50","5214.50","16415.28","1 through 10","482.18","3524.1","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","482.18","11.63","","400.94","400.94","400.94","1 through 10","482.18","3209","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1812.63","43.72","","1543.33","1543.33","1671.61","1 through 10","482.18","3209","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3014.97","72.72","","3700.21","2382.07","6427.18","53","482.18","3209","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3014.97","72.72","","12685.80","12685.80","12685.80","1 through 10","482.18","3209","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2607.83","62.9","","3408.87","2784.05","9859.40","46","482.18","3209","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3209.00","77.4","","5214.50","5214.50","16415.28","1 through 10","482.18","3209","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","482.18","3524.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2359.07","56.9","","2911.53","1863.86","5209.05","65","482.18","3524.1","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","482.18","11.63","","400.94","400.94","400.94","1 through 10","482.18","3524.1","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3209.00","77.4","","5214.50","5214.50","16415.28","1 through 10","482.18","3524.1","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","482.18","11.63","","400.94","400.94","400.94","1 through 10","482.18","3209","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1812.63","43.72","","1543.33","1543.33","1671.61","1 through 10","482.18","3209","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3014.97","72.72","","3700.21","2382.07","6427.18","53","482.18","3209","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3014.97","72.72","","12685.80","12685.80","12685.80","1 through 10","482.18","3209","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2607.83","62.9","","3408.87","2784.05","9859.40","46","482.18","3209","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3209.00","77.4","","5214.50","5214.50","16415.28","1 through 10","482.18","3209","percent of total billed charges",""
"HUMERAL INSERT 36X6.0MM AEQUALIS REVERSED LATERALIZED ROTATOR CUFF TEAR PLUS","SUP-ITM-10079330","CDM","C1776","HCPCS","0278","RC","","","","both","","","4843.91","2906.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","563.35","4117.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERAL INSERT 36X6.0MM AEQUALIS REVERSED LATERALIZED ROTATOR CUFF TEAR PLUS","SUP-ITM-10079330","CDM","C1776","HCPCS","0278","RC","","","","both","","","4843.91","2906.35","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2756.18","56.9","","2911.53","1863.86","5209.05","65","563.35","4117.32","percent of total billed charges",""
"HUMERAL INSERT 36X6.0MM AEQUALIS REVERSED LATERALIZED ROTATOR CUFF TEAR PLUS","SUP-ITM-10079330","CDM","C1776","HCPCS","0278","RC","","","","both","","","4843.91","2906.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","563.35","11.63","","400.94","400.94","400.94","1 through 10","563.35","4117.32","percent of total billed charges",""
"HUMERAL INSERT 36X6.0MM AEQUALIS REVERSED LATERALIZED ROTATOR CUFF TEAR PLUS","SUP-ITM-10079330","CDM","C1776","HCPCS","0278","RC","","","","both","","","4843.91","2906.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3749.19","77.4","","5214.50","5214.50","16415.28","1 through 10","563.35","4117.32","percent of total billed charges",""
"HUMERAL INSERT 36X6.0MM AEQUALIS REVERSED LATERALIZED ROTATOR CUFF TEAR PLUS","SUP-ITM-10079330","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4843.91","2906.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","563.35","11.63","","400.94","400.94","400.94","1 through 10","563.35","3749.19","percent of total billed charges",""
"HUMERAL INSERT 36X6.0MM AEQUALIS REVERSED LATERALIZED ROTATOR CUFF TEAR PLUS","SUP-ITM-10079330","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4843.91","2906.35","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2117.76","43.72","","1543.33","1543.33","1671.61","1 through 10","563.35","3749.19","percent of total billed charges",""
"HUMERAL INSERT 36X6.0MM AEQUALIS REVERSED LATERALIZED ROTATOR CUFF TEAR PLUS","SUP-ITM-10079330","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4843.91","2906.35","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3522.49","72.72","","3700.21","2382.07","6427.18","53","563.35","3749.19","percent of total billed charges",""
"HUMERAL INSERT 36X6.0MM AEQUALIS REVERSED LATERALIZED ROTATOR CUFF TEAR PLUS","SUP-ITM-10079330","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4843.91","2906.35","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3522.49","72.72","","12685.80","12685.80","12685.80","1 through 10","563.35","3749.19","percent of total billed charges",""
"HUMERAL INSERT 36X6.0MM AEQUALIS REVERSED LATERALIZED ROTATOR CUFF TEAR PLUS","SUP-ITM-10079330","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4843.91","2906.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3046.82","62.9","","3408.87","2784.05","9859.40","46","563.35","3749.19","percent of total billed charges",""
"HUMERAL INSERT 36X6.0MM AEQUALIS REVERSED LATERALIZED ROTATOR CUFF TEAR PLUS","SUP-ITM-10079330","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4843.91","2906.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3749.19","77.4","","5214.50","5214.50","16415.28","1 through 10","563.35","3749.19","percent of total billed charges",""
"HUMERAL INSERT 36X9.0MM AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135939","CDM","C1776","HCPCS","0278","RC","","","","both","","","5359.25","3215.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","623.28","4555.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERAL INSERT 36X9.0MM AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135939","CDM","C1776","HCPCS","0278","RC","","","","both","","","5359.25","3215.55","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3049.41","56.9","","2911.53","1863.86","5209.05","65","623.28","4555.36","percent of total billed charges",""
"HUMERAL INSERT 36X9.0MM AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135939","CDM","C1776","HCPCS","0278","RC","","","","both","","","5359.25","3215.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","623.28","11.63","","400.94","400.94","400.94","1 through 10","623.28","4555.36","percent of total billed charges",""
"HUMERAL INSERT 36X9.0MM AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135939","CDM","C1776","HCPCS","0278","RC","","","","both","","","5359.25","3215.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4148.06","77.4","","5214.50","5214.50","16415.28","1 through 10","623.28","4555.36","percent of total billed charges",""
"HUMERAL INSERT 36X9.0MM AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135939","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5359.25","3215.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","623.28","11.63","","400.94","400.94","400.94","1 through 10","623.28","4148.06","percent of total billed charges",""
"HUMERAL INSERT 36X9.0MM AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135939","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5359.25","3215.55","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2343.06","43.72","","1543.33","1543.33","1671.61","1 through 10","623.28","4148.06","percent of total billed charges",""
"HUMERAL INSERT 36X9.0MM AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135939","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5359.25","3215.55","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3897.25","72.72","","3700.21","2382.07","6427.18","53","623.28","4148.06","percent of total billed charges",""
"HUMERAL INSERT 36X9.0MM AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135939","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5359.25","3215.55","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3897.25","72.72","","12685.80","12685.80","12685.80","1 through 10","623.28","4148.06","percent of total billed charges",""
"HUMERAL INSERT 36X9.0MM AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135939","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5359.25","3215.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3370.97","62.9","","3408.87","2784.05","9859.40","46","623.28","4148.06","percent of total billed charges",""
"HUMERAL INSERT 36X9.0MM AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135939","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5359.25","3215.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4148.06","77.4","","5214.50","5214.50","16415.28","1 through 10","623.28","4148.06","percent of total billed charges",""
"HUMERAL LINER 38MM EQUINOXE POLYETHYLENE","SUP-ITM-10170083","CDM","C1776","HCPCS","0278","RC","","","","both","","","5154.86","3092.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","599.51","4381.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERAL LINER 38MM EQUINOXE POLYETHYLENE","SUP-ITM-10170083","CDM","C1776","HCPCS","0278","RC","","","","both","","","5154.86","3092.92","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2933.12","56.9","","2911.53","1863.86","5209.05","65","599.51","4381.63","percent of total billed charges",""
"HUMERAL LINER 38MM EQUINOXE POLYETHYLENE","SUP-ITM-10170083","CDM","C1776","HCPCS","0278","RC","","","","both","","","5154.86","3092.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","599.51","11.63","","400.94","400.94","400.94","1 through 10","599.51","4381.63","percent of total billed charges",""
"HUMERAL LINER 38MM EQUINOXE POLYETHYLENE","SUP-ITM-10170083","CDM","C1776","HCPCS","0278","RC","","","","both","","","5154.86","3092.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3989.86","77.4","","5214.50","5214.50","16415.28","1 through 10","599.51","4381.63","percent of total billed charges",""
"HUMERAL LINER 38MM EQUINOXE POLYETHYLENE","SUP-ITM-10170083","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5154.86","3092.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","599.51","11.63","","400.94","400.94","400.94","1 through 10","599.51","3989.86","percent of total billed charges",""
"HUMERAL LINER 38MM EQUINOXE POLYETHYLENE","SUP-ITM-10170083","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5154.86","3092.92","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2253.70","43.72","","1543.33","1543.33","1671.61","1 through 10","599.51","3989.86","percent of total billed charges",""
"HUMERAL LINER 38MM EQUINOXE POLYETHYLENE","SUP-ITM-10170083","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5154.86","3092.92","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3748.61","72.72","","3700.21","2382.07","6427.18","53","599.51","3989.86","percent of total billed charges",""
"HUMERAL LINER 38MM EQUINOXE POLYETHYLENE","SUP-ITM-10170083","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5154.86","3092.92","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3748.61","72.72","","12685.80","12685.80","12685.80","1 through 10","599.51","3989.86","percent of total billed charges",""
"HUMERAL LINER 38MM EQUINOXE POLYETHYLENE","SUP-ITM-10170083","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5154.86","3092.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3242.41","62.9","","3408.87","2784.05","9859.40","46","599.51","3989.86","percent of total billed charges",""
"HUMERAL LINER 38MM EQUINOXE POLYETHYLENE","SUP-ITM-10170083","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5154.86","3092.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3989.86","77.4","","5214.50","5214.50","16415.28","1 through 10","599.51","3989.86","percent of total billed charges",""
"HUMERAL SPACER 12MM STEM REVERSE TRABECULAR","SUP-ITM-10199783","CDM","C1776","HCPCS","0278","RC","","","","both","","","3946.99","2368.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","459.03","3354.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERAL SPACER 12MM STEM REVERSE TRABECULAR","SUP-ITM-10199783","CDM","C1776","HCPCS","0278","RC","","","","both","","","3946.99","2368.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2245.84","56.9","","2911.53","1863.86","5209.05","65","459.03","3354.94","percent of total billed charges",""
"HUMERAL SPACER 12MM STEM REVERSE TRABECULAR","SUP-ITM-10199783","CDM","C1776","HCPCS","0278","RC","","","","both","","","3946.99","2368.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","459.03","11.63","","400.94","400.94","400.94","1 through 10","459.03","3354.94","percent of total billed charges",""
"HUMERAL SPACER 12MM STEM REVERSE TRABECULAR","SUP-ITM-10199783","CDM","C1776","HCPCS","0278","RC","","","","both","","","3946.99","2368.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3054.97","77.4","","5214.50","5214.50","16415.28","1 through 10","459.03","3354.94","percent of total billed charges",""
"HUMERAL SPACER 12MM STEM REVERSE TRABECULAR","SUP-ITM-10199783","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3946.99","2368.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","459.03","11.63","","400.94","400.94","400.94","1 through 10","459.03","3054.97","percent of total billed charges",""
"HUMERAL SPACER 12MM STEM REVERSE TRABECULAR","SUP-ITM-10199783","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3946.99","2368.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1725.62","43.72","","1543.33","1543.33","1671.61","1 through 10","459.03","3054.97","percent of total billed charges",""
"HUMERAL SPACER 12MM STEM REVERSE TRABECULAR","SUP-ITM-10199783","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3946.99","2368.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2870.25","72.72","","3700.21","2382.07","6427.18","53","459.03","3054.97","percent of total billed charges",""
"HUMERAL SPACER 12MM STEM REVERSE TRABECULAR","SUP-ITM-10199783","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3946.99","2368.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2870.25","72.72","","12685.80","12685.80","12685.80","1 through 10","459.03","3054.97","percent of total billed charges",""
"HUMERAL SPACER 12MM STEM REVERSE TRABECULAR","SUP-ITM-10199783","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3946.99","2368.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2482.66","62.9","","3408.87","2784.05","9859.40","46","459.03","3054.97","percent of total billed charges",""
"HUMERAL SPACER 12MM STEM REVERSE TRABECULAR","SUP-ITM-10199783","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3946.99","2368.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3054.97","77.4","","5214.50","5214.50","16415.28","1 through 10","459.03","3054.97","percent of total billed charges",""
"HUMERAL STEM 10X120MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10118674","CDM","C1776","HCPCS","0278","RC","","","","both","","","18500.78","11100.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","2151.64","15725.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERAL STEM 10X120MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10118674","CDM","C1776","HCPCS","0278","RC","","","","both","","","18500.78","11100.47","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","10526.94","56.9","","2911.53","1863.86","5209.05","65","2151.64","15725.66","percent of total billed charges",""
"HUMERAL STEM 10X120MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10118674","CDM","C1776","HCPCS","0278","RC","","","","both","","","18500.78","11100.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2151.64","11.63","","400.94","400.94","400.94","1 through 10","2151.64","15725.66","percent of total billed charges",""
"HUMERAL STEM 10X120MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10118674","CDM","C1776","HCPCS","0278","RC","","","","both","","","18500.78","11100.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","14319.60","77.4","","5214.50","5214.50","16415.28","1 through 10","2151.64","15725.66","percent of total billed charges",""
"HUMERAL STEM 10X120MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10118674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","18500.78","11100.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2151.64","11.63","","400.94","400.94","400.94","1 through 10","2151.64","14319.6","percent of total billed charges",""
"HUMERAL STEM 10X120MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10118674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","18500.78","11100.47","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","8088.54","43.72","","1543.33","1543.33","1671.61","1 through 10","2151.64","14319.6","percent of total billed charges",""
"HUMERAL STEM 10X120MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10118674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","18500.78","11100.47","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","13453.77","72.72","","3700.21","2382.07","6427.18","53","2151.64","14319.6","percent of total billed charges",""
"HUMERAL STEM 10X120MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10118674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","18500.78","11100.47","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","13453.77","72.72","","12685.80","12685.80","12685.80","1 through 10","2151.64","14319.6","percent of total billed charges",""
"HUMERAL STEM 10X120MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10118674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","18500.78","11100.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","11636.99","62.9","","3408.87","2784.05","9859.40","46","2151.64","14319.6","percent of total billed charges",""
"HUMERAL STEM 10X120MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10118674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","18500.78","11100.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","14319.60","77.4","","5214.50","5214.50","16415.28","1 through 10","2151.64","14319.6","percent of total billed charges",""
"HUMERAL STEM 10X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121744","CDM","C1776","HCPCS","0278","RC","","","","both","","","10435.32","6261.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1213.63","8870.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERAL STEM 10X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121744","CDM","C1776","HCPCS","0278","RC","","","","both","","","10435.32","6261.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5937.70","56.9","","2911.53","1863.86","5209.05","65","1213.63","8870.02","percent of total billed charges",""
"HUMERAL STEM 10X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121744","CDM","C1776","HCPCS","0278","RC","","","","both","","","10435.32","6261.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1213.63","11.63","","400.94","400.94","400.94","1 through 10","1213.63","8870.02","percent of total billed charges",""
"HUMERAL STEM 10X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121744","CDM","C1776","HCPCS","0278","RC","","","","both","","","10435.32","6261.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8076.94","77.4","","5214.50","5214.50","16415.28","1 through 10","1213.63","8870.02","percent of total billed charges",""
"HUMERAL STEM 10X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121744","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10435.32","6261.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1213.63","11.63","","400.94","400.94","400.94","1 through 10","1213.63","8076.94","percent of total billed charges",""
"HUMERAL STEM 10X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121744","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10435.32","6261.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4562.32","43.72","","1543.33","1543.33","1671.61","1 through 10","1213.63","8076.94","percent of total billed charges",""
"HUMERAL STEM 10X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121744","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10435.32","6261.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7588.56","72.72","","3700.21","2382.07","6427.18","53","1213.63","8076.94","percent of total billed charges",""
"HUMERAL STEM 10X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121744","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10435.32","6261.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7588.56","72.72","","12685.80","12685.80","12685.80","1 through 10","1213.63","8076.94","percent of total billed charges",""
"HUMERAL STEM 10X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121744","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10435.32","6261.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6563.82","62.9","","3408.87","2784.05","9859.40","46","1213.63","8076.94","percent of total billed charges",""
"HUMERAL STEM 10X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10121744","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10435.32","6261.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8076.94","77.4","","5214.50","5214.50","16415.28","1 through 10","1213.63","8076.94","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1128.11","8245","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5519.30","56.9","","2911.53","1863.86","5209.05","65","1128.11","8245","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1128.11","11.63","","400.94","400.94","400.94","1 through 10","1128.11","8245","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7507.80","77.4","","5214.50","5214.50","16415.28","1 through 10","1128.11","8245","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1128.11","11.63","","400.94","400.94","400.94","1 through 10","1128.11","7507.8","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4240.84","43.72","","1543.33","1543.33","1671.61","1 through 10","1128.11","7507.8","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7053.84","72.72","","3700.21","2382.07","6427.18","53","1128.11","7507.8","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7053.84","72.72","","12685.80","12685.80","12685.80","1 through 10","1128.11","7507.8","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6101.30","62.9","","3408.87","2784.05","9859.40","46","1128.11","7507.8","percent of total billed charges",""
"HUMERAL STEM 12.0X100MM AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10017348","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7507.80","77.4","","5214.50","5214.50","16415.28","1 through 10","1128.11","7507.8","percent of total billed charges",""
"HUMERAL STEM 16X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10123269","CDM","C1776","HCPCS","0278","RC","","","","both","","","10435.32","6261.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1213.63","8870.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERAL STEM 16X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10123269","CDM","C1776","HCPCS","0278","RC","","","","both","","","10435.32","6261.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5937.70","56.9","","2911.53","1863.86","5209.05","65","1213.63","8870.02","percent of total billed charges",""
"HUMERAL STEM 16X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10123269","CDM","C1776","HCPCS","0278","RC","","","","both","","","10435.32","6261.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1213.63","11.63","","400.94","400.94","400.94","1 through 10","1213.63","8870.02","percent of total billed charges",""
"HUMERAL STEM 16X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10123269","CDM","C1776","HCPCS","0278","RC","","","","both","","","10435.32","6261.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8076.94","77.4","","5214.50","5214.50","16415.28","1 through 10","1213.63","8870.02","percent of total billed charges",""
"HUMERAL STEM 16X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10123269","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10435.32","6261.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1213.63","11.63","","400.94","400.94","400.94","1 through 10","1213.63","8076.94","percent of total billed charges",""
"HUMERAL STEM 16X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10123269","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10435.32","6261.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4562.32","43.72","","1543.33","1543.33","1671.61","1 through 10","1213.63","8076.94","percent of total billed charges",""
"HUMERAL STEM 16X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10123269","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10435.32","6261.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7588.56","72.72","","3700.21","2382.07","6427.18","53","1213.63","8076.94","percent of total billed charges",""
"HUMERAL STEM 16X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10123269","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10435.32","6261.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7588.56","72.72","","12685.80","12685.80","12685.80","1 through 10","1213.63","8076.94","percent of total billed charges",""
"HUMERAL STEM 16X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10123269","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10435.32","6261.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6563.82","62.9","","3408.87","2784.05","9859.40","46","1213.63","8076.94","percent of total billed charges",""
"HUMERAL STEM 16X83MM COMPREHENSIVE COBALT MACROBOND COATED MINI","SUP-ITM-10123269","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10435.32","6261.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8076.94","77.4","","5214.50","5214.50","16415.28","1 through 10","1213.63","8076.94","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","10908.00","6544.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1268.6","9271.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","10908.00","6544.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6206.65","56.9","","2911.53","1863.86","5209.05","65","1268.6","9271.8","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","10908.00","6544.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1268.60","11.63","","400.94","400.94","400.94","1 through 10","1268.6","9271.8","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","10908.00","6544.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8442.79","77.4","","5214.50","5214.50","16415.28","1 through 10","1268.6","9271.8","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10908.00","6544.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1268.60","11.63","","400.94","400.94","400.94","1 through 10","1268.6","8442.79","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10908.00","6544.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4768.98","43.72","","1543.33","1543.33","1671.61","1 through 10","1268.6","8442.79","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10908.00","6544.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7932.30","72.72","","3700.21","2382.07","6427.18","53","1268.6","8442.79","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10908.00","6544.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7932.30","72.72","","12685.80","12685.80","12685.80","1 through 10","1268.6","8442.79","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10908.00","6544.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6861.13","62.9","","3408.87","2784.05","9859.40","46","1268.6","8442.79","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10908.00","6544.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8442.79","77.4","","5214.50","5214.50","16415.28","1 through 10","1268.6","8442.79","percent of total billed charges",""
"HUMERAL STEM 9.0X130MM IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10091990","CDM","C1776","HCPCS","0278","RC","","","","both","","","18525.00","11115.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","2154.46","15746.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERAL STEM 9.0X130MM IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10091990","CDM","C1776","HCPCS","0278","RC","","","","both","","","18525.00","11115.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","10540.73","56.9","","2911.53","1863.86","5209.05","65","2154.46","15746.25","percent of total billed charges",""
"HUMERAL STEM 9.0X130MM IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10091990","CDM","C1776","HCPCS","0278","RC","","","","both","","","18525.00","11115.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2154.46","11.63","","400.94","400.94","400.94","1 through 10","2154.46","15746.25","percent of total billed charges",""
"HUMERAL STEM 9.0X130MM IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10091990","CDM","C1776","HCPCS","0278","RC","","","","both","","","18525.00","11115.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","14338.35","77.4","","5214.50","5214.50","16415.28","1 through 10","2154.46","15746.25","percent of total billed charges",""
"HUMERAL STEM 9.0X130MM IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10091990","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","18525.00","11115.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2154.46","11.63","","400.94","400.94","400.94","1 through 10","2154.46","14338.35","percent of total billed charges",""
"HUMERAL STEM 9.0X130MM IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10091990","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","18525.00","11115.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","8099.13","43.72","","1543.33","1543.33","1671.61","1 through 10","2154.46","14338.35","percent of total billed charges",""
"HUMERAL STEM 9.0X130MM IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10091990","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","18525.00","11115.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","13471.38","72.72","","3700.21","2382.07","6427.18","53","2154.46","14338.35","percent of total billed charges",""
"HUMERAL STEM 9.0X130MM IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10091990","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","18525.00","11115.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","13471.38","72.72","","12685.80","12685.80","12685.80","1 through 10","2154.46","14338.35","percent of total billed charges",""
"HUMERAL STEM 9.0X130MM IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10091990","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","18525.00","11115.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","11652.23","62.9","","3408.87","2784.05","9859.40","46","2154.46","14338.35","percent of total billed charges",""
"HUMERAL STEM 9.0X130MM IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10091990","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","18525.00","11115.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","14338.35","77.4","","5214.50","5214.50","16415.28","1 through 10","2154.46","14338.35","percent of total billed charges",""
"HUMERUS INSERT 36X6.0MM HUMERAL SHOULDER AEQUALIS REVERSED FRACTURE LATERALIZED FUNCTIONAL DELTOID PLUS","SUP-ITM-10091991","CDM","C1776","HCPCS","0278","RC","","","","both","","","5359.25","3215.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","623.28","4555.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS INSERT 36X6.0MM HUMERAL SHOULDER AEQUALIS REVERSED FRACTURE LATERALIZED FUNCTIONAL DELTOID PLUS","SUP-ITM-10091991","CDM","C1776","HCPCS","0278","RC","","","","both","","","5359.25","3215.55","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3049.41","56.9","","2911.53","1863.86","5209.05","65","623.28","4555.36","percent of total billed charges",""
"HUMERUS INSERT 36X6.0MM HUMERAL SHOULDER AEQUALIS REVERSED FRACTURE LATERALIZED FUNCTIONAL DELTOID PLUS","SUP-ITM-10091991","CDM","C1776","HCPCS","0278","RC","","","","both","","","5359.25","3215.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","623.28","11.63","","400.94","400.94","400.94","1 through 10","623.28","4555.36","percent of total billed charges",""
"HUMERUS INSERT 36X6.0MM HUMERAL SHOULDER AEQUALIS REVERSED FRACTURE LATERALIZED FUNCTIONAL DELTOID PLUS","SUP-ITM-10091991","CDM","C1776","HCPCS","0278","RC","","","","both","","","5359.25","3215.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4148.06","77.4","","5214.50","5214.50","16415.28","1 through 10","623.28","4555.36","percent of total billed charges",""
"HUMERUS INSERT 36X6.0MM HUMERAL SHOULDER AEQUALIS REVERSED FRACTURE LATERALIZED FUNCTIONAL DELTOID PLUS","SUP-ITM-10091991","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5359.25","3215.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","623.28","11.63","","400.94","400.94","400.94","1 through 10","623.28","4148.06","percent of total billed charges",""
"HUMERUS INSERT 36X6.0MM HUMERAL SHOULDER AEQUALIS REVERSED FRACTURE LATERALIZED FUNCTIONAL DELTOID PLUS","SUP-ITM-10091991","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5359.25","3215.55","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2343.06","43.72","","1543.33","1543.33","1671.61","1 through 10","623.28","4148.06","percent of total billed charges",""
"HUMERUS INSERT 36X6.0MM HUMERAL SHOULDER AEQUALIS REVERSED FRACTURE LATERALIZED FUNCTIONAL DELTOID PLUS","SUP-ITM-10091991","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5359.25","3215.55","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3897.25","72.72","","3700.21","2382.07","6427.18","53","623.28","4148.06","percent of total billed charges",""
"HUMERUS INSERT 36X6.0MM HUMERAL SHOULDER AEQUALIS REVERSED FRACTURE LATERALIZED FUNCTIONAL DELTOID PLUS","SUP-ITM-10091991","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5359.25","3215.55","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3897.25","72.72","","12685.80","12685.80","12685.80","1 through 10","623.28","4148.06","percent of total billed charges",""
"HUMERUS INSERT 36X6.0MM HUMERAL SHOULDER AEQUALIS REVERSED FRACTURE LATERALIZED FUNCTIONAL DELTOID PLUS","SUP-ITM-10091991","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5359.25","3215.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3370.97","62.9","","3408.87","2784.05","9859.40","46","623.28","4148.06","percent of total billed charges",""
"HUMERUS INSERT 36X6.0MM HUMERAL SHOULDER AEQUALIS REVERSED FRACTURE LATERALIZED FUNCTIONAL DELTOID PLUS","SUP-ITM-10091991","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5359.25","3215.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4148.06","77.4","","5214.50","5214.50","16415.28","1 through 10","623.28","4148.06","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","5982.68","3589.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","695.79","5085.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","5982.68","3589.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","695.79","5085.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","5982.68","3589.61","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3404.14","56.9","","812.12","238.65","1587.46","163","695.79","5085.28","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","5982.68","3589.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","695.79","11.63","","112.68","112.68","146.99","38","695.79","5085.28","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","5982.68","3589.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4630.59","77.4","","303.98","303.98","5854.79","1 through 10","695.79","5085.28","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","695.79","11.63","","112.68","112.68","146.99","38","695.79","4630.59","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3755.93","62.78","","780.86","208.94","10480.28","15","695.79","4630.59","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2615.63","43.72","","179.76","179.76","179.76","1 through 10","695.79","4630.59","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4350.60","72.72","","2355.45","298.99","3965.19","155","695.79","4630.59","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4350.60","72.72","","3643.09","3643.09","3643.09","1 through 10","695.79","4630.59","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3183.98","53.22","","554.28","554.28","554.28","16","695.79","4630.59","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3763.11","62.9","","619.64","173.09","2370.64","150","695.79","4630.59","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4630.59","77.4","","303.98","303.98","5854.79","1 through 10","695.79","4630.59","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE BONE VA LCP SS DISTAL MEDIAL RIGHT","SUP-ITM-10114070","CDM","C1713","HCPCS","0278","RC","","","","both","","","6248.57","3749.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","726.71","5311.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE BONE VA LCP SS DISTAL MEDIAL RIGHT","SUP-ITM-10114070","CDM","C1713","HCPCS","0278","RC","","","","both","","","6248.57","3749.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","726.71","5311.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE BONE VA LCP SS DISTAL MEDIAL RIGHT","SUP-ITM-10114070","CDM","C1713","HCPCS","0278","RC","","","","both","","","6248.57","3749.14","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3555.44","56.9","","812.12","238.65","1587.46","163","726.71","5311.28","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE BONE VA LCP SS DISTAL MEDIAL RIGHT","SUP-ITM-10114070","CDM","C1713","HCPCS","0278","RC","","","","both","","","6248.57","3749.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","726.71","11.63","","112.68","112.68","146.99","38","726.71","5311.28","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE BONE VA LCP SS DISTAL MEDIAL RIGHT","SUP-ITM-10114070","CDM","C1713","HCPCS","0278","RC","","","","both","","","6248.57","3749.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4836.39","77.4","","303.98","303.98","5854.79","1 through 10","726.71","5311.28","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE BONE VA LCP SS DISTAL MEDIAL RIGHT","SUP-ITM-10114070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6248.57","3749.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","726.71","11.63","","112.68","112.68","146.99","38","726.71","4836.39","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE BONE VA LCP SS DISTAL MEDIAL RIGHT","SUP-ITM-10114070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6248.57","3749.14","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3922.85","62.78","","780.86","208.94","10480.28","15","726.71","4836.39","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE BONE VA LCP SS DISTAL MEDIAL RIGHT","SUP-ITM-10114070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6248.57","3749.14","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2731.87","43.72","","179.76","179.76","179.76","1 through 10","726.71","4836.39","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE BONE VA LCP SS DISTAL MEDIAL RIGHT","SUP-ITM-10114070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6248.57","3749.14","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4543.96","72.72","","2355.45","298.99","3965.19","155","726.71","4836.39","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE BONE VA LCP SS DISTAL MEDIAL RIGHT","SUP-ITM-10114070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6248.57","3749.14","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4543.96","72.72","","3643.09","3643.09","3643.09","1 through 10","726.71","4836.39","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE BONE VA LCP SS DISTAL MEDIAL RIGHT","SUP-ITM-10114070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6248.57","3749.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3325.49","53.22","","554.28","554.28","554.28","16","726.71","4836.39","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE BONE VA LCP SS DISTAL MEDIAL RIGHT","SUP-ITM-10114070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6248.57","3749.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3930.35","62.9","","619.64","173.09","2370.64","150","726.71","4836.39","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X160MM 8 HOLE BONE VA LCP SS DISTAL MEDIAL RIGHT","SUP-ITM-10114070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6248.57","3749.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4836.39","77.4","","303.98","303.98","5854.79","1 through 10","726.71","4836.39","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","both","","","6442.88","3865.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","749.31","5476.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","both","","","6442.88","3865.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","749.31","5476.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","both","","","6442.88","3865.73","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3666.00","56.9","","812.12","238.65","1587.46","163","749.31","5476.45","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","both","","","6442.88","3865.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","749.31","11.63","","112.68","112.68","146.99","38","749.31","5476.45","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","both","","","6442.88","3865.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4986.79","77.4","","303.98","303.98","5854.79","1 through 10","749.31","5476.45","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6442.88","3865.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","749.31","11.63","","112.68","112.68","146.99","38","749.31","4986.79","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6442.88","3865.73","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4044.84","62.78","","780.86","208.94","10480.28","15","749.31","4986.79","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6442.88","3865.73","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2816.83","43.72","","179.76","179.76","179.76","1 through 10","749.31","4986.79","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6442.88","3865.73","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4685.26","72.72","","2355.45","298.99","3965.19","155","749.31","4986.79","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6442.88","3865.73","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4685.26","72.72","","3643.09","3643.09","3643.09","1 through 10","749.31","4986.79","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6442.88","3865.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3428.90","53.22","","554.28","554.28","554.28","16","749.31","4986.79","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6442.88","3865.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4052.57","62.9","","619.64","173.09","2370.64","150","749.31","4986.79","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X163MM 8 HOLE ELBOW VA LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6442.88","3865.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4986.79","77.4","","303.98","303.98","5854.79","1 through 10","749.31","4986.79","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","both","","","6248.57","3749.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","726.71","5311.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","both","","","6248.57","3749.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","726.71","5311.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","both","","","6248.57","3749.14","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3555.44","56.9","","812.12","238.65","1587.46","163","726.71","5311.28","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","both","","","6248.57","3749.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","726.71","11.63","","112.68","112.68","146.99","38","726.71","5311.28","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","both","","","6248.57","3749.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4836.39","77.4","","303.98","303.98","5854.79","1 through 10","726.71","5311.28","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6248.57","3749.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","726.71","11.63","","112.68","112.68","146.99","38","726.71","4836.39","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6248.57","3749.14","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3922.85","62.78","","780.86","208.94","10480.28","15","726.71","4836.39","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6248.57","3749.14","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2731.87","43.72","","179.76","179.76","179.76","1 through 10","726.71","4836.39","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6248.57","3749.14","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4543.96","72.72","","2355.45","298.99","3965.19","155","726.71","4836.39","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6248.57","3749.14","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4543.96","72.72","","3643.09","3643.09","3643.09","1 through 10","726.71","4836.39","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6248.57","3749.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3325.49","53.22","","554.28","554.28","554.28","16","726.71","4836.39","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6248.57","3749.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3930.35","62.9","","619.64","173.09","2370.64","150","726.71","4836.39","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X173MM 9 HOLE ELBOW VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6248.57","3749.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4836.39","77.4","","303.98","303.98","5854.79","1 through 10","726.71","4836.39","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","5982.68","3589.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","695.79","5085.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","5982.68","3589.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","695.79","5085.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","5982.68","3589.61","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3404.14","56.9","","812.12","238.65","1587.46","163","695.79","5085.28","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","5982.68","3589.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","695.79","11.63","","112.68","112.68","146.99","38","695.79","5085.28","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","5982.68","3589.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4630.59","77.4","","303.98","303.98","5854.79","1 through 10","695.79","5085.28","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","695.79","11.63","","112.68","112.68","146.99","38","695.79","4630.59","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3755.93","62.78","","780.86","208.94","10480.28","15","695.79","4630.59","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2615.63","43.72","","179.76","179.76","179.76","1 through 10","695.79","4630.59","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4350.60","72.72","","2355.45","298.99","3965.19","155","695.79","4630.59","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4350.60","72.72","","3643.09","3643.09","3643.09","1 through 10","695.79","4630.59","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3183.98","53.22","","554.28","554.28","554.28","16","695.79","4630.59","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3763.11","62.9","","619.64","173.09","2370.64","150","695.79","4630.59","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4630.59","77.4","","303.98","303.98","5854.79","1 through 10","695.79","4630.59","percent of total billed charges",""
"HUMERUS PLATE 3.5X115MM SMALL 5 HOLE BONE HUMERAL PROXIMALIMAL LOCKING FRAGMENT RIGHT","SUP-ITM-10064525","CDM","C1713","HCPCS","0278","RC","","","","both","","","15028.80","9017.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1747.85","12774.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X115MM SMALL 5 HOLE BONE HUMERAL PROXIMALIMAL LOCKING FRAGMENT RIGHT","SUP-ITM-10064525","CDM","C1713","HCPCS","0278","RC","","","","both","","","15028.80","9017.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1747.85","12774.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X115MM SMALL 5 HOLE BONE HUMERAL PROXIMALIMAL LOCKING FRAGMENT RIGHT","SUP-ITM-10064525","CDM","C1713","HCPCS","0278","RC","","","","both","","","15028.80","9017.28","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","8551.39","56.9","","812.12","238.65","1587.46","163","1747.85","12774.48","percent of total billed charges",""
"HUMERUS PLATE 3.5X115MM SMALL 5 HOLE BONE HUMERAL PROXIMALIMAL LOCKING FRAGMENT RIGHT","SUP-ITM-10064525","CDM","C1713","HCPCS","0278","RC","","","","both","","","15028.80","9017.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1747.85","11.63","","112.68","112.68","146.99","38","1747.85","12774.48","percent of total billed charges",""
"HUMERUS PLATE 3.5X115MM SMALL 5 HOLE BONE HUMERAL PROXIMALIMAL LOCKING FRAGMENT RIGHT","SUP-ITM-10064525","CDM","C1713","HCPCS","0278","RC","","","","both","","","15028.80","9017.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","11632.29","77.4","","303.98","303.98","5854.79","1 through 10","1747.85","12774.48","percent of total billed charges",""
"HUMERUS PLATE 3.5X115MM SMALL 5 HOLE BONE HUMERAL PROXIMALIMAL LOCKING FRAGMENT RIGHT","SUP-ITM-10064525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","15028.80","9017.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1747.85","11.63","","112.68","112.68","146.99","38","1747.85","11632.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X115MM SMALL 5 HOLE BONE HUMERAL PROXIMALIMAL LOCKING FRAGMENT RIGHT","SUP-ITM-10064525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","15028.80","9017.28","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","9435.08","62.78","","780.86","208.94","10480.28","15","1747.85","11632.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X115MM SMALL 5 HOLE BONE HUMERAL PROXIMALIMAL LOCKING FRAGMENT RIGHT","SUP-ITM-10064525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","15028.80","9017.28","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","6570.59","43.72","","179.76","179.76","179.76","1 through 10","1747.85","11632.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X115MM SMALL 5 HOLE BONE HUMERAL PROXIMALIMAL LOCKING FRAGMENT RIGHT","SUP-ITM-10064525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","15028.80","9017.28","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10928.94","72.72","","2355.45","298.99","3965.19","155","1747.85","11632.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X115MM SMALL 5 HOLE BONE HUMERAL PROXIMALIMAL LOCKING FRAGMENT RIGHT","SUP-ITM-10064525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","15028.80","9017.28","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","10928.94","72.72","","3643.09","3643.09","3643.09","1 through 10","1747.85","11632.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X115MM SMALL 5 HOLE BONE HUMERAL PROXIMALIMAL LOCKING FRAGMENT RIGHT","SUP-ITM-10064525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","15028.80","9017.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","7998.33","53.22","","554.28","554.28","554.28","16","1747.85","11632.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X115MM SMALL 5 HOLE BONE HUMERAL PROXIMALIMAL LOCKING FRAGMENT RIGHT","SUP-ITM-10064525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","15028.80","9017.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","9453.12","62.9","","619.64","173.09","2370.64","150","1747.85","11632.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X115MM SMALL 5 HOLE BONE HUMERAL PROXIMALIMAL LOCKING FRAGMENT RIGHT","SUP-ITM-10064525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","15028.80","9017.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","11632.29","77.4","","303.98","303.98","5854.79","1 through 10","1747.85","11632.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","both","","","6109.55","3665.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","710.54","5193.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","both","","","6109.55","3665.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","710.54","5193.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","both","","","6109.55","3665.73","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3476.33","56.9","","812.12","238.65","1587.46","163","710.54","5193.12","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","both","","","6109.55","3665.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","710.54","11.63","","112.68","112.68","146.99","38","710.54","5193.12","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","both","","","6109.55","3665.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4728.79","77.4","","303.98","303.98","5854.79","1 through 10","710.54","5193.12","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6109.55","3665.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","710.54","11.63","","112.68","112.68","146.99","38","710.54","4728.79","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6109.55","3665.73","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3835.58","62.78","","780.86","208.94","10480.28","15","710.54","4728.79","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6109.55","3665.73","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2671.10","43.72","","179.76","179.76","179.76","1 through 10","710.54","4728.79","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6109.55","3665.73","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4442.86","72.72","","2355.45","298.99","3965.19","155","710.54","4728.79","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6109.55","3665.73","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4442.86","72.72","","3643.09","3643.09","3643.09","1 through 10","710.54","4728.79","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6109.55","3665.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3251.50","53.22","","554.28","554.28","554.28","16","710.54","4728.79","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6109.55","3665.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3842.91","62.9","","619.64","173.09","2370.64","150","710.54","4728.79","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR RT","SUP-ITM-10090936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6109.55","3665.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4728.79","77.4","","303.98","303.98","5854.79","1 through 10","710.54","4728.79","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","both","","","7960.35","4776.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","925.79","6766.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","both","","","7960.35","4776.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","925.79","6766.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","both","","","7960.35","4776.21","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4529.44","56.9","","812.12","238.65","1587.46","163","925.79","6766.3","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","both","","","7960.35","4776.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","925.79","11.63","","112.68","112.68","146.99","38","925.79","6766.3","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","both","","","7960.35","4776.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6161.31","77.4","","303.98","303.98","5854.79","1 through 10","925.79","6766.3","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7960.35","4776.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","925.79","11.63","","112.68","112.68","146.99","38","925.79","6161.31","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7960.35","4776.21","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4997.51","62.78","","780.86","208.94","10480.28","15","925.79","6161.31","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7960.35","4776.21","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3480.27","43.72","","179.76","179.76","179.76","1 through 10","925.79","6161.31","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7960.35","4776.21","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5788.77","72.72","","2355.45","298.99","3965.19","155","925.79","6161.31","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7960.35","4776.21","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5788.77","72.72","","3643.09","3643.09","3643.09","1 through 10","925.79","6161.31","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7960.35","4776.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4236.50","53.22","","554.28","554.28","554.28","16","925.79","6161.31","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7960.35","4776.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5007.06","62.9","","619.64","173.09","2370.64","150","925.79","6161.31","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE PERIARTICULAR PROXIMAL RIGHT","SUP-ITM-10090938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7960.35","4776.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6161.31","77.4","","303.98","303.98","5854.79","1 through 10","925.79","6161.31","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022938","CDM","C1713","HCPCS","0278","RC","","","","both","","","5622.51","3373.51","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","653.9","4779.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022938","CDM","C1713","HCPCS","0278","RC","","","","both","","","5622.51","3373.51","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","653.9","4779.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022938","CDM","C1713","HCPCS","0278","RC","","","","both","","","5622.51","3373.51","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3199.21","56.9","","812.12","238.65","1587.46","163","653.9","4779.13","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022938","CDM","C1713","HCPCS","0278","RC","","","","both","","","5622.51","3373.51","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","653.90","11.63","","112.68","112.68","146.99","38","653.9","4779.13","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022938","CDM","C1713","HCPCS","0278","RC","","","","both","","","5622.51","3373.51","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4351.82","77.4","","303.98","303.98","5854.79","1 through 10","653.9","4779.13","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5622.51","3373.51","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","653.90","11.63","","112.68","112.68","146.99","38","653.9","4351.82","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5622.51","3373.51","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3529.81","62.78","","780.86","208.94","10480.28","15","653.9","4351.82","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5622.51","3373.51","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2458.16","43.72","","179.76","179.76","179.76","1 through 10","653.9","4351.82","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5622.51","3373.51","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4088.69","72.72","","2355.45","298.99","3965.19","155","653.9","4351.82","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5622.51","3373.51","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4088.69","72.72","","3643.09","3643.09","3643.09","1 through 10","653.9","4351.82","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5622.51","3373.51","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2992.30","53.22","","554.28","554.28","554.28","16","653.9","4351.82","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5622.51","3373.51","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3536.56","62.9","","619.64","173.09","2370.64","150","653.9","4351.82","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5622.51","3373.51","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4351.82","77.4","","303.98","303.98","5854.79","1 through 10","653.9","4351.82","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","8156.39","4893.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","948.59","6932.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","8156.39","4893.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","948.59","6932.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","8156.39","4893.83","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4640.99","56.9","","812.12","238.65","1587.46","163","948.59","6932.93","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","8156.39","4893.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","948.59","11.63","","112.68","112.68","146.99","38","948.59","6932.93","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","8156.39","4893.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6313.05","77.4","","303.98","303.98","5854.79","1 through 10","948.59","6932.93","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8156.39","4893.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","948.59","11.63","","112.68","112.68","146.99","38","948.59","6313.05","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8156.39","4893.83","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5120.58","62.78","","780.86","208.94","10480.28","15","948.59","6313.05","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8156.39","4893.83","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3565.97","43.72","","179.76","179.76","179.76","1 through 10","948.59","6313.05","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8156.39","4893.83","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5931.33","72.72","","2355.45","298.99","3965.19","155","948.59","6313.05","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8156.39","4893.83","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5931.33","72.72","","3643.09","3643.09","3643.09","1 through 10","948.59","6313.05","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8156.39","4893.83","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4340.83","53.22","","554.28","554.28","554.28","16","948.59","6313.05","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8156.39","4893.83","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5130.37","62.9","","619.64","173.09","2370.64","150","948.59","6313.05","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8156.39","4893.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6313.05","77.4","","303.98","303.98","5854.79","1 through 10","948.59","6313.05","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","5968.70","3581.22","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","694.16","5073.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","5968.70","3581.22","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","694.16","5073.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","5968.70","3581.22","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3396.19","56.9","","812.12","238.65","1587.46","163","694.16","5073.4","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","5968.70","3581.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","694.16","11.63","","112.68","112.68","146.99","38","694.16","5073.4","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","5968.70","3581.22","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4619.77","77.4","","303.98","303.98","5854.79","1 through 10","694.16","5073.4","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5968.70","3581.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","694.16","11.63","","112.68","112.68","146.99","38","694.16","4619.77","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5968.70","3581.22","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3747.15","62.78","","780.86","208.94","10480.28","15","694.16","4619.77","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5968.70","3581.22","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2609.52","43.72","","179.76","179.76","179.76","1 through 10","694.16","4619.77","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5968.70","3581.22","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4340.44","72.72","","2355.45","298.99","3965.19","155","694.16","4619.77","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5968.70","3581.22","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4340.44","72.72","","3643.09","3643.09","3643.09","1 through 10","694.16","4619.77","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5968.70","3581.22","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3176.54","53.22","","554.28","554.28","554.28","16","694.16","4619.77","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5968.70","3581.22","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3754.31","62.9","","619.64","173.09","2370.64","150","694.16","4619.77","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5968.70","3581.22","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4619.77","77.4","","303.98","303.98","5854.79","1 through 10","694.16","4619.77","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","6671.03","4002.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","775.84","5670.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","6671.03","4002.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","775.84","5670.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","6671.03","4002.62","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3795.82","56.9","","812.12","238.65","1587.46","163","775.84","5670.38","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","6671.03","4002.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","775.84","11.63","","112.68","112.68","146.99","38","775.84","5670.38","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","6671.03","4002.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5163.38","77.4","","303.98","303.98","5854.79","1 through 10","775.84","5670.38","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6671.03","4002.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","775.84","11.63","","112.68","112.68","146.99","38","775.84","5163.38","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6671.03","4002.62","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4188.07","62.78","","780.86","208.94","10480.28","15","775.84","5163.38","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6671.03","4002.62","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2916.57","43.72","","179.76","179.76","179.76","1 through 10","775.84","5163.38","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6671.03","4002.62","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4851.17","72.72","","2355.45","298.99","3965.19","155","775.84","5163.38","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6671.03","4002.62","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4851.17","72.72","","3643.09","3643.09","3643.09","1 through 10","775.84","5163.38","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6671.03","4002.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3550.32","53.22","","554.28","554.28","554.28","16","775.84","5163.38","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6671.03","4002.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4196.08","62.9","","619.64","173.09","2370.64","150","775.84","5163.38","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6671.03","4002.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5163.38","77.4","","303.98","303.98","5854.79","1 through 10","775.84","5163.38","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","8398.31","5038.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","976.72","7138.56","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","8398.31","5038.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","976.72","7138.56","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","8398.31","5038.99","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4778.64","56.9","","812.12","238.65","1587.46","163","976.72","7138.56","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","8398.31","5038.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","976.72","11.63","","112.68","112.68","146.99","38","976.72","7138.56","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","8398.31","5038.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6500.29","77.4","","303.98","303.98","5854.79","1 through 10","976.72","7138.56","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8398.31","5038.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","976.72","11.63","","112.68","112.68","146.99","38","976.72","6500.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8398.31","5038.99","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5272.46","62.78","","780.86","208.94","10480.28","15","976.72","6500.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8398.31","5038.99","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3671.74","43.72","","179.76","179.76","179.76","1 through 10","976.72","6500.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8398.31","5038.99","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6107.25","72.72","","2355.45","298.99","3965.19","155","976.72","6500.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8398.31","5038.99","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6107.25","72.72","","3643.09","3643.09","3643.09","1 through 10","976.72","6500.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8398.31","5038.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4469.58","53.22","","554.28","554.28","554.28","16","976.72","6500.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8398.31","5038.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5282.54","62.9","","619.64","173.09","2370.64","150","976.72","6500.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8398.31","5038.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6500.29","77.4","","303.98","303.98","5854.79","1 through 10","976.72","6500.29","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","6316.98","3790.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","734.66","5369.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","6316.98","3790.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","734.66","5369.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","6316.98","3790.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3594.36","56.9","","812.12","238.65","1587.46","163","734.66","5369.43","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","6316.98","3790.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","734.66","11.63","","112.68","112.68","146.99","38","734.66","5369.43","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","6316.98","3790.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4889.34","77.4","","303.98","303.98","5854.79","1 through 10","734.66","5369.43","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6316.98","3790.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","734.66","11.63","","112.68","112.68","146.99","38","734.66","4889.34","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6316.98","3790.19","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3965.80","62.78","","780.86","208.94","10480.28","15","734.66","4889.34","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6316.98","3790.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2761.78","43.72","","179.76","179.76","179.76","1 through 10","734.66","4889.34","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6316.98","3790.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4593.71","72.72","","2355.45","298.99","3965.19","155","734.66","4889.34","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6316.98","3790.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4593.71","72.72","","3643.09","3643.09","3643.09","1 through 10","734.66","4889.34","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6316.98","3790.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3361.90","53.22","","554.28","554.28","554.28","16","734.66","4889.34","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6316.98","3790.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3973.38","62.9","","619.64","173.09","2370.64","150","734.66","4889.34","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6316.98","3790.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4889.34","77.4","","303.98","303.98","5854.79","1 through 10","734.66","4889.34","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","both","","","8790.38","5274.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1022.32","7471.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","both","","","8790.38","5274.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1022.32","7471.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","both","","","8790.38","5274.23","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5001.73","56.9","","812.12","238.65","1587.46","163","1022.32","7471.82","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","both","","","8790.38","5274.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1022.32","11.63","","112.68","112.68","146.99","38","1022.32","7471.82","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","both","","","8790.38","5274.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6803.75","77.4","","303.98","303.98","5854.79","1 through 10","1022.32","7471.82","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8790.38","5274.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1022.32","11.63","","112.68","112.68","146.99","38","1022.32","6803.75","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8790.38","5274.23","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5518.60","62.78","","780.86","208.94","10480.28","15","1022.32","6803.75","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8790.38","5274.23","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3843.15","43.72","","179.76","179.76","179.76","1 through 10","1022.32","6803.75","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8790.38","5274.23","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6392.36","72.72","","2355.45","298.99","3965.19","155","1022.32","6803.75","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8790.38","5274.23","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6392.36","72.72","","3643.09","3643.09","3643.09","1 through 10","1022.32","6803.75","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8790.38","5274.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4678.24","53.22","","554.28","554.28","554.28","16","1022.32","6803.75","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8790.38","5274.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5529.15","62.9","","619.64","173.09","2370.64","150","1022.32","6803.75","percent of total billed charges",""
"HUMERUS PLATE 3.5X235MM 10 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10088560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8790.38","5274.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6803.75","77.4","","303.98","303.98","5854.79","1 through 10","1022.32","6803.75","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","both","","","7939.50","4763.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","923.36","6748.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","both","","","7939.50","4763.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","923.36","6748.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","both","","","7939.50","4763.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4517.58","56.9","","812.12","238.65","1587.46","163","923.36","6748.58","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","both","","","7939.50","4763.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","923.36","11.63","","112.68","112.68","146.99","38","923.36","6748.58","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","both","","","7939.50","4763.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6145.17","77.4","","303.98","303.98","5854.79","1 through 10","923.36","6748.58","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7939.50","4763.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","923.36","11.63","","112.68","112.68","146.99","38","923.36","6145.17","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7939.50","4763.70","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4984.42","62.78","","780.86","208.94","10480.28","15","923.36","6145.17","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7939.50","4763.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3471.15","43.72","","179.76","179.76","179.76","1 through 10","923.36","6145.17","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7939.50","4763.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5773.60","72.72","","2355.45","298.99","3965.19","155","923.36","6145.17","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7939.50","4763.70","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5773.60","72.72","","3643.09","3643.09","3643.09","1 through 10","923.36","6145.17","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7939.50","4763.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4225.40","53.22","","554.28","554.28","554.28","16","923.36","6145.17","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7939.50","4763.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4993.95","62.9","","619.64","173.09","2370.64","150","923.36","6145.17","percent of total billed charges",""
"HUMERUS PLATE 3.5X266MM 12 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7939.50","4763.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6145.17","77.4","","303.98","303.98","5854.79","1 through 10","923.36","6145.17","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","9136.58","5481.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1062.58","7766.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","9136.58","5481.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1062.58","7766.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","9136.58","5481.95","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5198.71","56.9","","812.12","238.65","1587.46","163","1062.58","7766.09","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","9136.58","5481.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1062.58","11.63","","112.68","112.68","146.99","38","1062.58","7766.09","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","9136.58","5481.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7071.71","77.4","","303.98","303.98","5854.79","1 through 10","1062.58","7766.09","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9136.58","5481.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1062.58","11.63","","112.68","112.68","146.99","38","1062.58","7071.71","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9136.58","5481.95","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5735.94","62.78","","780.86","208.94","10480.28","15","1062.58","7071.71","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9136.58","5481.95","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3994.51","43.72","","179.76","179.76","179.76","1 through 10","1062.58","7071.71","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9136.58","5481.95","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6644.12","72.72","","2355.45","298.99","3965.19","155","1062.58","7071.71","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9136.58","5481.95","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6644.12","72.72","","3643.09","3643.09","3643.09","1 through 10","1062.58","7071.71","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9136.58","5481.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4862.49","53.22","","554.28","554.28","554.28","16","1062.58","7071.71","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9136.58","5481.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5746.91","62.9","","619.64","173.09","2370.64","150","1062.58","7071.71","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9136.58","5481.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7071.71","77.4","","303.98","303.98","5854.79","1 through 10","1062.58","7071.71","percent of total billed charges",""
"HUMERUS PLATE 3.5X302MM 14 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036530","CDM","C1713","HCPCS","0278","RC","","","","both","","","8742.42","5245.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1016.74","7431.06","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X302MM 14 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036530","CDM","C1713","HCPCS","0278","RC","","","","both","","","8742.42","5245.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1016.74","7431.06","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X302MM 14 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036530","CDM","C1713","HCPCS","0278","RC","","","","both","","","8742.42","5245.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4974.44","56.9","","812.12","238.65","1587.46","163","1016.74","7431.06","percent of total billed charges",""
"HUMERUS PLATE 3.5X302MM 14 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036530","CDM","C1713","HCPCS","0278","RC","","","","both","","","8742.42","5245.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1016.74","11.63","","112.68","112.68","146.99","38","1016.74","7431.06","percent of total billed charges",""
"HUMERUS PLATE 3.5X302MM 14 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036530","CDM","C1713","HCPCS","0278","RC","","","","both","","","8742.42","5245.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6766.63","77.4","","303.98","303.98","5854.79","1 through 10","1016.74","7431.06","percent of total billed charges",""
"HUMERUS PLATE 3.5X302MM 14 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8742.42","5245.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1016.74","11.63","","112.68","112.68","146.99","38","1016.74","6766.63","percent of total billed charges",""
"HUMERUS PLATE 3.5X302MM 14 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8742.42","5245.45","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5488.49","62.78","","780.86","208.94","10480.28","15","1016.74","6766.63","percent of total billed charges",""
"HUMERUS PLATE 3.5X302MM 14 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8742.42","5245.45","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3822.19","43.72","","179.76","179.76","179.76","1 through 10","1016.74","6766.63","percent of total billed charges",""
"HUMERUS PLATE 3.5X302MM 14 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8742.42","5245.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6357.49","72.72","","2355.45","298.99","3965.19","155","1016.74","6766.63","percent of total billed charges",""
"HUMERUS PLATE 3.5X302MM 14 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8742.42","5245.45","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6357.49","72.72","","3643.09","3643.09","3643.09","1 through 10","1016.74","6766.63","percent of total billed charges",""
"HUMERUS PLATE 3.5X302MM 14 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8742.42","5245.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4652.72","53.22","","554.28","554.28","554.28","16","1016.74","6766.63","percent of total billed charges",""
"HUMERUS PLATE 3.5X302MM 14 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8742.42","5245.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5498.98","62.9","","619.64","173.09","2370.64","150","1016.74","6766.63","percent of total billed charges",""
"HUMERUS PLATE 3.5X302MM 14 HOLE LCP SS EXTRA ARTICULAR DISTAL RT STERILE","SUP-ITM-10036530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8742.42","5245.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6766.63","77.4","","303.98","303.98","5854.79","1 through 10","1016.74","6766.63","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","5931.45","3558.87","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","689.83","5041.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","5931.45","3558.87","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","689.83","5041.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","5931.45","3558.87","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3375.00","56.9","","812.12","238.65","1587.46","163","689.83","5041.73","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","5931.45","3558.87","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","689.83","11.63","","112.68","112.68","146.99","38","689.83","5041.73","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","5931.45","3558.87","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4590.94","77.4","","303.98","303.98","5854.79","1 through 10","689.83","5041.73","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5931.45","3558.87","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","689.83","11.63","","112.68","112.68","146.99","38","689.83","4590.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5931.45","3558.87","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3723.76","62.78","","780.86","208.94","10480.28","15","689.83","4590.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5931.45","3558.87","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2593.23","43.72","","179.76","179.76","179.76","1 through 10","689.83","4590.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5931.45","3558.87","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4313.35","72.72","","2355.45","298.99","3965.19","155","689.83","4590.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5931.45","3558.87","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4313.35","72.72","","3643.09","3643.09","3643.09","1 through 10","689.83","4590.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5931.45","3558.87","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3156.72","53.22","","554.28","554.28","554.28","16","689.83","4590.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5931.45","3558.87","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3730.88","62.9","","619.64","173.09","2370.64","150","689.83","4590.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5931.45","3558.87","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4590.94","77.4","","303.98","303.98","5854.79","1 through 10","689.83","4590.94","percent of total billed charges",""
"Hydroxyindolacetic 5-(Hiaa)","PX-30000516","CDM","83497","CPT","0301","RC","","","","outpatient","","","69.00","41.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","50.18","72.72","","48.72","48.72","48.72","1 through 10","12.01","53.41","percent of total billed charges",""
"Hydroxyindolacetic 5-(Hiaa)","PX-30000516","CDM","83497","CPT","0301","RC","","","","outpatient","","","69.00","41.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","43.40","62.9","","42.21","42.21","42.21","1 through 10","12.01","53.41","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","both","","","146.00","87.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","101.91","69.8","","98.42","88.69","98.42","1 through 10","17.66","139.98","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","both","","","146.00","87.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","101.91","69.8","","98.42","98.42","98.42","1 through 10","17.66","139.98","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","both","","","146.00","87.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","124.10","85","","24.45","24.45","24.45","1 through 10","17.66","139.98","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","outpatient","","","146.00","87.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","91.66","62.78","","88.52","88.52","88.52","1 through 10","25.32","113","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","outpatient","","","146.00","87.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","106.17","72.72","","102.54","102.54","102.54","1 through 10","25.32","113","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","outpatient","","","146.00","87.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","91.83","62.9","","88.83","88.83","88.83","1 through 10","25.32","113","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","outpatient","","","146.00","87.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","113.00","77.4","","109.28","109.28","109.28","1 through 10","25.32","113","percent of total billed charges",""
"Hyperbaric Oxygen Supervision 30 Min","PX-41000007","CDM","G0277","CPT","0410","RC","","","","both","","","1167.00","700.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","146.95","","APC Price ($144.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","144.09","144.09","144.09","152","141.19","991.95","other","OPPS APC"
"Hyperbaric Oxygen Supervision 30 Min","PX-41000007","CDM","G0277","CPT","0410","RC","","","","both","","","1167.00","700.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","141.19","","APC Price ($144.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","135.20","135.20","135.20","16","141.19","991.95","other","OPPS APC"
"Hyperbaric Oxygen Supervision 30 Min","PX-41000007","CDM","G0277","CPT","0410","RC","","","","both","","","1167.00","700.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","144.07","","APC Price ($144.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","132.50","132.50","132.50","1 through 10","141.19","991.95","other","OPPS APC"
"Hyperbaric Oxygen Supervision 30 Min","PX-41000007","CDM","G0277","CPT","0410","RC","","","","both","","","1167.00","700.20","MEDICARE [2001]","HB WDH MEDICARE","144.07","","APC Price ($144.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","144.09","135.20","144.09","319","141.19","991.95","other","OPPS APC"
"Hyperbaric Oxygen Supervision 30 Min","PX-41000007","CDM","G0277","CPT","0410","RC","","","","both","","","1167.00","700.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","144.07","","APC Price ($144.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","144.09","135.20","144.09","17","141.19","991.95","other","OPPS APC"
"Hyperbaric Oxygen Supervision 30 Min","PX-41000007","CDM","G0277","CPT","0410","RC","","","","outpatient","","","1167.00","700.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","135.72","11.63","","133.00","133.00","133.00","1 through 10","135.72","903.26","percent of total billed charges",""
"Hypertension With McC","304","MS-DRG","","","","","","","","inpatient","","","56921.24","34152.74","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","9301.94","","Case rate ($9,491.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,795.06, add-ons for qualifying new technology services are included. If operating cost exceeds $12,713.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,466.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,385.80 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,350.19 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $661.10. The transfer capital threshold is the transfer adjustment factor * $661.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9309.32","9309.32","9309.32","1 through 10","3975","45220.12","other","Inpatient DRG"
"Hypertension With McC","304","MS-DRG","","","","","","","","inpatient","","","56921.24","34152.74","MEDICARE [2001]","HB WDH MEDICARE","9491.78","","Case rate ($9,491.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,795.06, add-ons for qualifying new technology services are included. If operating cost exceeds $12,713.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,466.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,385.80 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,350.19 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $661.10. The transfer capital threshold is the transfer adjustment factor * $661.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9309.32","950.02","9332.41","1 through 10","3975","45220.12","other","Inpatient DRG"
"Hypertension With McC","304","MS-DRG","","","","","","","","inpatient","","","56921.24","34152.74","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","9491.78","","Case rate ($9,491.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,795.06, add-ons for qualifying new technology services are included. If operating cost exceeds $12,713.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,466.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,385.80 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,350.19 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $661.10. The transfer capital threshold is the transfer adjustment factor * $661.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11900.04","11900.04","11900.04","1 through 10","3975","45220.12","other","Inpatient DRG"
"Hypertension Without McC","305","MS-DRG","","","","","","","","inpatient","","","33852.81","20311.69","MEDICARE [2001]","HB WDH MEDICARE","6185.47","","Case rate ($6,185.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,743.38, add-ons for qualifying new technology services are included. If operating cost exceeds $9,661.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,224.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,321.11 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,298.51 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $419.49. The transfer capital threshold is the transfer adjustment factor * $419.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6123.98","6109.23","6124.38","1 through 10","3975","28693.88","other","Inpatient DRG"
"I&D Abscess Gland Bartholin's","PX-76001331","CDM","56420","CPT","0761","RC","","","","both","","","996.00","597.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","210.17","","APC Price ($210.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","210.20","210.20","210.20","1 through 10","205.97","1343.24","other","OPPS APC"
"I&D Abscess Perianal Superficial","PX-75000212","CDM","46050","CPT","0750","RC","","","","both","","","1024.00","614.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","714.75","69.8","","5274.09","5274.09","5274.09","1 through 10","104.77","6087.46","percent of total billed charges",""
"I&D Abscess Perianal Superficial","PX-75000212","CDM","46050","CPT","0750","RC","","","","both","","","1024.00","614.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","2621.26","","Case rate ($2,621.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2492.60","2492.60","2492.60","1 through 10","104.77","6087.46","other","OPPS APC"
"I&D Abscess Perianal Superficial","PX-75000212","CDM","46050","CPT","0750","RC","","","","both","","","1024.00","614.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","582.66","56.9","","6276.64","562.17","6276.64","1 through 10","104.77","6087.46","percent of total billed charges",""
"I&D Abscess Perianal Superficial","PX-75000212","CDM","46050","CPT","0750","RC","","","","both","","","1024.00","614.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","952.63","952.63","952.63","1 through 10","104.77","6087.46","other","OPPS APC"
"I&D Abscess Perianal Superficial","PX-75000212","CDM","46050","CPT","0750","RC","","","","both","","","1024.00","614.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","952.63","952.63","952.63","1 through 10","104.77","6087.46","other","OPPS APC"
"I&D Abscess Perianal Superficial","PX-75000212","CDM","46050","CPT","0750","RC","","","","outpatient","","","1024.00","614.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","119.09","11.63","","79.38","79.38","79.38","1 through 10","119.09","792.58","percent of total billed charges",""
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","1021.00","612.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","712.66","69.8","","467.66","467.66","670.00","1 through 10","105.81","1326.74","percent of total billed charges",""
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","1021.00","612.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1326.74","","Case rate ($1,326.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1294.39","1294.39","1294.39","1 through 10","105.81","1326.74","other","OPPS APC"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","1021.00","612.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","571.29","","Case rate ($571.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","557.37","557.37","557.37","1 through 10","105.81","1326.74","other","OPPS APC"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","1021.00","612.60","CHAMPVA [160001]","HB WDH MEDICARE","207.59","","APC Price ($207.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.62","207.62","207.62","1 through 10","105.81","1326.74","other","OPPS APC"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","1021.00","612.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","580.95","56.9","","381.23","381.23","513.87","15","105.81","1326.74","percent of total billed charges",""
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","1021.00","612.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","213.82","","APC Price ($207.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","196.89","196.89","196.89","1 through 10","105.81","1326.74","other","OPPS APC"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","1021.00","612.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","207.59","","APC Price ($207.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.62","207.62","207.62","1 through 10","105.81","1326.74","other","OPPS APC"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","1021.00","612.60","MEDICARE [2001]","HB WDH MEDICARE","207.59","","APC Price ($207.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.62","207.62","207.62","1 through 10","105.81","1326.74","other","OPPS APC"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","1021.00","612.60","TRICARE [160005]","HB WDH MEDICARE","207.59","","APC Price ($207.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.62","207.62","207.62","1 through 10","105.81","1326.74","other","OPPS APC"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","1021.00","612.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","207.59","","APC Price ($207.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.47","191.16","207.62","1 through 10","105.81","1326.74","other","OPPS APC"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","outpatient","","","1021.00","612.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","147.23","14.42","","82.81","82.81","1590.67","1 through 10","118.74","790.25","percent of total billed charges",""
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","outpatient","","","1021.00","612.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","118.74","11.63","","169.22","82.01","1302.94","1 through 10","118.74","790.25","percent of total billed charges",""
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","outpatient","","","1021.00","612.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","","","Payment is accumulated by procedure count. Procedure 1, 62.78% of billed. Procedures 2 - 9999, 31.39% of billed.","420.63","420.63","420.63","1 through 10","118.74","790.25","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","outpatient","","","1021.00","612.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","292.92","292.92","292.92","1 through 10","118.74","790.25","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","outpatient","","","1021.00","612.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","487.22","487.22","755.58","1 through 10","118.74","790.25","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","outpatient","","","1021.00","612.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","642.21","62.9","","1266.30","422.10","1266.30","1 through 10","118.74","790.25","percent of total billed charges",""
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","outpatient","","","1021.00","612.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","790.25","77.4","","670.00","519.25","5855.90","1 through 10","118.74","790.25","percent of total billed charges",""
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","outpatient","","","1021.00","612.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","118.74","11.63","","79.14","79.14","332.19","1 through 10","118.74","790.25","percent of total billed charges",""
"I&D Abscess Vulva/Perineal","PX-76001330","CDM","56405","CPT","0761","RC","","","","outpatient","","","1090.00","654.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","126.77","11.63","","105.62","105.62","105.62","1 through 10","126.77","843.66","percent of total billed charges",""
"I&D Cyst Pilonidal Complex","PX-76000007","CDM","10081","CPT","0761","RC","","","","both","","","1763.00","1057.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1003.15","56.9","","346.04","346.04","346.04","1 through 10","180.79","4697.85","percent of total billed charges",""
"I&D Cyst Pilonidal Smp","PX-76000006","CDM","10080","CPT","0761","RC","","","","both","","","1066.00","639.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","735.08","","APC Price ($735.08). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","672.61","672.61","672.61","1 through 10","108.69","4697.85","other","OPPS APC"
"I&D Cyst Pilonidal Smp","PX-76000006","CDM","10080","CPT","0761","RC","","","","outpatient","","","1066.00","639.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","123.98","11.63","","1152.84","1152.84","1152.84","1 through 10","123.98","825.08","percent of total billed charges",""
"I&D Hematoma/Seroma/Fluid","PX-76000010","CDM","10140","CPT","0761","RC","","","","both","","","2131.00","1278.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1666.10","1666.10","1666.10","1 through 10","307.29","10818.29","other","OPPS APC"
"I&D Hematoma/Seroma/Fluid","PX-76000010","CDM","10140","CPT","0761","RC","","","","both","","","2131.00","1278.60","MEDICARE [2001]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1692.96","1692.96","1692.96","1 through 10","307.29","10818.29","other","OPPS APC"
"I&D Wound Post OP Complex","PX-76000012","CDM","10180","CPT","0761","RC","","","","both","","","9583.00","5749.80","MEDICARE [2001]","HB WDH MEDICARE","2990.16","","APC Price ($2,990.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8971.50","8971.50","8971.50","1 through 10","2930.35","19109.85","other","OPPS APC"
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","both","","","391.00","234.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","272.92","69.8","","263.84","263.84","263.84","1 through 10","22.81","332.35","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","both","","","391.00","234.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","222.48","56.9","","233.64","215.08","645.24","19","22.81","332.35","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","outpatient","","","391.00","234.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","56.38","14.42","","31.26","31.26","31.26","1 through 10","45.47","302.63","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","outpatient","","","391.00","234.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","45.47","11.63","","30.96","30.96","30.96","1 through 10","45.47","302.63","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","outpatient","","","391.00","234.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","284.34","72.72","","274.88","274.88","274.88","1 through 10","45.47","302.63","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","outpatient","","","391.00","234.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","245.94","62.9","","457.82","238.14","714.42","15","45.47","302.63","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","outpatient","","","391.00","234.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","302.63","77.4","","292.95","274.88","292.95","1 through 10","45.47","302.63","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","outpatient","","","391.00","234.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","45.47","11.63","","55.30","30.96","56.14","1 through 10","45.47","302.63","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","both","","","392.00","235.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","273.62","69.8","","263.84","263.84","263.84","1 through 10","22.81","333.2","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","both","","","392.00","235.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","223.05","56.9","","215.08","215.08","233.64","1 through 10","22.81","333.2","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","outpatient","","","392.00","235.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","56.53","14.42","","31.26","31.26","31.26","1 through 10","45.59","303.41","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","outpatient","","","392.00","235.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","285.06","72.72","","274.88","274.88","274.88","1 through 10","45.59","303.41","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","outpatient","","","392.00","235.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","246.57","62.9","","238.14","238.14","238.14","1 through 10","45.59","303.41","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","outpatient","","","392.00","235.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","303.41","77.4","","292.95","274.88","292.95","1 through 10","45.59","303.41","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","outpatient","","","392.00","235.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","45.59","11.63","","56.14","55.30","56.14","1 through 10","45.59","303.41","percent of total billed charges",""
"Iadna Dna/Rna Rsv Amplified Probe Technique","PX-30003475","CDM","87634","CPT","0306","RC","","","","both","","","469.00","281.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","327.36","69.8","","284.94","284.94","284.94","1 through 10","70.2","398.65","percent of total billed charges",""
"Iadna Dna/Rna Rsv Amplified Probe Technique","PX-30003475","CDM","87634","CPT","0306","RC","","","","outpatient","","","469.00","281.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","67.63","14.42","","453.00","453.00","453.00","54","54.54","363.01","percent of total billed charges",""
"Iadna Dna/Rna Rsv Amplified Probe Technique","PX-30003475","CDM","87634","CPT","0306","RC","","","","outpatient","","","469.00","281.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","54.54","11.63","","453.00","42.96","453.00","1 through 10","54.54","363.01","percent of total billed charges",""
"Iadna Dna/Rna Rsv Amplified Probe Technique","PX-30003475","CDM","87634","CPT","0306","RC","","","","outpatient","","","469.00","281.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","54.54","11.63","","42.96","42.96","42.96","31","54.54","363.01","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","both","","","391.00","234.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","272.92","69.8","","263.84","263.84","263.84","1 through 10","22.81","332.35","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","both","","","391.00","234.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","222.48","56.9","","233.64","215.08","645.24","15","22.81","332.35","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","outpatient","","","391.00","234.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","56.38","14.42","","31.26","31.26","31.26","1 through 10","45.47","302.63","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","outpatient","","","391.00","234.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","284.34","72.72","","274.88","274.88","274.88","1 through 10","45.47","302.63","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","outpatient","","","391.00","234.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","245.94","62.9","","714.42","238.14","714.42","11","45.47","302.63","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","outpatient","","","391.00","234.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","302.63","77.4","","292.95","274.88","292.95","1 through 10","45.47","302.63","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","outpatient","","","391.00","234.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","45.47","11.63","","30.96","30.96","30.96","1 through 10","45.47","302.63","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","both","","","726.00","435.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","506.75","69.8","","490.00","441.56","490.00","135","45.63","617.1","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","both","","","726.00","435.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","413.09","56.9","","399.44","399.44","1302.17","312","45.63","617.1","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","both","","","726.00","435.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","506.75","69.8","","596.70","596.70","596.70","1 through 10","45.63","617.1","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","both","","","726.00","435.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","617.10","85","","399.44","399.44","399.44","1 through 10","45.63","617.1","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","726.00","435.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","104.69","14.42","","57.84","57.84","57.84","1 through 10","84.43","561.92","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","726.00","435.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","84.43","11.63","","57.28","57.28","57.28","1 through 10","84.43","561.92","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","726.00","435.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","527.95","72.72","","510.49","510.49","510.49","95","84.43","561.92","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","726.00","435.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","527.95","72.72","","510.49","510.49","510.49","1 through 10","84.43","561.92","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","726.00","435.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","386.38","53.22","","374.24","374.24","1122.72","15","84.43","561.92","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","726.00","435.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","456.65","62.9","","442.26","442.26","1326.78","237","84.43","561.92","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","726.00","435.60","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","527.95","72.72","","544.05","544.05","544.05","1 through 10","84.43","561.92","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","726.00","435.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","561.92","77.4","","544.05","544.05","544.05","90","84.43","561.92","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","726.00","435.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","527.95","72.72","","510.49","510.49","510.49","1 through 10","84.43","561.92","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","726.00","435.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","84.43","11.63","","110.64","110.64","110.64","1 through 10","84.43","561.92","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","both","","","273.00","163.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","190.55","69.8","","184.27","166.06","184.27","80","22.81","232.05","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","both","","","273.00","163.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","190.55","69.8","","224.40","224.40","224.40","1 through 10","22.81","232.05","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","outpatient","","","273.00","163.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","171.39","62.78","","165.74","165.74","165.74","1 through 10","23.06","211.3","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","outpatient","","","273.00","163.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","119.36","43.72","","115.42","115.42","115.42","1 through 10","23.06","211.3","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","outpatient","","","273.00","163.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","198.53","72.72","","191.98","191.98","383.96","163","23.06","211.3","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","outpatient","","","273.00","163.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","198.53","72.72","","191.98","191.98","191.98","1 through 10","23.06","211.3","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","outpatient","","","273.00","163.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","145.29","53.22","","140.74","140.74","281.48","1 through 10","23.06","211.3","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","outpatient","","","273.00","163.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","171.72","62.9","","332.64","166.32","498.96","258","23.06","211.3","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","outpatient","","","273.00","163.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","211.30","77.4","","204.60","204.60","204.60","54","23.06","211.3","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","outpatient","","","273.00","163.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","198.53","72.72","","191.98","191.98","191.98","1 through 10","23.06","211.3","percent of total billed charges",""
"Iadna Pneumocystis Jirovecii Amplified Probe Tq","PX-30003847","CDM","87594","CPT","0306","RC","","","","outpatient","","","363.00","217.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","52.34","14.42","","28.91","28.91","28.91","1 through 10","42.22","280.96","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","both","","","150.00","90.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","","69.8","69.8% of billed. Includes an additional $51.31 of payment.","104.70","51.31","104.70","28","33.35","127.5","other","COVID Test CPT 87635"
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","both","","","150.00","90.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","85.35","56.9","","85.35","70.66","131.07","85","33.35","127.5","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","both","","","150.00","90.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","","69.8","69.8% of billed. Includes an additional $51.31 of payment.","127.50","104.70","127.50","1 through 10","33.35","127.5","other","COVID Test CPT 87635"
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","both","","","150.00","90.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","127.50","85","","127.50","127.50","127.50","1 through 10","33.35","127.5","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","outpatient","","","150.00","90.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","21.63","14.42","","54.49","54.49","54.49","1 through 10","21.63","116.1","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","outpatient","","","150.00","90.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","94.17","62.78","","94.17","94.17","94.17","1 through 10","21.63","116.1","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","outpatient","","","150.00","90.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","65.58","43.72","","196.74","65.58","196.74","1 through 10","21.63","116.1","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","outpatient","","","150.00","90.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","109.08","72.72","","109.08","109.08","109.08","39","21.63","116.1","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","outpatient","","","150.00","90.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","109.08","72.72","","218.16","109.08","218.16","1 through 10","21.63","116.1","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","outpatient","","","150.00","90.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","116.10","77.4","","116.25","116.25","116.26","18","21.63","116.1","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq High Throughput Tech","PX-30003645","CDM","U0003","HCPCS","0300","RC","","","","outpatient","","","150.00","90.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","17.69","11.79","","153.00","76.50","153.00","22","17.69","116.1","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq High Throughput Tech","PX-30003645","CDM","U0003","HCPCS","0300","RC","","","","outpatient","","","150.00","90.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","116.10","77.4","","99.60","99.60","99.60","1 through 10","17.69","116.1","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq High Throughput Tech; Rsltd","PX-30003731","CDM","U0005","HCPCS","0300","RC","","","","both","","","25.00","15.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","14.23","56.9","","22.59","22.59","22.59","1 through 10","14.23","21.25","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq High Throughput Tech; Rsltd","PX-30003731","CDM","U0005","HCPCS","0300","RC","","","","outpatient","","","25.00","15.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2.95","11.79","","50.00","25.00","50.00","26","2.95","19.35","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq High Throughput Tech; Rsltd","PX-30003731","CDM","U0005","HCPCS","0300","RC","","","","outpatient","","","25.00","15.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","19.35","77.4","","16.60","16.60","16.60","1 through 10","2.95","19.35","percent of total billed charges",""
"Iadna Sarscov2 & Inf a&B & Rsv Mult Amp Probe Tq","PX-30003716","CDM","87637","CPT","0300","RC","","","","both","","","478.00","286.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","333.64","69.8","","333.64","333.64","333.64","1 through 10","142.63","406.3","percent of total billed charges",""
"Iadna Sarscov2 & Inf a&B & Rsv Mult Amp Probe Tq","PX-30003716","CDM","87637","CPT","0300","RC","","","","both","","","478.00","286.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","271.98","56.9","","749.98","749.98","749.98","1 through 10","142.63","406.3","percent of total billed charges",""
"Iadna Sarscov2 & Inf a&B Mult Amplified Probe Tq","PX-30003715","CDM","87636","CPT","0300","RC","","","","both","","","358.00","214.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","249.88","69.8","","249.88","225.18","249.88","1 through 10","142.63","304.3","percent of total billed charges",""
"Iadna Sarscov2 & Inf a&B Mult Amplified Probe Tq","PX-30003715","CDM","87636","CPT","0300","RC","","","","both","","","358.00","214.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","203.70","56.9","","162.46","46.70","222.19","14","142.63","304.3","percent of total billed charges",""
"Iadna Sarscov2 & Inf a&B Mult Amplified Probe Tq","PX-30003715","CDM","87636","CPT","0300","RC","","","","outpatient","","","358.00","214.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","260.34","72.72","","260.34","260.34","260.34","1 through 10","145.48","277.09","percent of total billed charges",""
"Iadna Sarscov2 & Inf a&B Mult Amplified Probe Tq","PX-30003715","CDM","87636","CPT","0300","RC","","","","outpatient","","","358.00","214.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","190.53","53.22","","190.85","190.85","190.85","1 through 10","145.48","277.09","percent of total billed charges",""
"Iadna Sarscov2 & Inf a&B Mult Amplified Probe Tq","PX-30003715","CDM","87636","CPT","0300","RC","","","","outpatient","","","358.00","214.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","225.18","62.9","","225.54","225.54","225.54","1 through 10","145.48","277.09","percent of total billed charges",""
"Iadna Sarscov2 & Inf a&B Mult Amplified Probe Tq","PX-30003715","CDM","87636","CPT","0300","RC","","","","outpatient","","","358.00","214.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","277.09","77.4","","277.45","277.45","277.45","1 through 10","145.48","277.09","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","273.00","163.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","190.55","69.8","","184.27","166.06","184.27","22","22.81","232.05","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","outpatient","","","273.00","163.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","171.39","62.78","","165.74","165.74","165.74","1 through 10","33.29","211.3","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","outpatient","","","273.00","163.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","198.53","72.72","","191.98","191.98","575.94","35","33.29","211.3","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","outpatient","","","273.00","163.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","198.53","72.72","","191.98","191.98","191.98","1 through 10","33.29","211.3","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","outpatient","","","273.00","163.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","145.29","53.22","","140.74","140.74","140.74","1 through 10","33.29","211.3","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","outpatient","","","273.00","163.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","171.72","62.9","","166.32","166.32","166.32","63","33.29","211.3","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","outpatient","","","273.00","163.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","211.30","77.4","","204.60","204.60","204.60","18","33.29","211.3","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","outpatient","","","273.00","163.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","198.53","72.72","","191.98","191.98","191.98","1 through 10","33.29","211.3","percent of total billed charges",""
"If Adenovirus Antigen","PX-30001206","CDM","87260","CPT","0306","RC","","","","both","","","68.00","40.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","47.46","69.8","","11.93","11.93","11.93","1 through 10","38.69","57.8","percent of total billed charges",""
"If Adenovirus Antigen","PX-30001206","CDM","87260","CPT","0306","RC","","","","outpatient","","","68.00","40.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","9.81","14.42","","12.85","12.85","12.85","1 through 10","8.02","52.63","percent of total billed charges",""
"If Adenovirus Antigen","PX-30001206","CDM","87260","CPT","0306","RC","","","","outpatient","","","68.00","40.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","8.02","11.79","","38.19","38.19","38.19","1 through 10","8.02","52.63","percent of total billed charges",""
"If Antigen Not Specified","PX-30001226","CDM","87299","CPT","0306","RC","","","","both","","","74.00","44.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","51.65","69.8","","13.01","13.01","13.01","1 through 10","42.11","62.9","percent of total billed charges",""
"If Antigen Not Specified","PX-30001226","CDM","87299","CPT","0306","RC","","","","outpatient","","","74.00","44.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","10.67","14.42","","14.35","14.35","14.35","1 through 10","8.72","57.28","percent of total billed charges",""
"If Antigen Not Specified","PX-30001226","CDM","87299","CPT","0306","RC","","","","outpatient","","","74.00","44.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","8.72","11.79","","42.63","42.63","42.63","1 through 10","8.72","57.28","percent of total billed charges",""
"If Herpes Smpx Type 2 Antigen","PX-30001213","CDM","87273","CPT","0306","RC","","","","outpatient","","","83.00","49.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","44.17","53.22","","42.65","42.65","42.65","1 through 10","10.68","64.24","percent of total billed charges",""
"If Influenza a Antigen","PX-30001216","CDM","87276","CPT","0306","RC","","","","both","","","74.00","44.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","51.65","69.8","","13.01","13.01","13.01","1 through 10","42.11","62.9","percent of total billed charges",""
"If Influenza a Antigen","PX-30001216","CDM","87276","CPT","0306","RC","","","","outpatient","","","74.00","44.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","10.67","14.42","","14.32","14.32","14.32","1 through 10","8.72","57.28","percent of total billed charges",""
"If Influenza a Antigen","PX-30001216","CDM","87276","CPT","0306","RC","","","","outpatient","","","74.00","44.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","8.72","11.79","","42.54","42.54","42.54","1 through 10","8.72","57.28","percent of total billed charges",""
"If Influenza B Antigen","PX-30001215","CDM","87275","CPT","0306","RC","","","","both","","","69.00","41.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","48.16","69.8","","12.11","12.11","12.11","1 through 10","39.26","58.65","percent of total billed charges",""
"If Influenza B Antigen","PX-30001215","CDM","87275","CPT","0306","RC","","","","outpatient","","","69.00","41.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","9.95","14.42","","10.92","10.92","10.92","1 through 10","8.14","53.41","percent of total billed charges",""
"If Influenza B Antigen","PX-30001215","CDM","87275","CPT","0306","RC","","","","outpatient","","","69.00","41.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","8.14","11.79","","32.43","32.43","32.43","1 through 10","8.14","53.41","percent of total billed charges",""
"If Parainfluenza Antigen","PX-30001219","CDM","87279","CPT","0306","RC","","","","both","","","75.00","45.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","52.35","69.8","","39.58","39.58","39.58","1 through 10","42.68","63.75","percent of total billed charges",""
"If Parainfluenza Antigen","PX-30001219","CDM","87279","CPT","0306","RC","","","","outpatient","","","75.00","45.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","10.82","14.42","","14.64","14.64","14.64","1 through 10","8.84","58.05","percent of total billed charges",""
"If Parainfluenza Antigen","PX-30001219","CDM","87279","CPT","0306","RC","","","","outpatient","","","75.00","45.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","8.84","11.79","","219.00","219.00","219.00","1 through 10","8.84","58.05","percent of total billed charges",""
"If Rsv Antigen","PX-30001221","CDM","87280","CPT","0306","RC","","","","both","","","66.00","39.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","46.07","69.8","","11.57","11.57","11.57","1 through 10","37.55","56.1","percent of total billed charges",""
"If Rsv Antigen","PX-30001221","CDM","87280","CPT","0306","RC","","","","outpatient","","","66.00","39.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","9.52","14.42","","11.96","11.96","11.96","1 through 10","7.78","51.08","percent of total billed charges",""
"If Rsv Antigen","PX-30001221","CDM","87280","CPT","0306","RC","","","","outpatient","","","66.00","39.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","7.78","11.79","","35.52","35.52","35.52","1 through 10","7.78","51.08","percent of total billed charges",""
"Ifr (During Dx/Pci Coronary Artery), Ea Addl Vessel","PX-48000492","CDM","93799","CPT","0481","RC","","","","both","","","1618.00","970.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1044.65","","Case rate ($1,044.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2303.00","2303.00","2303.00","1 through 10","160.19","1375.3","other","OPPS APC"
"Ifr (During Dx/Pci Coronary Artery), Ea Addl Vessel","PX-48000492","CDM","93799","CPT","0481","RC","","","","outpatient","","","1618.00","970.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1176.61","72.72","","2214.32","2214.32","2214.32","1 through 10","188.17","1252.33","percent of total billed charges",""
"Ifr (During Dx/Pci Coronary Artery), Init Vessel","PX-48000491","CDM","93799","CPT","0481","RC","","","","both","","","3156.00","1893.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1044.65","","Case rate ($1,044.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2303.00","2303.00","2303.00","1 through 10","160.19","2682.6","other","OPPS APC"
"Ifr (During Dx/Pci Coronary Artery), Init Vessel","PX-48000491","CDM","93799","CPT","0481","RC","","","","outpatient","","","3156.00","1893.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2295.04","72.72","","2214.32","2214.32","2214.32","1 through 10","367.04","2442.74","percent of total billed charges",""
"Iiv4 Vacc Presrv Free 0.5 Ml Dos for Im Use","PX-63600500","CDM","90686","CPT","0636","RC","","","","outpatient","","","63.00","37.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","7.33","11.63","","4.53","4.26","4.53","1 through 10","7.33","60.27","percent of total billed charges",""
"Iiv4 Vacc Presrv Free 0.5 Ml Dos for Im Use","PX-63600500","CDM","90686","CPT","0636","RC","","","","outpatient","","","63.00","37.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","39.63","62.9","","80.20","79.92","80.20","1 through 10","7.33","60.27","percent of total billed charges",""
"Image Cath Fluid Peri/Retro","PX-76001947","CDM","49406","CPT","0761","RC","","","","both","","","8361.00","5016.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1658.91","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1465.35","1465.35","1465.35","1 through 10","1658.91","10818.29","other","OPPS APC"
"Image Cath Fluid Peri/Retro","PX-76001947","CDM","49406","CPT","0761","RC","","","","both","","","8361.00","5016.60","MEDICARE [2001]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1692.96","1692.96","1692.96","1 through 10","1658.91","10818.29","other","OPPS APC"
"Image Cath Fluid Peri/Retro","PX-76001947","CDM","49406","CPT","0761","RC","","","","outpatient","","","8361.00","5016.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","972.38","11.63","","18467.85","18467.85","18467.85","1 through 10","972.38","6471.41","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","452.00","271.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","384.20","85","","370.60","370.60","370.60","1 through 10","270.92","384.2","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","outpatient","","","452.00","271.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","283.77","62.78","","273.72","273.72","273.72","1 through 10","52.57","349.85","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","outpatient","","","452.00","271.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","197.61","43.72","","190.62","190.62","190.62","16","52.57","349.85","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","outpatient","","","452.00","271.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","328.69","72.72","","317.06","317.06","317.06","165","52.57","349.85","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","outpatient","","","452.00","271.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","328.69","72.72","","317.06","317.06","317.06","1 through 10","52.57","349.85","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","outpatient","","","452.00","271.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","240.55","53.22","","232.43","232.43","232.43","29","52.57","349.85","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","outpatient","","","452.00","271.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","284.31","62.9","","274.68","274.68","1054.36","259","52.57","349.85","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","outpatient","","","452.00","271.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","349.85","77.4","","337.90","337.90","337.90","80","52.57","349.85","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","outpatient","","","452.00","271.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","328.69","72.72","","317.06","317.06","317.06","1 through 10","52.57","349.85","percent of total billed charges",""
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","both","","","902.00","541.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","375.82","","APC Price ($375.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","122.78","122.78","122.78","1 through 10","368.3","2401.82","other","OPPS APC"
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","outpatient","","","902.00","541.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","655.93","72.72","","634.12","634.12","1268.24","12","104.9","698.15","percent of total billed charges",""
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","outpatient","","","902.00","541.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","698.15","77.4","","1030.20","1030.20","1030.20","1 through 10","104.9","698.15","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","325.00","195.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","226.85","69.8","","578.64","219.17","5260.12","1 through 10","175.45","1144.2","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","325.00","195.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","924.85","","Case rate ($924.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","451.60","451.60","451.60","1 through 10","175.45","1144.2","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","325.00","195.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","184.40","","APC Price ($179.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","180.73","180.73","180.73","1 through 10","175.45","1144.2","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","325.00","195.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","179.03","","APC Price ($179.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","175.57","175.57","175.57","1 through 10","175.45","1144.2","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","325.00","195.00","MEDICARE [2001]","HB WDH MEDICARE","179.03","","APC Price ($179.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","179.05","179.05","179.05","1 through 10","175.45","1144.2","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","325.00","195.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","276.25","85","","237.43","237.43","310.04","14","175.45","1144.2","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","325.00","195.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","179.03","","APC Price ($179.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","175.47","87.74","179.05","1 through 10","175.45","1144.2","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","outpatient","","","325.00","195.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","46.87","14.42","","18.05","18.05","18.05","1 through 10","37.8","251.55","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","outpatient","","","325.00","195.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","204.04","62.78","","591.39","197.13","591.39","14","37.8","251.55","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","outpatient","","","325.00","195.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","142.09","43.72","","137.28","137.28","137.28","1 through 10","37.8","251.55","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","outpatient","","","325.00","195.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","236.34","72.72","","228.34","228.34","685.02","102","37.8","251.55","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","outpatient","","","325.00","195.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","236.34","72.72","","228.34","228.34","228.34","1 through 10","37.8","251.55","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","outpatient","","","325.00","195.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","172.97","53.22","","167.40","167.39","167.40","1 through 10","37.8","251.55","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","outpatient","","","325.00","195.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","204.43","62.9","","197.82","197.82","593.46","153","37.8","251.55","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","outpatient","","","325.00","195.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","251.55","77.4","","243.35","243.35","243.35","41","37.8","251.55","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","outpatient","","","325.00","195.00","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","236.34","72.72","","228.34","228.34","228.34","1 through 10","37.8","251.55","percent of total billed charges",""
"Immun Admin Any Route 1st Vacc/Tox","PX-77100001","CDM","90460","CPT","0771","RC","","","","outpatient","","","48.00","28.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","37.15","77.4","","35.65","35.65","35.65","1 through 10","5.58","37.15","percent of total billed charges",""
"Immun Admin Any Route Ea Addl Vacc/","PX-77100002","CDM","90461","CPT","0771","RC","","","","outpatient","","","48.00","28.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","37.15","77.4","","35.65","35.65","35.65","1 through 10","5.58","37.15","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","both","","","48.00","28.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","33.50","69.8","","32.11","32.11","32.11","1 through 10","13.29","40.8","percent of total billed charges",""
"Immune Admin Ea Add Vacc Im/Subq","PX-77100004","CDM","90472","CPT","0771","RC","","","","outpatient","","","48.00","28.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","37.15","77.4","","34.15","34.15","34.15","1 through 10","5.58","37.15","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","48.00","28.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","33.50","69.8","","32.11","28.93","32.11","24","25.55","475.23","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","48.00","28.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","204.63","","Case rate ($204.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","46.00","46.00","46.00","1 through 10","25.55","475.23","other","OPPS APC"
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","48.00","28.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","72.87","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","74.36","72.87","126.41","31","25.55","475.23","other","OPPS APC"
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","48.00","28.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","384.13","","Case rate ($384.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","85.55","85.55","85.55","1 through 10","25.55","475.23","other","OPPS APC"
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","48.00","28.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","27.31","56.9","","26.17","17.95","46.00","48","25.55","475.23","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","48.00","28.80","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","27.31","56.9","","26.17","26.17","26.17","1 through 10","25.55","475.23","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","48.00","28.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","74.36","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","72.87","72.87","72.87","1 through 10","25.55","475.23","other","OPPS APC"
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","48.00","28.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","30.19","62.9","","111.00","28.98","144.90","25","25.55","475.23","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","48.00","28.80","TRICARE [160005]","HB WDH MEDICARE","74.36","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","74.36","74.36","74.36","1 through 10","25.55","475.23","other","OPPS APC"
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","48.00","28.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","74.36","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","74.36","72.88","74.36","1 through 10","25.55","475.23","other","OPPS APC"
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","48.00","28.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","37.15","77.4","","35.65","35.64","35.65","11","25.55","475.23","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","outpatient","","","48.00","28.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","6.92","14.42","","6.63","5.69","6.63","1 through 10","5.58","6.92","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","outpatient","","","48.00","28.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","5.58","11.63","","6.33","5.44","16.32","13","5.58","6.92","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","outpatient","","","48.00","28.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","5.58","11.63","","5.44","5.44","349.80","23","5.58","6.92","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","both","","","163.00","97.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","113.77","69.8","","110.28","99.38","110.29","66","7.49","138.55","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","outpatient","","","163.00","97.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","102.33","62.78","","99.19","99.19","99.19","1 through 10","10.68","126.16","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","outpatient","","","163.00","97.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","71.26","43.72","","69.08","69.08","69.08","1 through 10","10.68","126.16","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","outpatient","","","163.00","97.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","118.53","72.72","","114.90","114.90","114.90","125","10.68","126.16","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","outpatient","","","163.00","97.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","118.53","72.72","","114.90","114.90","114.90","1 through 10","10.68","126.16","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","outpatient","","","163.00","97.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","86.75","53.22","","84.23","84.23","84.23","1 through 10","10.68","126.16","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","outpatient","","","163.00","97.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","102.53","62.9","","99.54","99.54","99.54","162","10.68","126.16","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","outpatient","","","163.00","97.80","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","118.53","72.72","","122.45","122.45","122.45","1 through 10","10.68","126.16","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","outpatient","","","163.00","97.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","126.16","77.4","","122.45","122.45","122.45","36","10.68","126.16","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","outpatient","","","163.00","97.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","118.53","72.72","","114.90","114.90","114.90","1 through 10","10.68","126.16","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0300","RC","","","","inpatient","","","200.00","120.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","153.72","76.86","","121.59","121.59","121.59","1 through 10","132.4","153.72","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","both","","","200.00","120.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","139.60","69.8","","134.71","14.76","134.71","17","11.23","170","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","145.44","72.72","","140.35","140.35","140.35","16","12.06","154.8","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","145.44","72.72","","140.35","140.35","140.35","1 through 10","12.06","154.8","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","106.44","53.22","","102.89","102.89","102.89","1 through 10","12.06","154.8","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","125.80","62.9","","243.18","121.59","364.77","19","12.06","154.8","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","154.80","77.4","","149.58","138.91","149.58","12","12.06","154.8","percent of total billed charges",""
"Immuno Qn Ria","PX-30000524","CDM","83519","CPT","0301","RC","","","","outpatient","","","80.00","48.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","34.98","43.72","","33.66","33.66","33.66","1 through 10","12.59","61.92","percent of total billed charges",""
"Immuno Qn Ria","PX-30000524","CDM","83519","CPT","0301","RC","","","","outpatient","","","80.00","48.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","58.18","72.72","","55.99","55.99","55.99","1 through 10","12.59","61.92","percent of total billed charges",""
"Immuno Qn Ria","PX-30000524","CDM","83519","CPT","0301","RC","","","","outpatient","","","80.00","48.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","50.32","62.9","","48.51","48.51","48.51","1 through 10","12.59","61.92","percent of total billed charges",""
"Immunoassay Optical Influenza","PX-30001350","CDM","87804","CPT","0306","RC","","","","both","","","116.00","69.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","80.97","69.8","","78.18","78.18","78.18","1 through 10","16.55","98.6","percent of total billed charges",""
"Immunoassay Optical Influenza","PX-30001350","CDM","87804","CPT","0306","RC","","","","both","","","116.00","69.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","80.97","69.8","","95.20","78.18","95.20","1 through 10","16.55","98.6","percent of total billed charges",""
"Immunoassay Optical Influenza","PX-30001350","CDM","87804","CPT","0306","RC","","","","both","","","116.00","69.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","72.96","62.9","","70.56","70.56","70.56","13","16.55","98.6","percent of total billed charges",""
"Immunoassay Optical Influenza","PX-30001350","CDM","87804","CPT","0306","RC","","","","both","","","116.00","69.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","89.78","77.4","","86.80","86.80","86.80","1 through 10","16.55","98.6","percent of total billed charges",""
"Immunoassay Optical Influenza","PX-30001350","CDM","87804","CPT","0306","RC","","","","outpatient","","","116.00","69.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","72.82","62.78","","70.31","70.31","70.31","1 through 10","10.68","84.36","percent of total billed charges",""
"Immunoassay Optical Influenza","PX-30001350","CDM","87804","CPT","0306","RC","","","","outpatient","","","116.00","69.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","84.36","72.72","","81.45","81.45","81.45","1 through 10","10.68","84.36","percent of total billed charges",""
"Immunoassay Optical Rsv","PX-30001352","CDM","87807","CPT","0306","RC","","","","both","","","103.00","61.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","71.89","69.8","","69.80","69.80","69.80","1 through 10","8.52","87.55","percent of total billed charges",""
"Immunoassay Optical Rsv","PX-30001352","CDM","87807","CPT","0306","RC","","","","both","","","103.00","61.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","64.79","62.9","","63.00","63.00","63.00","1 through 10","8.52","87.55","percent of total billed charges",""
"Immunoassay Optical Rsv","PX-30001352","CDM","87807","CPT","0306","RC","","","","both","","","103.00","61.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","79.72","77.4","","77.50","77.50","77.50","1 through 10","8.52","87.55","percent of total billed charges",""
"Immunoassay Optical Strep A","PX-30001357","CDM","87880","CPT","0306","RC","","","","outpatient","","","116.00","69.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","72.96","62.9","","70.56","70.56","70.56","1 through 10","10.68","89.78","percent of total billed charges",""
"Immunoassay Tumor Ag Other Ag Qn","PX-30000825","CDM","86316","CPT","0302","RC","","","","both","","","111.00","66.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","77.48","69.8","","74.69","74.69","74.69","1 through 10","13.53","106.86","percent of total billed charges",""
"Immunoassay Tumor Ag Other Ag Qn","PX-30000825","CDM","86316","CPT","0302","RC","","","","outpatient","","","111.00","66.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","80.72","72.72","","77.81","77.81","77.81","1 through 10","19.39","85.91","percent of total billed charges",""
"Immunoassay Tumor Ag Other Ag Qn","PX-30000825","CDM","86316","CPT","0302","RC","","","","outpatient","","","111.00","66.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","85.91","77.4","","82.93","77.81","82.93","1 through 10","19.39","85.91","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 125","PX-30000820","CDM","86304","CPT","0302","RC","","","","both","","","111.00","66.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","77.48","69.8","","74.69","67.30","74.69","11","13.53","106.86","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 125","PX-30000820","CDM","86304","CPT","0302","RC","","","","outpatient","","","111.00","66.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","48.53","43.72","","46.78","46.78","46.78","1 through 10","19.39","85.91","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 125","PX-30000820","CDM","86304","CPT","0302","RC","","","","outpatient","","","111.00","66.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","80.72","72.72","","77.81","77.81","77.81","1 through 10","19.39","85.91","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 125","PX-30000820","CDM","86304","CPT","0302","RC","","","","outpatient","","","111.00","66.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","69.82","62.9","","67.41","67.41","259.80","34","19.39","85.91","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 125","PX-30000820","CDM","86304","CPT","0302","RC","","","","outpatient","","","111.00","66.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","85.91","77.4","","82.93","82.92","82.93","1 through 10","19.39","85.91","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 125","PX-30000820","CDM","86304","CPT","0302","RC","","","","outpatient","","","111.00","66.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","80.72","72.72","","77.81","77.81","77.81","1 through 10","19.39","85.91","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 15-3","PX-30000818","CDM","86300","CPT","0302","RC","","","","both","","","111.00","66.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","77.48","69.8","","74.69","67.31","74.69","13","13.53","106.86","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 15-3","PX-30000818","CDM","86300","CPT","0302","RC","","","","both","","","111.00","66.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","77.48","69.8","","138.91","138.91","138.91","1 through 10","13.53","106.86","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 15-3","PX-30000818","CDM","86300","CPT","0302","RC","","","","both","","","111.00","66.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","94.35","85","","90.95","90.95","90.95","1 through 10","13.53","106.86","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 15-3","PX-30000818","CDM","86300","CPT","0302","RC","","","","outpatient","","","111.00","66.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","80.72","72.72","","77.81","77.81","77.81","11","19.39","85.91","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 15-3","PX-30000818","CDM","86300","CPT","0302","RC","","","","outpatient","","","111.00","66.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","69.82","62.9","","67.41","67.41","67.41","1 through 10","19.39","85.91","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 15-3","PX-30000818","CDM","86300","CPT","0302","RC","","","","outpatient","","","111.00","66.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","85.91","77.4","","82.93","82.93","82.93","1 through 10","19.39","85.91","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 19-9","PX-30000819","CDM","86301","CPT","0302","RC","","","","both","","","111.00","66.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","77.48","69.8","","74.69","74.69","74.69","1 through 10","13.53","106.86","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 19-9","PX-30000819","CDM","86301","CPT","0302","RC","","","","outpatient","","","111.00","66.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","48.53","43.72","","46.78","46.78","46.78","1 through 10","19.39","85.91","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 19-9","PX-30000819","CDM","86301","CPT","0302","RC","","","","outpatient","","","111.00","66.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","80.72","72.72","","77.81","77.81","77.81","13","19.39","85.91","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 19-9","PX-30000819","CDM","86301","CPT","0302","RC","","","","outpatient","","","111.00","66.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","59.07","53.22","","57.04","57.04","57.04","1 through 10","19.39","85.91","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 19-9","PX-30000819","CDM","86301","CPT","0302","RC","","","","outpatient","","","111.00","66.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","69.82","62.9","","67.41","67.41","259.80","22","19.39","85.91","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 19-9","PX-30000819","CDM","86301","CPT","0302","RC","","","","outpatient","","","111.00","66.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","85.91","77.4","","82.93","82.93","82.93","1 through 10","19.39","85.91","percent of total billed charges",""
"Immunodiffusion Gel Ea Ag Ab Ql","PX-30000834","CDM","86331","CPT","0302","RC","","","","both","","","138.00","82.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","96.32","69.8","","92.83","92.83","92.83","15","7.79","117.3","percent of total billed charges",""
"Immunodiffusion Gel Ea Ag Ab Ql","PX-30000834","CDM","86331","CPT","0302","RC","","","","outpatient","","","138.00","82.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","100.35","72.72","","96.72","96.72","96.72","1 through 10","14.36","106.81","percent of total billed charges",""
"Immunodiffusion Gel Ea Ag Ab Ql","PX-30000834","CDM","86331","CPT","0302","RC","","","","outpatient","","","138.00","82.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","86.80","62.9","","161.43","161.43","161.43","12","14.36","106.81","percent of total billed charges",""
"Immunodiffusion Gel Ea Ag Ab Ql","PX-30000834","CDM","86331","CPT","0302","RC","","","","outpatient","","","138.00","82.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","106.81","77.4","","515.38","515.38","515.38","1 through 10","14.36","106.81","percent of total billed charges",""
"Immunofixation Electroph Other","PX-30000839","CDM","86335","CPT","0302","RC","","","","both","","","202.00","121.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","141.00","69.8","","136.11","136.11","136.11","1 through 10","19.08","171.7","percent of total billed charges",""
"Immunofixation Electroph Other","PX-30000839","CDM","86335","CPT","0302","RC","","","","outpatient","","","202.00","121.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","146.89","72.72","","141.80","141.80","141.80","1 through 10","17.21","156.35","percent of total billed charges",""
"Immunofixation Electroph Other","PX-30000839","CDM","86335","CPT","0302","RC","","","","outpatient","","","202.00","121.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","127.06","62.9","","122.85","122.85","368.55","11","17.21","156.35","percent of total billed charges",""
"Immunofixation Electroph Other","PX-30000839","CDM","86335","CPT","0302","RC","","","","outpatient","","","202.00","121.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","156.35","77.4","","151.13","151.13","151.13","1 through 10","17.21","156.35","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","both","","","122.00","73.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","85.16","69.8","","82.36","82.36","82.36","30","14.52","115.9","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","outpatient","","","122.00","73.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","53.34","43.72","","51.59","51.59","51.59","1 through 10","26.79","94.43","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","outpatient","","","122.00","73.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","88.72","72.72","","85.81","85.81","852.28","17","26.79","94.43","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","outpatient","","","122.00","73.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","64.93","53.22","","62.91","62.91","62.91","1 through 10","26.79","94.43","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","outpatient","","","122.00","73.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","76.74","62.9","","74.34","74.34","223.02","17","26.79","94.43","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","outpatient","","","122.00","73.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","94.43","77.4","","91.45","91.45","91.45","27","26.79","94.43","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","200.00","120.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","139.60","69.8","","134.72","134.72","134.72","69","11.23","170","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","200.00","120.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","113.80","56.9","","109.82","109.82","219.63","105","11.23","170","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","200.00","120.00","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","113.80","56.9","","109.82","109.82","109.82","1 through 10","11.23","170","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","200.00","120.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","28.84","14.42","","15.39","15.39","15.39","1 through 10","23.26","154.8","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","200.00","120.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","23.26","11.63","","15.24","15.24","68.39","36","23.26","154.8","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","200.00","120.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","145.44","72.72","","140.35","140.35","280.70","44","23.26","154.8","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","200.00","120.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","106.44","53.22","","308.67","102.89","308.67","1 through 10","23.26","154.8","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","200.00","120.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","125.80","62.9","","121.59","121.59","364.77","58","23.26","154.8","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","200.00","120.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","154.80","77.4","","149.58","149.58","149.58","63","23.26","154.8","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","200.00","120.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","23.26","11.63","","15.24","15.24","15.24","12","23.26","154.8","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","both","","","43.00","25.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","30.01","69.8","","29.32","29.32","29.32","1 through 10","5.21","42.13","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","outpatient","","","43.00","25.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","31.27","72.72","","30.54","30.54","30.54","21","3.44","33.28","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","outpatient","","","43.00","25.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","27.05","62.9","","26.46","26.46","26.46","28","3.44","33.28","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","outpatient","","","43.00","25.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","33.28","77.4","","32.55","32.55","130.20","1 through 10","3.44","33.28","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","314.00","188.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","219.17","69.8","","578.64","219.17","5260.12","1 through 10","175.45","1144.2","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","314.00","188.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","924.85","","Case rate ($924.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","451.60","451.60","451.60","1 through 10","175.45","1144.2","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","314.00","188.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","184.40","","APC Price ($179.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","180.73","180.73","180.73","1 through 10","175.45","1144.2","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","314.00","188.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","179.03","","APC Price ($179.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","175.57","175.57","175.57","1 through 10","175.45","1144.2","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","314.00","188.40","MEDICARE [2001]","HB WDH MEDICARE","179.03","","APC Price ($179.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","179.05","179.05","179.05","1 through 10","175.45","1144.2","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","314.00","188.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","266.90","85","","237.43","237.43","310.04","14","175.45","1144.2","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","314.00","188.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","179.03","","APC Price ($179.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","175.47","87.74","179.05","1 through 10","175.45","1144.2","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","outpatient","","","314.00","188.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","45.28","14.42","","18.05","18.05","18.05","1 through 10","36.52","243.04","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","outpatient","","","314.00","188.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","197.13","62.78","","591.39","197.13","591.39","14","36.52","243.04","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","outpatient","","","314.00","188.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","137.28","43.72","","137.28","137.28","137.28","1 through 10","36.52","243.04","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","outpatient","","","314.00","188.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","228.34","72.72","","228.34","228.34","685.02","102","36.52","243.04","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","outpatient","","","314.00","188.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","228.34","72.72","","228.34","228.34","228.34","1 through 10","36.52","243.04","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","outpatient","","","314.00","188.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","167.11","53.22","","167.40","167.39","167.40","1 through 10","36.52","243.04","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","outpatient","","","314.00","188.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","197.51","62.9","","197.82","197.82","593.46","153","36.52","243.04","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","outpatient","","","314.00","188.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","243.04","77.4","","243.35","243.35","243.35","41","36.52","243.04","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","outpatient","","","314.00","188.40","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","228.34","72.72","","228.34","228.34","228.34","1 through 10","36.52","243.04","percent of total billed charges",""
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","21055.00","12633.00","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","6993.79","","APC Price ($6,856.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","3428.72","3428.72","3428.72","1 through 10","6719.52","43820.38","other","OPPS APC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","21055.00","12633.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","43820.38","","Case rate ($43,820.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","21375.85","21375.85","21375.85","1 through 10","6719.52","43820.38","other","OPPS APC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","21055.00","12633.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","18869.01","","Case rate ($18,869.01). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9326.01","9204.51","9326.01","1 through 10","6719.52","43820.38","other","OPPS APC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","21055.00","12633.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","6719.52","","APC Price ($6,856.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3428.72","3428.72","6754.58","1 through 10","6719.52","43820.38","other","OPPS APC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","21055.00","12633.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","35419.60","","Case rate ($35,419.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","25413.33","25413.33","25413.33","1 through 10","6719.52","43820.38","other","OPPS APC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","21055.00","12633.00","HARVARD PILGRIM [120001]","HB WDH MEDICARE","6856.66","","APC Price ($6,856.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3269.16","3269.16","3269.16","1 through 10","6719.52","43820.38","other","OPPS APC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","21055.00","12633.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","7062.36","","APC Price ($6,856.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3466.45","3466.45","3466.45","1 through 10","6719.52","43820.38","other","OPPS APC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","21055.00","12633.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","6856.66","","APC Price ($6,856.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3364.10","3362.90","14203.00","1 through 10","6719.52","43820.38","other","OPPS APC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","21055.00","12633.00","MEDICARE [2001]","HB WDH MEDICARE","6856.66","","APC Price ($6,856.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3428.72","3428.72","3428.72","30","6719.52","43820.38","other","OPPS APC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","21055.00","12633.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6856.66","","APC Price ($6,856.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3373.84","3363.65","3428.72","21","6719.52","43820.38","other","OPPS APC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","outpatient","","","21055.00","12633.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","3036.13","14.42","","2298.62","1797.53","2549.17","1 through 10","2448.7","16296.57","percent of total billed charges",""
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","outpatient","","","21055.00","12633.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2448.70","11.63","","5198.61","2486.80","5198.61","14","2448.7","16296.57","percent of total billed charges",""
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","outpatient","","","21055.00","12633.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","29549.04","29549.04","29549.04","1 through 10","2448.7","16296.57","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","outpatient","","","21055.00","12633.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","13243.60","62.9","","12799.71","11456.67","30127.56","1 through 10","2448.7","16296.57","percent of total billed charges",""
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","outpatient","","","21055.00","12633.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2448.70","11.63","","2399.77","2399.77","2703.73","1 through 10","2448.7","16296.57","percent of total billed charges",""
"Impl Elect Neurostim Peripher Perc","PX-76001555","CDM","64555","CPT","0761","RC","","","","both","","","40395.00","24237.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","6719.52","","APC Price ($6,856.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6721.09","4576.72","6725.43","1 through 10","6719.52","43820.38","other","OPPS APC"
"Impl Elect Neurostim Peripher Perc","PX-76001555","CDM","64555","CPT","0761","RC","","","","both","","","40395.00","24237.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","6856.66","","APC Price ($6,856.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6721.19","4576.34","6857.44","1 through 10","6719.52","43820.38","other","OPPS APC"
"Impl Elect Neurostim Peripher Perc","PX-76001555","CDM","64555","CPT","0761","RC","","","","both","","","40395.00","24237.00","MEDICARE [2001]","HB WDH MEDICARE","6856.66","","APC Price ($6,856.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6857.44","6663.68","6857.44","32","6719.52","43820.38","other","OPPS APC"
"Impl Elect Neurostim Peripher Perc","PX-76001555","CDM","64555","CPT","0761","RC","","","","both","","","40395.00","24237.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6856.66","","APC Price ($6,856.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6728.20","4563.60","6750.70","1 through 10","6719.52","43820.38","other","OPPS APC"
"Impl Elect Neurostim Peripher Perc","PX-76001555","CDM","64555","CPT","0761","RC","","","","both","","","40395.00","24237.00","WELLSENSE NH [1050]","HB WDH MEDICARE","6856.66","","APC Price ($6,856.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7063.60","7063.60","7063.60","1 through 10","6719.52","43820.38","other","OPPS APC"
"Impl Elect Neurostim Peripher Perc","PX-76001555","CDM","64555","CPT","0761","RC","","","","outpatient","","","40395.00","24237.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","4697.94","11.63","","4771.15","4771.15","4771.15","1 through 10","4697.94","31265.73","percent of total billed charges",""
"Impl Elect Neurostim Peripher Perc","PX-76001555","CDM","64555","CPT","0761","RC","","","","outpatient","","","40395.00","24237.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","4697.94","11.63","","13812.48","13812.48","13812.48","1 through 10","4697.94","31265.73","percent of total billed charges",""
"IMPLANT 16X10 7 EXCLUDER ENDOPROSTHEIS INTERNAL ILIAC BRANCH HC FA","SUP-ITM-10166187","CDM","C1874","HCPCS","0278","RC","","","","both","","","12439.16","7463.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7077.88","56.9","","4336.72","1572.72","9255.66","15","1446.67","10573.29","percent of total billed charges",""
"IMPLANT 16X10 7 EXCLUDER ENDOPROSTHEIS INTERNAL ILIAC BRANCH HC FA","SUP-ITM-10166187","CDM","C1874","HCPCS","0278","RC","","","","both","","","12439.16","7463.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9627.91","77.4","","2142.10","2142.10","2142.10","1 through 10","1446.67","10573.29","percent of total billed charges",""
"IMPLANT 16X10 7 EXCLUDER ENDOPROSTHEIS INTERNAL ILIAC BRANCH HC FA","SUP-ITM-10166187","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12439.16","7463.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","9045.76","72.72","","2261.23","2261.23","2261.23","1 through 10","1446.67","9627.91","percent of total billed charges",""
"IMPLANT 16X10 7 EXCLUDER ENDOPROSTHEIS INTERNAL ILIAC BRANCH HC FA","SUP-ITM-10166187","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12439.16","7463.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7824.23","62.9","","4353.04","1741.32","8465.73","1 through 10","1446.67","9627.91","percent of total billed charges",""
"IMPLANT 16X10 7 EXCLUDER ENDOPROSTHEIS INTERNAL ILIAC BRANCH HC FA","SUP-ITM-10166187","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12439.16","7463.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9627.91","77.4","","2142.10","2142.10","2142.10","1 through 10","1446.67","9627.91","percent of total billed charges",""
"IMPLANT 48MM SM BODY PROXIMALIMAL COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10123359","CDM","C1776","HCPCS","0278","RC","","","","both","","","10808.62","6485.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1257.04","9187.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"IMPLANT 48MM SM BODY PROXIMALIMAL COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10123359","CDM","C1776","HCPCS","0278","RC","","","","both","","","10808.62","6485.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6150.10","56.9","","2911.53","1863.86","5209.05","65","1257.04","9187.33","percent of total billed charges",""
"IMPLANT 48MM SM BODY PROXIMALIMAL COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10123359","CDM","C1776","HCPCS","0278","RC","","","","both","","","10808.62","6485.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1257.04","11.63","","400.94","400.94","400.94","1 through 10","1257.04","9187.33","percent of total billed charges",""
"IMPLANT 48MM SM BODY PROXIMALIMAL COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10123359","CDM","C1776","HCPCS","0278","RC","","","","both","","","10808.62","6485.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8365.87","77.4","","5214.50","5214.50","16415.28","1 through 10","1257.04","9187.33","percent of total billed charges",""
"IMPLANT 48MM SM BODY PROXIMALIMAL COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10123359","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10808.62","6485.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1257.04","11.63","","400.94","400.94","400.94","1 through 10","1257.04","8365.87","percent of total billed charges",""
"IMPLANT 48MM SM BODY PROXIMALIMAL COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10123359","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10808.62","6485.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4725.53","43.72","","1543.33","1543.33","1671.61","1 through 10","1257.04","8365.87","percent of total billed charges",""
"IMPLANT 48MM SM BODY PROXIMALIMAL COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10123359","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10808.62","6485.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7860.03","72.72","","3700.21","2382.07","6427.18","53","1257.04","8365.87","percent of total billed charges",""
"IMPLANT 48MM SM BODY PROXIMALIMAL COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10123359","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10808.62","6485.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7860.03","72.72","","12685.80","12685.80","12685.80","1 through 10","1257.04","8365.87","percent of total billed charges",""
"IMPLANT 48MM SM BODY PROXIMALIMAL COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10123359","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10808.62","6485.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6798.62","62.9","","3408.87","2784.05","9859.40","46","1257.04","8365.87","percent of total billed charges",""
"IMPLANT 48MM SM BODY PROXIMALIMAL COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10123359","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10808.62","6485.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8365.87","77.4","","5214.50","5214.50","16415.28","1 through 10","1257.04","8365.87","percent of total billed charges",""
"IMPLANT BIODESIGN 2.5X2.5CM OTOLOGIC","SUP-ITM-10215356","CDM","C1763","HCPCS","0278","RC","","","","both","","","2038.45","1223.07","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1159.88","56.9","","1156.60","963.29","1156.60","1 through 10","237.07","1732.68","percent of total billed charges",""
"IMPLANT BIODESIGN 2.5X2.5CM OTOLOGIC","SUP-ITM-10215356","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","2038.45","1223.07","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1482.36","72.72","","8111.92","3502.08","8111.92","1 through 10","237.07","1577.76","percent of total billed charges",""
"IMPLANT BIODESIGN 2.5X2.5CM OTOLOGIC","SUP-ITM-10215356","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","2038.45","1223.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1282.19","62.9","","1066.56","1066.56","1066.56","1 through 10","237.07","1577.76","percent of total billed charges",""
"IMPLANT BIODESIGN 6X9MM OTOLOGIC PRECUT","SUP-ITM-10215357","CDM","C1763","HCPCS","0278","RC","","","","both","","","1692.95","1015.77","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","963.29","56.9","","1156.60","963.29","1156.60","1 through 10","196.89","1439.01","percent of total billed charges",""
"IMPLANT BIODESIGN 6X9MM OTOLOGIC PRECUT","SUP-ITM-10215357","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","1692.95","1015.77","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1231.11","72.72","","8111.92","3502.08","8111.92","1 through 10","196.89","1310.34","percent of total billed charges",""
"IMPLANT BIODESIGN 6X9MM OTOLOGIC PRECUT","SUP-ITM-10215357","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","1692.95","1015.77","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1064.87","62.9","","1066.56","1066.56","1066.56","1 through 10","196.89","1310.34","percent of total billed charges",""
"IMPLANT EAR .84X4MM RICHARDS OFF CENTERED TORP HYDROXYLAPATITE","SUP-ITM-10237288","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","2308.84","1385.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1452.26","62.9","","2038.65","2038.65","2038.65","1 through 10","1228.76","1787.04","percent of total billed charges",""
"IMPLANT EAR .8X8MM OSSICULAR TORP GOLDENBERG HYDROXYLAPATITE","SUP-ITM-10019420","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","2735.12","1641.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1720.39","62.9","","2038.65","2038.65","2038.65","1 through 10","1455.63","2116.98","percent of total billed charges",""
"IMPLANT EAR .9X7.3X6.1X1.6X3.5MM MED WEHRS II INCUS STAPES DOUBLE NOTCH HYDROXYLAPATITE","SUP-ITM-10214801","CDM","L8613","HCPCS","0278","RC","","","","outpatient","","","2402.40","1441.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1511.11","62.9","","2038.65","2038.65","2038.65","1 through 10","1278.56","1859.46","percent of total billed charges",""
"IMPLANT EAR 1.17X4X4.75MM PORP MYRINGOTOMY PARTIAL CANNULATED","SUP-ITM-10237298","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","1456.01","873.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","915.83","62.9","","2038.65","2038.65","2038.65","1 through 10","774.89","1126.95","percent of total billed charges",""
"IMPLANT EAR 3.2X2X3MM DORNHOFFER INTERPOSITIONAL PORP HYDROXYLAPATITE HEAD TI SHAFT","SUP-ITM-10237280","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","2095.60","1257.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1318.13","62.9","","2038.65","2038.65","2038.65","1 through 10","1115.28","1621.99","percent of total billed charges",""
"IMPLANT EAR 4X1.17X5.1MM RICHARDS CENTERED PORP HYDROXYLAPATITE","SUP-ITM-10214796","CDM","L8613","HCPCS","0278","RC","","","","outpatient","","","2308.84","1385.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1452.26","62.9","","2038.65","2038.65","2038.65","1 through 10","1228.76","1787.04","percent of total billed charges",""
"IMPLANT EYE 14MM SPHERE ORBITAL STERILE SILICONE","SUP-ITM-10216889","CDM","C1713","HCPCS","0278","RC","","","","both","","","449.15","269.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","52.24","381.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"IMPLANT EYE 14MM SPHERE ORBITAL STERILE SILICONE","SUP-ITM-10216889","CDM","C1713","HCPCS","0278","RC","","","","both","","","449.15","269.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","52.24","381.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"IMPLANT EYE 14MM SPHERE ORBITAL STERILE SILICONE","SUP-ITM-10216889","CDM","C1713","HCPCS","0278","RC","","","","both","","","449.15","269.49","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","255.57","56.9","","812.12","238.65","1587.46","163","52.24","381.78","percent of total billed charges",""
"IMPLANT EYE 14MM SPHERE ORBITAL STERILE SILICONE","SUP-ITM-10216889","CDM","C1713","HCPCS","0278","RC","","","","both","","","449.15","269.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","52.24","11.63","","112.68","112.68","146.99","38","52.24","381.78","percent of total billed charges",""
"IMPLANT EYE 14MM SPHERE ORBITAL STERILE SILICONE","SUP-ITM-10216889","CDM","C1713","HCPCS","0278","RC","","","","both","","","449.15","269.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","347.64","77.4","","303.98","303.98","5854.79","1 through 10","52.24","381.78","percent of total billed charges",""
"IMPLANT EYE 14MM SPHERE ORBITAL STERILE SILICONE","SUP-ITM-10216889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","449.15","269.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","52.24","11.63","","112.68","112.68","146.99","38","52.24","347.64","percent of total billed charges",""
"IMPLANT EYE 14MM SPHERE ORBITAL STERILE SILICONE","SUP-ITM-10216889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","449.15","269.49","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","281.98","62.78","","780.86","208.94","10480.28","15","52.24","347.64","percent of total billed charges",""
"IMPLANT EYE 14MM SPHERE ORBITAL STERILE SILICONE","SUP-ITM-10216889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","449.15","269.49","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","196.37","43.72","","179.76","179.76","179.76","1 through 10","52.24","347.64","percent of total billed charges",""
"IMPLANT EYE 14MM SPHERE ORBITAL STERILE SILICONE","SUP-ITM-10216889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","449.15","269.49","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","326.62","72.72","","2355.45","298.99","3965.19","155","52.24","347.64","percent of total billed charges",""
"IMPLANT EYE 14MM SPHERE ORBITAL STERILE SILICONE","SUP-ITM-10216889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","449.15","269.49","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","326.62","72.72","","3643.09","3643.09","3643.09","1 through 10","52.24","347.64","percent of total billed charges",""
"IMPLANT EYE 14MM SPHERE ORBITAL STERILE SILICONE","SUP-ITM-10216889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","449.15","269.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","239.04","53.22","","554.28","554.28","554.28","16","52.24","347.64","percent of total billed charges",""
"IMPLANT EYE 14MM SPHERE ORBITAL STERILE SILICONE","SUP-ITM-10216889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","449.15","269.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","282.52","62.9","","619.64","173.09","2370.64","150","52.24","347.64","percent of total billed charges",""
"IMPLANT EYE 14MM SPHERE ORBITAL STERILE SILICONE","SUP-ITM-10216889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","449.15","269.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","347.64","77.4","","303.98","303.98","5854.79","1 through 10","52.24","347.64","percent of total billed charges",""
"IMPLANT FIBERSTITCH RC STRAIGHT","SUP-ITM-10319758","CDM","C1713","HCPCS","0278","RC","","","","both","","","3420.45","2052.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","397.8","2907.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"IMPLANT FIBERSTITCH RC STRAIGHT","SUP-ITM-10319758","CDM","C1713","HCPCS","0278","RC","","","","both","","","3420.45","2052.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","397.8","2907.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"IMPLANT FIBERSTITCH RC STRAIGHT","SUP-ITM-10319758","CDM","C1713","HCPCS","0278","RC","","","","both","","","3420.45","2052.27","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1946.24","56.9","","812.12","238.65","1587.46","163","397.8","2907.38","percent of total billed charges",""
"IMPLANT FIBERSTITCH RC STRAIGHT","SUP-ITM-10319758","CDM","C1713","HCPCS","0278","RC","","","","both","","","3420.45","2052.27","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","397.80","11.63","","112.68","112.68","146.99","38","397.8","2907.38","percent of total billed charges",""
"IMPLANT FIBERSTITCH RC STRAIGHT","SUP-ITM-10319758","CDM","C1713","HCPCS","0278","RC","","","","both","","","3420.45","2052.27","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2647.43","77.4","","303.98","303.98","5854.79","1 through 10","397.8","2907.38","percent of total billed charges",""
"IMPLANT FIBERSTITCH RC STRAIGHT","SUP-ITM-10319758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3420.45","2052.27","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","397.80","11.63","","112.68","112.68","146.99","38","397.8","2647.43","percent of total billed charges",""
"IMPLANT FIBERSTITCH RC STRAIGHT","SUP-ITM-10319758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3420.45","2052.27","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2147.36","62.78","","780.86","208.94","10480.28","15","397.8","2647.43","percent of total billed charges",""
"IMPLANT FIBERSTITCH RC STRAIGHT","SUP-ITM-10319758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3420.45","2052.27","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1495.42","43.72","","179.76","179.76","179.76","1 through 10","397.8","2647.43","percent of total billed charges",""
"IMPLANT FIBERSTITCH RC STRAIGHT","SUP-ITM-10319758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3420.45","2052.27","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2487.35","72.72","","2355.45","298.99","3965.19","155","397.8","2647.43","percent of total billed charges",""
"IMPLANT FIBERSTITCH RC STRAIGHT","SUP-ITM-10319758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3420.45","2052.27","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2487.35","72.72","","3643.09","3643.09","3643.09","1 through 10","397.8","2647.43","percent of total billed charges",""
"IMPLANT FIBERSTITCH RC STRAIGHT","SUP-ITM-10319758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3420.45","2052.27","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1820.36","53.22","","554.28","554.28","554.28","16","397.8","2647.43","percent of total billed charges",""
"IMPLANT FIBERSTITCH RC STRAIGHT","SUP-ITM-10319758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3420.45","2052.27","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2151.46","62.9","","619.64","173.09","2370.64","150","397.8","2647.43","percent of total billed charges",""
"IMPLANT FIBERSTITCH RC STRAIGHT","SUP-ITM-10319758","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3420.45","2052.27","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2647.43","77.4","","303.98","303.98","5854.79","1 through 10","397.8","2647.43","percent of total billed charges",""
"IMPLANT FIXATION G-LOK NO LOOP CORTICAL SUSPENSION","SUP-ITM-10191523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.60","1353.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","262.44","1918.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"IMPLANT FIXATION G-LOK NO LOOP CORTICAL SUSPENSION","SUP-ITM-10191523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.60","1353.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","262.44","1918.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"IMPLANT FIXATION G-LOK NO LOOP CORTICAL SUSPENSION","SUP-ITM-10191523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.60","1353.96","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1284.01","56.9","","812.12","238.65","1587.46","163","262.44","1918.11","percent of total billed charges",""
"IMPLANT FIXATION G-LOK NO LOOP CORTICAL SUSPENSION","SUP-ITM-10191523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.60","1353.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","262.44","11.63","","112.68","112.68","146.99","38","262.44","1918.11","percent of total billed charges",""
"IMPLANT FIXATION G-LOK NO LOOP CORTICAL SUSPENSION","SUP-ITM-10191523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.60","1353.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1746.61","77.4","","303.98","303.98","5854.79","1 through 10","262.44","1918.11","percent of total billed charges",""
"IMPLANT FIXATION G-LOK NO LOOP CORTICAL SUSPENSION","SUP-ITM-10191523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2256.60","1353.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","262.44","11.63","","112.68","112.68","146.99","38","262.44","1746.61","percent of total billed charges",""
"IMPLANT FIXATION G-LOK NO LOOP CORTICAL SUSPENSION","SUP-ITM-10191523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2256.60","1353.96","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1416.69","62.78","","780.86","208.94","10480.28","15","262.44","1746.61","percent of total billed charges",""
"IMPLANT FIXATION G-LOK NO LOOP CORTICAL SUSPENSION","SUP-ITM-10191523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2256.60","1353.96","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","986.59","43.72","","179.76","179.76","179.76","1 through 10","262.44","1746.61","percent of total billed charges",""
"IMPLANT FIXATION G-LOK NO LOOP CORTICAL SUSPENSION","SUP-ITM-10191523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2256.60","1353.96","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1641.00","72.72","","2355.45","298.99","3965.19","155","262.44","1746.61","percent of total billed charges",""
"IMPLANT FIXATION G-LOK NO LOOP CORTICAL SUSPENSION","SUP-ITM-10191523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2256.60","1353.96","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1641.00","72.72","","3643.09","3643.09","3643.09","1 through 10","262.44","1746.61","percent of total billed charges",""
"IMPLANT FIXATION G-LOK NO LOOP CORTICAL SUSPENSION","SUP-ITM-10191523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2256.60","1353.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1200.96","53.22","","554.28","554.28","554.28","16","262.44","1746.61","percent of total billed charges",""
"IMPLANT FIXATION G-LOK NO LOOP CORTICAL SUSPENSION","SUP-ITM-10191523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2256.60","1353.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1419.40","62.9","","619.64","173.09","2370.64","150","262.44","1746.61","percent of total billed charges",""
"IMPLANT FIXATION G-LOK NO LOOP CORTICAL SUSPENSION","SUP-ITM-10191523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2256.60","1353.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1746.61","77.4","","303.98","303.98","5854.79","1 through 10","262.44","1746.61","percent of total billed charges",""
"IMPLANT GENERATOR INTRSTM PLS NEUROSTIMULATORX 97800 X INCONTINENCE","SUP-ITM-10295475","CDM","C1820","HCPCS","0278","RC","","","","both","","","26491.00","15894.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","52982.00","26491.00","52982.00","1 through 10","3080.9","22517.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"IMPLANT GENERATOR INTRSTM PLS NEUROSTIMULATORX 97800 X INCONTINENCE","SUP-ITM-10295475","CDM","C1820","HCPCS","0278","RC","","","","both","","","26491.00","15894.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","15073.38","56.9","","45220.14","36256.68","45220.14","1 through 10","3080.9","22517.35","percent of total billed charges",""
"IMPLANT GENERATOR INTRSTM PLS NEUROSTIMULATORX 97800 X INCONTINENCE","SUP-ITM-10295475","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","26491.00","15894.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","19264.26","72.72","","18421.60","18421.60","18421.60","1 through 10","3080.9","20504.03","percent of total billed charges",""
"IMPLANT MESH LG REGENETEN BIOINDUCTIVE WITH DELIVERY SYSTEM","SUP-ITM-10261483","CDM","C1763","HCPCS","0278","RC","","","","both","","","11155.00","6693.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6347.20","56.9","","1156.60","963.29","1156.60","1 through 10","1297.33","9481.75","percent of total billed charges",""
"IMPLANT MESH LG REGENETEN BIOINDUCTIVE WITH DELIVERY SYSTEM","SUP-ITM-10261483","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","11155.00","6693.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8111.92","72.72","","8111.92","3502.08","8111.92","1 through 10","1297.33","8633.97","percent of total billed charges",""
"IMPLANT MESH LG REGENETEN BIOINDUCTIVE WITH DELIVERY SYSTEM","SUP-ITM-10261483","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","11155.00","6693.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7016.50","62.9","","1066.56","1066.56","1066.56","1 through 10","1297.33","8633.97","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","7250.75","4350.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","843.26","6163.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","7250.75","4350.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","843.26","6163.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","7250.75","4350.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4125.68","56.9","","812.12","238.65","1587.46","163","843.26","6163.14","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","7250.75","4350.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","843.26","11.63","","112.68","112.68","146.99","38","843.26","6163.14","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","7250.75","4350.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5612.08","77.4","","303.98","303.98","5854.79","1 through 10","843.26","6163.14","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","843.26","11.63","","112.68","112.68","146.99","38","843.26","5612.08","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4552.02","62.78","","780.86","208.94","10480.28","15","843.26","5612.08","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3170.03","43.72","","179.76","179.76","179.76","1 through 10","843.26","5612.08","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5272.75","72.72","","2355.45","298.99","3965.19","155","843.26","5612.08","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5272.75","72.72","","3643.09","3643.09","3643.09","1 through 10","843.26","5612.08","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3858.85","53.22","","554.28","554.28","554.28","16","843.26","5612.08","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4560.72","62.9","","619.64","173.09","2370.64","150","843.26","5612.08","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5612.08","77.4","","303.98","303.98","5854.79","1 through 10","843.26","5612.08","percent of total billed charges",""
"IMPLANT TCS 8MM SM LORDOTIC ENDO","SUP-ITM-10258321","CDM","C1889","HCPCS","0278","RC","","","","both","","","7881.25","4728.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","916.59","6699.06","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"IMPLANT TCS 8MM SM LORDOTIC ENDO","SUP-ITM-10258321","CDM","C1889","HCPCS","0278","RC","","","","both","","","7881.25","4728.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","916.59","6699.06","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"IMPLANT TCS 8MM SM LORDOTIC ENDO","SUP-ITM-10258321","CDM","C1889","HCPCS","0278","RC","","","","both","","","7881.25","4728.75","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4484.43","56.9","","0.63","0.63","0.63","1 through 10","916.59","6699.06","percent of total billed charges",""
"IMPLANT TCS 8MM SM LORDOTIC ENDO","SUP-ITM-10258321","CDM","C1889","HCPCS","0278","RC","","","","both","","","7881.25","4728.75","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1136.48","14.42","","317.14","317.14","317.14","1 through 10","916.59","6699.06","percent of total billed charges",""
"IMPLANT TCS 8MM SM LORDOTIC ENDO","SUP-ITM-10258321","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7881.25","4728.75","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1136.48","14.42","","317.14","317.14","317.14","1 through 10","916.59","6100.09","percent of total billed charges",""
"IMPLANT TCS 8MM SM LORDOTIC ENDO","SUP-ITM-10258321","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7881.25","4728.75","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4947.85","62.78","","1125.09","1125.09","1125.09","1 through 10","916.59","6100.09","percent of total billed charges",""
"IMPLANT TCS 8MM SM LORDOTIC ENDO","SUP-ITM-10258321","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7881.25","4728.75","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5731.25","72.72","","4732.50","1617.43","14180.40","1 through 10","916.59","6100.09","percent of total billed charges",""
"IMPLANT TCS 8MM SM LORDOTIC ENDO","SUP-ITM-10258321","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7881.25","4728.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4957.31","62.9","","3896.20","3341.38","3896.20","1 through 10","916.59","6100.09","percent of total billed charges",""
"IMPLANT TENDON REGENETEN COLLAGEN ROTATOR CUFF WITH DELIVERY SYSTEM MEDIUM","SUP-ITM-10269007","CDM","C1763","HCPCS","0278","RC","","","","both","","","11155.00","6693.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6347.20","56.9","","1156.60","963.29","1156.60","1 through 10","1297.33","9481.75","percent of total billed charges",""
"IMPLANT TENDON REGENETEN COLLAGEN ROTATOR CUFF WITH DELIVERY SYSTEM MEDIUM","SUP-ITM-10269007","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","11155.00","6693.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8111.92","72.72","","8111.92","3502.08","8111.92","1 through 10","1297.33","8633.97","percent of total billed charges",""
"IMPLANT TENDON REGENETEN COLLAGEN ROTATOR CUFF WITH DELIVERY SYSTEM MEDIUM","SUP-ITM-10269007","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","11155.00","6693.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7016.50","62.9","","1066.56","1066.56","1066.56","1 through 10","1297.33","8633.97","percent of total billed charges",""
"Inc Hemorrhoid External","PX-75000214","CDM","46083","CPT","0761","RC","","","","both","","","1043.00","625.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","593.47","56.9","","269.58","269.58","269.58","1 through 10","114.94","1623.9","percent of total billed charges",""
"Incision/Remove FB Subq Smp","PX-76000008","CDM","10120","CPT","0761","RC","","","","both","","","1076.00","645.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","751.05","69.8","","493.49","493.49","493.49","1 through 10","108.44","2667.66","percent of total billed charges",""
"Incision/Remove FB Subq Smp","PX-76000008","CDM","10120","CPT","0761","RC","","","","both","","","1076.00","645.60","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","425.76","","APC Price ($417.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","417.46","417.46","417.46","1 through 10","108.44","2667.66","other","OPPS APC"
"Incision/Remove FB Subq Smp","PX-76000008","CDM","10120","CPT","0761","RC","","","","both","","","1076.00","645.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","612.24","56.9","","337.69","281.15","445.63","1 through 10","108.44","2667.66","percent of total billed charges",""
"Incision/Remove FB Subq Smp","PX-76000008","CDM","10120","CPT","0761","RC","","","","both","","","1076.00","645.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","155.16","14.42","","101.95","87.39","101.95","1 through 10","108.44","2667.66","percent of total billed charges",""
"Incision/Remove FB Subq Smp","PX-76000008","CDM","10120","CPT","0761","RC","","","","outpatient","","","1076.00","645.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","125.14","11.63","","86.54","83.51","86.54","1 through 10","125.14","125.14","percent of total billed charges",""
"Incision/Remove FB Subq Smp","PX-76000008","CDM","10120","CPT","0761","RC","","","","outpatient","","","1076.00","645.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","125.14","11.63","","83.51","83.51","654.58","1 through 10","125.14","125.14","percent of total billed charges",""
"Incisional Biopsy Skin Single Lesion","PX-76002569","CDM","11106","CPT","0761","RC","","","","both","","","2111.00","1266.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1759.93","","Case rate ($1,759.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1712.85","1712.85","1712.85","1 through 10","626.74","4087.16","other","OPPS APC"
"Incisional Biopsy Skin Single Lesion","PX-76002569","CDM","11106","CPT","0761","RC","","","","both","","","2111.00","1266.60","MEDICARE [2001]","HB WDH MEDICARE","639.53","","APC Price ($639.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","639.60","639.60","639.60","1 through 10","626.74","4087.16","other","OPPS APC"
"Incisional Biopsy Skin Single Lesion","PX-76002569","CDM","11106","CPT","0761","RC","","","","outpatient","","","2111.00","1266.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1327.82","62.9","","3849.93","3849.93","4760.28","1 through 10","1123.47","1633.91","percent of total billed charges",""
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","","","","inpatient","","","30156.63","18093.98","MEDICARE [2001]","HB WDH MEDICARE","7887.66","","Case rate ($7,887.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,314.48, add-ons for qualifying new technology services are included. If operating cost exceeds $11,232.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,348.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $6,898.91 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,869.61 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $543.88. The transfer capital threshold is the transfer adjustment factor * $543.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","0.05","1 through 10","3975","37202.1","other","Inpatient DRG"
"Infections, Female Reproductive System With McC","757","MS-DRG","","","","","","","","inpatient","","","54514.29","32708.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","11104.17","","Case rate ($11,330.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,492.46, add-ons for qualifying new technology services are included. If operating cost exceeds $14,410.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,600.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $10,090.44 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,047.59 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $795.48. The transfer capital threshold is the transfer adjustment factor * $795.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10901.53","10901.53","10901.53","1 through 10","3975","54412.34","other","Inpatient DRG"
"Infectious Agent Dna Detection for Central Nervous Syst Pathogen 12-25 Targets","PX-30003344","CDM","87483","CPT","0306","RC","","","","both","","","4792.00","2875.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","3344.82","69.8","","3234.53","3234.53","3234.53","1 through 10","270.91","4073.2","percent of total billed charges",""
"Infectious Agent Dna Detection for Central Nervous Syst Pathogen 12-25 Targets","PX-30003344","CDM","87483","CPT","0306","RC","","","","outpatient","","","4792.00","2875.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3484.74","72.72","","3369.84","3369.84","3369.84","1 through 10","557.31","3709.01","percent of total billed charges",""
"Infectious Agent Dna Detection for Central Nervous Syst Pathogen 12-25 Targets","PX-30003344","CDM","87483","CPT","0306","RC","","","","outpatient","","","4792.00","2875.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","557.31","11.63","","255.07","255.07","255.07","1 through 10","557.31","3709.01","percent of total billed charges",""
"Infectious Agent Dna/Rna Influenza 1st 2 Types","PX-30001285","CDM","87502","CPT","0300","RC","","","","inpatient","","","585.00","351.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","449.63","76.86","","356.58","342.42","684.84","1 through 10","387.27","449.63","percent of total billed charges",""
"Infectious Agent Dna/Rna Influenza 1st 2 Types","PX-30001285","CDM","87502","CPT","0306","RC","","","","both","","","585.00","351.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","408.33","69.8","","395.07","352.46","395.07","14","95.8","497.25","percent of total billed charges",""
"Infectious Agent Dna/Rna Influenza 1st 2 Types","PX-30001285","CDM","87502","CPT","0306","RC","","","","both","","","585.00","351.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","408.33","69.8","","395.07","395.07","395.07","1 through 10","95.8","497.25","percent of total billed charges",""
"Infectious Agent Dna/Rna Influenza 1st 2 Types","PX-30001285","CDM","87502","CPT","0306","RC","","","","both","","","585.00","351.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","497.25","85","","481.10","481.10","481.10","1 through 10","95.8","497.25","percent of total billed charges",""
"Infectious Agent Dna/Rna Influenza 1st 2 Types","PX-30001285","CDM","87502","CPT","0306","RC","","","","outpatient","","","585.00","351.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","255.76","43.72","","742.38","742.38","742.38","1 through 10","51.46","452.79","percent of total billed charges",""
"Infectious Agent Dna/Rna Influenza 1st 2 Types","PX-30001285","CDM","87502","CPT","0306","RC","","","","outpatient","","","585.00","351.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","425.41","72.72","","411.60","411.60","792.46","15","51.46","452.79","percent of total billed charges",""
"Infectious Agent Dna/Rna Influenza 1st 2 Types","PX-30001285","CDM","87502","CPT","0306","RC","","","","outpatient","","","585.00","351.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","425.41","72.72","","823.20","823.20","823.20","1 through 10","51.46","452.79","percent of total billed charges",""
"Infectious Agent Dna/Rna Influenza 1st 2 Types","PX-30001285","CDM","87502","CPT","0306","RC","","","","outpatient","","","585.00","351.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","367.97","62.9","","684.84","356.58","1331.84","22","51.46","452.79","percent of total billed charges",""
"Infectious Agent Dna/Rna Influenza 1st 2 Types","PX-30001285","CDM","87502","CPT","0306","RC","","","","outpatient","","","585.00","351.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","452.79","77.4","","438.65","421.37","438.65","1 through 10","51.46","452.79","percent of total billed charges",""
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","","","","inpatient","","","45220.54","27132.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","75928.00","","Fee schedule rate ($75,928.00). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","44104.16","44104.16","44104.16","1 through 10","3975","75928","case rate",""
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","","","","inpatient","","","45220.54","27132.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","29897.33","","Fee schedule rate ($29,897.33). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","29168.12","29168.12","29168.12","1 through 10","3975","75928","case rate",""
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","","","","inpatient","","","45220.54","27132.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","15322.58","","Case rate ($15,635.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,465.46, add-ons for qualifying new technology services are included. If operating cost exceeds $18,383.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,915.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $14,080.39 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,020.60 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,110.03. The transfer capital threshold is the transfer adjustment factor * $1,110.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15243.78","15243.78","15243.78","1 through 10","3975","75928","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","","","","inpatient","","","45220.54","27132.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","60473.06","","Fee schedule rate ($60,473.06). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","42930.34","42930.34","42930.34","1 through 10","3975","75928","case rate",""
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","","","","inpatient","","","45220.54","27132.32","MARTIN'S POINT [160007]","HB WDH MEDICARE","15635.29","","Case rate ($15,635.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,465.46, add-ons for qualifying new technology services are included. If operating cost exceeds $18,383.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,915.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $14,080.39 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,020.60 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,110.03. The transfer capital threshold is the transfer adjustment factor * $1,110.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15241.14","15241.14","15258.74","1 through 10","3975","75928","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","","","","inpatient","","","45220.54","27132.32","MEDICARE [2001]","HB WDH MEDICARE","15635.29","","Case rate ($15,635.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,465.46, add-ons for qualifying new technology services are included. If operating cost exceeds $18,383.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,915.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $14,080.39 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,020.60 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,110.03. The transfer capital threshold is the transfer adjustment factor * $1,110.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","15560.85","1 through 10","3975","75928","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","","","","inpatient","","","45220.54","27132.32","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","15635.29","","Case rate ($15,635.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,465.46, add-ons for qualifying new technology services are included. If operating cost exceeds $18,383.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,915.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $14,080.39 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,020.60 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,110.03. The transfer capital threshold is the transfer adjustment factor * $1,110.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10382.31","10382.31","15289.14","1 through 10","3975","75928","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","116867.16","70120.30","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","38750.07","","Case rate ($37,990.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $35,098.85, add-ons for qualifying new technology services are included. If operating cost exceeds $39,017.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,548.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $34,801.78 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $34,653.98 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,743.61. The transfer capital threshold is the transfer adjustment factor * $2,743.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","38182.34","38182.34","38182.34","1 through 10","4637","187667.29","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","116867.16","70120.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","37230.45","","Case rate ($37,990.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $35,098.85, add-ons for qualifying new technology services are included. If operating cost exceeds $39,017.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,548.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $34,801.78 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $34,653.98 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,743.61. The transfer capital threshold is the transfer adjustment factor * $2,743.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","37452.26","37452.26","37515.11","1 through 10","4637","187667.29","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","116867.16","70120.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","149468.11","","Fee schedule rate ($149,468.11). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","115974.87","115974.87","115974.87","1 through 10","4637","187667.29","case rate",""
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","116867.16","70120.30","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","39129.97","","Case rate ($37,990.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $35,098.85, add-ons for qualifying new technology services are included. If operating cost exceeds $39,017.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,548.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $34,801.78 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $34,653.98 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,743.61. The transfer capital threshold is the transfer adjustment factor * $2,743.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","73166.66","73166.66","73166.66","1 through 10","4637","187667.29","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","116867.16","70120.30","MARTIN'S POINT [160007]","HB WDH MEDICARE","37990.26","","Case rate ($37,990.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $35,098.85, add-ons for qualifying new technology services are included. If operating cost exceeds $39,017.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,548.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $34,801.78 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $34,653.98 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,743.61. The transfer capital threshold is the transfer adjustment factor * $2,743.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","37471.24","35210.32","37567.61","1 through 10","4637","187667.29","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","116867.16","70120.30","MEDICARE [2001]","HB WDH MEDICARE","37990.26","","Case rate ($37,990.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $35,098.85, add-ons for qualifying new technology services are included. If operating cost exceeds $39,017.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,548.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $34,801.78 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $34,653.98 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,743.61. The transfer capital threshold is the transfer adjustment factor * $2,743.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27963.05","0.05","38280.72","26","4637","187667.29","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","116867.16","70120.30","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","37990.26","","Case rate ($37,990.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $35,098.85, add-ons for qualifying new technology services are included. If operating cost exceeds $39,017.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,548.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $34,801.78 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $34,653.98 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,743.61. The transfer capital threshold is the transfer adjustment factor * $2,743.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14690.59","12039.95","37463.75","1 through 10","4637","187667.29","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","116867.16","70120.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","101191.91","","Fee schedule rate ($101,191.91). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","102476.64","102476.64","102476.64","1 through 10","4637","187667.29","case rate",""
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","116867.16","70120.30","WELLSENSE NH [1050]","HB WDH MEDICARE","37990.26","","Case rate ($37,990.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $35,098.85, add-ons for qualifying new technology services are included. If operating cost exceeds $39,017.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,548.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $34,801.78 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $34,653.98 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,743.61. The transfer capital threshold is the transfer adjustment factor * $2,743.61. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","75155.90","75155.90","75155.90","1 through 10","4637","187667.29","other","Inpatient DRG"
"Inflammation Of The Male Reproductive System With McC","727","MS-DRG","","","","","","","","inpatient","","","28020.73","16812.44","MEDICARE [2001]","HB WDH MEDICARE","11718.52","","Case rate ($11,718.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,850.32, add-ons for qualifying new technology services are included. If operating cost exceeds $14,768.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,628.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,449.84 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,405.46 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $823.82. The transfer capital threshold is the transfer adjustment factor * $823.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11561.12","11561.12","11561.12","1 through 10","3975","56350.35","other","Inpatient DRG"
"Inflammation Of The Male Reproductive System Without McC","728","MS-DRG","","","","","","","","inpatient","","","26030.24","15618.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","24551.20","","Fee schedule rate ($24,551.20). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","24126.59","24126.59","24126.59","1 through 10","3975","30825.68","case rate",""
"Inflammation Of The Male Reproductive System Without McC","728","MS-DRG","","","","","","","","inpatient","","","26030.24","15618.14","MEDICARE [2001]","HB WDH MEDICARE","6611.97","","Case rate ($6,611.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,137.03, add-ons for qualifying new technology services are included. If operating cost exceeds $10,055.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,255.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,716.44 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,692.16 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $450.66. The transfer capital threshold is the transfer adjustment factor * $450.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6610.26","6610.26","6610.26","1 through 10","3975","30825.68","other","Inpatient DRG"
"Inflammation Of The Male Reproductive System Without McC","728","MS-DRG","","","","","","","","inpatient","","","26030.24","15618.14","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6611.97","","Case rate ($6,611.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,137.03, add-ons for qualifying new technology services are included. If operating cost exceeds $10,055.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,255.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $5,716.44 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,692.16 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $450.66. The transfer capital threshold is the transfer adjustment factor * $450.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6610.26","6610.26","6610.26","1 through 10","3975","30825.68","other","Inpatient DRG"
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","","","","inpatient","","","28575.18","17145.11","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","7709.79","","Case rate ($7,867.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,295.53, add-ons for qualifying new technology services are included. If operating cost exceeds $11,213.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,347.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,879.88 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,850.66 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.38. The transfer capital threshold is the transfer adjustment factor * $542.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7794.19","7794.19","7933.74","1 through 10","3975","37099.5","other","Inpatient DRG"
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","","","","inpatient","","","28575.18","17145.11","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","29547.99","","Fee schedule rate ($29,547.99). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","17238.61","17238.61","17238.61","1 through 10","3975","37099.5","case rate",""
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","","","","inpatient","","","28575.18","17145.11","MEDICARE [2001]","HB WDH MEDICARE","7867.13","","Case rate ($7,867.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,295.53, add-ons for qualifying new technology services are included. If operating cost exceeds $11,213.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,347.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,879.88 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,850.66 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.38. The transfer capital threshold is the transfer adjustment factor * $542.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","7953.26","1 through 10","3975","37099.5","other","Inpatient DRG"
"Inflammatory Bowel Disease With McC","385","MS-DRG","","","","","","","","inpatient","","","43024.31","25814.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","60127.56","","Fee schedule rate ($60,127.56). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","19604.71","19604.71","19604.71","1 through 10","3975","60127.56","case rate",""
"Inflammatory Bowel Disease With McC","385","MS-DRG","","","","","","","","inpatient","","","43024.31","25814.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","47888.75","","Fee schedule rate ($47,888.75). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","43523.81","43523.81","43523.81","1 through 10","3975","60127.56","case rate",""
"Inflammatory Bowel Disease With McC","385","MS-DRG","","","","","","","","inpatient","","","43024.31","25814.59","MEDICARE [2001]","HB WDH MEDICARE","12474.20","","Case rate ($12,474.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,547.82, add-ons for qualifying new technology services are included. If operating cost exceeds $15,466.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,684.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,150.30 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,102.94 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $879.04. The transfer capital threshold is the transfer adjustment factor * $879.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12704.81","12704.81","12704.81","1 through 10","3975","60127.56","other","Inpatient DRG"
"Inflammatory Bowel Disease With McC","385","MS-DRG","","","","","","","","inpatient","","","43024.31","25814.59","TRICARE [160005]","HB WDH MEDICARE","12474.20","","Case rate ($12,474.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,547.82, add-ons for qualifying new technology services are included. If operating cost exceeds $15,466.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,684.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,150.30 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,102.94 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $879.04. The transfer capital threshold is the transfer adjustment factor * $879.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5486.80","1486.26","11796.62","1 through 10","3975","60127.56","other","Inpatient DRG"
"Inflammatory Bowel Disease Without Cc/McC","387","MS-DRG","","","","","","","","inpatient","","","30838.34","18503.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","25889.47","","Fee schedule rate ($25,889.47). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","24850.21","24850.21","24850.21","1 through 10","3975","25889.47","case rate",""
"Inflammatory Bowel Disease Without Cc/McC","387","MS-DRG","","","","","","","","inpatient","","","30838.34","18503.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","10194.21","","Fee schedule rate ($10,194.21). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","9784.99","9784.99","9784.99","1 through 10","3975","25889.47","case rate",""
"Inflammatory Bowel Disease Without Cc/McC","387","MS-DRG","","","","","","","","inpatient","","","30838.34","18503.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","20619.74","","Fee schedule rate ($20,619.74). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","19792.01","19792.01","19792.01","1 through 10","3975","25889.47","case rate",""
"Inflammatory Bowel Disease Without Cc/McC","387","MS-DRG","","","","","","","","inpatient","","","30838.34","18503.00","MEDICARE [2001]","HB WDH MEDICARE","5624.41","","Case rate ($5,624.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,225.53, add-ons for qualifying new technology services are included. If operating cost exceeds $9,143.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,183.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,801.05 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,780.66 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.49. The transfer capital threshold is the transfer adjustment factor * $378.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5515.74","5515.74","5515.74","1 through 10","3975","25889.47","other","Inpatient DRG"
"Inflammatory Bowel Disease Without Cc/McC","387","MS-DRG","","","","","","","","inpatient","","","30838.34","18503.00","TRICARE [160005]","HB WDH MEDICARE","5624.41","","Case rate ($5,624.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,225.53, add-ons for qualifying new technology services are included. If operating cost exceeds $9,143.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,183.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $4,801.05 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,780.66 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.49. The transfer capital threshold is the transfer adjustment factor * $378.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","860.77","860.77","860.77","1 through 10","3975","25889.47","other","Inpatient DRG"
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","","","","inpatient","","","61780.01","37068.01","MEDICARE [2001]","HB WDH MEDICARE","12034.78","","Case rate ($12,034.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,142.23, add-ons for qualifying new technology services are included. If operating cost exceeds $15,060.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,651.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $10,742.99 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,697.36 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $846.93. The transfer capital threshold is the transfer adjustment factor * $846.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","0.05","1 through 10","3975","57931.15","other","Inpatient DRG"
"Inguinal And Femoral Hernia Procedures With McC","350","MS-DRG","","","","","","","","inpatient","","","78738.40","47243.04","MARTIN'S POINT [160007]","HB WDH MEDICARE","19389.38","","Case rate ($19,389.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $17,930.44, add-ons for qualifying new technology services are included. If operating cost exceeds $21,848.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,189.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $17,560.15 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,485.57 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,384.36. The transfer capital threshold is the transfer adjustment factor * $1,384.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26781.60","26781.60","26781.60","1 through 10","3975","94692.45","other","Inpatient DRG"
"Inguinal And Femoral Hernia Procedures With McC","350","MS-DRG","","","","","","","","inpatient","","","78738.40","47243.04","MEDICARE [2001]","HB WDH MEDICARE","19389.38","","Case rate ($19,389.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $17,930.44, add-ons for qualifying new technology services are included. If operating cost exceeds $21,848.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,189.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $17,560.15 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,485.57 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,384.36. The transfer capital threshold is the transfer adjustment factor * $1,384.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18742.78","18742.78","18742.78","1 through 10","3975","94692.45","other","Inpatient DRG"
"Inguinal And Femoral Hernia Procedures Without Cc/McC","352","MS-DRG","","","","","","","","inpatient","","","57636.98","34582.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","35343.79","","Fee schedule rate ($35,343.79). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","32556.58","32556.58","32556.58","1 through 10","3975","44376.52","case rate",""
"Inj Anes Ilioinguinal/Hypogastric","PX-76001508","CDM","64425","CPT","0761","RC","","","","both","","","2716.00","1629.60","MEDICARE [2001]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","723.60","723.60","723.60","1 through 10","709.05","4623.96","other","OPPS APC"
"Inj Cntr W/Fluor Evl G/D/J/G-J/C TB","PX-75000306","CDM","49465","CPT","0761","RC","","","","both","","","866.00","519.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","1 through 10","247.49","1613.96","other","OPPS APC"
"Inj Paravert F Jnt C/T 1 Lev","PX-76001532","CDM","64490","CPT","0761","RC","","","","both","","","5180.00","3108.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2947.42","56.9","","12161.81","12161.81","12161.81","1 through 10","911.54","5944.45","percent of total billed charges",""
"Inj Paravert F Jnt C/T 1 Lev","PX-76001532","CDM","64490","CPT","0761","RC","","","","both","","","5180.00","3108.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1373.06","915.37","1376.48","24","911.54","5944.45","other","OPPS APC"
"Inj Paravert F Jnt C/T 1 Lev","PX-76001532","CDM","64490","CPT","0761","RC","","","","outpatient","","","5180.00","3108.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3635.27","3635.27","3635.27","1 through 10","602.43","4009.32","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Inj Paravert F Jnt C/T 2 Lev","PX-76001535","CDM","64491","CPT","0761","RC","","","","outpatient","","","2930.00","1758.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","2055.79","2055.79","2055.79","1 through 10","340.76","2267.82","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Inj Paravert F Jnt C/T 3 Lev","PX-76001538","CDM","64492","CPT","0761","RC","","","","outpatient","","","2965.00","1779.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","15543.18","15543.18","15543.18","1 through 10","344.83","2294.91","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Inj Paravert F Jnt L/S 1 Lev","PX-76001541","CDM","64493","CPT","0761","RC","","","","both","","","4413.00","2647.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2511.00","56.9","","4848.74","4848.74","4848.74","1 through 10","911.54","5944.45","percent of total billed charges",""
"Inj Paravert F Jnt L/S 1 Lev","PX-76001541","CDM","64493","CPT","0761","RC","","","","both","","","4413.00","2647.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1373.79","1313.40","1391.25","51","911.54","5944.45","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","4413.00","2647.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","948.74","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","1395.37","1332.14","1395.37","11","911.54","958.04","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","4413.00","2647.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","911.54","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1395.37","1367.47","2051.21","35","911.54","958.04","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","4413.00","2647.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","958.04","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1419.50","1408.50","1420.82","13","911.54","958.04","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","4413.00","2647.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1332.14","912.54","1395.37","34","911.54","958.04","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","4413.00","2647.80","MEDICARE [2001]","HB WDH MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1395.37","1395.37","1395.37","175","911.54","958.04","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","4413.00","2647.80","TRICARE [160005]","HB WDH MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1395.37","1395.37","1395.37","1 through 10","911.54","958.04","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","4413.00","2647.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1395.37","1332.14","1395.37","18","911.54","958.04","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","4413.00","2647.80","WELLSENSE NH [1050]","HB WDH MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","16701.34","1443.45","18149.11","1 through 10","911.54","958.04","other","OPPS APC"
"Inj Paravert F Jnt L/S 2 Lev","PX-76001544","CDM","64494","CPT","0761","RC","","","","both","","","2540.00","1524.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1445.26","56.9","","2791.04","2791.04","2791.04","1 through 10","1445.26","2159","percent of total billed charges",""
"Inj Paravert F Jnt L/S 2 Lev","PX-76001544","CDM","64494","CPT","0761","RC","","","","outpatient","","","2540.00","1524.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","9757.57","9757.57","9757.57","1 through 10","295.4","1965.96","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Inj Sc/Im Chemo Hormonal Anti-Neoplastic – 96402","PX-33000002","CDM","96402","CPT","0331","RC","","","","both","","","332.00","199.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","231.74","69.8","","223.36","201.28","223.36","11","72.87","475.23","percent of total billed charges",""
"Inj Sc/Im Chemo Hormonal Anti-Neoplastic – 96402","PX-33000002","CDM","96402","CPT","0331","RC","","","","both","","","332.00","199.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","75.84","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","640.00","74.36","640.00","1 through 10","72.87","475.23","other","OPPS APC"
"Inj Sc/Im Chemo Hormonal Anti-Neoplastic – 96402","PX-33000002","CDM","96402","CPT","0331","RC","","","","both","","","332.00","199.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","475.23","","Case rate ($475.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","463.64","446.16","463.64","11","72.87","475.23","other","OPPS APC"
"Inj Sc/Im Chemo Hormonal Anti-Neoplastic – 96402","PX-33000002","CDM","96402","CPT","0331","RC","","","","both","","","332.00","199.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","204.63","","Case rate ($204.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.65","192.12","199.65","26","72.87","475.23","other","OPPS APC"
"Inj Sc/Im Chemo Hormonal Anti-Neoplastic – 96402","PX-33000002","CDM","96402","CPT","0331","RC","","","","both","","","332.00","199.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","72.87","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","74.36","68.64","74.36","42","72.87","475.23","other","OPPS APC"
"Inj Sc/Im Chemo Hormonal Anti-Neoplastic – 96402","PX-33000002","CDM","96402","CPT","0331","RC","","","","both","","","332.00","199.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","384.13","","Case rate ($384.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","374.75","187.38","374.75","41","72.87","475.23","other","OPPS APC"
"Inj Sc/Im Chemo Hormonal Anti-Neoplastic – 96402","PX-33000002","CDM","96402","CPT","0331","RC","","","","both","","","332.00","199.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","188.91","56.9","","182.08","182.08","182.08","1 through 10","72.87","475.23","percent of total billed charges",""
"Inj Sc/Im Chemo Hormonal Anti-Neoplastic – 96402","PX-33000002","CDM","96402","CPT","0331","RC","","","","both","","","332.00","199.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","76.59","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","76.56","70.70","76.56","1 through 10","72.87","475.23","other","OPPS APC"
"Inj Sc/Im Chemo Hormonal Anti-Neoplastic – 96402","PX-33000002","CDM","96402","CPT","0331","RC","","","","both","","","332.00","199.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","74.36","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","73.17","73.17","73.17","1 through 10","72.87","475.23","other","OPPS APC"
"Inj Sc/Im Chemo Hormonal Anti-Neoplastic – 96402","PX-33000002","CDM","96402","CPT","0331","RC","","","","both","","","332.00","199.20","MEDICARE [2001]","HB WDH MEDICARE","74.36","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","74.36","68.64","74.36","25","72.87","475.23","other","OPPS APC"
"Inj Sc/Im Chemo Hormonal Anti-Neoplastic – 96402","PX-33000002","CDM","96402","CPT","0331","RC","","","","both","","","332.00","199.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","74.36","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","73.18","67.55","74.36","12","72.87","475.23","other","OPPS APC"
"Inj Sc/Im Chemo Hormonal Anti-Neoplastic – 96402","PX-33000002","CDM","96402","CPT","0331","RC","","","","outpatient","","","332.00","199.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","47.87","14.42","","39.55","39.55","46.14","1 through 10","38.61","256.97","percent of total billed charges",""
"Inj Sc/Im Chemo Hormonal Anti-Neoplastic – 96402","PX-33000002","CDM","96402","CPT","0331","RC","","","","outpatient","","","332.00","199.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","38.61","11.63","","44.07","37.80","80.82","28","38.61","256.97","percent of total billed charges",""
"Inj Sc/Im Chemo Hormonal Anti-Neoplastic – 96402","PX-33000002","CDM","96402","CPT","0331","RC","","","","outpatient","","","332.00","199.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","208.83","62.9","","201.60","201.60","604.80","14","38.61","256.97","percent of total billed charges",""
"Inj Sc/Im Chemo Hormonal Anti-Neoplastic – 96402","PX-33000002","CDM","96402","CPT","0331","RC","","","","outpatient","","","332.00","199.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","256.97","77.4","","248.00","248.00","248.00","1 through 10","38.61","256.97","percent of total billed charges",""
"Inj Sc/Im Chemo Hormonal Anti-Neoplastic – 96402","PX-33000002","CDM","96402","CPT","0331","RC","","","","outpatient","","","332.00","199.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","38.61","11.63","","37.80","37.80","116.60","13","38.61","256.97","percent of total billed charges",""
"Inj Sc/Im Chemo Non-Hormonal Anti-Neoplastic - 96401","PX-33000001","CDM","96401","CPT","0331","RC","","","","both","","","688.00","412.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","480.22","69.8","","463.47","463.47","463.47","50","72.87","584.8","percent of total billed charges",""
"Inj Sc/Im Chemo Non-Hormonal Anti-Neoplastic - 96401","PX-33000001","CDM","96401","CPT","0331","RC","","","","both","","","688.00","412.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","75.84","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","74.36","74.36","74.36","1 through 10","72.87","584.8","other","OPPS APC"
"Inj Sc/Im Chemo Non-Hormonal Anti-Neoplastic - 96401","PX-33000001","CDM","96401","CPT","0331","RC","","","","both","","","688.00","412.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","475.23","","Case rate ($475.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","463.64","446.16","463.64","1 through 10","72.87","584.8","other","OPPS APC"
"Inj Sc/Im Chemo Non-Hormonal Anti-Neoplastic - 96401","PX-33000001","CDM","96401","CPT","0331","RC","","","","both","","","688.00","412.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","204.63","","Case rate ($204.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.65","96.06","199.65","77","72.87","584.8","other","OPPS APC"
"Inj Sc/Im Chemo Non-Hormonal Anti-Neoplastic - 96401","PX-33000001","CDM","96401","CPT","0331","RC","","","","both","","","688.00","412.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","72.87","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","74.36","37.18","74.36","28","72.87","584.8","other","OPPS APC"
"Inj Sc/Im Chemo Non-Hormonal Anti-Neoplastic - 96401","PX-33000001","CDM","96401","CPT","0331","RC","","","","both","","","688.00","412.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","384.13","","Case rate ($384.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","374.75","96.06","374.75","37","72.87","584.8","other","OPPS APC"
"Inj Sc/Im Chemo Non-Hormonal Anti-Neoplastic - 96401","PX-33000001","CDM","96401","CPT","0331","RC","","","","both","","","688.00","412.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","391.47","56.9","","377.82","377.82","1133.46","73","72.87","584.8","percent of total billed charges",""
"Inj Sc/Im Chemo Non-Hormonal Anti-Neoplastic - 96401","PX-33000001","CDM","96401","CPT","0331","RC","","","","both","","","688.00","412.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","74.36","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","36.59","36.59","73.17","13","72.87","584.8","other","OPPS APC"
"Inj Sc/Im Chemo Non-Hormonal Anti-Neoplastic - 96401","PX-33000001","CDM","96401","CPT","0331","RC","","","","both","","","688.00","412.80","MEDICARE [2001]","HB WDH MEDICARE","74.36","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","74.36","37.18","74.36","141","72.87","584.8","other","OPPS APC"
"Inj Sc/Im Chemo Non-Hormonal Anti-Neoplastic - 96401","PX-33000001","CDM","96401","CPT","0331","RC","","","","both","","","688.00","412.80","TRICARE [160005]","HB WDH MEDICARE","74.36","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","74.36","74.36","74.36","1 through 10","72.87","584.8","other","OPPS APC"
"Inj Sc/Im Chemo Non-Hormonal Anti-Neoplastic - 96401","PX-33000001","CDM","96401","CPT","0331","RC","","","","both","","","688.00","412.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","74.36","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","36.59","36.44","72.88","23","72.87","584.8","other","OPPS APC"
"Inj Sc/Im Chemo Non-Hormonal Anti-Neoplastic - 96401","PX-33000001","CDM","96401","CPT","0331","RC","","","","outpatient","","","688.00","412.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","99.21","14.42","","95.75","82.07","95.75","1 through 10","80.01","532.51","percent of total billed charges",""
"Inj Sc/Im Chemo Non-Hormonal Anti-Neoplastic - 96401","PX-33000001","CDM","96401","CPT","0331","RC","","","","outpatient","","","688.00","412.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","80.01","11.63","","167.70","91.43","167.70","1 through 10","80.01","532.51","percent of total billed charges",""
"Inj Sc/Im Chemo Non-Hormonal Anti-Neoplastic - 96401","PX-33000001","CDM","96401","CPT","0331","RC","","","","outpatient","","","688.00","412.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","432.75","62.9","","418.32","418.32","418.32","38","80.01","532.51","percent of total billed charges",""
"Inj Sc/Im Chemo Non-Hormonal Anti-Neoplastic - 96401","PX-33000001","CDM","96401","CPT","0331","RC","","","","outpatient","","","688.00","412.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","532.51","77.4","","514.60","514.60","514.60","48","80.01","532.51","percent of total billed charges",""
"Inj Sc/Im Chemo Non-Hormonal Anti-Neoplastic - 96401","PX-33000001","CDM","96401","CPT","0331","RC","","","","outpatient","","","688.00","412.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","80.01","11.63","","116.60","116.60","116.60","1 through 10","80.01","532.51","percent of total billed charges",""
"Inject Anes Hypogastric Plexus","PX-76001550","CDM","64517","CPT","0761","RC","","","","both","","","6151.00","3690.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","4804.84","","Case rate ($4,804.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4687.63","4666.13","4687.63","1 through 10","911.54","5944.45","other","OPPS APC"
"Inject Anes Hypogastric Plexus","PX-76001550","CDM","64517","CPT","0761","RC","","","","both","","","6151.00","3690.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","912.54","912.54","912.54","1 through 10","911.54","5944.45","other","OPPS APC"
"Inject Anes Lumbar/Thoracic","PX-76001551","CDM","64520","CPT","0761","RC","","","","both","","","4006.00","2403.60","MEDICARE [2001]","HB WDH MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","930.25","930.25","930.25","1 through 10","911.54","5944.45","other","OPPS APC"
"Inject Anes Lumbar/Thoracic","PX-76001551","CDM","64520","CPT","0761","RC","","","","both","","","4006.00","2403.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","911.65","911.65","911.65","1 through 10","911.54","5944.45","other","OPPS APC"
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","both","","","888.00","532.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1593.15","","Case rate ($1,593.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1554.28","1554.28","1554.28","1 through 10","302.23","1971.01","other","OPPS APC"
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","both","","","888.00","532.80","MEDICARE [2001]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","308.44","308.44","308.44","1 through 10","302.23","1971.01","other","OPPS APC"
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","both","","","888.00","532.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","141.99","141.99","141.99","1 through 10","302.23","1971.01","other","OPPS APC"
"Inject Anes Nerve Greater Occipital","PX-76001499","CDM","64405","CPT","0761","RC","","","","both","","","2634.00","1580.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","308.44","282.81","308.44","1 through 10","302.23","2238.9","other","OPPS APC"
"Inject Anes Nerve Greater Occipital","PX-76001499","CDM","64405","CPT","0761","RC","","","","both","","","2634.00","1580.40","MEDICARE [2001]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","308.44","308.44","308.44","1 through 10","302.23","2238.9","other","OPPS APC"
"Inject Anes Nerve Greater Occipital","PX-76001499","CDM","64405","CPT","0761","RC","","","","both","","","2634.00","1580.40","TRICARE [160005]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","308.44","308.44","308.44","1 through 10","302.23","2238.9","other","OPPS APC"
"Inject Anes Nerve Greater Occipital","PX-76001499","CDM","64405","CPT","0761","RC","","","","both","","","2634.00","1580.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","461.31","308.44","461.31","1 through 10","302.23","2238.9","other","OPPS APC"
"Inject Anes Nerve Greater Occipital|BILATERAL PROCEDURE","PX-76001499","CDM","64405","CPT","0761","RC","","","50","both","","","2634.00","1580.40","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","314.57","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","462.66","462.66","462.66","1 through 10","302.23","317.65","other","OPPS APC"
"Inject Anes Nerve Greater Occipital|BILATERAL PROCEDURE","PX-76001499","CDM","64405","CPT","0761","RC","","","50","both","","","2634.00","1580.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","302.23","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","453.41","453.41","453.41","1 through 10","302.23","317.65","other","OPPS APC"
"Inject Anes Nerve Greater Occipital|BILATERAL PROCEDURE","PX-76001499","CDM","64405","CPT","0761","RC","","","50","both","","","2634.00","1580.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","454.31","454.31","454.31","1 through 10","302.23","317.65","other","OPPS APC"
"Inject Anes Nerve Greater Occipital|BILATERAL PROCEDURE","PX-76001499","CDM","64405","CPT","0761","RC","","","50","both","","","2634.00","1580.40","MEDICARE [2001]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","462.66","432.88","925.32","1 through 10","302.23","317.65","other","OPPS APC"
"Inject Anes Nerve Greater Occipital|BILATERAL PROCEDURE","PX-76001499","CDM","64405","CPT","0761","RC","","","50","both","","","2634.00","1580.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","462.66","462.66","462.66","1 through 10","302.23","317.65","other","OPPS APC"
"Inject Anes Nerve Intercostal Multi","PX-76001507","CDM","64421","CPT","0761","RC","","","","both","","","4506.00","2703.60","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","948.74","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","930.25","930.25","930.25","1 through 10","911.54","5944.45","other","OPPS APC"
"Inject Anes Nerve Intercostal Sgl","PX-76001506","CDM","64420","CPT","0761","RC","","","","both","","","3282.00","1969.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","737.99","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","361.80","361.80","361.80","1 through 10","709.05","4623.96","other","OPPS APC"
"Inject Anes Nerve Intercostal Sgl","PX-76001506","CDM","64420","CPT","0761","RC","","","","both","","","3282.00","1969.20","MEDICARE [2001]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","723.60","723.60","723.60","1 through 10","709.05","4623.96","other","OPPS APC"
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","both","","","2191.00","1314.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","1529.32","69.8","","1475.57","1475.57","1475.57","1 through 10","709.05","4623.96","percent of total billed charges",""
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","both","","","2191.00","1314.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1246.68","56.9","","1202.87","1202.87","1202.87","1 through 10","709.05","4623.96","percent of total billed charges",""
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","both","","","2191.00","1314.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","723.60","723.60","723.60","1 through 10","709.05","4623.96","other","OPPS APC"
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","both","","","2191.00","1314.60","MEDICARE [2001]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","723.60","673.80","1447.20","1 through 10","709.05","4623.96","other","OPPS APC"
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","both","","","2191.00","1314.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","1862.35","85","","2110.70","2110.70","2110.70","1 through 10","709.05","4623.96","percent of total billed charges",""
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","both","","","2191.00","1314.60","TRICARE [160005]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","723.60","723.60","723.60","1 through 10","709.05","4623.96","other","OPPS APC"
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","both","","","2191.00","1314.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1068.04","716.83","1069.20","1 through 10","709.05","4623.96","other","OPPS APC"
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","both","","","2191.00","1314.60","WELLPOINT [1015]","HB WDH ANTHEM PPO","3737.50","","Case rate ($3,737.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4702.59","2583.00","4702.59","1 through 10","709.05","4623.96","other","OPPS APC"
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","outpatient","","","2191.00","1314.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1695.83","77.4","","1638.35","1638.35","1638.35","1 through 10","254.81","1695.83","percent of total billed charges",""
"Inject Anes Nerve Peripheral Other|BILATERAL PROCEDURE","PX-76001516","CDM","64450","CPT","0761","RC","","","50","both","","","2191.00","1314.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","709.05","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1010.71","1010.71","1010.71","1 through 10","709.05","745.22","other","OPPS APC"
"Inject Anes Nerve Peripheral Other|BILATERAL PROCEDURE","PX-76001516","CDM","64450","CPT","0761","RC","","","50","both","","","2191.00","1314.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1063.69","1063.69","1063.69","1 through 10","709.05","745.22","other","OPPS APC"
"Inject Anes Nerve Peripheral Other|BILATERAL PROCEDURE","PX-76001516","CDM","64450","CPT","0761","RC","","","50","both","","","2191.00","1314.60","MEDICARE [2001]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1085.40","1085.40","1085.40","1 through 10","709.05","745.22","other","OPPS APC"
"Inject Anes Nerve Peripheral Other|BILATERAL PROCEDURE","PX-76001516","CDM","64450","CPT","0761","RC","","","50","both","","","2191.00","1314.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1085.40","1085.40","1085.40","1 through 10","709.05","745.22","other","OPPS APC"
"Inject Anes Nerve Peripheral Other|BILATERAL PROCEDURE","PX-76001516","CDM","64450","CPT","0761","RC","","","50","both","","","2191.00","1314.60","WELLSENSE NH [1050]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1124.08","1121.44","1124.18","1 through 10","709.05","745.22","other","OPPS APC"
"Inject Anes Nerve Pudendal","PX-76001509","CDM","64430","CPT","0761","RC","","","","both","","","3927.00","2356.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","877.33","877.33","877.33","1 through 10","911.54","5944.45","other","OPPS APC"
"Inject Anes Nerve Trigeminal|BILATERAL PROCEDURE","PX-76001497","CDM","64400","CPT","0761","RC","","","50","both","","","752.00","451.20","MEDICARE [2001]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","462.66","462.66","462.66","1 through 10","302.23","317.65","other","OPPS APC"
"Inject Arthrogram Hip W/O Anes","PX-76000527","CDM","27093","CPT","0761","RC","","","","outpatient","","","1158.00","694.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","812.28","812.28","812.28","1 through 10","134.68","896.29","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Inject Arthrogram Sacroiliac Joint","PX-76001795","CDM","27096","CPT","0761","RC","","","","outpatient","","","4065.00","2439.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","5705.61","3993.93","5705.61","1 through 10","472.76","3146.31","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Inject Contrast Abcs/Cyst","PX-75000294","CDM","49424","CPT","0361","RC","","","","both","","","636.00","381.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","361.88","56.9","","349.37","349.37","349.37","1 through 10","361.88","540.6","percent of total billed charges",""
"Inject Contrast Abcs/Cyst","PX-75000294","CDM","49424","CPT","0361","RC","","","","outpatient","","","636.00","381.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","91.71","14.42","","88.54","88.54","88.54","1 through 10","73.97","492.26","percent of total billed charges",""
"Inject Contrast Abcs/Cyst","PX-75000294","CDM","49424","CPT","0361","RC","","","","outpatient","","","636.00","381.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","446.50","446.50","446.50","1 through 10","73.97","492.26","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Inject Contrast Abcs/Cyst","PX-75000294","CDM","49424","CPT","0361","RC","","","","outpatient","","","636.00","381.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","73.97","11.63","","1203.44","72.52","1203.44","1 through 10","73.97","492.26","percent of total billed charges",""
"Inject Cystogram/Voiding","PX-76001254","CDM","51600","CPT","0761","RC","","","","outpatient","","","742.00","445.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","107.00","14.42","","103.25","103.25","103.25","1 through 10","86.29","574.31","percent of total billed charges",""
"Inject Cystogram/Voiding","PX-76001254","CDM","51600","CPT","0761","RC","","","","outpatient","","","742.00","445.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","520.68","520.68","520.68","1 through 10","86.29","574.31","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","both","","","1173.00","703.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","818.75","69.8","","712.03","712.03","712.03","1 through 10","667.44","4623.96","percent of total billed charges",""
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","both","","","1173.00","703.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1991.07","","Case rate ($1,991.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1132.00","1132.00","1132.00","1 through 10","667.44","4623.96","other","OPPS APC"
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","both","","","1173.00","703.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","3737.50","","Case rate ($3,737.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3646.32","3646.32","3646.32","1 through 10","667.44","4623.96","other","OPPS APC"
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","both","","","1173.00","703.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","710.03","710.03","710.03","1 through 10","667.44","4623.96","other","OPPS APC"
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","both","","","1173.00","703.80","TRICARE [160005]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","723.60","723.60","723.60","1 through 10","667.44","4623.96","other","OPPS APC"
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","outpatient","","","1173.00","703.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","136.42","11.63","","285.89","285.89","285.89","1 through 10","136.42","907.9","percent of total billed charges",""
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","outpatient","","","1173.00","703.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","823.19","823.19","823.19","1 through 10","136.42","907.9","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","outpatient","","","1173.00","703.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","737.82","62.9","","713.16","713.16","713.16","1 through 10","136.42","907.9","percent of total billed charges",""
"Inject Sentinel Node ID","PX-76001212","CDM","38792","CPT","0761","RC","","","","both","","","2364.00","1418.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","1650.07","69.8","","5800.62","1434.75","10761.79","1 through 10","340.89","2683.02","percent of total billed charges",""
"Inject Sentinel Node ID","PX-76001212","CDM","38792","CPT","0761","RC","","","","both","","","2364.00","1418.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1155.31","","Case rate ($1,155.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1124.84","1124.84","1124.84","1 through 10","340.89","2683.02","other","OPPS APC"
"Inject Sentinel Node ID","PX-76001212","CDM","38792","CPT","0761","RC","","","","both","","","2364.00","1418.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1345.12","56.9","","1297.89","1297.87","1297.89","1 through 10","340.89","2683.02","percent of total billed charges",""
"Inject Sentinel Node ID","PX-76001212","CDM","38792","CPT","0761","RC","","","","outpatient","","","2364.00","1418.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","32976.31","1658.74","33465.46","1 through 10","274.93","274.93","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","1863.00","1117.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","1300.37","69.8","","1255.00","1255.00","1255.00","1 through 10","302.23","1971.01","percent of total billed charges",""
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","1863.00","1117.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1971.01","","Case rate ($1,971.01). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1836.30","289.39","1922.94","1 through 10","302.23","1971.01","other","OPPS APC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","1863.00","1117.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","848.71","","Case rate ($848.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","828.02","745.23","828.02","1 through 10","302.23","1971.01","other","OPPS APC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","1863.00","1117.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","302.23","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","303.17","288.58","308.44","1 through 10","302.23","1971.01","other","OPPS APC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","1863.00","1117.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1593.15","","Case rate ($1,593.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1554.28","1554.28","1554.28","1 through 10","302.23","1971.01","other","OPPS APC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","1863.00","1117.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1060.05","56.9","","1023.06","1023.06","1023.06","1 through 10","302.23","1971.01","percent of total billed charges",""
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","1863.00","1117.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","303.17","303.17","303.17","1 through 10","302.23","1971.01","other","OPPS APC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","1863.00","1117.80","MEDICARE [2001]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","308.44","288.58","308.44","19","302.23","1971.01","other","OPPS APC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","1863.00","1117.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","308.44","308.44","308.44","1 through 10","302.23","1971.01","other","OPPS APC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","1863.00","1117.80","WELLSENSE NH [1050]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","161.93","161.93","161.93","1 through 10","302.23","1971.01","other","OPPS APC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","outpatient","","","1863.00","1117.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","268.64","14.42","","222.23","222.23","222.23","1 through 10","216.67","1441.96","percent of total billed charges",""
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","outpatient","","","1863.00","1117.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","216.67","11.63","","247.58","247.58","247.58","1 through 10","216.67","1441.96","percent of total billed charges",""
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","outpatient","","","1863.00","1117.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3922.53","1307.51","3922.53","1 through 10","216.67","1441.96","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","outpatient","","","1863.00","1117.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1171.83","62.9","","3398.22","1132.74","3398.22","12","216.67","1441.96","percent of total billed charges",""
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","outpatient","","","1863.00","1117.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","216.67","11.63","","212.37","212.37","212.37","1 through 10","216.67","1441.96","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","2119.00","1271.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","1479.06","69.8","","1427.41","1286.31","1427.41","22","302.23","1971.01","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","2119.00","1271.40","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","314.57","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","308.44","288.58","308.44","25","302.23","1971.01","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","2119.00","1271.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1971.01","","Case rate ($1,971.01). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1730.66","1688.32","1730.66","52","302.23","1971.01","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","2119.00","1271.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","848.71","","Case rate ($848.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","745.23","726.99","745.23","71","302.23","1971.01","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","2119.00","1271.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","302.23","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","294.89","42.19","308.44","43","302.23","1971.01","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","2119.00","1271.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1593.15","","Case rate ($1,593.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1398.85","745.23","1398.85","54","302.23","1971.01","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","2119.00","1271.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1205.71","56.9","","1163.61","1163.60","1163.61","61","302.23","1971.01","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","2119.00","1271.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","317.65","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","317.69","297.24","317.69","11","302.23","1971.01","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","2119.00","1271.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","303.17","302.27","308.44","51","302.23","1971.01","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","2119.00","1271.40","MEDICARE [2001]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","308.44","308.44","308.44","193","302.23","1971.01","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","2119.00","1271.40","TRICARE [160005]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","308.44","308.44","308.44","13","302.23","1971.01","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","2119.00","1271.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","308.44","303.51","308.44","112","302.23","1971.01","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","2119.00","1271.40","WELLSENSE NH [1050]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","323.86","323.86","4346.66","1 through 10","302.23","1971.01","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","2119.00","1271.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","305.56","14.42","","294.89","252.76","294.89","14","246.44","1640.11","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","2119.00","1271.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","246.44","11.63","","281.60","241.55","516.47","86","246.44","1640.11","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","2119.00","1271.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","","","Payment is accumulated by procedure count. Procedure 1, 62.78% of billed. Procedures 2 - 9999, 31.39% of billed.","1283.85","1283.85","1283.85","1 through 10","246.44","1640.11","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","2119.00","1271.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","894.07","894.07","894.07","1 through 10","246.44","1640.11","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","2119.00","1271.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","1487.12","1487.12","1487.12","41","246.44","1640.11","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","2119.00","1271.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","1487.12","1487.12","1487.12","1 through 10","246.44","1640.11","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","2119.00","1271.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1332.85","62.9","","1288.35","1288.35","1288.35","31","246.44","1640.11","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","2119.00","1271.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1640.11","77.4","","1584.88","1584.87","1584.88","16","246.44","1640.11","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","2119.00","1271.40","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","1487.12","1487.12","1487.12","1 through 10","246.44","1640.11","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","2119.00","1271.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","246.44","11.63","","241.55","241.55","241.55","23","246.44","1640.11","percent of total billed charges",""
"Inject Tx Pseudoaneurysm Ext Perc","PX-76001029","CDM","36002","CPT","0361","RC","","","","both","","","8638.00","5182.80","MEDICARE [2001]","HB WDH MEDICARE","645.93","","APC Price ($645.93). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","646.01","646.01","646.01","1 through 10","633.01","7342.3","other","OPPS APC"
"Injection Aa&/Strd Genicular Nrv Branches W/Img","PX-76002664","CDM","64454","CPT","0761","RC","","","","both","","","2617.00","1570.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1068.04","673.80","1073.60","1 through 10","377.37","4623.96","other","OPPS APC"
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","both","","","5415.00","3249.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1593.15","","Case rate ($1,593.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1554.28","1554.28","1554.28","1 through 10","302.23","4602.75","other","OPPS APC"
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","both","","","5415.00","3249.00","MEDICARE [2001]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","308.44","308.44","308.44","1 through 10","302.23","4602.75","other","OPPS APC"
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","both","","","5415.00","3249.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","141.99","141.99","141.99","1 through 10","302.23","4602.75","other","OPPS APC"
"Injection Anesthetic/Therapeutic Agent, Erector Spinae Plane (Esp)","PX-76002834","CDM","64999","CPT","0761","RC","","","","both","","","3369.00","2021.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1593.15","","Case rate ($1,593.15). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1554.28","1554.28","1554.28","1 through 10","302.23","2863.65","other","OPPS APC"
"Injection Anesthetic/Therapeutic Agent, Erector Spinae Plane (Esp)","PX-76002834","CDM","64999","CPT","0761","RC","","","","both","","","3369.00","2021.40","MEDICARE [2001]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","308.44","308.44","308.44","1 through 10","302.23","2863.65","other","OPPS APC"
"Injection Anesthetic/Therapeutic Agent, Erector Spinae Plane (Esp)","PX-76002834","CDM","64999","CPT","0761","RC","","","","both","","","3369.00","2021.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","141.99","141.99","141.99","1 through 10","302.23","2863.65","other","OPPS APC"
"Injection Remdesivir, 1 Mg","PX-63601353","CDM","J0248","HCPCS","0636","RC","","","","both","","","33.80","20.28","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6.73","","APC Price ($6.73).","6.23","6.23","6.23","300","5.51","31.37","other","OPPS APC"
"Inpatient Hemodialysis","PX-80000003","CDM","90935","CPT","0801","RC","","","","outpatient","","","2711.00","1626.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","315.29","11.63","","292.10","292.10","340.53","1 through 10","315.29","2098.31","percent of total billed charges",""
"Inpatient Hemodialysis","PX-80000003","CDM","90935","CPT","0801","RC","","","","outpatient","","","2711.00","1626.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1185.25","43.72","","1081.20","1081.20","1081.20","1 through 10","315.29","2098.31","percent of total billed charges",""
"Ins New/ Repl Perm Pacemaker a/V","PX-48000045","CDM","33208","CPT","0480","RC","","","","both","","","48720.00","29232.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","27721.68","56.9","","26750.40","26750.40","26750.40","1 through 10","10715.08","69876.83","percent of total billed charges",""
"Ins New/ Repl Perm Pacemaker a/V","PX-48000045","CDM","33208","CPT","0480","RC","","","","both","","","48720.00","29232.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","10933.76","","APC Price ($10,933.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","10724.01","10716.31","10935.01","1 through 10","10715.08","69876.83","other","OPPS APC"
"Ins Vena Cava Filter Endovascular","PX-76001134","CDM","37191","CPT","0361","RC","","","","both","","","20576.00","12345.60","MEDICARE [2001]","HB WDH MEDICARE","5647.66","","APC Price ($5,647.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5648.31","5648.31","5648.31","1 through 10","5534.71","36093.78","other","OPPS APC"
"Ins/Rplcmnt Perm Subq Impltbl Dfb W/Subq Eltrd","PX-36000309","CDM","33270","CPT","0480","RC","","","","both","","","144737.00","86842.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","33496.66","","APC Price ($33,496.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","32838.39","32838.39","32838.39","1 through 10","32826.72","214074.65","other","OPPS APC"
"Ins/Rplcmnt Perm Subq Impltbl Dfb W/Subq Eltrd","PX-36000309","CDM","33270","CPT","0480","RC","","","","both","","","144737.00","86842.20","WELLSENSE NH [1050]","HB WDH MEDICARE","33496.66","","APC Price ($33,496.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","34479.62","34479.62","34479.62","1 through 10","32826.72","214074.65","other","OPPS APC"
"Ins/Rplcmnt Perm Subq Impltbl Dfb W/Subq Eltrd","PX-36000309","CDM","33270","CPT","0480","RC","","","","outpatient","","","144737.00","86842.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16832.91","11.63","","18531.21","18531.21","18531.21","1 through 10","16832.91","112026.44","percent of total billed charges",""
"Insert Cath Cv Non-Tunl >5yrs","PX-76001083","CDM","36556","CPT","0361","RC","","","","outpatient","","","2974.00","1784.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","345.88","11.63","","339.00","339.00","339.00","1 through 10","345.88","2301.88","percent of total billed charges",""
"Insert Cath Cv Tunlw/O Port >5yrs","PX-76001085","CDM","36558","CPT","0361","RC","","","","both","","","12150.00","7290.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","21015.78","","Case rate ($21,015.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","15103.70","15103.70","15103.70","1 through 10","3222.61","21015.78","other","OPPS APC"
"Insert Cath Cv Tunlw/O Port >5yrs","PX-76001085","CDM","36558","CPT","0361","RC","","","","both","","","12150.00","7290.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","3222.61","","APC Price ($3,288.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3222.98","3222.98","3222.98","1 through 10","3222.61","21015.78","other","OPPS APC"
"Insert Cath Cv Tunlw/O Port >5yrs","PX-76001085","CDM","36558","CPT","0361","RC","","","","both","","","12150.00","7290.00","MEDICARE [2001]","HB WDH MEDICARE","3288.38","","APC Price ($3,288.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9866.28","3288.76","9866.28","1 through 10","3222.61","21015.78","other","OPPS APC"
"Insert Cath Cv Tunlw/O Port >5yrs","PX-76001085","CDM","36558","CPT","0361","RC","","","","both","","","12150.00","7290.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","3288.38","","APC Price ($3,288.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3288.76","3230.89","3288.76","1 through 10","3222.61","21015.78","other","OPPS APC"
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","both","","","5132.00","3079.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","3582.14","69.8","","3456.50","3456.50","3456.50","1 through 10","1590.51","10372.29","percent of total billed charges",""
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","both","","","5132.00","3079.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","10372.29","","Case rate ($10,372.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7632.92","7632.92","7632.92","1 through 10","1590.51","10372.29","other","OPPS APC"
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","both","","","5132.00","3079.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","4466.30","","Case rate ($4,466.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4357.42","4357.42","4357.42","1 through 10","1590.51","10372.29","other","OPPS APC"
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","both","","","5132.00","3079.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1590.51","","APC Price ($1,622.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1560.45","1560.45","1623.16","1 through 10","1590.51","10372.29","other","OPPS APC"
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","both","","","5132.00","3079.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","8383.83","","Case rate ($8,383.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8198.78","8198.78","8198.78","1 through 10","1590.51","10372.29","other","OPPS APC"
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","both","","","5132.00","3079.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2920.11","56.9","","2817.69","2817.69","2817.69","1 through 10","1590.51","10372.29","percent of total billed charges",""
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","both","","","5132.00","3079.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","1671.66","","APC Price ($1,622.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1646.21","1638.41","1650.01","1 through 10","1590.51","10372.29","other","OPPS APC"
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","both","","","5132.00","3079.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","1622.97","","APC Price ($1,622.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1623.16","1590.70","4790.98","1 through 10","1590.51","10372.29","other","OPPS APC"
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","both","","","5132.00","3079.20","MEDICARE [2001]","HB WDH MEDICARE","1622.97","","APC Price ($1,622.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1623.16","1623.16","4681.35","18","1590.51","10372.29","other","OPPS APC"
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","both","","","5132.00","3079.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1622.97","","APC Price ($1,622.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1597.19","1590.70","11113.92","1 through 10","1590.51","10372.29","other","OPPS APC"
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","outpatient","","","5132.00","3079.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","740.03","14.42","","612.07","612.07","612.07","1 through 10","596.85","3972.17","percent of total billed charges",""
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","outpatient","","","5132.00","3079.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","596.85","11.63","","1250.63","584.91","1250.63","11","596.85","3972.17","percent of total billed charges",""
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","outpatient","","","5132.00","3079.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","10803.27","3601.09","10803.27","1 through 10","596.85","3972.17","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","outpatient","","","5132.00","3079.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","596.85","11.63","","584.91","584.91","584.91","1 through 10","596.85","3972.17","percent of total billed charges",""
"Insert Cath Pleural Indwel/Tunl W/","PX-76000826","CDM","32550","CPT","0761","RC","","","","both","","","11853.00","7111.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","3760.76","","APC Price ($3,687.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","6219.97","6219.97","6219.97","1 through 10","3613.28","23563.47","other","OPPS APC"
"Insert Cath Pleural Indwel/Tunl W/","PX-76000826","CDM","32550","CPT","0761","RC","","","","both","","","11853.00","7111.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","3687.02","","APC Price ($3,687.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3621.60","3621.60","3621.60","1 through 10","3613.28","23563.47","other","OPPS APC"
"Insert Device Cv W/Port > 5 Yrs","PX-76001087","CDM","36561","CPT","0361","RC","","","","both","","","11428.00","6856.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","3288.38","","APC Price ($3,288.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3230.89","3053.40","3236.14","12","3222.61","21015.78","other","OPPS APC"
"Insert Device Cv W/Port > 5 Yrs","PX-76001087","CDM","36561","CPT","0361","RC","","","","outpatient","","","11428.00","6856.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","8019.56","8019.56","8019.56","1 through 10","1329.08","8845.27","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Insert Drug Implant Device - 11981","PX-76000104","CDM","11981","CPT","0761","RC","","","","outpatient","","","814.00","488.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","117.38","14.42","","1045.88","1045.88","1045.88","1 through 10","94.67","630.04","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","1368.00","820.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","954.86","69.8","","3849.82","3375.07","22419.09","1 through 10","145.93","1162.8","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","1368.00","820.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","778.39","56.9","","4299.36","2149.68","7092.87","12","145.93","1162.8","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","1368.00","820.80","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","778.39","56.9","","6104.23","6104.23","6104.23","1 through 10","145.93","1162.8","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","outpatient","","","1368.00","820.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","197.27","14.42","","864.29","864.29","864.29","1 through 10","159.1","1058.83","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","outpatient","","","1368.00","820.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","159.10","11.63","","1338.72","462.43","1739.86","13","159.1","1058.83","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","outpatient","","","1368.00","820.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","2747.36","2747.36","10328.42","1 through 10","159.1","1058.83","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","outpatient","","","1368.00","820.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","2673.91","2673.91","2673.91","1 through 10","159.1","1058.83","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","outpatient","","","1368.00","820.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","860.47","62.9","","3474.77","2380.14","9138.78","1 through 10","159.1","1058.83","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","outpatient","","","1368.00","820.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1058.83","77.4","","4274.51","2608.14","4274.51","1 through 10","159.1","1058.83","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","outpatient","","","1368.00","820.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","159.10","11.63","","856.70","99.07","892.48","1 through 10","159.1","1058.83","percent of total billed charges",""
"INSERT TIBIAL 6MM ITOTAL IDENTITY POSTERIOR STABILIZED IPOLY","SUP-ITM-10283875","CDM","C1776","HCPCS","0278","RC","","","","both","","","1568.57","941.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","182.42","1333.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INSERT TIBIAL 6MM ITOTAL IDENTITY POSTERIOR STABILIZED IPOLY","SUP-ITM-10283875","CDM","C1776","HCPCS","0278","RC","","","","both","","","1568.57","941.14","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","892.52","56.9","","2911.53","1863.86","5209.05","65","182.42","1333.28","percent of total billed charges",""
"INSERT TIBIAL 6MM ITOTAL IDENTITY POSTERIOR STABILIZED IPOLY","SUP-ITM-10283875","CDM","C1776","HCPCS","0278","RC","","","","both","","","1568.57","941.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","182.42","11.63","","400.94","400.94","400.94","1 through 10","182.42","1333.28","percent of total billed charges",""
"INSERT TIBIAL 6MM ITOTAL IDENTITY POSTERIOR STABILIZED IPOLY","SUP-ITM-10283875","CDM","C1776","HCPCS","0278","RC","","","","both","","","1568.57","941.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1214.07","77.4","","5214.50","5214.50","16415.28","1 through 10","182.42","1333.28","percent of total billed charges",""
"INSERT TIBIAL 6MM ITOTAL IDENTITY POSTERIOR STABILIZED IPOLY","SUP-ITM-10283875","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1568.57","941.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","182.42","11.63","","400.94","400.94","400.94","1 through 10","182.42","1214.07","percent of total billed charges",""
"INSERT TIBIAL 6MM ITOTAL IDENTITY POSTERIOR STABILIZED IPOLY","SUP-ITM-10283875","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1568.57","941.14","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","685.78","43.72","","1543.33","1543.33","1671.61","1 through 10","182.42","1214.07","percent of total billed charges",""
"INSERT TIBIAL 6MM ITOTAL IDENTITY POSTERIOR STABILIZED IPOLY","SUP-ITM-10283875","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1568.57","941.14","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1140.66","72.72","","3700.21","2382.07","6427.18","53","182.42","1214.07","percent of total billed charges",""
"INSERT TIBIAL 6MM ITOTAL IDENTITY POSTERIOR STABILIZED IPOLY","SUP-ITM-10283875","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1568.57","941.14","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1140.66","72.72","","12685.80","12685.80","12685.80","1 through 10","182.42","1214.07","percent of total billed charges",""
"INSERT TIBIAL 6MM ITOTAL IDENTITY POSTERIOR STABILIZED IPOLY","SUP-ITM-10283875","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1568.57","941.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","986.63","62.9","","3408.87","2784.05","9859.40","46","182.42","1214.07","percent of total billed charges",""
"INSERT TIBIAL 6MM ITOTAL IDENTITY POSTERIOR STABILIZED IPOLY","SUP-ITM-10283875","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1568.57","941.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1214.07","77.4","","5214.50","5214.50","16415.28","1 through 10","182.42","1214.07","percent of total billed charges",""
"Insert Tun Intraperitoneal Cath","PX-75000289","CDM","49418","CPT","0361","RC","","","","both","","","11676.00","7005.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","3613.28","","APC Price ($3,687.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6268.65","6268.65","6268.65","1 through 10","3613.28","23563.47","other","OPPS APC"
"Insert Tun Intraperitoneal Cath","PX-75000289","CDM","49418","CPT","0361","RC","","","","both","","","11676.00","7005.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","3687.02","","APC Price ($3,687.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3622.60","3613.70","3622.60","1 through 10","3613.28","23563.47","other","OPPS APC"
"Insert Tun Intraperitoneal Cath","PX-75000289","CDM","49418","CPT","0361","RC","","","","outpatient","","","11676.00","7005.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1357.92","11.63","","1551.47","1551.47","1551.47","1 through 10","1357.92","9037.22","percent of total billed charges",""
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","both","","","1283.00","769.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","324.16","","APC Price ($317.81). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","317.84","317.84","317.84","1 through 10","311.45","2031.08","other","OPPS APC"
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","both","","","1283.00","769.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2031.08","","Case rate ($2,031.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1981.55","1981.55","1981.55","1 through 10","311.45","2031.08","other","OPPS APC"
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","both","","","1283.00","769.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","311.45","","APC Price ($317.81). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","306.32","306.32","306.32","1 through 10","311.45","2031.08","other","OPPS APC"
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","both","","","1283.00","769.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","317.81","","APC Price ($317.81). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","311.48","307.12","312.38","1 through 10","311.45","2031.08","other","OPPS APC"
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","both","","","1283.00","769.80","MEDICARE [2001]","HB WDH MEDICARE","317.81","","APC Price ($317.81). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","317.84","312.57","317.84","1 through 10","311.45","2031.08","other","OPPS APC"
"Insert Vaginal Rad Aftld Apparatus","PX-76001351","CDM","57156","CPT","0761","RC","","","","outpatient","","","1283.00","769.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","993.04","77.4","","959.45","959.45","959.45","1 through 10","149.21","993.04","percent of total billed charges",""
"INSERTER FIXATION 24X10MM FEMORAL APERFIX","SUP-ITM-10230032","CDM","C1713","HCPCS","0278","RC","","","","both","","","6893.14","4135.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","801.67","5859.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INSERTER FIXATION 24X10MM FEMORAL APERFIX","SUP-ITM-10230032","CDM","C1713","HCPCS","0278","RC","","","","both","","","6893.14","4135.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","801.67","5859.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INSERTER FIXATION 24X10MM FEMORAL APERFIX","SUP-ITM-10230032","CDM","C1713","HCPCS","0278","RC","","","","both","","","6893.14","4135.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3922.20","56.9","","812.12","238.65","1587.46","163","801.67","5859.17","percent of total billed charges",""
"INSERTER FIXATION 24X10MM FEMORAL APERFIX","SUP-ITM-10230032","CDM","C1713","HCPCS","0278","RC","","","","both","","","6893.14","4135.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","801.67","11.63","","112.68","112.68","146.99","38","801.67","5859.17","percent of total billed charges",""
"INSERTER FIXATION 24X10MM FEMORAL APERFIX","SUP-ITM-10230032","CDM","C1713","HCPCS","0278","RC","","","","both","","","6893.14","4135.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5335.29","77.4","","303.98","303.98","5854.79","1 through 10","801.67","5859.17","percent of total billed charges",""
"INSERTER FIXATION 24X10MM FEMORAL APERFIX","SUP-ITM-10230032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6893.14","4135.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","801.67","11.63","","112.68","112.68","146.99","38","801.67","5335.29","percent of total billed charges",""
"INSERTER FIXATION 24X10MM FEMORAL APERFIX","SUP-ITM-10230032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6893.14","4135.88","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4327.51","62.78","","780.86","208.94","10480.28","15","801.67","5335.29","percent of total billed charges",""
"INSERTER FIXATION 24X10MM FEMORAL APERFIX","SUP-ITM-10230032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6893.14","4135.88","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3013.68","43.72","","179.76","179.76","179.76","1 through 10","801.67","5335.29","percent of total billed charges",""
"INSERTER FIXATION 24X10MM FEMORAL APERFIX","SUP-ITM-10230032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6893.14","4135.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5012.69","72.72","","2355.45","298.99","3965.19","155","801.67","5335.29","percent of total billed charges",""
"INSERTER FIXATION 24X10MM FEMORAL APERFIX","SUP-ITM-10230032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6893.14","4135.88","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5012.69","72.72","","3643.09","3643.09","3643.09","1 through 10","801.67","5335.29","percent of total billed charges",""
"INSERTER FIXATION 24X10MM FEMORAL APERFIX","SUP-ITM-10230032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6893.14","4135.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3668.53","53.22","","554.28","554.28","554.28","16","801.67","5335.29","percent of total billed charges",""
"INSERTER FIXATION 24X10MM FEMORAL APERFIX","SUP-ITM-10230032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6893.14","4135.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4335.79","62.9","","619.64","173.09","2370.64","150","801.67","5335.29","percent of total billed charges",""
"INSERTER FIXATION 24X10MM FEMORAL APERFIX","SUP-ITM-10230032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6893.14","4135.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5335.29","77.4","","303.98","303.98","5854.79","1 through 10","801.67","5335.29","percent of total billed charges",""
"Insertion Dilator Cervical","PX-72000012","CDM","59200","CPT","0761","RC","","","","both","","","1149.00","689.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","653.78","56.9","","631.02","631.02","631.02","1 through 10","311.45","2031.08","percent of total billed charges",""
"Insertion Dilator Cervical","PX-72000012","CDM","59200","CPT","0761","RC","","","","both","","","1149.00","689.40","TRICARE [160005]","HB WDH MEDICARE","317.81","","APC Price ($317.81). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","317.84","317.84","317.84","1 through 10","311.45","2031.08","other","OPPS APC"
"Insertion Dilator Cervical","PX-72000012","CDM","59200","CPT","0761","RC","","","","outpatient","","","1149.00","689.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","722.72","62.9","","698.67","698.67","698.67","1 through 10","133.63","889.33","percent of total billed charges",""
"Insertion Drug Delivery Implant","PX-76002767","CDM","11981","CPT","0761","RC","","","","outpatient","","","844.00","506.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","121.70","14.42","","1045.88","1045.88","1045.88","1 through 10","98.16","653.26","percent of total billed charges",""
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","30777.00","18466.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","8819.34","","APC Price ($8,646.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","8647.41","8647.41","8647.41","1 through 10","8473.48","55258.59","other","OPPS APC"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","30777.00","18466.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","55258.59","","Case rate ($55,258.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","48064.18","48064.18","48064.18","1 through 10","8473.48","55258.59","other","OPPS APC"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","30777.00","18466.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","23794.29","","Case rate ($23,794.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","23214.21","23169.79","23214.21","1 through 10","8473.48","55258.59","other","OPPS APC"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","30777.00","18466.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","8473.48","","APC Price ($8,646.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","8474.46","8277.71","8647.41","1 through 10","8473.48","55258.59","other","OPPS APC"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","30777.00","18466.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","8905.81","","APC Price ($8,646.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","8748.78","8744.60","8748.78","1 through 10","8473.48","55258.59","other","OPPS APC"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","30777.00","18466.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","8646.41","","APC Price ($8,646.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8481.96","8479.96","8482.36","1 through 10","8473.48","55258.59","other","OPPS APC"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","30777.00","18466.20","MEDICARE [2001]","HB WDH MEDICARE","8646.41","","APC Price ($8,646.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8647.41","8647.41","16555.42","18","8473.48","55258.59","other","OPPS APC"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","both","","","30777.00","18466.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8646.41","","APC Price ($8,646.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8489.70","8112.16","8647.41","1 through 10","8473.48","55258.59","other","OPPS APC"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","outpatient","","","30777.00","18466.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","21597.11","21597.11","21597.11","1 through 10","16379.52","23821.4","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Insertion Subq Cardiac Rhythm Monitor W/Prgrmg","PX-36000448","CDM","33285","CPT","0361","RC","","","","outpatient","","","30777.00","18466.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","19358.73","62.9","","18710.37","18710.37","18710.37","1 through 10","16379.52","23821.4","percent of total billed charges",""
"Insj 1 Transvns Eltrd Perm Pacemaker/Impltbl Dfb","PX-48000052","CDM","33216","CPT","0361","RC","","","","both","","","36755.00","22053.00","MEDICARE [2001]","HB WDH MEDICARE","8646.41","","APC Price ($8,646.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","16555.42","8647.41","16555.42","1 through 10","8473.48","55258.59","other","OPPS APC"
"INSPIRE V IMPLANTABLE PULSE GENERATOR","SUP-ITM-10331441","CDM","C1767","HCPCS","0278","RC","","","","outpatient","","","50976.00","30585.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","32063.90","62.9","","79618.14","79618.14","79618.14","1 through 10","5928.51","39455.42","percent of total billed charges",""
"Instill Anticarcinogen Agnt Bladder","PX-76001263","CDM","51720","CPT","0761","RC","","","","both","","","380.00","228.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","216.22","56.9","","14964.70","14964.70","14964.70","1 through 10","216.22","4456.66","percent of total billed charges",""
"Insulin Antibody","PX-30000841","CDM","86337","CPT","0302","RC","","","","outpatient","","","115.00","69.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","83.63","72.72","","80.72","80.72","80.72","1 through 10","19.95","89.01","percent of total billed charges",""
"Insulin Antibody","PX-30000841","CDM","86337","CPT","0302","RC","","","","outpatient","","","115.00","69.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","72.34","62.9","","69.93","69.93","69.93","1 through 10","19.95","89.01","percent of total billed charges",""
"Insulin Antibody","PX-30000841","CDM","86337","CPT","0302","RC","","","","outpatient","","","115.00","69.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","89.01","77.4","","86.03","86.03","86.03","1 through 10","19.95","89.01","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","both","","","61.00","36.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","42.58","69.8","","41.18","37.11","41.18","14","7.43","58.69","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","outpatient","","","61.00","36.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","38.30","62.78","","37.04","25.79","37.04","1 through 10","10.65","47.21","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","outpatient","","","61.00","36.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","26.67","43.72","","25.79","25.79","25.79","1 through 10","10.65","47.21","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","outpatient","","","61.00","36.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","44.36","72.72","","42.90","42.90","42.90","30","10.65","47.21","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","outpatient","","","61.00","36.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","44.36","72.72","","42.90","42.90","42.90","1 through 10","10.65","47.21","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","outpatient","","","61.00","36.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","32.46","53.22","","31.45","31.45","31.45","1 through 10","10.65","47.21","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","outpatient","","","61.00","36.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","38.37","62.9","","37.17","37.17","37.17","33","10.65","47.21","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","outpatient","","","61.00","36.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","47.21","77.4","","45.73","45.73","45.73","1 through 10","10.65","47.21","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","6845.00","4107.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","4777.81","69.8","","4610.29","4154.55","4610.29","85","592.28","5818.25","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","6845.00","4107.00","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","616.45","","APC Price ($604.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","604.43","604.43","604.43","24","592.28","5818.25","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","6845.00","4107.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","3862.47","","Case rate ($3,862.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3768.27","3728.31","3768.27","154","592.28","5818.25","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","6845.00","4107.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1663.17","","Case rate ($1,663.17). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1605.42","1460.38","1622.63","138","592.28","5818.25","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","6845.00","4107.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","592.28","","APC Price ($604.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","594.76","592.34","604.43","253","592.28","5818.25","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","6845.00","4107.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","3122.00","","Case rate ($3,122.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3045.83","2741.25","3045.83","153","592.28","5818.25","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","6845.00","4107.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","622.49","","APC Price ($604.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","612.60","610.11","612.60","85","592.28","5818.25","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","6845.00","4107.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","604.36","","APC Price ($604.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","604.43","604.43","604.43","33","592.28","5818.25","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","6845.00","4107.00","MEDICARE [2001]","HB WDH MEDICARE","604.36","","APC Price ($604.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","604.43","573.56","604.43","1127","592.28","5818.25","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","6845.00","4107.00","TRICARE [160005]","HB WDH MEDICARE","604.36","","APC Price ($604.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","604.43","604.43","604.43","30","592.28","5818.25","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","6845.00","4107.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","604.36","","APC Price ($604.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","594.76","573.56","604.43","472","592.28","5818.25","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","both","","","6845.00","4107.00","WELLSENSE NH [1050]","HB WDH MEDICARE","604.36","","APC Price ($604.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","624.50","621.96","1243.92","43","592.28","5818.25","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","outpatient","","","6845.00","4107.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","987.05","14.42","","816.38","816.38","952.44","215","796.07","5298.03","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","outpatient","","","6845.00","4107.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","796.07","11.63","","909.51","815.60","2340.48","131","796.07","5298.03","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","outpatient","","","6845.00","4107.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4977.68","72.72","","4803.16","4803.16","14409.48","138","796.07","5298.03","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","outpatient","","","6845.00","4107.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4305.51","62.9","","4161.15","4161.15","4161.15","41","796.07","5298.03","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","outpatient","","","6845.00","4107.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5298.03","77.4","","5118.88","5118.88","5118.88","25","796.07","5298.03","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","outpatient","","","6845.00","4107.00","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","4977.68","72.72","","4803.16","4803.16","4803.16","1 through 10","796.07","5298.03","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Complex","PX-33000108","CDM","77386","CPT","0333","RC","","","","outpatient","","","6845.00","4107.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","796.07","11.63","","947.75","780.16","2340.48","189","796.07","5298.03","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","6560.00","3936.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","4578.88","69.8","","4418.34","3981.57","4418.34","110","592.28","5576","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","6560.00","3936.00","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","616.45","","APC Price ($604.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","604.43","604.43","604.43","282","592.28","5576","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","6560.00","3936.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","3862.47","","Case rate ($3,862.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3768.27","3768.27","3768.27","68","592.28","5576","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","6560.00","3936.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1663.17","","Case rate ($1,663.17). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1622.63","1605.42","1622.63","65","592.28","5576","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","6560.00","3936.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","592.28","","APC Price ($604.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","594.76","592.34","604.43","193","592.28","5576","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","6560.00","3936.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","3122.00","","Case rate ($3,122.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3045.83","1994.42","3045.83","43","592.28","5576","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","6560.00","3936.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","622.49","","APC Price ($604.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","612.60","610.11","612.60","67","592.28","5576","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","6560.00","3936.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","604.36","","APC Price ($604.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","604.43","573.56","604.43","82","592.28","5576","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","6560.00","3936.00","MEDICARE [2001]","HB WDH MEDICARE","604.36","","APC Price ($604.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","604.43","604.43","604.43","1259","592.28","5576","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","both","","","6560.00","3936.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","604.36","","APC Price ($604.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","594.76","592.35","604.43","572","592.28","5576","other","OPPS APC"
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","outpatient","","","6560.00","3936.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","945.95","14.42","","782.39","782.39","782.39","1 through 10","762.93","5077.44","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","outpatient","","","6560.00","3936.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4770.43","72.72","","4603.18","4166.41","4603.18","65","762.93","5077.44","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","outpatient","","","6560.00","3936.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4126.24","62.9","","3987.90","3987.90","3987.90","111","762.93","5077.44","percent of total billed charges",""
"Intensity Modulated Radiation Tx Dlvr Simple","PX-33000107","CDM","77385","CPT","0333","RC","","","","outpatient","","","6560.00","3936.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5077.44","77.4","","4905.75","4905.75","4905.75","78","762.93","5077.44","percent of total billed charges",""
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","14600.00","8760.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","10190.80","69.8","","9834.12","9834.12","9834.12","1 through 10","1400.91","12626.01","percent of total billed charges",""
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","14600.00","8760.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","9135.87","","Case rate ($9,135.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8913.06","8913.06","8913.06","1 through 10","1400.91","12626.01","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","14600.00","8760.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","3933.90","","Case rate ($3,933.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3837.99","3454.22","10150.55","1 through 10","1400.91","12626.01","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","14600.00","8760.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1400.91","","APC Price ($1,429.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1401.08","1350.07","1429.67","26","1400.91","12626.01","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","14600.00","8760.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","7384.44","","Case rate ($7,384.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7093.44","6384.10","20385.14","12","1400.91","12626.01","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","14600.00","8760.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","1472.39","","APC Price ($1,429.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1449.00","1443.11","1449.00","13","1400.91","12626.01","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","14600.00","8760.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","1429.50","","APC Price ($1,429.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1406.80","1401.08","1406.80","29","1400.91","12626.01","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","14600.00","8760.00","MEDICARE [2001]","HB WDH MEDICARE","1429.50","","APC Price ($1,429.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1429.67","1350.07","1429.67","120","1400.91","12626.01","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","14600.00","8760.00","TRICARE [160005]","HB WDH MEDICARE","1429.50","","APC Price ($1,429.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1429.67","1429.67","1429.67","1 through 10","1400.91","12626.01","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","14600.00","8760.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1429.50","","APC Price ($1,429.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1406.80","1401.08","1429.67","56","1400.91","12626.01","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","both","","","14600.00","8760.00","WELLSENSE NH [1050]","HB WDH MEDICARE","1429.50","","APC Price ($1,429.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2954.26","1471.13","4431.39","1 through 10","1400.91","12626.01","other","OPPS APC"
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","outpatient","","","14600.00","8760.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2105.32","14.42","","1741.40","1741.40","2031.63","11","1697.98","11300.4","percent of total billed charges",""
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","outpatient","","","14600.00","8760.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1697.98","11.63","","1940.06","1664.14","3558.21","1 through 10","1697.98","11300.4","percent of total billed charges",""
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","outpatient","","","14600.00","8760.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10617.12","72.72","","10245.52","10245.52","10245.52","1 through 10","1697.98","11300.4","percent of total billed charges",""
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","outpatient","","","14600.00","8760.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","9183.40","62.9","","8876.07","8876.07","8876.07","1 through 10","1697.98","11300.4","percent of total billed charges",""
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","outpatient","","","14600.00","8760.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","11300.40","77.4","","10918.98","10918.98","10918.98","1 through 10","1697.98","11300.4","percent of total billed charges",""
"Intensity Modulated Treatment Plan","PX-33000089","CDM","77301","CPT","0333","RC","","","","outpatient","","","14600.00","8760.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1697.98","11.63","","2241.72","1664.14","2287.47","1 through 10","1697.98","11300.4","percent of total billed charges",""
"INTERBODY FUSION DEVICE 6 DEG MEDIUM 8MM 5366-1408","SUP-ITM-10259539","CDM","C1821","HCPCS","0278","RC","","","","both","","","7881.25","4728.75","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4484.43","56.9","","166.05","166.05","166.05","1 through 10","916.59","6699.06","percent of total billed charges",""
"Interrog Dev Eval Implant Loop Rec","PX-48000017","CDM","93291","CPT","0480","RC","","","","both","","","173.00","103.80","MEDICARE [2001]","HB WDH MEDICARE","25.59","","APC Price ($25.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","25.59","25.59","25.59","1 through 10","25.07","163.55","other","OPPS APC"
"Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb","PX-48000015","CDM","93289","CPT","0480","RC","","","","both","","","329.00","197.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","36.74","36.74","36.74","1 through 10","38.18","279.65","other","OPPS APC"
"Interrogation Dev Eval Pacemaker","PX-48000014","CDM","93288","CPT","0480","RC","","","","both","","","388.00","232.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.22","38.22","38.30","1 through 10","38.18","329.8","other","OPPS APC"
"Interrogation Dev Eval Pacemaker","PX-48000014","CDM","93288","CPT","0480","RC","","","","both","","","388.00","232.80","MEDICARE [2001]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.96","38.96","38.96","1 through 10","38.18","329.8","other","OPPS APC"
"Interrogation Dev Eval Pacemaker","PX-48000014","CDM","93288","CPT","0480","RC","","","","both","","","388.00","232.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.96","38.34","38.96","1 through 10","38.18","329.8","other","OPPS APC"
"Interrogation Eval F2f Implant Subq Lead Defib","PX-48000422","CDM","93261","CPT","0480","RC","","","","both","","","223.00","133.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.18","38.18","38.18","1 through 10","38.18","248.99","other","OPPS APC"
"Interrogation Eval F2f Implant Subq Lead Defib","PX-48000422","CDM","93261","CPT","0480","RC","","","","both","","","223.00","133.80","MEDICARE [2001]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.96","38.96","38.96","1 through 10","38.18","248.99","other","OPPS APC"
"Interrogation Eval F2f Implant Subq Lead Defib","PX-48000422","CDM","93261","CPT","0480","RC","","","","outpatient","","","223.00","133.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","25.93","11.63","","54.31","25.40","54.31","1 through 10","25.93","172.6","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","226.00","135.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","157.75","69.8","","152.16","137.12","152.16","13","32.59","248.99","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","226.00","135.60","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","39.74","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","38.96","38.96","38.96","63","32.59","248.99","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","226.00","135.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","248.99","","Case rate ($248.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","218.00","218.00","218.00","13","32.59","248.99","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","226.00","135.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","107.21","","Case rate ($107.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.60","102.85","104.60","19","32.59","248.99","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","226.00","135.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","38.18","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","38.18","38.18","38.96","128","32.59","248.99","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","226.00","135.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","201.25","","Case rate ($201.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","196.34","104.60","196.34","24","32.59","248.99","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","226.00","135.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","128.59","56.9","","124.04","124.04","124.04","25","32.59","248.99","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","226.00","135.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","32.59","14.42","","26.94","26.94","26.94","1 through 10","32.59","248.99","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","226.00","135.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","40.13","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","40.13","39.49","40.13","48","32.59","248.99","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","226.00","135.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.18","38.18","38.96","173","32.59","248.99","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","226.00","135.60","MEDICARE [2001]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.96","36.74","38.96","829","32.59","248.99","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","226.00","135.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","142.15","62.9","","137.34","137.34","137.34","13","32.59","248.99","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","226.00","135.60","TRICARE [160005]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.96","38.96","38.96","1 through 10","32.59","248.99","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","226.00","135.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.69","36.74","38.96","283","32.59","248.99","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","226.00","135.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","174.92","77.4","","168.95","168.95","168.95","1 through 10","32.59","248.99","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","226.00","135.60","WELLPOINT [1015]","HB WDH ANTHEM PPO","201.25","","Case rate ($201.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","196.34","193.06","196.34","1 through 10","32.59","248.99","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","both","","","226.00","135.60","WELLSENSE NH [1050]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","80.18","40.09","80.18","12","32.59","248.99","other","OPPS APC"
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","outpatient","","","226.00","135.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","26.28","11.63","","30.02","25.74","30.02","15","26.28","164.35","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","outpatient","","","226.00","135.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","141.88","62.78","","95.31","95.31","95.31","1 through 10","26.28","164.35","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","outpatient","","","226.00","135.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","98.81","43.72","","95.31","95.31","95.31","1 through 10","26.28","164.35","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","outpatient","","","226.00","135.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","164.35","72.72","","158.53","158.53","158.53","15","26.28","164.35","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","outpatient","","","226.00","135.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","164.35","72.72","","158.53","158.53","158.53","1 through 10","26.28","164.35","percent of total billed charges",""
"Interrogation Remote </90 D Technician Review","PX-48000020","CDM","93296","CPT","0480","RC","","","","outpatient","","","226.00","135.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","26.28","11.63","","25.74","25.74","61.40","1 through 10","26.28","164.35","percent of total billed charges",""
"INTERSPACE SPACER 46X150MM SM FEMORAL SS GENTAMICIN HIGH RELEASE STEM CLASSIC","SUP-ITM-10046523","CDM","C1776","HCPCS","0278","RC","","","","both","","","13857.20","8314.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1611.59","11778.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTERSPACE SPACER 46X150MM SM FEMORAL SS GENTAMICIN HIGH RELEASE STEM CLASSIC","SUP-ITM-10046523","CDM","C1776","HCPCS","0278","RC","","","","both","","","13857.20","8314.32","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7884.75","56.9","","2911.53","1863.86","5209.05","65","1611.59","11778.62","percent of total billed charges",""
"INTERSPACE SPACER 46X150MM SM FEMORAL SS GENTAMICIN HIGH RELEASE STEM CLASSIC","SUP-ITM-10046523","CDM","C1776","HCPCS","0278","RC","","","","both","","","13857.20","8314.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1611.59","11.63","","400.94","400.94","400.94","1 through 10","1611.59","11778.62","percent of total billed charges",""
"INTERSPACE SPACER 46X150MM SM FEMORAL SS GENTAMICIN HIGH RELEASE STEM CLASSIC","SUP-ITM-10046523","CDM","C1776","HCPCS","0278","RC","","","","both","","","13857.20","8314.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10725.47","77.4","","5214.50","5214.50","16415.28","1 through 10","1611.59","11778.62","percent of total billed charges",""
"INTERSPACE SPACER 46X150MM SM FEMORAL SS GENTAMICIN HIGH RELEASE STEM CLASSIC","SUP-ITM-10046523","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1611.59","11.63","","400.94","400.94","400.94","1 through 10","1611.59","10725.47","percent of total billed charges",""
"INTERSPACE SPACER 46X150MM SM FEMORAL SS GENTAMICIN HIGH RELEASE STEM CLASSIC","SUP-ITM-10046523","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","6058.37","43.72","","1543.33","1543.33","1671.61","1 through 10","1611.59","10725.47","percent of total billed charges",""
"INTERSPACE SPACER 46X150MM SM FEMORAL SS GENTAMICIN HIGH RELEASE STEM CLASSIC","SUP-ITM-10046523","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10076.96","72.72","","3700.21","2382.07","6427.18","53","1611.59","10725.47","percent of total billed charges",""
"INTERSPACE SPACER 46X150MM SM FEMORAL SS GENTAMICIN HIGH RELEASE STEM CLASSIC","SUP-ITM-10046523","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","10076.96","72.72","","12685.80","12685.80","12685.80","1 through 10","1611.59","10725.47","percent of total billed charges",""
"INTERSPACE SPACER 46X150MM SM FEMORAL SS GENTAMICIN HIGH RELEASE STEM CLASSIC","SUP-ITM-10046523","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8716.18","62.9","","3408.87","2784.05","9859.40","46","1611.59","10725.47","percent of total billed charges",""
"INTERSPACE SPACER 46X150MM SM FEMORAL SS GENTAMICIN HIGH RELEASE STEM CLASSIC","SUP-ITM-10046523","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10725.47","77.4","","5214.50","5214.50","16415.28","1 through 10","1611.59","10725.47","percent of total billed charges",""
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","","","","inpatient","","","44186.67","26512.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","28724.78","","Fee schedule rate ($28,724.78). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","25327.20","25327.20","25327.20","1 through 10","3975","36065.89","case rate",""
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","","","","inpatient","","","44186.67","26512.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","7660.33","","Case rate ($7,660.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,104.67, add-ons for qualifying new technology services are included. If operating cost exceeds $11,022.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,332.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,688.20 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,659.80 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.27. The transfer capital threshold is the transfer adjustment factor * $527.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9533.28","9533.28","9533.28","1 through 10","3975","36065.89","other","Inpatient DRG"
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","","","","inpatient","","","44186.67","26512.00","MEDICARE [2001]","HB WDH MEDICARE","7660.33","","Case rate ($7,660.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,104.67, add-ons for qualifying new technology services are included. If operating cost exceeds $11,022.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,332.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,688.20 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,659.80 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $527.27. The transfer capital threshold is the transfer adjustment factor * $527.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7914.88","7914.88","7914.88","1 through 10","3975","36065.89","other","Inpatient DRG"
"Interstitial Lung Disease With McC","196","MS-DRG","","","","","","","","inpatient","","","51624.38","30974.63","MARTIN'S POINT [160007]","HB WDH MEDICARE","14792.18","","Case rate ($14,792.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,687.28, add-ons for qualifying new technology services are included. If operating cost exceeds $17,605.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,853.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,298.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,242.41 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.42. The transfer capital threshold is the transfer adjustment factor * $1,048.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14419.44","14419.44","14419.44","1 through 10","3975","71713.79","other","Inpatient DRG"
"Interstitial Lung Disease With McC","196","MS-DRG","","","","","","","","inpatient","","","51624.38","30974.63","MEDICARE [2001]","HB WDH MEDICARE","14792.18","","Case rate ($14,792.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,687.28, add-ons for qualifying new technology services are included. If operating cost exceeds $17,605.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,853.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,298.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,242.41 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.42. The transfer capital threshold is the transfer adjustment factor * $1,048.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12080.83","0.05","14698.41","1 through 10","3975","71713.79","other","Inpatient DRG"
"Interstitial Lung Disease With McC","196","MS-DRG","","","","","","","","inpatient","","","51624.38","30974.63","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","14792.18","","Case rate ($14,792.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,687.28, add-ons for qualifying new technology services are included. If operating cost exceeds $17,605.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,853.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,298.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,242.41 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.42. The transfer capital threshold is the transfer adjustment factor * $1,048.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14443.95","14443.95","14698.41","1 through 10","3975","71713.79","other","Inpatient DRG"
"Interstitial Lung Disease Without Cc/McC","198","MS-DRG","","","","","","","","inpatient","","","65021.96","39013.18","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","5889.74","","Case rate ($5,889.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,470.42, add-ons for qualifying new technology services are included. If operating cost exceeds $9,388.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,202.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,046.98 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,025.55 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $397.88. The transfer capital threshold is the transfer adjustment factor * $397.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5644.40","5644.40","5644.40","1 through 10","3975","27215.67","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","49369.93","29621.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","7963.10","","Case rate ($8,125.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,534.11, add-ons for qualifying new technology services are included. If operating cost exceeds $11,452.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,366.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,119.47 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,089.24 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.27. The transfer capital threshold is the transfer adjustment factor * $561.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7978.89","7978.89","7978.89","1 through 10","4637","38391.5","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","49369.93","29621.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","30577.01","","Fee schedule rate ($30,577.01). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","30026.10","30026.10","30026.10","1 through 10","4637","38391.5","case rate",""
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","49369.93","29621.96","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","8369.38","","Case rate ($8,125.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,534.11, add-ons for qualifying new technology services are included. If operating cost exceeds $11,452.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,366.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,119.47 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,089.24 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.27. The transfer capital threshold is the transfer adjustment factor * $561.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","4986.04","4986.04","4986.04","1 through 10","4637","38391.5","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","49369.93","29621.96","MARTIN'S POINT [160007]","HB WDH MEDICARE","8125.61","","Case rate ($8,125.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,534.11, add-ons for qualifying new technology services are included. If operating cost exceeds $11,452.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,366.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,119.47 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,089.24 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.27. The transfer capital threshold is the transfer adjustment factor * $561.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7982.59","7982.59","7982.59","1 through 10","4637","38391.5","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","49369.93","29621.96","MEDICARE [2001]","HB WDH MEDICARE","8125.61","","Case rate ($8,125.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,534.11, add-ons for qualifying new technology services are included. If operating cost exceeds $11,452.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,366.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,119.47 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,089.24 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.27. The transfer capital threshold is the transfer adjustment factor * $561.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8117.85","1187.27","8137.85","27","4637","38391.5","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","49369.93","29621.96","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8125.61","","Case rate ($8,125.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,534.11, add-ons for qualifying new technology services are included. If operating cost exceeds $11,452.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,366.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,119.47 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,089.24 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $561.27. The transfer capital threshold is the transfer adjustment factor * $561.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7986.10","5841.24","8137.85","1 through 10","4637","38391.5","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","58692.43","35215.46","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","16048.04","","Case rate ($15,733.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,555.98, add-ons for qualifying new technology services are included. If operating cost exceeds $18,474.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,922.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,171.30 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,111.12 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,117.20. The transfer capital threshold is the transfer adjustment factor * $1,117.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","8117.80","8117.80","8117.80","1 through 10","3975","76418.2","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","58692.43","35215.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","15418.70","","Case rate ($15,733.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,555.98, add-ons for qualifying new technology services are included. If operating cost exceeds $18,474.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,922.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,171.30 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,111.12 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,117.20. The transfer capital threshold is the transfer adjustment factor * $1,117.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10259.27","10259.27","10259.27","1 through 10","3975","76418.2","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","58692.43","35215.46","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","16205.37","","Case rate ($15,733.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,555.98, add-ons for qualifying new technology services are included. If operating cost exceeds $18,474.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,922.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,171.30 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,111.12 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,117.20. The transfer capital threshold is the transfer adjustment factor * $1,117.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","32711.17","32711.17","32711.17","1 through 10","3975","76418.2","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","58692.43","35215.46","MARTIN'S POINT [160007]","HB WDH MEDICARE","15733.37","","Case rate ($15,733.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,555.98, add-ons for qualifying new technology services are included. If operating cost exceeds $18,474.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,922.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,171.30 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,111.12 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,117.20. The transfer capital threshold is the transfer adjustment factor * $1,117.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21577.15","21577.15","21577.15","1 through 10","3975","76418.2","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","58692.43","35215.46","MEDICARE [2001]","HB WDH MEDICARE","15733.37","","Case rate ($15,733.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,555.98, add-ons for qualifying new technology services are included. If operating cost exceeds $18,474.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,922.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,171.30 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,111.12 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,117.20. The transfer capital threshold is the transfer adjustment factor * $1,117.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10477.78","0.05","15493.52","34","3975","76418.2","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","58692.43","35215.46","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","15733.37","","Case rate ($15,733.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,555.98, add-ons for qualifying new technology services are included. If operating cost exceeds $18,474.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,922.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,171.30 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,111.12 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,117.20. The transfer capital threshold is the transfer adjustment factor * $1,117.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15169.33","13821.60","15207.65","1 through 10","3975","76418.2","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","58692.43","35215.46","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","41205.39","","Fee schedule rate ($41,205.39). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","18114.98","18114.98","18114.98","1 through 10","3975","76418.2","case rate",""
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC","066","MS-DRG","","","","","","","","inpatient","","","41359.20","24815.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","20713.56","","Fee schedule rate ($20,713.56). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","10047.75","10047.75","10047.75","1 through 10","3975","26007.27","case rate",""
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC","066","MS-DRG","","","","","","","","inpatient","","","41359.20","24815.52","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","5817.42","","Case rate ($5,647.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,247.28, add-ons for qualifying new technology services are included. If operating cost exceeds $9,165.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,185.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,822.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,802.41 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.21. The transfer capital threshold is the transfer adjustment factor * $380.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","2467.66","2467.66","2467.66","1 through 10","3975","26007.27","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC","066","MS-DRG","","","","","","","","inpatient","","","41359.20","24815.52","MEDICARE [2001]","HB WDH MEDICARE","5647.98","","Case rate ($5,647.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,247.28, add-ons for qualifying new technology services are included. If operating cost exceeds $9,165.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,185.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,822.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,802.41 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.21. The transfer capital threshold is the transfer adjustment factor * $380.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5638.38","2964.29","5651.92","1 through 10","3975","26007.27","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC","066","MS-DRG","","","","","","","","inpatient","","","41359.20","24815.52","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","5647.98","","Case rate ($5,647.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,247.28, add-ons for qualifying new technology services are included. If operating cost exceeds $9,165.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,185.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $4,822.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,802.41 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $380.21. The transfer capital threshold is the transfer adjustment factor * $380.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5551.98","5551.98","5551.98","1 through 10","3975","26007.27","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC","066","MS-DRG","","","","","","","","inpatient","","","41359.20","24815.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","14023.36","","Fee schedule rate ($14,023.36). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","14103.27","14103.27","14103.27","1 through 10","3975","26007.27","case rate",""
"Intrinsic Factor Antibody","PX-30000842","CDM","86340","CPT","0302","RC","","","","outpatient","","","81.00","48.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","58.90","72.72","","56.72","56.72","56.72","1 through 10","18.06","62.69","percent of total billed charges",""
"Intro Cath Dialysis Circuit Dx Angrph Fluor S&I","PX-36000407","CDM","36901","CPT","0361","RC","","","","both","","","5863.00","3517.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","4092.37","69.8","","3949.28","3949.28","3949.28","1 through 10","1590.51","10372.29","percent of total billed charges",""
"Intro Cath Dialysis Circuit Dx Angrph Fluor S&I","PX-36000407","CDM","36901","CPT","0361","RC","","","","both","","","5863.00","3517.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","10372.29","","Case rate ($10,372.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6051.70","6051.70","6051.70","1 through 10","1590.51","10372.29","other","OPPS APC"
"Intro Cath Dialysis Circuit Dx Angrph Fluor S&I","PX-36000407","CDM","36901","CPT","0361","RC","","","","both","","","5863.00","3517.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","1671.66","","APC Price ($1,622.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1649.41","1649.41","1649.41","1 through 10","1590.51","10372.29","other","OPPS APC"
"Intro Cath Dialysis Circuit Dx Angrph Fluor S&I","PX-36000407","CDM","36901","CPT","0361","RC","","","","both","","","5863.00","3517.80","MEDICARE [2001]","HB WDH MEDICARE","1622.97","","APC Price ($1,622.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1623.16","1623.16","4869.48","1 through 10","1590.51","10372.29","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Tcat Plmt IV Stent","PX-36000409","CDM","36903","CPT","0361","RC","","","","both","","","48938.00","29362.80","MEDICARE [2001]","HB WDH MEDICARE","11848.17","","APC Price ($11,848.17). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","35548.59","22128.68","35548.59","1 through 10","11611.21","75720.79","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","both","","","24713.00","14827.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","6075.85","","APC Price ($5,956.72). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","5957.40","5957.40","5957.40","1 through 10","5837.59","38068.95","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","both","","","24713.00","14827.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","5837.59","","APC Price ($5,956.72). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5858.62","5457.64","5862.08","1 through 10","5837.59","38068.95","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","both","","","24713.00","14827.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","14061.70","56.9","","13568.95","13568.95","13568.95","1 through 10","5837.59","38068.95","percent of total billed charges",""
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","both","","","24713.00","14827.80","MEDICARE [2001]","HB WDH MEDICARE","5956.72","","APC Price ($5,956.72). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","17872.20","11138.04","17872.20","84","5837.59","38068.95","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","both","","","24713.00","14827.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","5956.72","","APC Price ($5,956.72). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5846.16","5838.26","5957.40","1 through 10","5837.59","38068.95","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","outpatient","","","24713.00","14827.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2874.12","11.63","","3283.73","3283.73","3283.73","1 through 10","2874.12","19127.86","percent of total billed charges",""
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","outpatient","","","24713.00","14827.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3242.64","3242.64","3242.64","1 through 10","2874.12","19127.86","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","both","","","670.20","402.12","AETNA [1001]","HB WDH AETNA COMMERCIAL","467.80","69.8","","94.15","94.15","427.63","1 through 10","77.94","569.67","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","both","","","670.20","402.12","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","77.94","569.67","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","both","","","670.20","402.12","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","381.34","56.9","","401.89","65.85","401.89","1 through 10","77.94","569.67","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","both","","","670.20","402.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","77.94","11.63","","49.19","10.57","114.40","19","77.94","569.67","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","both","","","670.20","402.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","518.73","77.4","","200.75","81.67","643.86","11","77.94","569.67","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","both","","","670.20","402.12","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","77.94","569.67","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","670.20","402.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","77.94","11.63","","49.19","10.57","114.40","19","77.94","518.73","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","670.20","402.12","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","420.75","62.78","","93.27","93.27","93.27","1 through 10","77.94","518.73","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","670.20","402.12","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","293.01","43.72","","363.22","363.22","363.22","1 through 10","77.94","518.73","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","670.20","402.12","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","487.37","72.72","","271.85","111.24","551.69","14","77.94","518.73","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","670.20","402.12","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","421.56","62.9","","706.53","93.60","938.00","53","77.94","518.73","percent of total billed charges",""
"INTRODUCER FLEXOR 10FR 3.4MM 80CM .038IN LARGE CHECK-FLO VALVE VASCULAR","SUP-ITM-10006970","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","670.20","402.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","518.73","77.4","","200.75","81.67","643.86","11","77.94","518.73","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10021399","CDM","C1894","HCPCS","0272","RC","","","","both","","","525.09","315.05","AETNA [1001]","HB WDH AETNA COMMERCIAL","366.51","69.8","","94.15","94.15","427.63","1 through 10","61.07","446.33","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10021399","CDM","C1894","HCPCS","0272","RC","","","","both","","","525.09","315.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","61.07","446.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER FLEXOR 5FR 1.9MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10021399","CDM","C1894","HCPCS","0272","RC","","","","both","","","525.09","315.05","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","298.78","56.9","","401.89","65.85","401.89","1 through 10","61.07","446.33","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10021399","CDM","C1894","HCPCS","0272","RC","","","","both","","","525.09","315.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","61.07","11.63","","49.19","10.57","114.40","19","61.07","446.33","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10021399","CDM","C1894","HCPCS","0272","RC","","","","both","","","525.09","315.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","406.42","77.4","","200.75","81.67","643.86","11","61.07","446.33","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10021399","CDM","C1894","HCPCS","0272","RC","","","","both","","","525.09","315.05","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","61.07","446.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER FLEXOR 5FR 1.9MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10021399","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","525.09","315.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","61.07","11.63","","49.19","10.57","114.40","19","61.07","406.42","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10021399","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","525.09","315.05","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","329.65","62.78","","93.27","93.27","93.27","1 through 10","61.07","406.42","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10021399","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","525.09","315.05","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","229.57","43.72","","363.22","363.22","363.22","1 through 10","61.07","406.42","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10021399","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","525.09","315.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","381.85","72.72","","271.85","111.24","551.69","14","61.07","406.42","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10021399","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","525.09","315.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","330.28","62.9","","706.53","93.60","938.00","53","61.07","406.42","percent of total billed charges",""
"INTRODUCER FLEXOR 5FR 1.9MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10021399","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","525.09","315.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","406.42","77.4","","200.75","81.67","643.86","11","61.07","406.42","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10013684","CDM","C1894","HCPCS","0272","RC","","","","both","","","525.09","315.05","AETNA [1001]","HB WDH AETNA COMMERCIAL","366.51","69.8","","94.15","94.15","427.63","1 through 10","61.07","446.33","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10013684","CDM","C1894","HCPCS","0272","RC","","","","both","","","525.09","315.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","61.07","446.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER FLEXOR 6FR 2.2MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10013684","CDM","C1894","HCPCS","0272","RC","","","","both","","","525.09","315.05","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","298.78","56.9","","401.89","65.85","401.89","1 through 10","61.07","446.33","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10013684","CDM","C1894","HCPCS","0272","RC","","","","both","","","525.09","315.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","61.07","11.63","","49.19","10.57","114.40","19","61.07","446.33","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10013684","CDM","C1894","HCPCS","0272","RC","","","","both","","","525.09","315.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","406.42","77.4","","200.75","81.67","643.86","11","61.07","446.33","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10013684","CDM","C1894","HCPCS","0272","RC","","","","both","","","525.09","315.05","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","61.07","446.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER FLEXOR 6FR 2.2MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10013684","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","525.09","315.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","61.07","11.63","","49.19","10.57","114.40","19","61.07","406.42","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10013684","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","525.09","315.05","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","329.65","62.78","","93.27","93.27","93.27","1 through 10","61.07","406.42","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10013684","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","525.09","315.05","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","229.57","43.72","","363.22","363.22","363.22","1 through 10","61.07","406.42","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10013684","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","525.09","315.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","381.85","72.72","","271.85","111.24","551.69","14","61.07","406.42","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10013684","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","525.09","315.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","330.28","62.9","","706.53","93.60","938.00","53","61.07","406.42","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 45CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE RENAL DOUBLE TIP","SUP-ITM-10013684","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","525.09","315.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","406.42","77.4","","200.75","81.67","643.86","11","61.07","406.42","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR STRAIGHT TIP","SUP-ITM-10087198","CDM","C1894","HCPCS","0272","RC","","","","both","","","545.82","327.49","AETNA [1001]","HB WDH AETNA COMMERCIAL","380.98","69.8","","94.15","94.15","427.63","1 through 10","63.48","463.95","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR STRAIGHT TIP","SUP-ITM-10087198","CDM","C1894","HCPCS","0272","RC","","","","both","","","545.82","327.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","63.48","463.95","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR STRAIGHT TIP","SUP-ITM-10087198","CDM","C1894","HCPCS","0272","RC","","","","both","","","545.82","327.49","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","310.57","56.9","","401.89","65.85","401.89","1 through 10","63.48","463.95","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR STRAIGHT TIP","SUP-ITM-10087198","CDM","C1894","HCPCS","0272","RC","","","","both","","","545.82","327.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","63.48","11.63","","49.19","10.57","114.40","19","63.48","463.95","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR STRAIGHT TIP","SUP-ITM-10087198","CDM","C1894","HCPCS","0272","RC","","","","both","","","545.82","327.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","422.46","77.4","","200.75","81.67","643.86","11","63.48","463.95","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR STRAIGHT TIP","SUP-ITM-10087198","CDM","C1894","HCPCS","0272","RC","","","","both","","","545.82","327.49","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","63.48","463.95","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR STRAIGHT TIP","SUP-ITM-10087198","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","545.82","327.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","63.48","11.63","","49.19","10.57","114.40","19","63.48","422.46","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR STRAIGHT TIP","SUP-ITM-10087198","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","545.82","327.49","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","342.67","62.78","","93.27","93.27","93.27","1 through 10","63.48","422.46","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR STRAIGHT TIP","SUP-ITM-10087198","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","545.82","327.49","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","238.63","43.72","","363.22","363.22","363.22","1 through 10","63.48","422.46","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR STRAIGHT TIP","SUP-ITM-10087198","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","545.82","327.49","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","396.92","72.72","","271.85","111.24","551.69","14","63.48","422.46","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR STRAIGHT TIP","SUP-ITM-10087198","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","545.82","327.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","343.32","62.9","","706.53","93.60","938.00","53","63.48","422.46","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .035IN ANSEL GUIDING SHEATH CHECK-FLO VALVE HIGH-FLEX DILATOR STRAIGHT TIP","SUP-ITM-10087198","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","545.82","327.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","422.46","77.4","","200.75","81.67","643.86","11","63.48","422.46","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008789","CDM","C1894","HCPCS","0272","RC","","","","both","","","462.90","277.74","AETNA [1001]","HB WDH AETNA COMMERCIAL","323.10","69.8","","94.15","94.15","427.63","1 through 10","53.84","393.47","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008789","CDM","C1894","HCPCS","0272","RC","","","","both","","","462.90","277.74","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","53.84","393.47","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008789","CDM","C1894","HCPCS","0272","RC","","","","both","","","462.90","277.74","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","263.39","56.9","","401.89","65.85","401.89","1 through 10","53.84","393.47","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008789","CDM","C1894","HCPCS","0272","RC","","","","both","","","462.90","277.74","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","53.84","11.63","","49.19","10.57","114.40","19","53.84","393.47","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008789","CDM","C1894","HCPCS","0272","RC","","","","both","","","462.90","277.74","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","358.28","77.4","","200.75","81.67","643.86","11","53.84","393.47","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008789","CDM","C1894","HCPCS","0272","RC","","","","both","","","462.90","277.74","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","53.84","393.47","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008789","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","462.90","277.74","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","53.84","11.63","","49.19","10.57","114.40","19","53.84","358.28","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008789","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","462.90","277.74","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","290.61","62.78","","93.27","93.27","93.27","1 through 10","53.84","358.28","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008789","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","462.90","277.74","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","202.38","43.72","","363.22","363.22","363.22","1 through 10","53.84","358.28","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008789","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","462.90","277.74","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","336.62","72.72","","271.85","111.24","551.69","14","53.84","358.28","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008789","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","462.90","277.74","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","291.16","62.9","","706.53","93.60","938.00","53","53.84","358.28","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 55CM .038IN RAABE GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10008789","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","462.90","277.74","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","358.28","77.4","","200.75","81.67","643.86","11","53.84","358.28","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE MULTIPURPOSE TIP","SUP-ITM-10087076","CDM","C1894","HCPCS","0272","RC","","","","both","","","953.51","572.11","AETNA [1001]","HB WDH AETNA COMMERCIAL","665.55","69.8","","94.15","94.15","427.63","1 through 10","110.89","810.48","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE MULTIPURPOSE TIP","SUP-ITM-10087076","CDM","C1894","HCPCS","0272","RC","","","","both","","","953.51","572.11","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","110.89","810.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE MULTIPURPOSE TIP","SUP-ITM-10087076","CDM","C1894","HCPCS","0272","RC","","","","both","","","953.51","572.11","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","542.55","56.9","","401.89","65.85","401.89","1 through 10","110.89","810.48","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE MULTIPURPOSE TIP","SUP-ITM-10087076","CDM","C1894","HCPCS","0272","RC","","","","both","","","953.51","572.11","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","110.89","11.63","","49.19","10.57","114.40","19","110.89","810.48","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE MULTIPURPOSE TIP","SUP-ITM-10087076","CDM","C1894","HCPCS","0272","RC","","","","both","","","953.51","572.11","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","738.02","77.4","","200.75","81.67","643.86","11","110.89","810.48","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE MULTIPURPOSE TIP","SUP-ITM-10087076","CDM","C1894","HCPCS","0272","RC","","","","both","","","953.51","572.11","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","110.89","810.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE MULTIPURPOSE TIP","SUP-ITM-10087076","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","953.51","572.11","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","110.89","11.63","","49.19","10.57","114.40","19","110.89","738.02","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE MULTIPURPOSE TIP","SUP-ITM-10087076","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","953.51","572.11","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","598.61","62.78","","93.27","93.27","93.27","1 through 10","110.89","738.02","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE MULTIPURPOSE TIP","SUP-ITM-10087076","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","953.51","572.11","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","416.87","43.72","","363.22","363.22","363.22","1 through 10","110.89","738.02","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE MULTIPURPOSE TIP","SUP-ITM-10087076","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","953.51","572.11","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","693.39","72.72","","271.85","111.24","551.69","14","110.89","738.02","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE MULTIPURPOSE TIP","SUP-ITM-10087076","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","953.51","572.11","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","599.76","62.9","","706.53","93.60","938.00","53","110.89","738.02","percent of total billed charges",""
"INTRODUCER FLEXOR 6FR 2.2MM 90CM .018IN/.038IN ANSEL GUIDING SHEATH CHECK-FLO VALVE MULTIPURPOSE TIP","SUP-ITM-10087076","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","953.51","572.11","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","738.02","77.4","","200.75","81.67","643.86","11","110.89","738.02","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007253","CDM","C1894","HCPCS","0272","RC","","","","both","","","497.45","298.47","AETNA [1001]","HB WDH AETNA COMMERCIAL","347.22","69.8","","94.15","94.15","427.63","1 through 10","57.85","422.83","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007253","CDM","C1894","HCPCS","0272","RC","","","","both","","","497.45","298.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","57.85","422.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER FLEXOR 7FR 2.5MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007253","CDM","C1894","HCPCS","0272","RC","","","","both","","","497.45","298.47","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","283.05","56.9","","401.89","65.85","401.89","1 through 10","57.85","422.83","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007253","CDM","C1894","HCPCS","0272","RC","","","","both","","","497.45","298.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","57.85","11.63","","49.19","10.57","114.40","19","57.85","422.83","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007253","CDM","C1894","HCPCS","0272","RC","","","","both","","","497.45","298.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","385.03","77.4","","200.75","81.67","643.86","11","57.85","422.83","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007253","CDM","C1894","HCPCS","0272","RC","","","","both","","","497.45","298.47","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","57.85","422.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER FLEXOR 7FR 2.5MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007253","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","497.45","298.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","57.85","11.63","","49.19","10.57","114.40","19","57.85","385.03","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007253","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","497.45","298.47","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","312.30","62.78","","93.27","93.27","93.27","1 through 10","57.85","385.03","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007253","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","497.45","298.47","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","217.49","43.72","","363.22","363.22","363.22","1 through 10","57.85","385.03","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007253","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","497.45","298.47","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","361.75","72.72","","271.85","111.24","551.69","14","57.85","385.03","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007253","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","497.45","298.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","312.90","62.9","","706.53","93.60","938.00","53","57.85","385.03","percent of total billed charges",""
"INTRODUCER FLEXOR 7FR 2.5MM 40CM .038IN BALKIN GUIDING SHEATH CHECK-FLO VALVE VASCULAR","SUP-ITM-10007253","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","497.45","298.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","385.03","77.4","","200.75","81.67","643.86","11","57.85","385.03","percent of total billed charges",""
"INTRODUCER PEEL AWAY KIT 6F 1 4CM 5","SUP-ITM-10206835","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","207.30","124.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","130.39","62.9","","141.92","141.92","141.92","1 through 10","24.11","160.45","percent of total billed charges",""
"INTRODUCER PEEL-AWAY 10FR 30CM .038IN MULTIPURPOSE SHEATH STRAIGHT W/OUT HEMOSTATIC VALVE CORONARY SINUS ACCESS NEEDLE RADIOPAQUE SYRINGE","SUP-ITM-10087321","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","452.54","271.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","284.65","62.9","","141.92","141.92","141.92","1 through 10","52.63","350.27","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 35CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10007760","CDM","C1894","HCPCS","0272","RC","","","","both","","","822.22","493.33","AETNA [1001]","HB WDH AETNA COMMERCIAL","573.91","69.8","","94.15","94.15","427.63","1 through 10","95.62","698.89","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 35CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10007760","CDM","C1894","HCPCS","0272","RC","","","","both","","","822.22","493.33","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","95.62","698.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER PERFORMER 16FR 5.3MM 35CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10007760","CDM","C1894","HCPCS","0272","RC","","","","both","","","822.22","493.33","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","467.84","56.9","","401.89","65.85","401.89","1 through 10","95.62","698.89","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 35CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10007760","CDM","C1894","HCPCS","0272","RC","","","","both","","","822.22","493.33","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","95.62","11.63","","49.19","10.57","114.40","19","95.62","698.89","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 35CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10007760","CDM","C1894","HCPCS","0272","RC","","","","both","","","822.22","493.33","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","636.40","77.4","","200.75","81.67","643.86","11","95.62","698.89","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 35CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10007760","CDM","C1894","HCPCS","0272","RC","","","","both","","","822.22","493.33","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","95.62","698.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER PERFORMER 16FR 5.3MM 35CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10007760","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","822.22","493.33","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","95.62","11.63","","49.19","10.57","114.40","19","95.62","636.4","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 35CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10007760","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","822.22","493.33","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","516.19","62.78","","93.27","93.27","93.27","1 through 10","95.62","636.4","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 35CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10007760","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","822.22","493.33","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","359.47","43.72","","363.22","363.22","363.22","1 through 10","95.62","636.4","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 35CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10007760","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","822.22","493.33","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","597.92","72.72","","271.85","111.24","551.69","14","95.62","636.4","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 35CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10007760","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","822.22","493.33","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","517.18","62.9","","706.53","93.60","938.00","53","95.62","636.4","percent of total billed charges",""
"INTRODUCER PERFORMER 16FR 5.3MM 35CM .038IN RADIOPAQUE BAND VASCULAR","SUP-ITM-10007760","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","822.22","493.33","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","636.40","77.4","","200.75","81.67","643.86","11","95.62","636.4","percent of total billed charges",""
"INTRODUCER PERFORMER SET 14FR 4.6MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 10FR 12FR 14FR DILATORS VASCULAR","SUP-ITM-10007346","CDM","C1894","HCPCS","0272","RC","","","","both","","","359.25","215.55","AETNA [1001]","HB WDH AETNA COMMERCIAL","250.76","69.8","","94.15","94.15","427.63","1 through 10","41.78","305.36","percent of total billed charges",""
"INTRODUCER PERFORMER SET 14FR 4.6MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 10FR 12FR 14FR DILATORS VASCULAR","SUP-ITM-10007346","CDM","C1894","HCPCS","0272","RC","","","","both","","","359.25","215.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","41.78","305.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER PERFORMER SET 14FR 4.6MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 10FR 12FR 14FR DILATORS VASCULAR","SUP-ITM-10007346","CDM","C1894","HCPCS","0272","RC","","","","both","","","359.25","215.55","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","204.41","56.9","","401.89","65.85","401.89","1 through 10","41.78","305.36","percent of total billed charges",""
"INTRODUCER PERFORMER SET 14FR 4.6MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 10FR 12FR 14FR DILATORS VASCULAR","SUP-ITM-10007346","CDM","C1894","HCPCS","0272","RC","","","","both","","","359.25","215.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","41.78","11.63","","49.19","10.57","114.40","19","41.78","305.36","percent of total billed charges",""
"INTRODUCER PERFORMER SET 14FR 4.6MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 10FR 12FR 14FR DILATORS VASCULAR","SUP-ITM-10007346","CDM","C1894","HCPCS","0272","RC","","","","both","","","359.25","215.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","278.06","77.4","","200.75","81.67","643.86","11","41.78","305.36","percent of total billed charges",""
"INTRODUCER PERFORMER SET 14FR 4.6MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 10FR 12FR 14FR DILATORS VASCULAR","SUP-ITM-10007346","CDM","C1894","HCPCS","0272","RC","","","","both","","","359.25","215.55","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","41.78","305.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER PERFORMER SET 14FR 4.6MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 10FR 12FR 14FR DILATORS VASCULAR","SUP-ITM-10007346","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","359.25","215.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","41.78","11.63","","49.19","10.57","114.40","19","41.78","278.06","percent of total billed charges",""
"INTRODUCER PERFORMER SET 14FR 4.6MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 10FR 12FR 14FR DILATORS VASCULAR","SUP-ITM-10007346","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","359.25","215.55","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","225.54","62.78","","93.27","93.27","93.27","1 through 10","41.78","278.06","percent of total billed charges",""
"INTRODUCER PERFORMER SET 14FR 4.6MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 10FR 12FR 14FR DILATORS VASCULAR","SUP-ITM-10007346","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","359.25","215.55","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","157.06","43.72","","363.22","363.22","363.22","1 through 10","41.78","278.06","percent of total billed charges",""
"INTRODUCER PERFORMER SET 14FR 4.6MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 10FR 12FR 14FR DILATORS VASCULAR","SUP-ITM-10007346","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","359.25","215.55","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","261.25","72.72","","271.85","111.24","551.69","14","41.78","278.06","percent of total billed charges",""
"INTRODUCER PERFORMER SET 14FR 4.6MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 10FR 12FR 14FR DILATORS VASCULAR","SUP-ITM-10007346","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","359.25","215.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","225.97","62.9","","706.53","93.60","938.00","53","41.78","278.06","percent of total billed charges",""
"INTRODUCER PERFORMER SET 14FR 4.6MM 13CM .038IN GUIDEWIRE STRAIGHT TIP 3MM J TIP 10FR 12FR 14FR DILATORS VASCULAR","SUP-ITM-10007346","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","359.25","215.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","278.06","77.4","","200.75","81.67","643.86","11","41.78","278.06","percent of total billed charges",""
"INTRODUCER SENTRANT 14FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10209081","CDM","C1894","HCPCS","0272","RC","","","","both","","","1464.92","878.95","AETNA [1001]","HB WDH AETNA COMMERCIAL","1022.51","69.8","","94.15","94.15","427.63","1 through 10","170.37","1245.18","percent of total billed charges",""
"INTRODUCER SENTRANT 14FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10209081","CDM","C1894","HCPCS","0272","RC","","","","both","","","1464.92","878.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","170.37","1245.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER SENTRANT 14FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10209081","CDM","C1894","HCPCS","0272","RC","","","","both","","","1464.92","878.95","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","833.54","56.9","","401.89","65.85","401.89","1 through 10","170.37","1245.18","percent of total billed charges",""
"INTRODUCER SENTRANT 14FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10209081","CDM","C1894","HCPCS","0272","RC","","","","both","","","1464.92","878.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","170.37","11.63","","49.19","10.57","114.40","19","170.37","1245.18","percent of total billed charges",""
"INTRODUCER SENTRANT 14FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10209081","CDM","C1894","HCPCS","0272","RC","","","","both","","","1464.92","878.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1133.85","77.4","","200.75","81.67","643.86","11","170.37","1245.18","percent of total billed charges",""
"INTRODUCER SENTRANT 14FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10209081","CDM","C1894","HCPCS","0272","RC","","","","both","","","1464.92","878.95","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","170.37","1245.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER SENTRANT 14FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10209081","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1464.92","878.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","170.37","11.63","","49.19","10.57","114.40","19","170.37","1133.85","percent of total billed charges",""
"INTRODUCER SENTRANT 14FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10209081","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1464.92","878.95","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","919.68","62.78","","93.27","93.27","93.27","1 through 10","170.37","1133.85","percent of total billed charges",""
"INTRODUCER SENTRANT 14FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10209081","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1464.92","878.95","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","640.46","43.72","","363.22","363.22","363.22","1 through 10","170.37","1133.85","percent of total billed charges",""
"INTRODUCER SENTRANT 14FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10209081","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1464.92","878.95","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1065.29","72.72","","271.85","111.24","551.69","14","170.37","1133.85","percent of total billed charges",""
"INTRODUCER SENTRANT 14FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10209081","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1464.92","878.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","921.43","62.9","","706.53","93.60","938.00","53","170.37","1133.85","percent of total billed charges",""
"INTRODUCER SENTRANT 14FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10209081","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1464.92","878.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1133.85","77.4","","200.75","81.67","643.86","11","170.37","1133.85","percent of total billed charges",""
"INTRODUCER SENTRANT 16FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10211809","CDM","C1894","HCPCS","0272","RC","","","","both","","","1464.92","878.95","AETNA [1001]","HB WDH AETNA COMMERCIAL","1022.51","69.8","","94.15","94.15","427.63","1 through 10","170.37","1245.18","percent of total billed charges",""
"INTRODUCER SENTRANT 16FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10211809","CDM","C1894","HCPCS","0272","RC","","","","both","","","1464.92","878.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","170.37","1245.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER SENTRANT 16FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10211809","CDM","C1894","HCPCS","0272","RC","","","","both","","","1464.92","878.95","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","833.54","56.9","","401.89","65.85","401.89","1 through 10","170.37","1245.18","percent of total billed charges",""
"INTRODUCER SENTRANT 16FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10211809","CDM","C1894","HCPCS","0272","RC","","","","both","","","1464.92","878.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","170.37","11.63","","49.19","10.57","114.40","19","170.37","1245.18","percent of total billed charges",""
"INTRODUCER SENTRANT 16FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10211809","CDM","C1894","HCPCS","0272","RC","","","","both","","","1464.92","878.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1133.85","77.4","","200.75","81.67","643.86","11","170.37","1245.18","percent of total billed charges",""
"INTRODUCER SENTRANT 16FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10211809","CDM","C1894","HCPCS","0272","RC","","","","both","","","1464.92","878.95","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","170.37","1245.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER SENTRANT 16FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10211809","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1464.92","878.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","170.37","11.63","","49.19","10.57","114.40","19","170.37","1133.85","percent of total billed charges",""
"INTRODUCER SENTRANT 16FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10211809","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1464.92","878.95","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","919.68","62.78","","93.27","93.27","93.27","1 through 10","170.37","1133.85","percent of total billed charges",""
"INTRODUCER SENTRANT 16FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10211809","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1464.92","878.95","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","640.46","43.72","","363.22","363.22","363.22","1 through 10","170.37","1133.85","percent of total billed charges",""
"INTRODUCER SENTRANT 16FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10211809","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1464.92","878.95","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1065.29","72.72","","271.85","111.24","551.69","14","170.37","1133.85","percent of total billed charges",""
"INTRODUCER SENTRANT 16FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10211809","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1464.92","878.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","921.43","62.9","","706.53","93.60","938.00","53","170.37","1133.85","percent of total billed charges",""
"INTRODUCER SENTRANT 16FR 28CM VASCULAR SHEATH HYDROPHILIC COATED STRAIGHT TIP HEMOSTASIS SEAL","SUP-ITM-10211809","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1464.92","878.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1133.85","77.4","","200.75","81.67","643.86","11","170.37","1133.85","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 11CM SUPER BX/10EA","SUP-ITM-10191198","CDM","C1894","HCPCS","0272","RC","","","","both","","","100.20","60.12","AETNA [1001]","HB WDH AETNA COMMERCIAL","69.94","69.8","","94.15","94.15","427.63","1 through 10","11.65","85.17","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 11CM SUPER BX/10EA","SUP-ITM-10191198","CDM","C1894","HCPCS","0272","RC","","","","both","","","100.20","60.12","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","11.65","85.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER SHEATH 12FR 11CM SUPER BX/10EA","SUP-ITM-10191198","CDM","C1894","HCPCS","0272","RC","","","","both","","","100.20","60.12","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","57.01","56.9","","401.89","65.85","401.89","1 through 10","11.65","85.17","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 11CM SUPER BX/10EA","SUP-ITM-10191198","CDM","C1894","HCPCS","0272","RC","","","","both","","","100.20","60.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","11.65","11.63","","49.19","10.57","114.40","19","11.65","85.17","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 11CM SUPER BX/10EA","SUP-ITM-10191198","CDM","C1894","HCPCS","0272","RC","","","","both","","","100.20","60.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","77.55","77.4","","200.75","81.67","643.86","11","11.65","85.17","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 11CM SUPER BX/10EA","SUP-ITM-10191198","CDM","C1894","HCPCS","0272","RC","","","","both","","","100.20","60.12","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","11.65","85.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER SHEATH 12FR 11CM SUPER BX/10EA","SUP-ITM-10191198","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","100.20","60.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","11.65","11.63","","49.19","10.57","114.40","19","11.65","77.55","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 11CM SUPER BX/10EA","SUP-ITM-10191198","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","100.20","60.12","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","62.91","62.78","","93.27","93.27","93.27","1 through 10","11.65","77.55","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 11CM SUPER BX/10EA","SUP-ITM-10191198","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","100.20","60.12","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","43.81","43.72","","363.22","363.22","363.22","1 through 10","11.65","77.55","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 11CM SUPER BX/10EA","SUP-ITM-10191198","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","100.20","60.12","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","72.87","72.72","","271.85","111.24","551.69","14","11.65","77.55","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 11CM SUPER BX/10EA","SUP-ITM-10191198","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","100.20","60.12","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","63.03","62.9","","706.53","93.60","938.00","53","11.65","77.55","percent of total billed charges",""
"INTRODUCER SHEATH 12FR 11CM SUPER BX/10EA","SUP-ITM-10191198","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","100.20","60.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","77.55","77.4","","200.75","81.67","643.86","11","11.65","77.55","percent of total billed charges",""
"INTRODUCER SHEATH 18FR 6X33CM DRYSEAL FLEX","SUP-ITM-10169115","CDM","C1894","HCPCS","0272","RC","","","","both","","","4194.37","2516.62","AETNA [1001]","HB WDH AETNA COMMERCIAL","2927.67","69.8","","94.15","94.15","427.63","1 through 10","487.81","3565.21","percent of total billed charges",""
"INTRODUCER SHEATH 18FR 6X33CM DRYSEAL FLEX","SUP-ITM-10169115","CDM","C1894","HCPCS","0272","RC","","","","both","","","4194.37","2516.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","487.81","3565.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER SHEATH 18FR 6X33CM DRYSEAL FLEX","SUP-ITM-10169115","CDM","C1894","HCPCS","0272","RC","","","","both","","","4194.37","2516.62","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2386.60","56.9","","401.89","65.85","401.89","1 through 10","487.81","3565.21","percent of total billed charges",""
"INTRODUCER SHEATH 18FR 6X33CM DRYSEAL FLEX","SUP-ITM-10169115","CDM","C1894","HCPCS","0272","RC","","","","both","","","4194.37","2516.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","487.81","11.63","","49.19","10.57","114.40","19","487.81","3565.21","percent of total billed charges",""
"INTRODUCER SHEATH 18FR 6X33CM DRYSEAL FLEX","SUP-ITM-10169115","CDM","C1894","HCPCS","0272","RC","","","","both","","","4194.37","2516.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3246.44","77.4","","200.75","81.67","643.86","11","487.81","3565.21","percent of total billed charges",""
"INTRODUCER SHEATH 18FR 6X33CM DRYSEAL FLEX","SUP-ITM-10169115","CDM","C1894","HCPCS","0272","RC","","","","both","","","4194.37","2516.62","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","487.81","3565.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER SHEATH 18FR 6X33CM DRYSEAL FLEX","SUP-ITM-10169115","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4194.37","2516.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","487.81","11.63","","49.19","10.57","114.40","19","487.81","3246.44","percent of total billed charges",""
"INTRODUCER SHEATH 18FR 6X33CM DRYSEAL FLEX","SUP-ITM-10169115","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4194.37","2516.62","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2633.23","62.78","","93.27","93.27","93.27","1 through 10","487.81","3246.44","percent of total billed charges",""
"INTRODUCER SHEATH 18FR 6X33CM DRYSEAL FLEX","SUP-ITM-10169115","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4194.37","2516.62","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1833.78","43.72","","363.22","363.22","363.22","1 through 10","487.81","3246.44","percent of total billed charges",""
"INTRODUCER SHEATH 18FR 6X33CM DRYSEAL FLEX","SUP-ITM-10169115","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4194.37","2516.62","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3050.15","72.72","","271.85","111.24","551.69","14","487.81","3246.44","percent of total billed charges",""
"INTRODUCER SHEATH 18FR 6X33CM DRYSEAL FLEX","SUP-ITM-10169115","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4194.37","2516.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2638.26","62.9","","706.53","93.60","938.00","53","487.81","3246.44","percent of total billed charges",""
"INTRODUCER SHEATH 18FR 6X33CM DRYSEAL FLEX","SUP-ITM-10169115","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4194.37","2516.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3246.44","77.4","","200.75","81.67","643.86","11","487.81","3246.44","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.39","108.83","AETNA [1001]","HB WDH AETNA COMMERCIAL","126.61","69.8","","94.15","94.15","427.63","1 through 10","21.1","154.18","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.39","108.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","21.1","154.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.39","108.83","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","103.21","56.9","","401.89","65.85","401.89","1 through 10","21.1","154.18","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.39","108.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","21.10","11.63","","49.19","10.57","114.40","19","21.1","154.18","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.39","108.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","140.40","77.4","","200.75","81.67","643.86","11","21.1","154.18","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.39","108.83","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","21.1","154.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","181.39","108.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","21.10","11.63","","49.19","10.57","114.40","19","21.1","140.4","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","181.39","108.83","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","113.88","62.78","","93.27","93.27","93.27","1 through 10","21.1","140.4","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","181.39","108.83","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","79.30","43.72","","363.22","363.22","363.22","1 through 10","21.1","140.4","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","181.39","108.83","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","131.91","72.72","","271.85","111.24","551.69","14","21.1","140.4","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","181.39","108.83","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","114.09","62.9","","706.53","93.60","938.00","53","21.1","140.4","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 23CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE GREEN BX/5EA","SUP-ITM-10013815","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","181.39","108.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","140.40","77.4","","200.75","81.67","643.86","11","21.1","140.4","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","both","","","68.96","41.38","AETNA [1001]","HB WDH AETNA COMMERCIAL","48.13","69.8","","94.15","94.15","427.63","1 through 10","8.02","58.62","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","both","","","68.96","41.38","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","8.02","58.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","both","","","68.96","41.38","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","39.24","56.9","","401.89","65.85","401.89","1 through 10","8.02","58.62","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","both","","","68.96","41.38","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","8.02","11.63","","49.19","10.57","114.40","19","8.02","58.62","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","both","","","68.96","41.38","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","53.38","77.4","","200.75","81.67","643.86","11","8.02","58.62","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","both","","","68.96","41.38","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","8.02","58.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","68.96","41.38","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","8.02","11.63","","49.19","10.57","114.40","19","8.02","53.38","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","68.96","41.38","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","43.29","62.78","","93.27","93.27","93.27","1 through 10","8.02","53.38","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","68.96","41.38","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","30.15","43.72","","363.22","363.22","363.22","1 through 10","8.02","53.38","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","68.96","41.38","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","50.15","72.72","","271.85","111.24","551.69","14","8.02","53.38","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","68.96","41.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","43.38","62.9","","706.53","93.60","938.00","53","8.02","53.38","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","68.96","41.38","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","53.38","77.4","","200.75","81.67","643.86","11","8.02","53.38","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX35CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE ORANGE BX/2EA","SUP-ITM-10008499","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.39","108.83","AETNA [1001]","HB WDH AETNA COMMERCIAL","126.61","69.8","","94.15","94.15","427.63","1 through 10","21.1","154.18","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX35CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE ORANGE BX/2EA","SUP-ITM-10008499","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.39","108.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","21.1","154.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER SHEATH 7FR 35MMX35CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE ORANGE BX/2EA","SUP-ITM-10008499","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.39","108.83","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","103.21","56.9","","401.89","65.85","401.89","1 through 10","21.1","154.18","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX35CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE ORANGE BX/2EA","SUP-ITM-10008499","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.39","108.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","21.10","11.63","","49.19","10.57","114.40","19","21.1","154.18","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX35CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE ORANGE BX/2EA","SUP-ITM-10008499","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.39","108.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","140.40","77.4","","200.75","81.67","643.86","11","21.1","154.18","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX35CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE ORANGE BX/2EA","SUP-ITM-10008499","CDM","C1894","HCPCS","0272","RC","","","","both","","","181.39","108.83","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","21.1","154.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER SHEATH 7FR 35MMX35CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE ORANGE BX/2EA","SUP-ITM-10008499","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","181.39","108.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","21.10","11.63","","49.19","10.57","114.40","19","21.1","140.4","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX35CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE ORANGE BX/2EA","SUP-ITM-10008499","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","181.39","108.83","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","113.88","62.78","","93.27","93.27","93.27","1 through 10","21.1","140.4","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX35CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE ORANGE BX/2EA","SUP-ITM-10008499","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","181.39","108.83","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","79.30","43.72","","363.22","363.22","363.22","1 through 10","21.1","140.4","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX35CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE ORANGE BX/2EA","SUP-ITM-10008499","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","181.39","108.83","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","131.91","72.72","","271.85","111.24","551.69","14","21.1","140.4","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX35CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE ORANGE BX/2EA","SUP-ITM-10008499","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","181.39","108.83","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","114.09","62.9","","706.53","93.60","938.00","53","21.1","140.4","percent of total billed charges",""
"INTRODUCER SHEATH 7FR 35MMX35CM .035IN BRITE TIP RADIOPAQUE WITHOUT MINI-WIRE ORANGE BX/2EA","SUP-ITM-10008499","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","181.39","108.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","140.40","77.4","","200.75","81.67","643.86","11","21.1","140.4","percent of total billed charges",""
"INTRODUCER SHEATH 8.5FR .038INX14CM PEEL-AWAY","SUP-ITM-10028263","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","207.30","124.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","130.39","62.9","","141.92","141.92","141.92","1 through 10","24.11","160.45","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","1969.35","1181.61","AETNA [1001]","HB WDH AETNA COMMERCIAL","1374.61","69.8","","94.15","94.15","427.63","1 through 10","229.04","1673.95","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","1969.35","1181.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","229.04","1673.95","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","1969.35","1181.61","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1120.56","56.9","","401.89","65.85","401.89","1 through 10","229.04","1673.95","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","1969.35","1181.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","229.04","11.63","","49.19","10.57","114.40","19","229.04","1673.95","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","1969.35","1181.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1524.28","77.4","","200.75","81.67","643.86","11","229.04","1673.95","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","both","","","1969.35","1181.61","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","229.04","1673.95","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1969.35","1181.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","229.04","11.63","","49.19","10.57","114.40","19","229.04","1524.28","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1969.35","1181.61","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1236.36","62.78","","93.27","93.27","93.27","1 through 10","229.04","1524.28","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1969.35","1181.61","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","861.00","43.72","","363.22","363.22","363.22","1 through 10","229.04","1524.28","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1969.35","1181.61","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1432.11","72.72","","271.85","111.24","551.69","14","229.04","1524.28","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1969.35","1181.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1238.72","62.9","","706.53","93.60","938.00","53","229.04","1524.28","percent of total billed charges",""
"INTRODUCER SHEATH AFX 17FR 45CM SINGLE LUMEN DILATOR HEMOSTASIS VALVE SIDEPORT","SUP-ITM-10091809","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1969.35","1181.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1524.28","77.4","","200.75","81.67","643.86","11","229.04","1524.28","percent of total billed charges",""
"INTRODUCER SHEATH PRELUDE SNAP 8FR 25CM 18G J TIPPED SPLITTABLE HEMOSTATIC DILATOR SYRINGE NEEDLE BLUE BX/5EA","SUP-ITM-10148323","CDM","C1892","HCPCS","0272","RC","","","","outpatient","","","323.39","194.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","203.41","62.9","","141.92","141.92","141.92","1 through 10","37.61","250.3","percent of total billed charges",""
"INTRODUCER VASCULAR 12FRX13CM W/OUT ADULT .038IN GUIDEWIRE CHECK FLO PERFORMER","SUP-ITM-10087379","CDM","C1894","HCPCS","0272","RC","","","","both","","","476.72","286.03","AETNA [1001]","HB WDH AETNA COMMERCIAL","332.75","69.8","","94.15","94.15","427.63","1 through 10","55.44","405.21","percent of total billed charges",""
"INTRODUCER VASCULAR 12FRX13CM W/OUT ADULT .038IN GUIDEWIRE CHECK FLO PERFORMER","SUP-ITM-10087379","CDM","C1894","HCPCS","0272","RC","","","","both","","","476.72","286.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","55.44","405.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER VASCULAR 12FRX13CM W/OUT ADULT .038IN GUIDEWIRE CHECK FLO PERFORMER","SUP-ITM-10087379","CDM","C1894","HCPCS","0272","RC","","","","both","","","476.72","286.03","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","271.25","56.9","","401.89","65.85","401.89","1 through 10","55.44","405.21","percent of total billed charges",""
"INTRODUCER VASCULAR 12FRX13CM W/OUT ADULT .038IN GUIDEWIRE CHECK FLO PERFORMER","SUP-ITM-10087379","CDM","C1894","HCPCS","0272","RC","","","","both","","","476.72","286.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","55.44","11.63","","49.19","10.57","114.40","19","55.44","405.21","percent of total billed charges",""
"INTRODUCER VASCULAR 12FRX13CM W/OUT ADULT .038IN GUIDEWIRE CHECK FLO PERFORMER","SUP-ITM-10087379","CDM","C1894","HCPCS","0272","RC","","","","both","","","476.72","286.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","368.98","77.4","","200.75","81.67","643.86","11","55.44","405.21","percent of total billed charges",""
"INTRODUCER VASCULAR 12FRX13CM W/OUT ADULT .038IN GUIDEWIRE CHECK FLO PERFORMER","SUP-ITM-10087379","CDM","C1894","HCPCS","0272","RC","","","","both","","","476.72","286.03","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","55.44","405.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER VASCULAR 12FRX13CM W/OUT ADULT .038IN GUIDEWIRE CHECK FLO PERFORMER","SUP-ITM-10087379","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","476.72","286.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","55.44","11.63","","49.19","10.57","114.40","19","55.44","368.98","percent of total billed charges",""
"INTRODUCER VASCULAR 12FRX13CM W/OUT ADULT .038IN GUIDEWIRE CHECK FLO PERFORMER","SUP-ITM-10087379","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","476.72","286.03","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","299.28","62.78","","93.27","93.27","93.27","1 through 10","55.44","368.98","percent of total billed charges",""
"INTRODUCER VASCULAR 12FRX13CM W/OUT ADULT .038IN GUIDEWIRE CHECK FLO PERFORMER","SUP-ITM-10087379","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","476.72","286.03","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","208.42","43.72","","363.22","363.22","363.22","1 through 10","55.44","368.98","percent of total billed charges",""
"INTRODUCER VASCULAR 12FRX13CM W/OUT ADULT .038IN GUIDEWIRE CHECK FLO PERFORMER","SUP-ITM-10087379","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","476.72","286.03","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","346.67","72.72","","271.85","111.24","551.69","14","55.44","368.98","percent of total billed charges",""
"INTRODUCER VASCULAR 12FRX13CM W/OUT ADULT .038IN GUIDEWIRE CHECK FLO PERFORMER","SUP-ITM-10087379","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","476.72","286.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","299.86","62.9","","706.53","93.60","938.00","53","55.44","368.98","percent of total billed charges",""
"INTRODUCER VASCULAR 12FRX13CM W/OUT ADULT .038IN GUIDEWIRE CHECK FLO PERFORMER","SUP-ITM-10087379","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","476.72","286.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","368.98","77.4","","200.75","81.67","643.86","11","55.44","368.98","percent of total billed charges",""
"INTRODUCER VASCULAR 90CMX5FR 1.9MM TO ADULT .018 .038IN FLEXOR ANSEL PTFE COTD GD SHEATH CHECK FLO VLV MP TIP","SUP-ITM-10087075","CDM","C1894","HCPCS","0272","RC","","","","both","","","953.51","572.11","AETNA [1001]","HB WDH AETNA COMMERCIAL","665.55","69.8","","94.15","94.15","427.63","1 through 10","110.89","810.48","percent of total billed charges",""
"INTRODUCER VASCULAR 90CMX5FR 1.9MM TO ADULT .018 .038IN FLEXOR ANSEL PTFE COTD GD SHEATH CHECK FLO VLV MP TIP","SUP-ITM-10087075","CDM","C1894","HCPCS","0272","RC","","","","both","","","953.51","572.11","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","110.89","810.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER VASCULAR 90CMX5FR 1.9MM TO ADULT .018 .038IN FLEXOR ANSEL PTFE COTD GD SHEATH CHECK FLO VLV MP TIP","SUP-ITM-10087075","CDM","C1894","HCPCS","0272","RC","","","","both","","","953.51","572.11","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","542.55","56.9","","401.89","65.85","401.89","1 through 10","110.89","810.48","percent of total billed charges",""
"INTRODUCER VASCULAR 90CMX5FR 1.9MM TO ADULT .018 .038IN FLEXOR ANSEL PTFE COTD GD SHEATH CHECK FLO VLV MP TIP","SUP-ITM-10087075","CDM","C1894","HCPCS","0272","RC","","","","both","","","953.51","572.11","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","110.89","11.63","","49.19","10.57","114.40","19","110.89","810.48","percent of total billed charges",""
"INTRODUCER VASCULAR 90CMX5FR 1.9MM TO ADULT .018 .038IN FLEXOR ANSEL PTFE COTD GD SHEATH CHECK FLO VLV MP TIP","SUP-ITM-10087075","CDM","C1894","HCPCS","0272","RC","","","","both","","","953.51","572.11","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","738.02","77.4","","200.75","81.67","643.86","11","110.89","810.48","percent of total billed charges",""
"INTRODUCER VASCULAR 90CMX5FR 1.9MM TO ADULT .018 .038IN FLEXOR ANSEL PTFE COTD GD SHEATH CHECK FLO VLV MP TIP","SUP-ITM-10087075","CDM","C1894","HCPCS","0272","RC","","","","both","","","953.51","572.11","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","110.89","810.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"INTRODUCER VASCULAR 90CMX5FR 1.9MM TO ADULT .018 .038IN FLEXOR ANSEL PTFE COTD GD SHEATH CHECK FLO VLV MP TIP","SUP-ITM-10087075","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","953.51","572.11","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","110.89","11.63","","49.19","10.57","114.40","19","110.89","738.02","percent of total billed charges",""
"INTRODUCER VASCULAR 90CMX5FR 1.9MM TO ADULT .018 .038IN FLEXOR ANSEL PTFE COTD GD SHEATH CHECK FLO VLV MP TIP","SUP-ITM-10087075","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","953.51","572.11","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","598.61","62.78","","93.27","93.27","93.27","1 through 10","110.89","738.02","percent of total billed charges",""
"INTRODUCER VASCULAR 90CMX5FR 1.9MM TO ADULT .018 .038IN FLEXOR ANSEL PTFE COTD GD SHEATH CHECK FLO VLV MP TIP","SUP-ITM-10087075","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","953.51","572.11","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","416.87","43.72","","363.22","363.22","363.22","1 through 10","110.89","738.02","percent of total billed charges",""
"INTRODUCER VASCULAR 90CMX5FR 1.9MM TO ADULT .018 .038IN FLEXOR ANSEL PTFE COTD GD SHEATH CHECK FLO VLV MP TIP","SUP-ITM-10087075","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","953.51","572.11","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","693.39","72.72","","271.85","111.24","551.69","14","110.89","738.02","percent of total billed charges",""
"INTRODUCER VASCULAR 90CMX5FR 1.9MM TO ADULT .018 .038IN FLEXOR ANSEL PTFE COTD GD SHEATH CHECK FLO VLV MP TIP","SUP-ITM-10087075","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","953.51","572.11","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","599.76","62.9","","706.53","93.60","938.00","53","110.89","738.02","percent of total billed charges",""
"INTRODUCER VASCULAR 90CMX5FR 1.9MM TO ADULT .018 .038IN FLEXOR ANSEL PTFE COTD GD SHEATH CHECK FLO VLV MP TIP","SUP-ITM-10087075","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","953.51","572.11","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","738.02","77.4","","200.75","81.67","643.86","11","110.89","738.02","percent of total billed charges",""
"Intubation Endotracheal","PX-76000762","CDM","31500","CPT","0761","RC","","","","outpatient","","","1581.00","948.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","186.40","11.79","","180.24","180.24","180.24","1 through 10","186.4","1223.69","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0300","RC","","","","inpatient","","","93.00","55.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","71.48","76.86","","54.23","54.23","54.23","1 through 10","61.57","71.48","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","93.00","55.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","64.91","69.8","","62.82","56.61","62.82","266","4.21","79.05","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","93.00","55.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","64.91","69.8","","62.82","62.82","62.82","1 through 10","4.21","79.05","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","93.00","55.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","79.05","85","","76.50","11.08","76.50","1 through 10","4.21","79.05","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","outpatient","","","93.00","55.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","58.39","62.78","","56.50","56.50","56.50","11","6.04","71.98","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","outpatient","","","93.00","55.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","40.66","43.72","","39.35","39.35","39.35","22","6.04","71.98","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","outpatient","","","93.00","55.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","67.63","72.72","","65.45","65.45","65.45","454","6.04","71.98","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","outpatient","","","93.00","55.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","67.63","72.72","","65.45","65.45","65.45","21","6.04","71.98","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","outpatient","","","93.00","55.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","49.49","53.22","","47.98","47.98","143.94","29","6.04","71.98","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","outpatient","","","93.00","55.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","58.50","62.9","","56.70","56.70","56.70","572","6.04","71.98","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","outpatient","","","93.00","55.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","71.98","77.4","","69.75","69.75","69.75","184","6.04","71.98","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","outpatient","","","93.00","55.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","67.63","72.72","","65.45","65.45","65.45","1 through 10","6.04","71.98","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0300","RC","","","","inpatient","","","124.00","74.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","95.31","76.86","","72.52","72.52","72.52","1 through 10","82.09","95.31","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","124.00","74.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","86.55","69.8","","83.76","75.48","83.76","258","5.68","105.4","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","124.00","74.40","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","86.55","69.8","","83.76","83.76","83.76","1 through 10","5.68","105.4","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","124.00","74.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","105.40","85","","102.00","14.77","102.00","1 through 10","5.68","105.4","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","outpatient","","","124.00","74.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","77.85","62.78","","75.34","75.34","75.34","11","8.14","95.98","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","outpatient","","","124.00","74.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","54.21","43.72","","52.46","52.46","52.46","22","8.14","95.98","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","outpatient","","","124.00","74.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","90.17","72.72","","87.26","87.26","87.26","436","8.14","95.98","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","outpatient","","","124.00","74.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","90.17","72.72","","87.26","87.26","87.26","21","8.14","95.98","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","outpatient","","","124.00","74.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","65.99","53.22","","63.97","63.97","191.91","25","8.14","95.98","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","outpatient","","","124.00","74.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","78.00","62.9","","75.60","75.60","75.60","563","8.14","95.98","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","outpatient","","","124.00","74.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","95.98","77.4","","93.00","93.00","93.00","179","8.14","95.98","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","outpatient","","","124.00","74.40","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","90.17","72.72","","87.26","87.26","87.26","1 through 10","8.14","95.98","percent of total billed charges",""
"Irrig/Lavage/Instill Bladder","PX-76001256","CDM","51700","CPT","0761","RC","","","","both","","","1664.00","998.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","254.10","","APC Price ($254.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","254.13","254.13","254.13","1 through 10","249.01","1623.9","other","OPPS APC"
"Irrigat Implant Ven Access Dvc","PX-94000007","CDM","96523","CPT","0260","RC","","","","both","","","262.00","157.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","182.88","69.8","","176.59","176.59","176.59","1 through 10","60.82","396.58","percent of total billed charges",""
"Irrigat Implant Ven Access Dvc","PX-94000007","CDM","96523","CPT","0260","RC","","","","both","","","262.00","157.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","63.30","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","62.07","62.07","62.07","1 through 10","60.82","396.58","other","OPPS APC"
"Irrigat Implant Ven Access Dvc","PX-94000007","CDM","96523","CPT","0260","RC","","","","both","","","262.00","157.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","396.58","","Case rate ($396.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","253.00","253.00","253.00","1 through 10","60.82","396.58","other","OPPS APC"
"Irrigat Implant Ven Access Dvc","PX-94000007","CDM","96523","CPT","0260","RC","","","","both","","","262.00","157.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","170.77","","Case rate ($170.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","166.60","166.60","166.81","1 through 10","60.82","396.58","other","OPPS APC"
"Irrigat Implant Ven Access Dvc","PX-94000007","CDM","96523","CPT","0260","RC","","","","both","","","262.00","157.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","60.82","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","60.83","59.60","62.07","19","60.82","396.58","other","OPPS APC"
"Irrigat Implant Ven Access Dvc","PX-94000007","CDM","96523","CPT","0260","RC","","","","both","","","262.00","157.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","320.55","","Case rate ($320.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","253.00","166.60","253.00","1 through 10","60.82","396.58","other","OPPS APC"
"Irrigat Implant Ven Access Dvc","PX-94000007","CDM","96523","CPT","0260","RC","","","","both","","","262.00","157.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","149.08","56.9","","143.96","143.96","143.96","13","60.82","396.58","percent of total billed charges",""
"Irrigat Implant Ven Access Dvc","PX-94000007","CDM","96523","CPT","0260","RC","","","","both","","","262.00","157.20","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","149.08","56.9","","143.96","143.96","143.96","1 through 10","60.82","396.58","percent of total billed charges",""
"Irrigat Implant Ven Access Dvc","PX-94000007","CDM","96523","CPT","0260","RC","","","","both","","","262.00","157.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","63.92","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","62.65","62.65","62.91","23","60.82","396.58","other","OPPS APC"
"Irrigat Implant Ven Access Dvc","PX-94000007","CDM","96523","CPT","0260","RC","","","","both","","","262.00","157.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","62.06","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","61.08","60.83","62.07","31","60.82","396.58","other","OPPS APC"
"Irrigat Implant Ven Access Dvc","PX-94000007","CDM","96523","CPT","0260","RC","","","","both","","","262.00","157.20","MEDICARE [2001]","HB WDH MEDICARE","62.06","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.07","62.07","62.07","154","60.82","396.58","other","OPPS APC"
"Irrigat Implant Ven Access Dvc","PX-94000007","CDM","96523","CPT","0260","RC","","","","both","","","262.00","157.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","62.06","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","60.83","60.83","60.83","92","60.82","396.58","other","OPPS APC"
"Irrigat Implant Ven Access Dvc","PX-94000007","CDM","96523","CPT","0260","RC","","","","both","","","262.00","157.20","WELLPOINT [1015]","HB WDH ANTHEM PPO","320.55","","Case rate ($320.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","253.00","253.00","253.00","1 through 10","60.82","396.58","other","OPPS APC"
"Irrigat Implant Ven Access Dvc","PX-94000007","CDM","96523","CPT","0260","RC","","","","outpatient","","","262.00","157.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","37.78","14.42","","31.27","31.27","31.27","1 through 10","30.47","202.79","percent of total billed charges",""
"Irrigat Implant Ven Access Dvc","PX-94000007","CDM","96523","CPT","0260","RC","","","","outpatient","","","262.00","157.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","30.47","11.63","","34.84","29.89","63.91","1 through 10","30.47","202.79","percent of total billed charges",""
"Irrigat Implant Ven Access Dvc","PX-94000007","CDM","96523","CPT","0260","RC","","","","outpatient","","","262.00","157.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","164.80","62.9","","159.39","159.39","159.39","1 through 10","30.47","202.79","percent of total billed charges",""
"Irrigat Implant Ven Access Dvc","PX-94000007","CDM","96523","CPT","0260","RC","","","","outpatient","","","262.00","157.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","202.79","77.4","","196.08","196.08","196.08","1 through 10","30.47","202.79","percent of total billed charges",""
"Irrigat Implant Ven Access Dvc","PX-94000007","CDM","96523","CPT","0260","RC","","","","outpatient","","","262.00","157.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","30.47","11.63","","29.89","29.89","29.89","1 through 10","30.47","202.79","percent of total billed charges",""
"Isavuconazole (Cresemba) Lc-Ms/Ms","PX-30003278","CDM","80299","CPT","0301","RC","","","","both","","","103.00","61.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","71.89","69.8","","69.80","62.90","69.80","1 through 10","12.12","87.55","percent of total billed charges",""
"Isavuconazole (Cresemba) Lc-Ms/Ms","PX-30003278","CDM","80299","CPT","0301","RC","","","","outpatient","","","103.00","61.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","45.03","43.72","","43.72","43.72","43.72","1 through 10","12.76","79.72","percent of total billed charges",""
"Isavuconazole (Cresemba) Lc-Ms/Ms","PX-30003278","CDM","80299","CPT","0301","RC","","","","outpatient","","","103.00","61.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","74.90","72.72","","72.72","72.72","72.72","1 through 10","12.76","79.72","percent of total billed charges",""
"Isavuconazole (Cresemba) Lc-Ms/Ms","PX-30003278","CDM","80299","CPT","0301","RC","","","","outpatient","","","103.00","61.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","74.90","72.72","","190.53","190.53","190.53","1 through 10","12.76","79.72","percent of total billed charges",""
"Isavuconazole (Cresemba) Lc-Ms/Ms","PX-30003278","CDM","80299","CPT","0301","RC","","","","outpatient","","","103.00","61.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","54.82","53.22","","53.31","53.31","53.31","1 through 10","12.76","79.72","percent of total billed charges",""
"Isavuconazole (Cresemba) Lc-Ms/Ms","PX-30003278","CDM","80299","CPT","0301","RC","","","","outpatient","","","103.00","61.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","64.79","62.9","","63.00","63.00","189.00","13","12.76","79.72","percent of total billed charges",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","","","","inpatient","","","115457.73","69274.64","MARTIN'S POINT [160007]","HB WDH MEDICARE","13803.87","","Case rate ($13,803.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,775.08, add-ons for qualifying new technology services are included. If operating cost exceeds $16,693.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,781.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $12,382.80 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,330.21 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $976.20. The transfer capital threshold is the transfer adjustment factor * $976.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Includes an additional $800 of payment.","17822.36","17822.36","17822.36","1 through 10","4637","66773.78","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC","061","MS-DRG","","","","","","","","inpatient","","","122594.64","73556.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","83444.40","","Fee schedule rate ($83,444.40). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","79823.56","79823.56","79823.56","1 through 10","3975","104770.08","case rate",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC","061","MS-DRG","","","","","","","","inpatient","","","122594.64","73556.78","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","22047.71","","Case rate ($21,405.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $19,791.34, add-ons for qualifying new technology services are included. If operating cost exceeds $23,709.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,336.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $19,428.99 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $19,346.47 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,531.69. The transfer capital threshold is the transfer adjustment factor * $1,531.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","10811.40","10811.40","10811.40","1 through 10","3975","104770.08","other","Inpatient DRG"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC","061","MS-DRG","","","","","","","","inpatient","","","122594.64","73556.78","MARTIN'S POINT [160007]","HB WDH MEDICARE","21405.54","","Case rate ($21,405.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $19,791.34, add-ons for qualifying new technology services are included. If operating cost exceeds $23,709.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,336.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $19,428.99 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $19,346.47 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,531.69. The transfer capital threshold is the transfer adjustment factor * $1,531.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9130.08","9130.08","9130.08","1 through 10","3975","104770.08","other","Inpatient DRG"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC","061","MS-DRG","","","","","","","","inpatient","","","122594.64","73556.78","MEDICARE [2001]","HB WDH MEDICARE","21405.54","","Case rate ($21,405.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $19,791.34, add-ons for qualifying new technology services are included. If operating cost exceeds $23,709.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,336.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $19,428.99 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $19,346.47 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,531.69. The transfer capital threshold is the transfer adjustment factor * $1,531.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20896.61","20896.61","20896.61","1 through 10","3975","104770.08","other","Inpatient DRG"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC","061","MS-DRG","","","","","","","","inpatient","","","122594.64","73556.78","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","21405.54","","Case rate ($21,405.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $19,791.34, add-ons for qualifying new technology services are included. If operating cost exceeds $23,709.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,336.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $19,428.99 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $19,346.47 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,531.69. The transfer capital threshold is the transfer adjustment factor * $1,531.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20450.60","20450.60","20450.60","1 through 10","3975","104770.08","other","Inpatient DRG"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/McC","063","MS-DRG","","","","","","","","inpatient","","","126339.29","75803.57","MEDICARE [2001]","HB WDH MEDICARE","11117.16","","Case rate ($11,117.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,295.28, add-ons for qualifying new technology services are included. If operating cost exceeds $14,213.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,584.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $9,892.43 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,850.41 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $779.87. The transfer capital threshold is the transfer adjustment factor * $779.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11072.40","11072.40","11072.40","1 through 10","4637","53344.54","other","Inpatient DRG"
"Islet Cell Antibody","PX-30000843","CDM","86341","CPT","0302","RC","","","","both","","","107.00","64.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","74.69","69.8","","71.90","71.90","71.90","1 through 10","15.32","102.34","percent of total billed charges",""
"Islet Cell Antibody","PX-30000843","CDM","86341","CPT","0302","RC","","","","both","","","107.00","64.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","74.69","69.8","","215.68","215.68","215.68","1 through 10","15.32","102.34","percent of total billed charges",""
"Islet Cell Antibody","PX-30000843","CDM","86341","CPT","0302","RC","","","","outpatient","","","107.00","64.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","77.81","72.72","","224.70","224.70","224.70","1 through 10","18.43","82.82","percent of total billed charges",""
"Islet Cell Antibody","PX-30000843","CDM","86341","CPT","0302","RC","","","","outpatient","","","107.00","64.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","67.30","62.9","","64.89","64.89","64.89","1 through 10","18.43","82.82","percent of total billed charges",""
"Islet Cell Antibody","PX-30000843","CDM","86341","CPT","0302","RC","","","","outpatient","","","107.00","64.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","82.82","77.4","","79.83","79.83","79.83","1 through 10","18.43","82.82","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","334.00","200.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","233.13","69.8","","224.76","202.54","224.76","124","47.24","308.05","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","334.00","200.40","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","49.17","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","48.21","46.28","48.21","94","47.24","308.05","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","334.00","200.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","308.05","","Case rate ($308.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","300.54","300.54","300.83","82","47.24","308.05","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","334.00","200.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","132.65","","Case rate ($132.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","129.41","129.41","129.54","129","47.24","308.05","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","334.00","200.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","47.24","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","48.15","46.29","48.21","154","47.24","308.05","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","334.00","200.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","248.99","","Case rate ($248.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","242.92","129.41","243.16","96","47.24","308.05","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","334.00","200.40","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","233.13","69.8","","19.60","19.60","19.60","1 through 10","47.24","308.05","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","334.00","200.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","49.65","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","48.86","48.66","48.86","235","47.24","308.05","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","334.00","200.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","48.21","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","47.44","46.28","48.21","91","47.24","308.05","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","334.00","200.40","MEDICARE [2001]","HB WDH MEDICARE","48.21","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","48.21","48.21","48.21","835","47.24","308.05","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","334.00","200.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","283.90","85","","248.70","248.70","248.70","1 through 10","47.24","308.05","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","334.00","200.40","TRICARE [160005]","HB WDH MEDICARE","48.21","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","48.21","48.21","241.05","1 through 10","47.24","308.05","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","334.00","200.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","48.21","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","47.45","47.25","48.21","284","47.24","308.05","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","334.00","200.40","WELLPOINT [1015]","HB WDH ANTHEM PPO","248.99","","Case rate ($248.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","242.92","242.92","243.15","1 through 10","47.24","308.05","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","334.00","200.40","WELLSENSE NH [1050]","HB WDH MEDICARE","48.21","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","148.83","148.83","248.03","31","47.24","308.05","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","inpatient","","","334.00","200.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","256.71","76.86","","202.86","202.86","389.71","18","221.11","256.71","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","outpatient","","","334.00","200.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","48.16","14.42","","46.43","39.80","46.43","194","38.84","258.52","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","outpatient","","","334.00","200.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","38.84","11.63","","44.34","38.04","85.88","269","38.84","258.52","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","outpatient","","","334.00","200.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","177.75","53.22","","343.32","343.32","343.32","48","38.84","258.52","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","outpatient","","","334.00","200.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","210.09","62.9","","202.86","202.86","608.58","298","38.84","258.52","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","outpatient","","","334.00","200.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","258.52","77.4","","249.55","78.87","786.99","74","38.84","258.52","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","outpatient","","","334.00","200.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","38.84","11.63","","38.04","38.03","114.12","210","38.84","258.52","percent of total billed charges",""
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","832.00","499.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","580.74","69.8","","560.49","505.09","560.49","21","215.72","1406.76","percent of total billed charges",""
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","832.00","499.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","224.52","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","220.15","208.84","220.15","23","215.72","1406.76","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","832.00","499.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1406.76","","Case rate ($1,406.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","824.17","790.46","1357.53","21","215.72","1406.76","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","832.00","499.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","605.75","","Case rate ($605.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","590.98","584.56","590.98","31","215.72","1406.76","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","832.00","499.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","215.72","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","215.75","215.75","220.15","194","215.72","1406.76","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","832.00","499.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1137.07","","Case rate ($1,137.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1097.27","590.98","1109.33","19","215.72","1406.76","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","832.00","499.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","226.72","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","223.12","222.21","223.12","67","215.72","1406.76","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","832.00","499.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","220.12","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","216.63","216.63","220.15","45","215.72","1406.76","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","832.00","499.20","MEDICARE [2001]","HB WDH MEDICARE","220.12","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","220.15","220.15","220.15","366","215.72","1406.76","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","832.00","499.20","TRICARE [160005]","HB WDH MEDICARE","220.12","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","220.15","220.15","220.15","12","215.72","1406.76","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","832.00","499.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","220.12","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","215.95","215.75","220.15","121","215.72","1406.76","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","832.00","499.20","WELLPOINT [1015]","HB WDH ANTHEM PPO","1137.07","","Case rate ($1,137.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","803.00","803.00","803.00","1 through 10","215.72","1406.76","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","832.00","499.20","WELLSENSE NH [1050]","HB WDH MEDICARE","220.12","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","226.54","226.54","226.54","35","215.72","1406.76","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","outpatient","","","832.00","499.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","119.97","14.42","","115.79","99.25","115.79","80","96.76","643.97","percent of total billed charges",""
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","outpatient","","","832.00","499.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","96.76","11.63","","110.57","94.85","202.81","127","96.76","643.97","percent of total billed charges",""
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","outpatient","","","832.00","499.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","523.33","62.9","","505.89","505.89","505.89","57","96.76","643.97","percent of total billed charges",""
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","outpatient","","","832.00","499.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","643.97","77.4","","622.33","622.33","622.33","17","96.76","643.97","percent of total billed charges",""
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","outpatient","","","832.00","499.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","96.76","11.63","","94.85","94.85","94.85","108","96.76","643.97","percent of total billed charges",""
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","427.00","256.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","298.05","69.8","","287.58","259.15","287.58","12","72.87","475.23","percent of total billed charges",""
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","427.00","256.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","75.84","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","74.36","68.64","74.36","1 through 10","72.87","475.23","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","427.00","256.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","475.23","","Case rate ($475.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","463.64","446.16","463.64","33","72.87","475.23","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","427.00","256.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","204.63","","Case rate ($204.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.65","192.12","199.65","63","72.87","475.23","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","427.00","256.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","72.87","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","72.87","68.64","74.36","63","72.87","475.23","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","427.00","256.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","384.13","","Case rate ($384.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","374.75","199.65","374.75","34","72.87","475.23","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","427.00","256.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","242.96","56.9","","234.43","234.43","703.29","65","72.87","475.23","percent of total billed charges",""
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","427.00","256.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","76.59","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","75.36","69.29","75.37","30","72.87","475.23","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","427.00","256.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","74.36","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","72.87","67.27","74.36","64","72.87","475.23","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","427.00","256.20","MEDICARE [2001]","HB WDH MEDICARE","74.36","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","74.36","74.36","74.37","305","72.87","475.23","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","427.00","256.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","74.36","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","73.18","72.88","74.36","243","72.87","475.23","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","427.00","256.20","WELLPOINT [1015]","HB WDH ANTHEM PPO","384.13","","Case rate ($384.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","360.62","360.62","360.62","1 through 10","72.87","475.23","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","427.00","256.20","WELLSENSE NH [1050]","HB WDH MEDICARE","74.36","","APC Price ($74.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","229.56","76.52","229.56","1 through 10","72.87","475.23","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","outpatient","","","427.00","256.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","61.57","14.42","","59.41","50.92","59.41","87","49.66","330.5","percent of total billed charges",""
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","outpatient","","","427.00","256.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","49.66","11.63","","56.73","50.43","104.05","51","49.66","330.5","percent of total billed charges",""
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","outpatient","","","427.00","256.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","268.58","62.9","","259.56","259.56","259.56","26","49.66","330.5","percent of total billed charges",""
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","outpatient","","","427.00","256.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","330.50","77.4","","319.30","72.88","319.31","15","49.66","330.5","percent of total billed charges",""
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","outpatient","","","427.00","256.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","49.66","11.63","","116.60","48.66","243.30","31","49.66","330.5","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1041.00","624.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","726.62","69.8","","701.49","632.15","701.49","68","215.72","1406.76","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1041.00","624.60","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","224.52","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","220.15","220.15","220.15","77","215.72","1406.76","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1041.00","624.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1406.76","","Case rate ($1,406.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1204.61","1184.59","1372.46","118","215.72","1406.76","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1041.00","624.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","605.75","","Case rate ($605.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","590.98","584.56","590.98","70","215.72","1406.76","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1041.00","624.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","215.72","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","215.75","215.75","220.15","217","215.72","1406.76","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1041.00","624.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1137.07","","Case rate ($1,137.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1109.33","590.98","1109.33","109","215.72","1406.76","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1041.00","624.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","226.72","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","222.21","222.21","223.12","99","215.72","1406.76","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1041.00","624.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","220.12","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","216.63","215.75","220.15","188","215.72","1406.76","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1041.00","624.60","MEDICARE [2001]","HB WDH MEDICARE","220.12","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","220.15","220.15","220.15","1535","215.72","1406.76","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1041.00","624.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","884.85","85","","854.25","854.25","854.25","1 through 10","215.72","1406.76","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1041.00","624.60","TRICARE [160005]","HB WDH MEDICARE","220.12","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","220.15","220.15","220.15","30","215.72","1406.76","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1041.00","624.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","220.12","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","216.63","215.75","220.15","568","215.72","1406.76","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1041.00","624.60","WELLPOINT [1015]","HB WDH ANTHEM PPO","1137.07","","Case rate ($1,137.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1057.36","1005.00","1109.33","17","215.72","1406.76","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","1041.00","624.60","WELLSENSE NH [1050]","HB WDH MEDICARE","220.12","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","679.62","226.54","679.62","33","215.72","1406.76","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","inpatient","","","1041.00","624.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","800.11","76.86","","607.90","607.90","607.90","1 through 10","689.14","800.11","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","outpatient","","","1041.00","624.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","150.11","14.42","","144.92","124.22","144.92","57","121.07","805.73","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","outpatient","","","1041.00","624.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","121.07","11.63","","138.39","118.71","253.82","153","121.07","805.73","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","outpatient","","","1041.00","624.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","654.79","62.9","","633.15","633.15","633.15","206","121.07","805.73","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","outpatient","","","1041.00","624.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","805.73","77.4","","778.88","778.87","778.88","18","121.07","805.73","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","outpatient","","","1041.00","624.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","121.07","11.63","","118.71","118.71","356.13","123","121.07","805.73","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","295.00","177.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","205.91","69.8","","198.93","179.27","198.93","94","47.24","308.05","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","295.00","177.00","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","49.17","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","48.21","48.21","48.21","138","47.24","308.05","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","295.00","177.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","308.05","","Case rate ($308.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","300.54","300.54","300.83","139","47.24","308.05","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","295.00","177.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","132.65","","Case rate ($132.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","129.54","129.41","129.54","45","47.24","308.05","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","295.00","177.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","47.24","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","48.21","47.25","81.96","242","47.24","308.05","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","295.00","177.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","248.99","","Case rate ($248.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","242.92","129.41","243.15","23","47.24","308.05","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","295.00","177.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","167.86","56.9","","244.91","162.17","648.66","29","47.24","308.05","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","295.00","177.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","49.65","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","48.67","46.72","97.32","94","47.24","308.05","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","295.00","177.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","48.21","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","47.44","46.29","48.21","113","47.24","308.05","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","295.00","177.00","MEDICARE [2001]","HB WDH MEDICARE","48.21","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","48.21","48.21","48.21","1615","47.24","308.05","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","295.00","177.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","250.75","85","","242.25","242.25","242.25","1 through 10","47.24","308.05","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","295.00","177.00","TRICARE [160005]","HB WDH MEDICARE","48.21","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","48.21","48.21","48.21","1 through 10","47.24","308.05","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","295.00","177.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","48.21","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","47.25","47.25","47.95","533","47.24","308.05","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","295.00","177.00","WELLPOINT [1015]","HB WDH ANTHEM PPO","248.99","","Case rate ($248.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","242.92","242.92","285.00","1 through 10","47.24","308.05","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","295.00","177.00","WELLSENSE NH [1050]","HB WDH MEDICARE","48.21","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","148.82","49.61","148.82","11","47.24","308.05","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","outpatient","","","295.00","177.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","42.54","14.42","","41.10","35.23","41.10","35","34.31","228.33","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","outpatient","","","295.00","177.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","34.31","11.63","","36.70","33.66","71.98","216","34.31","228.33","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","outpatient","","","295.00","177.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","185.56","62.9","","179.55","179.55","179.55","256","34.31","228.33","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","outpatient","","","295.00","177.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","228.33","77.4","","4165.70","47.25","4165.70","1 through 10","34.31","228.33","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","outpatient","","","295.00","177.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","34.31","11.63","","33.67","33.66","101.00","211","34.31","228.33","percent of total billed charges",""
"IV Non-Chemo Concurrent Infus - 96368","PX-26000006","CDM","96368","CPT","0260","RC","","","","both","","","285.00","171.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","198.93","69.8","","191.95","191.95","191.95","1 through 10","162.17","242.25","percent of total billed charges",""
"IV Non-Chemo Concurrent Infus - 96368","PX-26000006","CDM","96368","CPT","0260","RC","","","","both","","","285.00","171.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","162.17","56.9","","156.48","156.47","469.44","38","162.17","242.25","percent of total billed charges",""
"IV Non-Chemo Concurrent Infus - 96368","PX-26000006","CDM","96368","CPT","0260","RC","","","","outpatient","","","285.00","171.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","41.10","14.42","","39.66","33.99","39.66","1 through 10","33.15","220.59","percent of total billed charges",""
"IV Non-Chemo Concurrent Infus - 96368","PX-26000006","CDM","96368","CPT","0260","RC","","","","outpatient","","","285.00","171.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","33.15","11.63","","37.87","32.49","37.87","1 through 10","33.15","220.59","percent of total billed charges",""
"IV Non-Chemo Concurrent Infus - 96368","PX-26000006","CDM","96368","CPT","0260","RC","","","","outpatient","","","285.00","171.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","220.59","77.4","","213.13","213.13","213.13","1 through 10","33.15","220.59","percent of total billed charges",""
"IV Non-Chemo Concurrent Infus - 96368","PX-26000006","CDM","96368","CPT","0260","RC","","","","outpatient","","","285.00","171.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","33.15","11.63","","32.49","32.49","32.49","1 through 10","33.15","220.59","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","535.00","321.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","373.43","69.8","","360.17","324.56","360.17","44","215.72","1406.76","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","535.00","321.00","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","224.52","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","220.15","220.15","220.15","46","215.72","1406.76","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","535.00","321.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1406.76","","Case rate ($1,406.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","941.62","864.77","944.42","49","215.72","1406.76","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","535.00","321.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","605.75","","Case rate ($605.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","590.98","584.56","590.98","121","215.72","1406.76","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","535.00","321.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","215.72","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","215.75","215.75","220.15","163","215.72","1406.76","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","535.00","321.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1137.07","","Case rate ($1,137.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","941.62","676.08","1271.85","89","215.72","1406.76","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","535.00","321.00","CHAMPVA [160001]","HB WDH MEDICARE","220.12","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","220.15","220.15","220.15","1 through 10","215.72","1406.76","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","535.00","321.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","226.72","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","223.12","222.21","223.12","117","215.72","1406.76","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","535.00","321.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","220.12","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","216.63","215.75","220.15","216","215.72","1406.76","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","535.00","321.00","MEDICARE [2001]","HB WDH MEDICARE","220.12","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","220.15","220.15","220.15","777","215.72","1406.76","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","535.00","321.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","454.75","85","","152.24","152.24","438.60","1 through 10","215.72","1406.76","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","535.00","321.00","TRICARE [160005]","HB WDH MEDICARE","220.12","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","220.15","140.70","1110.30","18","215.72","1406.76","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","535.00","321.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","220.12","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","220.15","215.75","220.15","283","215.72","1406.76","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","535.00","321.00","WELLPOINT [1015]","HB WDH ANTHEM PPO","1137.07","","Case rate ($1,137.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","938.70","937.53","938.70","12","215.72","1406.76","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","535.00","321.00","WELLSENSE NH [1050]","HB WDH MEDICARE","220.12","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","226.54","226.54","679.62","31","215.72","1406.76","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","inpatient","","","535.00","321.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","411.20","76.86","","624.30","325.08","624.30","1 through 10","354.17","411.2","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","outpatient","","","535.00","321.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","77.15","14.42","","74.41","63.78","74.41","75","62.22","414.09","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","outpatient","","","535.00","321.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","62.22","11.63","","71.05","60.95","130.32","227","62.22","414.09","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","outpatient","","","535.00","321.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","284.73","53.22","","550.16","550.16","550.16","1 through 10","62.22","414.09","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","outpatient","","","535.00","321.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","336.52","62.9","","325.08","325.08","650.16","111","62.22","414.09","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","outpatient","","","535.00","321.00","PHCS MULTIPLAN [1022]","HB WDH AMERIHEALTH CARITAS","77.15","14.42","","63.78","63.78","63.78","1 through 10","62.22","414.09","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","outpatient","","","535.00","321.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","414.09","77.4","","399.90","399.90","399.90","34","62.22","414.09","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","outpatient","","","535.00","321.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","62.22","11.63","","60.95","60.95","352.24","88","62.22","414.09","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","both","","","375.00","225.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","261.75","69.8","","252.68","227.70","252.68","48","261.75","318.75","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","both","","","375.00","225.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","1448.00","362.00","1448.00","1 through 10","261.75","318.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","both","","","375.00","225.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","318.75","85","","307.70","257.70","307.70","1 through 10","261.75","318.75","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","inpatient","","","375.00","225.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","288.23","76.86","","228.06","228.06","228.06","1 through 10","248.25","288.23","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","outpatient","","","375.00","225.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","163.95","43.72","","158.27","158.27","158.27","1 through 10","163.95","290.25","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","outpatient","","","375.00","225.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","272.70","72.72","","526.50","263.25","526.50","12","163.95","290.25","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","outpatient","","","375.00","225.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","272.70","72.72","","263.25","263.25","263.25","1 through 10","163.95","290.25","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","outpatient","","","375.00","225.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","199.58","53.22","","385.96","385.96","385.96","1 through 10","163.95","290.25","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","outpatient","","","375.00","225.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","235.88","62.9","","228.06","228.06","875.28","31","163.95","290.25","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","outpatient","","","375.00","225.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","290.25","77.4","","280.55","280.55","280.55","1 through 10","163.95","290.25","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","227.00","136.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","158.45","69.8","","152.86","137.75","152.86","95","17.13","308.05","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","227.00","136.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","49.17","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","48.21","46.28","48.21","96","17.13","308.05","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","227.00","136.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","308.05","","Case rate ($308.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","300.54","300.54","300.83","147","17.13","308.05","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","227.00","136.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","132.65","","Case rate ($132.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","129.41","129.41","129.54","216","17.13","308.05","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","227.00","136.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","248.99","","Case rate ($248.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","242.92","129.41","243.15","221","17.13","308.05","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","227.00","136.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","158.45","69.8","","24.41","24.41","24.41","1 through 10","17.13","308.05","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","227.00","136.20","HARVARD PILGRIM [120001]","HB WDH MEDICARE","48.21","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","45.54","45.54","45.54","1 through 10","17.13","308.05","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","227.00","136.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","49.65","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","48.86","48.67","97.34","81","17.13","308.05","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","227.00","136.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","48.21","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","47.44","47.25","48.21","249","17.13","308.05","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","227.00","136.20","MEDICARE [2001]","HB WDH MEDICARE","48.21","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","48.21","48.21","138.84","1338","17.13","308.05","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","227.00","136.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","192.95","85","","186.15","186.15","186.15","1 through 10","17.13","308.05","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","227.00","136.20","TRICARE [160005]","HB WDH MEDICARE","48.21","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","48.21","48.21","144.63","1 through 10","17.13","308.05","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","227.00","136.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","48.21","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","48.21","47.25","48.21","588","17.13","308.05","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","227.00","136.20","WELLPOINT [1015]","HB WDH ANTHEM PPO","248.99","","Case rate ($248.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","242.92","242.92","242.92","23","17.13","308.05","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","227.00","136.20","WELLSENSE NH [1050]","HB WDH MEDICARE","48.21","","APC Price ($48.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","148.83","49.64","248.03","40","17.13","308.05","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","inpatient","","","227.00","136.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","174.47","76.86","","137.97","132.43","264.86","1 through 10","150.27","174.47","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","outpatient","","","227.00","136.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","32.73","14.42","","31.58","27.07","31.58","178","26.4","175.7","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","outpatient","","","227.00","136.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","26.40","11.63","","30.16","25.87","55.31","351","26.4","175.7","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","outpatient","","","227.00","136.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","120.81","53.22","","233.50","233.50","233.50","1 through 10","26.4","175.7","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","outpatient","","","227.00","136.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","142.78","62.9","","137.97","137.97","413.91","176","26.4","175.7","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","outpatient","","","227.00","136.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","175.70","77.4","","169.73","169.72","339.45","52","26.4","175.7","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","outpatient","","","227.00","136.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","26.40","11.63","","75.59","25.87","227.94","208","26.4","175.7","percent of total billed charges",""
"Jak2 Targeted Sequence Analysis","PX-31001134","CDM","81279","CPT","0310","RC","","","","both","","","1942.00","1165.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1105.00","56.9","","1068.58","1068.58","1068.58","1 through 10","120.38","1650.7","percent of total billed charges",""
"Jak2 Targeted Sequence Analysis","PX-31001134","CDM","81279","CPT","0310","RC","","","","outpatient","","","1942.00","1165.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","280.04","14.42","","165.01","165.01","165.01","1 through 10","225.85","1503.11","percent of total billed charges",""
"K-WIRE 1X150MM SS TROCAR POINT BX/6EA","SUP-ITM-10063367","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.76","149.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","28.93","211.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE 1X150MM SS TROCAR POINT BX/6EA","SUP-ITM-10063367","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.76","149.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","28.93","211.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE 1X150MM SS TROCAR POINT BX/6EA","SUP-ITM-10063367","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.76","149.26","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","141.54","56.9","","812.12","238.65","1587.46","163","28.93","211.45","percent of total billed charges",""
"K-WIRE 1X150MM SS TROCAR POINT BX/6EA","SUP-ITM-10063367","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.76","149.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","28.93","11.63","","112.68","112.68","146.99","38","28.93","211.45","percent of total billed charges",""
"K-WIRE 1X150MM SS TROCAR POINT BX/6EA","SUP-ITM-10063367","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.76","149.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","192.54","77.4","","303.98","303.98","5854.79","1 through 10","28.93","211.45","percent of total billed charges",""
"K-WIRE 1X150MM SS TROCAR POINT BX/6EA","SUP-ITM-10063367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.76","149.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","28.93","11.63","","112.68","112.68","146.99","38","28.93","192.54","percent of total billed charges",""
"K-WIRE 1X150MM SS TROCAR POINT BX/6EA","SUP-ITM-10063367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.76","149.26","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","156.17","62.78","","780.86","208.94","10480.28","15","28.93","192.54","percent of total billed charges",""
"K-WIRE 1X150MM SS TROCAR POINT BX/6EA","SUP-ITM-10063367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.76","149.26","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","108.76","43.72","","179.76","179.76","179.76","1 through 10","28.93","192.54","percent of total billed charges",""
"K-WIRE 1X150MM SS TROCAR POINT BX/6EA","SUP-ITM-10063367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.76","149.26","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","180.90","72.72","","2355.45","298.99","3965.19","155","28.93","192.54","percent of total billed charges",""
"K-WIRE 1X150MM SS TROCAR POINT BX/6EA","SUP-ITM-10063367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.76","149.26","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","180.90","72.72","","3643.09","3643.09","3643.09","1 through 10","28.93","192.54","percent of total billed charges",""
"K-WIRE 1X150MM SS TROCAR POINT BX/6EA","SUP-ITM-10063367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.76","149.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","132.39","53.22","","554.28","554.28","554.28","16","28.93","192.54","percent of total billed charges",""
"K-WIRE 1X150MM SS TROCAR POINT BX/6EA","SUP-ITM-10063367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.76","149.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","156.47","62.9","","619.64","173.09","2370.64","150","28.93","192.54","percent of total billed charges",""
"K-WIRE 1X150MM SS TROCAR POINT BX/6EA","SUP-ITM-10063367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.76","149.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","192.54","77.4","","303.98","303.98","5854.79","1 through 10","28.93","192.54","percent of total billed charges",""
"K-WIRE BONE .054X6IN BONE S/S SMOOTH DOUBLE TROCAR POINT STERILE DISPOSABLE PK/6EA","SUP-ITM-10216319","CDM","C1713","HCPCS","0278","RC","","","","both","","","38.57","23.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","4.49","32.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE .054X6IN BONE S/S SMOOTH DOUBLE TROCAR POINT STERILE DISPOSABLE PK/6EA","SUP-ITM-10216319","CDM","C1713","HCPCS","0278","RC","","","","both","","","38.57","23.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","4.49","32.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE .054X6IN BONE S/S SMOOTH DOUBLE TROCAR POINT STERILE DISPOSABLE PK/6EA","SUP-ITM-10216319","CDM","C1713","HCPCS","0278","RC","","","","both","","","38.57","23.14","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","21.95","56.9","","812.12","238.65","1587.46","163","4.49","32.78","percent of total billed charges",""
"K-WIRE BONE .054X6IN BONE S/S SMOOTH DOUBLE TROCAR POINT STERILE DISPOSABLE PK/6EA","SUP-ITM-10216319","CDM","C1713","HCPCS","0278","RC","","","","both","","","38.57","23.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","4.49","11.63","","112.68","112.68","146.99","38","4.49","32.78","percent of total billed charges",""
"K-WIRE BONE .054X6IN BONE S/S SMOOTH DOUBLE TROCAR POINT STERILE DISPOSABLE PK/6EA","SUP-ITM-10216319","CDM","C1713","HCPCS","0278","RC","","","","both","","","38.57","23.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","29.85","77.4","","303.98","303.98","5854.79","1 through 10","4.49","32.78","percent of total billed charges",""
"K-WIRE BONE .054X6IN BONE S/S SMOOTH DOUBLE TROCAR POINT STERILE DISPOSABLE PK/6EA","SUP-ITM-10216319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","38.57","23.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","4.49","11.63","","112.68","112.68","146.99","38","4.49","29.85","percent of total billed charges",""
"K-WIRE BONE .054X6IN BONE S/S SMOOTH DOUBLE TROCAR POINT STERILE DISPOSABLE PK/6EA","SUP-ITM-10216319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","38.57","23.14","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","24.21","62.78","","780.86","208.94","10480.28","15","4.49","29.85","percent of total billed charges",""
"K-WIRE BONE .054X6IN BONE S/S SMOOTH DOUBLE TROCAR POINT STERILE DISPOSABLE PK/6EA","SUP-ITM-10216319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","38.57","23.14","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","16.86","43.72","","179.76","179.76","179.76","1 through 10","4.49","29.85","percent of total billed charges",""
"K-WIRE BONE .054X6IN BONE S/S SMOOTH DOUBLE TROCAR POINT STERILE DISPOSABLE PK/6EA","SUP-ITM-10216319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","38.57","23.14","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","28.05","72.72","","2355.45","298.99","3965.19","155","4.49","29.85","percent of total billed charges",""
"K-WIRE BONE .054X6IN BONE S/S SMOOTH DOUBLE TROCAR POINT STERILE DISPOSABLE PK/6EA","SUP-ITM-10216319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","38.57","23.14","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","28.05","72.72","","3643.09","3643.09","3643.09","1 through 10","4.49","29.85","percent of total billed charges",""
"K-WIRE BONE .054X6IN BONE S/S SMOOTH DOUBLE TROCAR POINT STERILE DISPOSABLE PK/6EA","SUP-ITM-10216319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","38.57","23.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","20.53","53.22","","554.28","554.28","554.28","16","4.49","29.85","percent of total billed charges",""
"K-WIRE BONE .054X6IN BONE S/S SMOOTH DOUBLE TROCAR POINT STERILE DISPOSABLE PK/6EA","SUP-ITM-10216319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","38.57","23.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","24.26","62.9","","619.64","173.09","2370.64","150","4.49","29.85","percent of total billed charges",""
"K-WIRE BONE .054X6IN BONE S/S SMOOTH DOUBLE TROCAR POINT STERILE DISPOSABLE PK/6EA","SUP-ITM-10216319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","38.57","23.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","29.85","77.4","","303.98","303.98","5854.79","1 through 10","4.49","29.85","percent of total billed charges",""
"K-WIRE BONE .8X100MM COBALT ALLOY SPADE POINT NONTHREADED PK/10EA","SUP-ITM-10015256","CDM","C1713","HCPCS","0278","RC","","","","both","","","66.56","39.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","7.74","56.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE .8X100MM COBALT ALLOY SPADE POINT NONTHREADED PK/10EA","SUP-ITM-10015256","CDM","C1713","HCPCS","0278","RC","","","","both","","","66.56","39.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","7.74","56.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE .8X100MM COBALT ALLOY SPADE POINT NONTHREADED PK/10EA","SUP-ITM-10015256","CDM","C1713","HCPCS","0278","RC","","","","both","","","66.56","39.94","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","37.87","56.9","","812.12","238.65","1587.46","163","7.74","56.58","percent of total billed charges",""
"K-WIRE BONE .8X100MM COBALT ALLOY SPADE POINT NONTHREADED PK/10EA","SUP-ITM-10015256","CDM","C1713","HCPCS","0278","RC","","","","both","","","66.56","39.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","7.74","11.63","","112.68","112.68","146.99","38","7.74","56.58","percent of total billed charges",""
"K-WIRE BONE .8X100MM COBALT ALLOY SPADE POINT NONTHREADED PK/10EA","SUP-ITM-10015256","CDM","C1713","HCPCS","0278","RC","","","","both","","","66.56","39.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","51.52","77.4","","303.98","303.98","5854.79","1 through 10","7.74","56.58","percent of total billed charges",""
"K-WIRE BONE .8X100MM COBALT ALLOY SPADE POINT NONTHREADED PK/10EA","SUP-ITM-10015256","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","66.56","39.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","7.74","11.63","","112.68","112.68","146.99","38","7.74","51.52","percent of total billed charges",""
"K-WIRE BONE .8X100MM COBALT ALLOY SPADE POINT NONTHREADED PK/10EA","SUP-ITM-10015256","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","66.56","39.94","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","41.79","62.78","","780.86","208.94","10480.28","15","7.74","51.52","percent of total billed charges",""
"K-WIRE BONE .8X100MM COBALT ALLOY SPADE POINT NONTHREADED PK/10EA","SUP-ITM-10015256","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","66.56","39.94","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","29.10","43.72","","179.76","179.76","179.76","1 through 10","7.74","51.52","percent of total billed charges",""
"K-WIRE BONE .8X100MM COBALT ALLOY SPADE POINT NONTHREADED PK/10EA","SUP-ITM-10015256","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","66.56","39.94","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","48.40","72.72","","2355.45","298.99","3965.19","155","7.74","51.52","percent of total billed charges",""
"K-WIRE BONE .8X100MM COBALT ALLOY SPADE POINT NONTHREADED PK/10EA","SUP-ITM-10015256","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","66.56","39.94","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","48.40","72.72","","3643.09","3643.09","3643.09","1 through 10","7.74","51.52","percent of total billed charges",""
"K-WIRE BONE .8X100MM COBALT ALLOY SPADE POINT NONTHREADED PK/10EA","SUP-ITM-10015256","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","66.56","39.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","35.42","53.22","","554.28","554.28","554.28","16","7.74","51.52","percent of total billed charges",""
"K-WIRE BONE .8X100MM COBALT ALLOY SPADE POINT NONTHREADED PK/10EA","SUP-ITM-10015256","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","66.56","39.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","41.87","62.9","","619.64","173.09","2370.64","150","7.74","51.52","percent of total billed charges",""
"K-WIRE BONE .8X100MM COBALT ALLOY SPADE POINT NONTHREADED PK/10EA","SUP-ITM-10015256","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","66.56","39.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","51.52","77.4","","303.98","303.98","5854.79","1 through 10","7.74","51.52","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","266.31","159.79","AETNA [1001]","HB WDH AETNA COMMERCIAL","185.88","69.8","","279.80","225.71","279.80","16","30.97","226.36","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","266.31","159.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","30.97","226.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","266.31","159.79","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","151.53","56.9","","18.95","9.41","1260.18","1 through 10","30.97","226.36","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","266.31","159.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","30.97","11.63","","37.78","11.63","183.64","21","30.97","226.36","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","266.31","159.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","206.12","77.4","","225.79","68.39","1154.35","11","30.97","226.36","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","266.31","159.79","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","30.97","226.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","266.31","159.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","30.97","11.63","","37.78","11.63","183.64","21","30.97","206.12","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","266.31","159.79","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","167.19","62.78","","123.83","114.55","572.63","1 through 10","30.97","206.12","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","266.31","159.79","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","116.43","43.72","","127.38","127.38","148.03","1 through 10","30.97","206.12","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","266.31","159.79","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","193.66","72.72","","196.34","62.16","1727.00","33","30.97","206.12","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","266.31","159.79","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","193.66","72.72","","173.00","173.00","173.00","1 through 10","30.97","206.12","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","266.31","159.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","141.73","53.22","","205.24","190.08","205.24","1 through 10","30.97","206.12","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","266.31","159.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","167.51","62.9","","305.08","81.02","4529.24","103","30.97","206.12","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","266.31","159.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","206.12","77.4","","225.79","68.39","1154.35","11","30.97","206.12","percent of total billed charges",""
"K-WIRE BONE 1.1MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194111","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.20","82.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","16.07","117.47","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.1MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194111","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.20","82.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","16.07","117.47","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.1MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194111","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.20","82.92","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","78.64","56.9","","812.12","238.65","1587.46","163","16.07","117.47","percent of total billed charges",""
"K-WIRE BONE 1.1MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194111","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.20","82.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16.07","11.63","","112.68","112.68","146.99","38","16.07","117.47","percent of total billed charges",""
"K-WIRE BONE 1.1MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194111","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.20","82.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","106.97","77.4","","303.98","303.98","5854.79","1 through 10","16.07","117.47","percent of total billed charges",""
"K-WIRE BONE 1.1MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.20","82.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16.07","11.63","","112.68","112.68","146.99","38","16.07","106.97","percent of total billed charges",""
"K-WIRE BONE 1.1MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.20","82.92","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","86.76","62.78","","780.86","208.94","10480.28","15","16.07","106.97","percent of total billed charges",""
"K-WIRE BONE 1.1MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.20","82.92","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","60.42","43.72","","179.76","179.76","179.76","1 through 10","16.07","106.97","percent of total billed charges",""
"K-WIRE BONE 1.1MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.20","82.92","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","100.50","72.72","","2355.45","298.99","3965.19","155","16.07","106.97","percent of total billed charges",""
"K-WIRE BONE 1.1MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.20","82.92","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","100.50","72.72","","3643.09","3643.09","3643.09","1 through 10","16.07","106.97","percent of total billed charges",""
"K-WIRE BONE 1.1MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.20","82.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","73.55","53.22","","554.28","554.28","554.28","16","16.07","106.97","percent of total billed charges",""
"K-WIRE BONE 1.1MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.20","82.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","86.93","62.9","","619.64","173.09","2370.64","150","16.07","106.97","percent of total billed charges",""
"K-WIRE BONE 1.1MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.20","82.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","106.97","77.4","","303.98","303.98","5854.79","1 through 10","16.07","106.97","percent of total billed charges",""
"K-WIRE BONE 1.1X140MM GUIDE SS DOUBLE TROCAR POINT PK/6EA","SUP-ITM-10000258","CDM","C1713","HCPCS","0278","RC","","","","both","","","42.62","25.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","4.96","36.23","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.1X140MM GUIDE SS DOUBLE TROCAR POINT PK/6EA","SUP-ITM-10000258","CDM","C1713","HCPCS","0278","RC","","","","both","","","42.62","25.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","4.96","36.23","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.1X140MM GUIDE SS DOUBLE TROCAR POINT PK/6EA","SUP-ITM-10000258","CDM","C1713","HCPCS","0278","RC","","","","both","","","42.62","25.57","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","24.25","56.9","","812.12","238.65","1587.46","163","4.96","36.23","percent of total billed charges",""
"K-WIRE BONE 1.1X140MM GUIDE SS DOUBLE TROCAR POINT PK/6EA","SUP-ITM-10000258","CDM","C1713","HCPCS","0278","RC","","","","both","","","42.62","25.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","4.96","11.63","","112.68","112.68","146.99","38","4.96","36.23","percent of total billed charges",""
"K-WIRE BONE 1.1X140MM GUIDE SS DOUBLE TROCAR POINT PK/6EA","SUP-ITM-10000258","CDM","C1713","HCPCS","0278","RC","","","","both","","","42.62","25.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","32.99","77.4","","303.98","303.98","5854.79","1 through 10","4.96","36.23","percent of total billed charges",""
"K-WIRE BONE 1.1X140MM GUIDE SS DOUBLE TROCAR POINT PK/6EA","SUP-ITM-10000258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","42.62","25.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","4.96","11.63","","112.68","112.68","146.99","38","4.96","32.99","percent of total billed charges",""
"K-WIRE BONE 1.1X140MM GUIDE SS DOUBLE TROCAR POINT PK/6EA","SUP-ITM-10000258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","42.62","25.57","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","26.76","62.78","","780.86","208.94","10480.28","15","4.96","32.99","percent of total billed charges",""
"K-WIRE BONE 1.1X140MM GUIDE SS DOUBLE TROCAR POINT PK/6EA","SUP-ITM-10000258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","42.62","25.57","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","18.63","43.72","","179.76","179.76","179.76","1 through 10","4.96","32.99","percent of total billed charges",""
"K-WIRE BONE 1.1X140MM GUIDE SS DOUBLE TROCAR POINT PK/6EA","SUP-ITM-10000258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","42.62","25.57","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","30.99","72.72","","2355.45","298.99","3965.19","155","4.96","32.99","percent of total billed charges",""
"K-WIRE BONE 1.1X140MM GUIDE SS DOUBLE TROCAR POINT PK/6EA","SUP-ITM-10000258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","42.62","25.57","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","30.99","72.72","","3643.09","3643.09","3643.09","1 through 10","4.96","32.99","percent of total billed charges",""
"K-WIRE BONE 1.1X140MM GUIDE SS DOUBLE TROCAR POINT PK/6EA","SUP-ITM-10000258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","42.62","25.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","22.68","53.22","","554.28","554.28","554.28","16","4.96","32.99","percent of total billed charges",""
"K-WIRE BONE 1.1X140MM GUIDE SS DOUBLE TROCAR POINT PK/6EA","SUP-ITM-10000258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","42.62","25.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","26.81","62.9","","619.64","173.09","2370.64","150","4.96","32.99","percent of total billed charges",""
"K-WIRE BONE 1.1X140MM GUIDE SS DOUBLE TROCAR POINT PK/6EA","SUP-ITM-10000258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","42.62","25.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","32.99","77.4","","303.98","303.98","5854.79","1 through 10","4.96","32.99","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.83","74.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","14.4","105.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.83","74.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","14.4","105.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.83","74.30","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","70.46","56.9","","812.12","238.65","1587.46","163","14.4","105.26","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.83","74.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","14.40","11.63","","112.68","112.68","146.99","38","14.4","105.26","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","123.83","74.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","95.84","77.4","","303.98","303.98","5854.79","1 through 10","14.4","105.26","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.83","74.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","14.40","11.63","","112.68","112.68","146.99","38","14.4","95.84","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.83","74.30","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","77.74","62.78","","780.86","208.94","10480.28","15","14.4","95.84","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.83","74.30","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","54.14","43.72","","179.76","179.76","179.76","1 through 10","14.4","95.84","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.83","74.30","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","90.05","72.72","","2355.45","298.99","3965.19","155","14.4","95.84","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.83","74.30","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","90.05","72.72","","3643.09","3643.09","3643.09","1 through 10","14.4","95.84","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.83","74.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","65.90","53.22","","554.28","554.28","554.28","16","14.4","95.84","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.83","74.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","77.89","62.9","","619.64","173.09","2370.64","150","14.4","95.84","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","123.83","74.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","95.84","77.4","","303.98","303.98","5854.79","1 through 10","14.4","95.84","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.67","79.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","15.43","112.77","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.67","79.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","15.43","112.77","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.67","79.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","75.49","56.9","","812.12","238.65","1587.46","163","15.43","112.77","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.67","79.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","15.43","11.63","","112.68","112.68","146.99","38","15.43","112.77","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.67","79.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","102.69","77.4","","303.98","303.98","5854.79","1 through 10","15.43","112.77","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","132.67","79.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","15.43","11.63","","112.68","112.68","146.99","38","15.43","102.69","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","132.67","79.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","83.29","62.78","","780.86","208.94","10480.28","15","15.43","102.69","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","132.67","79.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","58.00","43.72","","179.76","179.76","179.76","1 through 10","15.43","102.69","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","132.67","79.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","96.48","72.72","","2355.45","298.99","3965.19","155","15.43","102.69","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","132.67","79.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","96.48","72.72","","3643.09","3643.09","3643.09","1 through 10","15.43","102.69","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","132.67","79.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","70.61","53.22","","554.28","554.28","554.28","16","15.43","102.69","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","132.67","79.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","83.45","62.9","","619.64","173.09","2370.64","150","15.43","102.69","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","132.67","79.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","102.69","77.4","","303.98","303.98","5854.79","1 through 10","15.43","102.69","percent of total billed charges",""
"K-WIRE BONE 1.4MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194123","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.20","82.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","16.07","117.47","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.4MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194123","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.20","82.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","16.07","117.47","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.4MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194123","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.20","82.92","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","78.64","56.9","","812.12","238.65","1587.46","163","16.07","117.47","percent of total billed charges",""
"K-WIRE BONE 1.4MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194123","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.20","82.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16.07","11.63","","112.68","112.68","146.99","38","16.07","117.47","percent of total billed charges",""
"K-WIRE BONE 1.4MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194123","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.20","82.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","106.97","77.4","","303.98","303.98","5854.79","1 through 10","16.07","117.47","percent of total billed charges",""
"K-WIRE BONE 1.4MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.20","82.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16.07","11.63","","112.68","112.68","146.99","38","16.07","106.97","percent of total billed charges",""
"K-WIRE BONE 1.4MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.20","82.92","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","86.76","62.78","","780.86","208.94","10480.28","15","16.07","106.97","percent of total billed charges",""
"K-WIRE BONE 1.4MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.20","82.92","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","60.42","43.72","","179.76","179.76","179.76","1 through 10","16.07","106.97","percent of total billed charges",""
"K-WIRE BONE 1.4MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.20","82.92","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","100.50","72.72","","2355.45","298.99","3965.19","155","16.07","106.97","percent of total billed charges",""
"K-WIRE BONE 1.4MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.20","82.92","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","100.50","72.72","","3643.09","3643.09","3643.09","1 through 10","16.07","106.97","percent of total billed charges",""
"K-WIRE BONE 1.4MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.20","82.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","73.55","53.22","","554.28","554.28","554.28","16","16.07","106.97","percent of total billed charges",""
"K-WIRE BONE 1.4MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.20","82.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","86.93","62.9","","619.64","173.09","2370.64","150","16.07","106.97","percent of total billed charges",""
"K-WIRE BONE 1.4MMX102 PHALINX TITANIUM FIXATION","SUP-ITM-10194123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.20","82.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","106.97","77.4","","303.98","303.98","5854.79","1 through 10","16.07","106.97","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.63","50.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","9.84","71.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.63","50.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","9.84","71.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.63","50.78","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","48.15","56.9","","812.12","238.65","1587.46","163","9.84","71.94","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.63","50.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","9.84","11.63","","112.68","112.68","146.99","38","9.84","71.94","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.63","50.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","65.50","77.4","","303.98","303.98","5854.79","1 through 10","9.84","71.94","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","84.63","50.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","9.84","11.63","","112.68","112.68","146.99","38","9.84","65.5","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","84.63","50.78","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","53.13","62.78","","780.86","208.94","10480.28","15","9.84","65.5","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","84.63","50.78","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","37.00","43.72","","179.76","179.76","179.76","1 through 10","9.84","65.5","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","84.63","50.78","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","61.54","72.72","","2355.45","298.99","3965.19","155","9.84","65.5","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","84.63","50.78","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","61.54","72.72","","3643.09","3643.09","3643.09","1 through 10","9.84","65.5","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","84.63","50.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","45.04","53.22","","554.28","554.28","554.28","16","9.84","65.5","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","84.63","50.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","53.23","62.9","","619.64","173.09","2370.64","150","9.84","65.5","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","84.63","50.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","65.50","77.4","","303.98","303.98","5854.79","1 through 10","9.84","65.5","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.38","74.63","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","14.47","105.72","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.38","74.63","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","14.47","105.72","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.38","74.63","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","70.77","56.9","","812.12","238.65","1587.46","163","14.47","105.72","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.38","74.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","14.47","11.63","","112.68","112.68","146.99","38","14.47","105.72","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.38","74.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","96.27","77.4","","303.98","303.98","5854.79","1 through 10","14.47","105.72","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.38","74.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","14.47","11.63","","112.68","112.68","146.99","38","14.47","96.27","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.38","74.63","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","78.09","62.78","","780.86","208.94","10480.28","15","14.47","96.27","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.38","74.63","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","54.38","43.72","","179.76","179.76","179.76","1 through 10","14.47","96.27","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.38","74.63","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","90.45","72.72","","2355.45","298.99","3965.19","155","14.47","96.27","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.38","74.63","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","90.45","72.72","","3643.09","3643.09","3643.09","1 through 10","14.47","96.27","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.38","74.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","66.20","53.22","","554.28","554.28","554.28","16","14.47","96.27","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.38","74.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","78.24","62.9","","619.64","173.09","2370.64","150","14.47","96.27","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.38","74.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","96.27","77.4","","303.98","303.98","5854.79","1 through 10","14.47","96.27","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION PERI LOC SS TROCAR POINT THREADED BX/6EA","SUP-ITM-10158693","CDM","C1713","HCPCS","0278","RC","","","","both","","","587.35","352.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","68.31","499.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.6X150MM FIXATION PERI LOC SS TROCAR POINT THREADED BX/6EA","SUP-ITM-10158693","CDM","C1713","HCPCS","0278","RC","","","","both","","","587.35","352.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","68.31","499.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.6X150MM FIXATION PERI LOC SS TROCAR POINT THREADED BX/6EA","SUP-ITM-10158693","CDM","C1713","HCPCS","0278","RC","","","","both","","","587.35","352.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","334.20","56.9","","812.12","238.65","1587.46","163","68.31","499.25","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION PERI LOC SS TROCAR POINT THREADED BX/6EA","SUP-ITM-10158693","CDM","C1713","HCPCS","0278","RC","","","","both","","","587.35","352.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","68.31","11.63","","112.68","112.68","146.99","38","68.31","499.25","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION PERI LOC SS TROCAR POINT THREADED BX/6EA","SUP-ITM-10158693","CDM","C1713","HCPCS","0278","RC","","","","both","","","587.35","352.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","454.61","77.4","","303.98","303.98","5854.79","1 through 10","68.31","499.25","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION PERI LOC SS TROCAR POINT THREADED BX/6EA","SUP-ITM-10158693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","587.35","352.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","68.31","11.63","","112.68","112.68","146.99","38","68.31","454.61","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION PERI LOC SS TROCAR POINT THREADED BX/6EA","SUP-ITM-10158693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","587.35","352.41","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","368.74","62.78","","780.86","208.94","10480.28","15","68.31","454.61","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION PERI LOC SS TROCAR POINT THREADED BX/6EA","SUP-ITM-10158693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","587.35","352.41","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","256.79","43.72","","179.76","179.76","179.76","1 through 10","68.31","454.61","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION PERI LOC SS TROCAR POINT THREADED BX/6EA","SUP-ITM-10158693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","587.35","352.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","427.12","72.72","","2355.45","298.99","3965.19","155","68.31","454.61","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION PERI LOC SS TROCAR POINT THREADED BX/6EA","SUP-ITM-10158693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","587.35","352.41","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","427.12","72.72","","3643.09","3643.09","3643.09","1 through 10","68.31","454.61","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION PERI LOC SS TROCAR POINT THREADED BX/6EA","SUP-ITM-10158693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","587.35","352.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","312.59","53.22","","554.28","554.28","554.28","16","68.31","454.61","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION PERI LOC SS TROCAR POINT THREADED BX/6EA","SUP-ITM-10158693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","587.35","352.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","369.44","62.9","","619.64","173.09","2370.64","150","68.31","454.61","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION PERI LOC SS TROCAR POINT THREADED BX/6EA","SUP-ITM-10158693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","587.35","352.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","454.61","77.4","","303.98","303.98","5854.79","1 through 10","68.31","454.61","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.69","32.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","6.24","45.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.69","32.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","6.24","45.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.69","32.21","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","30.55","56.9","","812.12","238.65","1587.46","163","6.24","45.64","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.69","32.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","6.24","11.63","","112.68","112.68","146.99","38","6.24","45.64","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.69","32.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","41.56","77.4","","303.98","303.98","5854.79","1 through 10","6.24","45.64","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","53.69","32.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","6.24","11.63","","112.68","112.68","146.99","38","6.24","41.56","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","53.69","32.21","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","33.71","62.78","","780.86","208.94","10480.28","15","6.24","41.56","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","53.69","32.21","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","23.47","43.72","","179.76","179.76","179.76","1 through 10","6.24","41.56","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","53.69","32.21","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","39.04","72.72","","2355.45","298.99","3965.19","155","6.24","41.56","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","53.69","32.21","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","39.04","72.72","","3643.09","3643.09","3643.09","1 through 10","6.24","41.56","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","53.69","32.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","28.57","53.22","","554.28","554.28","554.28","16","6.24","41.56","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","53.69","32.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","33.77","62.9","","619.64","173.09","2370.64","150","6.24","41.56","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM FIXATION SS DUAL END TROCAR POINT SMOOTH PK/10EA","SUP-ITM-10015789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","53.69","32.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","41.56","77.4","","303.98","303.98","5854.79","1 through 10","6.24","41.56","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.58","62.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","12.05","88.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.58","62.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","12.05","88.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.58","62.15","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","58.94","56.9","","812.12","238.65","1587.46","163","12.05","88.04","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.58","62.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","12.05","11.63","","112.68","112.68","146.99","38","12.05","88.04","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.58","62.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","80.17","77.4","","303.98","303.98","5854.79","1 through 10","12.05","88.04","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.58","62.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","12.05","11.63","","112.68","112.68","146.99","38","12.05","80.17","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.58","62.15","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","65.03","62.78","","780.86","208.94","10480.28","15","12.05","80.17","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.58","62.15","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","45.29","43.72","","179.76","179.76","179.76","1 through 10","12.05","80.17","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.58","62.15","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","75.32","72.72","","2355.45","298.99","3965.19","155","12.05","80.17","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.58","62.15","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","75.32","72.72","","3643.09","3643.09","3643.09","1 through 10","12.05","80.17","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.58","62.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","55.13","53.22","","554.28","554.28","554.28","16","12.05","80.17","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.58","62.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","65.15","62.9","","619.64","173.09","2370.64","150","12.05","80.17","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.58","62.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","80.17","77.4","","303.98","303.98","5854.79","1 through 10","12.05","80.17","percent of total billed charges",""
"K-WIRE BONE 1.6X285MM TROCAR POINT SS","SUP-ITM-10041386","CDM","C1713","HCPCS","0278","RC","","","","both","","","565.03","339.02","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","65.71","480.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.6X285MM TROCAR POINT SS","SUP-ITM-10041386","CDM","C1713","HCPCS","0278","RC","","","","both","","","565.03","339.02","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","65.71","480.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.6X285MM TROCAR POINT SS","SUP-ITM-10041386","CDM","C1713","HCPCS","0278","RC","","","","both","","","565.03","339.02","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","321.50","56.9","","812.12","238.65","1587.46","163","65.71","480.28","percent of total billed charges",""
"K-WIRE BONE 1.6X285MM TROCAR POINT SS","SUP-ITM-10041386","CDM","C1713","HCPCS","0278","RC","","","","both","","","565.03","339.02","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","65.71","11.63","","112.68","112.68","146.99","38","65.71","480.28","percent of total billed charges",""
"K-WIRE BONE 1.6X285MM TROCAR POINT SS","SUP-ITM-10041386","CDM","C1713","HCPCS","0278","RC","","","","both","","","565.03","339.02","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","437.33","77.4","","303.98","303.98","5854.79","1 through 10","65.71","480.28","percent of total billed charges",""
"K-WIRE BONE 1.6X285MM TROCAR POINT SS","SUP-ITM-10041386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","565.03","339.02","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","65.71","11.63","","112.68","112.68","146.99","38","65.71","437.33","percent of total billed charges",""
"K-WIRE BONE 1.6X285MM TROCAR POINT SS","SUP-ITM-10041386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","565.03","339.02","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","354.73","62.78","","780.86","208.94","10480.28","15","65.71","437.33","percent of total billed charges",""
"K-WIRE BONE 1.6X285MM TROCAR POINT SS","SUP-ITM-10041386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","565.03","339.02","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","247.03","43.72","","179.76","179.76","179.76","1 through 10","65.71","437.33","percent of total billed charges",""
"K-WIRE BONE 1.6X285MM TROCAR POINT SS","SUP-ITM-10041386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","565.03","339.02","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","410.89","72.72","","2355.45","298.99","3965.19","155","65.71","437.33","percent of total billed charges",""
"K-WIRE BONE 1.6X285MM TROCAR POINT SS","SUP-ITM-10041386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","565.03","339.02","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","410.89","72.72","","3643.09","3643.09","3643.09","1 through 10","65.71","437.33","percent of total billed charges",""
"K-WIRE BONE 1.6X285MM TROCAR POINT SS","SUP-ITM-10041386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","565.03","339.02","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","300.71","53.22","","554.28","554.28","554.28","16","65.71","437.33","percent of total billed charges",""
"K-WIRE BONE 1.6X285MM TROCAR POINT SS","SUP-ITM-10041386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","565.03","339.02","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","355.40","62.9","","619.64","173.09","2370.64","150","65.71","437.33","percent of total billed charges",""
"K-WIRE BONE 1.6X285MM TROCAR POINT SS","SUP-ITM-10041386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","565.03","339.02","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","437.33","77.4","","303.98","303.98","5854.79","1 through 10","65.71","437.33","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","40.40","24.24","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","4.7","34.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","40.40","24.24","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","4.7","34.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","40.40","24.24","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","22.99","56.9","","812.12","238.65","1587.46","163","4.7","34.34","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","40.40","24.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","4.70","11.63","","112.68","112.68","146.99","38","4.7","34.34","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","40.40","24.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","31.27","77.4","","303.98","303.98","5854.79","1 through 10","4.7","34.34","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","40.40","24.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","4.70","11.63","","112.68","112.68","146.99","38","4.7","31.27","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","40.40","24.24","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","25.36","62.78","","780.86","208.94","10480.28","15","4.7","31.27","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","40.40","24.24","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","17.66","43.72","","179.76","179.76","179.76","1 through 10","4.7","31.27","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","40.40","24.24","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","29.38","72.72","","2355.45","298.99","3965.19","155","4.7","31.27","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","40.40","24.24","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","29.38","72.72","","3643.09","3643.09","3643.09","1 through 10","4.7","31.27","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","40.40","24.24","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","21.50","53.22","","554.28","554.28","554.28","16","4.7","31.27","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","40.40","24.24","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","25.41","62.9","","619.64","173.09","2370.64","150","4.7","31.27","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","40.40","24.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","31.27","77.4","","303.98","303.98","5854.79","1 through 10","4.7","31.27","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.66","107.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","20.89","152.71","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.66","107.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","20.89","152.71","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.66","107.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","102.23","56.9","","812.12","238.65","1587.46","163","20.89","152.71","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.66","107.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.89","11.63","","112.68","112.68","146.99","38","20.89","152.71","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.66","107.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","139.06","77.4","","303.98","303.98","5854.79","1 through 10","20.89","152.71","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.66","107.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.89","11.63","","112.68","112.68","146.99","38","20.89","139.06","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.66","107.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","112.79","62.78","","780.86","208.94","10480.28","15","20.89","139.06","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.66","107.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","78.55","43.72","","179.76","179.76","179.76","1 through 10","20.89","139.06","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.66","107.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","130.65","72.72","","2355.45","298.99","3965.19","155","20.89","139.06","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.66","107.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","130.65","72.72","","3643.09","3643.09","3643.09","1 through 10","20.89","139.06","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.66","107.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","95.62","53.22","","554.28","554.28","554.28","16","20.89","139.06","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.66","107.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","113.01","62.9","","619.64","173.09","2370.64","150","20.89","139.06","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.66","107.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","139.06","77.4","","303.98","303.98","5854.79","1 through 10","20.89","139.06","percent of total billed charges",""
"K-WIRE BONE 17MM 1.1X6IN VARIAX SS BALL TIP STOP","SUP-ITM-10133301","CDM","C1713","HCPCS","0278","RC","","","","both","","","362.50","217.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","42.16","308.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 17MM 1.1X6IN VARIAX SS BALL TIP STOP","SUP-ITM-10133301","CDM","C1713","HCPCS","0278","RC","","","","both","","","362.50","217.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","42.16","308.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 17MM 1.1X6IN VARIAX SS BALL TIP STOP","SUP-ITM-10133301","CDM","C1713","HCPCS","0278","RC","","","","both","","","362.50","217.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","206.26","56.9","","812.12","238.65","1587.46","163","42.16","308.13","percent of total billed charges",""
"K-WIRE BONE 17MM 1.1X6IN VARIAX SS BALL TIP STOP","SUP-ITM-10133301","CDM","C1713","HCPCS","0278","RC","","","","both","","","362.50","217.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","42.16","11.63","","112.68","112.68","146.99","38","42.16","308.13","percent of total billed charges",""
"K-WIRE BONE 17MM 1.1X6IN VARIAX SS BALL TIP STOP","SUP-ITM-10133301","CDM","C1713","HCPCS","0278","RC","","","","both","","","362.50","217.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","280.58","77.4","","303.98","303.98","5854.79","1 through 10","42.16","308.13","percent of total billed charges",""
"K-WIRE BONE 17MM 1.1X6IN VARIAX SS BALL TIP STOP","SUP-ITM-10133301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","362.50","217.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","42.16","11.63","","112.68","112.68","146.99","38","42.16","280.58","percent of total billed charges",""
"K-WIRE BONE 17MM 1.1X6IN VARIAX SS BALL TIP STOP","SUP-ITM-10133301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","362.50","217.50","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","227.58","62.78","","780.86","208.94","10480.28","15","42.16","280.58","percent of total billed charges",""
"K-WIRE BONE 17MM 1.1X6IN VARIAX SS BALL TIP STOP","SUP-ITM-10133301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","362.50","217.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","158.49","43.72","","179.76","179.76","179.76","1 through 10","42.16","280.58","percent of total billed charges",""
"K-WIRE BONE 17MM 1.1X6IN VARIAX SS BALL TIP STOP","SUP-ITM-10133301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","362.50","217.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","263.61","72.72","","2355.45","298.99","3965.19","155","42.16","280.58","percent of total billed charges",""
"K-WIRE BONE 17MM 1.1X6IN VARIAX SS BALL TIP STOP","SUP-ITM-10133301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","362.50","217.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","263.61","72.72","","3643.09","3643.09","3643.09","1 through 10","42.16","280.58","percent of total billed charges",""
"K-WIRE BONE 17MM 1.1X6IN VARIAX SS BALL TIP STOP","SUP-ITM-10133301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","362.50","217.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","192.92","53.22","","554.28","554.28","554.28","16","42.16","280.58","percent of total billed charges",""
"K-WIRE BONE 17MM 1.1X6IN VARIAX SS BALL TIP STOP","SUP-ITM-10133301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","362.50","217.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","228.01","62.9","","619.64","173.09","2370.64","150","42.16","280.58","percent of total billed charges",""
"K-WIRE BONE 17MM 1.1X6IN VARIAX SS BALL TIP STOP","SUP-ITM-10133301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","362.50","217.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","280.58","77.4","","303.98","303.98","5854.79","1 through 10","42.16","280.58","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","145.11","87.07","AETNA [1001]","HB WDH AETNA COMMERCIAL","101.29","69.8","","279.80","225.71","279.80","16","16.88","123.34","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","145.11","87.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","16.88","123.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","145.11","87.07","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","82.57","56.9","","18.95","9.41","1260.18","1 through 10","16.88","123.34","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","145.11","87.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16.88","11.63","","37.78","11.63","183.64","21","16.88","123.34","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","145.11","87.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","112.32","77.4","","225.79","68.39","1154.35","11","16.88","123.34","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","145.11","87.07","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","16.88","123.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","145.11","87.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16.88","11.63","","37.78","11.63","183.64","21","16.88","112.32","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","145.11","87.07","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","91.10","62.78","","123.83","114.55","572.63","1 through 10","16.88","112.32","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","145.11","87.07","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","63.44","43.72","","127.38","127.38","148.03","1 through 10","16.88","112.32","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","145.11","87.07","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","105.52","72.72","","196.34","62.16","1727.00","33","16.88","112.32","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","145.11","87.07","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","105.52","72.72","","173.00","173.00","173.00","1 through 10","16.88","112.32","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","145.11","87.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","77.23","53.22","","205.24","190.08","205.24","1 through 10","16.88","112.32","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","145.11","87.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","91.27","62.9","","305.08","81.02","4529.24","103","16.88","112.32","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","145.11","87.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","112.32","77.4","","225.79","68.39","1154.35","11","16.88","112.32","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","565.03","339.02","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","65.71","480.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","565.03","339.02","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","65.71","480.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","565.03","339.02","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","321.50","56.9","","812.12","238.65","1587.46","163","65.71","480.28","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","565.03","339.02","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","65.71","11.63","","112.68","112.68","146.99","38","65.71","480.28","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","565.03","339.02","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","437.33","77.4","","303.98","303.98","5854.79","1 through 10","65.71","480.28","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","565.03","339.02","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","65.71","11.63","","112.68","112.68","146.99","38","65.71","437.33","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","565.03","339.02","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","354.73","62.78","","780.86","208.94","10480.28","15","65.71","437.33","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","565.03","339.02","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","247.03","43.72","","179.76","179.76","179.76","1 through 10","65.71","437.33","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","565.03","339.02","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","410.89","72.72","","2355.45","298.99","3965.19","155","65.71","437.33","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","565.03","339.02","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","410.89","72.72","","3643.09","3643.09","3643.09","1 through 10","65.71","437.33","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","565.03","339.02","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","300.71","53.22","","554.28","554.28","554.28","16","65.71","437.33","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","565.03","339.02","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","355.40","62.9","","619.64","173.09","2370.64","150","65.71","437.33","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","565.03","339.02","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","437.33","77.4","","303.98","303.98","5854.79","1 through 10","65.71","437.33","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.43","122.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","23.66","172.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.43","122.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","23.66","172.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.43","122.06","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","115.75","56.9","","812.12","238.65","1587.46","163","23.66","172.92","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.43","122.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","23.66","11.63","","112.68","112.68","146.99","38","23.66","172.92","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","203.43","122.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","157.45","77.4","","303.98","303.98","5854.79","1 through 10","23.66","172.92","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","203.43","122.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","23.66","11.63","","112.68","112.68","146.99","38","23.66","157.45","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","203.43","122.06","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","127.71","62.78","","780.86","208.94","10480.28","15","23.66","157.45","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","203.43","122.06","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","88.94","43.72","","179.76","179.76","179.76","1 through 10","23.66","157.45","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","203.43","122.06","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","147.93","72.72","","2355.45","298.99","3965.19","155","23.66","157.45","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","203.43","122.06","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","147.93","72.72","","3643.09","3643.09","3643.09","1 through 10","23.66","157.45","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","203.43","122.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","108.27","53.22","","554.28","554.28","554.28","16","23.66","157.45","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","203.43","122.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","127.96","62.9","","619.64","173.09","2370.64","150","23.66","157.45","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","203.43","122.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","157.45","77.4","","303.98","303.98","5854.79","1 through 10","23.66","157.45","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","45.51","27.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","5.29","38.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","45.51","27.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","5.29","38.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","45.51","27.31","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","25.90","56.9","","812.12","238.65","1587.46","163","5.29","38.68","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","45.51","27.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","5.29","11.63","","112.68","112.68","146.99","38","5.29","38.68","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","45.51","27.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","35.22","77.4","","303.98","303.98","5854.79","1 through 10","5.29","38.68","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","45.51","27.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","5.29","11.63","","112.68","112.68","146.99","38","5.29","35.22","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","45.51","27.31","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","28.57","62.78","","780.86","208.94","10480.28","15","5.29","35.22","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","45.51","27.31","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","19.90","43.72","","179.76","179.76","179.76","1 through 10","5.29","35.22","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","45.51","27.31","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","33.09","72.72","","2355.45","298.99","3965.19","155","5.29","35.22","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","45.51","27.31","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","33.09","72.72","","3643.09","3643.09","3643.09","1 through 10","5.29","35.22","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","45.51","27.31","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","24.22","53.22","","554.28","554.28","554.28","16","5.29","35.22","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","45.51","27.31","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","28.63","62.9","","619.64","173.09","2370.64","150","5.29","35.22","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","45.51","27.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","35.22","77.4","","303.98","303.98","5854.79","1 through 10","5.29","35.22","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","both","","","52.41","31.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","6.1","44.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","both","","","52.41","31.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","6.1","44.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","both","","","52.41","31.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","29.82","56.9","","812.12","238.65","1587.46","163","6.1","44.55","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","both","","","52.41","31.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","6.10","11.63","","112.68","112.68","146.99","38","6.1","44.55","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","both","","","52.41","31.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","40.57","77.4","","303.98","303.98","5854.79","1 through 10","6.1","44.55","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","52.41","31.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","6.10","11.63","","112.68","112.68","146.99","38","6.1","40.57","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","52.41","31.45","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","32.90","62.78","","780.86","208.94","10480.28","15","6.1","40.57","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","52.41","31.45","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","22.91","43.72","","179.76","179.76","179.76","1 through 10","6.1","40.57","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","52.41","31.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","38.11","72.72","","2355.45","298.99","3965.19","155","6.1","40.57","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","52.41","31.45","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","38.11","72.72","","3643.09","3643.09","3643.09","1 through 10","6.1","40.57","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","52.41","31.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","27.89","53.22","","554.28","554.28","554.28","16","6.1","40.57","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","52.41","31.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","32.97","62.9","","619.64","173.09","2370.64","150","6.1","40.57","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","52.41","31.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","40.57","77.4","","303.98","303.98","5854.79","1 through 10","6.1","40.57","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.26","102.16","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","19.8","144.72","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.26","102.16","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","19.8","144.72","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.26","102.16","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","96.88","56.9","","812.12","238.65","1587.46","163","19.8","144.72","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.26","102.16","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","19.80","11.63","","112.68","112.68","146.99","38","19.8","144.72","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.26","102.16","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","131.78","77.4","","303.98","303.98","5854.79","1 through 10","19.8","144.72","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.26","102.16","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","19.80","11.63","","112.68","112.68","146.99","38","19.8","131.78","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.26","102.16","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","106.89","62.78","","780.86","208.94","10480.28","15","19.8","131.78","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.26","102.16","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","74.44","43.72","","179.76","179.76","179.76","1 through 10","19.8","131.78","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.26","102.16","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","123.81","72.72","","2355.45","298.99","3965.19","155","19.8","131.78","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.26","102.16","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","123.81","72.72","","3643.09","3643.09","3643.09","1 through 10","19.8","131.78","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.26","102.16","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","90.61","53.22","","554.28","554.28","554.28","16","19.8","131.78","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.26","102.16","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","107.09","62.9","","619.64","173.09","2370.64","150","19.8","131.78","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.26","102.16","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","131.78","77.4","","303.98","303.98","5854.79","1 through 10","19.8","131.78","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.11","107.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","20.83","152.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.11","107.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","20.83","152.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.11","107.47","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","101.91","56.9","","812.12","238.65","1587.46","163","20.83","152.24","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.11","107.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.83","11.63","","112.68","112.68","146.99","38","20.83","152.24","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.11","107.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","138.63","77.4","","303.98","303.98","5854.79","1 through 10","20.83","152.24","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.11","107.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.83","11.63","","112.68","112.68","146.99","38","20.83","138.63","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.11","107.47","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","112.45","62.78","","780.86","208.94","10480.28","15","20.83","138.63","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.11","107.47","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","78.31","43.72","","179.76","179.76","179.76","1 through 10","20.83","138.63","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.11","107.47","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","130.25","72.72","","2355.45","298.99","3965.19","155","20.83","138.63","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.11","107.47","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","130.25","72.72","","3643.09","3643.09","3643.09","1 through 10","20.83","138.63","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.11","107.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","95.32","53.22","","554.28","554.28","554.28","16","20.83","138.63","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.11","107.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","112.66","62.9","","619.64","173.09","2370.64","150","20.83","138.63","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.11","107.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","138.63","77.4","","303.98","303.98","5854.79","1 through 10","20.83","138.63","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.30","102.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","19.92","145.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.30","102.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","19.92","145.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.30","102.78","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","97.47","56.9","","812.12","238.65","1587.46","163","19.92","145.61","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.30","102.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","19.92","11.63","","112.68","112.68","146.99","38","19.92","145.61","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.30","102.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","132.59","77.4","","303.98","303.98","5854.79","1 through 10","19.92","145.61","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","171.30","102.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","19.92","11.63","","112.68","112.68","146.99","38","19.92","132.59","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","171.30","102.78","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","107.54","62.78","","780.86","208.94","10480.28","15","19.92","132.59","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","171.30","102.78","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","74.89","43.72","","179.76","179.76","179.76","1 through 10","19.92","132.59","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","171.30","102.78","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","124.57","72.72","","2355.45","298.99","3965.19","155","19.92","132.59","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","171.30","102.78","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","124.57","72.72","","3643.09","3643.09","3643.09","1 through 10","19.92","132.59","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","171.30","102.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","91.17","53.22","","554.28","554.28","554.28","16","19.92","132.59","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","171.30","102.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","107.75","62.9","","619.64","173.09","2370.64","150","19.92","132.59","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","171.30","102.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","132.59","77.4","","303.98","303.98","5854.79","1 through 10","19.92","132.59","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.65","125.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","24.38","178.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.65","125.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","24.38","178.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.65","125.79","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","119.29","56.9","","812.12","238.65","1587.46","163","24.38","178.2","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.65","125.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","24.38","11.63","","112.68","112.68","146.99","38","24.38","178.2","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","209.65","125.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","162.27","77.4","","303.98","303.98","5854.79","1 through 10","24.38","178.2","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","209.65","125.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","24.38","11.63","","112.68","112.68","146.99","38","24.38","162.27","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","209.65","125.79","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","131.62","62.78","","780.86","208.94","10480.28","15","24.38","162.27","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","209.65","125.79","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","91.66","43.72","","179.76","179.76","179.76","1 through 10","24.38","162.27","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","209.65","125.79","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","152.46","72.72","","2355.45","298.99","3965.19","155","24.38","162.27","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","209.65","125.79","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","152.46","72.72","","3643.09","3643.09","3643.09","1 through 10","24.38","162.27","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","209.65","125.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","111.58","53.22","","554.28","554.28","554.28","16","24.38","162.27","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","209.65","125.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","131.87","62.9","","619.64","173.09","2370.64","150","24.38","162.27","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","209.65","125.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","162.27","77.4","","303.98","303.98","5854.79","1 through 10","24.38","162.27","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.40","240.84","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","46.68","341.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.40","240.84","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","46.68","341.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.40","240.84","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","228.40","56.9","","812.12","238.65","1587.46","163","46.68","341.19","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.40","240.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","46.68","11.63","","112.68","112.68","146.99","38","46.68","341.19","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.40","240.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","310.68","77.4","","303.98","303.98","5854.79","1 through 10","46.68","341.19","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","401.40","240.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","46.68","11.63","","112.68","112.68","146.99","38","46.68","310.68","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","401.40","240.84","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","252.00","62.78","","780.86","208.94","10480.28","15","46.68","310.68","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","401.40","240.84","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","175.49","43.72","","179.76","179.76","179.76","1 through 10","46.68","310.68","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","401.40","240.84","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","291.90","72.72","","2355.45","298.99","3965.19","155","46.68","310.68","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","401.40","240.84","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","291.90","72.72","","3643.09","3643.09","3643.09","1 through 10","46.68","310.68","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","401.40","240.84","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","213.63","53.22","","554.28","554.28","554.28","16","46.68","310.68","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","401.40","240.84","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","252.48","62.9","","619.64","173.09","2370.64","150","46.68","310.68","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","401.40","240.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","310.68","77.4","","303.98","303.98","5854.79","1 through 10","46.68","310.68","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","1375.99","825.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","160.03","1169.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","1375.99","825.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","160.03","1169.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","1375.99","825.59","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","782.94","56.9","","812.12","238.65","1587.46","163","160.03","1169.59","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","1375.99","825.59","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","160.03","11.63","","112.68","112.68","146.99","38","160.03","1169.59","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","1375.99","825.59","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1065.02","77.4","","303.98","303.98","5854.79","1 through 10","160.03","1169.59","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1375.99","825.59","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","160.03","11.63","","112.68","112.68","146.99","38","160.03","1065.02","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1375.99","825.59","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","863.85","62.78","","780.86","208.94","10480.28","15","160.03","1065.02","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1375.99","825.59","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","601.58","43.72","","179.76","179.76","179.76","1 through 10","160.03","1065.02","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1375.99","825.59","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1000.62","72.72","","2355.45","298.99","3965.19","155","160.03","1065.02","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1375.99","825.59","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1000.62","72.72","","3643.09","3643.09","3643.09","1 through 10","160.03","1065.02","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1375.99","825.59","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","732.30","53.22","","554.28","554.28","554.28","16","160.03","1065.02","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1375.99","825.59","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","865.50","62.9","","619.64","173.09","2370.64","150","160.03","1065.02","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1375.99","825.59","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1065.02","77.4","","303.98","303.98","5854.79","1 through 10","160.03","1065.02","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.79","212.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","41.15","300.72","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.79","212.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","41.15","300.72","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.79","212.27","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","201.31","56.9","","812.12","238.65","1587.46","163","41.15","300.72","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.79","212.27","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","41.15","11.63","","112.68","112.68","146.99","38","41.15","300.72","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","both","","","353.79","212.27","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","273.83","77.4","","303.98","303.98","5854.79","1 through 10","41.15","300.72","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.79","212.27","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","41.15","11.63","","112.68","112.68","146.99","38","41.15","273.83","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.79","212.27","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","222.11","62.78","","780.86","208.94","10480.28","15","41.15","273.83","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.79","212.27","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","154.68","43.72","","179.76","179.76","179.76","1 through 10","41.15","273.83","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.79","212.27","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","257.28","72.72","","2355.45","298.99","3965.19","155","41.15","273.83","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.79","212.27","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","257.28","72.72","","3643.09","3643.09","3643.09","1 through 10","41.15","273.83","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.79","212.27","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","188.29","53.22","","554.28","554.28","554.28","16","41.15","273.83","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.79","212.27","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","222.53","62.9","","619.64","173.09","2370.64","150","41.15","273.83","percent of total billed charges",""
"K-WIRE BONE DIA 2.0MM EQUNOX SS GLENOID","SUP-ITM-10170098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","353.79","212.27","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","273.83","77.4","","303.98","303.98","5854.79","1 through 10","41.15","273.83","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.40","165.84","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","32.15","234.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.40","165.84","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","32.15","234.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.40","165.84","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","157.27","56.9","","812.12","238.65","1587.46","163","32.15","234.94","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.40","165.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","32.15","11.63","","112.68","112.68","146.99","38","32.15","234.94","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.40","165.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","213.93","77.4","","303.98","303.98","5854.79","1 through 10","32.15","234.94","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.40","165.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","32.15","11.63","","112.68","112.68","146.99","38","32.15","213.93","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.40","165.84","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","173.52","62.78","","780.86","208.94","10480.28","15","32.15","213.93","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.40","165.84","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","120.84","43.72","","179.76","179.76","179.76","1 through 10","32.15","213.93","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.40","165.84","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","201.00","72.72","","2355.45","298.99","3965.19","155","32.15","213.93","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.40","165.84","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","201.00","72.72","","3643.09","3643.09","3643.09","1 through 10","32.15","213.93","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.40","165.84","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","147.10","53.22","","554.28","554.28","554.28","16","32.15","213.93","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.40","165.84","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","173.86","62.9","","619.64","173.09","2370.64","150","32.15","213.93","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.40","165.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","213.93","77.4","","303.98","303.98","5854.79","1 through 10","32.15","213.93","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.48","116.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","22.5","164.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.48","116.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","22.5","164.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.48","116.09","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","110.09","56.9","","812.12","238.65","1587.46","163","22.5","164.46","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.48","116.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","22.50","11.63","","112.68","112.68","146.99","38","22.5","164.46","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.48","116.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","149.75","77.4","","303.98","303.98","5854.79","1 through 10","22.5","164.46","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","193.48","116.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","22.50","11.63","","112.68","112.68","146.99","38","22.5","149.75","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","193.48","116.09","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","121.47","62.78","","780.86","208.94","10480.28","15","22.5","149.75","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","193.48","116.09","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","84.59","43.72","","179.76","179.76","179.76","1 through 10","22.5","149.75","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","193.48","116.09","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","140.70","72.72","","2355.45","298.99","3965.19","155","22.5","149.75","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","193.48","116.09","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","140.70","72.72","","3643.09","3643.09","3643.09","1 through 10","22.5","149.75","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","193.48","116.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","102.97","53.22","","554.28","554.28","554.28","16","22.5","149.75","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","193.48","116.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","121.70","62.9","","619.64","173.09","2370.64","150","22.5","149.75","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","193.48","116.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","149.75","77.4","","303.98","303.98","5854.79","1 through 10","22.5","149.75","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","132.67","79.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","92.60","69.8","","279.80","225.71","279.80","16","15.43","112.77","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","132.67","79.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","15.43","112.77","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","132.67","79.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","75.49","56.9","","18.95","9.41","1260.18","1 through 10","15.43","112.77","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","132.67","79.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","15.43","11.63","","37.78","11.63","183.64","21","15.43","112.77","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","132.67","79.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","102.69","77.4","","225.79","68.39","1154.35","11","15.43","112.77","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","132.67","79.60","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","15.43","112.77","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","132.67","79.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","15.43","11.63","","37.78","11.63","183.64","21","15.43","102.69","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","132.67","79.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","83.29","62.78","","123.83","114.55","572.63","1 through 10","15.43","102.69","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","132.67","79.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","58.00","43.72","","127.38","127.38","148.03","1 through 10","15.43","102.69","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","132.67","79.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","96.48","72.72","","196.34","62.16","1727.00","33","15.43","102.69","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","132.67","79.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","96.48","72.72","","173.00","173.00","173.00","1 through 10","15.43","102.69","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","132.67","79.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","70.61","53.22","","205.24","190.08","205.24","1 through 10","15.43","102.69","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","132.67","79.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","83.45","62.9","","305.08","81.02","4529.24","103","15.43","102.69","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","132.67","79.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","102.69","77.4","","225.79","68.39","1154.35","11","15.43","102.69","percent of total billed charges",""
"K-WIRE TROCAR 1.4X2MM","SUP-ITM-10239351","CDM","C1713","HCPCS","0278","RC","","","","both","","","152.02","91.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","17.68","129.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE TROCAR 1.4X2MM","SUP-ITM-10239351","CDM","C1713","HCPCS","0278","RC","","","","both","","","152.02","91.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","17.68","129.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"K-WIRE TROCAR 1.4X2MM","SUP-ITM-10239351","CDM","C1713","HCPCS","0278","RC","","","","both","","","152.02","91.21","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","86.50","56.9","","812.12","238.65","1587.46","163","17.68","129.22","percent of total billed charges",""
"K-WIRE TROCAR 1.4X2MM","SUP-ITM-10239351","CDM","C1713","HCPCS","0278","RC","","","","both","","","152.02","91.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","17.68","11.63","","112.68","112.68","146.99","38","17.68","129.22","percent of total billed charges",""
"K-WIRE TROCAR 1.4X2MM","SUP-ITM-10239351","CDM","C1713","HCPCS","0278","RC","","","","both","","","152.02","91.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","117.66","77.4","","303.98","303.98","5854.79","1 through 10","17.68","129.22","percent of total billed charges",""
"K-WIRE TROCAR 1.4X2MM","SUP-ITM-10239351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","152.02","91.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","17.68","11.63","","112.68","112.68","146.99","38","17.68","117.66","percent of total billed charges",""
"K-WIRE TROCAR 1.4X2MM","SUP-ITM-10239351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","152.02","91.21","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","95.44","62.78","","780.86","208.94","10480.28","15","17.68","117.66","percent of total billed charges",""
"K-WIRE TROCAR 1.4X2MM","SUP-ITM-10239351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","152.02","91.21","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","66.46","43.72","","179.76","179.76","179.76","1 through 10","17.68","117.66","percent of total billed charges",""
"K-WIRE TROCAR 1.4X2MM","SUP-ITM-10239351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","152.02","91.21","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","110.55","72.72","","2355.45","298.99","3965.19","155","17.68","117.66","percent of total billed charges",""
"K-WIRE TROCAR 1.4X2MM","SUP-ITM-10239351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","152.02","91.21","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","110.55","72.72","","3643.09","3643.09","3643.09","1 through 10","17.68","117.66","percent of total billed charges",""
"K-WIRE TROCAR 1.4X2MM","SUP-ITM-10239351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","152.02","91.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","80.91","53.22","","554.28","554.28","554.28","16","17.68","117.66","percent of total billed charges",""
"K-WIRE TROCAR 1.4X2MM","SUP-ITM-10239351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","152.02","91.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","95.62","62.9","","619.64","173.09","2370.64","150","17.68","117.66","percent of total billed charges",""
"K-WIRE TROCAR 1.4X2MM","SUP-ITM-10239351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","152.02","91.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","117.66","77.4","","303.98","303.98","5854.79","1 through 10","17.68","117.66","percent of total billed charges",""
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","","","","inpatient","","","65102.88","39061.73","MEDICARE [2001]","HB WDH MEDICARE","14357.31","","Case rate ($14,357.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,285.91, add-ons for qualifying new technology services are included. If operating cost exceeds $17,204.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,821.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $12,895.81 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,841.04 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,016.64. The transfer capital threshold is the transfer adjustment factor * $1,016.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14274.77","14274.77","14274.77","1 through 10","3975","69540.18","other","Inpatient DRG"
"Kidney And Ureter Procedures For Neoplasm Without Cc/McC","658","MS-DRG","","","","","","","","inpatient","","","71228.19","42736.91","MEDICARE [2001]","HB WDH MEDICARE","12242.34","","Case rate ($12,242.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,333.80, add-ons for qualifying new technology services are included. If operating cost exceeds $15,251.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,667.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $10,935.37 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,888.93 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $862.09. The transfer capital threshold is the transfer adjustment factor * $862.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11793.30","11793.30","11793.30","1 through 10","3975","58968.56","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","","","","inpatient","","","46527.81","27916.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","27081.63","","Fee schedule rate ($27,081.63). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","27456.60","27456.60","27456.60","1 through 10","3975","50224.73","case rate",""
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","","","","inpatient","","","46527.83","27916.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","10283.16","","Case rate ($10,493.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,719.20, add-ons for qualifying new technology services are included. If operating cost exceeds $13,637.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,539.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $9,313.88 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,274.32 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $734.26. The transfer capital threshold is the transfer adjustment factor * $734.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10344.71","10344.71","10344.71","1 through 10","3975","50224.73","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","","","","inpatient","","","46527.83","27916.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","40001.62","","Fee schedule rate ($40,001.62). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","35874.80","35874.80","35874.80","1 through 10","3975","50224.73","case rate",""
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","","","","inpatient","","","46527.83","27916.70","MEDICARE [2001]","HB WDH MEDICARE","10493.02","","Case rate ($10,493.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,719.20, add-ons for qualifying new technology services are included. If operating cost exceeds $13,637.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,539.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $9,313.88 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,274.32 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $734.26. The transfer capital threshold is the transfer adjustment factor * $734.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10555.83","0.05","10582.88","1 through 10","3975","50224.73","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","","","","inpatient","","","46527.83","27916.70","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","10493.02","","Case rate ($10,493.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,719.20, add-ons for qualifying new technology services are included. If operating cost exceeds $13,637.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,539.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $9,313.88 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,274.32 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $734.26. The transfer capital threshold is the transfer adjustment factor * $734.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10370.54","10351.94","10387.03","1 through 10","3975","50224.73","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","","","","inpatient","","","46527.83","27916.70","WELLSENSE NH [1050]","HB WDH MEDICARE","10493.02","","Case rate ($10,493.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,719.20, add-ons for qualifying new technology services are included. If operating cost exceeds $13,637.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,539.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $9,313.88 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,274.32 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $734.26. The transfer capital threshold is the transfer adjustment factor * $734.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10896.46","10896.46","10896.46","1 through 10","3975","50224.73","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With McC","659","MS-DRG","","","","","","","","inpatient","","","54800.03","32880.02","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","19366.67","","Case rate ($19,761.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $18,274.28, add-ons for qualifying new technology services are included. If operating cost exceeds $22,192.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,216.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $17,905.45 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,829.40 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,411.58. The transfer capital threshold is the transfer adjustment factor * $1,411.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19944.77","19944.77","19944.77","1 through 10","3975","96554.45","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With McC","659","MS-DRG","","","","","","","","inpatient","","","54800.03","32880.02","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","20354.77","","Case rate ($19,761.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $18,274.28, add-ons for qualifying new technology services are included. If operating cost exceeds $22,192.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,216.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $17,905.45 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,829.40 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,411.58. The transfer capital threshold is the transfer adjustment factor * $1,411.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","84714.80","84714.80","84714.80","1 through 10","3975","96554.45","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With McC","659","MS-DRG","","","","","","","","inpatient","","","54800.03","32880.02","MEDICARE [2001]","HB WDH MEDICARE","19761.91","","Case rate ($19,761.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $18,274.28, add-ons for qualifying new technology services are included. If operating cost exceeds $22,192.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,216.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $17,905.45 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,829.40 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,411.58. The transfer capital threshold is the transfer adjustment factor * $1,411.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19944.77","13161.16","19995.57","1 through 10","3975","96554.45","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With McC","659","MS-DRG","","","","","","","","inpatient","","","54800.03","32880.02","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","19761.91","","Case rate ($19,761.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $18,274.28, add-ons for qualifying new technology services are included. If operating cost exceeds $22,192.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,216.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $17,905.45 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,829.40 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,411.58. The transfer capital threshold is the transfer adjustment factor * $1,411.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19633.26","19633.26","19633.26","1 through 10","3975","96554.45","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC","661","MS-DRG","","","","","","","","inpatient","","","37448.83","22469.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","8150.11","","Case rate ($8,316.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,710.24, add-ons for qualifying new technology services are included. If operating cost exceeds $11,628.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,380.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,296.35 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,265.36 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.21. The transfer capital threshold is the transfer adjustment factor * $575.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8211.24","8211.24","8211.24","1 through 10","3975","39345.3","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC","661","MS-DRG","","","","","","","","inpatient","","","37448.83","22469.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","31336.67","","Fee schedule rate ($31,336.67). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","30312.52","30312.52","30312.52","1 through 10","3975","39345.3","case rate",""
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC","661","MS-DRG","","","","","","","","inpatient","","","37448.83","22469.30","MEDICARE [2001]","HB WDH MEDICARE","8316.44","","Case rate ($8,316.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,710.24, add-ons for qualifying new technology services are included. If operating cost exceeds $11,628.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,380.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,296.35 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,265.36 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.21. The transfer capital threshold is the transfer adjustment factor * $575.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8191.06","0.05","8211.24","1 through 10","3975","39345.3","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC","661","MS-DRG","","","","","","","","inpatient","","","37448.83","22469.30","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8316.44","","Case rate ($8,316.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,710.24, add-ons for qualifying new technology services are included. If operating cost exceeds $11,628.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,380.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,296.35 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,265.36 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.21. The transfer capital threshold is the transfer adjustment factor * $575.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8191.06","8191.06","8191.06","1 through 10","3975","39345.3","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC","661","MS-DRG","","","","","","","","inpatient","","","37448.83","22469.30","WELLSENSE NH [1050]","HB WDH MEDICARE","8316.44","","Case rate ($8,316.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,710.24, add-ons for qualifying new technology services are included. If operating cost exceeds $11,628.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,380.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $7,296.35 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,265.36 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $575.21. The transfer capital threshold is the transfer adjustment factor * $575.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8450.80","8450.80","8450.80","1 through 10","3975","39345.3","other","Inpatient DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","30408.72","18245.23","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","9451.30","","Case rate ($9,265.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,586.65, add-ons for qualifying new technology services are included. If operating cost exceeds $12,504.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,449.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,176.51 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,141.78 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.60. The transfer capital threshold is the transfer adjustment factor * $644.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","9275.35","9275.35","9275.35","1 through 10","3975","44091.52","other","Inpatient DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","30408.72","18245.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","9080.66","","Case rate ($9,265.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,586.65, add-ons for qualifying new technology services are included. If operating cost exceeds $12,504.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,449.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,176.51 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,141.78 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.60. The transfer capital threshold is the transfer adjustment factor * $644.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7285.99","7285.99","7285.99","1 through 10","3975","44091.52","other","Inpatient DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","30408.72","18245.23","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","9543.96","","Case rate ($9,265.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,586.65, add-ons for qualifying new technology services are included. If operating cost exceeds $12,504.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,449.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,176.51 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,141.78 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.60. The transfer capital threshold is the transfer adjustment factor * $644.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","5018.00","5018.00","5018.00","1 through 10","3975","44091.52","other","Inpatient DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","30408.72","18245.23","MEDICARE [2001]","HB WDH MEDICARE","9265.98","","Case rate ($9,265.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,586.65, add-ons for qualifying new technology services are included. If operating cost exceeds $12,504.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,449.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,176.51 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,141.78 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.60. The transfer capital threshold is the transfer adjustment factor * $644.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9275.35","203.70","9298.36","56","3975","44091.52","other","Inpatient DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","30408.72","18245.23","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","9265.98","","Case rate ($9,265.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,586.65, add-ons for qualifying new technology services are included. If operating cost exceeds $12,504.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,449.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,176.51 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,141.78 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.60. The transfer capital threshold is the transfer adjustment factor * $644.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9089.85","6405.05","14978.46","1 through 10","3975","44091.52","other","Inpatient DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","30408.72","18245.23","WELLSENSE NH [1050]","HB WDH MEDICARE","9265.98","","Case rate ($9,265.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,586.65, add-ons for qualifying new technology services are included. If operating cost exceeds $12,504.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,449.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $8,176.51 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,141.78 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $644.60. The transfer capital threshold is the transfer adjustment factor * $644.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9597.61","9597.61","9597.61","1 through 10","3975","44091.52","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","25108.70","15065.22","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","12112.45","","Fee schedule rate ($12,112.45). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","11716.29","11716.29","11716.29","1 through 10","3975","30761.08","case rate",""
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","25108.70","15065.22","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","6467.07","","Case rate ($6,599.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,125.11, add-ons for qualifying new technology services are included. If operating cost exceeds $10,043.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,254.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,704.46 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,680.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $449.71. The transfer capital threshold is the transfer adjustment factor * $449.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6419.83","6419.83","6419.83","1 through 10","3975","30761.08","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","25108.70","15065.22","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","6797.02","","Case rate ($6,599.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,125.11, add-ons for qualifying new technology services are included. If operating cost exceeds $10,043.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,254.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,704.46 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,680.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $449.71. The transfer capital threshold is the transfer adjustment factor * $449.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11702.03","7910.97","33533.03","1 through 10","3975","30761.08","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","25108.70","15065.22","MARTIN'S POINT [160007]","HB WDH MEDICARE","6599.05","","Case rate ($6,599.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,125.11, add-ons for qualifying new technology services are included. If operating cost exceeds $10,043.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,254.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,704.46 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,680.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $449.71. The transfer capital threshold is the transfer adjustment factor * $449.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6885.08","6885.08","6885.08","1 through 10","3975","30761.08","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","25108.70","15065.22","MEDICARE [2001]","HB WDH MEDICARE","6599.05","","Case rate ($6,599.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,125.11, add-ons for qualifying new technology services are included. If operating cost exceeds $10,043.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,254.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,704.46 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,680.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $449.71. The transfer capital threshold is the transfer adjustment factor * $449.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6500.86","0.05","6516.64","57","3975","30761.08","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","25108.70","15065.22","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6599.05","","Case rate ($6,599.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,125.11, add-ons for qualifying new technology services are included. If operating cost exceeds $10,043.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,254.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,704.46 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,680.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $449.71. The transfer capital threshold is the transfer adjustment factor * $449.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6394.54","732.96","6500.86","1 through 10","3975","30761.08","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","25108.70","15065.22","VETERANS ADMINISTRATION [160006]","HB WDH MEDICARE","6599.05","","Case rate ($6,599.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,125.11, add-ons for qualifying new technology services are included. If operating cost exceeds $10,043.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,254.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,704.46 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,680.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $449.71. The transfer capital threshold is the transfer adjustment factor * $449.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6621.30","6621.30","6621.30","1 through 10","3975","30761.08","other","Inpatient DRG"
"Kidney And Urinary Tract Neoplasms With McC","686","MS-DRG","","","","","","","","inpatient","","","56563.22","33937.93","MEDICARE [2001]","HB WDH MEDICARE","14157.39","","Case rate ($14,157.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,101.37, add-ons for qualifying new technology services are included. If operating cost exceeds $17,019.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,807.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,710.48 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,656.50 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,002.03. The transfer capital threshold is the transfer adjustment factor * $1,002.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14710.52","14710.52","14710.52","1 through 10","3975","68540.78","other","Inpatient DRG"
"Kidney And Urinary Tract Signs And Symptoms Without McC","696","MS-DRG","","","","","","","","inpatient","","","64242.95","38545.77","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","5796.61","","Case rate ($5,682.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,279.56, add-ons for qualifying new technology services are included. If operating cost exceeds $9,197.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,187.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,855.31 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,834.69 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $382.77. The transfer capital threshold is the transfer adjustment factor * $382.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","5664.80","5664.80","5664.80","1 through 10","3975","26182.07","other","Inpatient DRG"
"KIT 11X120MM 5 11GA SCP KNEE SIDE DELIVERY","SUP-ITM-10168042","CDM","C1776","HCPCS","0278","RC","","","","both","","","14855.48","8913.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1727.69","12627.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT 11X120MM 5 11GA SCP KNEE SIDE DELIVERY","SUP-ITM-10168042","CDM","C1776","HCPCS","0278","RC","","","","both","","","14855.48","8913.29","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","8452.77","56.9","","2911.53","1863.86","5209.05","65","1727.69","12627.16","percent of total billed charges",""
"KIT 11X120MM 5 11GA SCP KNEE SIDE DELIVERY","SUP-ITM-10168042","CDM","C1776","HCPCS","0278","RC","","","","both","","","14855.48","8913.29","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1727.69","11.63","","400.94","400.94","400.94","1 through 10","1727.69","12627.16","percent of total billed charges",""
"KIT 11X120MM 5 11GA SCP KNEE SIDE DELIVERY","SUP-ITM-10168042","CDM","C1776","HCPCS","0278","RC","","","","both","","","14855.48","8913.29","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","11498.14","77.4","","5214.50","5214.50","16415.28","1 through 10","1727.69","12627.16","percent of total billed charges",""
"KIT 11X120MM 5 11GA SCP KNEE SIDE DELIVERY","SUP-ITM-10168042","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14855.48","8913.29","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1727.69","11.63","","400.94","400.94","400.94","1 through 10","1727.69","11498.14","percent of total billed charges",""
"KIT 11X120MM 5 11GA SCP KNEE SIDE DELIVERY","SUP-ITM-10168042","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14855.48","8913.29","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","6494.82","43.72","","1543.33","1543.33","1671.61","1 through 10","1727.69","11498.14","percent of total billed charges",""
"KIT 11X120MM 5 11GA SCP KNEE SIDE DELIVERY","SUP-ITM-10168042","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14855.48","8913.29","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10802.91","72.72","","3700.21","2382.07","6427.18","53","1727.69","11498.14","percent of total billed charges",""
"KIT 11X120MM 5 11GA SCP KNEE SIDE DELIVERY","SUP-ITM-10168042","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14855.48","8913.29","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","10802.91","72.72","","12685.80","12685.80","12685.80","1 through 10","1727.69","11498.14","percent of total billed charges",""
"KIT 11X120MM 5 11GA SCP KNEE SIDE DELIVERY","SUP-ITM-10168042","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14855.48","8913.29","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","9344.10","62.9","","3408.87","2784.05","9859.40","46","1727.69","11498.14","percent of total billed charges",""
"KIT 11X120MM 5 11GA SCP KNEE SIDE DELIVERY","SUP-ITM-10168042","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14855.48","8913.29","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","11498.14","77.4","","5214.50","5214.50","16415.28","1 through 10","1727.69","11498.14","percent of total billed charges",""
"KIT ANCHOR 2.3MM SUTURE ICONIX FORCE FIBER NEEDLE PC/1EA","SUP-ITM-10306211","CDM","C1713","HCPCS","0278","RC","","","","both","","","3008.34","1805.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","349.87","2557.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT ANCHOR 2.3MM SUTURE ICONIX FORCE FIBER NEEDLE PC/1EA","SUP-ITM-10306211","CDM","C1713","HCPCS","0278","RC","","","","both","","","3008.34","1805.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","349.87","2557.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT ANCHOR 2.3MM SUTURE ICONIX FORCE FIBER NEEDLE PC/1EA","SUP-ITM-10306211","CDM","C1713","HCPCS","0278","RC","","","","both","","","3008.34","1805.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1711.75","56.9","","812.12","238.65","1587.46","163","349.87","2557.09","percent of total billed charges",""
"KIT ANCHOR 2.3MM SUTURE ICONIX FORCE FIBER NEEDLE PC/1EA","SUP-ITM-10306211","CDM","C1713","HCPCS","0278","RC","","","","both","","","3008.34","1805.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","349.87","11.63","","112.68","112.68","146.99","38","349.87","2557.09","percent of total billed charges",""
"KIT ANCHOR 2.3MM SUTURE ICONIX FORCE FIBER NEEDLE PC/1EA","SUP-ITM-10306211","CDM","C1713","HCPCS","0278","RC","","","","both","","","3008.34","1805.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2328.46","77.4","","303.98","303.98","5854.79","1 through 10","349.87","2557.09","percent of total billed charges",""
"KIT ANCHOR 2.3MM SUTURE ICONIX FORCE FIBER NEEDLE PC/1EA","SUP-ITM-10306211","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3008.34","1805.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","349.87","11.63","","112.68","112.68","146.99","38","349.87","2328.46","percent of total billed charges",""
"KIT ANCHOR 2.3MM SUTURE ICONIX FORCE FIBER NEEDLE PC/1EA","SUP-ITM-10306211","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3008.34","1805.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1888.64","62.78","","780.86","208.94","10480.28","15","349.87","2328.46","percent of total billed charges",""
"KIT ANCHOR 2.3MM SUTURE ICONIX FORCE FIBER NEEDLE PC/1EA","SUP-ITM-10306211","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3008.34","1805.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1315.25","43.72","","179.76","179.76","179.76","1 through 10","349.87","2328.46","percent of total billed charges",""
"KIT ANCHOR 2.3MM SUTURE ICONIX FORCE FIBER NEEDLE PC/1EA","SUP-ITM-10306211","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3008.34","1805.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2187.66","72.72","","2355.45","298.99","3965.19","155","349.87","2328.46","percent of total billed charges",""
"KIT ANCHOR 2.3MM SUTURE ICONIX FORCE FIBER NEEDLE PC/1EA","SUP-ITM-10306211","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3008.34","1805.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2187.66","72.72","","3643.09","3643.09","3643.09","1 through 10","349.87","2328.46","percent of total billed charges",""
"KIT ANCHOR 2.3MM SUTURE ICONIX FORCE FIBER NEEDLE PC/1EA","SUP-ITM-10306211","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3008.34","1805.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1601.04","53.22","","554.28","554.28","554.28","16","349.87","2328.46","percent of total billed charges",""
"KIT ANCHOR 2.3MM SUTURE ICONIX FORCE FIBER NEEDLE PC/1EA","SUP-ITM-10306211","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3008.34","1805.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1892.25","62.9","","619.64","173.09","2370.64","150","349.87","2328.46","percent of total billed charges",""
"KIT ANCHOR 2.3MM SUTURE ICONIX FORCE FIBER NEEDLE PC/1EA","SUP-ITM-10306211","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3008.34","1805.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2328.46","77.4","","303.98","303.98","5854.79","1 through 10","349.87","2328.46","percent of total billed charges",""
"KIT AUGMENTATION LIGAMENT INTERNALBRACE FIBERTAPE COLLAGEN COATED","SUP-ITM-10153743","CDM","C1713","HCPCS","0278","RC","","","","both","","","5213.75","3128.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","606.36","4431.69","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT AUGMENTATION LIGAMENT INTERNALBRACE FIBERTAPE COLLAGEN COATED","SUP-ITM-10153743","CDM","C1713","HCPCS","0278","RC","","","","both","","","5213.75","3128.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","606.36","4431.69","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT AUGMENTATION LIGAMENT INTERNALBRACE FIBERTAPE COLLAGEN COATED","SUP-ITM-10153743","CDM","C1713","HCPCS","0278","RC","","","","both","","","5213.75","3128.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2966.62","56.9","","812.12","238.65","1587.46","163","606.36","4431.69","percent of total billed charges",""
"KIT AUGMENTATION LIGAMENT INTERNALBRACE FIBERTAPE COLLAGEN COATED","SUP-ITM-10153743","CDM","C1713","HCPCS","0278","RC","","","","both","","","5213.75","3128.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","606.36","11.63","","112.68","112.68","146.99","38","606.36","4431.69","percent of total billed charges",""
"KIT AUGMENTATION LIGAMENT INTERNALBRACE FIBERTAPE COLLAGEN COATED","SUP-ITM-10153743","CDM","C1713","HCPCS","0278","RC","","","","both","","","5213.75","3128.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4035.44","77.4","","303.98","303.98","5854.79","1 through 10","606.36","4431.69","percent of total billed charges",""
"KIT AUGMENTATION LIGAMENT INTERNALBRACE FIBERTAPE COLLAGEN COATED","SUP-ITM-10153743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5213.75","3128.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","606.36","11.63","","112.68","112.68","146.99","38","606.36","4035.44","percent of total billed charges",""
"KIT AUGMENTATION LIGAMENT INTERNALBRACE FIBERTAPE COLLAGEN COATED","SUP-ITM-10153743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5213.75","3128.25","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3273.19","62.78","","780.86","208.94","10480.28","15","606.36","4035.44","percent of total billed charges",""
"KIT AUGMENTATION LIGAMENT INTERNALBRACE FIBERTAPE COLLAGEN COATED","SUP-ITM-10153743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5213.75","3128.25","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2279.45","43.72","","179.76","179.76","179.76","1 through 10","606.36","4035.44","percent of total billed charges",""
"KIT AUGMENTATION LIGAMENT INTERNALBRACE FIBERTAPE COLLAGEN COATED","SUP-ITM-10153743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5213.75","3128.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3791.44","72.72","","2355.45","298.99","3965.19","155","606.36","4035.44","percent of total billed charges",""
"KIT AUGMENTATION LIGAMENT INTERNALBRACE FIBERTAPE COLLAGEN COATED","SUP-ITM-10153743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5213.75","3128.25","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3791.44","72.72","","3643.09","3643.09","3643.09","1 through 10","606.36","4035.44","percent of total billed charges",""
"KIT AUGMENTATION LIGAMENT INTERNALBRACE FIBERTAPE COLLAGEN COATED","SUP-ITM-10153743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5213.75","3128.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2774.76","53.22","","554.28","554.28","554.28","16","606.36","4035.44","percent of total billed charges",""
"KIT AUGMENTATION LIGAMENT INTERNALBRACE FIBERTAPE COLLAGEN COATED","SUP-ITM-10153743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5213.75","3128.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3279.45","62.9","","619.64","173.09","2370.64","150","606.36","4035.44","percent of total billed charges",""
"KIT AUGMENTATION LIGAMENT INTERNALBRACE FIBERTAPE COLLAGEN COATED","SUP-ITM-10153743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5213.75","3128.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4035.44","77.4","","303.98","303.98","5854.79","1 through 10","606.36","4035.44","percent of total billed charges",""
"KIT BALLOON 30FR 12CM CATHETER DILATION NEPHROMAX HIGH PRESSURE RADIAL","SUP-ITM-10155554","CDM","C1726","HCPCS","0272","RC","","","","both","","","3063.06","1837.84","AETNA [1001]","HB WDH AETNA COMMERCIAL","2138.02","69.8","","166.96","137.81","825.49","1 through 10","356.23","2603.6","percent of total billed charges",""
"KIT BALLOON 30FR 12CM CATHETER DILATION NEPHROMAX HIGH PRESSURE RADIAL","SUP-ITM-10155554","CDM","C1726","HCPCS","0272","RC","","","","both","","","3063.06","1837.84","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1716.86","1716.86","1716.86","1 through 10","356.23","2603.6","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT BALLOON 30FR 12CM CATHETER DILATION NEPHROMAX HIGH PRESSURE RADIAL","SUP-ITM-10155554","CDM","C1726","HCPCS","0272","RC","","","","both","","","3063.06","1837.84","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","4281.09","1182.65","4281.09","1 through 10","356.23","2603.6","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT BALLOON 30FR 12CM CATHETER DILATION NEPHROMAX HIGH PRESSURE RADIAL","SUP-ITM-10155554","CDM","C1726","HCPCS","0272","RC","","","","both","","","3063.06","1837.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","356.23","11.63","","262.01","27.19","426.66","1 through 10","356.23","2603.6","percent of total billed charges",""
"KIT BALLOON 30FR 12CM CATHETER DILATION NEPHROMAX HIGH PRESSURE RADIAL","SUP-ITM-10155554","CDM","C1726","HCPCS","0272","RC","","","","both","","","3063.06","1837.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2370.81","77.4","","1411.46","916.55","1411.46","1 through 10","356.23","2603.6","percent of total billed charges",""
"KIT BALLOON 30FR 12CM CATHETER DILATION NEPHROMAX HIGH PRESSURE RADIAL","SUP-ITM-10155554","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","3063.06","1837.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","356.23","11.63","","262.01","27.19","426.66","1 through 10","356.23","2370.81","percent of total billed charges",""
"KIT BALLOON 30FR 12CM CATHETER DILATION NEPHROMAX HIGH PRESSURE RADIAL","SUP-ITM-10155554","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","3063.06","1837.84","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1339.17","43.72","","517.05","517.05","517.05","1 through 10","356.23","2370.81","percent of total billed charges",""
"KIT BALLOON 30FR 12CM CATHETER DILATION NEPHROMAX HIGH PRESSURE RADIAL","SUP-ITM-10155554","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","3063.06","1837.84","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2227.46","72.72","","1556.61","860.02","1914.17","1 through 10","356.23","2370.81","percent of total billed charges",""
"KIT BALLOON 30FR 12CM CATHETER DILATION NEPHROMAX HIGH PRESSURE RADIAL","SUP-ITM-10155554","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","3063.06","1837.84","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1926.66","62.9","","1348.55","745.07","1348.55","19","356.23","2370.81","percent of total billed charges",""
"KIT BALLOON 30FR 12CM CATHETER DILATION NEPHROMAX HIGH PRESSURE RADIAL","SUP-ITM-10155554","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","3063.06","1837.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2370.81","77.4","","1411.46","916.55","1411.46","1 through 10","356.23","2370.81","percent of total billed charges",""
"KIT BALLOON 30FR 12CM CATHETER DILATION NEPHROMAX HIGH PRESSURE RADIAL","SUP-ITM-10155554","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","3063.06","1837.84","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","2227.46","72.72","","860.02","860.02","860.02","1 through 10","356.23","2370.81","percent of total billed charges",""
"KIT BLOCK SIZE 5.0 5.0FR CUTTING LEGION VISIONAIRE PRIMARY RT KNEE FR","SUP-ITM-10082282","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.50","2280.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","442","3230.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT BLOCK SIZE 5.0 5.0FR CUTTING LEGION VISIONAIRE PRIMARY RT KNEE FR","SUP-ITM-10082282","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.50","2280.30","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2162.48","56.9","","2911.53","1863.86","5209.05","65","442","3230.43","percent of total billed charges",""
"KIT BLOCK SIZE 5.0 5.0FR CUTTING LEGION VISIONAIRE PRIMARY RT KNEE FR","SUP-ITM-10082282","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.50","2280.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","442.00","11.63","","400.94","400.94","400.94","1 through 10","442","3230.43","percent of total billed charges",""
"KIT BLOCK SIZE 5.0 5.0FR CUTTING LEGION VISIONAIRE PRIMARY RT KNEE FR","SUP-ITM-10082282","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.50","2280.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2941.59","77.4","","5214.50","5214.50","16415.28","1 through 10","442","3230.43","percent of total billed charges",""
"KIT BLOCK SIZE 5.0 5.0FR CUTTING LEGION VISIONAIRE PRIMARY RT KNEE FR","SUP-ITM-10082282","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.50","2280.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","442.00","11.63","","400.94","400.94","400.94","1 through 10","442","2941.59","percent of total billed charges",""
"KIT BLOCK SIZE 5.0 5.0FR CUTTING LEGION VISIONAIRE PRIMARY RT KNEE FR","SUP-ITM-10082282","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.50","2280.30","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1661.58","43.72","","1543.33","1543.33","1671.61","1 through 10","442","2941.59","percent of total billed charges",""
"KIT BLOCK SIZE 5.0 5.0FR CUTTING LEGION VISIONAIRE PRIMARY RT KNEE FR","SUP-ITM-10082282","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.50","2280.30","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2763.72","72.72","","3700.21","2382.07","6427.18","53","442","2941.59","percent of total billed charges",""
"KIT BLOCK SIZE 5.0 5.0FR CUTTING LEGION VISIONAIRE PRIMARY RT KNEE FR","SUP-ITM-10082282","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.50","2280.30","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2763.72","72.72","","12685.80","12685.80","12685.80","1 through 10","442","2941.59","percent of total billed charges",""
"KIT BLOCK SIZE 5.0 5.0FR CUTTING LEGION VISIONAIRE PRIMARY RT KNEE FR","SUP-ITM-10082282","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.50","2280.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2390.51","62.9","","3408.87","2784.05","9859.40","46","442","2941.59","percent of total billed charges",""
"KIT BLOCK SIZE 5.0 5.0FR CUTTING LEGION VISIONAIRE PRIMARY RT KNEE FR","SUP-ITM-10082282","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.50","2280.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2941.59","77.4","","5214.50","5214.50","16415.28","1 through 10","442","2941.59","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","8002.50","4801.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","930.69","6802.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","8002.50","4801.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","930.69","6802.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","8002.50","4801.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4553.42","56.9","","812.12","238.65","1587.46","163","930.69","6802.13","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","8002.50","4801.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","930.69","11.63","","112.68","112.68","146.99","38","930.69","6802.13","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","8002.50","4801.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6193.94","77.4","","303.98","303.98","5854.79","1 through 10","930.69","6802.13","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","930.69","11.63","","112.68","112.68","146.99","38","930.69","6193.94","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5023.97","62.78","","780.86","208.94","10480.28","15","930.69","6193.94","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3498.69","43.72","","179.76","179.76","179.76","1 through 10","930.69","6193.94","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5819.42","72.72","","2355.45","298.99","3965.19","155","930.69","6193.94","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5819.42","72.72","","3643.09","3643.09","3643.09","1 through 10","930.69","6193.94","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4258.93","53.22","","554.28","554.28","554.28","16","930.69","6193.94","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5033.57","62.9","","619.64","173.09","2370.64","150","930.69","6193.94","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6193.94","77.4","","303.98","303.98","5854.79","1 through 10","930.69","6193.94","percent of total billed charges",""
"KIT CAP 4.5X46MM SHOULDER LINER EQUINOXE REVERSE COMPRESS SCREW LCK","SUP-ITM-10195118","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.16","315.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","61.08","446.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT CAP 4.5X46MM SHOULDER LINER EQUINOXE REVERSE COMPRESS SCREW LCK","SUP-ITM-10195118","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.16","315.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","61.08","446.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT CAP 4.5X46MM SHOULDER LINER EQUINOXE REVERSE COMPRESS SCREW LCK","SUP-ITM-10195118","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.16","315.10","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","298.82","56.9","","812.12","238.65","1587.46","163","61.08","446.39","percent of total billed charges",""
"KIT CAP 4.5X46MM SHOULDER LINER EQUINOXE REVERSE COMPRESS SCREW LCK","SUP-ITM-10195118","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.16","315.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","61.08","11.63","","112.68","112.68","146.99","38","61.08","446.39","percent of total billed charges",""
"KIT CAP 4.5X46MM SHOULDER LINER EQUINOXE REVERSE COMPRESS SCREW LCK","SUP-ITM-10195118","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.16","315.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","406.47","77.4","","303.98","303.98","5854.79","1 through 10","61.08","446.39","percent of total billed charges",""
"KIT CAP 4.5X46MM SHOULDER LINER EQUINOXE REVERSE COMPRESS SCREW LCK","SUP-ITM-10195118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","61.08","11.63","","112.68","112.68","146.99","38","61.08","406.47","percent of total billed charges",""
"KIT CAP 4.5X46MM SHOULDER LINER EQUINOXE REVERSE COMPRESS SCREW LCK","SUP-ITM-10195118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","329.70","62.78","","780.86","208.94","10480.28","15","61.08","406.47","percent of total billed charges",""
"KIT CAP 4.5X46MM SHOULDER LINER EQUINOXE REVERSE COMPRESS SCREW LCK","SUP-ITM-10195118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","229.60","43.72","","179.76","179.76","179.76","1 through 10","61.08","406.47","percent of total billed charges",""
"KIT CAP 4.5X46MM SHOULDER LINER EQUINOXE REVERSE COMPRESS SCREW LCK","SUP-ITM-10195118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","381.90","72.72","","2355.45","298.99","3965.19","155","61.08","406.47","percent of total billed charges",""
"KIT CAP 4.5X46MM SHOULDER LINER EQUINOXE REVERSE COMPRESS SCREW LCK","SUP-ITM-10195118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","381.90","72.72","","3643.09","3643.09","3643.09","1 through 10","61.08","406.47","percent of total billed charges",""
"KIT CAP 4.5X46MM SHOULDER LINER EQUINOXE REVERSE COMPRESS SCREW LCK","SUP-ITM-10195118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","279.49","53.22","","554.28","554.28","554.28","16","61.08","406.47","percent of total billed charges",""
"KIT CAP 4.5X46MM SHOULDER LINER EQUINOXE REVERSE COMPRESS SCREW LCK","SUP-ITM-10195118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","330.33","62.9","","619.64","173.09","2370.64","150","61.08","406.47","percent of total billed charges",""
"KIT CAP 4.5X46MM SHOULDER LINER EQUINOXE REVERSE COMPRESS SCREW LCK","SUP-ITM-10195118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","406.47","77.4","","303.98","303.98","5854.79","1 through 10","61.08","406.47","percent of total billed charges",""
"KIT CAP 42MM LOCKING EXTENDED GLENOSPHERE EXPANDED","SUP-ITM-10289161","CDM","C1776","HCPCS","0278","RC","","","","both","","","7798.80","4679.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","907","6628.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT CAP 42MM LOCKING EXTENDED GLENOSPHERE EXPANDED","SUP-ITM-10289161","CDM","C1776","HCPCS","0278","RC","","","","both","","","7798.80","4679.28","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4437.52","56.9","","2911.53","1863.86","5209.05","65","907","6628.98","percent of total billed charges",""
"KIT CAP 42MM LOCKING EXTENDED GLENOSPHERE EXPANDED","SUP-ITM-10289161","CDM","C1776","HCPCS","0278","RC","","","","both","","","7798.80","4679.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","907.00","11.63","","400.94","400.94","400.94","1 through 10","907","6628.98","percent of total billed charges",""
"KIT CAP 42MM LOCKING EXTENDED GLENOSPHERE EXPANDED","SUP-ITM-10289161","CDM","C1776","HCPCS","0278","RC","","","","both","","","7798.80","4679.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6036.27","77.4","","5214.50","5214.50","16415.28","1 through 10","907","6628.98","percent of total billed charges",""
"KIT CAP 42MM LOCKING EXTENDED GLENOSPHERE EXPANDED","SUP-ITM-10289161","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7798.80","4679.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","907.00","11.63","","400.94","400.94","400.94","1 through 10","907","6036.27","percent of total billed charges",""
"KIT CAP 42MM LOCKING EXTENDED GLENOSPHERE EXPANDED","SUP-ITM-10289161","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7798.80","4679.28","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3409.64","43.72","","1543.33","1543.33","1671.61","1 through 10","907","6036.27","percent of total billed charges",""
"KIT CAP 42MM LOCKING EXTENDED GLENOSPHERE EXPANDED","SUP-ITM-10289161","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7798.80","4679.28","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5671.29","72.72","","3700.21","2382.07","6427.18","53","907","6036.27","percent of total billed charges",""
"KIT CAP 42MM LOCKING EXTENDED GLENOSPHERE EXPANDED","SUP-ITM-10289161","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7798.80","4679.28","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5671.29","72.72","","12685.80","12685.80","12685.80","1 through 10","907","6036.27","percent of total billed charges",""
"KIT CAP 42MM LOCKING EXTENDED GLENOSPHERE EXPANDED","SUP-ITM-10289161","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7798.80","4679.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4905.45","62.9","","3408.87","2784.05","9859.40","46","907","6036.27","percent of total billed charges",""
"KIT CAP 42MM LOCKING EXTENDED GLENOSPHERE EXPANDED","SUP-ITM-10289161","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7798.80","4679.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6036.27","77.4","","5214.50","5214.50","16415.28","1 through 10","907","6036.27","percent of total billed charges",""
"KIT CATHETER 12X10CM 7FR 55 DILATOR NEPHROSTOMY BALLOON STOPCOCK INFLATOR GAUGE","SUP-ITM-10015972","CDM","C1726","HCPCS","0272","RC","","","","both","","","3063.48","1838.09","AETNA [1001]","HB WDH AETNA COMMERCIAL","2138.31","69.8","","166.96","137.81","825.49","1 through 10","356.28","2603.96","percent of total billed charges",""
"KIT CATHETER 12X10CM 7FR 55 DILATOR NEPHROSTOMY BALLOON STOPCOCK INFLATOR GAUGE","SUP-ITM-10015972","CDM","C1726","HCPCS","0272","RC","","","","both","","","3063.48","1838.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1716.86","1716.86","1716.86","1 through 10","356.28","2603.96","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT CATHETER 12X10CM 7FR 55 DILATOR NEPHROSTOMY BALLOON STOPCOCK INFLATOR GAUGE","SUP-ITM-10015972","CDM","C1726","HCPCS","0272","RC","","","","both","","","3063.48","1838.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","4281.09","1182.65","4281.09","1 through 10","356.28","2603.96","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT CATHETER 12X10CM 7FR 55 DILATOR NEPHROSTOMY BALLOON STOPCOCK INFLATOR GAUGE","SUP-ITM-10015972","CDM","C1726","HCPCS","0272","RC","","","","both","","","3063.48","1838.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","356.28","11.63","","262.01","27.19","426.66","1 through 10","356.28","2603.96","percent of total billed charges",""
"KIT CATHETER 12X10CM 7FR 55 DILATOR NEPHROSTOMY BALLOON STOPCOCK INFLATOR GAUGE","SUP-ITM-10015972","CDM","C1726","HCPCS","0272","RC","","","","both","","","3063.48","1838.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2371.13","77.4","","1411.46","916.55","1411.46","1 through 10","356.28","2603.96","percent of total billed charges",""
"KIT CATHETER 12X10CM 7FR 55 DILATOR NEPHROSTOMY BALLOON STOPCOCK INFLATOR GAUGE","SUP-ITM-10015972","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","3063.48","1838.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","356.28","11.63","","262.01","27.19","426.66","1 through 10","356.28","2371.13","percent of total billed charges",""
"KIT CATHETER 12X10CM 7FR 55 DILATOR NEPHROSTOMY BALLOON STOPCOCK INFLATOR GAUGE","SUP-ITM-10015972","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","3063.48","1838.09","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1339.35","43.72","","517.05","517.05","517.05","1 through 10","356.28","2371.13","percent of total billed charges",""
"KIT CATHETER 12X10CM 7FR 55 DILATOR NEPHROSTOMY BALLOON STOPCOCK INFLATOR GAUGE","SUP-ITM-10015972","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","3063.48","1838.09","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2227.76","72.72","","1556.61","860.02","1914.17","1 through 10","356.28","2371.13","percent of total billed charges",""
"KIT CATHETER 12X10CM 7FR 55 DILATOR NEPHROSTOMY BALLOON STOPCOCK INFLATOR GAUGE","SUP-ITM-10015972","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","3063.48","1838.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1926.93","62.9","","1348.55","745.07","1348.55","19","356.28","2371.13","percent of total billed charges",""
"KIT CATHETER 12X10CM 7FR 55 DILATOR NEPHROSTOMY BALLOON STOPCOCK INFLATOR GAUGE","SUP-ITM-10015972","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","3063.48","1838.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2371.13","77.4","","1411.46","916.55","1411.46","1 through 10","356.28","2371.13","percent of total billed charges",""
"KIT CATHETER 12X10CM 7FR 55 DILATOR NEPHROSTOMY BALLOON STOPCOCK INFLATOR GAUGE","SUP-ITM-10015972","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","3063.48","1838.09","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","2227.76","72.72","","860.02","860.02","860.02","1 through 10","356.28","2371.13","percent of total billed charges",""
"KIT CATHETER 14FRX25CM 5 NEPHROSTOMY TAMPONADE BALOON STENT STYLET Y CONNECTING TUBE SYRINGE","SUP-ITM-10003667","CDM","C1729","HCPCS","0272","RC","","","","both","","","1600.36","960.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","186.12","11.63","","19.51","17.34","54.47","21","186.12","1360.31","percent of total billed charges",""
"KIT CATHETER 14FRX25CM 5 NEPHROSTOMY TAMPONADE BALOON STENT STYLET Y CONNECTING TUBE SYRINGE","SUP-ITM-10003667","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1600.36","960.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","186.12","11.63","","19.51","17.34","54.47","21","186.12","1238.68","percent of total billed charges",""
"KIT CATHETER 14FRX25CM 5 NEPHROSTOMY TAMPONADE BALOON STENT STYLET Y CONNECTING TUBE SYRINGE","SUP-ITM-10003667","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1600.36","960.22","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","699.68","43.72","","61.93","61.93","61.93","1 through 10","186.12","1238.68","percent of total billed charges",""
"KIT CATHETER 14FRX25CM 5 NEPHROSTOMY TAMPONADE BALOON STENT STYLET Y CONNECTING TUBE SYRINGE","SUP-ITM-10003667","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1600.36","960.22","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1163.78","72.72","","330.75","267.63","330.75","1 through 10","186.12","1238.68","percent of total billed charges",""
"KIT CATHETER 14FRX25CM 5 NEPHROSTOMY TAMPONADE BALOON STENT STYLET Y CONNECTING TUBE SYRINGE","SUP-ITM-10003667","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1600.36","960.22","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1006.63","62.9","","89.25","87.07","231.86","1 through 10","186.12","1238.68","percent of total billed charges",""
"KIT CATHETER 14FRX25CM 5 NEPHROSTOMY TAMPONADE BALOON STENT STYLET Y CONNECTING TUBE SYRINGE","SUP-ITM-10003667","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1600.36","960.22","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","1163.78","72.72","","267.63","267.63","267.63","1 through 10","186.12","1238.68","percent of total billed charges",""
"KIT CATHETER 15.5FR INSERTION PLEURX PLEURAL CS/10EA","SUP-ITM-10006715","CDM","C1729","HCPCS","0272","RC","","","","both","","","4095.97","2457.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","476.36","11.63","","19.51","17.34","54.47","21","476.36","3481.57","percent of total billed charges",""
"KIT CATHETER 15.5FR INSERTION PLEURX PLEURAL CS/10EA","SUP-ITM-10006715","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","4095.97","2457.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","476.36","11.63","","19.51","17.34","54.47","21","476.36","3170.28","percent of total billed charges",""
"KIT CATHETER 15.5FR INSERTION PLEURX PLEURAL CS/10EA","SUP-ITM-10006715","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","4095.97","2457.58","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1790.76","43.72","","61.93","61.93","61.93","1 through 10","476.36","3170.28","percent of total billed charges",""
"KIT CATHETER 15.5FR INSERTION PLEURX PLEURAL CS/10EA","SUP-ITM-10006715","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","4095.97","2457.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2978.59","72.72","","330.75","267.63","330.75","1 through 10","476.36","3170.28","percent of total billed charges",""
"KIT CATHETER 15.5FR INSERTION PLEURX PLEURAL CS/10EA","SUP-ITM-10006715","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","4095.97","2457.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2576.37","62.9","","89.25","87.07","231.86","1 through 10","476.36","3170.28","percent of total billed charges",""
"KIT CATHETER 15.5FR INSERTION PLEURX PLEURAL CS/10EA","SUP-ITM-10006715","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","4095.97","2457.58","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","2978.59","72.72","","267.63","267.63","267.63","1 through 10","476.36","3170.28","percent of total billed charges",""
"KIT CATHETER 62.5CM DIALYSIS ARGYLE PERITONEAL SWAN NECK CURL 2 CUFF LT","SUP-ITM-10215755","CDM","C1750","HCPCS","0278","RC","","","","both","","","1755.55","1053.33","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","998.91","56.9","","986.49","974.06","986.49","1 through 10","204.17","1492.22","percent of total billed charges",""
"KIT CATHETER 62.5CM DIALYSIS ARGYLE PERITONEAL SWAN NECK CURL 2 CUFF LT","SUP-ITM-10215755","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1755.55","1053.33","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","767.53","43.72","","951.63","951.63","951.63","1 through 10","204.17","1358.8","percent of total billed charges",""
"KIT CATHETER 62.5CM DIALYSIS ARGYLE PERITONEAL SWAN NECK CURL 2 CUFF LT","SUP-ITM-10215755","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","1755.55","1053.33","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1276.64","72.72","","1244.88","1244.88","1244.88","1 through 10","204.17","1358.8","percent of total billed charges",""
"KIT CONNECTOR PUMP SUTURELESS REVISION FOR SYNCHROMED III INFUSION SYSTEM","SUP-ITM-10021659","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.50","621.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","120.54","881.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT CONNECTOR PUMP SUTURELESS REVISION FOR SYNCHROMED III INFUSION SYSTEM","SUP-ITM-10021659","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.50","621.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","120.54","881.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT CONNECTOR PUMP SUTURELESS REVISION FOR SYNCHROMED III INFUSION SYSTEM","SUP-ITM-10021659","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.50","621.90","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","589.77","56.9","","0.63","0.63","0.63","1 through 10","120.54","881.03","percent of total billed charges",""
"KIT CONNECTOR PUMP SUTURELESS REVISION FOR SYNCHROMED III INFUSION SYSTEM","SUP-ITM-10021659","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.50","621.90","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","149.46","14.42","","317.14","317.14","317.14","1 through 10","120.54","881.03","percent of total billed charges",""
"KIT CONNECTOR PUMP SUTURELESS REVISION FOR SYNCHROMED III INFUSION SYSTEM","SUP-ITM-10021659","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","149.46","14.42","","317.14","317.14","317.14","1 through 10","120.54","802.25","percent of total billed charges",""
"KIT CONNECTOR PUMP SUTURELESS REVISION FOR SYNCHROMED III INFUSION SYSTEM","SUP-ITM-10021659","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","650.71","62.78","","1125.09","1125.09","1125.09","1 through 10","120.54","802.25","percent of total billed charges",""
"KIT CONNECTOR PUMP SUTURELESS REVISION FOR SYNCHROMED III INFUSION SYSTEM","SUP-ITM-10021659","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","753.74","72.72","","4732.50","1617.43","14180.40","1 through 10","120.54","802.25","percent of total billed charges",""
"KIT CONNECTOR PUMP SUTURELESS REVISION FOR SYNCHROMED III INFUSION SYSTEM","SUP-ITM-10021659","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","651.96","62.9","","3896.20","3341.38","3896.20","1 through 10","120.54","802.25","percent of total billed charges",""
"KIT CONTROL FREELINK REMOTE SPECTRA NOVI AND MONTAGE MRI SAFE","SUP-ITM-10174953","CDM","C1787","HCPCS","0270","RC","","","","both","","","5528.00","3316.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","3858.54","69.8","","1412.58","1412.58","1412.58","1 through 10","642.91","4698.8","percent of total billed charges",""
"KIT CONTROL FREELINK REMOTE SPECTRA NOVI AND MONTAGE MRI SAFE","SUP-ITM-10174953","CDM","C1787","HCPCS","0270","RC","","","","both","","","5528.00","3316.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","18158.40","2245.75","18158.40","1 through 10","642.91","4698.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT CONTROL FREELINK REMOTE SPECTRA NOVI AND MONTAGE MRI SAFE","SUP-ITM-10174953","CDM","C1787","HCPCS","0270","RC","","","","both","","","5528.00","3316.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3145.43","56.9","","15498.18","15498.18","15498.18","1 through 10","642.91","4698.8","percent of total billed charges",""
"KIT CONTROL FREELINK REMOTE SPECTRA NOVI AND MONTAGE MRI SAFE","SUP-ITM-10174953","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","5528.00","3316.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","4019.96","72.72","","4236.03","4236.03","4236.03","1 through 10","642.91","4278.67","percent of total billed charges",""
"KIT CONVERSION SINGLE LEAD SPR PENS X SPRINT THERAPEUTICS","SUP-ITM-10317484","CDM","C1778","HCPCS","0278","RC","","","","both","","","17875.00","10725.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","14342.00","14342.00","14342.00","1 through 10","2078.86","15193.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT CONVERSION SINGLE LEAD SPR PENS X SPRINT THERAPEUTICS","SUP-ITM-10317484","CDM","C1778","HCPCS","0278","RC","","","","both","","","17875.00","10725.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2078.86","11.63","","2253.51","2253.51","2253.51","1 through 10","2078.86","15193.75","percent of total billed charges",""
"KIT CONVERSION SINGLE LEAD SPR PENS X SPRINT THERAPEUTICS","SUP-ITM-10317484","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","17875.00","10725.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2078.86","11.63","","2253.51","2253.51","2253.51","1 through 10","2078.86","13835.25","percent of total billed charges",""
"KIT CONVERSION SINGLE LEAD SPR PENS X SPRINT THERAPEUTICS","SUP-ITM-10317484","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","17875.00","10725.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","11243.38","62.9","","21082.95","11598.93","21082.95","1 through 10","2078.86","13835.25","percent of total billed charges",""
"KIT DILATOR 5FR 15CM INTRODUCER ACCESS SHEATH MAK COAXIAL STIFFENED BX/5EA","SUP-ITM-10237312","CDM","C1894","HCPCS","0272","RC","","","","both","","","157.00","94.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","109.59","69.8","","94.15","94.15","427.63","1 through 10","18.26","133.45","percent of total billed charges",""
"KIT DILATOR 5FR 15CM INTRODUCER ACCESS SHEATH MAK COAXIAL STIFFENED BX/5EA","SUP-ITM-10237312","CDM","C1894","HCPCS","0272","RC","","","","both","","","157.00","94.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","18.26","133.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT DILATOR 5FR 15CM INTRODUCER ACCESS SHEATH MAK COAXIAL STIFFENED BX/5EA","SUP-ITM-10237312","CDM","C1894","HCPCS","0272","RC","","","","both","","","157.00","94.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","89.33","56.9","","401.89","65.85","401.89","1 through 10","18.26","133.45","percent of total billed charges",""
"KIT DILATOR 5FR 15CM INTRODUCER ACCESS SHEATH MAK COAXIAL STIFFENED BX/5EA","SUP-ITM-10237312","CDM","C1894","HCPCS","0272","RC","","","","both","","","157.00","94.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","18.26","11.63","","49.19","10.57","114.40","19","18.26","133.45","percent of total billed charges",""
"KIT DILATOR 5FR 15CM INTRODUCER ACCESS SHEATH MAK COAXIAL STIFFENED BX/5EA","SUP-ITM-10237312","CDM","C1894","HCPCS","0272","RC","","","","both","","","157.00","94.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","121.52","77.4","","200.75","81.67","643.86","11","18.26","133.45","percent of total billed charges",""
"KIT DILATOR 5FR 15CM INTRODUCER ACCESS SHEATH MAK COAXIAL STIFFENED BX/5EA","SUP-ITM-10237312","CDM","C1894","HCPCS","0272","RC","","","","both","","","157.00","94.20","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","18.26","133.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT DILATOR 5FR 15CM INTRODUCER ACCESS SHEATH MAK COAXIAL STIFFENED BX/5EA","SUP-ITM-10237312","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","157.00","94.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","18.26","11.63","","49.19","10.57","114.40","19","18.26","121.52","percent of total billed charges",""
"KIT DILATOR 5FR 15CM INTRODUCER ACCESS SHEATH MAK COAXIAL STIFFENED BX/5EA","SUP-ITM-10237312","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","157.00","94.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","98.56","62.78","","93.27","93.27","93.27","1 through 10","18.26","121.52","percent of total billed charges",""
"KIT DILATOR 5FR 15CM INTRODUCER ACCESS SHEATH MAK COAXIAL STIFFENED BX/5EA","SUP-ITM-10237312","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","157.00","94.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","68.64","43.72","","363.22","363.22","363.22","1 through 10","18.26","121.52","percent of total billed charges",""
"KIT DILATOR 5FR 15CM INTRODUCER ACCESS SHEATH MAK COAXIAL STIFFENED BX/5EA","SUP-ITM-10237312","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","157.00","94.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","114.17","72.72","","271.85","111.24","551.69","14","18.26","121.52","percent of total billed charges",""
"KIT DILATOR 5FR 15CM INTRODUCER ACCESS SHEATH MAK COAXIAL STIFFENED BX/5EA","SUP-ITM-10237312","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","157.00","94.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","98.75","62.9","","706.53","93.60","938.00","53","18.26","121.52","percent of total billed charges",""
"KIT DILATOR 5FR 15CM INTRODUCER ACCESS SHEATH MAK COAXIAL STIFFENED BX/5EA","SUP-ITM-10237312","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","157.00","94.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","121.52","77.4","","200.75","81.67","643.86","11","18.26","121.52","percent of total billed charges",""
"KIT ESOPHYXZ DEVICE WITH TWO SETS OF FASTENERS","SUP-ITM-10238456","CDM","C1889","HCPCS","0278","RC","","","","both","","","20312.50","12187.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","2362.34","17265.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT ESOPHYXZ DEVICE WITH TWO SETS OF FASTENERS","SUP-ITM-10238456","CDM","C1889","HCPCS","0278","RC","","","","both","","","20312.50","12187.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","2362.34","17265.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT ESOPHYXZ DEVICE WITH TWO SETS OF FASTENERS","SUP-ITM-10238456","CDM","C1889","HCPCS","0278","RC","","","","both","","","20312.50","12187.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","11557.81","56.9","","0.63","0.63","0.63","1 through 10","2362.34","17265.63","percent of total billed charges",""
"KIT ESOPHYXZ DEVICE WITH TWO SETS OF FASTENERS","SUP-ITM-10238456","CDM","C1889","HCPCS","0278","RC","","","","both","","","20312.50","12187.50","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2929.06","14.42","","317.14","317.14","317.14","1 through 10","2362.34","17265.63","percent of total billed charges",""
"KIT ESOPHYXZ DEVICE WITH TWO SETS OF FASTENERS","SUP-ITM-10238456","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","20312.50","12187.50","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2929.06","14.42","","317.14","317.14","317.14","1 through 10","2362.34","15721.88","percent of total billed charges",""
"KIT ESOPHYXZ DEVICE WITH TWO SETS OF FASTENERS","SUP-ITM-10238456","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","20312.50","12187.50","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","12752.19","62.78","","1125.09","1125.09","1125.09","1 through 10","2362.34","15721.88","percent of total billed charges",""
"KIT ESOPHYXZ DEVICE WITH TWO SETS OF FASTENERS","SUP-ITM-10238456","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","20312.50","12187.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","14771.25","72.72","","4732.50","1617.43","14180.40","1 through 10","2362.34","15721.88","percent of total billed charges",""
"KIT ESOPHYXZ DEVICE WITH TWO SETS OF FASTENERS","SUP-ITM-10238456","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","20312.50","12187.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","12776.56","62.9","","3896.20","3341.38","3896.20","1 through 10","2362.34","15721.88","percent of total billed charges",""
"KIT EXTENSION 4.32MM PERCUTANEOUS FOR INTERSTIM SURESCAN MRI LEAD","SUP-ITM-10277216","CDM","C1883","HCPCS","0278","RC","","","","outpatient","","","1658.40","995.04","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1043.13","62.9","","4897.47","4897.47","4897.47","1 through 10","192.87","1283.6","percent of total billed charges",""
"KIT FIBERTAK RC","SUP-ITM-10286966","CDM","C1713","HCPCS","0278","RC","","","","both","","","1347.45","808.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","156.71","1145.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT FIBERTAK RC","SUP-ITM-10286966","CDM","C1713","HCPCS","0278","RC","","","","both","","","1347.45","808.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","156.71","1145.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT FIBERTAK RC","SUP-ITM-10286966","CDM","C1713","HCPCS","0278","RC","","","","both","","","1347.45","808.47","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","766.70","56.9","","812.12","238.65","1587.46","163","156.71","1145.33","percent of total billed charges",""
"KIT FIBERTAK RC","SUP-ITM-10286966","CDM","C1713","HCPCS","0278","RC","","","","both","","","1347.45","808.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","156.71","11.63","","112.68","112.68","146.99","38","156.71","1145.33","percent of total billed charges",""
"KIT FIBERTAK RC","SUP-ITM-10286966","CDM","C1713","HCPCS","0278","RC","","","","both","","","1347.45","808.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1042.93","77.4","","303.98","303.98","5854.79","1 through 10","156.71","1145.33","percent of total billed charges",""
"KIT FIBERTAK RC","SUP-ITM-10286966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","156.71","11.63","","112.68","112.68","146.99","38","156.71","1042.93","percent of total billed charges",""
"KIT FIBERTAK RC","SUP-ITM-10286966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","845.93","62.78","","780.86","208.94","10480.28","15","156.71","1042.93","percent of total billed charges",""
"KIT FIBERTAK RC","SUP-ITM-10286966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","589.11","43.72","","179.76","179.76","179.76","1 through 10","156.71","1042.93","percent of total billed charges",""
"KIT FIBERTAK RC","SUP-ITM-10286966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","979.87","72.72","","2355.45","298.99","3965.19","155","156.71","1042.93","percent of total billed charges",""
"KIT FIBERTAK RC","SUP-ITM-10286966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","979.87","72.72","","3643.09","3643.09","3643.09","1 through 10","156.71","1042.93","percent of total billed charges",""
"KIT FIBERTAK RC","SUP-ITM-10286966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","717.11","53.22","","554.28","554.28","554.28","16","156.71","1042.93","percent of total billed charges",""
"KIT FIBERTAK RC","SUP-ITM-10286966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","847.55","62.9","","619.64","173.09","2370.64","150","156.71","1042.93","percent of total billed charges",""
"KIT FIBERTAK RC","SUP-ITM-10286966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1042.93","77.4","","303.98","303.98","5854.79","1 through 10","156.71","1042.93","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","21049.34","12629.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","2448.04","17891.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","21049.34","12629.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","2448.04","17891.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","21049.34","12629.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","11977.07","56.9","","812.12","238.65","1587.46","163","2448.04","17891.94","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","21049.34","12629.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2448.04","11.63","","112.68","112.68","146.99","38","2448.04","17891.94","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","21049.34","12629.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","16292.19","77.4","","303.98","303.98","5854.79","1 through 10","2448.04","17891.94","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","21049.34","12629.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2448.04","11.63","","112.68","112.68","146.99","38","2448.04","16292.19","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","21049.34","12629.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","13214.78","62.78","","780.86","208.94","10480.28","15","2448.04","16292.19","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","21049.34","12629.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","9202.77","43.72","","179.76","179.76","179.76","1 through 10","2448.04","16292.19","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","21049.34","12629.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","15307.08","72.72","","2355.45","298.99","3965.19","155","2448.04","16292.19","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","21049.34","12629.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","15307.08","72.72","","3643.09","3643.09","3643.09","1 through 10","2448.04","16292.19","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","21049.34","12629.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","11202.46","53.22","","554.28","554.28","554.28","16","2448.04","16292.19","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","21049.34","12629.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","13240.03","62.9","","619.64","173.09","2370.64","150","2448.04","16292.19","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","21049.34","12629.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","16292.19","77.4","","303.98","303.98","5854.79","1 through 10","2448.04","16292.19","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4332.57","2599.54","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","503.88","3682.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4332.57","2599.54","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","503.88","3682.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4332.57","2599.54","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2465.23","56.9","","812.12","238.65","1587.46","163","503.88","3682.68","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4332.57","2599.54","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","503.88","11.63","","112.68","112.68","146.99","38","503.88","3682.68","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","both","","","4332.57","2599.54","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3353.41","77.4","","303.98","303.98","5854.79","1 through 10","503.88","3682.68","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4332.57","2599.54","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","503.88","11.63","","112.68","112.68","146.99","38","503.88","3353.41","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4332.57","2599.54","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2719.99","62.78","","780.86","208.94","10480.28","15","503.88","3353.41","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4332.57","2599.54","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1894.20","43.72","","179.76","179.76","179.76","1 through 10","503.88","3353.41","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4332.57","2599.54","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3150.64","72.72","","2355.45","298.99","3965.19","155","503.88","3353.41","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4332.57","2599.54","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3150.64","72.72","","3643.09","3643.09","3643.09","1 through 10","503.88","3353.41","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4332.57","2599.54","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2305.79","53.22","","554.28","554.28","554.28","16","503.88","3353.41","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4332.57","2599.54","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2725.19","62.9","","619.64","173.09","2370.64","150","503.88","3353.41","percent of total billed charges",""
"KIT GRAFT 5.0ML BONE SUBSTITUTE RESORBABLE MINI BEAD OSTEOSET STANDARD CURE","SUP-ITM-10056984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4332.57","2599.54","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3353.41","77.4","","303.98","303.98","5854.79","1 through 10","503.88","3353.41","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","19112.92","11467.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","2222.83","16245.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","19112.92","11467.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","2222.83","16245.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","19112.92","11467.75","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","10875.25","56.9","","812.12","238.65","1587.46","163","2222.83","16245.98","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","19112.92","11467.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2222.83","11.63","","112.68","112.68","146.99","38","2222.83","16245.98","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","19112.92","11467.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","14793.40","77.4","","303.98","303.98","5854.79","1 through 10","2222.83","16245.98","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19112.92","11467.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2222.83","11.63","","112.68","112.68","146.99","38","2222.83","14793.4","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19112.92","11467.75","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","11999.09","62.78","","780.86","208.94","10480.28","15","2222.83","14793.4","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19112.92","11467.75","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","8356.17","43.72","","179.76","179.76","179.76","1 through 10","2222.83","14793.4","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19112.92","11467.75","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","13898.92","72.72","","2355.45","298.99","3965.19","155","2222.83","14793.4","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19112.92","11467.75","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","13898.92","72.72","","3643.09","3643.09","3643.09","1 through 10","2222.83","14793.4","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19112.92","11467.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","10171.90","53.22","","554.28","554.28","554.28","16","2222.83","14793.4","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19112.92","11467.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","12022.03","62.9","","619.64","173.09","2370.64","150","2222.83","14793.4","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19112.92","11467.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","14793.40","77.4","","303.98","303.98","5854.79","1 through 10","2222.83","14793.4","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","6793.15","4075.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","790.04","5774.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","6793.15","4075.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","790.04","5774.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","6793.15","4075.89","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3865.30","56.9","","812.12","238.65","1587.46","163","790.04","5774.18","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","6793.15","4075.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","790.04","11.63","","112.68","112.68","146.99","38","790.04","5774.18","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","6793.15","4075.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5257.90","77.4","","303.98","303.98","5854.79","1 through 10","790.04","5774.18","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6793.15","4075.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","790.04","11.63","","112.68","112.68","146.99","38","790.04","5257.9","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6793.15","4075.89","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4264.74","62.78","","780.86","208.94","10480.28","15","790.04","5257.9","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6793.15","4075.89","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2969.97","43.72","","179.76","179.76","179.76","1 through 10","790.04","5257.9","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6793.15","4075.89","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4939.98","72.72","","2355.45","298.99","3965.19","155","790.04","5257.9","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6793.15","4075.89","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4939.98","72.72","","3643.09","3643.09","3643.09","1 through 10","790.04","5257.9","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6793.15","4075.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3615.31","53.22","","554.28","554.28","554.28","16","790.04","5257.9","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6793.15","4075.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4272.89","62.9","","619.64","173.09","2370.64","150","790.04","5257.9","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6793.15","4075.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5257.90","77.4","","303.98","303.98","5854.79","1 through 10","790.04","5257.9","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM SPEEDTITAN COMPRESSION","SUP-ITM-10211706","CDM","C1776","HCPCS","0278","RC","","","","both","","","5323.05","3193.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","619.07","4524.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT IMPLANT 18X18X18MM SPEEDTITAN COMPRESSION","SUP-ITM-10211706","CDM","C1776","HCPCS","0278","RC","","","","both","","","5323.05","3193.83","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3028.82","56.9","","2911.53","1863.86","5209.05","65","619.07","4524.59","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM SPEEDTITAN COMPRESSION","SUP-ITM-10211706","CDM","C1776","HCPCS","0278","RC","","","","both","","","5323.05","3193.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","619.07","11.63","","400.94","400.94","400.94","1 through 10","619.07","4524.59","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM SPEEDTITAN COMPRESSION","SUP-ITM-10211706","CDM","C1776","HCPCS","0278","RC","","","","both","","","5323.05","3193.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4120.04","77.4","","5214.50","5214.50","16415.28","1 through 10","619.07","4524.59","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM SPEEDTITAN COMPRESSION","SUP-ITM-10211706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5323.05","3193.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","619.07","11.63","","400.94","400.94","400.94","1 through 10","619.07","4120.04","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM SPEEDTITAN COMPRESSION","SUP-ITM-10211706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5323.05","3193.83","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2327.24","43.72","","1543.33","1543.33","1671.61","1 through 10","619.07","4120.04","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM SPEEDTITAN COMPRESSION","SUP-ITM-10211706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5323.05","3193.83","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3870.92","72.72","","3700.21","2382.07","6427.18","53","619.07","4120.04","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM SPEEDTITAN COMPRESSION","SUP-ITM-10211706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5323.05","3193.83","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3870.92","72.72","","12685.80","12685.80","12685.80","1 through 10","619.07","4120.04","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM SPEEDTITAN COMPRESSION","SUP-ITM-10211706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5323.05","3193.83","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3348.20","62.9","","3408.87","2784.05","9859.40","46","619.07","4120.04","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM SPEEDTITAN COMPRESSION","SUP-ITM-10211706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5323.05","3193.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4120.04","77.4","","5214.50","5214.50","16415.28","1 through 10","619.07","4120.04","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","both","","","5216.61","3129.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","606.69","4434.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","both","","","5216.61","3129.97","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2968.25","56.9","","2911.53","1863.86","5209.05","65","606.69","4434.12","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","both","","","5216.61","3129.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","606.69","11.63","","400.94","400.94","400.94","1 through 10","606.69","4434.12","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","both","","","5216.61","3129.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4037.66","77.4","","5214.50","5214.50","16415.28","1 through 10","606.69","4434.12","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5216.61","3129.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","606.69","11.63","","400.94","400.94","400.94","1 through 10","606.69","4037.66","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5216.61","3129.97","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2280.70","43.72","","1543.33","1543.33","1671.61","1 through 10","606.69","4037.66","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5216.61","3129.97","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3793.52","72.72","","3700.21","2382.07","6427.18","53","606.69","4037.66","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5216.61","3129.97","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3793.52","72.72","","12685.80","12685.80","12685.80","1 through 10","606.69","4037.66","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5216.61","3129.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3281.25","62.9","","3408.87","2784.05","9859.40","46","606.69","4037.66","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5216.61","3129.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4037.66","77.4","","5214.50","5214.50","16415.28","1 through 10","606.69","4037.66","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","both","","","6593.73","3956.24","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","766.85","5604.67","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","both","","","6593.73","3956.24","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","766.85","5604.67","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","both","","","6593.73","3956.24","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3751.83","56.9","","812.12","238.65","1587.46","163","766.85","5604.67","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","both","","","6593.73","3956.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","766.85","11.63","","112.68","112.68","146.99","38","766.85","5604.67","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","both","","","6593.73","3956.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5103.55","77.4","","303.98","303.98","5854.79","1 through 10","766.85","5604.67","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6593.73","3956.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","766.85","11.63","","112.68","112.68","146.99","38","766.85","5103.55","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6593.73","3956.24","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4139.54","62.78","","780.86","208.94","10480.28","15","766.85","5103.55","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6593.73","3956.24","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2882.78","43.72","","179.76","179.76","179.76","1 through 10","766.85","5103.55","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6593.73","3956.24","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4794.96","72.72","","2355.45","298.99","3965.19","155","766.85","5103.55","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6593.73","3956.24","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4794.96","72.72","","3643.09","3643.09","3643.09","1 through 10","766.85","5103.55","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6593.73","3956.24","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3509.18","53.22","","554.28","554.28","554.28","16","766.85","5103.55","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6593.73","3956.24","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4147.46","62.9","","619.64","173.09","2370.64","150","766.85","5103.55","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6593.73","3956.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5103.55","77.4","","303.98","303.98","5854.79","1 through 10","766.85","5103.55","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","6583.50","3950.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","765.66","5595.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","6583.50","3950.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","765.66","5595.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","6583.50","3950.10","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3746.01","56.9","","812.12","238.65","1587.46","163","765.66","5595.98","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","6583.50","3950.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","765.66","11.63","","112.68","112.68","146.99","38","765.66","5595.98","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","6583.50","3950.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5095.63","77.4","","303.98","303.98","5854.79","1 through 10","765.66","5595.98","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6583.50","3950.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","765.66","11.63","","112.68","112.68","146.99","38","765.66","5095.63","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6583.50","3950.10","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4133.12","62.78","","780.86","208.94","10480.28","15","765.66","5095.63","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6583.50","3950.10","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2878.31","43.72","","179.76","179.76","179.76","1 through 10","765.66","5095.63","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6583.50","3950.10","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4787.52","72.72","","2355.45","298.99","3965.19","155","765.66","5095.63","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6583.50","3950.10","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4787.52","72.72","","3643.09","3643.09","3643.09","1 through 10","765.66","5095.63","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6583.50","3950.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3503.74","53.22","","554.28","554.28","554.28","16","765.66","5095.63","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6583.50","3950.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4141.02","62.9","","619.64","173.09","2370.64","150","765.66","5095.63","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6583.50","3950.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5095.63","77.4","","303.98","303.98","5854.79","1 through 10","765.66","5095.63","percent of total billed charges",""
"KIT IMPLANT 30X20X20X20X20MM ELITE COMPRESSION 4 LEG","SUP-ITM-10211738","CDM","C1776","HCPCS","0278","RC","","","","both","","","5315.31","3189.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","618.17","4518.01","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT IMPLANT 30X20X20X20X20MM ELITE COMPRESSION 4 LEG","SUP-ITM-10211738","CDM","C1776","HCPCS","0278","RC","","","","both","","","5315.31","3189.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3024.41","56.9","","2911.53","1863.86","5209.05","65","618.17","4518.01","percent of total billed charges",""
"KIT IMPLANT 30X20X20X20X20MM ELITE COMPRESSION 4 LEG","SUP-ITM-10211738","CDM","C1776","HCPCS","0278","RC","","","","both","","","5315.31","3189.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","618.17","11.63","","400.94","400.94","400.94","1 through 10","618.17","4518.01","percent of total billed charges",""
"KIT IMPLANT 30X20X20X20X20MM ELITE COMPRESSION 4 LEG","SUP-ITM-10211738","CDM","C1776","HCPCS","0278","RC","","","","both","","","5315.31","3189.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4114.05","77.4","","5214.50","5214.50","16415.28","1 through 10","618.17","4518.01","percent of total billed charges",""
"KIT IMPLANT 30X20X20X20X20MM ELITE COMPRESSION 4 LEG","SUP-ITM-10211738","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5315.31","3189.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","618.17","11.63","","400.94","400.94","400.94","1 through 10","618.17","4114.05","percent of total billed charges",""
"KIT IMPLANT 30X20X20X20X20MM ELITE COMPRESSION 4 LEG","SUP-ITM-10211738","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5315.31","3189.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2323.85","43.72","","1543.33","1543.33","1671.61","1 through 10","618.17","4114.05","percent of total billed charges",""
"KIT IMPLANT 30X20X20X20X20MM ELITE COMPRESSION 4 LEG","SUP-ITM-10211738","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5315.31","3189.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3865.29","72.72","","3700.21","2382.07","6427.18","53","618.17","4114.05","percent of total billed charges",""
"KIT IMPLANT 30X20X20X20X20MM ELITE COMPRESSION 4 LEG","SUP-ITM-10211738","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5315.31","3189.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3865.29","72.72","","12685.80","12685.80","12685.80","1 through 10","618.17","4114.05","percent of total billed charges",""
"KIT IMPLANT 30X20X20X20X20MM ELITE COMPRESSION 4 LEG","SUP-ITM-10211738","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5315.31","3189.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3343.33","62.9","","3408.87","2784.05","9859.40","46","618.17","4114.05","percent of total billed charges",""
"KIT IMPLANT 30X20X20X20X20MM ELITE COMPRESSION 4 LEG","SUP-ITM-10211738","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5315.31","3189.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4114.05","77.4","","5214.50","5214.50","16415.28","1 through 10","618.17","4114.05","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","both","","","14527.84","8716.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1689.59","12348.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","both","","","14527.84","8716.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","8266.34","56.9","","2911.53","1863.86","5209.05","65","1689.59","12348.66","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","both","","","14527.84","8716.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1689.59","11.63","","400.94","400.94","400.94","1 through 10","1689.59","12348.66","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","both","","","14527.84","8716.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","11244.55","77.4","","5214.50","5214.50","16415.28","1 through 10","1689.59","12348.66","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14527.84","8716.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1689.59","11.63","","400.94","400.94","400.94","1 through 10","1689.59","11244.55","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14527.84","8716.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","6351.57","43.72","","1543.33","1543.33","1671.61","1 through 10","1689.59","11244.55","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14527.84","8716.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10564.65","72.72","","3700.21","2382.07","6427.18","53","1689.59","11244.55","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14527.84","8716.70","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","10564.65","72.72","","12685.80","12685.80","12685.80","1 through 10","1689.59","11244.55","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14527.84","8716.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","9138.01","62.9","","3408.87","2784.05","9859.40","46","1689.59","11244.55","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14527.84","8716.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","11244.55","77.4","","5214.50","5214.50","16415.28","1 through 10","1689.59","11244.55","percent of total billed charges",""
"KIT IMPLANT LEAD TINED FORAMEN NEEDLE X2 SHORT DILATOR AND SHEATH TUNNELING TOOL AND DIRECTIONAL GUIDE EXTRA TUNNELING SHEATH","SUP-ITM-10266972","CDM","C1778","HCPCS","0278","RC","","","","both","","","2383.95","1430.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","14342.00","14342.00","14342.00","1 through 10","277.25","2026.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT IMPLANT LEAD TINED FORAMEN NEEDLE X2 SHORT DILATOR AND SHEATH TUNNELING TOOL AND DIRECTIONAL GUIDE EXTRA TUNNELING SHEATH","SUP-ITM-10266972","CDM","C1778","HCPCS","0278","RC","","","","both","","","2383.95","1430.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","277.25","11.63","","2253.51","2253.51","2253.51","1 through 10","277.25","2026.36","percent of total billed charges",""
"KIT IMPLANT LEAD TINED FORAMEN NEEDLE X2 SHORT DILATOR AND SHEATH TUNNELING TOOL AND DIRECTIONAL GUIDE EXTRA TUNNELING SHEATH","SUP-ITM-10266972","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","2383.95","1430.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","277.25","11.63","","2253.51","2253.51","2253.51","1 through 10","277.25","1845.18","percent of total billed charges",""
"KIT IMPLANT LEAD TINED FORAMEN NEEDLE X2 SHORT DILATOR AND SHEATH TUNNELING TOOL AND DIRECTIONAL GUIDE EXTRA TUNNELING SHEATH","SUP-ITM-10266972","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","2383.95","1430.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1499.50","62.9","","21082.95","11598.93","21082.95","1 through 10","277.25","1845.18","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","both","","","414.60","248.76","AETNA [1001]","HB WDH AETNA COMMERCIAL","289.39","69.8","","94.15","94.15","427.63","1 through 10","48.22","352.41","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","both","","","414.60","248.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","48.22","352.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","both","","","414.60","248.76","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","235.91","56.9","","401.89","65.85","401.89","1 through 10","48.22","352.41","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","both","","","414.60","248.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","48.22","11.63","","49.19","10.57","114.40","19","48.22","352.41","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","both","","","414.60","248.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","320.90","77.4","","200.75","81.67","643.86","11","48.22","352.41","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","both","","","414.60","248.76","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","48.22","352.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","414.60","248.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","48.22","11.63","","49.19","10.57","114.40","19","48.22","320.9","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","414.60","248.76","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","260.29","62.78","","93.27","93.27","93.27","1 through 10","48.22","320.9","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","414.60","248.76","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","181.26","43.72","","363.22","363.22","363.22","1 through 10","48.22","320.9","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","414.60","248.76","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","301.50","72.72","","271.85","111.24","551.69","14","48.22","320.9","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","414.60","248.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","260.78","62.9","","706.53","93.60","938.00","53","48.22","320.9","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","414.60","248.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","320.90","77.4","","200.75","81.67","643.86","11","48.22","320.9","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","1934.80","1160.88","AETNA [1001]","HB WDH AETNA COMMERCIAL","1350.49","69.8","","94.15","94.15","427.63","1 through 10","225.02","1644.58","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","1934.80","1160.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","225.02","1644.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","1934.80","1160.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1100.90","56.9","","401.89","65.85","401.89","1 through 10","225.02","1644.58","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","1934.80","1160.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","225.02","11.63","","49.19","10.57","114.40","19","225.02","1644.58","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","1934.80","1160.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1497.54","77.4","","200.75","81.67","643.86","11","225.02","1644.58","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","1934.80","1160.88","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","225.02","1644.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1934.80","1160.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","225.02","11.63","","49.19","10.57","114.40","19","225.02","1497.54","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1934.80","1160.88","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1214.67","62.78","","93.27","93.27","93.27","1 through 10","225.02","1497.54","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1934.80","1160.88","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","845.89","43.72","","363.22","363.22","363.22","1 through 10","225.02","1497.54","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1934.80","1160.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1406.99","72.72","","271.85","111.24","551.69","14","225.02","1497.54","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1934.80","1160.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1216.99","62.9","","706.53","93.60","938.00","53","225.02","1497.54","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1934.80","1160.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1497.54","77.4","","200.75","81.67","643.86","11","225.02","1497.54","percent of total billed charges",""
"KIT INTRODUCER 5FRX.018INX40CM MANDREL MICROPUNCTURE VASCULAR SOFT TIP TUNGSTEN NITINOL BX/10EA","SUP-ITM-10232295","CDM","C1894","HCPCS","0272","RC","","","","both","","","148.57","89.14","AETNA [1001]","HB WDH AETNA COMMERCIAL","103.70","69.8","","94.15","94.15","427.63","1 through 10","17.28","126.28","percent of total billed charges",""
"KIT INTRODUCER 5FRX.018INX40CM MANDREL MICROPUNCTURE VASCULAR SOFT TIP TUNGSTEN NITINOL BX/10EA","SUP-ITM-10232295","CDM","C1894","HCPCS","0272","RC","","","","both","","","148.57","89.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","17.28","126.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRODUCER 5FRX.018INX40CM MANDREL MICROPUNCTURE VASCULAR SOFT TIP TUNGSTEN NITINOL BX/10EA","SUP-ITM-10232295","CDM","C1894","HCPCS","0272","RC","","","","both","","","148.57","89.14","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","84.54","56.9","","401.89","65.85","401.89","1 through 10","17.28","126.28","percent of total billed charges",""
"KIT INTRODUCER 5FRX.018INX40CM MANDREL MICROPUNCTURE VASCULAR SOFT TIP TUNGSTEN NITINOL BX/10EA","SUP-ITM-10232295","CDM","C1894","HCPCS","0272","RC","","","","both","","","148.57","89.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","17.28","11.63","","49.19","10.57","114.40","19","17.28","126.28","percent of total billed charges",""
"KIT INTRODUCER 5FRX.018INX40CM MANDREL MICROPUNCTURE VASCULAR SOFT TIP TUNGSTEN NITINOL BX/10EA","SUP-ITM-10232295","CDM","C1894","HCPCS","0272","RC","","","","both","","","148.57","89.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","114.99","77.4","","200.75","81.67","643.86","11","17.28","126.28","percent of total billed charges",""
"KIT INTRODUCER 5FRX.018INX40CM MANDREL MICROPUNCTURE VASCULAR SOFT TIP TUNGSTEN NITINOL BX/10EA","SUP-ITM-10232295","CDM","C1894","HCPCS","0272","RC","","","","both","","","148.57","89.14","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","17.28","126.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRODUCER 5FRX.018INX40CM MANDREL MICROPUNCTURE VASCULAR SOFT TIP TUNGSTEN NITINOL BX/10EA","SUP-ITM-10232295","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","148.57","89.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","17.28","11.63","","49.19","10.57","114.40","19","17.28","114.99","percent of total billed charges",""
"KIT INTRODUCER 5FRX.018INX40CM MANDREL MICROPUNCTURE VASCULAR SOFT TIP TUNGSTEN NITINOL BX/10EA","SUP-ITM-10232295","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","148.57","89.14","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","93.27","62.78","","93.27","93.27","93.27","1 through 10","17.28","114.99","percent of total billed charges",""
"KIT INTRODUCER 5FRX.018INX40CM MANDREL MICROPUNCTURE VASCULAR SOFT TIP TUNGSTEN NITINOL BX/10EA","SUP-ITM-10232295","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","148.57","89.14","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","64.95","43.72","","363.22","363.22","363.22","1 through 10","17.28","114.99","percent of total billed charges",""
"KIT INTRODUCER 5FRX.018INX40CM MANDREL MICROPUNCTURE VASCULAR SOFT TIP TUNGSTEN NITINOL BX/10EA","SUP-ITM-10232295","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","148.57","89.14","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","108.04","72.72","","271.85","111.24","551.69","14","17.28","114.99","percent of total billed charges",""
"KIT INTRODUCER 5FRX.018INX40CM MANDREL MICROPUNCTURE VASCULAR SOFT TIP TUNGSTEN NITINOL BX/10EA","SUP-ITM-10232295","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","148.57","89.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","93.45","62.9","","706.53","93.60","938.00","53","17.28","114.99","percent of total billed charges",""
"KIT INTRODUCER 5FRX.018INX40CM MANDREL MICROPUNCTURE VASCULAR SOFT TIP TUNGSTEN NITINOL BX/10EA","SUP-ITM-10232295","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","148.57","89.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","114.99","77.4","","200.75","81.67","643.86","11","17.28","114.99","percent of total billed charges",""
"KIT INTRODUCER 7.0FRX14CM 0.038IN SHEATH PEEL AWAY UNIVERSAL","SUP-ITM-10133096","CDM","C1894","HCPCS","0272","RC","","","","both","","","207.30","124.38","AETNA [1001]","HB WDH AETNA COMMERCIAL","144.70","69.8","","94.15","94.15","427.63","1 through 10","24.11","176.21","percent of total billed charges",""
"KIT INTRODUCER 7.0FRX14CM 0.038IN SHEATH PEEL AWAY UNIVERSAL","SUP-ITM-10133096","CDM","C1894","HCPCS","0272","RC","","","","both","","","207.30","124.38","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","24.11","176.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRODUCER 7.0FRX14CM 0.038IN SHEATH PEEL AWAY UNIVERSAL","SUP-ITM-10133096","CDM","C1894","HCPCS","0272","RC","","","","both","","","207.30","124.38","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","117.95","56.9","","401.89","65.85","401.89","1 through 10","24.11","176.21","percent of total billed charges",""
"KIT INTRODUCER 7.0FRX14CM 0.038IN SHEATH PEEL AWAY UNIVERSAL","SUP-ITM-10133096","CDM","C1894","HCPCS","0272","RC","","","","both","","","207.30","124.38","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","24.11","11.63","","49.19","10.57","114.40","19","24.11","176.21","percent of total billed charges",""
"KIT INTRODUCER 7.0FRX14CM 0.038IN SHEATH PEEL AWAY UNIVERSAL","SUP-ITM-10133096","CDM","C1894","HCPCS","0272","RC","","","","both","","","207.30","124.38","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","160.45","77.4","","200.75","81.67","643.86","11","24.11","176.21","percent of total billed charges",""
"KIT INTRODUCER 7.0FRX14CM 0.038IN SHEATH PEEL AWAY UNIVERSAL","SUP-ITM-10133096","CDM","C1894","HCPCS","0272","RC","","","","both","","","207.30","124.38","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","24.11","176.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRODUCER 7.0FRX14CM 0.038IN SHEATH PEEL AWAY UNIVERSAL","SUP-ITM-10133096","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","207.30","124.38","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","24.11","11.63","","49.19","10.57","114.40","19","24.11","160.45","percent of total billed charges",""
"KIT INTRODUCER 7.0FRX14CM 0.038IN SHEATH PEEL AWAY UNIVERSAL","SUP-ITM-10133096","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","207.30","124.38","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","130.14","62.78","","93.27","93.27","93.27","1 through 10","24.11","160.45","percent of total billed charges",""
"KIT INTRODUCER 7.0FRX14CM 0.038IN SHEATH PEEL AWAY UNIVERSAL","SUP-ITM-10133096","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","207.30","124.38","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","90.63","43.72","","363.22","363.22","363.22","1 through 10","24.11","160.45","percent of total billed charges",""
"KIT INTRODUCER 7.0FRX14CM 0.038IN SHEATH PEEL AWAY UNIVERSAL","SUP-ITM-10133096","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","207.30","124.38","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","150.75","72.72","","271.85","111.24","551.69","14","24.11","160.45","percent of total billed charges",""
"KIT INTRODUCER 7.0FRX14CM 0.038IN SHEATH PEEL AWAY UNIVERSAL","SUP-ITM-10133096","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","207.30","124.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","130.39","62.9","","706.53","93.60","938.00","53","24.11","160.45","percent of total billed charges",""
"KIT INTRODUCER 7.0FRX14CM 0.038IN SHEATH PEEL AWAY UNIVERSAL","SUP-ITM-10133096","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","207.30","124.38","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","160.45","77.4","","200.75","81.67","643.86","11","24.11","160.45","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","both","","","269.35","161.61","AETNA [1001]","HB WDH AETNA COMMERCIAL","188.01","69.8","","94.15","94.15","427.63","1 through 10","31.33","228.95","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","both","","","269.35","161.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","31.33","228.95","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","both","","","269.35","161.61","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","153.26","56.9","","401.89","65.85","401.89","1 through 10","31.33","228.95","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","both","","","269.35","161.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","31.33","11.63","","49.19","10.57","114.40","19","31.33","228.95","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","both","","","269.35","161.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","208.48","77.4","","200.75","81.67","643.86","11","31.33","228.95","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","both","","","269.35","161.61","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","31.33","228.95","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","269.35","161.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","31.33","11.63","","49.19","10.57","114.40","19","31.33","208.48","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","269.35","161.61","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","169.10","62.78","","93.27","93.27","93.27","1 through 10","31.33","208.48","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","269.35","161.61","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","117.76","43.72","","363.22","363.22","363.22","1 through 10","31.33","208.48","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","269.35","161.61","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","195.87","72.72","","271.85","111.24","551.69","14","31.33","208.48","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","269.35","161.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","169.42","62.9","","706.53","93.60","938.00","53","31.33","208.48","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","269.35","161.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","208.48","77.4","","200.75","81.67","643.86","11","31.33","208.48","percent of total billed charges",""
"KIT INTRODUCER COAXIAL DILATOR ACCESS SHEATH S-MAK STIFFENED 5FR 10CM .018INX40CM NITINOL/PLATINUM TIP 21GX7CM ECHO ENHANCED BX/10EA","SUP-ITM-10235589","CDM","C1894","HCPCS","0272","RC","","","","both","","","244.34","146.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","170.55","69.8","","94.15","94.15","427.63","1 through 10","28.42","207.69","percent of total billed charges",""
"KIT INTRODUCER COAXIAL DILATOR ACCESS SHEATH S-MAK STIFFENED 5FR 10CM .018INX40CM NITINOL/PLATINUM TIP 21GX7CM ECHO ENHANCED BX/10EA","SUP-ITM-10235589","CDM","C1894","HCPCS","0272","RC","","","","both","","","244.34","146.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","28.42","207.69","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRODUCER COAXIAL DILATOR ACCESS SHEATH S-MAK STIFFENED 5FR 10CM .018INX40CM NITINOL/PLATINUM TIP 21GX7CM ECHO ENHANCED BX/10EA","SUP-ITM-10235589","CDM","C1894","HCPCS","0272","RC","","","","both","","","244.34","146.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","139.03","56.9","","401.89","65.85","401.89","1 through 10","28.42","207.69","percent of total billed charges",""
"KIT INTRODUCER COAXIAL DILATOR ACCESS SHEATH S-MAK STIFFENED 5FR 10CM .018INX40CM NITINOL/PLATINUM TIP 21GX7CM ECHO ENHANCED BX/10EA","SUP-ITM-10235589","CDM","C1894","HCPCS","0272","RC","","","","both","","","244.34","146.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","28.42","11.63","","49.19","10.57","114.40","19","28.42","207.69","percent of total billed charges",""
"KIT INTRODUCER COAXIAL DILATOR ACCESS SHEATH S-MAK STIFFENED 5FR 10CM .018INX40CM NITINOL/PLATINUM TIP 21GX7CM ECHO ENHANCED BX/10EA","SUP-ITM-10235589","CDM","C1894","HCPCS","0272","RC","","","","both","","","244.34","146.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","189.12","77.4","","200.75","81.67","643.86","11","28.42","207.69","percent of total billed charges",""
"KIT INTRODUCER COAXIAL DILATOR ACCESS SHEATH S-MAK STIFFENED 5FR 10CM .018INX40CM NITINOL/PLATINUM TIP 21GX7CM ECHO ENHANCED BX/10EA","SUP-ITM-10235589","CDM","C1894","HCPCS","0272","RC","","","","both","","","244.34","146.60","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","28.42","207.69","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRODUCER COAXIAL DILATOR ACCESS SHEATH S-MAK STIFFENED 5FR 10CM .018INX40CM NITINOL/PLATINUM TIP 21GX7CM ECHO ENHANCED BX/10EA","SUP-ITM-10235589","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","244.34","146.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","28.42","11.63","","49.19","10.57","114.40","19","28.42","189.12","percent of total billed charges",""
"KIT INTRODUCER COAXIAL DILATOR ACCESS SHEATH S-MAK STIFFENED 5FR 10CM .018INX40CM NITINOL/PLATINUM TIP 21GX7CM ECHO ENHANCED BX/10EA","SUP-ITM-10235589","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","244.34","146.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","153.40","62.78","","93.27","93.27","93.27","1 through 10","28.42","189.12","percent of total billed charges",""
"KIT INTRODUCER COAXIAL DILATOR ACCESS SHEATH S-MAK STIFFENED 5FR 10CM .018INX40CM NITINOL/PLATINUM TIP 21GX7CM ECHO ENHANCED BX/10EA","SUP-ITM-10235589","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","244.34","146.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","106.83","43.72","","363.22","363.22","363.22","1 through 10","28.42","189.12","percent of total billed charges",""
"KIT INTRODUCER COAXIAL DILATOR ACCESS SHEATH S-MAK STIFFENED 5FR 10CM .018INX40CM NITINOL/PLATINUM TIP 21GX7CM ECHO ENHANCED BX/10EA","SUP-ITM-10235589","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","244.34","146.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","177.68","72.72","","271.85","111.24","551.69","14","28.42","189.12","percent of total billed charges",""
"KIT INTRODUCER COAXIAL DILATOR ACCESS SHEATH S-MAK STIFFENED 5FR 10CM .018INX40CM NITINOL/PLATINUM TIP 21GX7CM ECHO ENHANCED BX/10EA","SUP-ITM-10235589","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","244.34","146.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","153.69","62.9","","706.53","93.60","938.00","53","28.42","189.12","percent of total billed charges",""
"KIT INTRODUCER COAXIAL DILATOR ACCESS SHEATH S-MAK STIFFENED 5FR 10CM .018INX40CM NITINOL/PLATINUM TIP 21GX7CM ECHO ENHANCED BX/10EA","SUP-ITM-10235589","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","244.34","146.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","189.12","77.4","","200.75","81.67","643.86","11","28.42","189.12","percent of total billed charges",""
"KIT INTRODUCER SIZE 3 TAMP BONE XPANDER II FIRST FRACTURE OSTEO","SUP-ITM-10094045","CDM","C1894","HCPCS","0272","RC","","","","both","","","4869.40","2921.64","AETNA [1001]","HB WDH AETNA COMMERCIAL","3398.84","69.8","","94.15","94.15","427.63","1 through 10","566.31","4138.99","percent of total billed charges",""
"KIT INTRODUCER SIZE 3 TAMP BONE XPANDER II FIRST FRACTURE OSTEO","SUP-ITM-10094045","CDM","C1894","HCPCS","0272","RC","","","","both","","","4869.40","2921.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","566.31","4138.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRODUCER SIZE 3 TAMP BONE XPANDER II FIRST FRACTURE OSTEO","SUP-ITM-10094045","CDM","C1894","HCPCS","0272","RC","","","","both","","","4869.40","2921.64","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2770.69","56.9","","401.89","65.85","401.89","1 through 10","566.31","4138.99","percent of total billed charges",""
"KIT INTRODUCER SIZE 3 TAMP BONE XPANDER II FIRST FRACTURE OSTEO","SUP-ITM-10094045","CDM","C1894","HCPCS","0272","RC","","","","both","","","4869.40","2921.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","566.31","11.63","","49.19","10.57","114.40","19","566.31","4138.99","percent of total billed charges",""
"KIT INTRODUCER SIZE 3 TAMP BONE XPANDER II FIRST FRACTURE OSTEO","SUP-ITM-10094045","CDM","C1894","HCPCS","0272","RC","","","","both","","","4869.40","2921.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3768.92","77.4","","200.75","81.67","643.86","11","566.31","4138.99","percent of total billed charges",""
"KIT INTRODUCER SIZE 3 TAMP BONE XPANDER II FIRST FRACTURE OSTEO","SUP-ITM-10094045","CDM","C1894","HCPCS","0272","RC","","","","both","","","4869.40","2921.64","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","566.31","4138.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT INTRODUCER SIZE 3 TAMP BONE XPANDER II FIRST FRACTURE OSTEO","SUP-ITM-10094045","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4869.40","2921.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","566.31","11.63","","49.19","10.57","114.40","19","566.31","3768.92","percent of total billed charges",""
"KIT INTRODUCER SIZE 3 TAMP BONE XPANDER II FIRST FRACTURE OSTEO","SUP-ITM-10094045","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4869.40","2921.64","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3057.01","62.78","","93.27","93.27","93.27","1 through 10","566.31","3768.92","percent of total billed charges",""
"KIT INTRODUCER SIZE 3 TAMP BONE XPANDER II FIRST FRACTURE OSTEO","SUP-ITM-10094045","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4869.40","2921.64","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2128.90","43.72","","363.22","363.22","363.22","1 through 10","566.31","3768.92","percent of total billed charges",""
"KIT INTRODUCER SIZE 3 TAMP BONE XPANDER II FIRST FRACTURE OSTEO","SUP-ITM-10094045","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4869.40","2921.64","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3541.03","72.72","","271.85","111.24","551.69","14","566.31","3768.92","percent of total billed charges",""
"KIT INTRODUCER SIZE 3 TAMP BONE XPANDER II FIRST FRACTURE OSTEO","SUP-ITM-10094045","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4869.40","2921.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3062.85","62.9","","706.53","93.60","938.00","53","566.31","3768.92","percent of total billed charges",""
"KIT INTRODUCER SIZE 3 TAMP BONE XPANDER II FIRST FRACTURE OSTEO","SUP-ITM-10094045","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","4869.40","2921.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3768.92","77.4","","200.75","81.67","643.86","11","566.31","3768.92","percent of total billed charges",""
"KIT IPG PROCLAIM ELITE 5 PATIENT CONTROLLER","SUP-ITM-10273122","CDM","C1767","HCPCS","0278","RC","","","","outpatient","","","37642.00","22585.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","23676.82","62.9","","79618.14","79618.14","79618.14","1 through 10","4377.76","29134.91","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","13760.24","8256.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1600.32","11696.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","13760.24","8256.14","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7829.58","56.9","","2911.53","1863.86","5209.05","65","1600.32","11696.2","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","13760.24","8256.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1600.32","11.63","","400.94","400.94","400.94","1 through 10","1600.32","11696.2","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","13760.24","8256.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10650.43","77.4","","5214.50","5214.50","16415.28","1 through 10","1600.32","11696.2","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13760.24","8256.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1600.32","11.63","","400.94","400.94","400.94","1 through 10","1600.32","10650.43","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13760.24","8256.14","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","6015.98","43.72","","1543.33","1543.33","1671.61","1 through 10","1600.32","10650.43","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13760.24","8256.14","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10006.45","72.72","","3700.21","2382.07","6427.18","53","1600.32","10650.43","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13760.24","8256.14","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","10006.45","72.72","","12685.80","12685.80","12685.80","1 through 10","1600.32","10650.43","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13760.24","8256.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8655.19","62.9","","3408.87","2784.05","9859.40","46","1600.32","10650.43","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13760.24","8256.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10650.43","77.4","","5214.50","5214.50","16415.28","1 through 10","1600.32","10650.43","percent of total billed charges",""
"KIT LABORATORY TOE STEM SWANSON HAMMERTOE SM SIZE 1S","SUP-ITM-10154566","CDM","C1776","HCPCS","0278","RC","","","","both","","","4857.73","2914.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","564.95","4129.07","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT LABORATORY TOE STEM SWANSON HAMMERTOE SM SIZE 1S","SUP-ITM-10154566","CDM","C1776","HCPCS","0278","RC","","","","both","","","4857.73","2914.64","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2764.05","56.9","","2911.53","1863.86","5209.05","65","564.95","4129.07","percent of total billed charges",""
"KIT LABORATORY TOE STEM SWANSON HAMMERTOE SM SIZE 1S","SUP-ITM-10154566","CDM","C1776","HCPCS","0278","RC","","","","both","","","4857.73","2914.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.95","11.63","","400.94","400.94","400.94","1 through 10","564.95","4129.07","percent of total billed charges",""
"KIT LABORATORY TOE STEM SWANSON HAMMERTOE SM SIZE 1S","SUP-ITM-10154566","CDM","C1776","HCPCS","0278","RC","","","","both","","","4857.73","2914.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3759.88","77.4","","5214.50","5214.50","16415.28","1 through 10","564.95","4129.07","percent of total billed charges",""
"KIT LABORATORY TOE STEM SWANSON HAMMERTOE SM SIZE 1S","SUP-ITM-10154566","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4857.73","2914.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.95","11.63","","400.94","400.94","400.94","1 through 10","564.95","3759.88","percent of total billed charges",""
"KIT LABORATORY TOE STEM SWANSON HAMMERTOE SM SIZE 1S","SUP-ITM-10154566","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4857.73","2914.64","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2123.80","43.72","","1543.33","1543.33","1671.61","1 through 10","564.95","3759.88","percent of total billed charges",""
"KIT LABORATORY TOE STEM SWANSON HAMMERTOE SM SIZE 1S","SUP-ITM-10154566","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4857.73","2914.64","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3532.54","72.72","","3700.21","2382.07","6427.18","53","564.95","3759.88","percent of total billed charges",""
"KIT LABORATORY TOE STEM SWANSON HAMMERTOE SM SIZE 1S","SUP-ITM-10154566","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4857.73","2914.64","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3532.54","72.72","","12685.80","12685.80","12685.80","1 through 10","564.95","3759.88","percent of total billed charges",""
"KIT LABORATORY TOE STEM SWANSON HAMMERTOE SM SIZE 1S","SUP-ITM-10154566","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4857.73","2914.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3055.51","62.9","","3408.87","2784.05","9859.40","46","564.95","3759.88","percent of total billed charges",""
"KIT LABORATORY TOE STEM SWANSON HAMMERTOE SM SIZE 1S","SUP-ITM-10154566","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4857.73","2914.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3759.88","77.4","","5214.50","5214.50","16415.28","1 through 10","564.95","3759.88","percent of total billed charges",""
"KIT LEAD 1X8 60CM NEUROSTIMULATOR VECTRIS SURESCAN MRI SAFE COMPACT OCTAPOLAR CONNECTOR","SUP-ITM-10124361","CDM","C1778","HCPCS","0278","RC","","","","both","","","10141.35","6084.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","14342.00","14342.00","14342.00","1 through 10","1179.44","8620.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT LEAD 1X8 60CM NEUROSTIMULATOR VECTRIS SURESCAN MRI SAFE COMPACT OCTAPOLAR CONNECTOR","SUP-ITM-10124361","CDM","C1778","HCPCS","0278","RC","","","","both","","","10141.35","6084.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1179.44","11.63","","2253.51","2253.51","2253.51","1 through 10","1179.44","8620.15","percent of total billed charges",""
"KIT LEAD 1X8 60CM NEUROSTIMULATOR VECTRIS SURESCAN MRI SAFE COMPACT OCTAPOLAR CONNECTOR","SUP-ITM-10124361","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","10141.35","6084.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1179.44","11.63","","2253.51","2253.51","2253.51","1 through 10","1179.44","7849.4","percent of total billed charges",""
"KIT LEAD 1X8 60CM NEUROSTIMULATOR VECTRIS SURESCAN MRI SAFE COMPACT OCTAPOLAR CONNECTOR","SUP-ITM-10124361","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","10141.35","6084.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6378.91","62.9","","21082.95","11598.93","21082.95","1 through 10","1179.44","7849.4","percent of total billed charges",""
"KIT LEAD 25CM PNS ONLY 4 CONTACT TINED","SUP-ITM-10294635","CDM","C1778","HCPCS","0278","RC","","","","both","","","5092.50","3055.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","14342.00","14342.00","14342.00","1 through 10","592.26","4328.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT LEAD 25CM PNS ONLY 4 CONTACT TINED","SUP-ITM-10294635","CDM","C1778","HCPCS","0278","RC","","","","both","","","5092.50","3055.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","592.26","11.63","","2253.51","2253.51","2253.51","1 through 10","592.26","4328.63","percent of total billed charges",""
"KIT LEAD 25CM PNS ONLY 4 CONTACT TINED","SUP-ITM-10294635","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","5092.50","3055.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","592.26","11.63","","2253.51","2253.51","2253.51","1 through 10","592.26","3941.6","percent of total billed charges",""
"KIT LEAD 25CM PNS ONLY 4 CONTACT TINED","SUP-ITM-10294635","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","5092.50","3055.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3203.18","62.9","","21082.95","11598.93","21082.95","1 through 10","592.26","3941.6","percent of total billed charges",""
"KIT LEAD 4.32MM 28CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277206","CDM","C1778","HCPCS","0278","RC","","","","both","","","14342.00","8605.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","14342.00","14342.00","14342.00","1 through 10","1667.97","12190.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT LEAD 4.32MM 28CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277206","CDM","C1778","HCPCS","0278","RC","","","","both","","","14342.00","8605.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1667.97","11.63","","2253.51","2253.51","2253.51","1 through 10","1667.97","12190.7","percent of total billed charges",""
"KIT LEAD 4.32MM 28CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277206","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","14342.00","8605.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1667.97","11.63","","2253.51","2253.51","2253.51","1 through 10","1667.97","11100.71","percent of total billed charges",""
"KIT LEAD 4.32MM 28CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277206","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","14342.00","8605.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","9021.12","62.9","","21082.95","11598.93","21082.95","1 through 10","1667.97","11100.71","percent of total billed charges",""
"KIT LEAD 40CM SCS 8 CONTACT","SUP-ITM-10294663","CDM","C1778","HCPCS","0278","RC","","","","both","","","6111.00","3666.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","14342.00","14342.00","14342.00","1 through 10","710.71","5194.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT LEAD 40CM SCS 8 CONTACT","SUP-ITM-10294663","CDM","C1778","HCPCS","0278","RC","","","","both","","","6111.00","3666.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","710.71","11.63","","2253.51","2253.51","2253.51","1 through 10","710.71","5194.35","percent of total billed charges",""
"KIT LEAD 40CM SCS 8 CONTACT","SUP-ITM-10294663","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","6111.00","3666.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","710.71","11.63","","2253.51","2253.51","2253.51","1 through 10","710.71","4729.91","percent of total billed charges",""
"KIT LEAD 40CM SCS 8 CONTACT","SUP-ITM-10294663","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","6111.00","3666.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3843.82","62.9","","21082.95","11598.93","21082.95","1 through 10","710.71","4729.91","percent of total billed charges",""
"KIT LEAD 5.0MM 70CM PERCUTANEOUS SENZA SPINAL CORD STIMULATION ELECTRODE SPACING LEAD1058-70B","SUP-ITM-10158049","CDM","C1778","HCPCS","0278","RC","","","","both","","","8002.50","4801.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","14342.00","14342.00","14342.00","1 through 10","930.69","6802.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT LEAD 5.0MM 70CM PERCUTANEOUS SENZA SPINAL CORD STIMULATION ELECTRODE SPACING LEAD1058-70B","SUP-ITM-10158049","CDM","C1778","HCPCS","0278","RC","","","","both","","","8002.50","4801.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","930.69","11.63","","2253.51","2253.51","2253.51","1 through 10","930.69","6802.13","percent of total billed charges",""
"KIT LEAD 5.0MM 70CM PERCUTANEOUS SENZA SPINAL CORD STIMULATION ELECTRODE SPACING LEAD1058-70B","SUP-ITM-10158049","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","930.69","11.63","","2253.51","2253.51","2253.51","1 through 10","930.69","6193.94","percent of total billed charges",""
"KIT LEAD 5.0MM 70CM PERCUTANEOUS SENZA SPINAL CORD STIMULATION ELECTRODE SPACING LEAD1058-70B","SUP-ITM-10158049","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","8002.50","4801.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5033.57","62.9","","21082.95","11598.93","21082.95","1 through 10","930.69","6193.94","percent of total billed charges",""
"KIT LEAD 5.0MM 70CM PERCUTANEOUS SENZA SPINAL CORD STIMULATION ELECTRODE SPACING TLEAD1058-70B","SUP-ITM-10158039","CDM","C1897","HCPCS","0278","RC","","","","both","","","4491.50","2694.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","522.36","11.63","","605.27","605.27","605.27","1 through 10","522.36","3817.78","percent of total billed charges",""
"KIT LEAD 5.0MM 70CM PERCUTANEOUS SENZA SPINAL CORD STIMULATION ELECTRODE SPACING TLEAD1058-70B","SUP-ITM-10158039","CDM","C1897","HCPCS","0278","RC","","","","outpatient","","","4491.50","2694.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","522.36","11.63","","605.27","605.27","605.27","1 through 10","522.36","3476.42","percent of total billed charges",""
"KIT LEAD 5.0MM 70CM PERCUTANEOUS SENZA SPINAL CORD STIMULATION ELECTRODE SPACING TLEAD1058-70B","SUP-ITM-10158039","CDM","C1897","HCPCS","0278","RC","","","","outpatient","","","4491.50","2694.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3266.22","72.72","","3596.00","3596.00","3596.00","1 through 10","522.36","3476.42","percent of total billed charges",""
"KIT LEAD 5.0MM 70CM PERCUTANEOUS SENZA SPINAL CORD STIMULATION ELECTRODE SPACING TLEAD1058-70B","SUP-ITM-10158039","CDM","C1897","HCPCS","0278","RC","","","","outpatient","","","4491.50","2694.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2825.15","62.9","","3130.19","3115.35","3130.19","1 through 10","522.36","3476.42","percent of total billed charges",""
"KIT LEAD 50CM .014IN NEUROSTIMULATOR LINEAR TRIAL PRELOADED STYLET PRECISION","SUP-ITM-10077048","CDM","C1897","HCPCS","0278","RC","","","","both","","","5804.40","3482.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","675.05","11.63","","605.27","605.27","605.27","1 through 10","675.05","4933.74","percent of total billed charges",""
"KIT LEAD 50CM .014IN NEUROSTIMULATOR LINEAR TRIAL PRELOADED STYLET PRECISION","SUP-ITM-10077048","CDM","C1897","HCPCS","0278","RC","","","","outpatient","","","5804.40","3482.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","675.05","11.63","","605.27","605.27","605.27","1 through 10","675.05","4492.61","percent of total billed charges",""
"KIT LEAD 50CM .014IN NEUROSTIMULATOR LINEAR TRIAL PRELOADED STYLET PRECISION","SUP-ITM-10077048","CDM","C1897","HCPCS","0278","RC","","","","outpatient","","","5804.40","3482.64","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4220.96","72.72","","3596.00","3596.00","3596.00","1 through 10","675.05","4492.61","percent of total billed charges",""
"KIT LEAD 50CM .014IN NEUROSTIMULATOR LINEAR TRIAL PRELOADED STYLET PRECISION","SUP-ITM-10077048","CDM","C1897","HCPCS","0278","RC","","","","outpatient","","","5804.40","3482.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3650.97","62.9","","3130.19","3115.35","3130.19","1 through 10","675.05","4492.61","percent of total billed charges",""
"KIT LEAD 50CM AXIUM IMPLANT SLIMTIP PERI OP DEVICES NEUROMODULATION","SUP-ITM-10174960","CDM","C1778","HCPCS","0278","RC","","","","both","","","11716.00","7029.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","14342.00","14342.00","14342.00","1 through 10","1362.57","9958.6","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT LEAD 50CM AXIUM IMPLANT SLIMTIP PERI OP DEVICES NEUROMODULATION","SUP-ITM-10174960","CDM","C1778","HCPCS","0278","RC","","","","both","","","11716.00","7029.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1362.57","11.63","","2253.51","2253.51","2253.51","1 through 10","1362.57","9958.6","percent of total billed charges",""
"KIT LEAD 50CM AXIUM IMPLANT SLIMTIP PERI OP DEVICES NEUROMODULATION","SUP-ITM-10174960","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","11716.00","7029.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1362.57","11.63","","2253.51","2253.51","2253.51","1 through 10","1362.57","9068.18","percent of total billed charges",""
"KIT LEAD 50CM AXIUM IMPLANT SLIMTIP PERI OP DEVICES NEUROMODULATION","SUP-ITM-10174960","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","11716.00","7029.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7369.36","62.9","","21082.95","11598.93","21082.95","1 through 10","1362.57","9068.18","percent of total billed charges",""
"KIT LEAD 56CM AVISTA MRI PERCUTANEOUS 8 CONTACT","SUP-ITM-10174950","CDM","C1778","HCPCS","0278","RC","","","","both","","","11155.00","6693.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","14342.00","14342.00","14342.00","1 through 10","1297.33","9481.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT LEAD 56CM AVISTA MRI PERCUTANEOUS 8 CONTACT","SUP-ITM-10174950","CDM","C1778","HCPCS","0278","RC","","","","both","","","11155.00","6693.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1297.33","11.63","","2253.51","2253.51","2253.51","1 through 10","1297.33","9481.75","percent of total billed charges",""
"KIT LEAD 56CM AVISTA MRI PERCUTANEOUS 8 CONTACT","SUP-ITM-10174950","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","11155.00","6693.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1297.33","11.63","","2253.51","2253.51","2253.51","1 through 10","1297.33","8633.97","percent of total billed charges",""
"KIT LEAD 56CM AVISTA MRI PERCUTANEOUS 8 CONTACT","SUP-ITM-10174950","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","11155.00","6693.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7016.50","62.9","","21082.95","11598.93","21082.95","1 through 10","1297.33","8633.97","percent of total billed charges",""
"KIT LEAD 8 CONTACT 60 CM TRIAL","SUP-ITM-10294661","CDM","C1897","HCPCS","0278","RC","","","","both","","","3800.50","2280.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","442.00","11.63","","605.27","605.27","605.27","1 through 10","442","3230.43","percent of total billed charges",""
"KIT LEAD 8 CONTACT 60 CM TRIAL","SUP-ITM-10294661","CDM","C1897","HCPCS","0278","RC","","","","outpatient","","","3800.50","2280.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","442.00","11.63","","605.27","605.27","605.27","1 through 10","442","2941.59","percent of total billed charges",""
"KIT LEAD 8 CONTACT 60 CM TRIAL","SUP-ITM-10294661","CDM","C1897","HCPCS","0278","RC","","","","outpatient","","","3800.50","2280.30","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2763.72","72.72","","3596.00","3596.00","3596.00","1 through 10","442","2941.59","percent of total billed charges",""
"KIT LEAD 8 CONTACT 60 CM TRIAL","SUP-ITM-10294661","CDM","C1897","HCPCS","0278","RC","","","","outpatient","","","3800.50","2280.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2390.51","62.9","","3130.19","3115.35","3130.19","1 through 10","442","2941.59","percent of total billed charges",""
"KIT LEAD TINED STRAIGHT STYLET CURVED STYLET TINED LEAD STIMULATION CABLE LITERATURE","SUP-ITM-10266973","CDM","C1778","HCPCS","0278","RC","","","","both","","","13154.24","7892.54","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","14342.00","14342.00","14342.00","1 through 10","1529.84","11181.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT LEAD TINED STRAIGHT STYLET CURVED STYLET TINED LEAD STIMULATION CABLE LITERATURE","SUP-ITM-10266973","CDM","C1778","HCPCS","0278","RC","","","","both","","","13154.24","7892.54","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1529.84","11.63","","2253.51","2253.51","2253.51","1 through 10","1529.84","11181.1","percent of total billed charges",""
"KIT LEAD TINED STRAIGHT STYLET CURVED STYLET TINED LEAD STIMULATION CABLE LITERATURE","SUP-ITM-10266973","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","13154.24","7892.54","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1529.84","11.63","","2253.51","2253.51","2253.51","1 through 10","1529.84","10181.38","percent of total billed charges",""
"KIT LEAD TINED STRAIGHT STYLET CURVED STYLET TINED LEAD STIMULATION CABLE LITERATURE","SUP-ITM-10266973","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","13154.24","7892.54","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8274.02","62.9","","21082.95","11598.93","21082.95","1 through 10","1529.84","10181.38","percent of total billed charges",""
"KIT LEAD TRIAL 60CM CAP12 EVOKE 12 ELECTRODES 4MM SPACING","SUP-ITM-10317729","CDM","C1897","HCPCS","0278","RC","","","","both","","","5820.00","3492.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","676.87","11.63","","605.27","605.27","605.27","1 through 10","676.87","4947","percent of total billed charges",""
"KIT LEAD TRIAL 60CM CAP12 EVOKE 12 ELECTRODES 4MM SPACING","SUP-ITM-10317729","CDM","C1897","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","676.87","11.63","","605.27","605.27","605.27","1 through 10","676.87","4504.68","percent of total billed charges",""
"KIT LEAD TRIAL 60CM CAP12 EVOKE 12 ELECTRODES 4MM SPACING","SUP-ITM-10317729","CDM","C1897","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4232.30","72.72","","3596.00","3596.00","3596.00","1 through 10","676.87","4504.68","percent of total billed charges",""
"KIT LEAD TRIAL 60CM CAP12 EVOKE 12 ELECTRODES 4MM SPACING","SUP-ITM-10317729","CDM","C1897","HCPCS","0278","RC","","","","outpatient","","","5820.00","3492.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3660.78","62.9","","3130.19","3115.35","3130.19","1 through 10","676.87","4504.68","percent of total billed charges",""
"KIT LIGAMENT AUGMENT REPAIR HAND WRIST INTERNAL BRACE","SUP-ITM-10286052","CDM","C1713","HCPCS","0278","RC","","","","both","","","7250.75","4350.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","843.26","6163.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT LIGAMENT AUGMENT REPAIR HAND WRIST INTERNAL BRACE","SUP-ITM-10286052","CDM","C1713","HCPCS","0278","RC","","","","both","","","7250.75","4350.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","843.26","6163.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT LIGAMENT AUGMENT REPAIR HAND WRIST INTERNAL BRACE","SUP-ITM-10286052","CDM","C1713","HCPCS","0278","RC","","","","both","","","7250.75","4350.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4125.68","56.9","","812.12","238.65","1587.46","163","843.26","6163.14","percent of total billed charges",""
"KIT LIGAMENT AUGMENT REPAIR HAND WRIST INTERNAL BRACE","SUP-ITM-10286052","CDM","C1713","HCPCS","0278","RC","","","","both","","","7250.75","4350.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","843.26","11.63","","112.68","112.68","146.99","38","843.26","6163.14","percent of total billed charges",""
"KIT LIGAMENT AUGMENT REPAIR HAND WRIST INTERNAL BRACE","SUP-ITM-10286052","CDM","C1713","HCPCS","0278","RC","","","","both","","","7250.75","4350.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5612.08","77.4","","303.98","303.98","5854.79","1 through 10","843.26","6163.14","percent of total billed charges",""
"KIT LIGAMENT AUGMENT REPAIR HAND WRIST INTERNAL BRACE","SUP-ITM-10286052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","843.26","11.63","","112.68","112.68","146.99","38","843.26","5612.08","percent of total billed charges",""
"KIT LIGAMENT AUGMENT REPAIR HAND WRIST INTERNAL BRACE","SUP-ITM-10286052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4552.02","62.78","","780.86","208.94","10480.28","15","843.26","5612.08","percent of total billed charges",""
"KIT LIGAMENT AUGMENT REPAIR HAND WRIST INTERNAL BRACE","SUP-ITM-10286052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3170.03","43.72","","179.76","179.76","179.76","1 through 10","843.26","5612.08","percent of total billed charges",""
"KIT LIGAMENT AUGMENT REPAIR HAND WRIST INTERNAL BRACE","SUP-ITM-10286052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5272.75","72.72","","2355.45","298.99","3965.19","155","843.26","5612.08","percent of total billed charges",""
"KIT LIGAMENT AUGMENT REPAIR HAND WRIST INTERNAL BRACE","SUP-ITM-10286052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5272.75","72.72","","3643.09","3643.09","3643.09","1 through 10","843.26","5612.08","percent of total billed charges",""
"KIT LIGAMENT AUGMENT REPAIR HAND WRIST INTERNAL BRACE","SUP-ITM-10286052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3858.85","53.22","","554.28","554.28","554.28","16","843.26","5612.08","percent of total billed charges",""
"KIT LIGAMENT AUGMENT REPAIR HAND WRIST INTERNAL BRACE","SUP-ITM-10286052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4560.72","62.9","","619.64","173.09","2370.64","150","843.26","5612.08","percent of total billed charges",""
"KIT LIGAMENT AUGMENT REPAIR HAND WRIST INTERNAL BRACE","SUP-ITM-10286052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5612.08","77.4","","303.98","303.98","5854.79","1 through 10","843.26","5612.08","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","1174.70","704.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","136.62","998.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","1174.70","704.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","136.62","998.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","1174.70","704.82","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","668.40","56.9","","812.12","238.65","1587.46","163","136.62","998.5","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","1174.70","704.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","136.62","11.63","","112.68","112.68","146.99","38","136.62","998.5","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","1174.70","704.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","909.22","77.4","","303.98","303.98","5854.79","1 through 10","136.62","998.5","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1174.70","704.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","136.62","11.63","","112.68","112.68","146.99","38","136.62","909.22","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1174.70","704.82","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","737.48","62.78","","780.86","208.94","10480.28","15","136.62","909.22","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1174.70","704.82","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","513.58","43.72","","179.76","179.76","179.76","1 through 10","136.62","909.22","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1174.70","704.82","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","854.24","72.72","","2355.45","298.99","3965.19","155","136.62","909.22","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1174.70","704.82","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","854.24","72.72","","3643.09","3643.09","3643.09","1 through 10","136.62","909.22","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1174.70","704.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","625.18","53.22","","554.28","554.28","554.28","16","136.62","909.22","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1174.70","704.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","738.89","62.9","","619.64","173.09","2370.64","150","136.62","909.22","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1174.70","704.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","909.22","77.4","","303.98","303.98","5854.79","1 through 10","136.62","909.22","percent of total billed charges",""
"KIT NAIL 10X360MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10094084","CDM","C1713","HCPCS","0278","RC","","","","both","","","14537.09","8722.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1690.66","12356.53","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT NAIL 10X360MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10094084","CDM","C1713","HCPCS","0278","RC","","","","both","","","14537.09","8722.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1690.66","12356.53","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT NAIL 10X360MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10094084","CDM","C1713","HCPCS","0278","RC","","","","both","","","14537.09","8722.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","8271.60","56.9","","812.12","238.65","1587.46","163","1690.66","12356.53","percent of total billed charges",""
"KIT NAIL 10X360MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10094084","CDM","C1713","HCPCS","0278","RC","","","","both","","","14537.09","8722.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1690.66","11.63","","112.68","112.68","146.99","38","1690.66","12356.53","percent of total billed charges",""
"KIT NAIL 10X360MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10094084","CDM","C1713","HCPCS","0278","RC","","","","both","","","14537.09","8722.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","11251.71","77.4","","303.98","303.98","5854.79","1 through 10","1690.66","12356.53","percent of total billed charges",""
"KIT NAIL 10X360MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10094084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14537.09","8722.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1690.66","11.63","","112.68","112.68","146.99","38","1690.66","11251.71","percent of total billed charges",""
"KIT NAIL 10X360MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10094084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14537.09","8722.25","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","9126.39","62.78","","780.86","208.94","10480.28","15","1690.66","11251.71","percent of total billed charges",""
"KIT NAIL 10X360MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10094084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14537.09","8722.25","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","6355.62","43.72","","179.76","179.76","179.76","1 through 10","1690.66","11251.71","percent of total billed charges",""
"KIT NAIL 10X360MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10094084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14537.09","8722.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10571.37","72.72","","2355.45","298.99","3965.19","155","1690.66","11251.71","percent of total billed charges",""
"KIT NAIL 10X360MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10094084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14537.09","8722.25","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","10571.37","72.72","","3643.09","3643.09","3643.09","1 through 10","1690.66","11251.71","percent of total billed charges",""
"KIT NAIL 10X360MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10094084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14537.09","8722.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","7736.64","53.22","","554.28","554.28","554.28","16","1690.66","11251.71","percent of total billed charges",""
"KIT NAIL 10X360MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10094084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14537.09","8722.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","9143.83","62.9","","619.64","173.09","2370.64","150","1690.66","11251.71","percent of total billed charges",""
"KIT NAIL 10X360MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10094084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14537.09","8722.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","11251.71","77.4","","303.98","303.98","5854.79","1 through 10","1690.66","11251.71","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","10550.98","6330.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1227.08","8968.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","10550.98","6330.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1227.08","8968.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","10550.98","6330.59","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6003.51","56.9","","812.12","238.65","1587.46","163","1227.08","8968.33","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","10550.98","6330.59","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1227.08","11.63","","112.68","112.68","146.99","38","1227.08","8968.33","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","10550.98","6330.59","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8166.46","77.4","","303.98","303.98","5854.79","1 through 10","1227.08","8968.33","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10550.98","6330.59","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1227.08","11.63","","112.68","112.68","146.99","38","1227.08","8166.46","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10550.98","6330.59","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6623.91","62.78","","780.86","208.94","10480.28","15","1227.08","8166.46","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10550.98","6330.59","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4612.89","43.72","","179.76","179.76","179.76","1 through 10","1227.08","8166.46","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10550.98","6330.59","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7672.67","72.72","","2355.45","298.99","3965.19","155","1227.08","8166.46","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10550.98","6330.59","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7672.67","72.72","","3643.09","3643.09","3643.09","1 through 10","1227.08","8166.46","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10550.98","6330.59","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","5615.23","53.22","","554.28","554.28","554.28","16","1227.08","8166.46","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10550.98","6330.59","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6636.57","62.9","","619.64","173.09","2370.64","150","1227.08","8166.46","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10550.98","6330.59","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8166.46","77.4","","303.98","303.98","5854.79","1 through 10","1227.08","8166.46","percent of total billed charges",""
"KIT NEVERTOUCH 65CM .035IN 21G ABLATION SYSTEM GOLD TIP FIBER","SUP-ITM-10100524","CDM","C1888","HCPCS","0272","RC","","","","both","","","2522.15","1513.29","AETNA [1001]","HB WDH AETNA COMMERCIAL","1760.46","69.8","","1760.46","1760.46","1760.46","1 through 10","293.33","2143.83","percent of total billed charges",""
"KIT NEVERTOUCH 65CM .035IN 21G ABLATION SYSTEM GOLD TIP FIBER","SUP-ITM-10100524","CDM","C1888","HCPCS","0272","RC","","","","both","","","2522.15","1513.29","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1435.10","56.9","","1435.10","1435.10","1435.10","1 through 10","293.33","2143.83","percent of total billed charges",""
"KIT NEVERTOUCH 65CM .035IN 21G ABLATION SYSTEM GOLD TIP FIBER","SUP-ITM-10100524","CDM","C1888","HCPCS","0272","RC","","","","both","","","2522.15","1513.29","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","1760.46","69.8","","1760.46","1760.46","1760.46","1 through 10","293.33","2143.83","percent of total billed charges",""
"KIT NEVERTOUCH 65CM .035IN 21G ABLATION SYSTEM GOLD TIP FIBER","SUP-ITM-10100524","CDM","C1888","HCPCS","0272","RC","","","","outpatient","","","2522.15","1513.29","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1586.43","62.9","","1588.95","1588.95","1588.95","1 through 10","293.33","1952.14","percent of total billed charges",""
"KIT ORTHOPEDIC TUBEROSITY T3 AMZ STERILE DISPOSABLE","SUP-ITM-10074551","CDM","C1713","HCPCS","0278","RC","","","","both","","","3448.09","2068.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","401.01","2930.88","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT ORTHOPEDIC TUBEROSITY T3 AMZ STERILE DISPOSABLE","SUP-ITM-10074551","CDM","C1713","HCPCS","0278","RC","","","","both","","","3448.09","2068.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","401.01","2930.88","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT ORTHOPEDIC TUBEROSITY T3 AMZ STERILE DISPOSABLE","SUP-ITM-10074551","CDM","C1713","HCPCS","0278","RC","","","","both","","","3448.09","2068.85","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1961.96","56.9","","812.12","238.65","1587.46","163","401.01","2930.88","percent of total billed charges",""
"KIT ORTHOPEDIC TUBEROSITY T3 AMZ STERILE DISPOSABLE","SUP-ITM-10074551","CDM","C1713","HCPCS","0278","RC","","","","both","","","3448.09","2068.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","401.01","11.63","","112.68","112.68","146.99","38","401.01","2930.88","percent of total billed charges",""
"KIT ORTHOPEDIC TUBEROSITY T3 AMZ STERILE DISPOSABLE","SUP-ITM-10074551","CDM","C1713","HCPCS","0278","RC","","","","both","","","3448.09","2068.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2668.82","77.4","","303.98","303.98","5854.79","1 through 10","401.01","2930.88","percent of total billed charges",""
"KIT ORTHOPEDIC TUBEROSITY T3 AMZ STERILE DISPOSABLE","SUP-ITM-10074551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3448.09","2068.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","401.01","11.63","","112.68","112.68","146.99","38","401.01","2668.82","percent of total billed charges",""
"KIT ORTHOPEDIC TUBEROSITY T3 AMZ STERILE DISPOSABLE","SUP-ITM-10074551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3448.09","2068.85","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2164.71","62.78","","780.86","208.94","10480.28","15","401.01","2668.82","percent of total billed charges",""
"KIT ORTHOPEDIC TUBEROSITY T3 AMZ STERILE DISPOSABLE","SUP-ITM-10074551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3448.09","2068.85","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1507.50","43.72","","179.76","179.76","179.76","1 through 10","401.01","2668.82","percent of total billed charges",""
"KIT ORTHOPEDIC TUBEROSITY T3 AMZ STERILE DISPOSABLE","SUP-ITM-10074551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3448.09","2068.85","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2507.45","72.72","","2355.45","298.99","3965.19","155","401.01","2668.82","percent of total billed charges",""
"KIT ORTHOPEDIC TUBEROSITY T3 AMZ STERILE DISPOSABLE","SUP-ITM-10074551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3448.09","2068.85","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2507.45","72.72","","3643.09","3643.09","3643.09","1 through 10","401.01","2668.82","percent of total billed charges",""
"KIT ORTHOPEDIC TUBEROSITY T3 AMZ STERILE DISPOSABLE","SUP-ITM-10074551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3448.09","2068.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1835.07","53.22","","554.28","554.28","554.28","16","401.01","2668.82","percent of total billed charges",""
"KIT ORTHOPEDIC TUBEROSITY T3 AMZ STERILE DISPOSABLE","SUP-ITM-10074551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3448.09","2068.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2168.85","62.9","","619.64","173.09","2370.64","150","401.01","2668.82","percent of total billed charges",""
"KIT ORTHOPEDIC TUBEROSITY T3 AMZ STERILE DISPOSABLE","SUP-ITM-10074551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3448.09","2068.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2668.82","77.4","","303.98","303.98","5854.79","1 through 10","401.01","2668.82","percent of total billed charges",""
"KIT PERICARDIOCENTESIS 8.3FR 40CM STRAIGHT TIP CATHETER 7 SPIRALING DRAINAGE HOLE BX/4EA","SUP-ITM-10294829","CDM","C1729","HCPCS","0272","RC","","","","both","","","884.48","530.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","102.87","11.63","","19.51","17.34","54.47","21","102.87","751.81","percent of total billed charges",""
"KIT PERICARDIOCENTESIS 8.3FR 40CM STRAIGHT TIP CATHETER 7 SPIRALING DRAINAGE HOLE BX/4EA","SUP-ITM-10294829","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","884.48","530.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","102.87","11.63","","19.51","17.34","54.47","21","102.87","684.59","percent of total billed charges",""
"KIT PERICARDIOCENTESIS 8.3FR 40CM STRAIGHT TIP CATHETER 7 SPIRALING DRAINAGE HOLE BX/4EA","SUP-ITM-10294829","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","884.48","530.69","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","386.69","43.72","","61.93","61.93","61.93","1 through 10","102.87","684.59","percent of total billed charges",""
"KIT PERICARDIOCENTESIS 8.3FR 40CM STRAIGHT TIP CATHETER 7 SPIRALING DRAINAGE HOLE BX/4EA","SUP-ITM-10294829","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","884.48","530.69","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","643.19","72.72","","330.75","267.63","330.75","1 through 10","102.87","684.59","percent of total billed charges",""
"KIT PERICARDIOCENTESIS 8.3FR 40CM STRAIGHT TIP CATHETER 7 SPIRALING DRAINAGE HOLE BX/4EA","SUP-ITM-10294829","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","884.48","530.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","556.34","62.9","","89.25","87.07","231.86","1 through 10","102.87","684.59","percent of total billed charges",""
"KIT PERICARDIOCENTESIS 8.3FR 40CM STRAIGHT TIP CATHETER 7 SPIRALING DRAINAGE HOLE BX/4EA","SUP-ITM-10294829","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","884.48","530.69","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","643.19","72.72","","267.63","267.63","267.63","1 through 10","102.87","684.59","percent of total billed charges",""
"KIT PLUG 29CM ACCESSORY NEUROSTIMULATION OCTOPOLAR INLINE LOW PROFILE CLOSED BOOT KT/1EA","SUP-ITM-10018141","CDM","C1778","HCPCS","0278","RC","","","","both","","","1036.50","621.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","14342.00","14342.00","14342.00","1 through 10","120.54","881.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT PLUG 29CM ACCESSORY NEUROSTIMULATION OCTOPOLAR INLINE LOW PROFILE CLOSED BOOT KT/1EA","SUP-ITM-10018141","CDM","C1778","HCPCS","0278","RC","","","","both","","","1036.50","621.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","120.54","11.63","","2253.51","2253.51","2253.51","1 through 10","120.54","881.03","percent of total billed charges",""
"KIT PLUG 29CM ACCESSORY NEUROSTIMULATION OCTOPOLAR INLINE LOW PROFILE CLOSED BOOT KT/1EA","SUP-ITM-10018141","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","120.54","11.63","","2253.51","2253.51","2253.51","1 through 10","120.54","802.25","percent of total billed charges",""
"KIT PLUG 29CM ACCESSORY NEUROSTIMULATION OCTOPOLAR INLINE LOW PROFILE CLOSED BOOT KT/1EA","SUP-ITM-10018141","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","651.96","62.9","","21082.95","11598.93","21082.95","1 through 10","120.54","802.25","percent of total billed charges",""
"KIT PNS IPG NEUROSTIMULATION DUAL CONNECTION 4 CONTACT","SUP-ITM-10294664","CDM","C1820","HCPCS","0278","RC","","","","both","","","35881.44","21528.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","52982.00","26491.00","52982.00","1 through 10","4173.01","30499.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT PNS IPG NEUROSTIMULATION DUAL CONNECTION 4 CONTACT","SUP-ITM-10294664","CDM","C1820","HCPCS","0278","RC","","","","both","","","35881.44","21528.86","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","20416.54","56.9","","45220.14","36256.68","45220.14","1 through 10","4173.01","30499.22","percent of total billed charges",""
"KIT PNS IPG NEUROSTIMULATION DUAL CONNECTION 4 CONTACT","SUP-ITM-10294664","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","35881.44","21528.86","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","26092.98","72.72","","18421.60","18421.60","18421.60","1 through 10","4173.01","27772.23","percent of total billed charges",""
"KIT PROGRAMMER PRECISION SPECTRA CONTROL REMOTE STIMULATION SPINAL CORD","SUP-ITM-10126495","CDM","C1787","HCPCS","0270","RC","","","","both","","","5528.00","3316.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","3858.54","69.8","","1412.58","1412.58","1412.58","1 through 10","642.91","4698.8","percent of total billed charges",""
"KIT PROGRAMMER PRECISION SPECTRA CONTROL REMOTE STIMULATION SPINAL CORD","SUP-ITM-10126495","CDM","C1787","HCPCS","0270","RC","","","","both","","","5528.00","3316.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","18158.40","2245.75","18158.40","1 through 10","642.91","4698.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT PROGRAMMER PRECISION SPECTRA CONTROL REMOTE STIMULATION SPINAL CORD","SUP-ITM-10126495","CDM","C1787","HCPCS","0270","RC","","","","both","","","5528.00","3316.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3145.43","56.9","","15498.18","15498.18","15498.18","1 through 10","642.91","4698.8","percent of total billed charges",""
"KIT PROGRAMMER PRECISION SPECTRA CONTROL REMOTE STIMULATION SPINAL CORD","SUP-ITM-10126495","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","5528.00","3316.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","4019.96","72.72","","4236.03","4236.03","4236.03","1 through 10","642.91","4278.67","percent of total billed charges",""
"KIT PULSE GENERATOR WAVEWRITER ALPHA 16 IMPLANTABLE","SUP-ITM-10282804","CDM","C1820","HCPCS","0278","RC","","","","both","","","41300.00","24780.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","52982.00","26491.00","52982.00","1 through 10","4803.19","35105","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT PULSE GENERATOR WAVEWRITER ALPHA 16 IMPLANTABLE","SUP-ITM-10282804","CDM","C1820","HCPCS","0278","RC","","","","both","","","41300.00","24780.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","23499.70","56.9","","45220.14","36256.68","45220.14","1 through 10","4803.19","35105","percent of total billed charges",""
"KIT PULSE GENERATOR WAVEWRITER ALPHA 16 IMPLANTABLE","SUP-ITM-10282804","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","41300.00","24780.00","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","30033.36","72.72","","18421.60","18421.60","18421.60","1 through 10","4803.19","31966.2","percent of total billed charges",""
"KIT PULSE GENERATOR WAVEWRITER ALPHA IMPLANTABLE","SUP-ITM-10282803","CDM","C1767","HCPCS","0278","RC","","","","outpatient","","","42126.00","25275.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","26497.25","62.9","","79618.14","79618.14","79618.14","1 through 10","4899.25","32605.52","percent of total billed charges",""
"KIT REMOTE CONTROL NEVRO SENZA PATIENT PROGRAMMER EXTERNAL","SUP-ITM-10158042","CDM","C1787","HCPCS","0270","RC","","","","both","","","5761.80","3457.08","AETNA [1001]","HB WDH AETNA COMMERCIAL","4021.74","69.8","","1412.58","1412.58","1412.58","1 through 10","670.1","4897.53","percent of total billed charges",""
"KIT REMOTE CONTROL NEVRO SENZA PATIENT PROGRAMMER EXTERNAL","SUP-ITM-10158042","CDM","C1787","HCPCS","0270","RC","","","","both","","","5761.80","3457.08","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","18158.40","2245.75","18158.40","1 through 10","670.1","4897.53","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT REMOTE CONTROL NEVRO SENZA PATIENT PROGRAMMER EXTERNAL","SUP-ITM-10158042","CDM","C1787","HCPCS","0270","RC","","","","both","","","5761.80","3457.08","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3278.46","56.9","","15498.18","15498.18","15498.18","1 through 10","670.1","4897.53","percent of total billed charges",""
"KIT REMOTE CONTROL NEVRO SENZA PATIENT PROGRAMMER EXTERNAL","SUP-ITM-10158042","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","5761.80","3457.08","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","4189.98","72.72","","4236.03","4236.03","4236.03","1 through 10","670.1","4459.63","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","6184.45","3710.67","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","719.25","5256.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","6184.45","3710.67","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3518.95","56.9","","2911.53","1863.86","5209.05","65","719.25","5256.78","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","6184.45","3710.67","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","719.25","11.63","","400.94","400.94","400.94","1 through 10","719.25","5256.78","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","6184.45","3710.67","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4786.76","77.4","","5214.50","5214.50","16415.28","1 through 10","719.25","5256.78","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6184.45","3710.67","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","719.25","11.63","","400.94","400.94","400.94","1 through 10","719.25","4786.76","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6184.45","3710.67","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2703.84","43.72","","1543.33","1543.33","1671.61","1 through 10","719.25","4786.76","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6184.45","3710.67","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4497.33","72.72","","3700.21","2382.07","6427.18","53","719.25","4786.76","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6184.45","3710.67","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4497.33","72.72","","12685.80","12685.80","12685.80","1 through 10","719.25","4786.76","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6184.45","3710.67","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3890.02","62.9","","3408.87","2784.05","9859.40","46","719.25","4786.76","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6184.45","3710.67","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4786.76","77.4","","5214.50","5214.50","16415.28","1 through 10","719.25","4786.76","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","both","","","5338.88","3203.33","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","620.91","4538.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","both","","","5338.88","3203.33","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","620.91","4538.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","both","","","5338.88","3203.33","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3037.82","56.9","","812.12","238.65","1587.46","163","620.91","4538.05","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","both","","","5338.88","3203.33","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","620.91","11.63","","112.68","112.68","146.99","38","620.91","4538.05","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","both","","","5338.88","3203.33","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4132.29","77.4","","303.98","303.98","5854.79","1 through 10","620.91","4538.05","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5338.88","3203.33","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","620.91","11.63","","112.68","112.68","146.99","38","620.91","4132.29","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5338.88","3203.33","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3351.75","62.78","","780.86","208.94","10480.28","15","620.91","4132.29","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5338.88","3203.33","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2334.16","43.72","","179.76","179.76","179.76","1 through 10","620.91","4132.29","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5338.88","3203.33","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3882.43","72.72","","2355.45","298.99","3965.19","155","620.91","4132.29","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5338.88","3203.33","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3882.43","72.72","","3643.09","3643.09","3643.09","1 through 10","620.91","4132.29","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5338.88","3203.33","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2841.35","53.22","","554.28","554.28","554.28","16","620.91","4132.29","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5338.88","3203.33","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3358.16","62.9","","619.64","173.09","2370.64","150","620.91","4132.29","percent of total billed charges",""
"KIT REPAIR FIXATION FIBULINK SYNDESMOSIS SYSTEM","SUP-ITM-10288122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5338.88","3203.33","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4132.29","77.4","","303.98","303.98","5854.79","1 through 10","620.91","4132.29","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","6737.25","4042.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","783.54","5726.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","6737.25","4042.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","783.54","5726.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","6737.25","4042.35","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3833.50","56.9","","812.12","238.65","1587.46","163","783.54","5726.66","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","6737.25","4042.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","783.54","11.63","","112.68","112.68","146.99","38","783.54","5726.66","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","6737.25","4042.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5214.63","77.4","","303.98","303.98","5854.79","1 through 10","783.54","5726.66","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6737.25","4042.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","783.54","11.63","","112.68","112.68","146.99","38","783.54","5214.63","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6737.25","4042.35","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4229.65","62.78","","780.86","208.94","10480.28","15","783.54","5214.63","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6737.25","4042.35","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2945.53","43.72","","179.76","179.76","179.76","1 through 10","783.54","5214.63","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6737.25","4042.35","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4899.33","72.72","","2355.45","298.99","3965.19","155","783.54","5214.63","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6737.25","4042.35","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4899.33","72.72","","3643.09","3643.09","3643.09","1 through 10","783.54","5214.63","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6737.25","4042.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3585.56","53.22","","554.28","554.28","554.28","16","783.54","5214.63","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6737.25","4042.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4237.73","62.9","","619.64","173.09","2370.64","150","783.54","5214.63","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6737.25","4042.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5214.63","77.4","","303.98","303.98","5854.79","1 through 10","783.54","5214.63","percent of total billed charges",""
"KIT REPAIR TRACTION FIXATION TIGHTROPE SS CANNULATED SYNDESMOSIS","SUP-ITM-10046824","CDM","C1713","HCPCS","0278","RC","","","","both","","","3627.75","2176.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","421.91","3083.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT REPAIR TRACTION FIXATION TIGHTROPE SS CANNULATED SYNDESMOSIS","SUP-ITM-10046824","CDM","C1713","HCPCS","0278","RC","","","","both","","","3627.75","2176.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","421.91","3083.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT REPAIR TRACTION FIXATION TIGHTROPE SS CANNULATED SYNDESMOSIS","SUP-ITM-10046824","CDM","C1713","HCPCS","0278","RC","","","","both","","","3627.75","2176.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2064.19","56.9","","812.12","238.65","1587.46","163","421.91","3083.59","percent of total billed charges",""
"KIT REPAIR TRACTION FIXATION TIGHTROPE SS CANNULATED SYNDESMOSIS","SUP-ITM-10046824","CDM","C1713","HCPCS","0278","RC","","","","both","","","3627.75","2176.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","421.91","11.63","","112.68","112.68","146.99","38","421.91","3083.59","percent of total billed charges",""
"KIT REPAIR TRACTION FIXATION TIGHTROPE SS CANNULATED SYNDESMOSIS","SUP-ITM-10046824","CDM","C1713","HCPCS","0278","RC","","","","both","","","3627.75","2176.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2807.88","77.4","","303.98","303.98","5854.79","1 through 10","421.91","3083.59","percent of total billed charges",""
"KIT REPAIR TRACTION FIXATION TIGHTROPE SS CANNULATED SYNDESMOSIS","SUP-ITM-10046824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3627.75","2176.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","421.91","11.63","","112.68","112.68","146.99","38","421.91","2807.88","percent of total billed charges",""
"KIT REPAIR TRACTION FIXATION TIGHTROPE SS CANNULATED SYNDESMOSIS","SUP-ITM-10046824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3627.75","2176.65","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2277.50","62.78","","780.86","208.94","10480.28","15","421.91","2807.88","percent of total billed charges",""
"KIT REPAIR TRACTION FIXATION TIGHTROPE SS CANNULATED SYNDESMOSIS","SUP-ITM-10046824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3627.75","2176.65","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1586.05","43.72","","179.76","179.76","179.76","1 through 10","421.91","2807.88","percent of total billed charges",""
"KIT REPAIR TRACTION FIXATION TIGHTROPE SS CANNULATED SYNDESMOSIS","SUP-ITM-10046824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3627.75","2176.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2638.10","72.72","","2355.45","298.99","3965.19","155","421.91","2807.88","percent of total billed charges",""
"KIT REPAIR TRACTION FIXATION TIGHTROPE SS CANNULATED SYNDESMOSIS","SUP-ITM-10046824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3627.75","2176.65","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2638.10","72.72","","3643.09","3643.09","3643.09","1 through 10","421.91","2807.88","percent of total billed charges",""
"KIT REPAIR TRACTION FIXATION TIGHTROPE SS CANNULATED SYNDESMOSIS","SUP-ITM-10046824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3627.75","2176.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1930.69","53.22","","554.28","554.28","554.28","16","421.91","2807.88","percent of total billed charges",""
"KIT REPAIR TRACTION FIXATION TIGHTROPE SS CANNULATED SYNDESMOSIS","SUP-ITM-10046824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3627.75","2176.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2281.85","62.9","","619.64","173.09","2370.64","150","421.91","2807.88","percent of total billed charges",""
"KIT REPAIR TRACTION FIXATION TIGHTROPE SS CANNULATED SYNDESMOSIS","SUP-ITM-10046824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3627.75","2176.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2807.88","77.4","","303.98","303.98","5854.79","1 through 10","421.91","2807.88","percent of total billed charges",""
"KIT REVISION 16MM FLEXIGRAFT BONE DOWEL","SUP-ITM-10287932","CDM","C1889","HCPCS","0278","RC","","","","both","","","4977.94","2986.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","578.93","4231.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT REVISION 16MM FLEXIGRAFT BONE DOWEL","SUP-ITM-10287932","CDM","C1889","HCPCS","0278","RC","","","","both","","","4977.94","2986.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","578.93","4231.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT REVISION 16MM FLEXIGRAFT BONE DOWEL","SUP-ITM-10287932","CDM","C1889","HCPCS","0278","RC","","","","both","","","4977.94","2986.76","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2832.45","56.9","","0.63","0.63","0.63","1 through 10","578.93","4231.25","percent of total billed charges",""
"KIT REVISION 16MM FLEXIGRAFT BONE DOWEL","SUP-ITM-10287932","CDM","C1889","HCPCS","0278","RC","","","","both","","","4977.94","2986.76","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","717.82","14.42","","317.14","317.14","317.14","1 through 10","578.93","4231.25","percent of total billed charges",""
"KIT REVISION 16MM FLEXIGRAFT BONE DOWEL","SUP-ITM-10287932","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4977.94","2986.76","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","717.82","14.42","","317.14","317.14","317.14","1 through 10","578.93","3852.93","percent of total billed charges",""
"KIT REVISION 16MM FLEXIGRAFT BONE DOWEL","SUP-ITM-10287932","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4977.94","2986.76","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3125.15","62.78","","1125.09","1125.09","1125.09","1 through 10","578.93","3852.93","percent of total billed charges",""
"KIT REVISION 16MM FLEXIGRAFT BONE DOWEL","SUP-ITM-10287932","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4977.94","2986.76","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3619.96","72.72","","4732.50","1617.43","14180.40","1 through 10","578.93","3852.93","percent of total billed charges",""
"KIT REVISION 16MM FLEXIGRAFT BONE DOWEL","SUP-ITM-10287932","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4977.94","2986.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3131.12","62.9","","3896.20","3341.38","3896.20","1 through 10","578.93","3852.93","percent of total billed charges",""
"KIT SCP COMPLETE KNEE WITH ACCUPORT END DELIVERY CANNULA","SUP-ITM-10188571","CDM","C1776","HCPCS","0278","RC","","","","both","","","14855.48","8913.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1727.69","12627.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT SCP COMPLETE KNEE WITH ACCUPORT END DELIVERY CANNULA","SUP-ITM-10188571","CDM","C1776","HCPCS","0278","RC","","","","both","","","14855.48","8913.29","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","8452.77","56.9","","2911.53","1863.86","5209.05","65","1727.69","12627.16","percent of total billed charges",""
"KIT SCP COMPLETE KNEE WITH ACCUPORT END DELIVERY CANNULA","SUP-ITM-10188571","CDM","C1776","HCPCS","0278","RC","","","","both","","","14855.48","8913.29","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1727.69","11.63","","400.94","400.94","400.94","1 through 10","1727.69","12627.16","percent of total billed charges",""
"KIT SCP COMPLETE KNEE WITH ACCUPORT END DELIVERY CANNULA","SUP-ITM-10188571","CDM","C1776","HCPCS","0278","RC","","","","both","","","14855.48","8913.29","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","11498.14","77.4","","5214.50","5214.50","16415.28","1 through 10","1727.69","12627.16","percent of total billed charges",""
"KIT SCP COMPLETE KNEE WITH ACCUPORT END DELIVERY CANNULA","SUP-ITM-10188571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14855.48","8913.29","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1727.69","11.63","","400.94","400.94","400.94","1 through 10","1727.69","11498.14","percent of total billed charges",""
"KIT SCP COMPLETE KNEE WITH ACCUPORT END DELIVERY CANNULA","SUP-ITM-10188571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14855.48","8913.29","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","6494.82","43.72","","1543.33","1543.33","1671.61","1 through 10","1727.69","11498.14","percent of total billed charges",""
"KIT SCP COMPLETE KNEE WITH ACCUPORT END DELIVERY CANNULA","SUP-ITM-10188571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14855.48","8913.29","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10802.91","72.72","","3700.21","2382.07","6427.18","53","1727.69","11498.14","percent of total billed charges",""
"KIT SCP COMPLETE KNEE WITH ACCUPORT END DELIVERY CANNULA","SUP-ITM-10188571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14855.48","8913.29","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","10802.91","72.72","","12685.80","12685.80","12685.80","1 through 10","1727.69","11498.14","percent of total billed charges",""
"KIT SCP COMPLETE KNEE WITH ACCUPORT END DELIVERY CANNULA","SUP-ITM-10188571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14855.48","8913.29","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","9344.10","62.9","","3408.87","2784.05","9859.40","46","1727.69","11498.14","percent of total billed charges",""
"KIT SCP COMPLETE KNEE WITH ACCUPORT END DELIVERY CANNULA","SUP-ITM-10188571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14855.48","8913.29","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","11498.14","77.4","","5214.50","5214.50","16415.28","1 through 10","1727.69","11498.14","percent of total billed charges",""
"KIT SCREW 4.5X34MM BONE COMPRESSION EQUINOXE SS LOCKING CAP REVERSE SHOULDER","SUP-ITM-10192424","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.16","315.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","61.08","446.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT SCREW 4.5X34MM BONE COMPRESSION EQUINOXE SS LOCKING CAP REVERSE SHOULDER","SUP-ITM-10192424","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.16","315.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","61.08","446.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT SCREW 4.5X34MM BONE COMPRESSION EQUINOXE SS LOCKING CAP REVERSE SHOULDER","SUP-ITM-10192424","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.16","315.10","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","298.82","56.9","","812.12","238.65","1587.46","163","61.08","446.39","percent of total billed charges",""
"KIT SCREW 4.5X34MM BONE COMPRESSION EQUINOXE SS LOCKING CAP REVERSE SHOULDER","SUP-ITM-10192424","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.16","315.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","61.08","11.63","","112.68","112.68","146.99","38","61.08","446.39","percent of total billed charges",""
"KIT SCREW 4.5X34MM BONE COMPRESSION EQUINOXE SS LOCKING CAP REVERSE SHOULDER","SUP-ITM-10192424","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.16","315.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","406.47","77.4","","303.98","303.98","5854.79","1 through 10","61.08","446.39","percent of total billed charges",""
"KIT SCREW 4.5X34MM BONE COMPRESSION EQUINOXE SS LOCKING CAP REVERSE SHOULDER","SUP-ITM-10192424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","61.08","11.63","","112.68","112.68","146.99","38","61.08","406.47","percent of total billed charges",""
"KIT SCREW 4.5X34MM BONE COMPRESSION EQUINOXE SS LOCKING CAP REVERSE SHOULDER","SUP-ITM-10192424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","329.70","62.78","","780.86","208.94","10480.28","15","61.08","406.47","percent of total billed charges",""
"KIT SCREW 4.5X34MM BONE COMPRESSION EQUINOXE SS LOCKING CAP REVERSE SHOULDER","SUP-ITM-10192424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","229.60","43.72","","179.76","179.76","179.76","1 through 10","61.08","406.47","percent of total billed charges",""
"KIT SCREW 4.5X34MM BONE COMPRESSION EQUINOXE SS LOCKING CAP REVERSE SHOULDER","SUP-ITM-10192424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","381.90","72.72","","2355.45","298.99","3965.19","155","61.08","406.47","percent of total billed charges",""
"KIT SCREW 4.5X34MM BONE COMPRESSION EQUINOXE SS LOCKING CAP REVERSE SHOULDER","SUP-ITM-10192424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","381.90","72.72","","3643.09","3643.09","3643.09","1 through 10","61.08","406.47","percent of total billed charges",""
"KIT SCREW 4.5X34MM BONE COMPRESSION EQUINOXE SS LOCKING CAP REVERSE SHOULDER","SUP-ITM-10192424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","279.49","53.22","","554.28","554.28","554.28","16","61.08","406.47","percent of total billed charges",""
"KIT SCREW 4.5X34MM BONE COMPRESSION EQUINOXE SS LOCKING CAP REVERSE SHOULDER","SUP-ITM-10192424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","330.33","62.9","","619.64","173.09","2370.64","150","61.08","406.47","percent of total billed charges",""
"KIT SCREW 4.5X34MM BONE COMPRESSION EQUINOXE SS LOCKING CAP REVERSE SHOULDER","SUP-ITM-10192424","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","406.47","77.4","","303.98","303.98","5854.79","1 through 10","61.08","406.47","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.00","829.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","160.73","1174.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.00","829.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","160.73","1174.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.00","829.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","786.36","56.9","","812.12","238.65","1587.46","163","160.73","1174.7","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.00","829.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","160.73","11.63","","112.68","112.68","146.99","38","160.73","1174.7","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.00","829.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1069.67","77.4","","303.98","303.98","5854.79","1 through 10","160.73","1174.7","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.00","829.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","160.73","11.63","","112.68","112.68","146.99","38","160.73","1069.67","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.00","829.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","867.62","62.78","","780.86","208.94","10480.28","15","160.73","1069.67","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.00","829.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","604.21","43.72","","179.76","179.76","179.76","1 through 10","160.73","1069.67","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.00","829.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1004.99","72.72","","2355.45","298.99","3965.19","155","160.73","1069.67","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.00","829.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1004.99","72.72","","3643.09","3643.09","3643.09","1 through 10","160.73","1069.67","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.00","829.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","735.50","53.22","","554.28","554.28","554.28","16","160.73","1069.67","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.00","829.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","869.28","62.9","","619.64","173.09","2370.64","150","160.73","1069.67","percent of total billed charges",""
"KIT SCREW SHOULDER EQUINOX SQUARE TORQUE DEFINE DRIVE","SUP-ITM-10195021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.00","829.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1069.67","77.4","","303.98","303.98","5854.79","1 through 10","160.73","1069.67","percent of total billed charges",""
"KIT SEAL 8FR THORACENTESIS PLEURA SHARPS SAFETY CS/10EA","SUP-ITM-10006103","CDM","C1729","HCPCS","0272","RC","","","","both","","","274.95","164.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","31.98","11.63","","19.51","17.34","54.47","21","31.98","233.71","percent of total billed charges",""
"KIT SEAL 8FR THORACENTESIS PLEURA SHARPS SAFETY CS/10EA","SUP-ITM-10006103","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","274.95","164.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","31.98","11.63","","19.51","17.34","54.47","21","31.98","212.81","percent of total billed charges",""
"KIT SEAL 8FR THORACENTESIS PLEURA SHARPS SAFETY CS/10EA","SUP-ITM-10006103","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","274.95","164.97","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","120.21","43.72","","61.93","61.93","61.93","1 through 10","31.98","212.81","percent of total billed charges",""
"KIT SEAL 8FR THORACENTESIS PLEURA SHARPS SAFETY CS/10EA","SUP-ITM-10006103","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","274.95","164.97","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","199.94","72.72","","330.75","267.63","330.75","1 through 10","31.98","212.81","percent of total billed charges",""
"KIT SEAL 8FR THORACENTESIS PLEURA SHARPS SAFETY CS/10EA","SUP-ITM-10006103","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","274.95","164.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","172.94","62.9","","89.25","87.07","231.86","1 through 10","31.98","212.81","percent of total billed charges",""
"KIT SEAL 8FR THORACENTESIS PLEURA SHARPS SAFETY CS/10EA","SUP-ITM-10006103","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","274.95","164.97","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","199.94","72.72","","267.63","267.63","267.63","1 through 10","31.98","212.81","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","both","","","72.21","43.33","AETNA [1001]","HB WDH AETNA COMMERCIAL","50.40","69.8","","94.15","94.15","427.63","1 through 10","8.4","61.38","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","both","","","72.21","43.33","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","8.4","61.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","both","","","72.21","43.33","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","41.09","56.9","","401.89","65.85","401.89","1 through 10","8.4","61.38","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","both","","","72.21","43.33","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","8.40","11.63","","49.19","10.57","114.40","19","8.4","61.38","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","both","","","72.21","43.33","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","55.89","77.4","","200.75","81.67","643.86","11","8.4","61.38","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","both","","","72.21","43.33","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","8.4","61.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","72.21","43.33","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","8.40","11.63","","49.19","10.57","114.40","19","8.4","55.89","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","72.21","43.33","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","45.33","62.78","","93.27","93.27","93.27","1 through 10","8.4","55.89","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","72.21","43.33","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","31.57","43.72","","363.22","363.22","363.22","1 through 10","8.4","55.89","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","72.21","43.33","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","52.51","72.72","","271.85","111.24","551.69","14","8.4","55.89","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","72.21","43.33","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","45.42","62.9","","706.53","93.60","938.00","53","8.4","55.89","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","72.21","43.33","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","55.89","77.4","","200.75","81.67","643.86","11","8.4","55.89","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","both","","","5698.75","3419.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","662.76","4843.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","both","","","5698.75","3419.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","662.76","4843.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","both","","","5698.75","3419.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3242.59","56.9","","812.12","238.65","1587.46","163","662.76","4843.94","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","both","","","5698.75","3419.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","662.76","11.63","","112.68","112.68","146.99","38","662.76","4843.94","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","both","","","5698.75","3419.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4410.83","77.4","","303.98","303.98","5854.79","1 through 10","662.76","4843.94","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5698.75","3419.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","662.76","11.63","","112.68","112.68","146.99","38","662.76","4410.83","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5698.75","3419.25","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3577.68","62.78","","780.86","208.94","10480.28","15","662.76","4410.83","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5698.75","3419.25","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2491.49","43.72","","179.76","179.76","179.76","1 through 10","662.76","4410.83","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5698.75","3419.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4144.13","72.72","","2355.45","298.99","3965.19","155","662.76","4410.83","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5698.75","3419.25","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4144.13","72.72","","3643.09","3643.09","3643.09","1 through 10","662.76","4410.83","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5698.75","3419.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3032.87","53.22","","554.28","554.28","554.28","16","662.76","4410.83","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5698.75","3419.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3584.51","62.9","","619.64","173.09","2370.64","150","662.76","4410.83","percent of total billed charges",""
"KIT SET TRACTION FIXATION TIGHTROPE SYNDESMOSIS REPAIR TITANIUM","SUP-ITM-10100469","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5698.75","3419.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4410.83","77.4","","303.98","303.98","5854.79","1 through 10","662.76","4410.83","percent of total billed charges",""
"KIT SNARE AMPLATZ GOOSENECK 6FR 102CM 15MM 120CM VASCULAR 90DEGREE COAXIAL LOOP","SUP-ITM-10000132","CDM","C1773","HCPCS","0272","RC","","","","both","","","1540.93","924.56","AETNA [1001]","HB WDH AETNA COMMERCIAL","1075.57","69.8","","421.75","101.11","421.75","1 through 10","179.21","1309.79","percent of total billed charges",""
"KIT SNARE AMPLATZ GOOSENECK 6FR 102CM 15MM 120CM VASCULAR 90DEGREE COAXIAL LOOP","SUP-ITM-10000132","CDM","C1773","HCPCS","0272","RC","","","","both","","","1540.93","924.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1032.01","1032.01","1032.01","1 through 10","179.21","1309.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT SNARE AMPLATZ GOOSENECK 6FR 102CM 15MM 120CM VASCULAR 90DEGREE COAXIAL LOOP","SUP-ITM-10000132","CDM","C1773","HCPCS","0272","RC","","","","both","","","1540.93","924.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1192.68","77.4","","468.85","468.85","468.85","1 through 10","179.21","1309.79","percent of total billed charges",""
"KIT SNARE AMPLATZ GOOSENECK 6FR 102CM 15MM 120CM VASCULAR 90DEGREE COAXIAL LOOP","SUP-ITM-10000132","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","1540.93","924.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","969.24","62.9","","381.13","381.13","381.13","1 through 10","179.21","1192.68","percent of total billed charges",""
"KIT SNARE AMPLATZ GOOSENECK 6FR 102CM 15MM 120CM VASCULAR 90DEGREE COAXIAL LOOP","SUP-ITM-10000132","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","1540.93","924.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1192.68","77.4","","468.85","468.85","468.85","1 through 10","179.21","1192.68","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","both","","","1173.04","703.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","764.25","764.25","764.25","1 through 10","136.42","997.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","both","","","1173.04","703.82","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","667.46","56.9","","434.86","434.86","472.36","15","136.42","997.08","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","both","","","1173.04","703.82","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","667.46","56.9","","434.86","434.86","434.86","1 through 10","136.42","997.08","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","both","","","1173.04","703.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","136.42","11.63","","105.24","93.54","105.24","1 through 10","136.42","997.08","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","both","","","1173.04","703.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","907.93","77.4","","592.29","592.29","592.29","1 through 10","136.42","997.08","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1173.04","703.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","136.42","11.63","","105.24","93.54","105.24","1 through 10","136.42","907.93","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1173.04","703.82","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","512.85","43.72","","334.13","334.13","334.13","1 through 10","136.42","907.93","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1173.04","703.82","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","853.03","72.72","","555.76","555.76","555.76","1 through 10","136.42","907.93","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1173.04","703.82","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","853.03","72.72","","555.76","555.76","555.76","1 through 10","136.42","907.93","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1173.04","703.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","624.29","53.22","","859.65","859.65","859.65","1 through 10","136.42","907.93","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1173.04","703.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","737.84","62.9","","481.48","481.48","481.48","1 through 10","136.42","907.93","percent of total billed charges",""
"KIT STENT 22 30CM 4.8FR UROLGCL DBL PIGTL THRED GUIDWR HYDRPL COTD PERCUFLEX POSTNR RADIOPQ Y CONTUR","SUP-ITM-10042586","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1173.04","703.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","907.93","77.4","","592.29","592.29","592.29","1 through 10","136.42","907.93","percent of total billed charges",""
"KIT STENT 6.0FR 26CM URETERAL RESONANCE METALLIC SHEATH CATHETER COIL DESIGN PIGTAIL RADIOPAQUE TIP","SUP-ITM-10025365","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","5544.04","3326.42","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4031.63","72.72","","324.46","324.46","324.46","1 through 10","644.77","4291.09","percent of total billed charges",""
"KIT SUBSTANCE 4.75MM ARCHILLES BIOCOMPOSITE SPEEDBRIDGE MID","SUP-ITM-10154170","CDM","C1776","HCPCS","0278","RC","","","","both","","","6737.25","4042.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","783.54","5726.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT SUBSTANCE 4.75MM ARCHILLES BIOCOMPOSITE SPEEDBRIDGE MID","SUP-ITM-10154170","CDM","C1776","HCPCS","0278","RC","","","","both","","","6737.25","4042.35","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3833.50","56.9","","2911.53","1863.86","5209.05","65","783.54","5726.66","percent of total billed charges",""
"KIT SUBSTANCE 4.75MM ARCHILLES BIOCOMPOSITE SPEEDBRIDGE MID","SUP-ITM-10154170","CDM","C1776","HCPCS","0278","RC","","","","both","","","6737.25","4042.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","783.54","11.63","","400.94","400.94","400.94","1 through 10","783.54","5726.66","percent of total billed charges",""
"KIT SUBSTANCE 4.75MM ARCHILLES BIOCOMPOSITE SPEEDBRIDGE MID","SUP-ITM-10154170","CDM","C1776","HCPCS","0278","RC","","","","both","","","6737.25","4042.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5214.63","77.4","","5214.50","5214.50","16415.28","1 through 10","783.54","5726.66","percent of total billed charges",""
"KIT SUBSTANCE 4.75MM ARCHILLES BIOCOMPOSITE SPEEDBRIDGE MID","SUP-ITM-10154170","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6737.25","4042.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","783.54","11.63","","400.94","400.94","400.94","1 through 10","783.54","5214.63","percent of total billed charges",""
"KIT SUBSTANCE 4.75MM ARCHILLES BIOCOMPOSITE SPEEDBRIDGE MID","SUP-ITM-10154170","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6737.25","4042.35","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2945.53","43.72","","1543.33","1543.33","1671.61","1 through 10","783.54","5214.63","percent of total billed charges",""
"KIT SUBSTANCE 4.75MM ARCHILLES BIOCOMPOSITE SPEEDBRIDGE MID","SUP-ITM-10154170","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6737.25","4042.35","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4899.33","72.72","","3700.21","2382.07","6427.18","53","783.54","5214.63","percent of total billed charges",""
"KIT SUBSTANCE 4.75MM ARCHILLES BIOCOMPOSITE SPEEDBRIDGE MID","SUP-ITM-10154170","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6737.25","4042.35","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4899.33","72.72","","12685.80","12685.80","12685.80","1 through 10","783.54","5214.63","percent of total billed charges",""
"KIT SUBSTANCE 4.75MM ARCHILLES BIOCOMPOSITE SPEEDBRIDGE MID","SUP-ITM-10154170","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6737.25","4042.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4237.73","62.9","","3408.87","2784.05","9859.40","46","783.54","5214.63","percent of total billed charges",""
"KIT SUBSTANCE 4.75MM ARCHILLES BIOCOMPOSITE SPEEDBRIDGE MID","SUP-ITM-10154170","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6737.25","4042.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5214.63","77.4","","5214.50","5214.50","16415.28","1 through 10","783.54","5214.63","percent of total billed charges",""
"KIT SYRINGE MULTI-USE BX/10EA","SUP-ITM-10018395","CDM","L8699","HCPCS","0278","RC","","","","both","","","247.38","148.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","292.76","292.76","292.76","1 through 10","28.77","210.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT TAMP 10X3MM BONE KYPHOPAK EXPANDER II 10/3 ADDITIONAL FRACTURE","SUP-ITM-10092371","CDM","C1889","HCPCS","0272","RC","","","","both","","","11091.95","6655.17","AETNA [1001]","HB WDH AETNA COMMERCIAL","7742.18","69.8","","1552.48","1552.48","1552.48","1 through 10","1289.99","9428.16","percent of total billed charges",""
"KIT TAMP 10X3MM BONE KYPHOPAK EXPANDER II 10/3 ADDITIONAL FRACTURE","SUP-ITM-10092371","CDM","C1889","HCPCS","0272","RC","","","","both","","","11091.95","6655.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","1289.99","9428.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT TAMP 10X3MM BONE KYPHOPAK EXPANDER II 10/3 ADDITIONAL FRACTURE","SUP-ITM-10092371","CDM","C1889","HCPCS","0272","RC","","","","both","","","11091.95","6655.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","1289.99","9428.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT TAMP 10X3MM BONE KYPHOPAK EXPANDER II 10/3 ADDITIONAL FRACTURE","SUP-ITM-10092371","CDM","C1889","HCPCS","0272","RC","","","","both","","","11091.95","6655.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6311.32","56.9","","0.63","0.63","0.63","1 through 10","1289.99","9428.16","percent of total billed charges",""
"KIT TAMP 10X3MM BONE KYPHOPAK EXPANDER II 10/3 ADDITIONAL FRACTURE","SUP-ITM-10092371","CDM","C1889","HCPCS","0272","RC","","","","both","","","11091.95","6655.17","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1599.46","14.42","","317.14","317.14","317.14","1 through 10","1289.99","9428.16","percent of total billed charges",""
"KIT TAMP 10X3MM BONE KYPHOPAK EXPANDER II 10/3 ADDITIONAL FRACTURE","SUP-ITM-10092371","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","11091.95","6655.17","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1599.46","14.42","","317.14","317.14","317.14","1 through 10","1289.99","8585.17","percent of total billed charges",""
"KIT TAMP 10X3MM BONE KYPHOPAK EXPANDER II 10/3 ADDITIONAL FRACTURE","SUP-ITM-10092371","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","11091.95","6655.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6963.53","62.78","","1125.09","1125.09","1125.09","1 through 10","1289.99","8585.17","percent of total billed charges",""
"KIT TAMP 10X3MM BONE KYPHOPAK EXPANDER II 10/3 ADDITIONAL FRACTURE","SUP-ITM-10092371","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","11091.95","6655.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8066.07","72.72","","4732.50","1617.43","14180.40","1 through 10","1289.99","8585.17","percent of total billed charges",""
"KIT TAMP 10X3MM BONE KYPHOPAK EXPANDER II 10/3 ADDITIONAL FRACTURE","SUP-ITM-10092371","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","11091.95","6655.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6976.84","62.9","","3896.20","3341.38","3896.20","1 through 10","1289.99","8585.17","percent of total billed charges",""
"KIT TEMPLATE PATELLA ANTERIOR","SUP-ITM-10285901","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.93","625.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","121.29","886.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT TEMPLATE PATELLA ANTERIOR","SUP-ITM-10285901","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.93","625.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","121.29","886.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT TEMPLATE PATELLA ANTERIOR","SUP-ITM-10285901","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.93","625.76","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","593.43","56.9","","812.12","238.65","1587.46","163","121.29","886.49","percent of total billed charges",""
"KIT TEMPLATE PATELLA ANTERIOR","SUP-ITM-10285901","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.93","625.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","121.29","11.63","","112.68","112.68","146.99","38","121.29","886.49","percent of total billed charges",""
"KIT TEMPLATE PATELLA ANTERIOR","SUP-ITM-10285901","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.93","625.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","807.23","77.4","","303.98","303.98","5854.79","1 through 10","121.29","886.49","percent of total billed charges",""
"KIT TEMPLATE PATELLA ANTERIOR","SUP-ITM-10285901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.93","625.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","121.29","11.63","","112.68","112.68","146.99","38","121.29","807.23","percent of total billed charges",""
"KIT TEMPLATE PATELLA ANTERIOR","SUP-ITM-10285901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.93","625.76","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","654.75","62.78","","780.86","208.94","10480.28","15","121.29","807.23","percent of total billed charges",""
"KIT TEMPLATE PATELLA ANTERIOR","SUP-ITM-10285901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.93","625.76","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","455.97","43.72","","179.76","179.76","179.76","1 through 10","121.29","807.23","percent of total billed charges",""
"KIT TEMPLATE PATELLA ANTERIOR","SUP-ITM-10285901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.93","625.76","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","758.42","72.72","","2355.45","298.99","3965.19","155","121.29","807.23","percent of total billed charges",""
"KIT TEMPLATE PATELLA ANTERIOR","SUP-ITM-10285901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.93","625.76","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","758.42","72.72","","3643.09","3643.09","3643.09","1 through 10","121.29","807.23","percent of total billed charges",""
"KIT TEMPLATE PATELLA ANTERIOR","SUP-ITM-10285901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.93","625.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","555.05","53.22","","554.28","554.28","554.28","16","121.29","807.23","percent of total billed charges",""
"KIT TEMPLATE PATELLA ANTERIOR","SUP-ITM-10285901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.93","625.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","656.00","62.9","","619.64","173.09","2370.64","150","121.29","807.23","percent of total billed charges",""
"KIT TEMPLATE PATELLA ANTERIOR","SUP-ITM-10285901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.93","625.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","807.23","77.4","","303.98","303.98","5854.79","1 through 10","121.29","807.23","percent of total billed charges",""
"KIT TRAY TIBIAL CR ITOTAL","SUP-ITM-10209155","CDM","C1776","HCPCS","0278","RC","","","","both","","","7546.60","4527.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","877.67","6414.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT TRAY TIBIAL CR ITOTAL","SUP-ITM-10209155","CDM","C1776","HCPCS","0278","RC","","","","both","","","7546.60","4527.96","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4294.02","56.9","","2911.53","1863.86","5209.05","65","877.67","6414.61","percent of total billed charges",""
"KIT TRAY TIBIAL CR ITOTAL","SUP-ITM-10209155","CDM","C1776","HCPCS","0278","RC","","","","both","","","7546.60","4527.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","877.67","11.63","","400.94","400.94","400.94","1 through 10","877.67","6414.61","percent of total billed charges",""
"KIT TRAY TIBIAL CR ITOTAL","SUP-ITM-10209155","CDM","C1776","HCPCS","0278","RC","","","","both","","","7546.60","4527.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5841.07","77.4","","5214.50","5214.50","16415.28","1 through 10","877.67","6414.61","percent of total billed charges",""
"KIT TRAY TIBIAL CR ITOTAL","SUP-ITM-10209155","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7546.60","4527.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","877.67","11.63","","400.94","400.94","400.94","1 through 10","877.67","5841.07","percent of total billed charges",""
"KIT TRAY TIBIAL CR ITOTAL","SUP-ITM-10209155","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7546.60","4527.96","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3299.37","43.72","","1543.33","1543.33","1671.61","1 through 10","877.67","5841.07","percent of total billed charges",""
"KIT TRAY TIBIAL CR ITOTAL","SUP-ITM-10209155","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7546.60","4527.96","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5487.89","72.72","","3700.21","2382.07","6427.18","53","877.67","5841.07","percent of total billed charges",""
"KIT TRAY TIBIAL CR ITOTAL","SUP-ITM-10209155","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7546.60","4527.96","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5487.89","72.72","","12685.80","12685.80","12685.80","1 through 10","877.67","5841.07","percent of total billed charges",""
"KIT TRAY TIBIAL CR ITOTAL","SUP-ITM-10209155","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7546.60","4527.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4746.81","62.9","","3408.87","2784.05","9859.40","46","877.67","5841.07","percent of total billed charges",""
"KIT TRAY TIBIAL CR ITOTAL","SUP-ITM-10209155","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7546.60","4527.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5841.07","77.4","","5214.50","5214.50","16415.28","1 through 10","877.67","5841.07","percent of total billed charges",""
"KIT TRIAL 50CM AXIUM LEAD SLIMTIP PERI OP IMPLANT DEVICES NEUROMODULATION","SUP-ITM-10174962","CDM","C1778","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","14342.00","14342.00","14342.00","1 through 10","1128.11","8245","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KIT TRIAL 50CM AXIUM LEAD SLIMTIP PERI OP IMPLANT DEVICES NEUROMODULATION","SUP-ITM-10174962","CDM","C1778","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1128.11","11.63","","2253.51","2253.51","2253.51","1 through 10","1128.11","8245","percent of total billed charges",""
"KIT TRIAL 50CM AXIUM LEAD SLIMTIP PERI OP IMPLANT DEVICES NEUROMODULATION","SUP-ITM-10174962","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1128.11","11.63","","2253.51","2253.51","2253.51","1 through 10","1128.11","7507.8","percent of total billed charges",""
"KIT TRIAL 50CM AXIUM LEAD SLIMTIP PERI OP IMPLANT DEVICES NEUROMODULATION","SUP-ITM-10174962","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6101.30","62.9","","21082.95","11598.93","21082.95","1 through 10","1128.11","7507.8","percent of total billed charges",""
"KIT URETHRAL BULKAMID","SUP-ITM-10287459","CDM","L8606","HCPCS","0278","RC","","","","both","","","5092.50","3055.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2897.63","56.9","","2897.63","2897.63","2897.63","1 through 10","734.34","4328.63","percent of total billed charges",""
"KNEE BASE SZ 4 TIBIAL ROTATING PLATFORM","SUP-ITM-10235715","CDM","C1776","HCPCS","0278","RC","","","","both","","","6426.30","3855.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","747.38","5462.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE BASE SZ 4 TIBIAL ROTATING PLATFORM","SUP-ITM-10235715","CDM","C1776","HCPCS","0278","RC","","","","both","","","6426.30","3855.78","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3656.56","56.9","","2911.53","1863.86","5209.05","65","747.38","5462.36","percent of total billed charges",""
"KNEE BASE SZ 4 TIBIAL ROTATING PLATFORM","SUP-ITM-10235715","CDM","C1776","HCPCS","0278","RC","","","","both","","","6426.30","3855.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","747.38","11.63","","400.94","400.94","400.94","1 through 10","747.38","5462.36","percent of total billed charges",""
"KNEE BASE SZ 4 TIBIAL ROTATING PLATFORM","SUP-ITM-10235715","CDM","C1776","HCPCS","0278","RC","","","","both","","","6426.30","3855.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4973.96","77.4","","5214.50","5214.50","16415.28","1 through 10","747.38","5462.36","percent of total billed charges",""
"KNEE BASE SZ 4 TIBIAL ROTATING PLATFORM","SUP-ITM-10235715","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6426.30","3855.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","747.38","11.63","","400.94","400.94","400.94","1 through 10","747.38","4973.96","percent of total billed charges",""
"KNEE BASE SZ 4 TIBIAL ROTATING PLATFORM","SUP-ITM-10235715","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6426.30","3855.78","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2809.58","43.72","","1543.33","1543.33","1671.61","1 through 10","747.38","4973.96","percent of total billed charges",""
"KNEE BASE SZ 4 TIBIAL ROTATING PLATFORM","SUP-ITM-10235715","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6426.30","3855.78","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4673.21","72.72","","3700.21","2382.07","6427.18","53","747.38","4973.96","percent of total billed charges",""
"KNEE BASE SZ 4 TIBIAL ROTATING PLATFORM","SUP-ITM-10235715","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6426.30","3855.78","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4673.21","72.72","","12685.80","12685.80","12685.80","1 through 10","747.38","4973.96","percent of total billed charges",""
"KNEE BASE SZ 4 TIBIAL ROTATING PLATFORM","SUP-ITM-10235715","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6426.30","3855.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4042.14","62.9","","3408.87","2784.05","9859.40","46","747.38","4973.96","percent of total billed charges",""
"KNEE BASE SZ 4 TIBIAL ROTATING PLATFORM","SUP-ITM-10235715","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6426.30","3855.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4973.96","77.4","","5214.50","5214.50","16415.28","1 through 10","747.38","4973.96","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","789.68","5771.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3863.51","56.9","","2911.53","1863.86","5209.05","65","789.68","5771.5","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","789.68","11.63","","400.94","400.94","400.94","1 through 10","789.68","5771.5","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5255.46","77.4","","5214.50","5214.50","16415.28","1 through 10","789.68","5771.5","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","789.68","11.63","","400.94","400.94","400.94","1 through 10","789.68","5255.46","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2968.59","43.72","","1543.33","1543.33","1671.61","1 through 10","789.68","5255.46","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4937.69","72.72","","3700.21","2382.07","6427.18","53","789.68","5255.46","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4937.69","72.72","","12685.80","12685.80","12685.80","1 through 10","789.68","5255.46","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4270.91","62.9","","3408.87","2784.05","9859.40","46","789.68","5255.46","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5255.46","77.4","","5214.50","5214.50","16415.28","1 through 10","789.68","5255.46","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","564.06","4122.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","564.06","4122.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2759.65","56.9","","812.12","238.65","1587.46","163","564.06","4122.5","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.06","11.63","","112.68","112.68","146.99","38","564.06","4122.5","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3753.90","77.4","","303.98","303.98","5854.79","1 through 10","564.06","4122.5","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.06","11.63","","112.68","112.68","146.99","38","564.06","3753.9","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3044.83","62.78","","780.86","208.94","10480.28","15","564.06","3753.9","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2120.42","43.72","","179.76","179.76","179.76","1 through 10","564.06","3753.9","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3526.92","72.72","","2355.45","298.99","3965.19","155","564.06","3753.9","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3526.92","72.72","","3643.09","3643.09","3643.09","1 through 10","564.06","3753.9","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2581.17","53.22","","554.28","554.28","554.28","16","564.06","3753.9","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3050.65","62.9","","619.64","173.09","2370.64","150","564.06","3753.9","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3753.90","77.4","","303.98","303.98","5854.79","1 through 10","564.06","3753.9","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","4353.30","2611.98","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","506.29","3700.31","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","4353.30","2611.98","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2477.03","56.9","","2911.53","1863.86","5209.05","65","506.29","3700.31","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","4353.30","2611.98","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","506.29","11.63","","400.94","400.94","400.94","1 through 10","506.29","3700.31","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","4353.30","2611.98","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3369.45","77.4","","5214.50","5214.50","16415.28","1 through 10","506.29","3700.31","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4353.30","2611.98","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","506.29","11.63","","400.94","400.94","400.94","1 through 10","506.29","3369.45","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4353.30","2611.98","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1903.26","43.72","","1543.33","1543.33","1671.61","1 through 10","506.29","3369.45","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4353.30","2611.98","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3165.72","72.72","","3700.21","2382.07","6427.18","53","506.29","3369.45","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4353.30","2611.98","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3165.72","72.72","","12685.80","12685.80","12685.80","1 through 10","506.29","3369.45","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4353.30","2611.98","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2738.23","62.9","","3408.87","2784.05","9859.40","46","506.29","3369.45","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4353.30","2611.98","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3369.45","77.4","","5214.50","5214.50","16415.28","1 through 10","506.29","3369.45","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","both","","","5393.20","3235.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","627.23","4584.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","both","","","5393.20","3235.92","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3068.73","56.9","","2911.53","1863.86","5209.05","65","627.23","4584.22","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","both","","","5393.20","3235.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","627.23","11.63","","400.94","400.94","400.94","1 through 10","627.23","4584.22","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","both","","","5393.20","3235.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4174.34","77.4","","5214.50","5214.50","16415.28","1 through 10","627.23","4584.22","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5393.20","3235.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","627.23","11.63","","400.94","400.94","400.94","1 through 10","627.23","4174.34","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5393.20","3235.92","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2357.91","43.72","","1543.33","1543.33","1671.61","1 through 10","627.23","4174.34","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5393.20","3235.92","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3921.94","72.72","","3700.21","2382.07","6427.18","53","627.23","4174.34","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5393.20","3235.92","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3921.94","72.72","","12685.80","12685.80","12685.80","1 through 10","627.23","4174.34","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5393.20","3235.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3392.32","62.9","","3408.87","2784.05","9859.40","46","627.23","4174.34","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5393.20","3235.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4174.34","77.4","","5214.50","5214.50","16415.28","1 through 10","627.23","4174.34","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","5393.20","3235.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","627.23","4584.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","5393.20","3235.92","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3068.73","56.9","","2911.53","1863.86","5209.05","65","627.23","4584.22","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","5393.20","3235.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","627.23","11.63","","400.94","400.94","400.94","1 through 10","627.23","4584.22","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","5393.20","3235.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4174.34","77.4","","5214.50","5214.50","16415.28","1 through 10","627.23","4584.22","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5393.20","3235.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","627.23","11.63","","400.94","400.94","400.94","1 through 10","627.23","4174.34","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5393.20","3235.92","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2357.91","43.72","","1543.33","1543.33","1671.61","1 through 10","627.23","4174.34","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5393.20","3235.92","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3921.94","72.72","","3700.21","2382.07","6427.18","53","627.23","4174.34","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5393.20","3235.92","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3921.94","72.72","","12685.80","12685.80","12685.80","1 through 10","627.23","4174.34","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5393.20","3235.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3392.32","62.9","","3408.87","2784.05","9859.40","46","627.23","4174.34","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5393.20","3235.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4174.34","77.4","","5214.50","5214.50","16415.28","1 through 10","627.23","4174.34","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","both","","","5393.20","3235.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","627.23","4584.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","both","","","5393.20","3235.92","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3068.73","56.9","","2911.53","1863.86","5209.05","65","627.23","4584.22","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","both","","","5393.20","3235.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","627.23","11.63","","400.94","400.94","400.94","1 through 10","627.23","4584.22","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","both","","","5393.20","3235.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4174.34","77.4","","5214.50","5214.50","16415.28","1 through 10","627.23","4584.22","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5393.20","3235.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","627.23","11.63","","400.94","400.94","400.94","1 through 10","627.23","4174.34","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5393.20","3235.92","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2357.91","43.72","","1543.33","1543.33","1671.61","1 through 10","627.23","4174.34","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5393.20","3235.92","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3921.94","72.72","","3700.21","2382.07","6427.18","53","627.23","4174.34","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5393.20","3235.92","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3921.94","72.72","","12685.80","12685.80","12685.80","1 through 10","627.23","4174.34","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5393.20","3235.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3392.32","62.9","","3408.87","2784.05","9859.40","46","627.23","4174.34","percent of total billed charges",""
"KNEE BASEPLATE SZ 6 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10021933","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5393.20","3235.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4174.34","77.4","","5214.50","5214.50","16415.28","1 through 10","627.23","4174.34","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","642.91","4698.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3145.43","56.9","","2911.53","1863.86","5209.05","65","642.91","4698.8","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","642.91","11.63","","400.94","400.94","400.94","1 through 10","642.91","4698.8","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4278.67","77.4","","5214.50","5214.50","16415.28","1 through 10","642.91","4698.8","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","642.91","11.63","","400.94","400.94","400.94","1 through 10","642.91","4278.67","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2416.84","43.72","","1543.33","1543.33","1671.61","1 through 10","642.91","4278.67","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4019.96","72.72","","3700.21","2382.07","6427.18","53","642.91","4278.67","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4019.96","72.72","","12685.80","12685.80","12685.80","1 through 10","642.91","4278.67","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3477.11","62.9","","3408.87","2784.05","9859.40","46","642.91","4278.67","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4278.67","77.4","","5214.50","5214.50","16415.28","1 through 10","642.91","4278.67","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","564.06","4122.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2759.65","56.9","","2911.53","1863.86","5209.05","65","564.06","4122.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.06","11.63","","400.94","400.94","400.94","1 through 10","564.06","4122.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3753.90","77.4","","5214.50","5214.50","16415.28","1 through 10","564.06","4122.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.06","11.63","","400.94","400.94","400.94","1 through 10","564.06","3753.9","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2120.42","43.72","","1543.33","1543.33","1671.61","1 through 10","564.06","3753.9","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3526.92","72.72","","3700.21","2382.07","6427.18","53","564.06","3753.9","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3526.92","72.72","","12685.80","12685.80","12685.80","1 through 10","564.06","3753.9","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3050.65","62.9","","3408.87","2784.05","9859.40","46","564.06","3753.9","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3753.90","77.4","","5214.50","5214.50","16415.28","1 through 10","564.06","3753.9","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","564.06","4122.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2759.65","56.9","","2911.53","1863.86","5209.05","65","564.06","4122.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.06","11.63","","400.94","400.94","400.94","1 through 10","564.06","4122.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3753.90","77.4","","5214.50","5214.50","16415.28","1 through 10","564.06","4122.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.06","11.63","","400.94","400.94","400.94","1 through 10","564.06","3753.9","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2120.42","43.72","","1543.33","1543.33","1671.61","1 through 10","564.06","3753.9","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3526.92","72.72","","3700.21","2382.07","6427.18","53","564.06","3753.9","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3526.92","72.72","","12685.80","12685.80","12685.80","1 through 10","564.06","3753.9","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3050.65","62.9","","3408.87","2784.05","9859.40","46","564.06","3753.9","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3753.90","77.4","","5214.50","5214.50","16415.28","1 through 10","564.06","3753.9","percent of total billed charges",""
"KNEE BEARING 3MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10023133","CDM","C1776","HCPCS","0278","RC","","","","both","","","3453.62","2072.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","401.66","2935.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE BEARING 3MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10023133","CDM","C1776","HCPCS","0278","RC","","","","both","","","3453.62","2072.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1965.11","56.9","","2911.53","1863.86","5209.05","65","401.66","2935.58","percent of total billed charges",""
"KNEE BEARING 3MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10023133","CDM","C1776","HCPCS","0278","RC","","","","both","","","3453.62","2072.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","401.66","11.63","","400.94","400.94","400.94","1 through 10","401.66","2935.58","percent of total billed charges",""
"KNEE BEARING 3MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10023133","CDM","C1776","HCPCS","0278","RC","","","","both","","","3453.62","2072.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2673.10","77.4","","5214.50","5214.50","16415.28","1 through 10","401.66","2935.58","percent of total billed charges",""
"KNEE BEARING 3MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10023133","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3453.62","2072.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","401.66","11.63","","400.94","400.94","400.94","1 through 10","401.66","2673.1","percent of total billed charges",""
"KNEE BEARING 3MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10023133","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3453.62","2072.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1509.92","43.72","","1543.33","1543.33","1671.61","1 through 10","401.66","2673.1","percent of total billed charges",""
"KNEE BEARING 3MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10023133","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3453.62","2072.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2511.47","72.72","","3700.21","2382.07","6427.18","53","401.66","2673.1","percent of total billed charges",""
"KNEE BEARING 3MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10023133","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3453.62","2072.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2511.47","72.72","","12685.80","12685.80","12685.80","1 through 10","401.66","2673.1","percent of total billed charges",""
"KNEE BEARING 3MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10023133","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3453.62","2072.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2172.33","62.9","","3408.87","2784.05","9859.40","46","401.66","2673.1","percent of total billed charges",""
"KNEE BEARING 3MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10023133","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3453.62","2072.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2673.10","77.4","","5214.50","5214.50","16415.28","1 through 10","401.66","2673.1","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LT","SUP-ITM-10020388","CDM","C1776","HCPCS","0278","RC","","","","both","","","3453.62","2072.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","401.66","2935.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LT","SUP-ITM-10020388","CDM","C1776","HCPCS","0278","RC","","","","both","","","3453.62","2072.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1965.11","56.9","","2911.53","1863.86","5209.05","65","401.66","2935.58","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LT","SUP-ITM-10020388","CDM","C1776","HCPCS","0278","RC","","","","both","","","3453.62","2072.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","401.66","11.63","","400.94","400.94","400.94","1 through 10","401.66","2935.58","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LT","SUP-ITM-10020388","CDM","C1776","HCPCS","0278","RC","","","","both","","","3453.62","2072.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2673.10","77.4","","5214.50","5214.50","16415.28","1 through 10","401.66","2935.58","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LT","SUP-ITM-10020388","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3453.62","2072.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","401.66","11.63","","400.94","400.94","400.94","1 through 10","401.66","2673.1","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LT","SUP-ITM-10020388","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3453.62","2072.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1509.92","43.72","","1543.33","1543.33","1671.61","1 through 10","401.66","2673.1","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LT","SUP-ITM-10020388","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3453.62","2072.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2511.47","72.72","","3700.21","2382.07","6427.18","53","401.66","2673.1","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LT","SUP-ITM-10020388","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3453.62","2072.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2511.47","72.72","","12685.80","12685.80","12685.80","1 through 10","401.66","2673.1","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LT","SUP-ITM-10020388","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3453.62","2072.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2172.33","62.9","","3408.87","2784.05","9859.40","46","401.66","2673.1","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LT","SUP-ITM-10020388","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3453.62","2072.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2673.10","77.4","","5214.50","5214.50","16415.28","1 through 10","401.66","2673.1","percent of total billed charges",""
"KNEE BEARING MED SZ 7 OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RIGHT","SUP-ITM-10026847","CDM","C1776","HCPCS","0278","RC","","","","both","","","3453.62","2072.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","401.66","2935.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE BEARING MED SZ 7 OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RIGHT","SUP-ITM-10026847","CDM","C1776","HCPCS","0278","RC","","","","both","","","3453.62","2072.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1965.11","56.9","","2911.53","1863.86","5209.05","65","401.66","2935.58","percent of total billed charges",""
"KNEE BEARING MED SZ 7 OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RIGHT","SUP-ITM-10026847","CDM","C1776","HCPCS","0278","RC","","","","both","","","3453.62","2072.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","401.66","11.63","","400.94","400.94","400.94","1 through 10","401.66","2935.58","percent of total billed charges",""
"KNEE BEARING MED SZ 7 OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RIGHT","SUP-ITM-10026847","CDM","C1776","HCPCS","0278","RC","","","","both","","","3453.62","2072.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2673.10","77.4","","5214.50","5214.50","16415.28","1 through 10","401.66","2935.58","percent of total billed charges",""
"KNEE BEARING MED SZ 7 OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RIGHT","SUP-ITM-10026847","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3453.62","2072.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","401.66","11.63","","400.94","400.94","400.94","1 through 10","401.66","2673.1","percent of total billed charges",""
"KNEE BEARING MED SZ 7 OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RIGHT","SUP-ITM-10026847","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3453.62","2072.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1509.92","43.72","","1543.33","1543.33","1671.61","1 through 10","401.66","2673.1","percent of total billed charges",""
"KNEE BEARING MED SZ 7 OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RIGHT","SUP-ITM-10026847","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3453.62","2072.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2511.47","72.72","","3700.21","2382.07","6427.18","53","401.66","2673.1","percent of total billed charges",""
"KNEE BEARING MED SZ 7 OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RIGHT","SUP-ITM-10026847","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3453.62","2072.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2511.47","72.72","","12685.80","12685.80","12685.80","1 through 10","401.66","2673.1","percent of total billed charges",""
"KNEE BEARING MED SZ 7 OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RIGHT","SUP-ITM-10026847","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3453.62","2072.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2172.33","62.9","","3408.87","2784.05","9859.40","46","401.66","2673.1","percent of total billed charges",""
"KNEE BEARING MED SZ 7 OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RIGHT","SUP-ITM-10026847","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3453.62","2072.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2673.10","77.4","","5214.50","5214.50","16415.28","1 through 10","401.66","2673.1","percent of total billed charges",""
"KNEE COMPONENT 10MM IPOLY XE ITOTAL IDENTITY CR MEDIAL","SUP-ITM-10283924","CDM","C1776","HCPCS","0278","RC","","","","both","","","1796.60","1077.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","208.94","1527.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE COMPONENT 10MM IPOLY XE ITOTAL IDENTITY CR MEDIAL","SUP-ITM-10283924","CDM","C1776","HCPCS","0278","RC","","","","both","","","1796.60","1077.96","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1022.27","56.9","","2911.53","1863.86","5209.05","65","208.94","1527.11","percent of total billed charges",""
"KNEE COMPONENT 10MM IPOLY XE ITOTAL IDENTITY CR MEDIAL","SUP-ITM-10283924","CDM","C1776","HCPCS","0278","RC","","","","both","","","1796.60","1077.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","208.94","11.63","","400.94","400.94","400.94","1 through 10","208.94","1527.11","percent of total billed charges",""
"KNEE COMPONENT 10MM IPOLY XE ITOTAL IDENTITY CR MEDIAL","SUP-ITM-10283924","CDM","C1776","HCPCS","0278","RC","","","","both","","","1796.60","1077.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1390.57","77.4","","5214.50","5214.50","16415.28","1 through 10","208.94","1527.11","percent of total billed charges",""
"KNEE COMPONENT 10MM IPOLY XE ITOTAL IDENTITY CR MEDIAL","SUP-ITM-10283924","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1796.60","1077.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","208.94","11.63","","400.94","400.94","400.94","1 through 10","208.94","1390.57","percent of total billed charges",""
"KNEE COMPONENT 10MM IPOLY XE ITOTAL IDENTITY CR MEDIAL","SUP-ITM-10283924","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1796.60","1077.96","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","785.47","43.72","","1543.33","1543.33","1671.61","1 through 10","208.94","1390.57","percent of total billed charges",""
"KNEE COMPONENT 10MM IPOLY XE ITOTAL IDENTITY CR MEDIAL","SUP-ITM-10283924","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1796.60","1077.96","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1306.49","72.72","","3700.21","2382.07","6427.18","53","208.94","1390.57","percent of total billed charges",""
"KNEE COMPONENT 10MM IPOLY XE ITOTAL IDENTITY CR MEDIAL","SUP-ITM-10283924","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1796.60","1077.96","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1306.49","72.72","","12685.80","12685.80","12685.80","1 through 10","208.94","1390.57","percent of total billed charges",""
"KNEE COMPONENT 10MM IPOLY XE ITOTAL IDENTITY CR MEDIAL","SUP-ITM-10283924","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1796.60","1077.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1130.06","62.9","","3408.87","2784.05","9859.40","46","208.94","1390.57","percent of total billed charges",""
"KNEE COMPONENT 10MM IPOLY XE ITOTAL IDENTITY CR MEDIAL","SUP-ITM-10283924","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1796.60","1077.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1390.57","77.4","","5214.50","5214.50","16415.28","1 through 10","208.94","1390.57","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","1934.80","1160.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","225.02","1644.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","1934.80","1160.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1100.90","56.9","","2911.53","1863.86","5209.05","65","225.02","1644.58","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","1934.80","1160.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","225.02","11.63","","400.94","400.94","400.94","1 through 10","225.02","1644.58","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","1934.80","1160.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1497.54","77.4","","5214.50","5214.50","16415.28","1 through 10","225.02","1644.58","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1934.80","1160.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","225.02","11.63","","400.94","400.94","400.94","1 through 10","225.02","1497.54","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1934.80","1160.88","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","845.89","43.72","","1543.33","1543.33","1671.61","1 through 10","225.02","1497.54","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1934.80","1160.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1406.99","72.72","","3700.21","2382.07","6427.18","53","225.02","1497.54","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1934.80","1160.88","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1406.99","72.72","","12685.80","12685.80","12685.80","1 through 10","225.02","1497.54","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1934.80","1160.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1216.99","62.9","","3408.87","2784.05","9859.40","46","225.02","1497.54","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1934.80","1160.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1497.54","77.4","","5214.50","5214.50","16415.28","1 through 10","225.02","1497.54","percent of total billed charges",""
"KNEE COMPONENT 8MM IPOLY XE ITOTAL IDENTITY CR MEDIAL","SUP-ITM-10283910","CDM","C1776","HCPCS","0278","RC","","","","both","","","1796.60","1077.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","208.94","1527.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE COMPONENT 8MM IPOLY XE ITOTAL IDENTITY CR MEDIAL","SUP-ITM-10283910","CDM","C1776","HCPCS","0278","RC","","","","both","","","1796.60","1077.96","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1022.27","56.9","","2911.53","1863.86","5209.05","65","208.94","1527.11","percent of total billed charges",""
"KNEE COMPONENT 8MM IPOLY XE ITOTAL IDENTITY CR MEDIAL","SUP-ITM-10283910","CDM","C1776","HCPCS","0278","RC","","","","both","","","1796.60","1077.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","208.94","11.63","","400.94","400.94","400.94","1 through 10","208.94","1527.11","percent of total billed charges",""
"KNEE COMPONENT 8MM IPOLY XE ITOTAL IDENTITY CR MEDIAL","SUP-ITM-10283910","CDM","C1776","HCPCS","0278","RC","","","","both","","","1796.60","1077.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1390.57","77.4","","5214.50","5214.50","16415.28","1 through 10","208.94","1527.11","percent of total billed charges",""
"KNEE COMPONENT 8MM IPOLY XE ITOTAL IDENTITY CR MEDIAL","SUP-ITM-10283910","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1796.60","1077.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","208.94","11.63","","400.94","400.94","400.94","1 through 10","208.94","1390.57","percent of total billed charges",""
"KNEE COMPONENT 8MM IPOLY XE ITOTAL IDENTITY CR MEDIAL","SUP-ITM-10283910","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1796.60","1077.96","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","785.47","43.72","","1543.33","1543.33","1671.61","1 through 10","208.94","1390.57","percent of total billed charges",""
"KNEE COMPONENT 8MM IPOLY XE ITOTAL IDENTITY CR MEDIAL","SUP-ITM-10283910","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1796.60","1077.96","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1306.49","72.72","","3700.21","2382.07","6427.18","53","208.94","1390.57","percent of total billed charges",""
"KNEE COMPONENT 8MM IPOLY XE ITOTAL IDENTITY CR MEDIAL","SUP-ITM-10283910","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1796.60","1077.96","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1306.49","72.72","","12685.80","12685.80","12685.80","1 through 10","208.94","1390.57","percent of total billed charges",""
"KNEE COMPONENT 8MM IPOLY XE ITOTAL IDENTITY CR MEDIAL","SUP-ITM-10283910","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1796.60","1077.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1130.06","62.9","","3408.87","2784.05","9859.40","46","208.94","1390.57","percent of total billed charges",""
"KNEE COMPONENT 8MM IPOLY XE ITOTAL IDENTITY CR MEDIAL","SUP-ITM-10283910","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1796.60","1077.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1390.57","77.4","","5214.50","5214.50","16415.28","1 through 10","208.94","1390.57","percent of total billed charges",""
"KNEE COMPONENT IJIGS SURGICAL PLAN","SUP-ITM-10283872","CDM","C1776","HCPCS","0278","RC","","","","both","","","2356.31","1413.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","274.04","2002.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE COMPONENT IJIGS SURGICAL PLAN","SUP-ITM-10283872","CDM","C1776","HCPCS","0278","RC","","","","both","","","2356.31","1413.79","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1340.74","56.9","","2911.53","1863.86","5209.05","65","274.04","2002.86","percent of total billed charges",""
"KNEE COMPONENT IJIGS SURGICAL PLAN","SUP-ITM-10283872","CDM","C1776","HCPCS","0278","RC","","","","both","","","2356.31","1413.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","274.04","11.63","","400.94","400.94","400.94","1 through 10","274.04","2002.86","percent of total billed charges",""
"KNEE COMPONENT IJIGS SURGICAL PLAN","SUP-ITM-10283872","CDM","C1776","HCPCS","0278","RC","","","","both","","","2356.31","1413.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1823.78","77.4","","5214.50","5214.50","16415.28","1 through 10","274.04","2002.86","percent of total billed charges",""
"KNEE COMPONENT IJIGS SURGICAL PLAN","SUP-ITM-10283872","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2356.31","1413.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","274.04","11.63","","400.94","400.94","400.94","1 through 10","274.04","1823.78","percent of total billed charges",""
"KNEE COMPONENT IJIGS SURGICAL PLAN","SUP-ITM-10283872","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2356.31","1413.79","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1030.18","43.72","","1543.33","1543.33","1671.61","1 through 10","274.04","1823.78","percent of total billed charges",""
"KNEE COMPONENT IJIGS SURGICAL PLAN","SUP-ITM-10283872","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2356.31","1413.79","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1713.51","72.72","","3700.21","2382.07","6427.18","53","274.04","1823.78","percent of total billed charges",""
"KNEE COMPONENT IJIGS SURGICAL PLAN","SUP-ITM-10283872","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2356.31","1413.79","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1713.51","72.72","","12685.80","12685.80","12685.80","1 through 10","274.04","1823.78","percent of total billed charges",""
"KNEE COMPONENT IJIGS SURGICAL PLAN","SUP-ITM-10283872","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2356.31","1413.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1482.12","62.9","","3408.87","2784.05","9859.40","46","274.04","1823.78","percent of total billed charges",""
"KNEE COMPONENT IJIGS SURGICAL PLAN","SUP-ITM-10283872","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2356.31","1413.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1823.78","77.4","","5214.50","5214.50","16415.28","1 through 10","274.04","1823.78","percent of total billed charges",""
"KNEE COMPONENT SURGICAL PLAN","SUP-ITM-10283596","CDM","C1776","HCPCS","0278","RC","","","","both","","","2003.90","1202.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","233.05","1703.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE COMPONENT SURGICAL PLAN","SUP-ITM-10283596","CDM","C1776","HCPCS","0278","RC","","","","both","","","2003.90","1202.34","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1140.22","56.9","","2911.53","1863.86","5209.05","65","233.05","1703.32","percent of total billed charges",""
"KNEE COMPONENT SURGICAL PLAN","SUP-ITM-10283596","CDM","C1776","HCPCS","0278","RC","","","","both","","","2003.90","1202.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","233.05","11.63","","400.94","400.94","400.94","1 through 10","233.05","1703.32","percent of total billed charges",""
"KNEE COMPONENT SURGICAL PLAN","SUP-ITM-10283596","CDM","C1776","HCPCS","0278","RC","","","","both","","","2003.90","1202.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1551.02","77.4","","5214.50","5214.50","16415.28","1 through 10","233.05","1703.32","percent of total billed charges",""
"KNEE COMPONENT SURGICAL PLAN","SUP-ITM-10283596","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2003.90","1202.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","233.05","11.63","","400.94","400.94","400.94","1 through 10","233.05","1551.02","percent of total billed charges",""
"KNEE COMPONENT SURGICAL PLAN","SUP-ITM-10283596","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2003.90","1202.34","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","876.11","43.72","","1543.33","1543.33","1671.61","1 through 10","233.05","1551.02","percent of total billed charges",""
"KNEE COMPONENT SURGICAL PLAN","SUP-ITM-10283596","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2003.90","1202.34","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1457.24","72.72","","3700.21","2382.07","6427.18","53","233.05","1551.02","percent of total billed charges",""
"KNEE COMPONENT SURGICAL PLAN","SUP-ITM-10283596","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2003.90","1202.34","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1457.24","72.72","","12685.80","12685.80","12685.80","1 through 10","233.05","1551.02","percent of total billed charges",""
"KNEE COMPONENT SURGICAL PLAN","SUP-ITM-10283596","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2003.90","1202.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1260.45","62.9","","3408.87","2784.05","9859.40","46","233.05","1551.02","percent of total billed charges",""
"KNEE COMPONENT SURGICAL PLAN","SUP-ITM-10283596","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2003.90","1202.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1551.02","77.4","","5214.50","5214.50","16415.28","1 through 10","233.05","1551.02","percent of total billed charges",""
"KNEE CONE 22MM TIBIAL SHORT LEGION","SUP-ITM-10198689","CDM","C1776","HCPCS","0278","RC","","","","both","","","8841.55","5304.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1028.27","7515.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE CONE 22MM TIBIAL SHORT LEGION","SUP-ITM-10198689","CDM","C1776","HCPCS","0278","RC","","","","both","","","8841.55","5304.93","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5030.84","56.9","","2911.53","1863.86","5209.05","65","1028.27","7515.32","percent of total billed charges",""
"KNEE CONE 22MM TIBIAL SHORT LEGION","SUP-ITM-10198689","CDM","C1776","HCPCS","0278","RC","","","","both","","","8841.55","5304.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1028.27","11.63","","400.94","400.94","400.94","1 through 10","1028.27","7515.32","percent of total billed charges",""
"KNEE CONE 22MM TIBIAL SHORT LEGION","SUP-ITM-10198689","CDM","C1776","HCPCS","0278","RC","","","","both","","","8841.55","5304.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6843.36","77.4","","5214.50","5214.50","16415.28","1 through 10","1028.27","7515.32","percent of total billed charges",""
"KNEE CONE 22MM TIBIAL SHORT LEGION","SUP-ITM-10198689","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8841.55","5304.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1028.27","11.63","","400.94","400.94","400.94","1 through 10","1028.27","6843.36","percent of total billed charges",""
"KNEE CONE 22MM TIBIAL SHORT LEGION","SUP-ITM-10198689","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8841.55","5304.93","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3865.53","43.72","","1543.33","1543.33","1671.61","1 through 10","1028.27","6843.36","percent of total billed charges",""
"KNEE CONE 22MM TIBIAL SHORT LEGION","SUP-ITM-10198689","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8841.55","5304.93","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6429.58","72.72","","3700.21","2382.07","6427.18","53","1028.27","6843.36","percent of total billed charges",""
"KNEE CONE 22MM TIBIAL SHORT LEGION","SUP-ITM-10198689","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8841.55","5304.93","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6429.58","72.72","","12685.80","12685.80","12685.80","1 through 10","1028.27","6843.36","percent of total billed charges",""
"KNEE CONE 22MM TIBIAL SHORT LEGION","SUP-ITM-10198689","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8841.55","5304.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5561.33","62.9","","3408.87","2784.05","9859.40","46","1028.27","6843.36","percent of total billed charges",""
"KNEE CONE 22MM TIBIAL SHORT LEGION","SUP-ITM-10198689","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8841.55","5304.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6843.36","77.4","","5214.50","5214.50","16415.28","1 through 10","1028.27","6843.36","percent of total billed charges",""
"KNEE HEAD 36MM FEMORAL BIOLOX DELTA LONG","SUP-ITM-10267748","CDM","C1776","HCPCS","0278","RC","","","","both","","","3752.13","2251.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","436.37","3189.31","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE HEAD 36MM FEMORAL BIOLOX DELTA LONG","SUP-ITM-10267748","CDM","C1776","HCPCS","0278","RC","","","","both","","","3752.13","2251.28","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2134.96","56.9","","2911.53","1863.86","5209.05","65","436.37","3189.31","percent of total billed charges",""
"KNEE HEAD 36MM FEMORAL BIOLOX DELTA LONG","SUP-ITM-10267748","CDM","C1776","HCPCS","0278","RC","","","","both","","","3752.13","2251.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","436.37","11.63","","400.94","400.94","400.94","1 through 10","436.37","3189.31","percent of total billed charges",""
"KNEE HEAD 36MM FEMORAL BIOLOX DELTA LONG","SUP-ITM-10267748","CDM","C1776","HCPCS","0278","RC","","","","both","","","3752.13","2251.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2904.15","77.4","","5214.50","5214.50","16415.28","1 through 10","436.37","3189.31","percent of total billed charges",""
"KNEE HEAD 36MM FEMORAL BIOLOX DELTA LONG","SUP-ITM-10267748","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3752.13","2251.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","436.37","11.63","","400.94","400.94","400.94","1 through 10","436.37","2904.15","percent of total billed charges",""
"KNEE HEAD 36MM FEMORAL BIOLOX DELTA LONG","SUP-ITM-10267748","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3752.13","2251.28","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1640.43","43.72","","1543.33","1543.33","1671.61","1 through 10","436.37","2904.15","percent of total billed charges",""
"KNEE HEAD 36MM FEMORAL BIOLOX DELTA LONG","SUP-ITM-10267748","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3752.13","2251.28","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2728.55","72.72","","3700.21","2382.07","6427.18","53","436.37","2904.15","percent of total billed charges",""
"KNEE HEAD 36MM FEMORAL BIOLOX DELTA LONG","SUP-ITM-10267748","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3752.13","2251.28","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2728.55","72.72","","12685.80","12685.80","12685.80","1 through 10","436.37","2904.15","percent of total billed charges",""
"KNEE HEAD 36MM FEMORAL BIOLOX DELTA LONG","SUP-ITM-10267748","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3752.13","2251.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2360.09","62.9","","3408.87","2784.05","9859.40","46","436.37","2904.15","percent of total billed charges",""
"KNEE HEAD 36MM FEMORAL BIOLOX DELTA LONG","SUP-ITM-10267748","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3752.13","2251.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2904.15","77.4","","5214.50","5214.50","16415.28","1 through 10","436.37","2904.15","percent of total billed charges",""
"KNEE IMPLANT 10MM SIZE 11 TIBIAL PATELLA M DOME SCORPIO 06","SUP-ITM-10018058","CDM","C1776","HCPCS","0278","RC","","","","both","","","2031.54","1218.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","236.27","1726.81","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE IMPLANT 10MM SIZE 11 TIBIAL PATELLA M DOME SCORPIO 06","SUP-ITM-10018058","CDM","C1776","HCPCS","0278","RC","","","","both","","","2031.54","1218.92","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1155.95","56.9","","2911.53","1863.86","5209.05","65","236.27","1726.81","percent of total billed charges",""
"KNEE IMPLANT 10MM SIZE 11 TIBIAL PATELLA M DOME SCORPIO 06","SUP-ITM-10018058","CDM","C1776","HCPCS","0278","RC","","","","both","","","2031.54","1218.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","236.27","11.63","","400.94","400.94","400.94","1 through 10","236.27","1726.81","percent of total billed charges",""
"KNEE IMPLANT 10MM SIZE 11 TIBIAL PATELLA M DOME SCORPIO 06","SUP-ITM-10018058","CDM","C1776","HCPCS","0278","RC","","","","both","","","2031.54","1218.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1572.41","77.4","","5214.50","5214.50","16415.28","1 through 10","236.27","1726.81","percent of total billed charges",""
"KNEE IMPLANT 10MM SIZE 11 TIBIAL PATELLA M DOME SCORPIO 06","SUP-ITM-10018058","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2031.54","1218.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","236.27","11.63","","400.94","400.94","400.94","1 through 10","236.27","1572.41","percent of total billed charges",""
"KNEE IMPLANT 10MM SIZE 11 TIBIAL PATELLA M DOME SCORPIO 06","SUP-ITM-10018058","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2031.54","1218.92","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","888.19","43.72","","1543.33","1543.33","1671.61","1 through 10","236.27","1572.41","percent of total billed charges",""
"KNEE IMPLANT 10MM SIZE 11 TIBIAL PATELLA M DOME SCORPIO 06","SUP-ITM-10018058","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2031.54","1218.92","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1477.34","72.72","","3700.21","2382.07","6427.18","53","236.27","1572.41","percent of total billed charges",""
"KNEE IMPLANT 10MM SIZE 11 TIBIAL PATELLA M DOME SCORPIO 06","SUP-ITM-10018058","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2031.54","1218.92","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1477.34","72.72","","12685.80","12685.80","12685.80","1 through 10","236.27","1572.41","percent of total billed charges",""
"KNEE IMPLANT 10MM SIZE 11 TIBIAL PATELLA M DOME SCORPIO 06","SUP-ITM-10018058","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2031.54","1218.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1277.84","62.9","","3408.87","2784.05","9859.40","46","236.27","1572.41","percent of total billed charges",""
"KNEE IMPLANT 10MM SIZE 11 TIBIAL PATELLA M DOME SCORPIO 06","SUP-ITM-10018058","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2031.54","1218.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1572.41","77.4","","5214.50","5214.50","16415.28","1 through 10","236.27","1572.41","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","241.09","1762.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1179.54","56.9","","2911.53","1863.86","5209.05","65","241.09","1762.05","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","241.09","11.63","","400.94","400.94","400.94","1 through 10","241.09","1762.05","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1604.50","77.4","","5214.50","5214.50","16415.28","1 through 10","241.09","1762.05","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","241.09","11.63","","400.94","400.94","400.94","1 through 10","241.09","1604.5","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","906.32","43.72","","1543.33","1543.33","1671.61","1 through 10","241.09","1604.5","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1507.49","72.72","","3700.21","2382.07","6427.18","53","241.09","1604.5","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1507.49","72.72","","12685.80","12685.80","12685.80","1 through 10","241.09","1604.5","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1303.92","62.9","","3408.87","2784.05","9859.40","46","241.09","1604.5","percent of total billed charges",""
"KNEE IMPLANT 9.0X29MM PATELLA ASYMMETRIC TRIATHLON 06","SUP-ITM-10019263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1604.50","77.4","","5214.50","5214.50","16415.28","1 through 10","241.09","1604.5","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","both","","","17792.16","10675.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","2069.23","15123.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","both","","","17792.16","10675.30","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","10123.74","56.9","","2911.53","1863.86","5209.05","65","2069.23","15123.34","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","both","","","17792.16","10675.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2069.23","11.63","","400.94","400.94","400.94","1 through 10","2069.23","15123.34","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","both","","","17792.16","10675.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","13771.13","77.4","","5214.50","5214.50","16415.28","1 through 10","2069.23","15123.34","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17792.16","10675.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2069.23","11.63","","400.94","400.94","400.94","1 through 10","2069.23","13771.13","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17792.16","10675.30","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","7778.73","43.72","","1543.33","1543.33","1671.61","1 through 10","2069.23","13771.13","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17792.16","10675.30","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","12938.46","72.72","","3700.21","2382.07","6427.18","53","2069.23","13771.13","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17792.16","10675.30","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","12938.46","72.72","","12685.80","12685.80","12685.80","1 through 10","2069.23","13771.13","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17792.16","10675.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","11191.27","62.9","","3408.87","2784.05","9859.40","46","2069.23","13771.13","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","17792.16","10675.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","13771.13","77.4","","5214.50","5214.50","16415.28","1 through 10","2069.23","13771.13","percent of total billed charges",""
"KNEE IMPLANT LARGE COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL","SUP-ITM-10117151","CDM","C1776","HCPCS","0278","RC","","","","both","","","7129.50","4277.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","829.16","6060.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE IMPLANT LARGE COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL","SUP-ITM-10117151","CDM","C1776","HCPCS","0278","RC","","","","both","","","7129.50","4277.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4056.69","56.9","","2911.53","1863.86","5209.05","65","829.16","6060.08","percent of total billed charges",""
"KNEE IMPLANT LARGE COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL","SUP-ITM-10117151","CDM","C1776","HCPCS","0278","RC","","","","both","","","7129.50","4277.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","829.16","11.63","","400.94","400.94","400.94","1 through 10","829.16","6060.08","percent of total billed charges",""
"KNEE IMPLANT LARGE COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL","SUP-ITM-10117151","CDM","C1776","HCPCS","0278","RC","","","","both","","","7129.50","4277.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5518.23","77.4","","5214.50","5214.50","16415.28","1 through 10","829.16","6060.08","percent of total billed charges",""
"KNEE IMPLANT LARGE COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL","SUP-ITM-10117151","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7129.50","4277.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","829.16","11.63","","400.94","400.94","400.94","1 through 10","829.16","5518.23","percent of total billed charges",""
"KNEE IMPLANT LARGE COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL","SUP-ITM-10117151","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7129.50","4277.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3117.02","43.72","","1543.33","1543.33","1671.61","1 through 10","829.16","5518.23","percent of total billed charges",""
"KNEE IMPLANT LARGE COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL","SUP-ITM-10117151","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7129.50","4277.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5184.57","72.72","","3700.21","2382.07","6427.18","53","829.16","5518.23","percent of total billed charges",""
"KNEE IMPLANT LARGE COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL","SUP-ITM-10117151","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7129.50","4277.70","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5184.57","72.72","","12685.80","12685.80","12685.80","1 through 10","829.16","5518.23","percent of total billed charges",""
"KNEE IMPLANT LARGE COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL","SUP-ITM-10117151","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7129.50","4277.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4484.46","62.9","","3408.87","2784.05","9859.40","46","829.16","5518.23","percent of total billed charges",""
"KNEE IMPLANT LARGE COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL","SUP-ITM-10117151","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7129.50","4277.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5518.23","77.4","","5214.50","5214.50","16415.28","1 through 10","829.16","5518.23","percent of total billed charges",""
"KNEE IMPLANT MEDIUM COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL","SUP-ITM-10107412","CDM","C1776","HCPCS","0278","RC","","","","both","","","7129.50","4277.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","829.16","6060.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE IMPLANT MEDIUM COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL","SUP-ITM-10107412","CDM","C1776","HCPCS","0278","RC","","","","both","","","7129.50","4277.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4056.69","56.9","","2911.53","1863.86","5209.05","65","829.16","6060.08","percent of total billed charges",""
"KNEE IMPLANT MEDIUM COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL","SUP-ITM-10107412","CDM","C1776","HCPCS","0278","RC","","","","both","","","7129.50","4277.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","829.16","11.63","","400.94","400.94","400.94","1 through 10","829.16","6060.08","percent of total billed charges",""
"KNEE IMPLANT MEDIUM COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL","SUP-ITM-10107412","CDM","C1776","HCPCS","0278","RC","","","","both","","","7129.50","4277.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5518.23","77.4","","5214.50","5214.50","16415.28","1 through 10","829.16","6060.08","percent of total billed charges",""
"KNEE IMPLANT MEDIUM COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL","SUP-ITM-10107412","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7129.50","4277.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","829.16","11.63","","400.94","400.94","400.94","1 through 10","829.16","5518.23","percent of total billed charges",""
"KNEE IMPLANT MEDIUM COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL","SUP-ITM-10107412","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7129.50","4277.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3117.02","43.72","","1543.33","1543.33","1671.61","1 through 10","829.16","5518.23","percent of total billed charges",""
"KNEE IMPLANT MEDIUM COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL","SUP-ITM-10107412","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7129.50","4277.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5184.57","72.72","","3700.21","2382.07","6427.18","53","829.16","5518.23","percent of total billed charges",""
"KNEE IMPLANT MEDIUM COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL","SUP-ITM-10107412","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7129.50","4277.70","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5184.57","72.72","","12685.80","12685.80","12685.80","1 through 10","829.16","5518.23","percent of total billed charges",""
"KNEE IMPLANT MEDIUM COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL","SUP-ITM-10107412","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7129.50","4277.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4484.46","62.9","","3408.87","2784.05","9859.40","46","829.16","5518.23","percent of total billed charges",""
"KNEE IMPLANT MEDIUM COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL","SUP-ITM-10107412","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7129.50","4277.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5518.23","77.4","","5214.50","5214.50","16415.28","1 through 10","829.16","5518.23","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10025654","CDM","C1776","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","987.1","7214.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10025654","CDM","C1776","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4829.39","56.9","","2911.53","1863.86","5209.05","65","987.1","7214.38","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10025654","CDM","C1776","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","987.10","11.63","","400.94","400.94","400.94","1 through 10","987.1","7214.38","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10025654","CDM","C1776","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6569.33","77.4","","5214.50","5214.50","16415.28","1 through 10","987.1","7214.38","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10025654","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","987.10","11.63","","400.94","400.94","400.94","1 through 10","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10025654","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3710.74","43.72","","1543.33","1543.33","1671.61","1 through 10","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10025654","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6172.11","72.72","","3700.21","2382.07","6427.18","53","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10025654","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6172.11","72.72","","12685.80","12685.80","12685.80","1 through 10","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10025654","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5338.64","62.9","","3408.87","2784.05","9859.40","46","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 3 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10025654","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6569.33","77.4","","5214.50","5214.50","16415.28","1 through 10","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 4 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED RT","SUP-ITM-10018672","CDM","C1776","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","987.1","7214.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE IMPLANT SZ 4 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED RT","SUP-ITM-10018672","CDM","C1776","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4829.39","56.9","","2911.53","1863.86","5209.05","65","987.1","7214.38","percent of total billed charges",""
"KNEE IMPLANT SZ 4 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED RT","SUP-ITM-10018672","CDM","C1776","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","987.10","11.63","","400.94","400.94","400.94","1 through 10","987.1","7214.38","percent of total billed charges",""
"KNEE IMPLANT SZ 4 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED RT","SUP-ITM-10018672","CDM","C1776","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6569.33","77.4","","5214.50","5214.50","16415.28","1 through 10","987.1","7214.38","percent of total billed charges",""
"KNEE IMPLANT SZ 4 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED RT","SUP-ITM-10018672","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","987.10","11.63","","400.94","400.94","400.94","1 through 10","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 4 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED RT","SUP-ITM-10018672","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3710.74","43.72","","1543.33","1543.33","1671.61","1 through 10","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 4 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED RT","SUP-ITM-10018672","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6172.11","72.72","","3700.21","2382.07","6427.18","53","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 4 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED RT","SUP-ITM-10018672","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6172.11","72.72","","12685.80","12685.80","12685.80","1 through 10","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 4 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED RT","SUP-ITM-10018672","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5338.64","62.9","","3408.87","2784.05","9859.40","46","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 4 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED RT","SUP-ITM-10018672","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6569.33","77.4","","5214.50","5214.50","16415.28","1 through 10","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","987.1","7214.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","987.1","7214.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4829.39","56.9","","812.12","238.65","1587.46","163","987.1","7214.38","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","987.10","11.63","","112.68","112.68","146.99","38","987.1","7214.38","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6569.33","77.4","","303.98","303.98","5854.79","1 through 10","987.1","7214.38","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","987.10","11.63","","112.68","112.68","146.99","38","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5328.45","62.78","","780.86","208.94","10480.28","15","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3710.74","43.72","","179.76","179.76","179.76","1 through 10","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6172.11","72.72","","2355.45","298.99","3965.19","155","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6172.11","72.72","","3643.09","3643.09","3643.09","1 through 10","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4517.05","53.22","","554.28","554.28","554.28","16","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5338.64","62.9","","619.64","173.09","2370.64","150","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6569.33","77.4","","303.98","303.98","5854.79","1 through 10","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","7760.00","4656.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","902.49","6596","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","7760.00","4656.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4415.44","56.9","","2911.53","1863.86","5209.05","65","902.49","6596","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","7760.00","4656.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","902.49","11.63","","400.94","400.94","400.94","1 through 10","902.49","6596","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","7760.00","4656.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6006.24","77.4","","5214.50","5214.50","16415.28","1 through 10","902.49","6596","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7760.00","4656.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","902.49","11.63","","400.94","400.94","400.94","1 through 10","902.49","6006.24","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7760.00","4656.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3392.67","43.72","","1543.33","1543.33","1671.61","1 through 10","902.49","6006.24","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7760.00","4656.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5643.07","72.72","","3700.21","2382.07","6427.18","53","902.49","6006.24","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7760.00","4656.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5643.07","72.72","","12685.80","12685.80","12685.80","1 through 10","902.49","6006.24","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7760.00","4656.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4881.04","62.9","","3408.87","2784.05","9859.40","46","902.49","6006.24","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7760.00","4656.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6006.24","77.4","","5214.50","5214.50","16415.28","1 through 10","902.49","6006.24","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON RT MEDIAL LT LATERAL PARTIAL RESURFACING","SUP-ITM-10029023","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","789.68","5771.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON RT MEDIAL LT LATERAL PARTIAL RESURFACING","SUP-ITM-10029023","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3863.51","56.9","","2911.53","1863.86","5209.05","65","789.68","5771.5","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON RT MEDIAL LT LATERAL PARTIAL RESURFACING","SUP-ITM-10029023","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","789.68","11.63","","400.94","400.94","400.94","1 through 10","789.68","5771.5","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON RT MEDIAL LT LATERAL PARTIAL RESURFACING","SUP-ITM-10029023","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5255.46","77.4","","5214.50","5214.50","16415.28","1 through 10","789.68","5771.5","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON RT MEDIAL LT LATERAL PARTIAL RESURFACING","SUP-ITM-10029023","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","789.68","11.63","","400.94","400.94","400.94","1 through 10","789.68","5255.46","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON RT MEDIAL LT LATERAL PARTIAL RESURFACING","SUP-ITM-10029023","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2968.59","43.72","","1543.33","1543.33","1671.61","1 through 10","789.68","5255.46","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON RT MEDIAL LT LATERAL PARTIAL RESURFACING","SUP-ITM-10029023","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4937.69","72.72","","3700.21","2382.07","6427.18","53","789.68","5255.46","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON RT MEDIAL LT LATERAL PARTIAL RESURFACING","SUP-ITM-10029023","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4937.69","72.72","","12685.80","12685.80","12685.80","1 through 10","789.68","5255.46","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON RT MEDIAL LT LATERAL PARTIAL RESURFACING","SUP-ITM-10029023","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4270.91","62.9","","3408.87","2784.05","9859.40","46","789.68","5255.46","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON RT MEDIAL LT LATERAL PARTIAL RESURFACING","SUP-ITM-10029023","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5255.46","77.4","","5214.50","5214.50","16415.28","1 through 10","789.68","5255.46","percent of total billed charges",""
"KNEE IMPLANT SZ 5 FEMORAL COMPONENT ATTUNE AOX ANTIOXIDANT POLYETHYLENE CEMENTED CRUCIATE RETAINING RT 150400225","SUP-ITM-10094088","CDM","C1776","HCPCS","0278","RC","","","","both","","","5335.00","3201.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","620.46","4534.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE IMPLANT SZ 5 FEMORAL COMPONENT ATTUNE AOX ANTIOXIDANT POLYETHYLENE CEMENTED CRUCIATE RETAINING RT 150400225","SUP-ITM-10094088","CDM","C1776","HCPCS","0278","RC","","","","both","","","5335.00","3201.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3035.62","56.9","","2911.53","1863.86","5209.05","65","620.46","4534.75","percent of total billed charges",""
"KNEE IMPLANT SZ 5 FEMORAL COMPONENT ATTUNE AOX ANTIOXIDANT POLYETHYLENE CEMENTED CRUCIATE RETAINING RT 150400225","SUP-ITM-10094088","CDM","C1776","HCPCS","0278","RC","","","","both","","","5335.00","3201.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","620.46","11.63","","400.94","400.94","400.94","1 through 10","620.46","4534.75","percent of total billed charges",""
"KNEE IMPLANT SZ 5 FEMORAL COMPONENT ATTUNE AOX ANTIOXIDANT POLYETHYLENE CEMENTED CRUCIATE RETAINING RT 150400225","SUP-ITM-10094088","CDM","C1776","HCPCS","0278","RC","","","","both","","","5335.00","3201.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4129.29","77.4","","5214.50","5214.50","16415.28","1 through 10","620.46","4534.75","percent of total billed charges",""
"KNEE IMPLANT SZ 5 FEMORAL COMPONENT ATTUNE AOX ANTIOXIDANT POLYETHYLENE CEMENTED CRUCIATE RETAINING RT 150400225","SUP-ITM-10094088","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5335.00","3201.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","620.46","11.63","","400.94","400.94","400.94","1 through 10","620.46","4129.29","percent of total billed charges",""
"KNEE IMPLANT SZ 5 FEMORAL COMPONENT ATTUNE AOX ANTIOXIDANT POLYETHYLENE CEMENTED CRUCIATE RETAINING RT 150400225","SUP-ITM-10094088","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5335.00","3201.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2332.46","43.72","","1543.33","1543.33","1671.61","1 through 10","620.46","4129.29","percent of total billed charges",""
"KNEE IMPLANT SZ 5 FEMORAL COMPONENT ATTUNE AOX ANTIOXIDANT POLYETHYLENE CEMENTED CRUCIATE RETAINING RT 150400225","SUP-ITM-10094088","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5335.00","3201.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3879.61","72.72","","3700.21","2382.07","6427.18","53","620.46","4129.29","percent of total billed charges",""
"KNEE IMPLANT SZ 5 FEMORAL COMPONENT ATTUNE AOX ANTIOXIDANT POLYETHYLENE CEMENTED CRUCIATE RETAINING RT 150400225","SUP-ITM-10094088","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5335.00","3201.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3879.61","72.72","","12685.80","12685.80","12685.80","1 through 10","620.46","4129.29","percent of total billed charges",""
"KNEE IMPLANT SZ 5 FEMORAL COMPONENT ATTUNE AOX ANTIOXIDANT POLYETHYLENE CEMENTED CRUCIATE RETAINING RT 150400225","SUP-ITM-10094088","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5335.00","3201.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3355.72","62.9","","3408.87","2784.05","9859.40","46","620.46","4129.29","percent of total billed charges",""
"KNEE IMPLANT SZ 5 FEMORAL COMPONENT ATTUNE AOX ANTIOXIDANT POLYETHYLENE CEMENTED CRUCIATE RETAINING RT 150400225","SUP-ITM-10094088","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5335.00","3201.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4129.29","77.4","","5214.50","5214.50","16415.28","1 through 10","620.46","4129.29","percent of total billed charges",""
"KNEE IMPLANT SZ 7 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10018350","CDM","C1776","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","987.1","7214.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE IMPLANT SZ 7 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10018350","CDM","C1776","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4829.39","56.9","","2911.53","1863.86","5209.05","65","987.1","7214.38","percent of total billed charges",""
"KNEE IMPLANT SZ 7 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10018350","CDM","C1776","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","987.10","11.63","","400.94","400.94","400.94","1 through 10","987.1","7214.38","percent of total billed charges",""
"KNEE IMPLANT SZ 7 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10018350","CDM","C1776","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6569.33","77.4","","5214.50","5214.50","16415.28","1 through 10","987.1","7214.38","percent of total billed charges",""
"KNEE IMPLANT SZ 7 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10018350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","987.10","11.63","","400.94","400.94","400.94","1 through 10","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 7 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10018350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3710.74","43.72","","1543.33","1543.33","1671.61","1 through 10","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 7 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10018350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6172.11","72.72","","3700.21","2382.07","6427.18","53","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 7 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10018350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6172.11","72.72","","12685.80","12685.80","12685.80","1 through 10","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 7 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10018350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5338.64","62.9","","3408.87","2784.05","9859.40","46","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 7 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10018350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6569.33","77.4","","5214.50","5214.50","16415.28","1 through 10","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10134726","CDM","C1776","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","987.1","7214.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10134726","CDM","C1776","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4829.39","56.9","","2911.53","1863.86","5209.05","65","987.1","7214.38","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10134726","CDM","C1776","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","987.10","11.63","","400.94","400.94","400.94","1 through 10","987.1","7214.38","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10134726","CDM","C1776","HCPCS","0278","RC","","","","both","","","8487.50","5092.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6569.33","77.4","","5214.50","5214.50","16415.28","1 through 10","987.1","7214.38","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10134726","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","987.10","11.63","","400.94","400.94","400.94","1 through 10","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10134726","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3710.74","43.72","","1543.33","1543.33","1671.61","1 through 10","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10134726","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6172.11","72.72","","3700.21","2382.07","6427.18","53","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10134726","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6172.11","72.72","","12685.80","12685.80","12685.80","1 through 10","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10134726","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5338.64","62.9","","3408.87","2784.05","9859.40","46","987.1","6569.33","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXINIUM OXIDIZED ZIRCONIUM POSTERIOR STABILIZING CEMENTED RT","SUP-ITM-10134726","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8487.50","5092.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6569.33","77.4","","5214.50","5214.50","16415.28","1 through 10","987.1","6569.33","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","both","","","6232.82","3739.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","724.88","5297.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","both","","","6232.82","3739.69","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3546.47","56.9","","2911.53","1863.86","5209.05","65","724.88","5297.9","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","both","","","6232.82","3739.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","724.88","11.63","","400.94","400.94","400.94","1 through 10","724.88","5297.9","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","both","","","6232.82","3739.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4824.20","77.4","","5214.50","5214.50","16415.28","1 through 10","724.88","5297.9","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6232.82","3739.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","724.88","11.63","","400.94","400.94","400.94","1 through 10","724.88","4824.2","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6232.82","3739.69","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2724.99","43.72","","1543.33","1543.33","1671.61","1 through 10","724.88","4824.2","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6232.82","3739.69","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4532.51","72.72","","3700.21","2382.07","6427.18","53","724.88","4824.2","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6232.82","3739.69","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4532.51","72.72","","12685.80","12685.80","12685.80","1 through 10","724.88","4824.2","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6232.82","3739.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3920.44","62.9","","3408.87","2784.05","9859.40","46","724.88","4824.2","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6232.82","3739.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4824.20","77.4","","5214.50","5214.50","16415.28","1 through 10","724.88","4824.2","percent of total billed charges",""
"KNEE INSERT 10X29MM FEMORAL APERFIX II IMPLANT","SUP-ITM-10044369","CDM","C1713","HCPCS","0278","RC","","","","both","","","6430.52","3858.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","747.87","5465.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE INSERT 10X29MM FEMORAL APERFIX II IMPLANT","SUP-ITM-10044369","CDM","C1713","HCPCS","0278","RC","","","","both","","","6430.52","3858.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","747.87","5465.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE INSERT 10X29MM FEMORAL APERFIX II IMPLANT","SUP-ITM-10044369","CDM","C1713","HCPCS","0278","RC","","","","both","","","6430.52","3858.31","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3658.97","56.9","","812.12","238.65","1587.46","163","747.87","5465.94","percent of total billed charges",""
"KNEE INSERT 10X29MM FEMORAL APERFIX II IMPLANT","SUP-ITM-10044369","CDM","C1713","HCPCS","0278","RC","","","","both","","","6430.52","3858.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","747.87","11.63","","112.68","112.68","146.99","38","747.87","5465.94","percent of total billed charges",""
"KNEE INSERT 10X29MM FEMORAL APERFIX II IMPLANT","SUP-ITM-10044369","CDM","C1713","HCPCS","0278","RC","","","","both","","","6430.52","3858.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4977.22","77.4","","303.98","303.98","5854.79","1 through 10","747.87","5465.94","percent of total billed charges",""
"KNEE INSERT 10X29MM FEMORAL APERFIX II IMPLANT","SUP-ITM-10044369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6430.52","3858.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","747.87","11.63","","112.68","112.68","146.99","38","747.87","4977.22","percent of total billed charges",""
"KNEE INSERT 10X29MM FEMORAL APERFIX II IMPLANT","SUP-ITM-10044369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6430.52","3858.31","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4037.08","62.78","","780.86","208.94","10480.28","15","747.87","4977.22","percent of total billed charges",""
"KNEE INSERT 10X29MM FEMORAL APERFIX II IMPLANT","SUP-ITM-10044369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6430.52","3858.31","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2811.42","43.72","","179.76","179.76","179.76","1 through 10","747.87","4977.22","percent of total billed charges",""
"KNEE INSERT 10X29MM FEMORAL APERFIX II IMPLANT","SUP-ITM-10044369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6430.52","3858.31","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4676.27","72.72","","2355.45","298.99","3965.19","155","747.87","4977.22","percent of total billed charges",""
"KNEE INSERT 10X29MM FEMORAL APERFIX II IMPLANT","SUP-ITM-10044369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6430.52","3858.31","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4676.27","72.72","","3643.09","3643.09","3643.09","1 through 10","747.87","4977.22","percent of total billed charges",""
"KNEE INSERT 10X29MM FEMORAL APERFIX II IMPLANT","SUP-ITM-10044369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6430.52","3858.31","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3422.32","53.22","","554.28","554.28","554.28","16","747.87","4977.22","percent of total billed charges",""
"KNEE INSERT 10X29MM FEMORAL APERFIX II IMPLANT","SUP-ITM-10044369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6430.52","3858.31","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4044.80","62.9","","619.64","173.09","2370.64","150","747.87","4977.22","percent of total billed charges",""
"KNEE INSERT 10X29MM FEMORAL APERFIX II IMPLANT","SUP-ITM-10044369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6430.52","3858.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4977.22","77.4","","303.98","303.98","5854.79","1 through 10","747.87","4977.22","percent of total billed charges",""
"KNEE INSERT 13MM SZ 3 TO 4 RIGHT ARTICULAR REVISION JOURNEY BCS STANDARD","SUP-ITM-10282344","CDM","C1769","HCPCS","0272","RC","","","","both","","","3289.16","1973.50","AETNA [1001]","HB WDH AETNA COMMERCIAL","2295.83","69.8","","279.80","225.71","279.80","16","382.53","2795.79","percent of total billed charges",""
"KNEE INSERT 13MM SZ 3 TO 4 RIGHT ARTICULAR REVISION JOURNEY BCS STANDARD","SUP-ITM-10282344","CDM","C1769","HCPCS","0272","RC","","","","both","","","3289.16","1973.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","382.53","2795.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE INSERT 13MM SZ 3 TO 4 RIGHT ARTICULAR REVISION JOURNEY BCS STANDARD","SUP-ITM-10282344","CDM","C1769","HCPCS","0272","RC","","","","both","","","3289.16","1973.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1871.53","56.9","","18.95","9.41","1260.18","1 through 10","382.53","2795.79","percent of total billed charges",""
"KNEE INSERT 13MM SZ 3 TO 4 RIGHT ARTICULAR REVISION JOURNEY BCS STANDARD","SUP-ITM-10282344","CDM","C1769","HCPCS","0272","RC","","","","both","","","3289.16","1973.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","382.53","11.63","","37.78","11.63","183.64","21","382.53","2795.79","percent of total billed charges",""
"KNEE INSERT 13MM SZ 3 TO 4 RIGHT ARTICULAR REVISION JOURNEY BCS STANDARD","SUP-ITM-10282344","CDM","C1769","HCPCS","0272","RC","","","","both","","","3289.16","1973.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2545.81","77.4","","225.79","68.39","1154.35","11","382.53","2795.79","percent of total billed charges",""
"KNEE INSERT 13MM SZ 3 TO 4 RIGHT ARTICULAR REVISION JOURNEY BCS STANDARD","SUP-ITM-10282344","CDM","C1769","HCPCS","0272","RC","","","","both","","","3289.16","1973.50","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","382.53","2795.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE INSERT 13MM SZ 3 TO 4 RIGHT ARTICULAR REVISION JOURNEY BCS STANDARD","SUP-ITM-10282344","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","3289.16","1973.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","382.53","11.63","","37.78","11.63","183.64","21","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 13MM SZ 3 TO 4 RIGHT ARTICULAR REVISION JOURNEY BCS STANDARD","SUP-ITM-10282344","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","3289.16","1973.50","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2064.93","62.78","","123.83","114.55","572.63","1 through 10","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 13MM SZ 3 TO 4 RIGHT ARTICULAR REVISION JOURNEY BCS STANDARD","SUP-ITM-10282344","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","3289.16","1973.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1438.02","43.72","","127.38","127.38","148.03","1 through 10","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 13MM SZ 3 TO 4 RIGHT ARTICULAR REVISION JOURNEY BCS STANDARD","SUP-ITM-10282344","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","3289.16","1973.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2391.88","72.72","","196.34","62.16","1727.00","33","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 13MM SZ 3 TO 4 RIGHT ARTICULAR REVISION JOURNEY BCS STANDARD","SUP-ITM-10282344","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","3289.16","1973.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2391.88","72.72","","173.00","173.00","173.00","1 through 10","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 13MM SZ 3 TO 4 RIGHT ARTICULAR REVISION JOURNEY BCS STANDARD","SUP-ITM-10282344","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","3289.16","1973.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1750.49","53.22","","205.24","190.08","205.24","1 through 10","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 13MM SZ 3 TO 4 RIGHT ARTICULAR REVISION JOURNEY BCS STANDARD","SUP-ITM-10282344","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","3289.16","1973.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2068.88","62.9","","305.08","81.02","4529.24","103","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 13MM SZ 3 TO 4 RIGHT ARTICULAR REVISION JOURNEY BCS STANDARD","SUP-ITM-10282344","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","3289.16","1973.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2545.81","77.4","","225.79","68.39","1154.35","11","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","5507.27","3304.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","640.5","4681.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","5507.27","3304.36","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3133.64","56.9","","2911.53","1863.86","5209.05","65","640.5","4681.18","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","5507.27","3304.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","640.50","11.63","","400.94","400.94","400.94","1 through 10","640.5","4681.18","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","5507.27","3304.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4262.63","77.4","","5214.50","5214.50","16415.28","1 through 10","640.5","4681.18","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5507.27","3304.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","640.50","11.63","","400.94","400.94","400.94","1 through 10","640.5","4262.63","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5507.27","3304.36","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2407.78","43.72","","1543.33","1543.33","1671.61","1 through 10","640.5","4262.63","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5507.27","3304.36","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4004.89","72.72","","3700.21","2382.07","6427.18","53","640.5","4262.63","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5507.27","3304.36","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4004.89","72.72","","12685.80","12685.80","12685.80","1 through 10","640.5","4262.63","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5507.27","3304.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3464.07","62.9","","3408.87","2784.05","9859.40","46","640.5","4262.63","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5507.27","3304.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4262.63","77.4","","5214.50","5214.50","16415.28","1 through 10","640.5","4262.63","percent of total billed charges",""
"KNEE INSERT 19MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10043027","CDM","C1776","HCPCS","0278","RC","","","","both","","","5507.27","3304.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","640.5","4681.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE INSERT 19MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10043027","CDM","C1776","HCPCS","0278","RC","","","","both","","","5507.27","3304.36","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3133.64","56.9","","2911.53","1863.86","5209.05","65","640.5","4681.18","percent of total billed charges",""
"KNEE INSERT 19MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10043027","CDM","C1776","HCPCS","0278","RC","","","","both","","","5507.27","3304.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","640.50","11.63","","400.94","400.94","400.94","1 through 10","640.5","4681.18","percent of total billed charges",""
"KNEE INSERT 19MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10043027","CDM","C1776","HCPCS","0278","RC","","","","both","","","5507.27","3304.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4262.63","77.4","","5214.50","5214.50","16415.28","1 through 10","640.5","4681.18","percent of total billed charges",""
"KNEE INSERT 19MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10043027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5507.27","3304.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","640.50","11.63","","400.94","400.94","400.94","1 through 10","640.5","4262.63","percent of total billed charges",""
"KNEE INSERT 19MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10043027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5507.27","3304.36","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2407.78","43.72","","1543.33","1543.33","1671.61","1 through 10","640.5","4262.63","percent of total billed charges",""
"KNEE INSERT 19MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10043027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5507.27","3304.36","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4004.89","72.72","","3700.21","2382.07","6427.18","53","640.5","4262.63","percent of total billed charges",""
"KNEE INSERT 19MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10043027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5507.27","3304.36","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4004.89","72.72","","12685.80","12685.80","12685.80","1 through 10","640.5","4262.63","percent of total billed charges",""
"KNEE INSERT 19MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10043027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5507.27","3304.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3464.07","62.9","","3408.87","2784.05","9859.40","46","640.5","4262.63","percent of total billed charges",""
"KNEE INSERT 19MM SIZE 5 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10043027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5507.27","3304.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4262.63","77.4","","5214.50","5214.50","16415.28","1 through 10","640.5","4262.63","percent of total billed charges",""
"KNEE INSERT 2 12MM SIZE 1 JOURNEY II BCS CROSSLINKED POLYETHYLENE LEFT","SUP-ITM-10174265","CDM","C1776","HCPCS","0278","RC","","","","both","","","3289.16","1973.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","382.53","2795.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE INSERT 2 12MM SIZE 1 JOURNEY II BCS CROSSLINKED POLYETHYLENE LEFT","SUP-ITM-10174265","CDM","C1776","HCPCS","0278","RC","","","","both","","","3289.16","1973.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1871.53","56.9","","2911.53","1863.86","5209.05","65","382.53","2795.79","percent of total billed charges",""
"KNEE INSERT 2 12MM SIZE 1 JOURNEY II BCS CROSSLINKED POLYETHYLENE LEFT","SUP-ITM-10174265","CDM","C1776","HCPCS","0278","RC","","","","both","","","3289.16","1973.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","382.53","11.63","","400.94","400.94","400.94","1 through 10","382.53","2795.79","percent of total billed charges",""
"KNEE INSERT 2 12MM SIZE 1 JOURNEY II BCS CROSSLINKED POLYETHYLENE LEFT","SUP-ITM-10174265","CDM","C1776","HCPCS","0278","RC","","","","both","","","3289.16","1973.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2545.81","77.4","","5214.50","5214.50","16415.28","1 through 10","382.53","2795.79","percent of total billed charges",""
"KNEE INSERT 2 12MM SIZE 1 JOURNEY II BCS CROSSLINKED POLYETHYLENE LEFT","SUP-ITM-10174265","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","382.53","11.63","","400.94","400.94","400.94","1 through 10","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 2 12MM SIZE 1 JOURNEY II BCS CROSSLINKED POLYETHYLENE LEFT","SUP-ITM-10174265","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1438.02","43.72","","1543.33","1543.33","1671.61","1 through 10","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 2 12MM SIZE 1 JOURNEY II BCS CROSSLINKED POLYETHYLENE LEFT","SUP-ITM-10174265","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2391.88","72.72","","3700.21","2382.07","6427.18","53","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 2 12MM SIZE 1 JOURNEY II BCS CROSSLINKED POLYETHYLENE LEFT","SUP-ITM-10174265","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2391.88","72.72","","12685.80","12685.80","12685.80","1 through 10","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 2 12MM SIZE 1 JOURNEY II BCS CROSSLINKED POLYETHYLENE LEFT","SUP-ITM-10174265","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2068.88","62.9","","3408.87","2784.05","9859.40","46","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 2 12MM SIZE 1 JOURNEY II BCS CROSSLINKED POLYETHYLENE LEFT","SUP-ITM-10174265","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2545.81","77.4","","5214.50","5214.50","16415.28","1 through 10","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","both","","","6232.82","3739.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","724.88","5297.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","both","","","6232.82","3739.69","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3546.47","56.9","","2911.53","1863.86","5209.05","65","724.88","5297.9","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","both","","","6232.82","3739.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","724.88","11.63","","400.94","400.94","400.94","1 through 10","724.88","5297.9","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","both","","","6232.82","3739.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4824.20","77.4","","5214.50","5214.50","16415.28","1 through 10","724.88","5297.9","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6232.82","3739.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","724.88","11.63","","400.94","400.94","400.94","1 through 10","724.88","4824.2","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6232.82","3739.69","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2724.99","43.72","","1543.33","1543.33","1671.61","1 through 10","724.88","4824.2","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6232.82","3739.69","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4532.51","72.72","","3700.21","2382.07","6427.18","53","724.88","4824.2","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6232.82","3739.69","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4532.51","72.72","","12685.80","12685.80","12685.80","1 through 10","724.88","4824.2","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6232.82","3739.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3920.44","62.9","","3408.87","2784.05","9859.40","46","724.88","4824.2","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6232.82","3739.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4824.20","77.4","","5214.50","5214.50","16415.28","1 through 10","724.88","4824.2","percent of total billed charges",""
"KNEE INSERT 6 25MM SIZE 5 GENESIS II POLYETHYLENE CONSTRAINED","SUP-ITM-10121303","CDM","C1776","HCPCS","0278","RC","","","","both","","","3289.16","1973.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","382.53","2795.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE INSERT 6 25MM SIZE 5 GENESIS II POLYETHYLENE CONSTRAINED","SUP-ITM-10121303","CDM","C1776","HCPCS","0278","RC","","","","both","","","3289.16","1973.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1871.53","56.9","","2911.53","1863.86","5209.05","65","382.53","2795.79","percent of total billed charges",""
"KNEE INSERT 6 25MM SIZE 5 GENESIS II POLYETHYLENE CONSTRAINED","SUP-ITM-10121303","CDM","C1776","HCPCS","0278","RC","","","","both","","","3289.16","1973.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","382.53","11.63","","400.94","400.94","400.94","1 through 10","382.53","2795.79","percent of total billed charges",""
"KNEE INSERT 6 25MM SIZE 5 GENESIS II POLYETHYLENE CONSTRAINED","SUP-ITM-10121303","CDM","C1776","HCPCS","0278","RC","","","","both","","","3289.16","1973.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2545.81","77.4","","5214.50","5214.50","16415.28","1 through 10","382.53","2795.79","percent of total billed charges",""
"KNEE INSERT 6 25MM SIZE 5 GENESIS II POLYETHYLENE CONSTRAINED","SUP-ITM-10121303","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","382.53","11.63","","400.94","400.94","400.94","1 through 10","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 6 25MM SIZE 5 GENESIS II POLYETHYLENE CONSTRAINED","SUP-ITM-10121303","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1438.02","43.72","","1543.33","1543.33","1671.61","1 through 10","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 6 25MM SIZE 5 GENESIS II POLYETHYLENE CONSTRAINED","SUP-ITM-10121303","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2391.88","72.72","","3700.21","2382.07","6427.18","53","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 6 25MM SIZE 5 GENESIS II POLYETHYLENE CONSTRAINED","SUP-ITM-10121303","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2391.88","72.72","","12685.80","12685.80","12685.80","1 through 10","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 6 25MM SIZE 5 GENESIS II POLYETHYLENE CONSTRAINED","SUP-ITM-10121303","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2068.88","62.9","","3408.87","2784.05","9859.40","46","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 6 25MM SIZE 5 GENESIS II POLYETHYLENE CONSTRAINED","SUP-ITM-10121303","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2545.81","77.4","","5214.50","5214.50","16415.28","1 through 10","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 8 11MM SIZE 7 GENESIS II POLYETHYLENE DISHED","SUP-ITM-10016896","CDM","C1776","HCPCS","0278","RC","","","","both","","","3289.16","1973.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","382.53","2795.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE INSERT 8 11MM SIZE 7 GENESIS II POLYETHYLENE DISHED","SUP-ITM-10016896","CDM","C1776","HCPCS","0278","RC","","","","both","","","3289.16","1973.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1871.53","56.9","","2911.53","1863.86","5209.05","65","382.53","2795.79","percent of total billed charges",""
"KNEE INSERT 8 11MM SIZE 7 GENESIS II POLYETHYLENE DISHED","SUP-ITM-10016896","CDM","C1776","HCPCS","0278","RC","","","","both","","","3289.16","1973.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","382.53","11.63","","400.94","400.94","400.94","1 through 10","382.53","2795.79","percent of total billed charges",""
"KNEE INSERT 8 11MM SIZE 7 GENESIS II POLYETHYLENE DISHED","SUP-ITM-10016896","CDM","C1776","HCPCS","0278","RC","","","","both","","","3289.16","1973.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2545.81","77.4","","5214.50","5214.50","16415.28","1 through 10","382.53","2795.79","percent of total billed charges",""
"KNEE INSERT 8 11MM SIZE 7 GENESIS II POLYETHYLENE DISHED","SUP-ITM-10016896","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","382.53","11.63","","400.94","400.94","400.94","1 through 10","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 8 11MM SIZE 7 GENESIS II POLYETHYLENE DISHED","SUP-ITM-10016896","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1438.02","43.72","","1543.33","1543.33","1671.61","1 through 10","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 8 11MM SIZE 7 GENESIS II POLYETHYLENE DISHED","SUP-ITM-10016896","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2391.88","72.72","","3700.21","2382.07","6427.18","53","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 8 11MM SIZE 7 GENESIS II POLYETHYLENE DISHED","SUP-ITM-10016896","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2391.88","72.72","","12685.80","12685.80","12685.80","1 through 10","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 8 11MM SIZE 7 GENESIS II POLYETHYLENE DISHED","SUP-ITM-10016896","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2068.88","62.9","","3408.87","2784.05","9859.40","46","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 8 11MM SIZE 7 GENESIS II POLYETHYLENE DISHED","SUP-ITM-10016896","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2545.81","77.4","","5214.50","5214.50","16415.28","1 through 10","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT 8MM SIZE 4 CRUCIATE BEARING RETAINING CURVED TIBIAL","SUP-ITM-10005153","CDM","C1713","HCPCS","0278","RC","","","","both","","","6232.82","3739.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","724.88","5297.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE INSERT 8MM SIZE 4 CRUCIATE BEARING RETAINING CURVED TIBIAL","SUP-ITM-10005153","CDM","C1713","HCPCS","0278","RC","","","","both","","","6232.82","3739.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","724.88","5297.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE INSERT 8MM SIZE 4 CRUCIATE BEARING RETAINING CURVED TIBIAL","SUP-ITM-10005153","CDM","C1713","HCPCS","0278","RC","","","","both","","","6232.82","3739.69","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3546.47","56.9","","812.12","238.65","1587.46","163","724.88","5297.9","percent of total billed charges",""
"KNEE INSERT 8MM SIZE 4 CRUCIATE BEARING RETAINING CURVED TIBIAL","SUP-ITM-10005153","CDM","C1713","HCPCS","0278","RC","","","","both","","","6232.82","3739.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","724.88","11.63","","112.68","112.68","146.99","38","724.88","5297.9","percent of total billed charges",""
"KNEE INSERT 8MM SIZE 4 CRUCIATE BEARING RETAINING CURVED TIBIAL","SUP-ITM-10005153","CDM","C1713","HCPCS","0278","RC","","","","both","","","6232.82","3739.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4824.20","77.4","","303.98","303.98","5854.79","1 through 10","724.88","5297.9","percent of total billed charges",""
"KNEE INSERT 8MM SIZE 4 CRUCIATE BEARING RETAINING CURVED TIBIAL","SUP-ITM-10005153","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6232.82","3739.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","724.88","11.63","","112.68","112.68","146.99","38","724.88","4824.2","percent of total billed charges",""
"KNEE INSERT 8MM SIZE 4 CRUCIATE BEARING RETAINING CURVED TIBIAL","SUP-ITM-10005153","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6232.82","3739.69","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3912.96","62.78","","780.86","208.94","10480.28","15","724.88","4824.2","percent of total billed charges",""
"KNEE INSERT 8MM SIZE 4 CRUCIATE BEARING RETAINING CURVED TIBIAL","SUP-ITM-10005153","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6232.82","3739.69","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2724.99","43.72","","179.76","179.76","179.76","1 through 10","724.88","4824.2","percent of total billed charges",""
"KNEE INSERT 8MM SIZE 4 CRUCIATE BEARING RETAINING CURVED TIBIAL","SUP-ITM-10005153","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6232.82","3739.69","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4532.51","72.72","","2355.45","298.99","3965.19","155","724.88","4824.2","percent of total billed charges",""
"KNEE INSERT 8MM SIZE 4 CRUCIATE BEARING RETAINING CURVED TIBIAL","SUP-ITM-10005153","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6232.82","3739.69","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4532.51","72.72","","3643.09","3643.09","3643.09","1 through 10","724.88","4824.2","percent of total billed charges",""
"KNEE INSERT 8MM SIZE 4 CRUCIATE BEARING RETAINING CURVED TIBIAL","SUP-ITM-10005153","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6232.82","3739.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3317.11","53.22","","554.28","554.28","554.28","16","724.88","4824.2","percent of total billed charges",""
"KNEE INSERT 8MM SIZE 4 CRUCIATE BEARING RETAINING CURVED TIBIAL","SUP-ITM-10005153","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6232.82","3739.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3920.44","62.9","","619.64","173.09","2370.64","150","724.88","4824.2","percent of total billed charges",""
"KNEE INSERT 8MM SIZE 4 CRUCIATE BEARING RETAINING CURVED TIBIAL","SUP-ITM-10005153","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6232.82","3739.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4824.20","77.4","","303.98","303.98","5854.79","1 through 10","724.88","4824.2","percent of total billed charges",""
"KNEE INSERT 9MM SIZE 4 TRIATHLON POLYETHYLENE STABILIZED","SUP-ITM-10021782","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","482.18","3524.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE INSERT 9MM SIZE 4 TRIATHLON POLYETHYLENE STABILIZED","SUP-ITM-10021782","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2359.07","56.9","","2911.53","1863.86","5209.05","65","482.18","3524.1","percent of total billed charges",""
"KNEE INSERT 9MM SIZE 4 TRIATHLON POLYETHYLENE STABILIZED","SUP-ITM-10021782","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","482.18","11.63","","400.94","400.94","400.94","1 through 10","482.18","3524.1","percent of total billed charges",""
"KNEE INSERT 9MM SIZE 4 TRIATHLON POLYETHYLENE STABILIZED","SUP-ITM-10021782","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3209.00","77.4","","5214.50","5214.50","16415.28","1 through 10","482.18","3524.1","percent of total billed charges",""
"KNEE INSERT 9MM SIZE 4 TRIATHLON POLYETHYLENE STABILIZED","SUP-ITM-10021782","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","482.18","11.63","","400.94","400.94","400.94","1 through 10","482.18","3209","percent of total billed charges",""
"KNEE INSERT 9MM SIZE 4 TRIATHLON POLYETHYLENE STABILIZED","SUP-ITM-10021782","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1812.63","43.72","","1543.33","1543.33","1671.61","1 through 10","482.18","3209","percent of total billed charges",""
"KNEE INSERT 9MM SIZE 4 TRIATHLON POLYETHYLENE STABILIZED","SUP-ITM-10021782","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3014.97","72.72","","3700.21","2382.07","6427.18","53","482.18","3209","percent of total billed charges",""
"KNEE INSERT 9MM SIZE 4 TRIATHLON POLYETHYLENE STABILIZED","SUP-ITM-10021782","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3014.97","72.72","","12685.80","12685.80","12685.80","1 through 10","482.18","3209","percent of total billed charges",""
"KNEE INSERT 9MM SIZE 4 TRIATHLON POLYETHYLENE STABILIZED","SUP-ITM-10021782","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2607.83","62.9","","3408.87","2784.05","9859.40","46","482.18","3209","percent of total billed charges",""
"KNEE INSERT 9MM SIZE 4 TRIATHLON POLYETHYLENE STABILIZED","SUP-ITM-10021782","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3209.00","77.4","","5214.50","5214.50","16415.28","1 through 10","482.18","3209","percent of total billed charges",""
"KNEE INSERT SIZE 5 TRIATHLON PS TITANIUM CEMENTED STABILIZED RIGHT","SUP-ITM-10016695","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","789.68","5771.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE INSERT SIZE 5 TRIATHLON PS TITANIUM CEMENTED STABILIZED RIGHT","SUP-ITM-10016695","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3863.51","56.9","","2911.53","1863.86","5209.05","65","789.68","5771.5","percent of total billed charges",""
"KNEE INSERT SIZE 5 TRIATHLON PS TITANIUM CEMENTED STABILIZED RIGHT","SUP-ITM-10016695","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","789.68","11.63","","400.94","400.94","400.94","1 through 10","789.68","5771.5","percent of total billed charges",""
"KNEE INSERT SIZE 5 TRIATHLON PS TITANIUM CEMENTED STABILIZED RIGHT","SUP-ITM-10016695","CDM","C1776","HCPCS","0278","RC","","","","both","","","6790.00","4074.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5255.46","77.4","","5214.50","5214.50","16415.28","1 through 10","789.68","5771.5","percent of total billed charges",""
"KNEE INSERT SIZE 5 TRIATHLON PS TITANIUM CEMENTED STABILIZED RIGHT","SUP-ITM-10016695","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","789.68","11.63","","400.94","400.94","400.94","1 through 10","789.68","5255.46","percent of total billed charges",""
"KNEE INSERT SIZE 5 TRIATHLON PS TITANIUM CEMENTED STABILIZED RIGHT","SUP-ITM-10016695","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2968.59","43.72","","1543.33","1543.33","1671.61","1 through 10","789.68","5255.46","percent of total billed charges",""
"KNEE INSERT SIZE 5 TRIATHLON PS TITANIUM CEMENTED STABILIZED RIGHT","SUP-ITM-10016695","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4937.69","72.72","","3700.21","2382.07","6427.18","53","789.68","5255.46","percent of total billed charges",""
"KNEE INSERT SIZE 5 TRIATHLON PS TITANIUM CEMENTED STABILIZED RIGHT","SUP-ITM-10016695","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4937.69","72.72","","12685.80","12685.80","12685.80","1 through 10","789.68","5255.46","percent of total billed charges",""
"KNEE INSERT SIZE 5 TRIATHLON PS TITANIUM CEMENTED STABILIZED RIGHT","SUP-ITM-10016695","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4270.91","62.9","","3408.87","2784.05","9859.40","46","789.68","5255.46","percent of total billed charges",""
"KNEE INSERT SIZE 5 TRIATHLON PS TITANIUM CEMENTED STABILIZED RIGHT","SUP-ITM-10016695","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6790.00","4074.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5255.46","77.4","","5214.50","5214.50","16415.28","1 through 10","789.68","5255.46","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","both","","","3289.16","1973.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","382.53","2795.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","both","","","3289.16","1973.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1871.53","56.9","","2911.53","1863.86","5209.05","65","382.53","2795.79","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","both","","","3289.16","1973.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","382.53","11.63","","400.94","400.94","400.94","1 through 10","382.53","2795.79","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","both","","","3289.16","1973.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2545.81","77.4","","5214.50","5214.50","16415.28","1 through 10","382.53","2795.79","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","382.53","11.63","","400.94","400.94","400.94","1 through 10","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1438.02","43.72","","1543.33","1543.33","1671.61","1 through 10","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2391.88","72.72","","3700.21","2382.07","6427.18","53","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2391.88","72.72","","12685.80","12685.80","12685.80","1 through 10","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2068.88","62.9","","3408.87","2784.05","9859.40","46","382.53","2545.81","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3289.16","1973.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2545.81","77.4","","5214.50","5214.50","16415.28","1 through 10","382.53","2545.81","percent of total billed charges",""
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","","","","inpatient","","","82178.49","49307.09","MEDICARE [2001]","HB WDH MEDICARE","16342.32","","Case rate ($16,342.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,118.04, add-ons for qualifying new technology services are included. If operating cost exceeds $19,036.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,966.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $14,735.76 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,673.17 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,161.70. The transfer capital threshold is the transfer adjustment factor * $1,161.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16448.17","16448.17","16448.17","1 through 10","3975","79462.01","other","Inpatient DRG"
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","","","","inpatient","","","82178.49","49307.09","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","16342.32","","Case rate ($16,342.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,118.04, add-ons for qualifying new technology services are included. If operating cost exceeds $19,036.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,966.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $14,735.76 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,673.17 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,161.70. The transfer capital threshold is the transfer adjustment factor * $1,161.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12158.52","12158.52","12158.52","1 through 10","3975","79462.01","other","Inpatient DRG"
"Knee Procedures With Principal Diagnosis Of Infection With McC","485","MS-DRG","","","","","","","","inpatient","","","110761.89","66457.13","MEDICARE [2001]","HB WDH MEDICARE","24978.68","","Case rate ($24,978.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $23,089.31, add-ons for qualifying new technology services are included. If operating cost exceeds $27,007.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,597.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $22,741.02 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $22,644.45 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,792.79. The transfer capital threshold is the transfer adjustment factor * $1,792.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24736.21","24736.21","24736.21","1 through 10","3975","65524.97","other","Inpatient DRG"
"Knee Procedures With Principal Diagnosis Of Infection With McC","485","MS-DRG","","","","","","","","inpatient","","","110761.89","66457.13","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","24978.68","","Case rate ($24,978.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $23,089.31, add-ons for qualifying new technology services are included. If operating cost exceeds $27,007.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,597.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $22,741.02 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $22,644.45 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,792.79. The transfer capital threshold is the transfer adjustment factor * $1,792.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24341.11","24341.11","24341.11","1 through 10","3975","65524.97","other","Inpatient DRG"
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/McC","487","MS-DRG","","","","","","","","inpatient","","","61450.01","36870.01","MEDICARE [2001]","HB WDH MEDICARE","12351.80","","Case rate ($12,351.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,434.84, add-ons for qualifying new technology services are included. If operating cost exceeds $15,353.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,675.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $11,036.84 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,989.97 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $870.09. The transfer capital threshold is the transfer adjustment factor * $870.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12399.35","12399.35","12399.35","1 through 10","3975","59515.76","other","Inpatient DRG"
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/McC","488","MS-DRG","","","","","","","","inpatient","","","93671.53","56202.92","MEDICARE [2001]","HB WDH MEDICARE","13892.82","","Case rate ($13,892.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,857.18, add-ons for qualifying new technology services are included. If operating cost exceeds $16,775.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,787.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $12,465.25 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,412.31 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $982.70. The transfer capital threshold is the transfer adjustment factor * $982.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15313.46","15313.46","15313.46","1 through 10","3975","67218.38","other","Inpatient DRG"
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/McC","489","MS-DRG","","","","","","","","inpatient","","","66729.94","40037.96","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8935.27","","Case rate ($8,935.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,281.42, add-ons for qualifying new technology services are included. If operating cost exceeds $12,199.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,425.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $7,869.97 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,836.55 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $620.43. The transfer capital threshold is the transfer adjustment factor * $620.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9789.20","9789.20","9789.20","1 through 10","3975","42438.51","other","Inpatient DRG"
"KNEE SPACER 64X47 70 42 17MM MD INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10050515","CDM","C1776","HCPCS","0278","RC","","","","both","","","13857.20","8314.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1611.59","11778.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE SPACER 64X47 70 42 17MM MD INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10050515","CDM","C1776","HCPCS","0278","RC","","","","both","","","13857.20","8314.32","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7884.75","56.9","","2911.53","1863.86","5209.05","65","1611.59","11778.62","percent of total billed charges",""
"KNEE SPACER 64X47 70 42 17MM MD INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10050515","CDM","C1776","HCPCS","0278","RC","","","","both","","","13857.20","8314.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1611.59","11.63","","400.94","400.94","400.94","1 through 10","1611.59","11778.62","percent of total billed charges",""
"KNEE SPACER 64X47 70 42 17MM MD INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10050515","CDM","C1776","HCPCS","0278","RC","","","","both","","","13857.20","8314.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10725.47","77.4","","5214.50","5214.50","16415.28","1 through 10","1611.59","11778.62","percent of total billed charges",""
"KNEE SPACER 64X47 70 42 17MM MD INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10050515","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1611.59","11.63","","400.94","400.94","400.94","1 through 10","1611.59","10725.47","percent of total billed charges",""
"KNEE SPACER 64X47 70 42 17MM MD INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10050515","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","6058.37","43.72","","1543.33","1543.33","1671.61","1 through 10","1611.59","10725.47","percent of total billed charges",""
"KNEE SPACER 64X47 70 42 17MM MD INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10050515","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10076.96","72.72","","3700.21","2382.07","6427.18","53","1611.59","10725.47","percent of total billed charges",""
"KNEE SPACER 64X47 70 42 17MM MD INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10050515","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","10076.96","72.72","","12685.80","12685.80","12685.80","1 through 10","1611.59","10725.47","percent of total billed charges",""
"KNEE SPACER 64X47 70 42 17MM MD INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10050515","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8716.18","62.9","","3408.87","2784.05","9859.40","46","1611.59","10725.47","percent of total billed charges",""
"KNEE SPACER 64X47 70 42 17MM MD INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10050515","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10725.47","77.4","","5214.50","5214.50","16415.28","1 through 10","1611.59","10725.47","percent of total billed charges",""
"KNEE SPACER 74X54 80 48 18MM LG INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10020254","CDM","C1776","HCPCS","0278","RC","","","","both","","","13857.20","8314.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1611.59","11778.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE SPACER 74X54 80 48 18MM LG INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10020254","CDM","C1776","HCPCS","0278","RC","","","","both","","","13857.20","8314.32","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7884.75","56.9","","2911.53","1863.86","5209.05","65","1611.59","11778.62","percent of total billed charges",""
"KNEE SPACER 74X54 80 48 18MM LG INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10020254","CDM","C1776","HCPCS","0278","RC","","","","both","","","13857.20","8314.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1611.59","11.63","","400.94","400.94","400.94","1 through 10","1611.59","11778.62","percent of total billed charges",""
"KNEE SPACER 74X54 80 48 18MM LG INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10020254","CDM","C1776","HCPCS","0278","RC","","","","both","","","13857.20","8314.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10725.47","77.4","","5214.50","5214.50","16415.28","1 through 10","1611.59","11778.62","percent of total billed charges",""
"KNEE SPACER 74X54 80 48 18MM LG INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10020254","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1611.59","11.63","","400.94","400.94","400.94","1 through 10","1611.59","10725.47","percent of total billed charges",""
"KNEE SPACER 74X54 80 48 18MM LG INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10020254","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","6058.37","43.72","","1543.33","1543.33","1671.61","1 through 10","1611.59","10725.47","percent of total billed charges",""
"KNEE SPACER 74X54 80 48 18MM LG INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10020254","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10076.96","72.72","","3700.21","2382.07","6427.18","53","1611.59","10725.47","percent of total billed charges",""
"KNEE SPACER 74X54 80 48 18MM LG INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10020254","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","10076.96","72.72","","12685.80","12685.80","12685.80","1 through 10","1611.59","10725.47","percent of total billed charges",""
"KNEE SPACER 74X54 80 48 18MM LG INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10020254","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8716.18","62.9","","3408.87","2784.05","9859.40","46","1611.59","10725.47","percent of total billed charges",""
"KNEE SPACER 74X54 80 48 18MM LG INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10020254","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10725.47","77.4","","5214.50","5214.50","16415.28","1 through 10","1611.59","10725.47","percent of total billed charges",""
"KNEE SPACER XL INTERSPACE TEMPORARY HIGH RELEASE","SUP-ITM-10196153","CDM","C1776","HCPCS","0278","RC","","","","both","","","13857.20","8314.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1611.59","11778.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE SPACER XL INTERSPACE TEMPORARY HIGH RELEASE","SUP-ITM-10196153","CDM","C1776","HCPCS","0278","RC","","","","both","","","13857.20","8314.32","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7884.75","56.9","","2911.53","1863.86","5209.05","65","1611.59","11778.62","percent of total billed charges",""
"KNEE SPACER XL INTERSPACE TEMPORARY HIGH RELEASE","SUP-ITM-10196153","CDM","C1776","HCPCS","0278","RC","","","","both","","","13857.20","8314.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1611.59","11.63","","400.94","400.94","400.94","1 through 10","1611.59","11778.62","percent of total billed charges",""
"KNEE SPACER XL INTERSPACE TEMPORARY HIGH RELEASE","SUP-ITM-10196153","CDM","C1776","HCPCS","0278","RC","","","","both","","","13857.20","8314.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10725.47","77.4","","5214.50","5214.50","16415.28","1 through 10","1611.59","11778.62","percent of total billed charges",""
"KNEE SPACER XL INTERSPACE TEMPORARY HIGH RELEASE","SUP-ITM-10196153","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1611.59","11.63","","400.94","400.94","400.94","1 through 10","1611.59","10725.47","percent of total billed charges",""
"KNEE SPACER XL INTERSPACE TEMPORARY HIGH RELEASE","SUP-ITM-10196153","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","6058.37","43.72","","1543.33","1543.33","1671.61","1 through 10","1611.59","10725.47","percent of total billed charges",""
"KNEE SPACER XL INTERSPACE TEMPORARY HIGH RELEASE","SUP-ITM-10196153","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10076.96","72.72","","3700.21","2382.07","6427.18","53","1611.59","10725.47","percent of total billed charges",""
"KNEE SPACER XL INTERSPACE TEMPORARY HIGH RELEASE","SUP-ITM-10196153","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","10076.96","72.72","","12685.80","12685.80","12685.80","1 through 10","1611.59","10725.47","percent of total billed charges",""
"KNEE SPACER XL INTERSPACE TEMPORARY HIGH RELEASE","SUP-ITM-10196153","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8716.18","62.9","","3408.87","2784.05","9859.40","46","1611.59","10725.47","percent of total billed charges",""
"KNEE SPACER XL INTERSPACE TEMPORARY HIGH RELEASE","SUP-ITM-10196153","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13857.20","8314.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10725.47","77.4","","5214.50","5214.50","16415.28","1 through 10","1611.59","10725.47","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","2086.82","1252.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","242.7","1773.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","2086.82","1252.09","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1187.40","56.9","","2911.53","1863.86","5209.05","65","242.7","1773.8","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","2086.82","1252.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","242.70","11.63","","400.94","400.94","400.94","1 through 10","242.7","1773.8","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","2086.82","1252.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1615.20","77.4","","5214.50","5214.50","16415.28","1 through 10","242.7","1773.8","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2086.82","1252.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","242.70","11.63","","400.94","400.94","400.94","1 through 10","242.7","1615.2","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2086.82","1252.09","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","912.36","43.72","","1543.33","1543.33","1671.61","1 through 10","242.7","1615.2","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2086.82","1252.09","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1517.54","72.72","","3700.21","2382.07","6427.18","53","242.7","1615.2","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2086.82","1252.09","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1517.54","72.72","","12685.80","12685.80","12685.80","1 through 10","242.7","1615.2","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2086.82","1252.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1312.61","62.9","","3408.87","2784.05","9859.40","46","242.7","1615.2","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2086.82","1252.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1615.20","77.4","","5214.50","5214.50","16415.28","1 through 10","242.7","1615.2","percent of total billed charges",""
"KNEE STEM 14X75MM IMPLANT TIBIAL REVISION FLUTED 11 UNIVERSAL","SUP-ITM-10028518","CDM","C1776","HCPCS","0278","RC","","","","both","","","5335.00","3201.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","620.46","4534.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE STEM 14X75MM IMPLANT TIBIAL REVISION FLUTED 11 UNIVERSAL","SUP-ITM-10028518","CDM","C1776","HCPCS","0278","RC","","","","both","","","5335.00","3201.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3035.62","56.9","","2911.53","1863.86","5209.05","65","620.46","4534.75","percent of total billed charges",""
"KNEE STEM 14X75MM IMPLANT TIBIAL REVISION FLUTED 11 UNIVERSAL","SUP-ITM-10028518","CDM","C1776","HCPCS","0278","RC","","","","both","","","5335.00","3201.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","620.46","11.63","","400.94","400.94","400.94","1 through 10","620.46","4534.75","percent of total billed charges",""
"KNEE STEM 14X75MM IMPLANT TIBIAL REVISION FLUTED 11 UNIVERSAL","SUP-ITM-10028518","CDM","C1776","HCPCS","0278","RC","","","","both","","","5335.00","3201.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4129.29","77.4","","5214.50","5214.50","16415.28","1 through 10","620.46","4534.75","percent of total billed charges",""
"KNEE STEM 14X75MM IMPLANT TIBIAL REVISION FLUTED 11 UNIVERSAL","SUP-ITM-10028518","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5335.00","3201.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","620.46","11.63","","400.94","400.94","400.94","1 through 10","620.46","4129.29","percent of total billed charges",""
"KNEE STEM 14X75MM IMPLANT TIBIAL REVISION FLUTED 11 UNIVERSAL","SUP-ITM-10028518","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5335.00","3201.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2332.46","43.72","","1543.33","1543.33","1671.61","1 through 10","620.46","4129.29","percent of total billed charges",""
"KNEE STEM 14X75MM IMPLANT TIBIAL REVISION FLUTED 11 UNIVERSAL","SUP-ITM-10028518","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5335.00","3201.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3879.61","72.72","","3700.21","2382.07","6427.18","53","620.46","4129.29","percent of total billed charges",""
"KNEE STEM 14X75MM IMPLANT TIBIAL REVISION FLUTED 11 UNIVERSAL","SUP-ITM-10028518","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5335.00","3201.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3879.61","72.72","","12685.80","12685.80","12685.80","1 through 10","620.46","4129.29","percent of total billed charges",""
"KNEE STEM 14X75MM IMPLANT TIBIAL REVISION FLUTED 11 UNIVERSAL","SUP-ITM-10028518","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5335.00","3201.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3355.72","62.9","","3408.87","2784.05","9859.40","46","620.46","4129.29","percent of total billed charges",""
"KNEE STEM 14X75MM IMPLANT TIBIAL REVISION FLUTED 11 UNIVERSAL","SUP-ITM-10028518","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5335.00","3201.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4129.29","77.4","","5214.50","5214.50","16415.28","1 through 10","620.46","4129.29","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 3 SCREW ON LEGION","SUP-ITM-10121428","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.97","1936.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","375.3","2742.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE WEDGE 15MM SIZE 3 SCREW ON LEGION","SUP-ITM-10121428","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.97","1936.18","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1836.15","56.9","","2911.53","1863.86","5209.05","65","375.3","2742.92","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 3 SCREW ON LEGION","SUP-ITM-10121428","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.97","1936.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","375.30","11.63","","400.94","400.94","400.94","1 through 10","375.3","2742.92","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 3 SCREW ON LEGION","SUP-ITM-10121428","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.97","1936.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2497.67","77.4","","5214.50","5214.50","16415.28","1 through 10","375.3","2742.92","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 3 SCREW ON LEGION","SUP-ITM-10121428","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","375.30","11.63","","400.94","400.94","400.94","1 through 10","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 3 SCREW ON LEGION","SUP-ITM-10121428","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1410.83","43.72","","1543.33","1543.33","1671.61","1 through 10","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 3 SCREW ON LEGION","SUP-ITM-10121428","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2346.65","72.72","","3700.21","2382.07","6427.18","53","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 3 SCREW ON LEGION","SUP-ITM-10121428","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2346.65","72.72","","12685.80","12685.80","12685.80","1 through 10","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 3 SCREW ON LEGION","SUP-ITM-10121428","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2029.76","62.9","","3408.87","2784.05","9859.40","46","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE 15MM SIZE 3 SCREW ON LEGION","SUP-ITM-10121428","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2497.67","77.4","","5214.50","5214.50","16415.28","1 through 10","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE 18MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198671","CDM","C1776","HCPCS","0278","RC","","","","both","","","8841.55","5304.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1028.27","7515.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE WEDGE 18MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198671","CDM","C1776","HCPCS","0278","RC","","","","both","","","8841.55","5304.93","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5030.84","56.9","","2911.53","1863.86","5209.05","65","1028.27","7515.32","percent of total billed charges",""
"KNEE WEDGE 18MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198671","CDM","C1776","HCPCS","0278","RC","","","","both","","","8841.55","5304.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1028.27","11.63","","400.94","400.94","400.94","1 through 10","1028.27","7515.32","percent of total billed charges",""
"KNEE WEDGE 18MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198671","CDM","C1776","HCPCS","0278","RC","","","","both","","","8841.55","5304.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6843.36","77.4","","5214.50","5214.50","16415.28","1 through 10","1028.27","7515.32","percent of total billed charges",""
"KNEE WEDGE 18MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198671","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8841.55","5304.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1028.27","11.63","","400.94","400.94","400.94","1 through 10","1028.27","6843.36","percent of total billed charges",""
"KNEE WEDGE 18MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198671","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8841.55","5304.93","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3865.53","43.72","","1543.33","1543.33","1671.61","1 through 10","1028.27","6843.36","percent of total billed charges",""
"KNEE WEDGE 18MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198671","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8841.55","5304.93","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6429.58","72.72","","3700.21","2382.07","6427.18","53","1028.27","6843.36","percent of total billed charges",""
"KNEE WEDGE 18MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198671","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8841.55","5304.93","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6429.58","72.72","","12685.80","12685.80","12685.80","1 through 10","1028.27","6843.36","percent of total billed charges",""
"KNEE WEDGE 18MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198671","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8841.55","5304.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5561.33","62.9","","3408.87","2784.05","9859.40","46","1028.27","6843.36","percent of total billed charges",""
"KNEE WEDGE 18MM FEMORAL CONE LEGION RIGHT","SUP-ITM-10198671","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8841.55","5304.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6843.36","77.4","","5214.50","5214.50","16415.28","1 through 10","1028.27","6843.36","percent of total billed charges",""
"KNEE WEDGE 5MM SIZE 3 SCREW ON 09","SUP-ITM-10019441","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.97","1936.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","375.3","2742.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE WEDGE 5MM SIZE 3 SCREW ON 09","SUP-ITM-10019441","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.97","1936.18","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1836.15","56.9","","2911.53","1863.86","5209.05","65","375.3","2742.92","percent of total billed charges",""
"KNEE WEDGE 5MM SIZE 3 SCREW ON 09","SUP-ITM-10019441","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.97","1936.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","375.30","11.63","","400.94","400.94","400.94","1 through 10","375.3","2742.92","percent of total billed charges",""
"KNEE WEDGE 5MM SIZE 3 SCREW ON 09","SUP-ITM-10019441","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.97","1936.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2497.67","77.4","","5214.50","5214.50","16415.28","1 through 10","375.3","2742.92","percent of total billed charges",""
"KNEE WEDGE 5MM SIZE 3 SCREW ON 09","SUP-ITM-10019441","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","375.30","11.63","","400.94","400.94","400.94","1 through 10","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE 5MM SIZE 3 SCREW ON 09","SUP-ITM-10019441","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1410.83","43.72","","1543.33","1543.33","1671.61","1 through 10","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE 5MM SIZE 3 SCREW ON 09","SUP-ITM-10019441","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2346.65","72.72","","3700.21","2382.07","6427.18","53","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE 5MM SIZE 3 SCREW ON 09","SUP-ITM-10019441","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2346.65","72.72","","12685.80","12685.80","12685.80","1 through 10","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE 5MM SIZE 3 SCREW ON 09","SUP-ITM-10019441","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2029.76","62.9","","3408.87","2784.05","9859.40","46","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE 5MM SIZE 3 SCREW ON 09","SUP-ITM-10019441","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2497.67","77.4","","5214.50","5214.50","16415.28","1 through 10","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE 5MM SZ 6 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10021616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.97","1936.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","375.3","2742.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE WEDGE 5MM SZ 6 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10021616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.97","1936.18","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1836.15","56.9","","2911.53","1863.86","5209.05","65","375.3","2742.92","percent of total billed charges",""
"KNEE WEDGE 5MM SZ 6 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10021616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.97","1936.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","375.30","11.63","","400.94","400.94","400.94","1 through 10","375.3","2742.92","percent of total billed charges",""
"KNEE WEDGE 5MM SZ 6 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10021616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.97","1936.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2497.67","77.4","","5214.50","5214.50","16415.28","1 through 10","375.3","2742.92","percent of total billed charges",""
"KNEE WEDGE 5MM SZ 6 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10021616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","375.30","11.63","","400.94","400.94","400.94","1 through 10","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE 5MM SZ 6 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10021616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1410.83","43.72","","1543.33","1543.33","1671.61","1 through 10","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE 5MM SZ 6 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10021616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2346.65","72.72","","3700.21","2382.07","6427.18","53","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE 5MM SZ 6 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10021616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2346.65","72.72","","12685.80","12685.80","12685.80","1 through 10","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE 5MM SZ 6 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10021616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2029.76","62.9","","3408.87","2784.05","9859.40","46","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE 5MM SZ 6 LEGION RK REVISION TITANIUM SCREW ON","SUP-ITM-10021616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2497.67","77.4","","5214.50","5214.50","16415.28","1 through 10","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE TIBIAL 4 10MM SIZE 3 LEGION RK REVISION TITANIUM HEMI STEPPED SCREW ON LT MEDIAL RT LATERAL DISPOS","SUP-ITM-10146036","CDM","C1713","HCPCS","0278","RC","","","","both","","","3226.97","1936.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","375.3","2742.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE WEDGE TIBIAL 4 10MM SIZE 3 LEGION RK REVISION TITANIUM HEMI STEPPED SCREW ON LT MEDIAL RT LATERAL DISPOS","SUP-ITM-10146036","CDM","C1713","HCPCS","0278","RC","","","","both","","","3226.97","1936.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","375.3","2742.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"KNEE WEDGE TIBIAL 4 10MM SIZE 3 LEGION RK REVISION TITANIUM HEMI STEPPED SCREW ON LT MEDIAL RT LATERAL DISPOS","SUP-ITM-10146036","CDM","C1713","HCPCS","0278","RC","","","","both","","","3226.97","1936.18","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1836.15","56.9","","812.12","238.65","1587.46","163","375.3","2742.92","percent of total billed charges",""
"KNEE WEDGE TIBIAL 4 10MM SIZE 3 LEGION RK REVISION TITANIUM HEMI STEPPED SCREW ON LT MEDIAL RT LATERAL DISPOS","SUP-ITM-10146036","CDM","C1713","HCPCS","0278","RC","","","","both","","","3226.97","1936.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","375.30","11.63","","112.68","112.68","146.99","38","375.3","2742.92","percent of total billed charges",""
"KNEE WEDGE TIBIAL 4 10MM SIZE 3 LEGION RK REVISION TITANIUM HEMI STEPPED SCREW ON LT MEDIAL RT LATERAL DISPOS","SUP-ITM-10146036","CDM","C1713","HCPCS","0278","RC","","","","both","","","3226.97","1936.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2497.67","77.4","","303.98","303.98","5854.79","1 through 10","375.3","2742.92","percent of total billed charges",""
"KNEE WEDGE TIBIAL 4 10MM SIZE 3 LEGION RK REVISION TITANIUM HEMI STEPPED SCREW ON LT MEDIAL RT LATERAL DISPOS","SUP-ITM-10146036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","375.30","11.63","","112.68","112.68","146.99","38","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE TIBIAL 4 10MM SIZE 3 LEGION RK REVISION TITANIUM HEMI STEPPED SCREW ON LT MEDIAL RT LATERAL DISPOS","SUP-ITM-10146036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2025.89","62.78","","780.86","208.94","10480.28","15","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE TIBIAL 4 10MM SIZE 3 LEGION RK REVISION TITANIUM HEMI STEPPED SCREW ON LT MEDIAL RT LATERAL DISPOS","SUP-ITM-10146036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1410.83","43.72","","179.76","179.76","179.76","1 through 10","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE TIBIAL 4 10MM SIZE 3 LEGION RK REVISION TITANIUM HEMI STEPPED SCREW ON LT MEDIAL RT LATERAL DISPOS","SUP-ITM-10146036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2346.65","72.72","","2355.45","298.99","3965.19","155","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE TIBIAL 4 10MM SIZE 3 LEGION RK REVISION TITANIUM HEMI STEPPED SCREW ON LT MEDIAL RT LATERAL DISPOS","SUP-ITM-10146036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2346.65","72.72","","3643.09","3643.09","3643.09","1 through 10","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE TIBIAL 4 10MM SIZE 3 LEGION RK REVISION TITANIUM HEMI STEPPED SCREW ON LT MEDIAL RT LATERAL DISPOS","SUP-ITM-10146036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1717.39","53.22","","554.28","554.28","554.28","16","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE TIBIAL 4 10MM SIZE 3 LEGION RK REVISION TITANIUM HEMI STEPPED SCREW ON LT MEDIAL RT LATERAL DISPOS","SUP-ITM-10146036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2029.76","62.9","","619.64","173.09","2370.64","150","375.3","2497.67","percent of total billed charges",""
"KNEE WEDGE TIBIAL 4 10MM SIZE 3 LEGION RK REVISION TITANIUM HEMI STEPPED SCREW ON LT MEDIAL RT LATERAL DISPOS","SUP-ITM-10146036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2497.67","77.4","","303.98","303.98","5854.79","1 through 10","375.3","2497.67","percent of total billed charges",""
"Lacosamide 80299","PX-30003299","CDM","80299","CPT","0301","RC","","","","both","","","271.00","162.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","189.16","69.8","","69.80","62.90","69.80","1 through 10","12.12","230.35","percent of total billed charges",""
"Lacosamide 80299","PX-30003299","CDM","80299","CPT","0301","RC","","","","outpatient","","","271.00","162.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","118.48","43.72","","43.72","43.72","43.72","1 through 10","12.76","209.75","percent of total billed charges",""
"Lacosamide 80299","PX-30003299","CDM","80299","CPT","0301","RC","","","","outpatient","","","271.00","162.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","197.07","72.72","","72.72","72.72","72.72","1 through 10","12.76","209.75","percent of total billed charges",""
"Lacosamide 80299","PX-30003299","CDM","80299","CPT","0301","RC","","","","outpatient","","","271.00","162.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","197.07","72.72","","190.53","190.53","190.53","1 through 10","12.76","209.75","percent of total billed charges",""
"Lacosamide 80299","PX-30003299","CDM","80299","CPT","0301","RC","","","","outpatient","","","271.00","162.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","144.23","53.22","","53.31","53.31","53.31","1 through 10","12.76","209.75","percent of total billed charges",""
"Lacosamide 80299","PX-30003299","CDM","80299","CPT","0301","RC","","","","outpatient","","","271.00","162.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","170.46","62.9","","63.00","63.00","189.00","13","12.76","209.75","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","both","","","86.00","51.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","60.03","69.8","","57.93","52.21","57.93","42","3.93","73.1","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","both","","","86.00","51.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","60.03","69.8","","7.79","7.79","7.79","1 through 10","3.93","73.1","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","outpatient","","","86.00","51.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","53.99","62.78","","52.11","52.11","52.11","1 through 10","5.62","66.56","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","outpatient","","","86.00","51.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","37.60","43.72","","36.29","36.29","36.29","1 through 10","5.62","66.56","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","outpatient","","","86.00","51.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","62.54","72.72","","60.36","60.36","60.36","64","5.62","66.56","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","outpatient","","","86.00","51.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","62.54","72.72","","60.36","60.36","60.36","13","5.62","66.56","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","outpatient","","","86.00","51.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","54.09","62.9","","52.29","52.29","156.87","75","5.62","66.56","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","outpatient","","","86.00","51.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","66.56","77.4","","64.33","64.33","64.33","56","5.62","66.56","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0300","RC","","","","inpatient","","","152.00","91.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","116.83","76.86","","92.61","88.91","177.83","12","100.62","116.83","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","both","","","152.00","91.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","106.10","69.8","","102.61","91.52","102.61","19","7.52","129.2","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","outpatient","","","152.00","91.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","95.43","62.78","","92.29","92.29","92.29","1 through 10","9.95","117.65","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","outpatient","","","152.00","91.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","66.45","43.72","","64.27","64.27","192.81","1 through 10","9.95","117.65","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","outpatient","","","152.00","91.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","110.53","72.72","","106.90","106.90","213.80","37","9.95","117.65","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","outpatient","","","152.00","91.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","110.53","72.72","","106.90","106.90","106.90","1 through 10","9.95","117.65","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","outpatient","","","152.00","91.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","95.61","62.9","","92.61","92.61","355.64","65","9.95","117.65","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","outpatient","","","152.00","91.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","117.65","77.4","","113.93","113.92","227.86","14","9.95","117.65","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","outpatient","","","152.00","91.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","110.53","72.72","","106.90","106.90","106.90","1 through 10","9.95","117.65","percent of total billed charges",""
"Lactation Classes, Non Physician Provider, per Session","PX-94000043","CDM","S9443","HCPCS","0940","RC","","","","both","","","301.00","180.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","255.85","85","","247.35","247.35","247.35","1 through 10","160.1","255.85","percent of total billed charges",""
"Lactation Classes, Non Physician Provider, per Session","PX-94000043","CDM","S9443","HCPCS","0940","RC","","","","outpatient","","","301.00","180.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","43.40","14.42","","41.96","35.97","41.96","1 through 10","35.01","232.97","percent of total billed charges",""
"Lactation Classes, Non Physician Provider, per Session","PX-94000043","CDM","S9443","HCPCS","0940","RC","","","","outpatient","","","301.00","180.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","35.01","11.63","","34.37","34.37","34.37","1 through 10","35.01","232.97","percent of total billed charges",""
"Lactation Classes, Non Physician Provider, per Session","PX-94000043","CDM","S9443","HCPCS","0940","RC","","","","outpatient","","","301.00","180.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","218.89","72.72","","211.62","211.62","211.62","35","35.01","232.97","percent of total billed charges",""
"Lactation Classes, Non Physician Provider, per Session","PX-94000043","CDM","S9443","HCPCS","0940","RC","","","","outpatient","","","301.00","180.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","218.89","72.72","","211.62","211.62","211.62","1 through 10","35.01","232.97","percent of total billed charges",""
"Lactation Classes, Non Physician Provider, per Session","PX-94000043","CDM","S9443","HCPCS","0940","RC","","","","outpatient","","","301.00","180.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","189.33","62.9","","183.33","183.33","183.33","15","35.01","232.97","percent of total billed charges",""
"Lactation Classes, Non Physician Provider, per Session","PX-94000043","CDM","S9443","HCPCS","0940","RC","","","","outpatient","","","301.00","180.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","218.89","72.72","","211.62","211.62","211.62","1 through 10","35.01","232.97","percent of total billed charges",""
"Lactation Classes, Non Physician Provider, per Session","PX-94000043","CDM","S9443","HCPCS","0940","RC","","","","outpatient","","","301.00","180.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","35.01","11.63","","34.37","34.37","34.37","1 through 10","35.01","232.97","percent of total billed charges",""
"Lactoferrin Fecal Ql","PX-30000540","CDM","83630","CPT","0301","RC","","","","outpatient","","","105.00","63.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","66.05","62.9","","64.26","64.26","64.26","1 through 10","13.34","81.27","percent of total billed charges",""
"Laminot/Laminect Lumbar Perc","PX-76001741","CDM","0275T","CPT","0761","RC","","","","both","","","25710.00","15426.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","47698.57","","Case rate ($47,698.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","24809.00","24809.00","24809.00","1 through 10","7314.21","47698.57","other","OPPS APC"
"Laminot/Laminect Lumbar Perc","PX-76001741","CDM","0275T","CPT","0761","RC","","","","both","","","25710.00","15426.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7463.48","","APC Price ($7,463.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7464.34","7315.06","7464.34","1 through 10","7314.21","47698.57","other","OPPS APC"
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","","","","inpatient","","","80261.90","48157.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","64280.97","","Fee schedule rate ($64,280.97). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","46055.03","46055.03","46055.03","1 through 10","3975","64280.97","case rate",""
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","","","","inpatient","","","80261.90","48157.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","13039.05","","Case rate ($13,305.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,314.76, add-ons for qualifying new technology services are included. If operating cost exceeds $16,232.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,744.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $11,920.52 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,869.90 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $939.76. The transfer capital threshold is the transfer adjustment factor * $939.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12731.81","12731.81","12731.81","1 through 10","3975","64280.97","other","Inpatient DRG"
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","","","","inpatient","","","80261.90","48157.14","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","13704.30","","Case rate ($13,305.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,314.76, add-ons for qualifying new technology services are included. If operating cost exceeds $16,232.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,744.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $11,920.52 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,869.90 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $939.76. The transfer capital threshold is the transfer adjustment factor * $939.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","10564.26","10564.26","10564.26","1 through 10","3975","64280.97","other","Inpatient DRG"
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","","","","inpatient","","","80261.90","48157.14","MARTIN'S POINT [160007]","HB WDH MEDICARE","13305.15","","Case rate ($13,305.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,314.76, add-ons for qualifying new technology services are included. If operating cost exceeds $16,232.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,744.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $11,920.52 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,869.90 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $939.76. The transfer capital threshold is the transfer adjustment factor * $939.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18732.03","18732.03","18732.03","1 through 10","3975","64280.97","other","Inpatient DRG"
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","","","","inpatient","","","80261.90","48157.14","MEDICARE [2001]","HB WDH MEDICARE","13305.15","","Case rate ($13,305.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,314.76, add-ons for qualifying new technology services are included. If operating cost exceeds $16,232.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,744.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $11,920.52 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,869.90 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $939.76. The transfer capital threshold is the transfer adjustment factor * $939.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12990.95","0.05","12990.95","12","3975","64280.97","other","Inpatient DRG"
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","","","","inpatient","","","80261.90","48157.14","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","13305.15","","Case rate ($13,305.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,314.76, add-ons for qualifying new technology services are included. If operating cost exceeds $16,232.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,744.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $11,920.52 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,869.90 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $939.76. The transfer capital threshold is the transfer adjustment factor * $939.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12958.34","12958.34","12958.34","1 through 10","3975","64280.97","other","Inpatient DRG"
"Laparoscopic Cholecystectomy Without C.D.E. With McC","417","MS-DRG","","","","","","","","inpatient","","","105552.34","63331.40","MEDICARE [2001]","HB WDH MEDICARE","18587.32","","Case rate ($18,587.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $17,190.16, add-ons for qualifying new technology services are included. If operating cost exceeds $21,108.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,130.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $16,816.70 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $16,745.28 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,325.75. The transfer capital threshold is the transfer adjustment factor * $1,325.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18423.54","18376.82","18424.78","1 through 10","3975","90683.44","other","Inpatient DRG"
"Laparoscopic Cholecystectomy Without C.D.E. With McC","417","MS-DRG","","","","","","","","inpatient","","","105552.34","63331.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","18587.32","","Case rate ($18,587.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $17,190.16, add-ons for qualifying new technology services are included. If operating cost exceeds $21,108.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,130.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $16,816.70 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $16,745.28 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,325.75. The transfer capital threshold is the transfer adjustment factor * $1,325.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18089.27","18089.27","18089.27","1 through 10","3975","90683.44","other","Inpatient DRG"
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC","419","MS-DRG","","","","","","","","inpatient","","","70207.56","42124.54","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","51900.54","","Fee schedule rate ($51,900.54). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","48847.74","48847.74","48847.74","1 through 10","3975","51900.54","case rate",""
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC","419","MS-DRG","","","","","","","","inpatient","","","70207.56","42124.54","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","41336.32","","Fee schedule rate ($41,336.32). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","38904.90","38904.90","38904.90","1 through 10","3975","51900.54","case rate",""
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC","419","MS-DRG","","","","","","","","inpatient","","","70207.56","42124.54","MARTIN'S POINT [160007]","HB WDH MEDICARE","10828.28","","Case rate ($10,828.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,028.64, add-ons for qualifying new technology services are included. If operating cost exceeds $13,946.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,563.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $9,624.64 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,583.77 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $758.76. The transfer capital threshold is the transfer adjustment factor * $758.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Includes an additional $800 of payment.","14573.14","14573.14","14573.14","1 through 10","3975","51900.54","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC","419","MS-DRG","","","","","","","","inpatient","","","70207.56","42124.54","MEDICARE [2001]","HB WDH MEDICARE","10828.28","","Case rate ($10,828.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,028.64, add-ons for qualifying new technology services are included. If operating cost exceeds $13,946.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,563.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $9,624.64 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,583.77 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $758.76. The transfer capital threshold is the transfer adjustment factor * $758.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Includes an additional $800 of payment.","10386.81","10386.81","10386.81","1 through 10","3975","51900.54","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC","419","MS-DRG","","","","","","","","inpatient","","","70207.56","42124.54","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","10828.28","","Case rate ($10,828.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,028.64, add-ons for qualifying new technology services are included. If operating cost exceeds $13,946.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,563.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $9,624.64 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,583.77 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $758.76. The transfer capital threshold is the transfer adjustment factor * $758.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Includes an additional $800 of payment.","10204.46","10204.46","10204.46","1 through 10","3975","51900.54","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Laryngoscopy Flex","PX-76000771","CDM","31575","CPT","0761","RC","","","","both","","","1124.00","674.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1296.26","","Case rate ($1,296.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1085.00","1085.00","1085.00","1 through 10","198.77","1296.26","other","OPPS APC"
"Laryngoscopy Flex","PX-76000771","CDM","31575","CPT","0761","RC","","","","both","","","1124.00","674.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","558.17","","Case rate ($558.17). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","544.56","540.21","544.56","1 through 10","198.77","1296.26","other","OPPS APC"
"Laryngoscopy Flex","PX-76000771","CDM","31575","CPT","0761","RC","","","","both","","","1124.00","674.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","198.77","","APC Price ($202.83). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","199.79","199.79","199.79","1 through 10","198.77","1296.26","other","OPPS APC"
"Laryngoscopy Flex","PX-76000771","CDM","31575","CPT","0761","RC","","","","both","","","1124.00","674.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","639.56","56.9","","617.37","617.37","617.37","1 through 10","198.77","1296.26","percent of total billed charges",""
"Laryngoscopy Flex","PX-76000771","CDM","31575","CPT","0761","RC","","","","both","","","1124.00","674.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","208.91","","APC Price ($202.83). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","208.94","208.94","208.94","1 through 10","198.77","1296.26","other","OPPS APC"
"Laryngoscopy Flex","PX-76000771","CDM","31575","CPT","0761","RC","","","","both","","","1124.00","674.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","202.83","","APC Price ($202.83). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","198.79","198.79","198.79","1 through 10","198.77","1296.26","other","OPPS APC"
"Laryngoscopy Flex","PX-76000771","CDM","31575","CPT","0761","RC","","","","both","","","1124.00","674.40","MEDICARE [2001]","HB WDH MEDICARE","202.83","","APC Price ($202.83). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","202.85","193.00","202.85","1 through 10","198.77","1296.26","other","OPPS APC"
"Laryngoscopy Flex","PX-76000771","CDM","31575","CPT","0761","RC","","","","both","","","1124.00","674.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","202.83","","APC Price ($202.83). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","202.85","199.61","202.85","1 through 10","198.77","1296.26","other","OPPS APC"
"Laryngoscopy Flex","PX-76000771","CDM","31575","CPT","0761","RC","","","","outpatient","","","1124.00","674.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","162.08","14.42","","156.46","156.46","156.46","1 through 10","130.72","869.98","percent of total billed charges",""
"Laryngoscopy Flex","PX-76000771","CDM","31575","CPT","0761","RC","","","","outpatient","","","1124.00","674.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","789.01","789.01","789.01","1 through 10","130.72","869.98","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Laryngoscopy Flex","PX-76000771","CDM","31575","CPT","0761","RC","","","","outpatient","","","1124.00","674.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","130.72","11.63","","324.56","324.56","324.56","1 through 10","130.72","869.98","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","both","","","67.00","40.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","46.77","69.8","","45.37","40.89","45.37","16","7.87","63.21","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","outpatient","","","67.00","40.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","48.72","72.72","","47.27","47.27","47.27","14","11.27","51.86","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","outpatient","","","67.00","40.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","48.72","72.72","","47.27","47.27","47.27","1 through 10","11.27","51.86","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","outpatient","","","67.00","40.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","42.14","62.9","","40.95","40.95","40.95","25","11.27","51.86","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","outpatient","","","67.00","40.20","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","48.72","72.72","","50.38","50.38","50.38","1 through 10","11.27","51.86","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","outpatient","","","67.00","40.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","51.86","77.4","","50.38","47.27","50.38","1 through 10","11.27","51.86","percent of total billed charges",""
"LEAD 25CM EXTENDER NEUROSTIMULATOR 8CONTACT PHASE III PRECISION","SUP-ITM-10030186","CDM","C1883","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3911.75","62.9","","4897.47","4897.47","4897.47","1 through 10","723.27","4813.51","percent of total billed charges",""
"LEAD ELECTRODE 52MMX60CM TRIAL OCTRODE 8 NEUROSTIMULATOR","SUP-ITM-10018946","CDM","C1897","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.06","11.63","","605.27","605.27","605.27","1 through 10","564.06","4122.5","percent of total billed charges",""
"LEAD ELECTRODE 52MMX60CM TRIAL OCTRODE 8 NEUROSTIMULATOR","SUP-ITM-10018946","CDM","C1897","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.06","11.63","","605.27","605.27","605.27","1 through 10","564.06","3753.9","percent of total billed charges",""
"LEAD ELECTRODE 52MMX60CM TRIAL OCTRODE 8 NEUROSTIMULATOR","SUP-ITM-10018946","CDM","C1897","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3526.92","72.72","","3596.00","3596.00","3596.00","1 through 10","564.06","3753.9","percent of total billed charges",""
"LEAD ELECTRODE 52MMX60CM TRIAL OCTRODE 8 NEUROSTIMULATOR","SUP-ITM-10018946","CDM","C1897","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3050.65","62.9","","3130.19","3115.35","3130.19","1 through 10","564.06","3753.9","percent of total billed charges",""
"LEAD MRI 74CM SAFE AVISTA","SUP-ITM-10191385","CDM","C1778","HCPCS","0278","RC","","","","both","","","11155.00","6693.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","14342.00","14342.00","14342.00","1 through 10","1297.33","9481.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"LEAD MRI 74CM SAFE AVISTA","SUP-ITM-10191385","CDM","C1778","HCPCS","0278","RC","","","","both","","","11155.00","6693.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1297.33","11.63","","2253.51","2253.51","2253.51","1 through 10","1297.33","9481.75","percent of total billed charges",""
"LEAD MRI 74CM SAFE AVISTA","SUP-ITM-10191385","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","11155.00","6693.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1297.33","11.63","","2253.51","2253.51","2253.51","1 through 10","1297.33","8633.97","percent of total billed charges",""
"LEAD MRI 74CM SAFE AVISTA","SUP-ITM-10191385","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","11155.00","6693.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7016.50","62.9","","21082.95","11598.93","21082.95","1 through 10","1297.33","8633.97","percent of total billed charges",""
"LEAD NEUROMODULATION 1.0X16 50CM SPINAL INFINEON PERCUTANEOUS TRIAL","SUP-ITM-10126480","CDM","C1778","HCPCS","0278","RC","","","","both","","","5335.00","3201.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","14342.00","14342.00","14342.00","1 through 10","620.46","4534.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"LEAD NEUROMODULATION 1.0X16 50CM SPINAL INFINEON PERCUTANEOUS TRIAL","SUP-ITM-10126480","CDM","C1778","HCPCS","0278","RC","","","","both","","","5335.00","3201.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","620.46","11.63","","2253.51","2253.51","2253.51","1 through 10","620.46","4534.75","percent of total billed charges",""
"LEAD NEUROMODULATION 1.0X16 50CM SPINAL INFINEON PERCUTANEOUS TRIAL","SUP-ITM-10126480","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","5335.00","3201.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","620.46","11.63","","2253.51","2253.51","2253.51","1 through 10","620.46","4129.29","percent of total billed charges",""
"LEAD NEUROMODULATION 1.0X16 50CM SPINAL INFINEON PERCUTANEOUS TRIAL","SUP-ITM-10126480","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","5335.00","3201.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3355.72","62.9","","21082.95","11598.93","21082.95","1 through 10","620.46","4129.29","percent of total billed charges",""
"LEAD NEUROMODULATION 70CM SPINAL PRECISION LINEAR 8 CONTACT ENHANCED","SUP-ITM-10077213","CDM","C1778","HCPCS","0278","RC","","","","both","","","7275.00","4365.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","14342.00","14342.00","14342.00","1 through 10","846.08","6183.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"LEAD NEUROMODULATION 70CM SPINAL PRECISION LINEAR 8 CONTACT ENHANCED","SUP-ITM-10077213","CDM","C1778","HCPCS","0278","RC","","","","both","","","7275.00","4365.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","846.08","11.63","","2253.51","2253.51","2253.51","1 through 10","846.08","6183.75","percent of total billed charges",""
"LEAD NEUROMODULATION 70CM SPINAL PRECISION LINEAR 8 CONTACT ENHANCED","SUP-ITM-10077213","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","846.08","11.63","","2253.51","2253.51","2253.51","1 through 10","846.08","5630.85","percent of total billed charges",""
"LEAD NEUROMODULATION 70CM SPINAL PRECISION LINEAR 8 CONTACT ENHANCED","SUP-ITM-10077213","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4575.98","62.9","","21082.95","11598.93","21082.95","1 through 10","846.08","5630.85","percent of total billed charges",""
"Lead Neurostimulator Test Kit T1","PX-27000191","CDM","C1897","HCPCS","0278","RC","","","","outpatient","","","4945.00","2967.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","575.10","11.63","","605.27","605.27","605.27","1 through 10","575.1","3827.43","percent of total billed charges",""
"Lead Neurostimulator Test Kit T1","PX-27000191","CDM","C1897","HCPCS","0278","RC","","","","outpatient","","","4945.00","2967.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3596.00","72.72","","3596.00","3596.00","3596.00","1 through 10","575.1","3827.43","percent of total billed charges",""
"Lead Neurostimulator Test Kit T1","PX-27000191","CDM","C1897","HCPCS","0278","RC","","","","outpatient","","","4945.00","2967.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3110.41","62.9","","3130.19","3115.35","3130.19","1 through 10","575.1","3827.43","percent of total billed charges",""
"LEAD OCTRODE 60CM NEUROSTIMULATOR","SUP-ITM-10019318","CDM","C1778","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","14342.00","14342.00","14342.00","1 through 10","1128.11","8245","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"LEAD OCTRODE 60CM NEUROSTIMULATOR","SUP-ITM-10019318","CDM","C1778","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1128.11","11.63","","2253.51","2253.51","2253.51","1 through 10","1128.11","8245","percent of total billed charges",""
"LEAD OCTRODE 60CM NEUROSTIMULATOR","SUP-ITM-10019318","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1128.11","11.63","","2253.51","2253.51","2253.51","1 through 10","1128.11","7507.8","percent of total billed charges",""
"LEAD OCTRODE 60CM NEUROSTIMULATOR","SUP-ITM-10019318","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6101.30","62.9","","21082.95","11598.93","21082.95","1 through 10","1128.11","7507.8","percent of total billed charges",""
"LEAD STIMULATION","SUP-ITM-10209083","CDM","C1778","HCPCS","0278","RC","","","","both","","","9457.50","5674.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","14342.00","14342.00","14342.00","1 through 10","1099.91","8038.88","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"LEAD STIMULATION","SUP-ITM-10209083","CDM","C1778","HCPCS","0278","RC","","","","both","","","9457.50","5674.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1099.91","11.63","","2253.51","2253.51","2253.51","1 through 10","1099.91","8038.88","percent of total billed charges",""
"LEAD STIMULATION","SUP-ITM-10209083","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","9457.50","5674.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1099.91","11.63","","2253.51","2253.51","2253.51","1 through 10","1099.91","7320.11","percent of total billed charges",""
"LEAD STIMULATION","SUP-ITM-10209083","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","9457.50","5674.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5948.77","62.9","","21082.95","11598.93","21082.95","1 through 10","1099.91","7320.11","percent of total billed charges",""
"LEAD STIMULATOR 50CM INFINEON 16 CONTACT","SUP-ITM-10126479","CDM","C1778","HCPCS","0278","RC","","","","both","","","13332.00","7999.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","14342.00","14342.00","14342.00","1 through 10","1550.51","11332.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"LEAD STIMULATOR 50CM INFINEON 16 CONTACT","SUP-ITM-10126479","CDM","C1778","HCPCS","0278","RC","","","","both","","","13332.00","7999.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1550.51","11.63","","2253.51","2253.51","2253.51","1 through 10","1550.51","11332.2","percent of total billed charges",""
"LEAD STIMULATOR 50CM INFINEON 16 CONTACT","SUP-ITM-10126479","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","13332.00","7999.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1550.51","11.63","","2253.51","2253.51","2253.51","1 through 10","1550.51","10318.97","percent of total billed charges",""
"LEAD STIMULATOR 50CM INFINEON 16 CONTACT","SUP-ITM-10126479","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","13332.00","7999.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8385.83","62.9","","21082.95","11598.93","21082.95","1 through 10","1550.51","10318.97","percent of total billed charges",""
"LEAD STIMULATOR 60CM LAMITRODE 16CH 5 COLUMN PENTA","SUP-ITM-10086854","CDM","C1778","HCPCS","0278","RC","","","","both","","","18180.00","10908.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","14342.00","14342.00","14342.00","1 through 10","2114.33","15453","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"LEAD STIMULATOR 60CM LAMITRODE 16CH 5 COLUMN PENTA","SUP-ITM-10086854","CDM","C1778","HCPCS","0278","RC","","","","both","","","18180.00","10908.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2114.33","11.63","","2253.51","2253.51","2253.51","1 through 10","2114.33","15453","percent of total billed charges",""
"LEAD STIMULATOR 60CM LAMITRODE 16CH 5 COLUMN PENTA","SUP-ITM-10086854","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","18180.00","10908.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2114.33","11.63","","2253.51","2253.51","2253.51","1 through 10","2114.33","14071.32","percent of total billed charges",""
"LEAD STIMULATOR 60CM LAMITRODE 16CH 5 COLUMN PENTA","SUP-ITM-10086854","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","18180.00","10908.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","11435.22","62.9","","21082.95","11598.93","21082.95","1 through 10","2114.33","14071.32","percent of total billed charges",""
"LEAD TRIAL NEUROSTIMULATOR 1X16 70CM INFINION","SUP-ITM-10280226","CDM","C1778","HCPCS","0278","RC","","","","both","","","5335.00","3201.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","14342.00","14342.00","14342.00","1 through 10","620.46","4534.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"LEAD TRIAL NEUROSTIMULATOR 1X16 70CM INFINION","SUP-ITM-10280226","CDM","C1778","HCPCS","0278","RC","","","","both","","","5335.00","3201.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","620.46","11.63","","2253.51","2253.51","2253.51","1 through 10","620.46","4534.75","percent of total billed charges",""
"LEAD TRIAL NEUROSTIMULATOR 1X16 70CM INFINION","SUP-ITM-10280226","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","5335.00","3201.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","620.46","11.63","","2253.51","2253.51","2253.51","1 through 10","620.46","4129.29","percent of total billed charges",""
"LEAD TRIAL NEUROSTIMULATOR 1X16 70CM INFINION","SUP-ITM-10280226","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","5335.00","3201.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3355.72","62.9","","21082.95","11598.93","21082.95","1 through 10","620.46","4129.29","percent of total billed charges",""
"Leflunomide Metabolite (Teriflunomide), Serum","PX-30003064","CDM","80299","CPT","0300","RC","","","","both","","","271.00","162.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","189.16","69.8","","69.80","62.90","69.80","1 through 10","12.12","230.35","percent of total billed charges",""
"Leflunomide Metabolite (Teriflunomide), Serum","PX-30003064","CDM","80299","CPT","0300","RC","","","","outpatient","","","271.00","162.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","118.48","43.72","","43.72","43.72","43.72","1 through 10","12.76","209.75","percent of total billed charges",""
"Leflunomide Metabolite (Teriflunomide), Serum","PX-30003064","CDM","80299","CPT","0300","RC","","","","outpatient","","","271.00","162.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","197.07","72.72","","72.72","72.72","72.72","1 through 10","12.76","209.75","percent of total billed charges",""
"Leflunomide Metabolite (Teriflunomide), Serum","PX-30003064","CDM","80299","CPT","0300","RC","","","","outpatient","","","271.00","162.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","197.07","72.72","","190.53","190.53","190.53","1 through 10","12.76","209.75","percent of total billed charges",""
"Leflunomide Metabolite (Teriflunomide), Serum","PX-30003064","CDM","80299","CPT","0300","RC","","","","outpatient","","","271.00","162.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","144.23","53.22","","53.31","53.31","53.31","1 through 10","12.76","209.75","percent of total billed charges",""
"Leflunomide Metabolite (Teriflunomide), Serum","PX-30003064","CDM","80299","CPT","0300","RC","","","","outpatient","","","271.00","162.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","170.46","62.9","","63.00","63.00","189.00","13","12.76","209.75","percent of total billed charges",""
"Left Heart Artery/Graft Angio","PX-48000124","CDM","93459","CPT","0481","RC","","","","both","","","17038.00","10222.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","9247.52","","Case rate ($9,247.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9022.08","9022.08","9022.08","1 through 10","3293.17","21475.95","other","OPPS APC"
"Left Heart Artery/Graft Angio","PX-48000124","CDM","93459","CPT","0481","RC","","","","both","","","17038.00","10222.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","9694.62","56.9","","791.97","791.97","9791.70","1 through 10","3293.17","21475.95","percent of total billed charges",""
"Left Heart Artery/Graft Angio","PX-48000124","CDM","93459","CPT","0481","RC","","","","both","","","17038.00","10222.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3360.76","3360.76","3360.76","1 through 10","3293.17","21475.95","other","OPPS APC"
"Left Heart Artery/Graft Angio","PX-48000124","CDM","93459","CPT","0481","RC","","","","both","","","17038.00","10222.80","MEDICARE [2001]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3360.76","3360.76","3360.76","1 through 10","3293.17","21475.95","other","OPPS APC"
"Left Heart Artery/Graft Angio","PX-48000124","CDM","93459","CPT","0481","RC","","","","both","","","17038.00","10222.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3360.76","3301.55","5846.16","1 through 10","3293.17","21475.95","other","OPPS APC"
"Left Heart Artery/Graft Angio","PX-48000124","CDM","93459","CPT","0481","RC","","","","both","","","17038.00","10222.80","WELLPOINT [1015]","HB WDH ANTHEM PPO","17358.81","","Case rate ($17,358.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","14629.00","14629.00","14629.00","1 through 10","3293.17","21475.95","other","OPPS APC"
"Left Heart Artery/Graft Angio","PX-48000124","CDM","93459","CPT","0481","RC","","","","both","","","17038.00","10222.80","WELLSENSE NH [1050]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3458.22","3458.22","3458.22","1 through 10","3293.17","21475.95","other","OPPS APC"
"Left Heart Artery/Graft Angio","PX-48000124","CDM","93459","CPT","0481","RC","","","","outpatient","","","17038.00","10222.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1981.52","11.63","","2263.93","2263.93","2263.93","1 through 10","1981.52","13187.41","percent of total billed charges",""
"Left Heart Artery/Graft Angio","PX-48000124","CDM","93459","CPT","0481","RC","","","","outpatient","","","17038.00","10222.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","10716.90","62.9","","10357.83","10357.83","10357.83","1 through 10","1981.52","13187.41","percent of total billed charges",""
"Left Heart Artery/Graft Angio","PX-48000124","CDM","93459","CPT","0481","RC","","","","outpatient","","","17038.00","10222.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","13187.41","77.4","","12741.78","12741.78","12741.78","1 through 10","1981.52","13187.41","percent of total billed charges",""
"LENS INTRAOCULAR AC MTA4U0 16.0D","SUP-ITM-10024800","CDM","V2630","HCPCS","0276","RC","","","","both","","","587.35","352.41","AETNA [1001]","HB WDH AETNA COMMERCIAL","409.97","69.8","","573.96","573.96","573.96","1 through 10","68.31","499.25","percent of total billed charges",""
"LENS INTRAOCULAR AC MTA4U0 16.0D","SUP-ITM-10024800","CDM","V2630","HCPCS","0276","RC","","","","both","","","587.35","352.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","334.20","56.9","","467.88","467.88","467.88","1 through 10","68.31","499.25","percent of total billed charges",""
"LENS INTRAOCULAR AC MTA4U0 16.0D","SUP-ITM-10024800","CDM","V2630","HCPCS","0276","RC","","","","outpatient","","","587.35","352.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","369.44","62.9","","5563.53","1036.08","5563.53","12","68.31","454.61","percent of total billed charges",""
"LENS INTRAOCULAR CT LUCIA 602 20.5D","SUP-ITM-10232352","CDM","V2630","HCPCS","0276","RC","","","","both","","","1001.95","601.17","AETNA [1001]","HB WDH AETNA COMMERCIAL","699.36","69.8","","573.96","573.96","573.96","1 through 10","116.53","851.66","percent of total billed charges",""
"LENS INTRAOCULAR CT LUCIA 602 20.5D","SUP-ITM-10232352","CDM","V2630","HCPCS","0276","RC","","","","both","","","1001.95","601.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","570.11","56.9","","467.88","467.88","467.88","1 through 10","116.53","851.66","percent of total billed charges",""
"LENS INTRAOCULAR CT LUCIA 602 20.5D","SUP-ITM-10232352","CDM","V2630","HCPCS","0276","RC","","","","outpatient","","","1001.95","601.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","630.23","62.9","","5563.53","1036.08","5563.53","12","116.53","775.51","percent of total billed charges",""
"LENS INTRAOCULAR ENVISTA MX60 15.5D","SUP-ITM-10214258","CDM","V2630","HCPCS","0276","RC","","","","both","","","822.29","493.37","AETNA [1001]","HB WDH AETNA COMMERCIAL","573.96","69.8","","573.96","573.96","573.96","1 through 10","95.63","698.95","percent of total billed charges",""
"LENS INTRAOCULAR ENVISTA MX60 15.5D","SUP-ITM-10214258","CDM","V2630","HCPCS","0276","RC","","","","both","","","822.29","493.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","467.88","56.9","","467.88","467.88","467.88","1 through 10","95.63","698.95","percent of total billed charges",""
"LENS INTRAOCULAR ENVISTA MX60 15.5D","SUP-ITM-10214258","CDM","V2630","HCPCS","0276","RC","","","","outpatient","","","822.29","493.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","517.22","62.9","","5563.53","1036.08","5563.53","12","95.63","636.45","percent of total billed charges",""
"LENS INTRAOCULAR SOFPORT LI61AO 19.5D","SUP-ITM-10157528","CDM","V2630","HCPCS","0276","RC","","","","both","","","780.83","468.50","AETNA [1001]","HB WDH AETNA COMMERCIAL","545.02","69.8","","573.96","573.96","573.96","1 through 10","90.81","663.71","percent of total billed charges",""
"LENS INTRAOCULAR SOFPORT LI61AO 19.5D","SUP-ITM-10157528","CDM","V2630","HCPCS","0276","RC","","","","both","","","780.83","468.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","444.29","56.9","","467.88","467.88","467.88","1 through 10","90.81","663.71","percent of total billed charges",""
"LENS INTRAOCULAR SOFPORT LI61AO 19.5D","SUP-ITM-10157528","CDM","V2630","HCPCS","0276","RC","","","","outpatient","","","780.83","468.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","491.14","62.9","","5563.53","1036.08","5563.53","12","90.81","604.36","percent of total billed charges",""
"LENS INTRAOCULAR SOFPORT LI61AO 9.0D","SUP-ITM-10214302","CDM","V2630","HCPCS","0276","RC","","","","both","","","780.83","468.50","AETNA [1001]","HB WDH AETNA COMMERCIAL","545.02","69.8","","573.96","573.96","573.96","1 through 10","90.81","663.71","percent of total billed charges",""
"LENS INTRAOCULAR SOFPORT LI61AO 9.0D","SUP-ITM-10214302","CDM","V2630","HCPCS","0276","RC","","","","both","","","780.83","468.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","444.29","56.9","","467.88","467.88","467.88","1 through 10","90.81","663.71","percent of total billed charges",""
"LENS INTRAOCULAR SOFPORT LI61AO 9.0D","SUP-ITM-10214302","CDM","V2630","HCPCS","0276","RC","","","","outpatient","","","780.83","468.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","491.14","62.9","","5563.53","1036.08","5563.53","12","90.81","604.36","percent of total billed charges",""
"LENS INTRAOCULAR TECNIS PRE-LOADED DCB00 17.5D","SUP-ITM-10276260","CDM","V2632","HCPCS","0276","RC","","","","outpatient","","","932.85","559.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","586.76","62.9","","648.64","518.04","648.64","1 through 10","108.49","722.03","percent of total billed charges",""
"LENS INTRAOCULAR TECNIS ZCB00 9.5D","SUP-ITM-10215062","CDM","V2630","HCPCS","0276","RC","","","","both","","","932.85","559.71","AETNA [1001]","HB WDH AETNA COMMERCIAL","651.13","69.8","","573.96","573.96","573.96","1 through 10","108.49","792.92","percent of total billed charges",""
"LENS INTRAOCULAR TECNIS ZCB00 9.5D","SUP-ITM-10215062","CDM","V2630","HCPCS","0276","RC","","","","both","","","932.85","559.71","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","530.79","56.9","","467.88","467.88","467.88","1 through 10","108.49","792.92","percent of total billed charges",""
"LENS INTRAOCULAR TECNIS ZCB00 9.5D","SUP-ITM-10215062","CDM","V2630","HCPCS","0276","RC","","","","outpatient","","","932.85","559.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","586.76","62.9","","5563.53","1036.08","5563.53","12","108.49","722.03","percent of total billed charges",""
"Leukocyte Assess Fecal Qn/Semi Qn","PX-30001369","CDM","89055","CPT","0306","RC","","","","both","","","65.00","39.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","45.37","69.8","","83.60","43.97","83.60","1 through 10","2.78","55.25","percent of total billed charges",""
"Leukocyte Assess Fecal Qn/Semi Qn","PX-30001369","CDM","89055","CPT","0306","RC","","","","outpatient","","","65.00","39.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","47.27","72.72","","45.81","45.81","45.81","1 through 10","3.98","50.31","percent of total billed charges",""
"Leukocyte Assess Fecal Qn/Semi Qn","PX-30001369","CDM","89055","CPT","0306","RC","","","","outpatient","","","65.00","39.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","34.59","53.22","","33.59","33.59","33.59","1 through 10","3.98","50.31","percent of total billed charges",""
"Leukocyte Assess Fecal Qn/Semi Qn","PX-30001369","CDM","89055","CPT","0306","RC","","","","outpatient","","","65.00","39.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","40.89","62.9","","39.69","39.69","39.69","1 through 10","3.98","50.31","percent of total billed charges",""
"Leukocyte Assess Fecal Qn/Semi Qn","PX-30001369","CDM","89055","CPT","0306","RC","","","","outpatient","","","65.00","39.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","50.31","77.4","","48.83","48.83","48.83","1 through 10","3.98","50.31","percent of total billed charges",""
"Ligate Fistula Av Angioaccess","PX-76001166","CDM","37607","CPT","0761","RC","","","","both","","","11441.00","6864.60","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","3354.15","","APC Price ($3,288.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","3288.76","3288.76","3288.76","1 through 10","3222.61","21015.78","other","OPPS APC"
"Ligate Fistula Av Angioaccess","PX-76001166","CDM","37607","CPT","0761","RC","","","","both","","","11441.00","6864.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","21015.78","","Case rate ($21,015.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7562.18","7562.18","7562.18","1 through 10","3222.61","21015.78","other","OPPS APC"
"Ligate Fistula Av Angioaccess","PX-76001166","CDM","37607","CPT","0761","RC","","","","both","","","11441.00","6864.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6509.93","56.9","","4299.36","4299.36","4299.36","1 through 10","3222.61","21015.78","percent of total billed charges",""
"Ligate Fistula Av Angioaccess","PX-76001166","CDM","37607","CPT","0761","RC","","","","both","","","11441.00","6864.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","3288.38","","APC Price ($3,288.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3228.48","3048.60","3228.48","1 through 10","3222.61","21015.78","other","OPPS APC"
"Ligate Fistula Av Angioaccess","PX-76001166","CDM","37607","CPT","0761","RC","","","","both","","","11441.00","6864.60","MEDICARE [2001]","HB WDH MEDICARE","3288.38","","APC Price ($3,288.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9866.28","3288.76","9866.28","11","3222.61","21015.78","other","OPPS APC"
"Ligate Fistula Av Angioaccess","PX-76001166","CDM","37607","CPT","0761","RC","","","","both","","","11441.00","6864.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","3288.38","","APC Price ($3,288.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3222.99","3043.60","3222.99","1 through 10","3222.61","21015.78","other","OPPS APC"
"Ligate Fistula Av Angioaccess","PX-76001166","CDM","37607","CPT","0761","RC","","","","outpatient","","","11441.00","6864.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","5494.72","5494.72","5494.72","1 through 10","1330.59","8855.33","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Ligate Fistula Av Angioaccess","PX-76001166","CDM","37607","CPT","0761","RC","","","","outpatient","","","11441.00","6864.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7196.39","62.9","","4845.96","4845.96","4845.96","1 through 10","1330.59","8855.33","percent of total billed charges",""
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","","","","inpatient","","","98267.56","58960.54","MARTIN'S POINT [160007]","HB WDH MEDICARE","29052.82","","Case rate ($29,052.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $26,849.70, add-ons for qualifying new technology services are included. If operating cost exceeds $30,767.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,895.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $26,517.45 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $26,404.84 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,090.51. The transfer capital threshold is the transfer adjustment factor * $2,090.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","28753.69","28753.69","28753.69","1 through 10","3975","142994.38","other","Inpatient DRG"
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","","","","inpatient","","","98267.56","58960.54","MEDICARE [2001]","HB WDH MEDICARE","29052.82","","Case rate ($29,052.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $26,849.70, add-ons for qualifying new technology services are included. If operating cost exceeds $30,767.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,895.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $26,517.45 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $26,404.84 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,090.51. The transfer capital threshold is the transfer adjustment factor * $2,090.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19053.74","19053.74","29362.08","1 through 10","3975","142994.38","other","Inpatient DRG"
"Lipase","PX-30000551","CDM","83690","CPT","0300","RC","","","","inpatient","","","98.00","58.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","75.32","76.86","","59.85","59.85","114.76","1 through 10","64.88","75.32","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","both","","","98.00","58.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","68.40","69.8","","66.31","59.76","66.31","51","4.48","83.3","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","both","","","98.00","58.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","83.30","85","","80.75","80.75","80.75","1 through 10","4.48","83.3","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","outpatient","","","98.00","58.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","61.52","62.78","","59.64","59.64","59.64","1 through 10","6.42","75.85","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","outpatient","","","98.00","58.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","42.85","43.72","","41.53","41.53","124.59","1 through 10","6.42","75.85","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","outpatient","","","98.00","58.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","71.27","72.72","","69.08","69.08","69.08","109","6.42","75.85","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","outpatient","","","98.00","58.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","71.27","72.72","","138.16","69.08","138.16","1 through 10","6.42","75.85","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","outpatient","","","98.00","58.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","52.16","53.22","","50.64","50.64","101.28","1 through 10","6.42","75.85","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","outpatient","","","98.00","58.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","61.64","62.9","","59.85","59.85","222.82","128","6.42","75.85","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","outpatient","","","98.00","58.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","75.85","77.4","","73.63","73.63","73.63","53","6.42","75.85","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","outpatient","","","98.00","58.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","71.27","72.72","","69.08","69.08","69.08","1 through 10","6.42","75.85","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","189.00","113.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","131.92","69.8","","127.73","115.11","127.73","978","8.7","160.65","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","189.00","113.40","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","131.92","69.8","","127.73","114.24","127.73","1 through 10","8.7","160.65","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","189.00","113.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","160.65","85","","70.00","18.75","155.55","31","8.7","160.65","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","189.00","113.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","118.65","62.78","","114.89","114.89","114.89","51","12.48","146.29","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","189.00","113.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","82.63","43.72","","80.01","80.01","80.01","70","12.48","146.29","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","189.00","113.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","137.44","72.72","","133.08","133.08","133.08","1620","12.48","146.29","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","189.00","113.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","137.44","72.72","","133.08","133.08","133.08","59","12.48","146.29","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","189.00","113.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","100.59","53.22","","97.56","97.56","97.56","116","12.48","146.29","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","189.00","113.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","118.88","62.9","","115.29","115.29","115.29","2007","12.48","146.29","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","189.00","113.40","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","137.44","72.72","","133.08","133.08","141.83","1 through 10","12.48","146.29","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","189.00","113.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","146.29","77.4","","141.83","141.83","141.83","686","12.48","146.29","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","189.00","113.40","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","137.44","72.72","","133.08","133.08","133.08","16","12.48","146.29","percent of total billed charges",""
"Lithium","PX-30000185","CDM","80178","CPT","0301","RC","","","","both","","","95.00","57.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","66.31","69.8","","64.22","64.22","64.22","1 through 10","4.3","80.75","percent of total billed charges",""
"Lithium","PX-30000185","CDM","80178","CPT","0301","RC","","","","outpatient","","","95.00","57.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","59.64","62.78","","57.76","57.76","57.76","1 through 10","6.16","73.53","percent of total billed charges",""
"Lithium","PX-30000185","CDM","80178","CPT","0301","RC","","","","outpatient","","","95.00","57.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","69.08","72.72","","66.90","66.90","66.90","1 through 10","6.16","73.53","percent of total billed charges",""
"Lithium","PX-30000185","CDM","80178","CPT","0301","RC","","","","outpatient","","","95.00","57.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","50.56","53.22","","49.05","49.05","49.05","1 through 10","6.16","73.53","percent of total billed charges",""
"Lithium","PX-30000185","CDM","80178","CPT","0301","RC","","","","outpatient","","","95.00","57.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","59.76","62.9","","57.96","57.96","57.96","1 through 10","6.16","73.53","percent of total billed charges",""
"Lithium","PX-30000185","CDM","80178","CPT","0301","RC","","","","outpatient","","","95.00","57.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","73.53","77.4","","71.30","71.30","71.30","1 through 10","6.16","73.53","percent of total billed charges",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","","","","inpatient","","","60392.18","36235.31","MEDICARE [2001]","HB WDH MEDICARE","14158.90","","Case rate ($14,158.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,102.77, add-ons for qualifying new technology services are included. If operating cost exceeds $17,020.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,807.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,711.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,657.90 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,002.15. The transfer capital threshold is the transfer adjustment factor * $1,002.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15370.96","15370.96","15370.96","1 through 10","3975","68548.38","other","Inpatient DRG"
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/McC","499","MS-DRG","","","","","","","","inpatient","","","27004.17","16202.50","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","15762.26","","Case rate ($15,762.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,582.65, add-ons for qualifying new technology services are included. If operating cost exceeds $18,500.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,924.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $14,198.08 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,137.78 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,119.31. The transfer capital threshold is the transfer adjustment factor * $1,119.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9203.67","9203.67","9203.67","1 through 10","3975","76562.6","other","Inpatient DRG"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","6477.00","3886.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","4520.95","69.8","","4362.50","3931.25","4362.50","31","108.88","5505.45","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","6477.00","3886.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","113.32","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","111.11","111.11","111.11","30","108.88","5505.45","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","6477.00","3886.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","692.73","696.33","27","108.88","5505.45","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","6477.00","3886.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","299.84","61","108.88","5505.45","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","6477.00","3886.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","108.89","107.12","111.11","71","108.88","5505.45","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","6477.00","3886.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","298.29","562.84","33","108.88","5505.45","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","6477.00","3886.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3685.41","56.9","","3556.25","3556.25","3556.25","47","108.88","5505.45","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","6477.00","3886.20","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","3685.41","56.9","","3556.25","3556.25","3556.25","1 through 10","108.88","5505.45","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","6477.00","3886.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","112.15","112.15","112.15","40","108.88","5505.45","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","6477.00","3886.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","108.89","108.89","111.11","87","108.88","5505.45","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","6477.00","3886.20","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","121","108.88","5505.45","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","6477.00","3886.20","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","6326.37","1 through 10","108.88","5505.45","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","6477.00","3886.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","108.89","108.89","108.89","140","108.88","5505.45","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","6477.00","3886.20","WELLSENSE NH [1050]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","115.64","114.34","345.62","18","108.88","5505.45","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","6477.00","3886.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","933.98","14.42","","772.50","772.50","901.25","16","753.28","5013.2","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","6477.00","3886.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","753.28","11.63","","860.63","738.23","1578.46","35","753.28","5013.2","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","6477.00","3886.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4066.26","62.78","","3923.75","3923.75","3923.75","1 through 10","753.28","5013.2","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","6477.00","3886.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2831.74","43.72","","2732.50","2732.50","2732.50","1 through 10","753.28","5013.2","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","6477.00","3886.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4710.07","72.72","","4545.00","4545.00","4545.00","17","753.28","5013.2","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","6477.00","3886.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4710.07","72.72","","4545.00","4545.00","4545.00","1 through 10","753.28","5013.2","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","6477.00","3886.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3447.06","53.22","","3331.88","3331.88","3331.88","1 through 10","753.28","5013.2","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","6477.00","3886.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4074.03","62.9","","3937.50","3937.50","7560.90","41","753.28","5013.2","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","6477.00","3886.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5013.20","77.4","","4843.75","4843.75","4843.75","18","753.28","5013.2","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","6477.00","3886.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","753.28","11.63","","738.23","175.11","738.23","31","753.28","5013.2","percent of total billed charges",""
"Low Frequency Non-Thermal Ultrasound per Day","PX-51000160","CDM","97610","CPT","0510","RC","","","","both","","","595.00","357.00","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","211.75","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","188.22","188.22","188.22","1 through 10","203.44","1326.74","other","OPPS APC"
"Low Frequency Non-Thermal Ultrasound per Day","PX-51000160","CDM","97610","CPT","0510","RC","","","","both","","","595.00","357.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","207.59","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","204.37","191.96","204.37","1 through 10","203.44","1326.74","other","OPPS APC"
"Low Frequency Non-Thermal Ultrasound per Day","PX-51000160","CDM","97610","CPT","0510","RC","","","","both","","","595.00","357.00","MEDICARE [2001]","HB WDH MEDICARE","207.59","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.62","207.62","207.62","84","203.44","1326.74","other","OPPS APC"
"Low Frequency Non-Thermal Ultrasound per Day","PX-51000160","CDM","97610","CPT","0510","RC","","","","both","","","595.00","357.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","207.59","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.62","204.07","207.62","29","203.44","1326.74","other","OPPS APC"
"Low Frequency Non-Thermal Ultrasound per Day","PX-51000160","CDM","97610","CPT","0510","RC","","","","both","","","595.00","357.00","WELLSENSE NH [1050]","HB WDH MEDICARE","207.59","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","214.14","214.14","214.14","1 through 10","203.44","1326.74","other","OPPS APC"
"Low Frequency Non-Thermal Ultrasound per Day","PX-51000160","CDM","97610","CPT","0510","RC","","","","outpatient","","","595.00","357.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","374.26","62.9","","361.62","361.62","361.62","12","316.66","460.53","percent of total billed charges",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","","","","inpatient","","","82591.48","49554.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","37947.36","","Fee schedule rate ($37,947.36). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","35049.62","35049.62","35049.62","1 through 10","3975","96372.05","case rate",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","","","","inpatient","","","82591.48","49554.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","19330.91","","Case rate ($19,725.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $18,240.60, add-ons for qualifying new technology services are included. If operating cost exceeds $22,158.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,213.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,871.62 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,795.72 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,408.91. The transfer capital threshold is the transfer adjustment factor * $1,408.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18608.88","18608.88","18608.88","1 through 10","3975","96372.05","other","Inpatient DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","","","","inpatient","","","82591.48","49554.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","76755.78","","Fee schedule rate ($76,755.78). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","70894.56","70894.56","70894.56","1 through 10","3975","96372.05","case rate",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","","","","inpatient","","","82591.48","49554.89","MARTIN'S POINT [160007]","HB WDH MEDICARE","19725.42","","Case rate ($19,725.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $18,240.60, add-ons for qualifying new technology services are included. If operating cost exceeds $22,158.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,213.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,871.62 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,795.72 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,408.91. The transfer capital threshold is the transfer adjustment factor * $1,408.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18289.20","18289.20","18289.20","1 through 10","3975","96372.05","other","Inpatient DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","","","","inpatient","","","82591.48","49554.89","MEDICARE [2001]","HB WDH MEDICARE","19725.42","","Case rate ($19,725.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $18,240.60, add-ons for qualifying new technology services are included. If operating cost exceeds $22,158.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,213.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,871.62 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,795.72 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,408.91. The transfer capital threshold is the transfer adjustment factor * $1,408.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18608.88","16013.22","18608.88","1 through 10","3975","96372.05","other","Inpatient DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","","","","inpatient","","","82591.48","49554.89","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","19725.42","","Case rate ($19,725.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $18,240.60, add-ons for qualifying new technology services are included. If operating cost exceeds $22,158.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,213.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,871.62 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,795.72 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,408.91. The transfer capital threshold is the transfer adjustment factor * $1,408.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18130.49","18130.49","18130.49","1 through 10","3975","96372.05","other","Inpatient DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With McC","492","MS-DRG","","","","","","","","inpatient","","","85587.94","51352.76","MEDICARE [2001]","HB WDH MEDICARE","28357.98","","Case rate ($28,357.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $26,208.36, add-ons for qualifying new technology services are included. If operating cost exceeds $30,126.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,844.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $25,873.37 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $25,763.49 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,039.73. The transfer capital threshold is the transfer adjustment factor * $2,039.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27310.39","27310.39","27310.39","1 through 10","3975","139521.17","other","Inpatient DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With McC","492","MS-DRG","","","","","","","","inpatient","","","85587.94","51352.76","WELLSENSE NH [1050]","HB WDH MEDICARE","28357.98","","Case rate ($28,357.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $26,208.36, add-ons for qualifying new technology services are included. If operating cost exceeds $30,126.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,844.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $25,873.37 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $25,763.49 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,039.73. The transfer capital threshold is the transfer adjustment factor * $2,039.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26764.18","26764.18","26764.18","1 through 10","3975","139521.17","other","Inpatient DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/McC","494","MS-DRG","","","","","","","","inpatient","","","80681.11","48408.67","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","15385.18","","Case rate ($15,699.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,524.41, add-ons for qualifying new technology services are included. If operating cost exceeds $18,442.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,919.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,139.59 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,079.54 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,114.70. The transfer capital threshold is the transfer adjustment factor * $1,114.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14410.41","14410.41","14410.41","1 through 10","3975","76247.2","other","Inpatient DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/McC","494","MS-DRG","","","","","","","","inpatient","","","80681.11","48408.67","MEDICARE [2001]","HB WDH MEDICARE","15699.16","","Case rate ($15,699.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,524.41, add-ons for qualifying new technology services are included. If operating cost exceeds $18,442.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,919.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,139.59 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,079.54 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,114.70. The transfer capital threshold is the transfer adjustment factor * $1,114.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","713.29","713.29","14671.19","1 through 10","3975","76247.2","other","Inpatient DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/McC","494","MS-DRG","","","","","","","","inpatient","","","80681.11","48408.67","TRICARE [160005]","HB WDH MEDICARE","15699.16","","Case rate ($15,699.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,524.41, add-ons for qualifying new technology services are included. If operating cost exceeds $18,442.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,919.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,139.59 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,079.54 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,114.70. The transfer capital threshold is the transfer adjustment factor * $1,114.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19075.39","19075.39","19075.39","1 through 10","3975","76247.2","other","Inpatient DRG"
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","both","","","15767.00","9460.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","21475.95","","Case rate ($21,475.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","20952.20","16974.19","20952.20","1 through 10","3293.17","21475.95","other","OPPS APC"
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","both","","","15767.00","9460.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","9247.52","","Case rate ($9,247.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9022.08","8886.89","9022.08","1 through 10","3293.17","21475.95","other","OPPS APC"
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","both","","","15767.00","9460.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","3293.17","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3360.76","3293.54","5957.40","1 through 10","3293.17","21475.95","other","OPPS APC"
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","both","","","15767.00","9460.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","17358.81","","Case rate ($17,358.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","16935.33","9022.08","26115.51","11","3293.17","21475.95","other","OPPS APC"
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","both","","","15767.00","9460.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","8971.42","56.9","","8657.34","8657.33","8657.34","11","3293.17","21475.95","percent of total billed charges",""
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","both","","","15767.00","9460.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","3461.19","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3403.35","3394.55","6024.40","1 through 10","3293.17","21475.95","other","OPPS APC"
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","both","","","15767.00","9460.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3301.04","3299.04","5845.75","32","3293.17","21475.95","other","OPPS APC"
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","both","","","15767.00","9460.20","MEDICARE [2001]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3360.76","3360.76","10082.28","65","3293.17","21475.95","other","OPPS APC"
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","both","","","15767.00","9460.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","13401.95","85","","3527.34","3527.34","3527.34","1 through 10","3293.17","21475.95","percent of total billed charges",""
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","both","","","15767.00","9460.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3321.32","3293.55","5846.16","41","3293.17","21475.95","other","OPPS APC"
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","both","","","15767.00","9460.20","WELLSENSE NH [1050]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","33279.62","3458.22","33279.62","1 through 10","3293.17","21475.95","other","OPPS APC"
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","outpatient","","","15767.00","9460.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2273.60","14.42","","2194.00","1880.57","2194.00","1 through 10","1833.7","12203.66","percent of total billed charges",""
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","outpatient","","","15767.00","9460.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1833.70","11.63","","1862.32","1862.32","2095.11","1 through 10","1833.7","12203.66","percent of total billed charges",""
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","outpatient","","","15767.00","9460.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","11465.76","72.72","","11064.35","11064.35","11064.35","1 through 10","1833.7","12203.66","percent of total billed charges",""
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","outpatient","","","15767.00","9460.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","9917.44","62.9","","28756.35","9585.45","28756.35","17","1833.7","12203.66","percent of total billed charges",""
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","outpatient","","","15767.00","9460.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12203.66","77.4","","10171.29","10171.29","10171.29","1 through 10","1833.7","12203.66","percent of total billed charges",""
"Lt Hrt Art/Ventricle Angio","PX-48000123","CDM","93458","CPT","0481","RC","","","","outpatient","","","15767.00","9460.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1833.70","11.63","","1797.14","1797.14","1797.14","1 through 10","1833.7","12203.66","percent of total billed charges",""
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","both","","","2394.00","1436.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","3737.50","","Case rate ($3,737.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3646.32","3646.32","3646.32","1 through 10","709.05","4623.96","other","OPPS APC"
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","both","","","2394.00","1436.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1362.19","56.9","","2310.00","2310.00","2310.00","1 through 10","709.05","4623.96","percent of total billed charges",""
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","both","","","2394.00","1436.40","MEDICARE [2001]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","723.60","723.60","723.60","1 through 10","709.05","4623.96","other","OPPS APC"
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","outpatient","","","2394.00","1436.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1505.83","62.9","","1455.30","1455.30","1455.30","1 through 10","278.42","1852.96","percent of total billed charges",""
"LUMBAR SPACER 32X23 14MM LG 12DEG SOVEREIGN PEEK","SUP-ITM-10089242","CDM","C1889","HCPCS","0278","RC","","","","both","","","14948.00","8968.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","1738.45","12705.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"LUMBAR SPACER 32X23 14MM LG 12DEG SOVEREIGN PEEK","SUP-ITM-10089242","CDM","C1889","HCPCS","0278","RC","","","","both","","","14948.00","8968.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","1738.45","12705.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"LUMBAR SPACER 32X23 14MM LG 12DEG SOVEREIGN PEEK","SUP-ITM-10089242","CDM","C1889","HCPCS","0278","RC","","","","both","","","14948.00","8968.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","8505.41","56.9","","0.63","0.63","0.63","1 through 10","1738.45","12705.8","percent of total billed charges",""
"LUMBAR SPACER 32X23 14MM LG 12DEG SOVEREIGN PEEK","SUP-ITM-10089242","CDM","C1889","HCPCS","0278","RC","","","","both","","","14948.00","8968.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2155.50","14.42","","317.14","317.14","317.14","1 through 10","1738.45","12705.8","percent of total billed charges",""
"LUMBAR SPACER 32X23 14MM LG 12DEG SOVEREIGN PEEK","SUP-ITM-10089242","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","14948.00","8968.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2155.50","14.42","","317.14","317.14","317.14","1 through 10","1738.45","11569.75","percent of total billed charges",""
"LUMBAR SPACER 32X23 14MM LG 12DEG SOVEREIGN PEEK","SUP-ITM-10089242","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","14948.00","8968.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","9384.35","62.78","","1125.09","1125.09","1125.09","1 through 10","1738.45","11569.75","percent of total billed charges",""
"LUMBAR SPACER 32X23 14MM LG 12DEG SOVEREIGN PEEK","SUP-ITM-10089242","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","14948.00","8968.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10870.19","72.72","","4732.50","1617.43","14180.40","1 through 10","1738.45","11569.75","percent of total billed charges",""
"LUMBAR SPACER 32X23 14MM LG 12DEG SOVEREIGN PEEK","SUP-ITM-10089242","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","14948.00","8968.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","9402.29","62.9","","3896.20","3341.38","3896.20","1 through 10","1738.45","11569.75","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","both","","","263.00","157.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","183.57","69.8","","177.29","159.77","177.29","39","12.04","223.55","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","outpatient","","","263.00","157.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","165.11","62.78","","159.46","159.46","159.46","1 through 10","17.26","203.56","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","outpatient","","","263.00","157.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","114.98","43.72","","111.05","111.05","111.05","1 through 10","17.26","203.56","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","outpatient","","","263.00","157.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","191.25","72.72","","184.71","184.71","184.71","48","17.26","203.56","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","outpatient","","","263.00","157.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","191.25","72.72","","184.71","184.71","184.71","1 through 10","17.26","203.56","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","outpatient","","","263.00","157.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","139.97","53.22","","135.41","135.41","135.41","1 through 10","17.26","203.56","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","outpatient","","","263.00","157.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","165.43","62.9","","160.02","160.02","160.02","65","17.26","203.56","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","outpatient","","","263.00","157.80","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","191.25","72.72","","196.85","196.85","196.85","1 through 10","17.26","203.56","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","outpatient","","","263.00","157.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","203.56","77.4","","196.85","196.85","196.85","26","17.26","203.56","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","both","","","242.00","145.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","168.92","69.8","","163.33","147.19","163.33","38","11.07","205.7","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","outpatient","","","242.00","145.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","151.93","62.78","","440.73","440.73","440.73","1 through 10","13.31","187.31","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","outpatient","","","242.00","145.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","105.80","43.72","","204.60","102.30","204.60","1 through 10","13.31","187.31","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","outpatient","","","242.00","145.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","175.98","72.72","","170.16","170.16","170.17","77","13.31","187.31","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","outpatient","","","242.00","145.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","175.98","72.72","","170.16","170.16","340.32","1 through 10","13.31","187.31","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","outpatient","","","242.00","145.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","128.79","53.22","","124.75","124.75","124.75","1 through 10","13.31","187.31","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","outpatient","","","242.00","145.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","152.22","62.9","","147.42","147.42","442.26","124","13.31","187.31","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","outpatient","","","242.00","145.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","187.31","77.4","","181.35","181.35","181.35","22","13.31","187.31","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","outpatient","","","242.00","145.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","175.98","72.72","","170.16","170.16","170.16","1 through 10","13.31","187.31","percent of total billed charges",""
"Lyme Disease Antibody Confirm","PX-30000891","CDM","86617","CPT","0302","RC","","","","both","","","83.00","49.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","57.93","69.8","","55.84","17.66","55.84","19","10.07","79.77","percent of total billed charges",""
"Lyme Disease Antibody Confirm","PX-30000891","CDM","86617","CPT","0302","RC","","","","outpatient","","","83.00","49.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","60.36","72.72","","58.18","58.18","116.35","17","14.43","64.24","percent of total billed charges",""
"Lyme Disease Antibody Confirm","PX-30000891","CDM","86617","CPT","0302","RC","","","","outpatient","","","83.00","49.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","60.36","72.72","","58.18","58.18","58.18","1 through 10","14.43","64.24","percent of total billed charges",""
"Lyme Disease Antibody Confirm","PX-30000891","CDM","86617","CPT","0302","RC","","","","outpatient","","","83.00","49.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","52.21","62.9","","50.40","50.40","50.40","40","14.43","64.24","percent of total billed charges",""
"Lyme Disease Antibody Confirm","PX-30000891","CDM","86617","CPT","0302","RC","","","","outpatient","","","83.00","49.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","64.24","77.4","","62.00","62.00","62.00","1 through 10","14.43","64.24","percent of total billed charges",""
"Lymphocyte Transformation Mitogen","PX-30000847","CDM","86353","CPT","0302","RC","","","","both","","","564.00","338.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","393.67","69.8","","380.41","380.41","380.41","1 through 10","31.87","479.4","percent of total billed charges",""
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","","","","inpatient","","","121833.67","73100.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","12847.47","","Case rate ($12,847.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,892.34, add-ons for qualifying new technology services are included. If operating cost exceeds $15,810.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,711.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,496.30 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,447.48 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.31. The transfer capital threshold is the transfer adjustment factor * $906.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12114.80","12114.80","12114.80","1 through 10","3975","61993.36","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With McC","840","MS-DRG","","","","","","","","inpatient","","","61066.40","36639.84","MARTIN'S POINT [160007]","HB WDH MEDICARE","25037.99","","Case rate ($25,037.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $23,144.05, add-ons for qualifying new technology services are included. If operating cost exceeds $27,062.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,602.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $22,795.99 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $22,699.18 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,797.13. The transfer capital threshold is the transfer adjustment factor * $1,797.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","38494.03","38494.03","38494.03","1 through 10","3975","122926.52","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With McC","840","MS-DRG","","","","","","","","inpatient","","","61066.40","36639.84","MEDICARE [2001]","HB WDH MEDICARE","25037.99","","Case rate ($25,037.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $23,144.05, add-ons for qualifying new technology services are included. If operating cost exceeds $27,062.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,602.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $22,795.99 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $22,699.18 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,797.13. The transfer capital threshold is the transfer adjustment factor * $1,797.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18449.63","14810.27","24570.27","1 through 10","3975","122926.52","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With McC","840","MS-DRG","","","","","","","","inpatient","","","61066.40","36639.84","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","25037.99","","Case rate ($25,037.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $23,144.05, add-ons for qualifying new technology services are included. If operating cost exceeds $27,062.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,602.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $22,795.99 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $22,699.18 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,797.13. The transfer capital threshold is the transfer adjustment factor * $1,797.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24017.42","24017.42","24017.42","1 through 10","3975","122926.52","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","","","","inpatient","","","111566.85","66940.11","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","17668.94","","Case rate ($17,668.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $16,342.50, add-ons for qualifying new technology services are included. If operating cost exceeds $20,260.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,063.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $15,965.44 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,897.63 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,258.64. The transfer capital threshold is the transfer adjustment factor * $1,258.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16739.19","16739.19","16739.19","1 through 10","3975","86093.03","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With Other Procedures With McC","823","MS-DRG","","","","","","","","inpatient","","","51471.74","30883.04","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","34594.51","","Case rate ($35,300.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $32,616.25, add-ons for qualifying new technology services are included. If operating cost exceeds $36,534.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,352.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $32,308.59 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $32,171.38 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,547.06. The transfer capital threshold is the transfer adjustment factor * $2,547.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","35072.67","35072.67","35072.67","1 through 10","3975","174222.86","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With Other Procedures With McC","823","MS-DRG","","","","","","","","inpatient","","","51471.74","30883.04","MEDICARE [2001]","HB WDH MEDICARE","35300.52","","Case rate ($35,300.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $32,616.25, add-ons for qualifying new technology services are included. If operating cost exceeds $36,534.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,352.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $32,308.59 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $32,171.38 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,547.06. The transfer capital threshold is the transfer adjustment factor * $2,547.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","35754.23","35754.23","35754.23","1 through 10","3975","174222.86","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia With Other Procedures With McC","823","MS-DRG","","","","","","","","inpatient","","","51471.74","30883.04","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","35300.52","","Case rate ($35,300.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $32,616.25, add-ons for qualifying new technology services are included. If operating cost exceeds $36,534.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,352.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.1. The base transfer operating payment is the transfer adjustment factor * $32,308.59 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $32,171.38 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,547.06. The transfer capital threshold is the transfer adjustment factor * $2,547.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","35754.23","35754.23","35754.23","1 through 10","3975","174222.86","other","Inpatient DRG"
"Lysis of Labial Lesion(S)","PX-76002266","CDM","56441","CPT","0761","RC","","","","both","","","16831.00","10098.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","21229.64","","Case rate ($21,229.64). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","17974.60","17974.60","17974.60","1 through 10","3255.41","21229.64","other","OPPS APC"
"Lysis/Excis,Penile Postcircum Adhesions","PX-76002869","CDM","54162","CPT","0761","RC","","","","both","","","11102.00","6661.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","7749.20","69.8","","7477.67","7037.93","7477.67","1 through 10","2097.4","13677.84","percent of total billed charges",""
"Lysis/Excis,Penile Postcircum Adhesions","PX-76002869","CDM","54162","CPT","0761","RC","","","","both","","","11102.00","6661.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","2097.40","","APC Price ($2,140.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2140.45","2140.45","2140.45","1 through 10","2097.4","13677.84","other","OPPS APC"
"Lysis/Excis,Penile Postcircum Adhesions","PX-76002869","CDM","54162","CPT","0761","RC","","","","both","","","11102.00","6661.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6317.04","56.9","","6095.70","6095.70","6095.70","1 through 10","2097.4","13677.84","percent of total billed charges",""
"Lysis/Excis,Penile Postcircum Adhesions","PX-76002869","CDM","54162","CPT","0761","RC","","","","outpatient","","","11102.00","6661.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1291.16","11.63","","1475.18","1475.18","1475.18","1 through 10","1291.16","8592.95","percent of total billed charges",""
"M/Phmtrc Alys Ish Quant/Semiq Cptr Each Multiprb","PX-31000496","CDM","88374","CPT","0310","RC","","","","both","","","1348.00","808.80","MEDICARE [2001]","HB WDH MEDICARE","179.03","","APC Price ($179.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","44.76","44.76","44.76","1 through 10","175.45","1276.27","other","OPPS APC"
"M/Phmtrc Alys Ish Quant/Semiq Cptr Each Multiprb","PX-31000496","CDM","88374","CPT","0310","RC","","","","both","","","1348.00","808.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","179.03","","APC Price ($179.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","58.49","58.49","58.49","1 through 10","175.45","1276.27","other","OPPS APC"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","452.00","271.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","315.50","69.8","","1167.06","912.98","1167.06","1 through 10","175.45","1144.2","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","452.00","271.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","384.20","85","","1482.40","1482.40","1482.40","1 through 10","175.45","1144.2","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","452.00","271.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","179.03","","APC Price ($179.03). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","40.94","40.94","175.47","1 through 10","175.45","1144.2","other","OPPS APC"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","outpatient","","","452.00","271.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","283.77","62.78","","273.72","273.72","273.72","1 through 10","77.73","349.85","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","outpatient","","","452.00","271.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","197.61","43.72","","571.86","571.86","571.86","12","77.73","349.85","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","outpatient","","","452.00","271.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","328.69","72.72","","951.18","317.06","951.18","69","77.73","349.85","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","outpatient","","","452.00","271.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","240.55","53.22","","232.43","232.43","232.43","1 through 10","77.73","349.85","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","outpatient","","","452.00","271.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","284.31","62.9","","274.68","274.68","274.68","21","77.73","349.85","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","outpatient","","","452.00","271.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","349.85","77.4","","337.90","337.90","337.90","21","77.73","349.85","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","outpatient","","","452.00","271.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","328.69","72.72","","266.69","266.69","266.69","1 through 10","77.73","349.85","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0300","RC","","","","inpatient","","","96.00","57.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","73.79","76.86","","58.59","56.12","112.24","12","63.55","73.79","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","96.00","57.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","67.01","69.8","","64.91","58.50","64.91","316","4.36","81.6","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","96.00","57.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","67.01","69.8","","8.64","8.64","64.91","1 through 10","4.36","81.6","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","96.00","57.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","81.60","85","","49.18","16.49","132.51","1 through 10","4.36","81.6","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","outpatient","","","96.00","57.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","60.27","62.78","","58.39","58.39","58.39","1 through 10","6.24","74.3","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","outpatient","","","96.00","57.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","41.97","43.72","","40.66","40.66","121.98","52","6.24","74.3","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","outpatient","","","96.00","57.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","69.81","72.72","","67.63","67.63","67.63","444","6.24","74.3","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","outpatient","","","96.00","57.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","69.81","72.72","","67.63","67.63","135.26","15","6.24","74.3","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","outpatient","","","96.00","57.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","51.09","53.22","","49.58","49.58","49.58","24","6.24","74.3","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","outpatient","","","96.00","57.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","60.38","62.9","","58.59","58.59","217.76","536","6.24","74.3","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","outpatient","","","96.00","57.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","74.30","77.4","","72.08","72.08","135.26","167","6.24","74.3","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","outpatient","","","96.00","57.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","69.81","72.72","","135.26","67.63","338.15","11","6.24","74.3","percent of total billed charges",""
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","62504.72","37502.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","19240.75","","Case rate ($19,633.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $18,155.69, add-ons for qualifying new technology services are included. If operating cost exceeds $22,073.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,207.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $17,786.35 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,710.82 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,402.19. The transfer capital threshold is the transfer adjustment factor * $1,402.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","19096.71","19096.71","19436.96","1 through 10","3975","95912.25","other","Inpatient DRG"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","62504.72","37502.83","MARTIN'S POINT [160007]","HB WDH MEDICARE","19633.42","","Case rate ($19,633.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $18,155.69, add-ons for qualifying new technology services are included. If operating cost exceeds $22,073.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,207.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $17,786.35 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,710.82 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,402.19. The transfer capital threshold is the transfer adjustment factor * $1,402.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23623.66","23623.66","23623.66","1 through 10","3975","95912.25","other","Inpatient DRG"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","62504.72","37502.83","MEDICARE [2001]","HB WDH MEDICARE","19633.42","","Case rate ($19,633.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $18,155.69, add-ons for qualifying new technology services are included. If operating cost exceeds $22,073.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,207.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $17,786.35 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,710.82 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,402.19. The transfer capital threshold is the transfer adjustment factor * $1,402.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19486.44","19436.96","19486.44","1 through 10","3975","95912.25","other","Inpatient DRG"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","62504.72","37502.83","WELLSENSE NH [1050]","HB WDH MEDICARE","19633.42","","Case rate ($19,633.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $18,155.69, add-ons for qualifying new technology services are included. If operating cost exceeds $22,073.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,207.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $17,786.35 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,710.82 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,402.19. The transfer capital threshold is the transfer adjustment factor * $1,402.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","22089.11","22089.11","22089.11","1 through 10","3975","95912.25","other","Inpatient DRG"
"Major Chest Procedures With McC","163","MS-DRG","","","","","","","","inpatient","","","72915.54","43749.32","MEDICARE [2001]","HB WDH MEDICARE","34517.47","","Case rate ($34,517.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $31,893.50, add-ons for qualifying new technology services are included. If operating cost exceeds $35,811.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,294.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $31,582.76 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $31,448.63 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,489.84. The transfer capital threshold is the transfer adjustment factor * $2,489.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","35314.40","35314.40","35314.40","1 through 10","3975","170308.85","other","Inpatient DRG"
"Major Chest Procedures Without Cc/McC","165","MS-DRG","","","","","","","","inpatient","","","50635.23","30381.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","57933.80","","Fee schedule rate ($57,933.80). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","49825.86","49825.86","49825.86","1 through 10","3975","72739.79","case rate",""
"Major Chest Procedures Without Cc/McC","165","MS-DRG","","","","","","","","inpatient","","","50635.23","30381.14","MARTIN'S POINT [160007]","HB WDH MEDICARE","14997.44","","Case rate ($14,997.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,876.74, add-ons for qualifying new technology services are included. If operating cost exceeds $17,794.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,868.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $13,489.16 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,431.87 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,063.42. The transfer capital threshold is the transfer adjustment factor * $1,063.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14271.44","14271.44","14271.44","1 through 10","3975","72739.79","other","Inpatient DRG"
"Major Chest Procedures Without Cc/McC","165","MS-DRG","","","","","","","","inpatient","","","50635.23","30381.14","MEDICARE [2001]","HB WDH MEDICARE","14997.44","","Case rate ($14,997.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,876.74, add-ons for qualifying new technology services are included. If operating cost exceeds $17,794.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,868.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $13,489.16 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,431.87 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,063.42. The transfer capital threshold is the transfer adjustment factor * $1,063.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14546.37","0.05","14546.37","1 through 10","3975","72739.79","other","Inpatient DRG"
"Major Chest Procedures Without Cc/McC","165","MS-DRG","","","","","","","","inpatient","","","50635.23","30381.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","39221.96","","Fee schedule rate ($39,221.96). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","38193.36","38193.36","38193.36","1 through 10","3975","72739.79","case rate",""
"Major Chest Trauma With Cc","184","MS-DRG","","","","","","","","inpatient","","","45316.65","27189.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","32205.28","","Fee schedule rate ($32,205.28). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","31537.89","31537.89","31537.89","1 through 10","3975","40435.91","case rate",""
"Major Chest Trauma With Cc","184","MS-DRG","","","","","","","","inpatient","","","45316.65","27189.99","MARTIN'S POINT [160007]","HB WDH MEDICARE","8534.63","","Case rate ($8,534.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,911.62, add-ons for qualifying new technology services are included. If operating cost exceeds $11,829.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,396.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,498.60 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,466.75 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $591.15. The transfer capital threshold is the transfer adjustment factor * $591.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9583.11","9583.11","9583.11","1 through 10","3975","40435.91","other","Inpatient DRG"
"Major Chest Trauma With Cc","184","MS-DRG","","","","","","","","inpatient","","","45316.65","27189.99","MEDICARE [2001]","HB WDH MEDICARE","8534.63","","Case rate ($8,534.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,911.62, add-ons for qualifying new technology services are included. If operating cost exceeds $11,829.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,396.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,498.60 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,466.75 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $591.15. The transfer capital threshold is the transfer adjustment factor * $591.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8525.19","8504.19","8525.19","1 through 10","3975","40435.91","other","Inpatient DRG"
"Major Chest Trauma With McC","183","MS-DRG","","","","","","","","inpatient","","","48974.34","29384.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","11834.32","","Case rate ($12,075.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,180.13, add-ons for qualifying new technology services are included. If operating cost exceeds $15,098.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,654.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,781.04 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,735.25 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $849.93. The transfer capital threshold is the transfer adjustment factor * $849.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12173.41","12173.41","12173.41","1 through 10","3975","58136.35","other","Inpatient DRG"
"Major Chest Trauma With McC","183","MS-DRG","","","","","","","","inpatient","","","48974.34","29384.60","MEDICARE [2001]","HB WDH MEDICARE","12075.84","","Case rate ($12,075.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,180.13, add-ons for qualifying new technology services are included. If operating cost exceeds $15,098.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,654.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,781.04 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,735.25 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $849.93. The transfer capital threshold is the transfer adjustment factor * $849.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","860.77","0.05","12453.89","1 through 10","3975","58136.35","other","Inpatient DRG"
"Major Chest Trauma With McC","183","MS-DRG","","","","","","","","inpatient","","","48974.34","29384.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","12075.84","","Case rate ($12,075.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,180.13, add-ons for qualifying new technology services are included. If operating cost exceeds $15,098.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,654.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,781.04 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,735.25 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $849.93. The transfer capital threshold is the transfer adjustment factor * $849.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12243.50","12243.50","12453.06","1 through 10","3975","58136.35","other","Inpatient DRG"
"Major Chest Trauma Without Cc/McC","185","MS-DRG","","","","","","","","inpatient","","","26450.90","15870.54","MEDICARE [2001]","HB WDH MEDICARE","6424.18","","Case rate ($6,424.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,963.71, add-ons for qualifying new technology services are included. If operating cost exceeds $9,881.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,241.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,542.38 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,518.84 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $436.94. The transfer capital threshold is the transfer adjustment factor * $436.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6328.25","6328.25","6328.25","1 through 10","5616.89","29887.08","other","Inpatient DRG"
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","","","","inpatient","","","38627.66","23176.60","MEDICARE [2001]","HB WDH MEDICARE","8048.83","","Case rate ($8,048.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,463.24, add-ons for qualifying new technology services are included. If operating cost exceeds $11,381.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,360.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,048.30 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,018.37 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $555.65. The transfer capital threshold is the transfer adjustment factor * $555.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8143.16","8143.16","8143.16","1 through 10","3975","38007.7","other","Inpatient DRG"
"Major Esophageal Disorders With McC","368","MS-DRG","","","","","","","","inpatient","","","70873.69","42524.21","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","12923.61","","Case rate ($12,547.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,615.18, add-ons for qualifying new technology services are included. If operating cost exceeds $15,533.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,689.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,217.95 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,170.31 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $884.37. The transfer capital threshold is the transfer adjustment factor * $884.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7505.14","7505.14","7505.14","1 through 10","4637","32322.89","other","Inpatient DRG"
"Major Esophageal Disorders With McC","368","MS-DRG","","","","","","","","inpatient","","","70873.69","42524.21","MARTIN'S POINT [160007]","HB WDH MEDICARE","12547.19","","Case rate ($12,547.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,615.18, add-ons for qualifying new technology services are included. If operating cost exceeds $15,533.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,689.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,217.95 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,170.31 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $884.37. The transfer capital threshold is the transfer adjustment factor * $884.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6339.34","6339.34","6339.34","1 through 10","4637","32322.89","other","Inpatient DRG"
"Major Esophageal Disorders With McC","368","MS-DRG","","","","","","","","inpatient","","","70873.69","42524.21","MEDICARE [2001]","HB WDH MEDICARE","12547.19","","Case rate ($12,547.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,615.18, add-ons for qualifying new technology services are included. If operating cost exceeds $15,533.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,689.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,217.95 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,170.31 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $884.37. The transfer capital threshold is the transfer adjustment factor * $884.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13045.87","13045.87","13045.87","1 through 10","4637","32322.89","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","","","","inpatient","","","36963.70","22178.22","MEDICARE [2001]","HB WDH MEDICARE","8206.95","","Case rate ($8,206.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,609.19, add-ons for qualifying new technology services are included. If operating cost exceeds $11,527.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,372.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,194.88 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,164.32 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $567.21. The transfer capital threshold is the transfer adjustment factor * $567.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","8231.66","1 through 10","3975","38798.1","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","","","","inpatient","","","36963.70","22178.22","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8206.95","","Case rate ($8,206.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,609.19, add-ons for qualifying new technology services are included. If operating cost exceeds $11,527.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,372.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,194.88 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,164.32 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $567.21. The transfer capital threshold is the transfer adjustment factor * $567.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8110.95","8110.95","8110.95","1 through 10","3975","38798.1","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","","","","inpatient","","","36963.70","22178.22","WELLSENSE NH [1050]","HB WDH MEDICARE","8206.95","","Case rate ($8,206.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,609.19, add-ons for qualifying new technology services are included. If operating cost exceeds $11,527.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,372.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $7,194.88 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,164.32 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $567.21. The transfer capital threshold is the transfer adjustment factor * $567.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8518.52","8518.52","8518.52","1 through 10","3975","38798.1","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With McC","371","MS-DRG","","","","","","","","inpatient","","","38483.92","23090.35","MARTIN'S POINT [160007]","HB WDH MEDICARE","13924.75","","Case rate ($13,924.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,886.65, add-ons for qualifying new technology services are included. If operating cost exceeds $16,804.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,790.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $12,494.84 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,441.78 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $985.03. The transfer capital threshold is the transfer adjustment factor * $985.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5334.31","5334.31","5334.31","1 through 10","3975","67377.98","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With McC","371","MS-DRG","","","","","","","","inpatient","","","38483.92","23090.35","MEDICARE [2001]","HB WDH MEDICARE","13924.75","","Case rate ($13,924.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,886.65, add-ons for qualifying new technology services are included. If operating cost exceeds $16,804.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,790.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $12,494.84 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,441.78 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $985.03. The transfer capital threshold is the transfer adjustment factor * $985.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12920.31","0.05","13668.80","11","3975","67377.98","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With McC","371","MS-DRG","","","","","","","","inpatient","","","38483.92","23090.35","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","13924.75","","Case rate ($13,924.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,886.65, add-ons for qualifying new technology services are included. If operating cost exceeds $16,804.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,790.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $12,494.84 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,441.78 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $985.03. The transfer capital threshold is the transfer adjustment factor * $985.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12345.15","7774.75","13634.43","1 through 10","3975","67377.98","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC","373","MS-DRG","","","","","","","","inpatient","","","23585.90","14151.54","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","5855.38","","Case rate ($5,974.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,549.01, add-ons for qualifying new technology services are included. If operating cost exceeds $9,467.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,209.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,125.91 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,104.14 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $404.10. The transfer capital threshold is the transfer adjustment factor * $404.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10061.16","10061.16","10061.16","1 through 10","3975","27641.27","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC","373","MS-DRG","","","","","","","","inpatient","","","23585.90","14151.54","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","22014.96","","Fee schedule rate ($22,014.96). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","10589.33","10589.33","10589.33","1 through 10","3975","27641.27","case rate",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc","809","MS-DRG","","","","","","","","inpatient","","","32165.46","19299.28","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","10270.17","","Case rate ($10,068.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,327.64, add-ons for qualifying new technology services are included. If operating cost exceeds $13,245.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,508.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,920.66 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,882.77 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $703.26. The transfer capital threshold is the transfer adjustment factor * $703.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","9789.96","9789.96","9789.96","1 through 10","3975","48104.33","other","Inpatient DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc","809","MS-DRG","","","","","","","","inpatient","","","32165.46","19299.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","18941.51","","Fee schedule rate ($18,941.51). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","18079.53","18079.53","18079.53","1 through 10","3975","48104.33","case rate",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc","809","MS-DRG","","","","","","","","inpatient","","","32165.46","19299.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","9867.41","","Case rate ($10,068.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,327.64, add-ons for qualifying new technology services are included. If operating cost exceeds $13,245.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,508.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,920.66 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,882.77 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $703.26. The transfer capital threshold is the transfer adjustment factor * $703.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9814.30","9814.30","9814.30","1 through 10","3975","48104.33","other","Inpatient DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc","809","MS-DRG","","","","","","","","inpatient","","","32165.46","19299.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","38312.82","","Fee schedule rate ($38,312.82). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","35647.90","35647.90","35647.90","1 through 10","3975","48104.33","case rate",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc","809","MS-DRG","","","","","","","","inpatient","","","32165.46","19299.28","MARTIN'S POINT [160007]","HB WDH MEDICARE","10068.79","","Case rate ($10,068.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,327.64, add-ons for qualifying new technology services are included. If operating cost exceeds $13,245.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,508.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,920.66 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,882.77 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $703.26. The transfer capital threshold is the transfer adjustment factor * $703.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10863.42","10863.42","10863.42","1 through 10","3975","48104.33","other","Inpatient DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc","809","MS-DRG","","","","","","","","inpatient","","","32165.46","19299.28","MEDICARE [2001]","HB WDH MEDICARE","10068.79","","Case rate ($10,068.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,327.64, add-ons for qualifying new technology services are included. If operating cost exceeds $13,245.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,508.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,920.66 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,882.77 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $703.26. The transfer capital threshold is the transfer adjustment factor * $703.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9789.96","0.05","9814.30","1 through 10","3975","48104.33","other","Inpatient DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc","809","MS-DRG","","","","","","","","inpatient","","","32165.46","19299.28","WELLPOINT [1015]","HB WDH ANTHEM PPO","38312.82","","Fee schedule rate ($38,312.82). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","36569.31","36569.31","36569.31","1 through 10","3975","48104.33","case rate",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC","808","MS-DRG","","","","","","","","inpatient","","","66865.59","40119.35","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","17574.91","","Case rate ($17,230.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,937.63, add-ons for qualifying new technology services are included. If operating cost exceeds $19,855.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,031.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $15,558.83 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,492.76 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,226.58. The transfer capital threshold is the transfer adjustment factor * $1,226.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","17726.39","17726.39","17726.39","1 through 10","3975","83900.42","other","Inpatient DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC","808","MS-DRG","","","","","","","","inpatient","","","66865.59","40119.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","83900.42","","Fee schedule rate ($83,900.42). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","84908.91","84908.91","84908.91","1 through 10","3975","83900.42","case rate",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC","808","MS-DRG","","","","","","","","inpatient","","","66865.59","40119.35","MARTIN'S POINT [160007]","HB WDH MEDICARE","17230.30","","Case rate ($17,230.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,937.63, add-ons for qualifying new technology services are included. If operating cost exceeds $19,855.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,031.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $15,558.83 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,492.76 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,226.58. The transfer capital threshold is the transfer adjustment factor * $1,226.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17415.98","17415.98","17415.98","1 through 10","3975","83900.42","other","Inpatient DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC","808","MS-DRG","","","","","","","","inpatient","","","66865.59","40119.35","MEDICARE [2001]","HB WDH MEDICARE","17230.30","","Case rate ($17,230.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,937.63, add-ons for qualifying new technology services are included. If operating cost exceeds $19,855.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,031.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $15,558.83 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,492.76 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,226.58. The transfer capital threshold is the transfer adjustment factor * $1,226.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17771.41","17726.39","17771.41","1 through 10","3975","83900.42","other","Inpatient DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC","808","MS-DRG","","","","","","","","inpatient","","","66865.59","40119.35","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","17230.30","","Case rate ($17,230.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,937.63, add-ons for qualifying new technology services are included. If operating cost exceeds $19,855.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,031.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $15,558.83 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,492.76 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,226.58. The transfer capital threshold is the transfer adjustment factor * $1,226.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17771.41","17771.41","17771.41","1 through 10","3975","83900.42","other","Inpatient DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders Without Cc/McC","810","MS-DRG","","","","","","","","inpatient","","","12127.95","7276.77","MEDICARE [2001]","HB WDH MEDICARE","8401.58","","Case rate ($8,401.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,788.82, add-ons for qualifying new technology services are included. If operating cost exceeds $11,707.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,386.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,375.28 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,343.95 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $581.43. The transfer capital threshold is the transfer adjustment factor * $581.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Includes an additional $800 of payment.","7645.35","7645.35","7645.35","1 through 10","3975","39770.9","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders Without Cc/McC","810","MS-DRG","","","","","","","","inpatient","","","12127.95","7276.77","TRICARE [160005]","HB WDH MEDICARE","8401.58","","Case rate ($8,401.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,788.82, add-ons for qualifying new technology services are included. If operating cost exceeds $11,707.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,386.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,375.28 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,343.95 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $581.43. The transfer capital threshold is the transfer adjustment factor * $581.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Includes an additional $800 of payment.","6027.79","6027.79","6027.79","1 through 10","3975","39770.9","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders Without Cc/McC","810","MS-DRG","","","","","","","","inpatient","","","12127.95","7276.77","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8401.58","","Case rate ($8,401.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,788.82, add-ons for qualifying new technology services are included. If operating cost exceeds $11,707.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,386.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,375.28 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,343.95 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $581.43. The transfer capital threshold is the transfer adjustment factor * $581.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Includes an additional $800 of payment.","7626.64","7626.64","7626.64","1 through 10","3975","39770.9","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement","469","MS-DRG","","","","","","","","inpatient","","","107472.80","64483.68","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","24209.73","","Case rate ($23,504.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $21,728.73, add-ons for qualifying new technology services are included. If operating cost exceeds $25,646.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,490.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $21,374.63 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $21,283.86 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,685.07. The transfer capital threshold is the transfer adjustment factor * $1,685.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","199853.12","199853.12","199853.12","1 through 10","21661.99","115261.9","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement","469","MS-DRG","","","","","","","","inpatient","","","107472.80","64483.68","MEDICARE [2001]","HB WDH MEDICARE","23504.59","","Case rate ($23,504.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $21,728.73, add-ons for qualifying new technology services are included. If operating cost exceeds $25,646.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,490.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $21,374.63 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $21,283.86 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,685.07. The transfer capital threshold is the transfer adjustment factor * $1,685.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","25108.96","25108.96","25173.22","1 through 10","21661.99","115261.9","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement","469","MS-DRG","","","","","","","","inpatient","","","107472.80","64483.68","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","23504.59","","Case rate ($23,504.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $21,728.73, add-ons for qualifying new technology services are included. If operating cost exceeds $25,646.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,490.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $21,374.63 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $21,283.86 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,685.07. The transfer capital threshold is the transfer adjustment factor * $1,685.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","25173.22","25173.22","25173.22","1 through 10","21661.99","115261.9","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","81707.20","49024.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","14807.04","","Case rate ($15,109.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,979.90, add-ons for qualifying new technology services are included. If operating cost exceeds $17,898.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,876.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $13,592.75 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,535.02 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,071.59. The transfer capital threshold is the transfer adjustment factor * $1,071.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","90049.84","90049.84","90049.84","1 through 10","13775.49","73298.39","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","81707.20","49024.32","MARTIN'S POINT [160007]","HB WDH MEDICARE","15109.22","","Case rate ($15,109.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,979.90, add-ons for qualifying new technology services are included. If operating cost exceeds $17,898.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,876.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $13,592.75 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,535.02 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,071.59. The transfer capital threshold is the transfer adjustment factor * $1,071.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","14393.50","14393.50","14393.50","1 through 10","13775.49","73298.39","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","81707.20","49024.32","MEDICARE [2001]","HB WDH MEDICARE","15109.22","","Case rate ($15,109.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,979.90, add-ons for qualifying new technology services are included. If operating cost exceeds $17,898.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,876.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $13,592.75 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,535.02 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,071.59. The transfer capital threshold is the transfer adjustment factor * $1,071.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","14671.94","0.05","14709.01","25","13775.49","73298.39","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","81707.20","49024.32","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","15109.22","","Case rate ($15,109.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,979.90, add-ons for qualifying new technology services are included. If operating cost exceeds $17,898.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,876.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $13,592.75 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,535.02 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,071.59. The transfer capital threshold is the transfer adjustment factor * $1,071.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","14430.63","14430.63","14671.94","1 through 10","13775.49","73298.39","other","Inpatient DRG"
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","","","","inpatient","","","80240.67","48144.40","MEDICARE [2001]","HB WDH MEDICARE","21518.06","","Case rate ($21,518.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $19,895.19, add-ons for qualifying new technology services are included. If operating cost exceeds $23,813.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,344.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $19,533.28 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $19,450.32 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,539.91. The transfer capital threshold is the transfer adjustment factor * $1,539.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19722.49","19722.49","19722.49","1 through 10","3975","105332.48","other","Inpatient DRG"
"Major Male Pelvic Procedures Without Cc/McC","708","MS-DRG","","","","","","","","inpatient","","","86820.68","52092.41","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","12108.53","","Case rate ($12,108.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,210.30, add-ons for qualifying new technology services are included. If operating cost exceeds $15,128.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,657.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $10,811.34 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,765.43 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $852.31. The transfer capital threshold is the transfer adjustment factor * $852.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11631.08","11631.08","11631.08","1 through 10","3975","58299.75","other","Inpatient DRG"
"Major Skin Disorders Without McC","596","MS-DRG","","","","","","","","inpatient","","","11005.10","6603.06","MEDICARE [2001]","HB WDH MEDICARE","8674.51","","Case rate ($8,674.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,040.74, add-ons for qualifying new technology services are included. If operating cost exceeds $11,958.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,406.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,628.26 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,595.86 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $601.38. The transfer capital threshold is the transfer adjustment factor * $601.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8623.55","8623.55","8623.55","1 through 10","3975","41135.11","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","87572.15","52543.29","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","19042.82","","Case rate ($18,669.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $17,265.94, add-ons for qualifying new technology services are included. If operating cost exceeds $21,184.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,136.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,892.81 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $16,821.07 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,331.75. The transfer capital threshold is the transfer adjustment factor * $1,331.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","18280.23","18280.23","18280.23","1 through 10","17119.92","91093.84","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","87572.15","52543.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","35869.02","","Fee schedule rate ($35,869.02). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","34505.12","34505.12","34505.12","1 through 10","17119.92","91093.84","case rate",""
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","87572.15","52543.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","18296.04","","Case rate ($18,669.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $17,265.94, add-ons for qualifying new technology services are included. If operating cost exceeds $21,184.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,136.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,892.81 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $16,821.07 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,331.75. The transfer capital threshold is the transfer adjustment factor * $1,331.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18280.23","17976.77","18326.70","1 through 10","17119.92","91093.84","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","87572.15","52543.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","72551.93","","Fee schedule rate ($72,551.93). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","69793.20","69793.20","69793.20","1 through 10","17119.92","91093.84","case rate",""
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","87572.15","52543.29","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","19229.51","","Case rate ($18,669.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $17,265.94, add-ons for qualifying new technology services are included. If operating cost exceeds $21,184.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,136.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,892.81 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $16,821.07 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,331.75. The transfer capital threshold is the transfer adjustment factor * $1,331.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11719.17","11719.17","11719.17","1 through 10","17119.92","91093.84","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","87572.15","52543.29","MARTIN'S POINT [160007]","HB WDH MEDICARE","18669.43","","Case rate ($18,669.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $17,265.94, add-ons for qualifying new technology services are included. If operating cost exceeds $21,184.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,136.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,892.81 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $16,821.07 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,331.75. The transfer capital threshold is the transfer adjustment factor * $1,331.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17975.17","17975.17","17975.97","1 through 10","17119.92","91093.84","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","87572.15","52543.29","MEDICARE [2001]","HB WDH MEDICARE","18669.43","","Case rate ($18,669.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $17,265.94, add-ons for qualifying new technology services are included. If operating cost exceeds $21,184.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,136.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,892.81 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $16,821.07 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,331.75. The transfer capital threshold is the transfer adjustment factor * $1,331.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18326.70","0.05","18326.70","1 through 10","17119.92","91093.84","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","87572.15","52543.29","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","18669.43","","Case rate ($18,669.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $17,265.94, add-ons for qualifying new technology services are included. If operating cost exceeds $21,184.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,136.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,892.81 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $16,821.07 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,331.75. The transfer capital threshold is the transfer adjustment factor * $1,331.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17948.63","17948.63","17997.77","1 through 10","17119.92","91093.84","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With McC","329","MS-DRG","","","","","","","","inpatient","","","117000.49","70200.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","68776.88","","Fee schedule rate ($68,776.88). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","67032.23","67032.23","67032.23","1 through 10","32826.5","174667.46","case rate",""
"Major Small And Large Bowel Procedures With McC","329","MS-DRG","","","","","","","","inpatient","","","117000.49","70200.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","34681.68","","Case rate ($35,389.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $32,698.35, add-ons for qualifying new technology services are included. If operating cost exceeds $36,616.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,358.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $32,391.04 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $32,253.48 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,553.56. The transfer capital threshold is the transfer adjustment factor * $2,553.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","35093.25","35093.25","35093.25","1 through 10","32826.5","174667.46","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With McC","329","MS-DRG","","","","","","","","inpatient","","","117000.49","70200.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","139114.36","","Fee schedule rate ($139,114.36). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","130359.46","130359.46","130359.46","1 through 10","32826.5","174667.46","case rate",""
"Major Small And Large Bowel Procedures With McC","329","MS-DRG","","","","","","","","inpatient","","","117000.49","70200.29","MEDICARE [2001]","HB WDH MEDICARE","35389.47","","Case rate ($35,389.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $32,698.35, add-ons for qualifying new technology services are included. If operating cost exceeds $36,616.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,358.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $32,391.04 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $32,253.48 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,553.56. The transfer capital threshold is the transfer adjustment factor * $2,553.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","35183.53","33012.35","35183.53","1 through 10","32826.5","174667.46","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With McC","329","MS-DRG","","","","","","","","inpatient","","","117000.49","70200.29","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","35389.47","","Case rate ($35,389.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $32,698.35, add-ons for qualifying new technology services are included. If operating cost exceeds $36,616.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,358.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $32,391.04 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $32,253.48 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,553.56. The transfer capital threshold is the transfer adjustment factor * $2,553.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","34517.46","34391.39","35093.25","1 through 10","32826.5","174667.46","other","Inpatient DRG"
"Major Small And Large Bowel Procedures Without Cc/McC","331","MS-DRG","","","","","","","","inpatient","","","75107.42","45064.45","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","13503.79","","Case rate ($13,239.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,253.72, add-ons for qualifying new technology services are included. If operating cost exceeds $16,171.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,739.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,859.21 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,808.85 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.92. The transfer capital threshold is the transfer adjustment factor * $934.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","12934.96","12934.96","12934.96","1 through 10","12018.65","63950.37","other","Inpatient DRG"
"Major Small And Large Bowel Procedures Without Cc/McC","331","MS-DRG","","","","","","","","inpatient","","","75107.42","45064.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","63950.37","","Fee schedule rate ($63,950.37). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","61207.96","61207.96","61207.96","1 through 10","12018.65","63950.37","case rate",""
"Major Small And Large Bowel Procedures Without Cc/McC","331","MS-DRG","","","","","","","","inpatient","","","75107.42","45064.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","25181.03","","Fee schedule rate ($25,181.03). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","24101.18","24101.18","24101.18","1 through 10","12018.65","63950.37","case rate",""
"Major Small And Large Bowel Procedures Without Cc/McC","331","MS-DRG","","","","","","","","inpatient","","","75107.42","45064.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","12974.23","","Case rate ($13,239.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,253.72, add-ons for qualifying new technology services are included. If operating cost exceeds $16,171.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,739.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,859.21 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,808.85 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.92. The transfer capital threshold is the transfer adjustment factor * $934.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12902.50","12902.50","12902.50","1 through 10","12018.65","63950.37","other","Inpatient DRG"
"Major Small And Large Bowel Procedures Without Cc/McC","331","MS-DRG","","","","","","","","inpatient","","","75107.42","45064.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","50933.44","","Fee schedule rate ($50,933.44). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","48749.24","48749.24","48749.24","1 through 10","12018.65","63950.37","case rate",""
"Major Small And Large Bowel Procedures Without Cc/McC","331","MS-DRG","","","","","","","","inpatient","","","75107.42","45064.45","MEDICARE [2001]","HB WDH MEDICARE","13239.01","","Case rate ($13,239.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,253.72, add-ons for qualifying new technology services are included. If operating cost exceeds $16,171.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,739.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,859.21 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,808.85 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.92. The transfer capital threshold is the transfer adjustment factor * $934.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12902.50","12902.50","12934.96","1 through 10","12018.65","63950.37","other","Inpatient DRG"
"Major Small And Large Bowel Procedures Without Cc/McC","331","MS-DRG","","","","","","","","inpatient","","","75107.42","45064.45","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","13239.01","","Case rate ($13,239.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,253.72, add-ons for qualifying new technology services are included. If operating cost exceeds $16,171.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,739.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $11,859.21 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,808.85 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.92. The transfer capital threshold is the transfer adjustment factor * $934.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12902.50","12902.50","12902.50","1 through 10","12018.65","63950.37","other","Inpatient DRG"
"Major Small And Large Bowel Procedures Without Cc/McC","331","MS-DRG","","","","","","","","inpatient","","","75107.42","45064.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","34482.62","","Fee schedule rate ($34,482.62). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","29112.08","29112.08","29112.08","1 through 10","12018.65","63950.37","case rate",""
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","","","","inpatient","","","33395.41","20037.25","MEDICARE [2001]","HB WDH MEDICARE","9043.98","","Case rate ($9,043.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,381.75, add-ons for qualifying new technology services are included. If operating cost exceeds $12,299.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,433.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,970.74 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,936.89 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $628.38. The transfer capital threshold is the transfer adjustment factor * $628.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8976.67","8976.67","8976.67","1 through 10","3975","42981.91","other","Inpatient DRG"
"Malignancy Of Hepatobiliary System Or Pancreas With McC","435","MS-DRG","","","","","","","","inpatient","","","46298.99","27779.39","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","14696.44","","Case rate ($14,408.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,332.93, add-ons for qualifying new technology services are included. If operating cost exceeds $17,251.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,825.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,943.03 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,888.06 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.37. The transfer capital threshold is the transfer adjustment factor * $1,020.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","11777.47","11777.47","11777.47","1 through 10","3975","69794.78","other","Inpatient DRG"
"Malignancy Of Hepatobiliary System Or Pancreas With McC","435","MS-DRG","","","","","","","","inpatient","","","46298.99","27779.39","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","14120.10","","Case rate ($14,408.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,332.93, add-ons for qualifying new technology services are included. If operating cost exceeds $17,251.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,825.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,943.03 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,888.06 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.37. The transfer capital threshold is the transfer adjustment factor * $1,020.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20310.31","20310.31","20310.31","1 through 10","3975","69794.78","other","Inpatient DRG"
"Malignancy Of Hepatobiliary System Or Pancreas With McC","435","MS-DRG","","","","","","","","inpatient","","","46298.99","27779.39","MARTIN'S POINT [160007]","HB WDH MEDICARE","14408.27","","Case rate ($14,408.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,332.93, add-ons for qualifying new technology services are included. If operating cost exceeds $17,251.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,825.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,943.03 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,888.06 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.37. The transfer capital threshold is the transfer adjustment factor * $1,020.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14020.26","14020.26","14020.26","1 through 10","3975","69794.78","other","Inpatient DRG"
"Malignancy Of Hepatobiliary System Or Pancreas With McC","435","MS-DRG","","","","","","","","inpatient","","","46298.99","27779.39","MEDICARE [2001]","HB WDH MEDICARE","14408.27","","Case rate ($14,408.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,332.93, add-ons for qualifying new technology services are included. If operating cost exceeds $17,251.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,825.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,943.03 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,888.06 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.37. The transfer capital threshold is the transfer adjustment factor * $1,020.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14248.29","14212.42","14248.29","11","3975","69794.78","other","Inpatient DRG"
"Malignancy Of Hepatobiliary System Or Pancreas With McC","435","MS-DRG","","","","","","","","inpatient","","","46298.99","27779.39","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","14408.27","","Case rate ($14,408.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,332.93, add-ons for qualifying new technology services are included. If operating cost exceeds $17,251.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,825.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,943.03 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,888.06 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.37. The transfer capital threshold is the transfer adjustment factor * $1,020.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13967.98","13967.98","13967.98","1 through 10","3975","69794.78","other","Inpatient DRG"
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/McC","437","MS-DRG","","","","","","","","inpatient","","","24338.36","14603.02","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6932.03","","Case rate ($6,932.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,432.44, add-ons for qualifying new technology services are included. If operating cost exceeds $10,350.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,279.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,013.11 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,987.58 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $474.05. The transfer capital threshold is the transfer adjustment factor * $474.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5596.96","5596.96","5596.96","1 through 10","3975","17325.92","other","Inpatient DRG"
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","","","","inpatient","","","39268.98","23561.39","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","16276.62","","Fee schedule rate ($16,276.62). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","16205.16","16205.16","16205.16","1 through 10","3975","41336.51","case rate",""
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","","","","inpatient","","","39268.98","23561.39","MEDICARE [2001]","HB WDH MEDICARE","8714.80","","Case rate ($8,714.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,077.93, add-ons for qualifying new technology services are included. If operating cost exceeds $11,996.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,409.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,665.61 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,633.05 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $604.32. The transfer capital threshold is the transfer adjustment factor * $604.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","0.05","1 through 10","3975","41336.51","other","Inpatient DRG"
"Malignancy, Female Reproductive System With McC","754","MS-DRG","","","","","","","","inpatient","","","34530.48","20718.29","MEDICARE [2001]","HB WDH MEDICARE","14446.29","","Case rate ($14,446.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,368.02, add-ons for qualifying new technology services are included. If operating cost exceeds $17,286.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,828.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $12,978.26 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,923.14 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,023.14. The transfer capital threshold is the transfer adjustment factor * $1,023.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","0.05","1 through 10","3975","37394.98","other","Inpatient DRG"
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","","","","inpatient","","","21924.81","13154.89","MEDICARE [2001]","HB WDH MEDICARE","9132.18","","Case rate ($9,132.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,463.16, add-ons for qualifying new technology services are included. If operating cost exceeds $12,381.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,439.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,052.48 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,018.29 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $634.82. The transfer capital threshold is the transfer adjustment factor * $634.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8917.70","8917.70","8917.70","1 through 10","3975","43422.71","other","Inpatient DRG"
"Malignant Breast Disorders With McC","597","MS-DRG","","","","","","","","inpatient","","","22236.45","13341.87","MEDICARE [2001]","HB WDH MEDICARE","13118.90","","Case rate ($13,118.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,142.85, add-ons for qualifying new technology services are included. If operating cost exceeds $16,061.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,731.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $11,747.87 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,697.98 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $926.15. The transfer capital threshold is the transfer adjustment factor * $926.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13700.06","13700.06","13700.06","1 through 10","3975","63349.97","other","Inpatient DRG"
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","1123.00","673.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","783.85","69.8","","756.63","756.63","756.63","31","92.6","954.55","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","1123.00","673.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","638.99","56.9","","797.07","797.07","797.07","832","92.6","954.55","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","1123.00","673.80","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","638.99","56.9","","771.99","771.99","771.99","1 through 10","92.6","954.55","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","1123.00","673.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","783.85","69.8","","756.63","756.63","756.63","1 through 10","92.6","954.55","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","1123.00","673.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","954.55","85","","577.15","167.87","881.47","17","92.6","954.55","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","1123.00","673.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","161.94","14.42","","156.31","133.98","156.31","82","130.6","869.2","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","1123.00","673.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","130.60","11.63","","149.27","128.04","273.77","195","130.6","869.2","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","1123.00","673.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","705.02","62.78","","680.54","680.54","2041.62","18","130.6","869.2","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","1123.00","673.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","490.98","43.72","","473.92","473.92","473.92","46","130.6","869.2","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","1123.00","673.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","816.65","72.72","","788.28","788.28","987.53","497","130.6","869.2","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","1123.00","673.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","816.65","72.72","","788.28","788.28","788.28","11","130.6","869.2","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","1123.00","673.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","597.66","53.22","","577.88","577.88","577.88","16","130.6","869.2","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","1123.00","673.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","706.37","62.9","","682.92","682.92","682.92","600","130.6","869.2","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","1123.00","673.80","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","816.65","72.72","","788.28","788.28","840.10","1 through 10","130.6","869.2","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","1123.00","673.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","869.20","77.4","","840.10","840.10","840.10","232","130.6","869.2","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","1123.00","673.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","816.65","72.72","","788.28","788.28","788.28","12","130.6","869.2","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","1123.00","673.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","130.60","11.63","","128.04","128.04","145.20","180","130.6","869.2","percent of total billed charges",""
"MANDIBULAR PLATE 1.5MM 17 PLUS 5 HOLE RT PRIMARY RECONSTRUCTION HEMI","SUP-ITM-10216595","CDM","C1713","HCPCS","0278","RC","","","","both","","","5293.87","3176.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","615.68","4499.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MANDIBULAR PLATE 1.5MM 17 PLUS 5 HOLE RT PRIMARY RECONSTRUCTION HEMI","SUP-ITM-10216595","CDM","C1713","HCPCS","0278","RC","","","","both","","","5293.87","3176.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","615.68","4499.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MANDIBULAR PLATE 1.5MM 17 PLUS 5 HOLE RT PRIMARY RECONSTRUCTION HEMI","SUP-ITM-10216595","CDM","C1713","HCPCS","0278","RC","","","","both","","","5293.87","3176.32","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3012.21","56.9","","812.12","238.65","1587.46","163","615.68","4499.79","percent of total billed charges",""
"MANDIBULAR PLATE 1.5MM 17 PLUS 5 HOLE RT PRIMARY RECONSTRUCTION HEMI","SUP-ITM-10216595","CDM","C1713","HCPCS","0278","RC","","","","both","","","5293.87","3176.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","615.68","11.63","","112.68","112.68","146.99","38","615.68","4499.79","percent of total billed charges",""
"MANDIBULAR PLATE 1.5MM 17 PLUS 5 HOLE RT PRIMARY RECONSTRUCTION HEMI","SUP-ITM-10216595","CDM","C1713","HCPCS","0278","RC","","","","both","","","5293.87","3176.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4097.46","77.4","","303.98","303.98","5854.79","1 through 10","615.68","4499.79","percent of total billed charges",""
"MANDIBULAR PLATE 1.5MM 17 PLUS 5 HOLE RT PRIMARY RECONSTRUCTION HEMI","SUP-ITM-10216595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5293.87","3176.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","615.68","11.63","","112.68","112.68","146.99","38","615.68","4097.46","percent of total billed charges",""
"MANDIBULAR PLATE 1.5MM 17 PLUS 5 HOLE RT PRIMARY RECONSTRUCTION HEMI","SUP-ITM-10216595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5293.87","3176.32","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3323.49","62.78","","780.86","208.94","10480.28","15","615.68","4097.46","percent of total billed charges",""
"MANDIBULAR PLATE 1.5MM 17 PLUS 5 HOLE RT PRIMARY RECONSTRUCTION HEMI","SUP-ITM-10216595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5293.87","3176.32","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2314.48","43.72","","179.76","179.76","179.76","1 through 10","615.68","4097.46","percent of total billed charges",""
"MANDIBULAR PLATE 1.5MM 17 PLUS 5 HOLE RT PRIMARY RECONSTRUCTION HEMI","SUP-ITM-10216595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5293.87","3176.32","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3849.70","72.72","","2355.45","298.99","3965.19","155","615.68","4097.46","percent of total billed charges",""
"MANDIBULAR PLATE 1.5MM 17 PLUS 5 HOLE RT PRIMARY RECONSTRUCTION HEMI","SUP-ITM-10216595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5293.87","3176.32","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3849.70","72.72","","3643.09","3643.09","3643.09","1 through 10","615.68","4097.46","percent of total billed charges",""
"MANDIBULAR PLATE 1.5MM 17 PLUS 5 HOLE RT PRIMARY RECONSTRUCTION HEMI","SUP-ITM-10216595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5293.87","3176.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2817.40","53.22","","554.28","554.28","554.28","16","615.68","4097.46","percent of total billed charges",""
"MANDIBULAR PLATE 1.5MM 17 PLUS 5 HOLE RT PRIMARY RECONSTRUCTION HEMI","SUP-ITM-10216595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5293.87","3176.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3329.84","62.9","","619.64","173.09","2370.64","150","615.68","4097.46","percent of total billed charges",""
"MANDIBULAR PLATE 1.5MM 17 PLUS 5 HOLE RT PRIMARY RECONSTRUCTION HEMI","SUP-ITM-10216595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5293.87","3176.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4097.46","77.4","","303.98","303.98","5854.79","1 through 10","615.68","4097.46","percent of total billed charges",""
"Manipulation Knee Joint Under General Anesthesia","PX-36000085","CDM","27570","CPT","0361","RC","","","","both","","","1698.00","1018.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1672.04","","APC Price ($1,672.04). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1646.70","1646.70","1646.70","1 through 10","966.16","10685.94","other","OPPS APC"
"Mass Spectrometry Qn","PX-30000569","CDM","83789","CPT","0301","RC","","","","outpatient","","","105.00","63.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","76.36","72.72","","74.17","74.17","74.17","1 through 10","16.24","81.27","percent of total billed charges",""
"Mass Spectrometry Qn","PX-30000569","CDM","83789","CPT","0301","RC","","","","outpatient","","","105.00","63.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","81.27","77.4","","79.05","79.05","79.05","1 through 10","16.24","81.27","percent of total billed charges",""
"MATRIX TISSUE 2X4CM THIN 1-.2MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10287356","CDM","Q4116","HCPCS","0636","RC","","","","both","","","2985.12","1791.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","109.46","109.46","109.46","480","80.3","2537.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MATRIX TISSUE 2X4CM THIN 1-.2MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10287356","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","2985.12","1791.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1877.64","62.9","","1012.29","1012.29","1012.29","1008","54.99","2310.48","percent of total billed charges",""
"MATRIX TISSUE LG ALLODERM RTU CONTOUR PERFORATED THIN","SUP-ITM-10174648","CDM","Q4116","HCPCS","0636","RC","","","","both","","","19525.32","11715.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","109.46","109.46","109.46","480","80.3","16596.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MATRIX TISSUE LG ALLODERM RTU CONTOUR PERFORATED THIN","SUP-ITM-10174648","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","19525.32","11715.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","12281.43","62.9","","1012.29","1012.29","1012.29","1008","54.99","15112.6","percent of total billed charges",""
"Mayo, Ptnt Prothrombin G20210a Mutation, Blood","PX-31001431","CDM","81240","CPT","0310","RC","","","","both","","","354.00","212.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","247.09","69.8","","193.35","193.35","193.35","1 through 10","42.7","300.9","percent of total billed charges",""
"Mayo, Ptnt Prothrombin G20210a Mutation, Blood","PX-31001431","CDM","81240","CPT","0310","RC","","","","outpatient","","","354.00","212.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","51.05","14.42","","277.00","277.00","277.00","1 through 10","41.17","274","percent of total billed charges",""
"Mayo, Ptnt Prothrombin G20210a Mutation, Blood","PX-31001431","CDM","81240","CPT","0310","RC","","","","outpatient","","","354.00","212.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","41.17","11.63","","277.00","40.20","277.00","1 through 10","41.17","274","percent of total billed charges",""
"Mayo, Ptnt Prothrombin G20210a Mutation, Blood","PX-31001431","CDM","81240","CPT","0310","RC","","","","outpatient","","","354.00","212.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","257.43","72.72","","201.43","201.43","201.43","1 through 10","41.17","274","percent of total billed charges",""
"Mayo, Ptnt Prothrombin G20210a Mutation, Blood","PX-31001431","CDM","81240","CPT","0310","RC","","","","outpatient","","","354.00","212.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","257.43","72.72","","201.43","201.43","201.43","1 through 10","41.17","274","percent of total billed charges",""
"Mayo, Ptnt Prothrombin G20210a Mutation, Blood","PX-31001431","CDM","81240","CPT","0310","RC","","","","outpatient","","","354.00","212.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","222.67","62.9","","174.51","174.51","174.51","1 through 10","41.17","274","percent of total billed charges",""
"Mayo, Ptnt Prothrombin G20210a Mutation, Blood","PX-31001431","CDM","81240","CPT","0310","RC","","","","outpatient","","","354.00","212.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","274.00","77.4","","214.67","214.67","214.67","1 through 10","41.17","274","percent of total billed charges",""
"Mayo, Ptnt Prothrombin G20210a Mutation, Blood","PX-31001431","CDM","81240","CPT","0310","RC","","","","outpatient","","","354.00","212.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","41.17","11.63","","120.60","40.20","120.60","13","41.17","274","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","7211.95","4327.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","838.75","6130.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","7211.95","4327.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","838.75","6130.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","7211.95","4327.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4103.60","56.9","","812.12","238.65","1587.46","163","838.75","6130.16","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","7211.95","4327.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","838.75","11.63","","112.68","112.68","146.99","38","838.75","6130.16","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","7211.95","4327.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5582.05","77.4","","303.98","303.98","5854.79","1 through 10","838.75","6130.16","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7211.95","4327.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","838.75","11.63","","112.68","112.68","146.99","38","838.75","5582.05","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7211.95","4327.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4527.66","62.78","","780.86","208.94","10480.28","15","838.75","5582.05","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7211.95","4327.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3153.06","43.72","","179.76","179.76","179.76","1 through 10","838.75","5582.05","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7211.95","4327.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5244.53","72.72","","2355.45","298.99","3965.19","155","838.75","5582.05","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7211.95","4327.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5244.53","72.72","","3643.09","3643.09","3643.09","1 through 10","838.75","5582.05","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7211.95","4327.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3838.20","53.22","","554.28","554.28","554.28","16","838.75","5582.05","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7211.95","4327.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4536.32","62.9","","619.64","173.09","2370.64","150","838.75","5582.05","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7211.95","4327.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5582.05","77.4","","303.98","303.98","5854.79","1 through 10","838.75","5582.05","percent of total billed charges",""
"Medical Back Problems With McC","551","MS-DRG","","","","","","","","inpatient","","","50957.80","30574.68","MARTIN'S POINT [160007]","HB WDH MEDICARE","13187.32","","Case rate ($13,187.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,206.01, add-ons for qualifying new technology services are included. If operating cost exceeds $16,124.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,736.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,811.30 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,761.13 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $931.15. The transfer capital threshold is the transfer adjustment factor * $931.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13101.72","13101.72","13101.72","1 through 10","3975","63691.97","other","Inpatient DRG"
"Medical Back Problems With McC","551","MS-DRG","","","","","","","","inpatient","","","50957.80","30574.68","MEDICARE [2001]","HB WDH MEDICARE","13187.32","","Case rate ($13,187.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,206.01, add-ons for qualifying new technology services are included. If operating cost exceeds $16,124.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,736.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,811.30 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,761.13 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $931.15. The transfer capital threshold is the transfer adjustment factor * $931.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8864.22","6043.15","13320.53","13","3975","63691.97","other","Inpatient DRG"
"Medical Back Problems With McC","551","MS-DRG","","","","","","","","inpatient","","","50957.80","30574.68","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","13187.32","","Case rate ($13,187.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,206.01, add-ons for qualifying new technology services are included. If operating cost exceeds $16,124.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,736.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,811.30 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,761.13 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $931.15. The transfer capital threshold is the transfer adjustment factor * $931.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11437.29","11437.29","13320.53","1 through 10","3975","63691.97","other","Inpatient DRG"
"Medical Back Problems Without McC","552","MS-DRG","","","","","","","","inpatient","","","36567.40","21940.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","14383.82","","Fee schedule rate ($14,383.82). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","14069.48","14069.48","14069.48","1 through 10","3975","36529.5","case rate",""
"Medical Back Problems Without McC","552","MS-DRG","","","","","","","","inpatient","","","36567.40","21940.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","29094.01","","Fee schedule rate ($29,094.01). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","22240.11","22240.11","22240.11","1 through 10","3975","36529.5","case rate",""
"Medical Back Problems Without McC","552","MS-DRG","","","","","","","","inpatient","","","36567.40","21940.44","MARTIN'S POINT [160007]","HB WDH MEDICARE","7753.10","","Case rate ($7,753.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,190.28, add-ons for qualifying new technology services are included. If operating cost exceeds $11,108.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,339.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,774.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,745.41 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $534.04. The transfer capital threshold is the transfer adjustment factor * $534.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8198.29","8198.29","8198.29","1 through 10","3975","36529.5","other","Inpatient DRG"
"Medical Back Problems Without McC","552","MS-DRG","","","","","","","","inpatient","","","36567.40","21940.44","MEDICARE [2001]","HB WDH MEDICARE","7753.10","","Case rate ($7,753.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,190.28, add-ons for qualifying new technology services are included. If operating cost exceeds $11,108.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,339.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,774.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,745.41 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $534.04. The transfer capital threshold is the transfer adjustment factor * $534.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7717.19","0.05","7717.19","38","3975","36529.5","other","Inpatient DRG"
"Medical Back Problems Without McC","552","MS-DRG","","","","","","","","inpatient","","","36567.40","21940.44","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7753.10","","Case rate ($7,753.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,190.28, add-ons for qualifying new technology services are included. If operating cost exceeds $11,108.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,339.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,774.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,745.41 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $534.04. The transfer capital threshold is the transfer adjustment factor * $534.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7619.01","7619.01","7736.64","1 through 10","3975","36529.5","other","Inpatient DRG"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1358.00","814.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","947.88","69.8","","914.38","823.99","914.38","72","135.94","1154.3","percent of total billed charges",""
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1358.00","814.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","141.49","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","138.73","138.73","138.73","76","135.94","1154.3","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1358.00","814.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","886.52","","Case rate ($886.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","864.90","859.38","864.90","81","135.94","1154.3","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1358.00","814.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","381.73","","Case rate ($381.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","372.43","370.05","372.43","72","135.94","1154.3","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1358.00","814.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","135.94","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","136.51","135.96","224.74","151","135.94","1154.3","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1358.00","814.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","716.57","","Case rate ($716.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","629.18","592.49","699.09","70","135.94","1154.3","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1358.00","814.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","142.87","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","140.60","140.03","140.60","60","135.94","1154.3","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1358.00","814.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","136.51","135.96","138.73","210","135.94","1154.3","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1358.00","814.80","MEDICARE [2001]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","138.73","138.73","138.73","678","135.94","1154.3","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1358.00","814.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","1154.30","85","","850.32","850.32","850.32","1 through 10","135.94","1154.3","percent of total billed charges",""
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1358.00","814.80","TRICARE [160005]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","138.73","138.73","138.73","1 through 10","135.94","1154.3","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1358.00","814.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","136.52","135.96","138.73","266","135.94","1154.3","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1358.00","814.80","WELLPOINT [1015]","HB WDH ANTHEM PPO","716.57","","Case rate ($716.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","699.09","699.09","699.09","1 through 10","135.94","1154.3","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","both","","","1358.00","814.80","WELLSENSE NH [1050]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","143.34","143.34","143.34","15","135.94","1154.3","other","OPPS APC"
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","outpatient","","","1358.00","814.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","195.82","14.42","","188.90","161.92","188.90","54","157.94","1051.09","percent of total billed charges",""
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","outpatient","","","1358.00","814.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","157.94","11.63","","180.39","154.73","330.84","37","157.94","1051.09","percent of total billed charges",""
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","outpatient","","","1358.00","814.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","852.55","62.78","","822.42","822.42","822.42","1 through 10","157.94","1051.09","percent of total billed charges",""
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","outpatient","","","1358.00","814.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","987.54","72.72","","952.63","917.23","4763.15","81","157.94","1051.09","percent of total billed charges",""
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","outpatient","","","1358.00","814.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","854.18","62.9","","825.30","825.30","825.30","53","157.94","1051.09","percent of total billed charges",""
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","outpatient","","","1358.00","814.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1051.09","77.4","","1015.25","952.63","1015.25","26","157.94","1051.09","percent of total billed charges",""
"Medical Physics Continuing","PX-33000025","CDM","77336","CPT","0333","RC","","","","outpatient","","","1358.00","814.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","157.94","11.63","","652.59","154.73","1083.11","80","157.94","1051.09","percent of total billed charges",""
"Medical Physics Special","PX-33000027","CDM","77370","CPT","0333","RC","","","","both","","","2116.00","1269.60","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","141.49","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","138.73","138.73","138.73","1 through 10","135.94","1798.6","other","OPPS APC"
"Medical Physics Special","PX-33000027","CDM","77370","CPT","0333","RC","","","","both","","","2116.00","1269.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","886.52","","Case rate ($886.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","864.90","864.90","864.90","1 through 10","135.94","1798.6","other","OPPS APC"
"Medical Physics Special","PX-33000027","CDM","77370","CPT","0333","RC","","","","both","","","2116.00","1269.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","135.94","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","138.73","135.96","138.73","1 through 10","135.94","1798.6","other","OPPS APC"
"Medical Physics Special","PX-33000027","CDM","77370","CPT","0333","RC","","","","both","","","2116.00","1269.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","142.87","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","140.60","140.60","140.60","1 through 10","135.94","1798.6","other","OPPS APC"
"Medical Physics Special","PX-33000027","CDM","77370","CPT","0333","RC","","","","both","","","2116.00","1269.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","136.51","136.51","136.51","1 through 10","135.94","1798.6","other","OPPS APC"
"Medical Physics Special","PX-33000027","CDM","77370","CPT","0333","RC","","","","both","","","2116.00","1269.60","MEDICARE [2001]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","138.73","138.73","138.73","1 through 10","135.94","1798.6","other","OPPS APC"
"Medical Physics Special","PX-33000027","CDM","77370","CPT","0333","RC","","","","both","","","2116.00","1269.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","138.73","136.52","138.73","1 through 10","135.94","1798.6","other","OPPS APC"
"Mee Anti-Neuronal Antibodies","PX-30003155","CDM","86255","CPT","0302","RC","","","","both","","","65.00","39.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","45.37","69.8","","43.97","43.97","43.97","1 through 10","7.83","61.69","percent of total billed charges",""
"Mee Anti-Neuronal Antibodies","PX-30003155","CDM","86255","CPT","0302","RC","","","","inpatient","","","65.00","39.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","49.96","76.86","","39.69","39.69","39.69","1 through 10","43.03","49.96","percent of total billed charges",""
"Mee Anti-Neuronal Antibodies","PX-30003155","CDM","86255","CPT","0302","RC","","","","outpatient","","","65.00","39.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","47.27","72.72","","45.81","45.81","87.56","1 through 10","12.16","50.31","percent of total billed charges",""
"Mee Anti-Neuronal Antibodies","PX-30003155","CDM","86255","CPT","0302","RC","","","","outpatient","","","65.00","39.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","40.89","62.9","","39.69","39.69","39.69","11","12.16","50.31","percent of total billed charges",""
"Mee Varicella Zoster Pcr Vitreous","PX-30003243","CDM","87798","CPT","0306","RC","","","","both","","","188.00","112.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","131.22","69.8","","127.04","114.48","508.14","20","22.81","180.59","percent of total billed charges",""
"Mee Varicella Zoster Pcr Vitreous","PX-30003243","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","118.03","62.78","","114.26","114.26","114.26","1 through 10","24.28","145.51","percent of total billed charges",""
"Mee Varicella Zoster Pcr Vitreous","PX-30003243","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","82.19","43.72","","79.57","79.57","79.57","1 through 10","24.28","145.51","percent of total billed charges",""
"Mee Varicella Zoster Pcr Vitreous","PX-30003243","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","529.40","79","24.28","145.51","percent of total billed charges",""
"Mee Varicella Zoster Pcr Vitreous","PX-30003243","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Mee Varicella Zoster Pcr Vitreous","PX-30003243","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","118.25","62.9","","114.66","114.66","114.66","231","24.28","145.51","percent of total billed charges",""
"Mee Varicella Zoster Pcr Vitreous","PX-30003243","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","145.51","77.4","","141.05","141.05","564.20","57","24.28","145.51","percent of total billed charges",""
"Mee Varicella Zoster Pcr Vitreous","PX-30003243","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Mercury","PX-30000571","CDM","83825","CPT","0301","RC","","","","outpatient","","","88.00","52.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","55.35","62.9","","53.55","53.55","53.55","1 through 10","15.15","68.11","percent of total billed charges",""
"Mercury","PX-30000571","CDM","83825","CPT","0301","RC","","","","outpatient","","","88.00","52.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","68.11","77.4","","65.88","65.88","65.88","1 through 10","15.15","68.11","percent of total billed charges",""
"MESH COMPOSITE 12CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158109","CDM","C1781","HCPCS","0278","RC","","","","both","","","2517.87","1510.72","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","292.83","2140.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH COMPOSITE 12CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158109","CDM","C1781","HCPCS","0278","RC","","","","both","","","2517.87","1510.72","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1432.67","56.9","","1333.47","776.80","2316.37","34","292.83","2140.19","percent of total billed charges",""
"MESH COMPOSITE 12CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158109","CDM","C1781","HCPCS","0278","RC","","","","both","","","2517.87","1510.72","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","292.83","11.63","","348.38","187.99","380.51","1 through 10","292.83","2140.19","percent of total billed charges",""
"MESH COMPOSITE 12CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158109","CDM","C1781","HCPCS","0278","RC","","","","both","","","2517.87","1510.72","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1583.74","62.9","","1793.12","860.08","3673.04","20","292.83","2140.19","percent of total billed charges",""
"MESH COMPOSITE 12CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158109","CDM","C1781","HCPCS","0278","RC","","","","both","","","2517.87","1510.72","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1948.83","77.4","","1107.52","186.36","4312.65","1 through 10","292.83","2140.19","percent of total billed charges",""
"MESH COMPOSITE 12CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158109","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2517.87","1510.72","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","292.83","11.63","","348.38","187.99","380.51","1 through 10","292.83","1831","percent of total billed charges",""
"MESH COMPOSITE 12CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158109","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2517.87","1510.72","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1580.72","62.78","","9719.10","2943.96","9719.10","1 through 10","292.83","1831","percent of total billed charges",""
"MESH COMPOSITE 12CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158109","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2517.87","1510.72","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1831.00","72.72","","2009.48","1217.35","3752.64","17","292.83","1831","percent of total billed charges",""
"MESH GRAFT 10CMX16CM 3D MID LEFT LARGE CS/1EA","SUP-ITM-10280229","CDM","C1781","HCPCS","0278","RC","","","","both","","","2570.52","1542.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","298.95","2184.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH GRAFT 10CMX16CM 3D MID LEFT LARGE CS/1EA","SUP-ITM-10280229","CDM","C1781","HCPCS","0278","RC","","","","both","","","2570.52","1542.31","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1462.63","56.9","","1333.47","776.80","2316.37","34","298.95","2184.94","percent of total billed charges",""
"MESH GRAFT 10CMX16CM 3D MID LEFT LARGE CS/1EA","SUP-ITM-10280229","CDM","C1781","HCPCS","0278","RC","","","","both","","","2570.52","1542.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","298.95","11.63","","348.38","187.99","380.51","1 through 10","298.95","2184.94","percent of total billed charges",""
"MESH GRAFT 10CMX16CM 3D MID LEFT LARGE CS/1EA","SUP-ITM-10280229","CDM","C1781","HCPCS","0278","RC","","","","both","","","2570.52","1542.31","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1616.86","62.9","","1793.12","860.08","3673.04","20","298.95","2184.94","percent of total billed charges",""
"MESH GRAFT 10CMX16CM 3D MID LEFT LARGE CS/1EA","SUP-ITM-10280229","CDM","C1781","HCPCS","0278","RC","","","","both","","","2570.52","1542.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1989.58","77.4","","1107.52","186.36","4312.65","1 through 10","298.95","2184.94","percent of total billed charges",""
"MESH GRAFT 10CMX16CM 3D MID LEFT LARGE CS/1EA","SUP-ITM-10280229","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2570.52","1542.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","298.95","11.63","","348.38","187.99","380.51","1 through 10","298.95","1869.28","percent of total billed charges",""
"MESH GRAFT 10CMX16CM 3D MID LEFT LARGE CS/1EA","SUP-ITM-10280229","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2570.52","1542.31","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1613.77","62.78","","9719.10","2943.96","9719.10","1 through 10","298.95","1869.28","percent of total billed charges",""
"MESH GRAFT 10CMX16CM 3D MID LEFT LARGE CS/1EA","SUP-ITM-10280229","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2570.52","1542.31","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1869.28","72.72","","2009.48","1217.35","3752.64","17","298.95","1869.28","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE FLAT SHEET","SUP-ITM-10151456","CDM","C1781","HCPCS","0278","RC","","","","both","","","1992.84","1195.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","231.77","1693.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE FLAT SHEET","SUP-ITM-10151456","CDM","C1781","HCPCS","0278","RC","","","","both","","","1992.84","1195.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1133.93","56.9","","1333.47","776.80","2316.37","34","231.77","1693.91","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE FLAT SHEET","SUP-ITM-10151456","CDM","C1781","HCPCS","0278","RC","","","","both","","","1992.84","1195.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","231.77","11.63","","348.38","187.99","380.51","1 through 10","231.77","1693.91","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE FLAT SHEET","SUP-ITM-10151456","CDM","C1781","HCPCS","0278","RC","","","","both","","","1992.84","1195.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1253.50","62.9","","1793.12","860.08","3673.04","20","231.77","1693.91","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE FLAT SHEET","SUP-ITM-10151456","CDM","C1781","HCPCS","0278","RC","","","","both","","","1992.84","1195.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1542.46","77.4","","1107.52","186.36","4312.65","1 through 10","231.77","1693.91","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE FLAT SHEET","SUP-ITM-10151456","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1992.84","1195.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","231.77","11.63","","348.38","187.99","380.51","1 through 10","231.77","1449.19","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE FLAT SHEET","SUP-ITM-10151456","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1992.84","1195.70","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1251.10","62.78","","9719.10","2943.96","9719.10","1 through 10","231.77","1449.19","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE FLAT SHEET","SUP-ITM-10151456","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1992.84","1195.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1449.19","72.72","","2009.48","1217.35","3752.64","17","231.77","1449.19","percent of total billed charges",""
"MESH GRAFT 15X10CM COMPOSITE SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE BX/1EA","SUP-ITM-10148177","CDM","C1781","HCPCS","0278","RC","","","","both","","","2323.35","1394.01","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","270.21","1974.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH GRAFT 15X10CM COMPOSITE SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE BX/1EA","SUP-ITM-10148177","CDM","C1781","HCPCS","0278","RC","","","","both","","","2323.35","1394.01","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1321.99","56.9","","1333.47","776.80","2316.37","34","270.21","1974.85","percent of total billed charges",""
"MESH GRAFT 15X10CM COMPOSITE SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE BX/1EA","SUP-ITM-10148177","CDM","C1781","HCPCS","0278","RC","","","","both","","","2323.35","1394.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","270.21","11.63","","348.38","187.99","380.51","1 through 10","270.21","1974.85","percent of total billed charges",""
"MESH GRAFT 15X10CM COMPOSITE SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE BX/1EA","SUP-ITM-10148177","CDM","C1781","HCPCS","0278","RC","","","","both","","","2323.35","1394.01","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1461.39","62.9","","1793.12","860.08","3673.04","20","270.21","1974.85","percent of total billed charges",""
"MESH GRAFT 15X10CM COMPOSITE SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE BX/1EA","SUP-ITM-10148177","CDM","C1781","HCPCS","0278","RC","","","","both","","","2323.35","1394.01","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1798.27","77.4","","1107.52","186.36","4312.65","1 through 10","270.21","1974.85","percent of total billed charges",""
"MESH GRAFT 15X10CM COMPOSITE SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE BX/1EA","SUP-ITM-10148177","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2323.35","1394.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","270.21","11.63","","348.38","187.99","380.51","1 through 10","270.21","1689.54","percent of total billed charges",""
"MESH GRAFT 15X10CM COMPOSITE SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE BX/1EA","SUP-ITM-10148177","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2323.35","1394.01","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1458.60","62.78","","9719.10","2943.96","9719.10","1 through 10","270.21","1689.54","percent of total billed charges",""
"MESH GRAFT 15X10CM COMPOSITE SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE BX/1EA","SUP-ITM-10148177","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2323.35","1394.01","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1689.54","72.72","","2009.48","1217.35","3752.64","17","270.21","1689.54","percent of total billed charges",""
"MESH GRAFT 15X9CM TISSUE BIO A SYNTHETIC POLYMER NONWOVEN NONPERMANENT","SUP-ITM-10076201","CDM","C1781","HCPCS","0278","RC","","","","both","","","5078.85","3047.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","590.67","4317.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH GRAFT 15X9CM TISSUE BIO A SYNTHETIC POLYMER NONWOVEN NONPERMANENT","SUP-ITM-10076201","CDM","C1781","HCPCS","0278","RC","","","","both","","","5078.85","3047.31","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2889.87","56.9","","1333.47","776.80","2316.37","34","590.67","4317.02","percent of total billed charges",""
"MESH GRAFT 15X9CM TISSUE BIO A SYNTHETIC POLYMER NONWOVEN NONPERMANENT","SUP-ITM-10076201","CDM","C1781","HCPCS","0278","RC","","","","both","","","5078.85","3047.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","590.67","11.63","","348.38","187.99","380.51","1 through 10","590.67","4317.02","percent of total billed charges",""
"MESH GRAFT 15X9CM TISSUE BIO A SYNTHETIC POLYMER NONWOVEN NONPERMANENT","SUP-ITM-10076201","CDM","C1781","HCPCS","0278","RC","","","","both","","","5078.85","3047.31","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3194.60","62.9","","1793.12","860.08","3673.04","20","590.67","4317.02","percent of total billed charges",""
"MESH GRAFT 15X9CM TISSUE BIO A SYNTHETIC POLYMER NONWOVEN NONPERMANENT","SUP-ITM-10076201","CDM","C1781","HCPCS","0278","RC","","","","both","","","5078.85","3047.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3931.03","77.4","","1107.52","186.36","4312.65","1 through 10","590.67","4317.02","percent of total billed charges",""
"MESH GRAFT 15X9CM TISSUE BIO A SYNTHETIC POLYMER NONWOVEN NONPERMANENT","SUP-ITM-10076201","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5078.85","3047.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","590.67","11.63","","348.38","187.99","380.51","1 through 10","590.67","3693.34","percent of total billed charges",""
"MESH GRAFT 15X9CM TISSUE BIO A SYNTHETIC POLYMER NONWOVEN NONPERMANENT","SUP-ITM-10076201","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5078.85","3047.31","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3188.50","62.78","","9719.10","2943.96","9719.10","1 through 10","590.67","3693.34","percent of total billed charges",""
"MESH GRAFT 15X9CM TISSUE BIO A SYNTHETIC POLYMER NONWOVEN NONPERMANENT","SUP-ITM-10076201","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5078.85","3047.31","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3693.34","72.72","","2009.48","1217.35","3752.64","17","590.67","3693.34","percent of total billed charges",""
"MESH GRAFT 19CM 28 TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE CA/1EA","SUP-ITM-10077481","CDM","C1781","HCPCS","0278","RC","","","","both","","","39176.00","23505.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","4556.17","33299.6","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH GRAFT 19CM 28 TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE CA/1EA","SUP-ITM-10077481","CDM","C1781","HCPCS","0278","RC","","","","both","","","39176.00","23505.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","22291.14","56.9","","1333.47","776.80","2316.37","34","4556.17","33299.6","percent of total billed charges",""
"MESH GRAFT 19CM 28 TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE CA/1EA","SUP-ITM-10077481","CDM","C1781","HCPCS","0278","RC","","","","both","","","39176.00","23505.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","4556.17","11.63","","348.38","187.99","380.51","1 through 10","4556.17","33299.6","percent of total billed charges",""
"MESH GRAFT 19CM 28 TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE CA/1EA","SUP-ITM-10077481","CDM","C1781","HCPCS","0278","RC","","","","both","","","39176.00","23505.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","24641.70","62.9","","1793.12","860.08","3673.04","20","4556.17","33299.6","percent of total billed charges",""
"MESH GRAFT 19CM 28 TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE CA/1EA","SUP-ITM-10077481","CDM","C1781","HCPCS","0278","RC","","","","both","","","39176.00","23505.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","30322.22","77.4","","1107.52","186.36","4312.65","1 through 10","4556.17","33299.6","percent of total billed charges",""
"MESH GRAFT 19CM 28 TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE CA/1EA","SUP-ITM-10077481","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","39176.00","23505.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","4556.17","11.63","","348.38","187.99","380.51","1 through 10","4556.17","28488.79","percent of total billed charges",""
"MESH GRAFT 19CM 28 TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE CA/1EA","SUP-ITM-10077481","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","39176.00","23505.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","24594.69","62.78","","9719.10","2943.96","9719.10","1 through 10","4556.17","28488.79","percent of total billed charges",""
"MESH GRAFT 19CM 28 TISSUE XENMATRIX COLLAGEN PORCINE ACELLULAR RECTANGLE CA/1EA","SUP-ITM-10077481","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","39176.00","23505.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","28488.79","72.72","","2009.48","1217.35","3752.64","17","4556.17","28488.79","percent of total billed charges",""
"MESH GRAFT 25.5CMX20 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10092289","CDM","C1781","HCPCS","0278","RC","","","","both","","","10807.00","6484.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","1256.85","9185.95","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH GRAFT 25.5CMX20 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10092289","CDM","C1781","HCPCS","0278","RC","","","","both","","","10807.00","6484.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6149.18","56.9","","1333.47","776.80","2316.37","34","1256.85","9185.95","percent of total billed charges",""
"MESH GRAFT 25.5CMX20 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10092289","CDM","C1781","HCPCS","0278","RC","","","","both","","","10807.00","6484.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1256.85","11.63","","348.38","187.99","380.51","1 through 10","1256.85","9185.95","percent of total billed charges",""
"MESH GRAFT 25.5CMX20 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10092289","CDM","C1781","HCPCS","0278","RC","","","","both","","","10807.00","6484.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6797.60","62.9","","1793.12","860.08","3673.04","20","1256.85","9185.95","percent of total billed charges",""
"MESH GRAFT 25.5CMX20 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10092289","CDM","C1781","HCPCS","0278","RC","","","","both","","","10807.00","6484.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8364.62","77.4","","1107.52","186.36","4312.65","1 through 10","1256.85","9185.95","percent of total billed charges",""
"MESH GRAFT 25.5CMX20 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10092289","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","10807.00","6484.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1256.85","11.63","","348.38","187.99","380.51","1 through 10","1256.85","7858.85","percent of total billed charges",""
"MESH GRAFT 25.5CMX20 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10092289","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","10807.00","6484.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6784.63","62.78","","9719.10","2943.96","9719.10","1 through 10","1256.85","7858.85","percent of total billed charges",""
"MESH GRAFT 25.5CMX20 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10092289","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","10807.00","6484.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7858.85","72.72","","2009.48","1217.35","3752.64","17","1256.85","7858.85","percent of total billed charges",""
"MESH GRAFT 4.0X6.0IN VENTRALIGHT ST POLYPROPYLENE ECHO PS POSITIONING SYSTEM HYDROGEL BARRIER HERNIA ELLIPSE CS/1EA","SUP-ITM-10168313","CDM","C1781","HCPCS","0278","RC","","","","both","","","6806.35","4083.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","791.58","5785.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH GRAFT 4.0X6.0IN VENTRALIGHT ST POLYPROPYLENE ECHO PS POSITIONING SYSTEM HYDROGEL BARRIER HERNIA ELLIPSE CS/1EA","SUP-ITM-10168313","CDM","C1781","HCPCS","0278","RC","","","","both","","","6806.35","4083.81","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3872.81","56.9","","1333.47","776.80","2316.37","34","791.58","5785.4","percent of total billed charges",""
"MESH GRAFT 4.0X6.0IN VENTRALIGHT ST POLYPROPYLENE ECHO PS POSITIONING SYSTEM HYDROGEL BARRIER HERNIA ELLIPSE CS/1EA","SUP-ITM-10168313","CDM","C1781","HCPCS","0278","RC","","","","both","","","6806.35","4083.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","791.58","11.63","","348.38","187.99","380.51","1 through 10","791.58","5785.4","percent of total billed charges",""
"MESH GRAFT 4.0X6.0IN VENTRALIGHT ST POLYPROPYLENE ECHO PS POSITIONING SYSTEM HYDROGEL BARRIER HERNIA ELLIPSE CS/1EA","SUP-ITM-10168313","CDM","C1781","HCPCS","0278","RC","","","","both","","","6806.35","4083.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4281.19","62.9","","1793.12","860.08","3673.04","20","791.58","5785.4","percent of total billed charges",""
"MESH GRAFT 4.0X6.0IN VENTRALIGHT ST POLYPROPYLENE ECHO PS POSITIONING SYSTEM HYDROGEL BARRIER HERNIA ELLIPSE CS/1EA","SUP-ITM-10168313","CDM","C1781","HCPCS","0278","RC","","","","both","","","6806.35","4083.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5268.11","77.4","","1107.52","186.36","4312.65","1 through 10","791.58","5785.4","percent of total billed charges",""
"MESH GRAFT 4.0X6.0IN VENTRALIGHT ST POLYPROPYLENE ECHO PS POSITIONING SYSTEM HYDROGEL BARRIER HERNIA ELLIPSE CS/1EA","SUP-ITM-10168313","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6806.35","4083.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","791.58","11.63","","348.38","187.99","380.51","1 through 10","791.58","4949.58","percent of total billed charges",""
"MESH GRAFT 4.0X6.0IN VENTRALIGHT ST POLYPROPYLENE ECHO PS POSITIONING SYSTEM HYDROGEL BARRIER HERNIA ELLIPSE CS/1EA","SUP-ITM-10168313","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6806.35","4083.81","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4273.03","62.78","","9719.10","2943.96","9719.10","1 through 10","791.58","4949.58","percent of total billed charges",""
"MESH GRAFT 4.0X6.0IN VENTRALIGHT ST POLYPROPYLENE ECHO PS POSITIONING SYSTEM HYDROGEL BARRIER HERNIA ELLIPSE CS/1EA","SUP-ITM-10168313","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6806.35","4083.81","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4949.58","72.72","","2009.48","1217.35","3752.64","17","791.58","4949.58","percent of total billed charges",""
"MESH GRAFT 4.5IN VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR CIRCLE CS/1EA","SUP-ITM-10188467","CDM","C1781","HCPCS","0278","RC","","","","both","","","6014.00","3608.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","699.43","5111.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH GRAFT 4.5IN VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR CIRCLE CS/1EA","SUP-ITM-10188467","CDM","C1781","HCPCS","0278","RC","","","","both","","","6014.00","3608.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3421.97","56.9","","1333.47","776.80","2316.37","34","699.43","5111.9","percent of total billed charges",""
"MESH GRAFT 4.5IN VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR CIRCLE CS/1EA","SUP-ITM-10188467","CDM","C1781","HCPCS","0278","RC","","","","both","","","6014.00","3608.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","699.43","11.63","","348.38","187.99","380.51","1 through 10","699.43","5111.9","percent of total billed charges",""
"MESH GRAFT 4.5IN VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR CIRCLE CS/1EA","SUP-ITM-10188467","CDM","C1781","HCPCS","0278","RC","","","","both","","","6014.00","3608.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3782.81","62.9","","1793.12","860.08","3673.04","20","699.43","5111.9","percent of total billed charges",""
"MESH GRAFT 4.5IN VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR CIRCLE CS/1EA","SUP-ITM-10188467","CDM","C1781","HCPCS","0278","RC","","","","both","","","6014.00","3608.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4654.84","77.4","","1107.52","186.36","4312.65","1 through 10","699.43","5111.9","percent of total billed charges",""
"MESH GRAFT 4.5IN VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR CIRCLE CS/1EA","SUP-ITM-10188467","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6014.00","3608.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","699.43","11.63","","348.38","187.99","380.51","1 through 10","699.43","4373.38","percent of total billed charges",""
"MESH GRAFT 4.5IN VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR CIRCLE CS/1EA","SUP-ITM-10188467","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6014.00","3608.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3775.59","62.78","","9719.10","2943.96","9719.10","1 through 10","699.43","4373.38","percent of total billed charges",""
"MESH GRAFT 4.5IN VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR CIRCLE CS/1EA","SUP-ITM-10188467","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6014.00","3608.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4373.38","72.72","","2009.48","1217.35","3752.64","17","699.43","4373.38","percent of total billed charges",""
"MESH GRAFT 6.0IN VENTRALIGHT ST POLYPROPYLENE ECHO POSITIONING SYSTEM HYDROGEL BARRIER HERNIA CIRCLE CS/1EA","SUP-ITM-10168314","CDM","C1781","HCPCS","0278","RC","","","","both","","","7032.50","4219.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","817.88","5977.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH GRAFT 6.0IN VENTRALIGHT ST POLYPROPYLENE ECHO POSITIONING SYSTEM HYDROGEL BARRIER HERNIA CIRCLE CS/1EA","SUP-ITM-10168314","CDM","C1781","HCPCS","0278","RC","","","","both","","","7032.50","4219.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4001.49","56.9","","1333.47","776.80","2316.37","34","817.88","5977.63","percent of total billed charges",""
"MESH GRAFT 6.0IN VENTRALIGHT ST POLYPROPYLENE ECHO POSITIONING SYSTEM HYDROGEL BARRIER HERNIA CIRCLE CS/1EA","SUP-ITM-10168314","CDM","C1781","HCPCS","0278","RC","","","","both","","","7032.50","4219.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","817.88","11.63","","348.38","187.99","380.51","1 through 10","817.88","5977.63","percent of total billed charges",""
"MESH GRAFT 6.0IN VENTRALIGHT ST POLYPROPYLENE ECHO POSITIONING SYSTEM HYDROGEL BARRIER HERNIA CIRCLE CS/1EA","SUP-ITM-10168314","CDM","C1781","HCPCS","0278","RC","","","","both","","","7032.50","4219.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4423.44","62.9","","1793.12","860.08","3673.04","20","817.88","5977.63","percent of total billed charges",""
"MESH GRAFT 6.0IN VENTRALIGHT ST POLYPROPYLENE ECHO POSITIONING SYSTEM HYDROGEL BARRIER HERNIA CIRCLE CS/1EA","SUP-ITM-10168314","CDM","C1781","HCPCS","0278","RC","","","","both","","","7032.50","4219.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5443.16","77.4","","1107.52","186.36","4312.65","1 through 10","817.88","5977.63","percent of total billed charges",""
"MESH GRAFT 6.0IN VENTRALIGHT ST POLYPROPYLENE ECHO POSITIONING SYSTEM HYDROGEL BARRIER HERNIA CIRCLE CS/1EA","SUP-ITM-10168314","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","7032.50","4219.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","817.88","11.63","","348.38","187.99","380.51","1 through 10","817.88","5114.03","percent of total billed charges",""
"MESH GRAFT 6.0IN VENTRALIGHT ST POLYPROPYLENE ECHO POSITIONING SYSTEM HYDROGEL BARRIER HERNIA CIRCLE CS/1EA","SUP-ITM-10168314","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","7032.50","4219.50","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4415.00","62.78","","9719.10","2943.96","9719.10","1 through 10","817.88","5114.03","percent of total billed charges",""
"MESH GRAFT 6.0IN VENTRALIGHT ST POLYPROPYLENE ECHO POSITIONING SYSTEM HYDROGEL BARRIER HERNIA CIRCLE CS/1EA","SUP-ITM-10168314","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","7032.50","4219.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5114.03","72.72","","2009.48","1217.35","3752.64","17","817.88","5114.03","percent of total billed charges",""
"MESH GRAFT 7.0X10CM TISSUE BIO A SYNTHETIC POLYMERS HIATAL HERNIA REPAIR","SUP-ITM-10076202","CDM","C1781","HCPCS","0278","RC","","","","both","","","3558.65","2135.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","413.87","3024.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH GRAFT 7.0X10CM TISSUE BIO A SYNTHETIC POLYMERS HIATAL HERNIA REPAIR","SUP-ITM-10076202","CDM","C1781","HCPCS","0278","RC","","","","both","","","3558.65","2135.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2024.87","56.9","","1333.47","776.80","2316.37","34","413.87","3024.85","percent of total billed charges",""
"MESH GRAFT 7.0X10CM TISSUE BIO A SYNTHETIC POLYMERS HIATAL HERNIA REPAIR","SUP-ITM-10076202","CDM","C1781","HCPCS","0278","RC","","","","both","","","3558.65","2135.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","413.87","11.63","","348.38","187.99","380.51","1 through 10","413.87","3024.85","percent of total billed charges",""
"MESH GRAFT 7.0X10CM TISSUE BIO A SYNTHETIC POLYMERS HIATAL HERNIA REPAIR","SUP-ITM-10076202","CDM","C1781","HCPCS","0278","RC","","","","both","","","3558.65","2135.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2238.39","62.9","","1793.12","860.08","3673.04","20","413.87","3024.85","percent of total billed charges",""
"MESH GRAFT 7.0X10CM TISSUE BIO A SYNTHETIC POLYMERS HIATAL HERNIA REPAIR","SUP-ITM-10076202","CDM","C1781","HCPCS","0278","RC","","","","both","","","3558.65","2135.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2754.40","77.4","","1107.52","186.36","4312.65","1 through 10","413.87","3024.85","percent of total billed charges",""
"MESH GRAFT 7.0X10CM TISSUE BIO A SYNTHETIC POLYMERS HIATAL HERNIA REPAIR","SUP-ITM-10076202","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3558.65","2135.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","413.87","11.63","","348.38","187.99","380.51","1 through 10","413.87","2587.85","percent of total billed charges",""
"MESH GRAFT 7.0X10CM TISSUE BIO A SYNTHETIC POLYMERS HIATAL HERNIA REPAIR","SUP-ITM-10076202","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3558.65","2135.19","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2234.12","62.78","","9719.10","2943.96","9719.10","1 through 10","413.87","2587.85","percent of total billed charges",""
"MESH GRAFT 7.0X10CM TISSUE BIO A SYNTHETIC POLYMERS HIATAL HERNIA REPAIR","SUP-ITM-10076202","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3558.65","2135.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2587.85","72.72","","2009.48","1217.35","3752.64","17","413.87","2587.85","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","both","","","2323.35","1394.01","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","270.21","1974.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","both","","","2323.35","1394.01","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1321.99","56.9","","1333.47","776.80","2316.37","34","270.21","1974.85","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","both","","","2323.35","1394.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","270.21","11.63","","348.38","187.99","380.51","1 through 10","270.21","1974.85","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","both","","","2323.35","1394.01","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1461.39","62.9","","1793.12","860.08","3673.04","20","270.21","1974.85","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","both","","","2323.35","1394.01","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1798.27","77.4","","1107.52","186.36","4312.65","1 through 10","270.21","1974.85","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2323.35","1394.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","270.21","11.63","","348.38","187.99","380.51","1 through 10","270.21","1689.54","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2323.35","1394.01","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1458.60","62.78","","9719.10","2943.96","9719.10","1 through 10","270.21","1689.54","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2323.35","1394.01","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1689.54","72.72","","2009.48","1217.35","3752.64","17","270.21","1689.54","percent of total billed charges",""
"MESH HERNIA 15X10CM LEFT X1 DEXTILE","SUP-ITM-10273468","CDM","C1781","HCPCS","0278","RC","","","","both","","","1001.95","601.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","116.53","851.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH HERNIA 15X10CM LEFT X1 DEXTILE","SUP-ITM-10273468","CDM","C1781","HCPCS","0278","RC","","","","both","","","1001.95","601.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","570.11","56.9","","1333.47","776.80","2316.37","34","116.53","851.66","percent of total billed charges",""
"MESH HERNIA 15X10CM LEFT X1 DEXTILE","SUP-ITM-10273468","CDM","C1781","HCPCS","0278","RC","","","","both","","","1001.95","601.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","116.53","11.63","","348.38","187.99","380.51","1 through 10","116.53","851.66","percent of total billed charges",""
"MESH HERNIA 15X10CM LEFT X1 DEXTILE","SUP-ITM-10273468","CDM","C1781","HCPCS","0278","RC","","","","both","","","1001.95","601.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","630.23","62.9","","1793.12","860.08","3673.04","20","116.53","851.66","percent of total billed charges",""
"MESH HERNIA 15X10CM LEFT X1 DEXTILE","SUP-ITM-10273468","CDM","C1781","HCPCS","0278","RC","","","","both","","","1001.95","601.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","775.51","77.4","","1107.52","186.36","4312.65","1 through 10","116.53","851.66","percent of total billed charges",""
"MESH HERNIA 15X10CM LEFT X1 DEXTILE","SUP-ITM-10273468","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1001.95","601.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","116.53","11.63","","348.38","187.99","380.51","1 through 10","116.53","728.62","percent of total billed charges",""
"MESH HERNIA 15X10CM LEFT X1 DEXTILE","SUP-ITM-10273468","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1001.95","601.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","629.02","62.78","","9719.10","2943.96","9719.10","1 through 10","116.53","728.62","percent of total billed charges",""
"MESH HERNIA 15X10CM LEFT X1 DEXTILE","SUP-ITM-10273468","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1001.95","601.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","728.62","72.72","","2009.48","1217.35","3752.64","17","116.53","728.62","percent of total billed charges",""
"MESH HERNIA 16X12CM RIGHT X1 DEXTILE","SUP-ITM-10273465","CDM","C1781","HCPCS","0278","RC","","","","both","","","1071.05","642.63","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","124.56","910.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH HERNIA 16X12CM RIGHT X1 DEXTILE","SUP-ITM-10273465","CDM","C1781","HCPCS","0278","RC","","","","both","","","1071.05","642.63","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","609.43","56.9","","1333.47","776.80","2316.37","34","124.56","910.39","percent of total billed charges",""
"MESH HERNIA 16X12CM RIGHT X1 DEXTILE","SUP-ITM-10273465","CDM","C1781","HCPCS","0278","RC","","","","both","","","1071.05","642.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","124.56","11.63","","348.38","187.99","380.51","1 through 10","124.56","910.39","percent of total billed charges",""
"MESH HERNIA 16X12CM RIGHT X1 DEXTILE","SUP-ITM-10273465","CDM","C1781","HCPCS","0278","RC","","","","both","","","1071.05","642.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","673.69","62.9","","1793.12","860.08","3673.04","20","124.56","910.39","percent of total billed charges",""
"MESH HERNIA 16X12CM RIGHT X1 DEXTILE","SUP-ITM-10273465","CDM","C1781","HCPCS","0278","RC","","","","both","","","1071.05","642.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","828.99","77.4","","1107.52","186.36","4312.65","1 through 10","124.56","910.39","percent of total billed charges",""
"MESH HERNIA 16X12CM RIGHT X1 DEXTILE","SUP-ITM-10273465","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1071.05","642.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","124.56","11.63","","348.38","187.99","380.51","1 through 10","124.56","778.87","percent of total billed charges",""
"MESH HERNIA 16X12CM RIGHT X1 DEXTILE","SUP-ITM-10273465","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1071.05","642.63","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","672.41","62.78","","9719.10","2943.96","9719.10","1 through 10","124.56","778.87","percent of total billed charges",""
"MESH HERNIA 16X12CM RIGHT X1 DEXTILE","SUP-ITM-10273465","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1071.05","642.63","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","778.87","72.72","","2009.48","1217.35","3752.64","17","124.56","778.87","percent of total billed charges",""
"MESH HERNIA 25X20CM 9.8 7.9IN COMPOSITE SYMBOTEX 3DMONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE","SUP-ITM-10267614","CDM","C1781","HCPCS","0278","RC","","","","both","","","5859.96","3515.98","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","681.51","4980.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH HERNIA 25X20CM 9.8 7.9IN COMPOSITE SYMBOTEX 3DMONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE","SUP-ITM-10267614","CDM","C1781","HCPCS","0278","RC","","","","both","","","5859.96","3515.98","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3334.32","56.9","","1333.47","776.80","2316.37","34","681.51","4980.97","percent of total billed charges",""
"MESH HERNIA 25X20CM 9.8 7.9IN COMPOSITE SYMBOTEX 3DMONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE","SUP-ITM-10267614","CDM","C1781","HCPCS","0278","RC","","","","both","","","5859.96","3515.98","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","681.51","11.63","","348.38","187.99","380.51","1 through 10","681.51","4980.97","percent of total billed charges",""
"MESH HERNIA 25X20CM 9.8 7.9IN COMPOSITE SYMBOTEX 3DMONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE","SUP-ITM-10267614","CDM","C1781","HCPCS","0278","RC","","","","both","","","5859.96","3515.98","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3685.91","62.9","","1793.12","860.08","3673.04","20","681.51","4980.97","percent of total billed charges",""
"MESH HERNIA 25X20CM 9.8 7.9IN COMPOSITE SYMBOTEX 3DMONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE","SUP-ITM-10267614","CDM","C1781","HCPCS","0278","RC","","","","both","","","5859.96","3515.98","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4535.61","77.4","","1107.52","186.36","4312.65","1 through 10","681.51","4980.97","percent of total billed charges",""
"MESH HERNIA 25X20CM 9.8 7.9IN COMPOSITE SYMBOTEX 3DMONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE","SUP-ITM-10267614","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5859.96","3515.98","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","681.51","11.63","","348.38","187.99","380.51","1 through 10","681.51","4261.36","percent of total billed charges",""
"MESH HERNIA 25X20CM 9.8 7.9IN COMPOSITE SYMBOTEX 3DMONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE","SUP-ITM-10267614","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5859.96","3515.98","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3678.88","62.78","","9719.10","2943.96","9719.10","1 through 10","681.51","4261.36","percent of total billed charges",""
"MESH HERNIA 25X20CM 9.8 7.9IN COMPOSITE SYMBOTEX 3DMONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE","SUP-ITM-10267614","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5859.96","3515.98","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4261.36","72.72","","2009.48","1217.35","3752.64","17","681.51","4261.36","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","both","","","2846.23","1707.74","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","331.02","2419.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","both","","","2846.23","1707.74","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1619.50","56.9","","1333.47","776.80","2316.37","34","331.02","2419.3","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","both","","","2846.23","1707.74","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","331.02","11.63","","348.38","187.99","380.51","1 through 10","331.02","2419.3","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","both","","","2846.23","1707.74","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1790.28","62.9","","1793.12","860.08","3673.04","20","331.02","2419.3","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","both","","","2846.23","1707.74","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2202.98","77.4","","1107.52","186.36","4312.65","1 through 10","331.02","2419.3","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2846.23","1707.74","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","331.02","11.63","","348.38","187.99","380.51","1 through 10","331.02","2069.78","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2846.23","1707.74","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1786.86","62.78","","9719.10","2943.96","9719.10","1 through 10","331.02","2069.78","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2846.23","1707.74","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2069.78","72.72","","2009.48","1217.35","3752.64","17","331.02","2069.78","percent of total billed charges",""
"MESH HERNIAL 15X20CM OVAL SYNTHETIC PARTIALLY ABSORBABLE","SUP-ITM-10295707","CDM","C1781","HCPCS","0278","RC","","","","both","","","7144.05","4286.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","830.85","6072.44","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH HERNIAL 15X20CM OVAL SYNTHETIC PARTIALLY ABSORBABLE","SUP-ITM-10295707","CDM","C1781","HCPCS","0278","RC","","","","both","","","7144.05","4286.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4064.96","56.9","","1333.47","776.80","2316.37","34","830.85","6072.44","percent of total billed charges",""
"MESH HERNIAL 15X20CM OVAL SYNTHETIC PARTIALLY ABSORBABLE","SUP-ITM-10295707","CDM","C1781","HCPCS","0278","RC","","","","both","","","7144.05","4286.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","830.85","11.63","","348.38","187.99","380.51","1 through 10","830.85","6072.44","percent of total billed charges",""
"MESH HERNIAL 15X20CM OVAL SYNTHETIC PARTIALLY ABSORBABLE","SUP-ITM-10295707","CDM","C1781","HCPCS","0278","RC","","","","both","","","7144.05","4286.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4493.61","62.9","","1793.12","860.08","3673.04","20","830.85","6072.44","percent of total billed charges",""
"MESH HERNIAL 15X20CM OVAL SYNTHETIC PARTIALLY ABSORBABLE","SUP-ITM-10295707","CDM","C1781","HCPCS","0278","RC","","","","both","","","7144.05","4286.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5529.49","77.4","","1107.52","186.36","4312.65","1 through 10","830.85","6072.44","percent of total billed charges",""
"MESH HERNIAL 15X20CM OVAL SYNTHETIC PARTIALLY ABSORBABLE","SUP-ITM-10295707","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","7144.05","4286.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","830.85","11.63","","348.38","187.99","380.51","1 through 10","830.85","5195.15","percent of total billed charges",""
"MESH HERNIAL 15X20CM OVAL SYNTHETIC PARTIALLY ABSORBABLE","SUP-ITM-10295707","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","7144.05","4286.43","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4485.03","62.78","","9719.10","2943.96","9719.10","1 through 10","830.85","5195.15","percent of total billed charges",""
"MESH HERNIAL 15X20CM OVAL SYNTHETIC PARTIALLY ABSORBABLE","SUP-ITM-10295707","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","7144.05","4286.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5195.15","72.72","","2009.48","1217.35","3752.64","17","830.85","5195.15","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","both","","","5160.40","3096.24","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","600.15","4386.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","both","","","5160.40","3096.24","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2936.27","56.9","","1333.47","776.80","2316.37","34","600.15","4386.34","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","both","","","5160.40","3096.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","600.15","11.63","","348.38","187.99","380.51","1 through 10","600.15","4386.34","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","both","","","5160.40","3096.24","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3245.89","62.9","","1793.12","860.08","3673.04","20","600.15","4386.34","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","both","","","5160.40","3096.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3994.15","77.4","","1107.52","186.36","4312.65","1 through 10","600.15","4386.34","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5160.40","3096.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","600.15","11.63","","348.38","187.99","380.51","1 through 10","600.15","3752.64","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5160.40","3096.24","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3239.70","62.78","","9719.10","2943.96","9719.10","1 through 10","600.15","3752.64","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","5160.40","3096.24","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3752.64","72.72","","2009.48","1217.35","3752.64","17","600.15","3752.64","percent of total billed charges",""
"MESH PHASIX LG 1.5X1.9IN RESORBABLE SYTHETIC MONOFILAMENT WOVEN RESORBABLE PLUG PATCH CS/1EA","SUP-ITM-10159300","CDM","C1781","HCPCS","0278","RC","","","","both","","","4203.35","2522.01","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","488.85","3572.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH PHASIX LG 1.5X1.9IN RESORBABLE SYTHETIC MONOFILAMENT WOVEN RESORBABLE PLUG PATCH CS/1EA","SUP-ITM-10159300","CDM","C1781","HCPCS","0278","RC","","","","both","","","4203.35","2522.01","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2391.71","56.9","","1333.47","776.80","2316.37","34","488.85","3572.85","percent of total billed charges",""
"MESH PHASIX LG 1.5X1.9IN RESORBABLE SYTHETIC MONOFILAMENT WOVEN RESORBABLE PLUG PATCH CS/1EA","SUP-ITM-10159300","CDM","C1781","HCPCS","0278","RC","","","","both","","","4203.35","2522.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","488.85","11.63","","348.38","187.99","380.51","1 through 10","488.85","3572.85","percent of total billed charges",""
"MESH PHASIX LG 1.5X1.9IN RESORBABLE SYTHETIC MONOFILAMENT WOVEN RESORBABLE PLUG PATCH CS/1EA","SUP-ITM-10159300","CDM","C1781","HCPCS","0278","RC","","","","both","","","4203.35","2522.01","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2643.91","62.9","","1793.12","860.08","3673.04","20","488.85","3572.85","percent of total billed charges",""
"MESH PHASIX LG 1.5X1.9IN RESORBABLE SYTHETIC MONOFILAMENT WOVEN RESORBABLE PLUG PATCH CS/1EA","SUP-ITM-10159300","CDM","C1781","HCPCS","0278","RC","","","","both","","","4203.35","2522.01","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3253.39","77.4","","1107.52","186.36","4312.65","1 through 10","488.85","3572.85","percent of total billed charges",""
"MESH PHASIX LG 1.5X1.9IN RESORBABLE SYTHETIC MONOFILAMENT WOVEN RESORBABLE PLUG PATCH CS/1EA","SUP-ITM-10159300","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4203.35","2522.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","488.85","11.63","","348.38","187.99","380.51","1 through 10","488.85","3056.68","percent of total billed charges",""
"MESH PHASIX LG 1.5X1.9IN RESORBABLE SYTHETIC MONOFILAMENT WOVEN RESORBABLE PLUG PATCH CS/1EA","SUP-ITM-10159300","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4203.35","2522.01","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2638.86","62.78","","9719.10","2943.96","9719.10","1 through 10","488.85","3056.68","percent of total billed charges",""
"MESH PHASIX LG 1.5X1.9IN RESORBABLE SYTHETIC MONOFILAMENT WOVEN RESORBABLE PLUG PATCH CS/1EA","SUP-ITM-10159300","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4203.35","2522.01","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3056.68","72.72","","2009.48","1217.35","3752.64","17","488.85","3056.68","percent of total billed charges",""
"MESH PHASIX XL 1.4X2IN RESORBABLE SYTHETIC MONOFILAMENT WOVEN RESORBABLE PLUG PATCH CS/1EA","SUP-ITM-10159301","CDM","C1781","HCPCS","0278","RC","","","","both","","","4287.66","2572.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","498.65","3644.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH PHASIX XL 1.4X2IN RESORBABLE SYTHETIC MONOFILAMENT WOVEN RESORBABLE PLUG PATCH CS/1EA","SUP-ITM-10159301","CDM","C1781","HCPCS","0278","RC","","","","both","","","4287.66","2572.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2439.68","56.9","","1333.47","776.80","2316.37","34","498.65","3644.51","percent of total billed charges",""
"MESH PHASIX XL 1.4X2IN RESORBABLE SYTHETIC MONOFILAMENT WOVEN RESORBABLE PLUG PATCH CS/1EA","SUP-ITM-10159301","CDM","C1781","HCPCS","0278","RC","","","","both","","","4287.66","2572.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","498.65","11.63","","348.38","187.99","380.51","1 through 10","498.65","3644.51","percent of total billed charges",""
"MESH PHASIX XL 1.4X2IN RESORBABLE SYTHETIC MONOFILAMENT WOVEN RESORBABLE PLUG PATCH CS/1EA","SUP-ITM-10159301","CDM","C1781","HCPCS","0278","RC","","","","both","","","4287.66","2572.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2696.94","62.9","","1793.12","860.08","3673.04","20","498.65","3644.51","percent of total billed charges",""
"MESH PHASIX XL 1.4X2IN RESORBABLE SYTHETIC MONOFILAMENT WOVEN RESORBABLE PLUG PATCH CS/1EA","SUP-ITM-10159301","CDM","C1781","HCPCS","0278","RC","","","","both","","","4287.66","2572.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3318.65","77.4","","1107.52","186.36","4312.65","1 through 10","498.65","3644.51","percent of total billed charges",""
"MESH PHASIX XL 1.4X2IN RESORBABLE SYTHETIC MONOFILAMENT WOVEN RESORBABLE PLUG PATCH CS/1EA","SUP-ITM-10159301","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4287.66","2572.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","498.65","11.63","","348.38","187.99","380.51","1 through 10","498.65","3117.99","percent of total billed charges",""
"MESH PHASIX XL 1.4X2IN RESORBABLE SYTHETIC MONOFILAMENT WOVEN RESORBABLE PLUG PATCH CS/1EA","SUP-ITM-10159301","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4287.66","2572.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2691.79","62.78","","9719.10","2943.96","9719.10","1 through 10","498.65","3117.99","percent of total billed charges",""
"MESH PHASIX XL 1.4X2IN RESORBABLE SYTHETIC MONOFILAMENT WOVEN RESORBABLE PLUG PATCH CS/1EA","SUP-ITM-10159301","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4287.66","2572.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3117.99","72.72","","2009.48","1217.35","3752.64","17","498.65","3117.99","percent of total billed charges",""
"MESH ROUND 15CM PHASIX ST FULLY RESORBABLE","SUP-ITM-10159303","CDM","C1781","HCPCS","0278","RC","","","","both","","","19552.65","11731.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","2273.97","16619.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH ROUND 15CM PHASIX ST FULLY RESORBABLE","SUP-ITM-10159303","CDM","C1781","HCPCS","0278","RC","","","","both","","","19552.65","11731.59","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","11125.46","56.9","","1333.47","776.80","2316.37","34","2273.97","16619.75","percent of total billed charges",""
"MESH ROUND 15CM PHASIX ST FULLY RESORBABLE","SUP-ITM-10159303","CDM","C1781","HCPCS","0278","RC","","","","both","","","19552.65","11731.59","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2273.97","11.63","","348.38","187.99","380.51","1 through 10","2273.97","16619.75","percent of total billed charges",""
"MESH ROUND 15CM PHASIX ST FULLY RESORBABLE","SUP-ITM-10159303","CDM","C1781","HCPCS","0278","RC","","","","both","","","19552.65","11731.59","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","12298.62","62.9","","1793.12","860.08","3673.04","20","2273.97","16619.75","percent of total billed charges",""
"MESH ROUND 15CM PHASIX ST FULLY RESORBABLE","SUP-ITM-10159303","CDM","C1781","HCPCS","0278","RC","","","","both","","","19552.65","11731.59","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","15133.75","77.4","","1107.52","186.36","4312.65","1 through 10","2273.97","16619.75","percent of total billed charges",""
"MESH ROUND 15CM PHASIX ST FULLY RESORBABLE","SUP-ITM-10159303","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","19552.65","11731.59","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2273.97","11.63","","348.38","187.99","380.51","1 through 10","2273.97","14218.69","percent of total billed charges",""
"MESH ROUND 15CM PHASIX ST FULLY RESORBABLE","SUP-ITM-10159303","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","19552.65","11731.59","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","12275.15","62.78","","9719.10","2943.96","9719.10","1 through 10","2273.97","14218.69","percent of total billed charges",""
"MESH ROUND 15CM PHASIX ST FULLY RESORBABLE","SUP-ITM-10159303","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","19552.65","11731.59","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","14218.69","72.72","","2009.48","1217.35","3752.64","17","2273.97","14218.69","percent of total billed charges",""
"MESH SELF FIXATING 16CMX12 PROGRIP LAPAROSCOPIC","SUP-ITM-10158037","CDM","C1781","HCPCS","0278","RC","","","","both","","","2231.93","1339.16","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","259.57","1897.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH SELF FIXATING 16CMX12 PROGRIP LAPAROSCOPIC","SUP-ITM-10158037","CDM","C1781","HCPCS","0278","RC","","","","both","","","2231.93","1339.16","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1269.97","56.9","","1333.47","776.80","2316.37","34","259.57","1897.14","percent of total billed charges",""
"MESH SELF FIXATING 16CMX12 PROGRIP LAPAROSCOPIC","SUP-ITM-10158037","CDM","C1781","HCPCS","0278","RC","","","","both","","","2231.93","1339.16","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","259.57","11.63","","348.38","187.99","380.51","1 through 10","259.57","1897.14","percent of total billed charges",""
"MESH SELF FIXATING 16CMX12 PROGRIP LAPAROSCOPIC","SUP-ITM-10158037","CDM","C1781","HCPCS","0278","RC","","","","both","","","2231.93","1339.16","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1403.88","62.9","","1793.12","860.08","3673.04","20","259.57","1897.14","percent of total billed charges",""
"MESH SELF FIXATING 16CMX12 PROGRIP LAPAROSCOPIC","SUP-ITM-10158037","CDM","C1781","HCPCS","0278","RC","","","","both","","","2231.93","1339.16","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1727.51","77.4","","1107.52","186.36","4312.65","1 through 10","259.57","1897.14","percent of total billed charges",""
"MESH SELF FIXATING 16CMX12 PROGRIP LAPAROSCOPIC","SUP-ITM-10158037","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2231.93","1339.16","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","259.57","11.63","","348.38","187.99","380.51","1 through 10","259.57","1623.06","percent of total billed charges",""
"MESH SELF FIXATING 16CMX12 PROGRIP LAPAROSCOPIC","SUP-ITM-10158037","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2231.93","1339.16","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1401.21","62.78","","9719.10","2943.96","9719.10","1 through 10","259.57","1623.06","percent of total billed charges",""
"MESH SELF FIXATING 16CMX12 PROGRIP LAPAROSCOPIC","SUP-ITM-10158037","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2231.93","1339.16","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1623.06","72.72","","2009.48","1217.35","3752.64","17","259.57","1623.06","percent of total billed charges",""
"MESH SURGICAL 10INX12 PHASIX ST FULLY RESORBABLE SCAFFOLD ABSORBABLE BARRIER RECTANGLE","SUP-ITM-10159309","CDM","C1781","HCPCS","0278","RC","","","","both","","","51899.94","31139.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","6035.96","44114.95","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH SURGICAL 10INX12 PHASIX ST FULLY RESORBABLE SCAFFOLD ABSORBABLE BARRIER RECTANGLE","SUP-ITM-10159309","CDM","C1781","HCPCS","0278","RC","","","","both","","","51899.94","31139.96","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","29531.07","56.9","","1333.47","776.80","2316.37","34","6035.96","44114.95","percent of total billed charges",""
"MESH SURGICAL 10INX12 PHASIX ST FULLY RESORBABLE SCAFFOLD ABSORBABLE BARRIER RECTANGLE","SUP-ITM-10159309","CDM","C1781","HCPCS","0278","RC","","","","both","","","51899.94","31139.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","6035.96","11.63","","348.38","187.99","380.51","1 through 10","6035.96","44114.95","percent of total billed charges",""
"MESH SURGICAL 10INX12 PHASIX ST FULLY RESORBABLE SCAFFOLD ABSORBABLE BARRIER RECTANGLE","SUP-ITM-10159309","CDM","C1781","HCPCS","0278","RC","","","","both","","","51899.94","31139.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","32645.06","62.9","","1793.12","860.08","3673.04","20","6035.96","44114.95","percent of total billed charges",""
"MESH SURGICAL 10INX12 PHASIX ST FULLY RESORBABLE SCAFFOLD ABSORBABLE BARRIER RECTANGLE","SUP-ITM-10159309","CDM","C1781","HCPCS","0278","RC","","","","both","","","51899.94","31139.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","40170.55","77.4","","1107.52","186.36","4312.65","1 through 10","6035.96","44114.95","percent of total billed charges",""
"MESH SURGICAL 10INX12 PHASIX ST FULLY RESORBABLE SCAFFOLD ABSORBABLE BARRIER RECTANGLE","SUP-ITM-10159309","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","51899.94","31139.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","6035.96","11.63","","348.38","187.99","380.51","1 through 10","6035.96","37741.64","percent of total billed charges",""
"MESH SURGICAL 10INX12 PHASIX ST FULLY RESORBABLE SCAFFOLD ABSORBABLE BARRIER RECTANGLE","SUP-ITM-10159309","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","51899.94","31139.96","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","32582.78","62.78","","9719.10","2943.96","9719.10","1 through 10","6035.96","37741.64","percent of total billed charges",""
"MESH SURGICAL 10INX12 PHASIX ST FULLY RESORBABLE SCAFFOLD ABSORBABLE BARRIER RECTANGLE","SUP-ITM-10159309","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","51899.94","31139.96","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","37741.64","72.72","","2009.48","1217.35","3752.64","17","6035.96","37741.64","percent of total billed charges",""
"MESH SURGICAL 15X12CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10269319","CDM","C1781","HCPCS","0278","RC","","","","both","","","6529.95","3917.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","759.43","5550.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH SURGICAL 15X12CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10269319","CDM","C1781","HCPCS","0278","RC","","","","both","","","6529.95","3917.97","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3715.54","56.9","","1333.47","776.80","2316.37","34","759.43","5550.46","percent of total billed charges",""
"MESH SURGICAL 15X12CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10269319","CDM","C1781","HCPCS","0278","RC","","","","both","","","6529.95","3917.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","759.43","11.63","","348.38","187.99","380.51","1 through 10","759.43","5550.46","percent of total billed charges",""
"MESH SURGICAL 15X12CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10269319","CDM","C1781","HCPCS","0278","RC","","","","both","","","6529.95","3917.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4107.34","62.9","","1793.12","860.08","3673.04","20","759.43","5550.46","percent of total billed charges",""
"MESH SURGICAL 15X12CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10269319","CDM","C1781","HCPCS","0278","RC","","","","both","","","6529.95","3917.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5054.18","77.4","","1107.52","186.36","4312.65","1 through 10","759.43","5550.46","percent of total billed charges",""
"MESH SURGICAL 15X12CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10269319","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6529.95","3917.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","759.43","11.63","","348.38","187.99","380.51","1 through 10","759.43","4748.58","percent of total billed charges",""
"MESH SURGICAL 15X12CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10269319","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6529.95","3917.97","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4099.50","62.78","","9719.10","2943.96","9719.10","1 through 10","759.43","4748.58","percent of total billed charges",""
"MESH SURGICAL 15X12CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10269319","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6529.95","3917.97","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4748.58","72.72","","2009.48","1217.35","3752.64","17","759.43","4748.58","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST RESORBABLE RECTANGLE CS1EA","SUP-ITM-10159307","CDM","C1781","HCPCS","0278","RC","","","","both","","","21177.22","12706.33","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","2462.91","18000.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH SURGICAL 15X20CM PHASIX ST RESORBABLE RECTANGLE CS1EA","SUP-ITM-10159307","CDM","C1781","HCPCS","0278","RC","","","","both","","","21177.22","12706.33","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","12049.84","56.9","","1333.47","776.80","2316.37","34","2462.91","18000.64","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST RESORBABLE RECTANGLE CS1EA","SUP-ITM-10159307","CDM","C1781","HCPCS","0278","RC","","","","both","","","21177.22","12706.33","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2462.91","11.63","","348.38","187.99","380.51","1 through 10","2462.91","18000.64","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST RESORBABLE RECTANGLE CS1EA","SUP-ITM-10159307","CDM","C1781","HCPCS","0278","RC","","","","both","","","21177.22","12706.33","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","13320.47","62.9","","1793.12","860.08","3673.04","20","2462.91","18000.64","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST RESORBABLE RECTANGLE CS1EA","SUP-ITM-10159307","CDM","C1781","HCPCS","0278","RC","","","","both","","","21177.22","12706.33","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","16391.17","77.4","","1107.52","186.36","4312.65","1 through 10","2462.91","18000.64","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST RESORBABLE RECTANGLE CS1EA","SUP-ITM-10159307","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","21177.22","12706.33","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2462.91","11.63","","348.38","187.99","380.51","1 through 10","2462.91","15400.07","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST RESORBABLE RECTANGLE CS1EA","SUP-ITM-10159307","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","21177.22","12706.33","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","13295.06","62.78","","9719.10","2943.96","9719.10","1 through 10","2462.91","15400.07","percent of total billed charges",""
"MESH SURGICAL 15X20CM PHASIX ST RESORBABLE RECTANGLE CS1EA","SUP-ITM-10159307","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","21177.22","12706.33","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","15400.07","72.72","","2009.48","1217.35","3752.64","17","2462.91","15400.07","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159308","CDM","C1781","HCPCS","0278","RC","","","","both","","","34814.01","20888.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","4048.87","29591.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH SURGICAL 20X25CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159308","CDM","C1781","HCPCS","0278","RC","","","","both","","","34814.01","20888.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","19809.17","56.9","","1333.47","776.80","2316.37","34","4048.87","29591.91","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159308","CDM","C1781","HCPCS","0278","RC","","","","both","","","34814.01","20888.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","4048.87","11.63","","348.38","187.99","380.51","1 through 10","4048.87","29591.91","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159308","CDM","C1781","HCPCS","0278","RC","","","","both","","","34814.01","20888.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","21898.01","62.9","","1793.12","860.08","3673.04","20","4048.87","29591.91","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159308","CDM","C1781","HCPCS","0278","RC","","","","both","","","34814.01","20888.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","26946.04","77.4","","1107.52","186.36","4312.65","1 through 10","4048.87","29591.91","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159308","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","34814.01","20888.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","4048.87","11.63","","348.38","187.99","380.51","1 through 10","4048.87","25316.75","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159308","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","34814.01","20888.41","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","21856.24","62.78","","9719.10","2943.96","9719.10","1 through 10","4048.87","25316.75","percent of total billed charges",""
"MESH SURGICAL 20X25CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159308","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","34814.01","20888.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","25316.75","72.72","","2009.48","1217.35","3752.64","17","4048.87","25316.75","percent of total billed charges",""
"MESH SURGICAL 6.5CM ROUND SEMI RESORBABLE KEYHOLE PATCHPARIETEX POLYESTER IMPLANTABLE STERILE CS/3EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10267573","CDM","C1781","HCPCS","0278","RC","","","","both","","","592.51","355.51","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","68.91","503.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH SURGICAL 6.5CM ROUND SEMI RESORBABLE KEYHOLE PATCHPARIETEX POLYESTER IMPLANTABLE STERILE CS/3EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10267573","CDM","C1781","HCPCS","0278","RC","","","","both","","","592.51","355.51","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","337.14","56.9","","1333.47","776.80","2316.37","34","68.91","503.63","percent of total billed charges",""
"MESH SURGICAL 6.5CM ROUND SEMI RESORBABLE KEYHOLE PATCHPARIETEX POLYESTER IMPLANTABLE STERILE CS/3EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10267573","CDM","C1781","HCPCS","0278","RC","","","","both","","","592.51","355.51","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","68.91","11.63","","348.38","187.99","380.51","1 through 10","68.91","503.63","percent of total billed charges",""
"MESH SURGICAL 6.5CM ROUND SEMI RESORBABLE KEYHOLE PATCHPARIETEX POLYESTER IMPLANTABLE STERILE CS/3EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10267573","CDM","C1781","HCPCS","0278","RC","","","","both","","","592.51","355.51","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","372.69","62.9","","1793.12","860.08","3673.04","20","68.91","503.63","percent of total billed charges",""
"MESH SURGICAL 6.5CM ROUND SEMI RESORBABLE KEYHOLE PATCHPARIETEX POLYESTER IMPLANTABLE STERILE CS/3EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10267573","CDM","C1781","HCPCS","0278","RC","","","","both","","","592.51","355.51","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","458.60","77.4","","1107.52","186.36","4312.65","1 through 10","68.91","503.63","percent of total billed charges",""
"MESH SURGICAL 6.5CM ROUND SEMI RESORBABLE KEYHOLE PATCHPARIETEX POLYESTER IMPLANTABLE STERILE CS/3EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10267573","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","592.51","355.51","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","68.91","11.63","","348.38","187.99","380.51","1 through 10","68.91","430.87","percent of total billed charges",""
"MESH SURGICAL 6.5CM ROUND SEMI RESORBABLE KEYHOLE PATCHPARIETEX POLYESTER IMPLANTABLE STERILE CS/3EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10267573","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","592.51","355.51","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","371.98","62.78","","9719.10","2943.96","9719.10","1 through 10","68.91","430.87","percent of total billed charges",""
"MESH SURGICAL 6.5CM ROUND SEMI RESORBABLE KEYHOLE PATCHPARIETEX POLYESTER IMPLANTABLE STERILE CS/3EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10267573","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","592.51","355.51","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","430.87","72.72","","2009.48","1217.35","3752.64","17","68.91","430.87","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","both","","","11539.61","6923.77","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","1342.06","9808.67","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","both","","","11539.61","6923.77","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6566.04","56.9","","1333.47","776.80","2316.37","34","1342.06","9808.67","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","both","","","11539.61","6923.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1342.06","11.63","","348.38","187.99","380.51","1 through 10","1342.06","9808.67","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","both","","","11539.61","6923.77","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7258.41","62.9","","1793.12","860.08","3673.04","20","1342.06","9808.67","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","both","","","11539.61","6923.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8931.66","77.4","","1107.52","186.36","4312.65","1 through 10","1342.06","9808.67","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","11539.61","6923.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1342.06","11.63","","348.38","187.99","380.51","1 through 10","1342.06","8391.6","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","11539.61","6923.77","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","7244.57","62.78","","9719.10","2943.96","9719.10","1 through 10","1342.06","8391.6","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","11539.61","6923.77","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8391.60","72.72","","2009.48","1217.35","3752.64","17","1342.06","8391.6","percent of total billed charges",""
"MESH SURGICAL POSITIONING Y SHAPED FLAT SUTURING SURFACE MULTI DIRECTIONAL VAGINAL UPSYLON COLPASSIST IMPLANTABLE SACRAL COLPOPE","SUP-ITM-10118315","CDM","C1763","HCPCS","0278","RC","","","","both","","","6160.47","3696.28","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3505.31","56.9","","1156.60","963.29","1156.60","1 through 10","716.46","5236.4","percent of total billed charges",""
"MESH SURGICAL POSITIONING Y SHAPED FLAT SUTURING SURFACE MULTI DIRECTIONAL VAGINAL UPSYLON COLPASSIST IMPLANTABLE SACRAL COLPOPE","SUP-ITM-10118315","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","6160.47","3696.28","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4479.89","72.72","","8111.92","3502.08","8111.92","1 through 10","716.46","4768.2","percent of total billed charges",""
"MESH SURGICAL POSITIONING Y SHAPED FLAT SUTURING SURFACE MULTI DIRECTIONAL VAGINAL UPSYLON COLPASSIST IMPLANTABLE SACRAL COLPOPE","SUP-ITM-10118315","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","6160.47","3696.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3874.94","62.9","","1066.56","1066.56","1066.56","1 through 10","716.46","4768.2","percent of total billed charges",""
"Metanephrines","PX-30000572","CDM","83835","CPT","0301","RC","","","","both","","","92.00","55.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","64.22","69.8","","62.12","55.98","62.12","1 through 10","11.01","87.29","percent of total billed charges",""
"Metanephrines","PX-30000572","CDM","83835","CPT","0301","RC","","","","outpatient","","","92.00","55.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","66.90","72.72","","64.72","64.72","64.72","1 through 10","15.79","71.21","percent of total billed charges",""
"Metanephrines","PX-30000572","CDM","83835","CPT","0301","RC","","","","outpatient","","","92.00","55.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","57.87","62.9","","56.07","56.07","56.07","1 through 10","15.79","71.21","percent of total billed charges",""
"Metanephrines","PX-30000572","CDM","83835","CPT","0301","RC","","","","outpatient","","","92.00","55.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","71.21","77.4","","68.98","68.98","68.98","1 through 10","15.79","71.21","percent of total billed charges",""
"METATARSAL PLATE FIFTH HOOK RT LONG","SUP-ITM-10192427","CDM","C1713","HCPCS","0278","RC","","","","both","","","6183.75","3710.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","719.17","5256.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"METATARSAL PLATE FIFTH HOOK RT LONG","SUP-ITM-10192427","CDM","C1713","HCPCS","0278","RC","","","","both","","","6183.75","3710.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","719.17","5256.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"METATARSAL PLATE FIFTH HOOK RT LONG","SUP-ITM-10192427","CDM","C1713","HCPCS","0278","RC","","","","both","","","6183.75","3710.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3518.55","56.9","","812.12","238.65","1587.46","163","719.17","5256.19","percent of total billed charges",""
"METATARSAL PLATE FIFTH HOOK RT LONG","SUP-ITM-10192427","CDM","C1713","HCPCS","0278","RC","","","","both","","","6183.75","3710.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","719.17","11.63","","112.68","112.68","146.99","38","719.17","5256.19","percent of total billed charges",""
"METATARSAL PLATE FIFTH HOOK RT LONG","SUP-ITM-10192427","CDM","C1713","HCPCS","0278","RC","","","","both","","","6183.75","3710.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4786.22","77.4","","303.98","303.98","5854.79","1 through 10","719.17","5256.19","percent of total billed charges",""
"METATARSAL PLATE FIFTH HOOK RT LONG","SUP-ITM-10192427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6183.75","3710.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","719.17","11.63","","112.68","112.68","146.99","38","719.17","4786.22","percent of total billed charges",""
"METATARSAL PLATE FIFTH HOOK RT LONG","SUP-ITM-10192427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6183.75","3710.25","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3882.16","62.78","","780.86","208.94","10480.28","15","719.17","4786.22","percent of total billed charges",""
"METATARSAL PLATE FIFTH HOOK RT LONG","SUP-ITM-10192427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6183.75","3710.25","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2703.54","43.72","","179.76","179.76","179.76","1 through 10","719.17","4786.22","percent of total billed charges",""
"METATARSAL PLATE FIFTH HOOK RT LONG","SUP-ITM-10192427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6183.75","3710.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4496.82","72.72","","2355.45","298.99","3965.19","155","719.17","4786.22","percent of total billed charges",""
"METATARSAL PLATE FIFTH HOOK RT LONG","SUP-ITM-10192427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6183.75","3710.25","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4496.82","72.72","","3643.09","3643.09","3643.09","1 through 10","719.17","4786.22","percent of total billed charges",""
"METATARSAL PLATE FIFTH HOOK RT LONG","SUP-ITM-10192427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6183.75","3710.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3290.99","53.22","","554.28","554.28","554.28","16","719.17","4786.22","percent of total billed charges",""
"METATARSAL PLATE FIFTH HOOK RT LONG","SUP-ITM-10192427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6183.75","3710.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3889.58","62.9","","619.64","173.09","2370.64","150","719.17","4786.22","percent of total billed charges",""
"METATARSAL PLATE FIFTH HOOK RT LONG","SUP-ITM-10192427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6183.75","3710.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4786.22","77.4","","303.98","303.98","5854.79","1 through 10","719.17","4786.22","percent of total billed charges",""
"METATARSO PLATE 42MM SM 6 HOLE 0.0DEG BONE ORTHOLOC 3DI PHALANGEAL FUSION TITANIUM FIXATION COMPRESSION ANGLE RIGHT","SUP-ITM-10126020","CDM","C1713","HCPCS","0278","RC","","","","both","","","5766.65","3459.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","670.66","4901.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"METATARSO PLATE 42MM SM 6 HOLE 0.0DEG BONE ORTHOLOC 3DI PHALANGEAL FUSION TITANIUM FIXATION COMPRESSION ANGLE RIGHT","SUP-ITM-10126020","CDM","C1713","HCPCS","0278","RC","","","","both","","","5766.65","3459.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","670.66","4901.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"METATARSO PLATE 42MM SM 6 HOLE 0.0DEG BONE ORTHOLOC 3DI PHALANGEAL FUSION TITANIUM FIXATION COMPRESSION ANGLE RIGHT","SUP-ITM-10126020","CDM","C1713","HCPCS","0278","RC","","","","both","","","5766.65","3459.99","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3281.22","56.9","","812.12","238.65","1587.46","163","670.66","4901.65","percent of total billed charges",""
"METATARSO PLATE 42MM SM 6 HOLE 0.0DEG BONE ORTHOLOC 3DI PHALANGEAL FUSION TITANIUM FIXATION COMPRESSION ANGLE RIGHT","SUP-ITM-10126020","CDM","C1713","HCPCS","0278","RC","","","","both","","","5766.65","3459.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","670.66","11.63","","112.68","112.68","146.99","38","670.66","4901.65","percent of total billed charges",""
"METATARSO PLATE 42MM SM 6 HOLE 0.0DEG BONE ORTHOLOC 3DI PHALANGEAL FUSION TITANIUM FIXATION COMPRESSION ANGLE RIGHT","SUP-ITM-10126020","CDM","C1713","HCPCS","0278","RC","","","","both","","","5766.65","3459.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4463.39","77.4","","303.98","303.98","5854.79","1 through 10","670.66","4901.65","percent of total billed charges",""
"METATARSO PLATE 42MM SM 6 HOLE 0.0DEG BONE ORTHOLOC 3DI PHALANGEAL FUSION TITANIUM FIXATION COMPRESSION ANGLE RIGHT","SUP-ITM-10126020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5766.65","3459.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","670.66","11.63","","112.68","112.68","146.99","38","670.66","4463.39","percent of total billed charges",""
"METATARSO PLATE 42MM SM 6 HOLE 0.0DEG BONE ORTHOLOC 3DI PHALANGEAL FUSION TITANIUM FIXATION COMPRESSION ANGLE RIGHT","SUP-ITM-10126020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5766.65","3459.99","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3620.30","62.78","","780.86","208.94","10480.28","15","670.66","4463.39","percent of total billed charges",""
"METATARSO PLATE 42MM SM 6 HOLE 0.0DEG BONE ORTHOLOC 3DI PHALANGEAL FUSION TITANIUM FIXATION COMPRESSION ANGLE RIGHT","SUP-ITM-10126020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5766.65","3459.99","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2521.18","43.72","","179.76","179.76","179.76","1 through 10","670.66","4463.39","percent of total billed charges",""
"METATARSO PLATE 42MM SM 6 HOLE 0.0DEG BONE ORTHOLOC 3DI PHALANGEAL FUSION TITANIUM FIXATION COMPRESSION ANGLE RIGHT","SUP-ITM-10126020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5766.65","3459.99","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4193.51","72.72","","2355.45","298.99","3965.19","155","670.66","4463.39","percent of total billed charges",""
"METATARSO PLATE 42MM SM 6 HOLE 0.0DEG BONE ORTHOLOC 3DI PHALANGEAL FUSION TITANIUM FIXATION COMPRESSION ANGLE RIGHT","SUP-ITM-10126020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5766.65","3459.99","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4193.51","72.72","","3643.09","3643.09","3643.09","1 through 10","670.66","4463.39","percent of total billed charges",""
"METATARSO PLATE 42MM SM 6 HOLE 0.0DEG BONE ORTHOLOC 3DI PHALANGEAL FUSION TITANIUM FIXATION COMPRESSION ANGLE RIGHT","SUP-ITM-10126020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5766.65","3459.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3069.01","53.22","","554.28","554.28","554.28","16","670.66","4463.39","percent of total billed charges",""
"METATARSO PLATE 42MM SM 6 HOLE 0.0DEG BONE ORTHOLOC 3DI PHALANGEAL FUSION TITANIUM FIXATION COMPRESSION ANGLE RIGHT","SUP-ITM-10126020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5766.65","3459.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3627.22","62.9","","619.64","173.09","2370.64","150","670.66","4463.39","percent of total billed charges",""
"METATARSO PLATE 42MM SM 6 HOLE 0.0DEG BONE ORTHOLOC 3DI PHALANGEAL FUSION TITANIUM FIXATION COMPRESSION ANGLE RIGHT","SUP-ITM-10126020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5766.65","3459.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4463.39","77.4","","303.98","303.98","5854.79","1 through 10","670.66","4463.39","percent of total billed charges",""
"Mgh 1 3 Betad Glucan","PX-30002252","CDM","87449","CPT","0300","RC","","","","inpatient","","","103.00","61.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","79.17","76.86","","63.00","63.00","63.00","1 through 10","68.19","79.17","percent of total billed charges",""
"Mgh 1 3 Betad Glucan","PX-30002252","CDM","87449","CPT","0306","RC","","","","both","","","103.00","61.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","71.89","69.8","","62.90","62.90","64.92","1 through 10","7.79","87.55","percent of total billed charges",""
"Mgh 1 3 Betad Glucan","PX-30002252","CDM","87449","CPT","0306","RC","","","","outpatient","","","103.00","61.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","74.90","72.72","","72.72","72.72","72.72","1 through 10","10.68","79.72","percent of total billed charges",""
"Mgh 1 3 Betad Glucan","PX-30002252","CDM","87449","CPT","0306","RC","","","","outpatient","","","103.00","61.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","64.79","62.9","","63.00","63.00","63.00","1 through 10","10.68","79.72","percent of total billed charges",""
"Mgh 1 3 Betad Glucan","PX-30002252","CDM","87449","CPT","0306","RC","","","","outpatient","","","103.00","61.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","79.72","77.4","","77.50","77.50","77.50","1 through 10","10.68","79.72","percent of total billed charges",""
"Mgh Jc Virus, Pcr","PX-30002301","CDM","87798","CPT","0306","RC","","","","both","","","188.00","112.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","131.22","69.8","","127.04","114.48","508.14","20","22.81","180.59","percent of total billed charges",""
"Mgh Jc Virus, Pcr","PX-30002301","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","118.03","62.78","","114.26","114.26","114.26","1 through 10","24.28","145.51","percent of total billed charges",""
"Mgh Jc Virus, Pcr","PX-30002301","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","82.19","43.72","","79.57","79.57","79.57","1 through 10","24.28","145.51","percent of total billed charges",""
"Mgh Jc Virus, Pcr","PX-30002301","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","529.40","79","24.28","145.51","percent of total billed charges",""
"Mgh Jc Virus, Pcr","PX-30002301","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Mgh Jc Virus, Pcr","PX-30002301","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","118.25","62.9","","114.66","114.66","114.66","231","24.28","145.51","percent of total billed charges",""
"Mgh Jc Virus, Pcr","PX-30002301","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","145.51","77.4","","141.05","141.05","564.20","57","24.28","145.51","percent of total billed charges",""
"Mgh Jc Virus, Pcr","PX-30002301","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Mgh Revise Av Fistula,W/O Thrombectomy","PX-36000361","CDM","36832","CPT","0361","RC","","","","both","","","54895.00","32937.00","MEDICARE [2001]","HB WDH MEDICARE","5647.66","","APC Price ($5,647.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","16944.93","16944.93","16944.93","1 through 10","5534.71","46660.75","other","OPPS APC"
"Mgh Strongyloides Ab Igg","PX-30002231","CDM","86682","CPT","0302","RC","","","","outpatient","","","71.00","42.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","51.63","72.72","","50.18","50.18","50.18","1 through 10","9.1","54.95","percent of total billed charges",""
"Mgh Strongyloides Ab Igg","PX-30002231","CDM","86682","CPT","0302","RC","","","","outpatient","","","71.00","42.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","44.66","62.9","","43.47","43.47","43.47","1 through 10","9.1","54.95","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","81.00","48.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","56.54","69.8","","54.44","49.06","54.44","103","3.76","68.85","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","81.00","48.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","68.85","85","","13.83","8.09","13.83","1 through 10","3.76","68.85","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","outpatient","","","81.00","48.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","50.85","62.78","","48.97","48.97","48.97","1 through 10","5.04","62.69","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","outpatient","","","81.00","48.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","35.41","43.72","","34.10","34.10","34.10","1 through 10","5.04","62.69","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","outpatient","","","81.00","48.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","58.90","72.72","","56.72","56.72","56.72","184","5.04","62.69","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","outpatient","","","81.00","48.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","58.90","72.72","","56.72","56.72","56.72","1 through 10","5.04","62.69","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","outpatient","","","81.00","48.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","43.11","53.22","","41.58","41.58","78.20","18","5.04","62.69","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","outpatient","","","81.00","48.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","50.95","62.9","","49.14","49.14","49.14","204","5.04","62.69","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","outpatient","","","81.00","48.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","62.69","77.4","","60.45","60.45","60.45","90","5.04","62.69","percent of total billed charges",""
"Microbiology Unlstd Proc","PX-30001367","CDM","87999","CPT","0306","RC","","","","both","","","409.00","245.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","266.00","266.00","266.00","1 through 10","50.49","347.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MICROCATHETER CARAVEL 1.9FR 135CM .40MM TIP HYDROPHILIC COATING","SUP-ITM-10165963","CDM","C1887","HCPCS","0272","RC","","","","both","","","2729.45","1637.67","AETNA [1001]","HB WDH AETNA COMMERCIAL","1905.16","69.8","","211.78","89.23","211.78","1 through 10","317.44","2320.03","percent of total billed charges",""
"MICROCATHETER CARAVEL 1.9FR 135CM .40MM TIP HYDROPHILIC COATING","SUP-ITM-10165963","CDM","C1887","HCPCS","0272","RC","","","","both","","","2729.45","1637.67","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1553.06","56.9","","383.50","68.20","383.50","1 through 10","317.44","2320.03","percent of total billed charges",""
"MICROCATHETER CARAVEL 1.9FR 135CM .40MM TIP HYDROPHILIC COATING","SUP-ITM-10165963","CDM","C1887","HCPCS","0272","RC","","","","both","","","2729.45","1637.67","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","317.44","11.63","","8.44","7.37","15.65","12","317.44","2320.03","percent of total billed charges",""
"MICROCATHETER CARAVEL 1.9FR 135CM .40MM TIP HYDROPHILIC COATING","SUP-ITM-10165963","CDM","C1887","HCPCS","0272","RC","","","","both","","","2729.45","1637.67","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2112.59","77.4","","41.50","41.50","214.21","1 through 10","317.44","2320.03","percent of total billed charges",""
"MICROCATHETER CARAVEL 1.9FR 135CM .40MM TIP HYDROPHILIC COATING","SUP-ITM-10165963","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2729.45","1637.67","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","317.44","11.63","","8.44","7.37","15.65","12","317.44","2112.59","percent of total billed charges",""
"MICROCATHETER CARAVEL 1.9FR 135CM .40MM TIP HYDROPHILIC COATING","SUP-ITM-10165963","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2729.45","1637.67","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1984.86","72.72","","92.96","38.94","158.55","24","317.44","2112.59","percent of total billed charges",""
"MICROCATHETER CARAVEL 1.9FR 135CM .40MM TIP HYDROPHILIC COATING","SUP-ITM-10165963","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2729.45","1637.67","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1716.82","62.9","","208.96","33.74","457.91","69","317.44","2112.59","percent of total billed charges",""
"MICROCATHETER CARAVEL 1.9FR 135CM .40MM TIP HYDROPHILIC COATING","SUP-ITM-10165963","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","2729.45","1637.67","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2112.59","77.4","","41.50","41.50","214.21","1 through 10","317.44","2112.59","percent of total billed charges",""
"MICROCATHETER LANTERN 150CM .025IN 45DEGREE ANGLE","SUP-ITM-10169109","CDM","C1887","HCPCS","0272","RC","","","","both","","","4491.50","2694.90","AETNA [1001]","HB WDH AETNA COMMERCIAL","3135.07","69.8","","211.78","89.23","211.78","1 through 10","522.36","3817.78","percent of total billed charges",""
"MICROCATHETER LANTERN 150CM .025IN 45DEGREE ANGLE","SUP-ITM-10169109","CDM","C1887","HCPCS","0272","RC","","","","both","","","4491.50","2694.90","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2555.66","56.9","","383.50","68.20","383.50","1 through 10","522.36","3817.78","percent of total billed charges",""
"MICROCATHETER LANTERN 150CM .025IN 45DEGREE ANGLE","SUP-ITM-10169109","CDM","C1887","HCPCS","0272","RC","","","","both","","","4491.50","2694.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","522.36","11.63","","8.44","7.37","15.65","12","522.36","3817.78","percent of total billed charges",""
"MICROCATHETER LANTERN 150CM .025IN 45DEGREE ANGLE","SUP-ITM-10169109","CDM","C1887","HCPCS","0272","RC","","","","both","","","4491.50","2694.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3476.42","77.4","","41.50","41.50","214.21","1 through 10","522.36","3817.78","percent of total billed charges",""
"MICROCATHETER LANTERN 150CM .025IN 45DEGREE ANGLE","SUP-ITM-10169109","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","4491.50","2694.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","522.36","11.63","","8.44","7.37","15.65","12","522.36","3476.42","percent of total billed charges",""
"MICROCATHETER LANTERN 150CM .025IN 45DEGREE ANGLE","SUP-ITM-10169109","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","4491.50","2694.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3266.22","72.72","","92.96","38.94","158.55","24","522.36","3476.42","percent of total billed charges",""
"MICROCATHETER LANTERN 150CM .025IN 45DEGREE ANGLE","SUP-ITM-10169109","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","4491.50","2694.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2825.15","62.9","","208.96","33.74","457.91","69","522.36","3476.42","percent of total billed charges",""
"MICROCATHETER LANTERN 150CM .025IN 45DEGREE ANGLE","SUP-ITM-10169109","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","4491.50","2694.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3476.42","77.4","","41.50","41.50","214.21","1 through 10","522.36","3476.42","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 130CM .018IN EMBOLIZATION STRAIGHT STC-18 HYDROPHILIC","SUP-ITM-10100940","CDM","C1751","HCPCS","0272","RC","","","","both","","","2538.46","1523.08","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","295.22","11.63","","214.95","191.07","214.95","1 through 10","295.22","2157.69","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 130CM .018IN EMBOLIZATION STRAIGHT STC-18 HYDROPHILIC","SUP-ITM-10100940","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","2538.46","1523.08","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","295.22","11.63","","214.95","191.07","214.95","1 through 10","295.22","1964.77","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 130CM .018IN EMBOLIZATION STRAIGHT STC-18 HYDROPHILIC","SUP-ITM-10100940","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","2538.46","1523.08","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1845.97","72.72","","3405.48","1135.16","3405.48","1 through 10","295.22","1964.77","percent of total billed charges",""
"MICROCATHETER RENEGADE 3FR 20CM 130CM .018IN EMBOLIZATION STRAIGHT STC-18 HYDROPHILIC","SUP-ITM-10100940","CDM","C1751","HCPCS","0272","RC","","","","outpatient","","","2538.46","1523.08","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1596.69","62.9","","3937.48","3937.48","3937.48","1 through 10","295.22","1964.77","percent of total billed charges",""
"MICROCOIL HILAL 3MM 3CM .018IN EMBOLIZATION SOFT STRETCH VASCULAR PK/2EA","SUP-ITM-10008209","CDM","C1889","HCPCS","0278","RC","","","","both","","","303.81","182.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","35.33","258.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MICROCOIL HILAL 3MM 3CM .018IN EMBOLIZATION SOFT STRETCH VASCULAR PK/2EA","SUP-ITM-10008209","CDM","C1889","HCPCS","0278","RC","","","","both","","","303.81","182.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","35.33","258.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MICROCOIL HILAL 3MM 3CM .018IN EMBOLIZATION SOFT STRETCH VASCULAR PK/2EA","SUP-ITM-10008209","CDM","C1889","HCPCS","0278","RC","","","","both","","","303.81","182.29","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","172.87","56.9","","0.63","0.63","0.63","1 through 10","35.33","258.24","percent of total billed charges",""
"MICROCOIL HILAL 3MM 3CM .018IN EMBOLIZATION SOFT STRETCH VASCULAR PK/2EA","SUP-ITM-10008209","CDM","C1889","HCPCS","0278","RC","","","","both","","","303.81","182.29","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","43.81","14.42","","317.14","317.14","317.14","1 through 10","35.33","258.24","percent of total billed charges",""
"MICROCOIL HILAL 3MM 3CM .018IN EMBOLIZATION SOFT STRETCH VASCULAR PK/2EA","SUP-ITM-10008209","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","303.81","182.29","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","43.81","14.42","","317.14","317.14","317.14","1 through 10","35.33","235.15","percent of total billed charges",""
"MICROCOIL HILAL 3MM 3CM .018IN EMBOLIZATION SOFT STRETCH VASCULAR PK/2EA","SUP-ITM-10008209","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","303.81","182.29","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","190.73","62.78","","1125.09","1125.09","1125.09","1 through 10","35.33","235.15","percent of total billed charges",""
"MICROCOIL HILAL 3MM 3CM .018IN EMBOLIZATION SOFT STRETCH VASCULAR PK/2EA","SUP-ITM-10008209","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","303.81","182.29","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","220.93","72.72","","4732.50","1617.43","14180.40","1 through 10","35.33","235.15","percent of total billed charges",""
"MICROCOIL HILAL 3MM 3CM .018IN EMBOLIZATION SOFT STRETCH VASCULAR PK/2EA","SUP-ITM-10008209","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","303.81","182.29","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","191.10","62.9","","3896.20","3341.38","3896.20","1 through 10","35.33","235.15","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","both","","","207.00","124.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","144.49","69.8","","139.60","125.80","139.60","22","9.46","175.95","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","both","","","207.00","124.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","175.95","85","","75.25","13.09","75.25","1 through 10","9.46","175.95","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","outpatient","","","207.00","124.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","129.95","62.78","","125.56","125.56","125.56","1 through 10","13.56","160.22","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","outpatient","","","207.00","124.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","90.50","43.72","","87.44","87.44","87.44","1 through 10","13.56","160.22","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","outpatient","","","207.00","124.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","150.53","72.72","","145.44","145.44","145.44","45","13.56","160.22","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","outpatient","","","207.00","124.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","150.53","72.72","","145.44","145.44","145.44","1 through 10","13.56","160.22","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","outpatient","","","207.00","124.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","110.17","53.22","","106.62","106.62","106.62","1 through 10","13.56","160.22","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","outpatient","","","207.00","124.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","130.20","62.9","","126.00","126.00","126.00","64","13.56","160.22","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","outpatient","","","207.00","124.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","160.22","77.4","","155.00","154.99","155.00","21","13.56","160.22","percent of total billed charges",""
"MIDSHAFT PLATE 99MM 8 HOLE BONE VARIAX TITANIUM SUPERIOR LEFT","SUP-ITM-10144640","CDM","C1713","HCPCS","0278","RC","","","","both","","","8868.61","5321.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1031.42","7538.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MIDSHAFT PLATE 99MM 8 HOLE BONE VARIAX TITANIUM SUPERIOR LEFT","SUP-ITM-10144640","CDM","C1713","HCPCS","0278","RC","","","","both","","","8868.61","5321.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1031.42","7538.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MIDSHAFT PLATE 99MM 8 HOLE BONE VARIAX TITANIUM SUPERIOR LEFT","SUP-ITM-10144640","CDM","C1713","HCPCS","0278","RC","","","","both","","","8868.61","5321.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5046.24","56.9","","812.12","238.65","1587.46","163","1031.42","7538.32","percent of total billed charges",""
"MIDSHAFT PLATE 99MM 8 HOLE BONE VARIAX TITANIUM SUPERIOR LEFT","SUP-ITM-10144640","CDM","C1713","HCPCS","0278","RC","","","","both","","","8868.61","5321.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1031.42","11.63","","112.68","112.68","146.99","38","1031.42","7538.32","percent of total billed charges",""
"MIDSHAFT PLATE 99MM 8 HOLE BONE VARIAX TITANIUM SUPERIOR LEFT","SUP-ITM-10144640","CDM","C1713","HCPCS","0278","RC","","","","both","","","8868.61","5321.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6864.30","77.4","","303.98","303.98","5854.79","1 through 10","1031.42","7538.32","percent of total billed charges",""
"MIDSHAFT PLATE 99MM 8 HOLE BONE VARIAX TITANIUM SUPERIOR LEFT","SUP-ITM-10144640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8868.61","5321.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1031.42","11.63","","112.68","112.68","146.99","38","1031.42","6864.3","percent of total billed charges",""
"MIDSHAFT PLATE 99MM 8 HOLE BONE VARIAX TITANIUM SUPERIOR LEFT","SUP-ITM-10144640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8868.61","5321.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5567.71","62.78","","780.86","208.94","10480.28","15","1031.42","6864.3","percent of total billed charges",""
"MIDSHAFT PLATE 99MM 8 HOLE BONE VARIAX TITANIUM SUPERIOR LEFT","SUP-ITM-10144640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8868.61","5321.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3877.36","43.72","","179.76","179.76","179.76","1 through 10","1031.42","6864.3","percent of total billed charges",""
"MIDSHAFT PLATE 99MM 8 HOLE BONE VARIAX TITANIUM SUPERIOR LEFT","SUP-ITM-10144640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8868.61","5321.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6449.25","72.72","","2355.45","298.99","3965.19","155","1031.42","6864.3","percent of total billed charges",""
"MIDSHAFT PLATE 99MM 8 HOLE BONE VARIAX TITANIUM SUPERIOR LEFT","SUP-ITM-10144640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8868.61","5321.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6449.25","72.72","","3643.09","3643.09","3643.09","1 through 10","1031.42","6864.3","percent of total billed charges",""
"MIDSHAFT PLATE 99MM 8 HOLE BONE VARIAX TITANIUM SUPERIOR LEFT","SUP-ITM-10144640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8868.61","5321.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4719.87","53.22","","554.28","554.28","554.28","16","1031.42","6864.3","percent of total billed charges",""
"MIDSHAFT PLATE 99MM 8 HOLE BONE VARIAX TITANIUM SUPERIOR LEFT","SUP-ITM-10144640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8868.61","5321.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5578.36","62.9","","619.64","173.09","2370.64","150","1031.42","6864.3","percent of total billed charges",""
"MIDSHAFT PLATE 99MM 8 HOLE BONE VARIAX TITANIUM SUPERIOR LEFT","SUP-ITM-10144640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8868.61","5321.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6864.30","77.4","","303.98","303.98","5854.79","1 through 10","1031.42","6864.3","percent of total billed charges",""
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","","","","inpatient","","","31493.09","18895.85","MEDICARE [2001]","HB WDH MEDICARE","12002.10","","Case rate ($12,002.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,112.06, add-ons for qualifying new technology services are included. If operating cost exceeds $15,030.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,649.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,712.68 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,667.19 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $844.54. The transfer capital threshold is the transfer adjustment factor * $844.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11969.88","11969.88","11969.88","1 through 10","3975","57767.75","other","Inpatient DRG"
"Minor Bladder Procedures With McC","662","MS-DRG","","","","","","","","inpatient","","","79742.32","47845.39","MEDICARE [2001]","HB WDH MEDICARE","23719.72","","Case rate ($23,719.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $21,927.31, add-ons for qualifying new technology services are included. If operating cost exceeds $25,845.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,505.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $21,574.06 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $21,482.44 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,700.80. The transfer capital threshold is the transfer adjustment factor * $1,700.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24046.87","24046.87","24046.87","1 through 10","3975","116337.31","other","Inpatient DRG"
"Minor Skin Disorders With McC","606","MS-DRG","","","","","","","","inpatient","","","34542.39","20725.43","MEDICARE [2001]","HB WDH MEDICARE","11948.88","","Case rate ($11,948.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,062.94, add-ons for qualifying new technology services are included. If operating cost exceeds $14,981.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,645.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,663.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,618.07 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $840.65. The transfer capital threshold is the transfer adjustment factor * $840.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12595.40","12595.40","12595.40","1 through 10","3975","57501.75","other","Inpatient DRG"
"Minor Skin Disorders With McC","606","MS-DRG","","","","","","","","inpatient","","","34542.39","20725.43","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","11948.88","","Case rate ($11,948.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,062.94, add-ons for qualifying new technology services are included. If operating cost exceeds $14,981.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,645.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $10,663.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,618.07 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $840.65. The transfer capital threshold is the transfer adjustment factor * $840.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12595.40","12595.40","12595.40","1 through 10","3975","57501.75","other","Inpatient DRG"
"Minor Skin Disorders Without McC","607","MS-DRG","","","","","","","","inpatient","","","11750.36","7050.22","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","34443.29","","Fee schedule rate ($34,443.29). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","9694.87","9694.87","9694.87","1 through 10","3975","34443.29","case rate",""
"Minor Skin Disorders Without McC","607","MS-DRG","","","","","","","","inpatient","","","11750.36","7050.22","MEDICARE [2001]","HB WDH MEDICARE","7335.71","","Case rate ($7,335.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,805.05, add-ons for qualifying new technology services are included. If operating cost exceeds $10,723.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,308.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,387.30 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,360.18 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $503.54. The transfer capital threshold is the transfer adjustment factor * $503.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6982.64","6982.64","6982.64","1 through 10","3975","34443.29","other","Inpatient DRG"
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","","","","inpatient","","","77849.69","46709.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","45540.17","","Fee schedule rate ($45,540.17). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","43956.99","43956.99","43956.99","1 through 10","3975","57178.75","case rate",""
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","","","","inpatient","","","77849.69","46709.81","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","12240.79","","Case rate ($11,884.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,003.30, add-ons for qualifying new technology services are included. If operating cost exceeds $14,921.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,640.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,603.46 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,558.43 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $835.93. The transfer capital threshold is the transfer adjustment factor * $835.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","3816.02","3816.02","3816.02","1 through 10","3975","57178.75","other","Inpatient DRG"
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","","","","inpatient","","","77849.69","46709.81","MEDICARE [2001]","HB WDH MEDICARE","11884.26","","Case rate ($11,884.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,003.30, add-ons for qualifying new technology services are included. If operating cost exceeds $14,921.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,640.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,603.46 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,558.43 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $835.93. The transfer capital threshold is the transfer adjustment factor * $835.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","0.05","1 through 10","3975","57178.75","other","Inpatient DRG"
"Minor Small And Large Bowel Procedures With McC","344","MS-DRG","","","","","","","","inpatient","","","40709.55","24425.73","MEDICARE [2001]","HB WDH MEDICARE","20080.44","","Case rate ($20,080.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $18,568.29, add-ons for qualifying new technology services are included. If operating cost exceeds $22,486.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,239.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $18,200.71 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $18,123.42 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,434.86. The transfer capital threshold is the transfer adjustment factor * $1,434.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20776.29","20776.29","20776.29","1 through 10","3975","98146.66","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","40002.83","24001.70","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","10810.65","","Case rate ($10,598.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,816.73, add-ons for qualifying new technology services are included. If operating cost exceeds $13,734.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,547.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,411.83 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,371.86 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $741.98. The transfer capital threshold is the transfer adjustment factor * $741.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","10465.29","10465.29","10465.29","1 through 10","3975","50752.93","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","40002.83","24001.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","10386.71","","Case rate ($10,598.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,816.73, add-ons for qualifying new technology services are included. If operating cost exceeds $13,734.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,547.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,411.83 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,371.86 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $741.98. The transfer capital threshold is the transfer adjustment factor * $741.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10295.48","10295.48","191218.52","1 through 10","3975","50752.93","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","40002.83","24001.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","40422.31","","Fee schedule rate ($40,422.31). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","19386.05","19386.05","26696.89","1 through 10","3975","50752.93","case rate",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","40002.83","24001.70","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","10916.64","","Case rate ($10,598.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,816.73, add-ons for qualifying new technology services are included. If operating cost exceeds $13,734.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,547.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,411.83 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,371.86 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $741.98. The transfer capital threshold is the transfer adjustment factor * $741.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","8228.82","8228.82","8228.82","1 through 10","3975","50752.93","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","40002.83","24001.70","MARTIN'S POINT [160007]","HB WDH MEDICARE","10598.68","","Case rate ($10,598.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,816.73, add-ons for qualifying new technology services are included. If operating cost exceeds $13,734.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,547.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,411.83 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,371.86 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $741.98. The transfer capital threshold is the transfer adjustment factor * $741.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10289.07","10289.07","12297.54","1 through 10","3975","50752.93","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","40002.83","24001.70","MEDICARE [2001]","HB WDH MEDICARE","10598.68","","Case rate ($10,598.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,816.73, add-ons for qualifying new technology services are included. If operating cost exceeds $13,734.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,547.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,411.83 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,371.86 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $741.98. The transfer capital threshold is the transfer adjustment factor * $741.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10465.29","0.05","10491.40","45","3975","50752.93","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","40002.83","24001.70","TRICARE [160005]","HB WDH MEDICARE","10598.68","","Case rate ($10,598.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,816.73, add-ons for qualifying new technology services are included. If operating cost exceeds $13,734.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,547.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,411.83 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,371.86 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $741.98. The transfer capital threshold is the transfer adjustment factor * $741.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11774.99","11774.99","11774.99","1 through 10","3975","50752.93","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","40002.83","24001.70","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","10598.68","","Case rate ($10,598.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,816.73, add-ons for qualifying new technology services are included. If operating cost exceeds $13,734.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,547.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,411.83 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,371.86 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $741.98. The transfer capital threshold is the transfer adjustment factor * $741.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10293.59","6026.68","10491.40","11","3975","50752.93","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","22824.21","13694.53","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","6488.30","","Case rate ($6,361.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,905.47, add-ons for qualifying new technology services are included. If operating cost exceeds $9,823.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,237.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,483.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,460.60 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $432.32. The transfer capital threshold is the transfer adjustment factor * $432.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","6356.25","6356.25","6356.25","1 through 10","3975","29571.68","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","22824.21","13694.53","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","6233.86","","Case rate ($6,361.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,905.47, add-ons for qualifying new technology services are included. If operating cost exceeds $9,823.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,237.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,483.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,460.60 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $432.32. The transfer capital threshold is the transfer adjustment factor * $432.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6356.25","6356.25","6356.25","1 through 10","3975","29571.68","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","22824.21","13694.53","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","23552.44","","Fee schedule rate ($23,552.44). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","23072.47","23072.47","23072.47","1 through 10","3975","29571.68","case rate",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","22824.21","13694.53","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","6551.91","","Case rate ($6,361.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,905.47, add-ons for qualifying new technology services are included. If operating cost exceeds $9,823.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,237.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,483.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,460.60 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $432.32. The transfer capital threshold is the transfer adjustment factor * $432.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","5953.51","5953.51","5953.51","1 through 10","3975","29571.68","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","22824.21","13694.53","MARTIN'S POINT [160007]","HB WDH MEDICARE","6361.08","","Case rate ($6,361.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,905.47, add-ons for qualifying new technology services are included. If operating cost exceeds $9,823.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,237.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,483.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,460.60 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $432.32. The transfer capital threshold is the transfer adjustment factor * $432.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6862.82","6862.82","6862.82","1 through 10","3975","29571.68","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","22824.21","13694.53","MEDICARE [2001]","HB WDH MEDICARE","6361.08","","Case rate ($6,361.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,905.47, add-ons for qualifying new technology services are included. If operating cost exceeds $9,823.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,237.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,483.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,460.60 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $432.32. The transfer capital threshold is the transfer adjustment factor * $432.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6340.89","0.05","6356.25","51","3975","29571.68","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","22824.21","13694.53","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6361.08","","Case rate ($6,361.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,905.47, add-ons for qualifying new technology services are included. If operating cost exceeds $9,823.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,237.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,483.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,460.60 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $432.32. The transfer capital threshold is the transfer adjustment factor * $432.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6260.73","6229.13","6356.25","1 through 10","3975","29571.68","other","Inpatient DRG"
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","both","","","294.00","176.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","205.21","69.8","","20.61","20.61","198.23","1 through 10","16.54","249.9","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","both","","","294.00","176.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","167.29","56.9","","161.60","161.60","161.60","19","16.54","249.9","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","294.00","176.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","42.39","14.42","","22.67","22.67","22.67","1 through 10","34.19","227.56","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","294.00","176.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","34.19","11.63","","22.45","22.45","71.73","1 through 10","34.19","227.56","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","294.00","176.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","213.80","72.72","","206.52","206.52","206.52","15","34.19","227.56","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","294.00","176.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","184.93","62.9","","178.92","178.92","686.08","32","34.19","227.56","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","294.00","176.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","227.56","77.4","","220.10","50.36","220.10","1 through 10","34.19","227.56","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","294.00","176.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","34.19","11.63","","22.45","22.45","40.72","1 through 10","34.19","227.56","percent of total billed charges",""
"MIX BONE 10CC ALLOGRAFT DBX DEMINERALIZED MATRIX FREEZE DRIED","SUP-ITM-10048897","CDM","C1889","HCPCS","0278","RC","","","","both","","","5303.77","3182.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","616.83","4508.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MIX BONE 10CC ALLOGRAFT DBX DEMINERALIZED MATRIX FREEZE DRIED","SUP-ITM-10048897","CDM","C1889","HCPCS","0278","RC","","","","both","","","5303.77","3182.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","616.83","4508.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"MIX BONE 10CC ALLOGRAFT DBX DEMINERALIZED MATRIX FREEZE DRIED","SUP-ITM-10048897","CDM","C1889","HCPCS","0278","RC","","","","both","","","5303.77","3182.26","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3017.85","56.9","","0.63","0.63","0.63","1 through 10","616.83","4508.2","percent of total billed charges",""
"MIX BONE 10CC ALLOGRAFT DBX DEMINERALIZED MATRIX FREEZE DRIED","SUP-ITM-10048897","CDM","C1889","HCPCS","0278","RC","","","","both","","","5303.77","3182.26","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","764.80","14.42","","317.14","317.14","317.14","1 through 10","616.83","4508.2","percent of total billed charges",""
"MIX BONE 10CC ALLOGRAFT DBX DEMINERALIZED MATRIX FREEZE DRIED","SUP-ITM-10048897","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5303.77","3182.26","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","764.80","14.42","","317.14","317.14","317.14","1 through 10","616.83","4105.12","percent of total billed charges",""
"MIX BONE 10CC ALLOGRAFT DBX DEMINERALIZED MATRIX FREEZE DRIED","SUP-ITM-10048897","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5303.77","3182.26","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3329.71","62.78","","1125.09","1125.09","1125.09","1 through 10","616.83","4105.12","percent of total billed charges",""
"MIX BONE 10CC ALLOGRAFT DBX DEMINERALIZED MATRIX FREEZE DRIED","SUP-ITM-10048897","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5303.77","3182.26","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3856.90","72.72","","4732.50","1617.43","14180.40","1 through 10","616.83","4105.12","percent of total billed charges",""
"MIX BONE 10CC ALLOGRAFT DBX DEMINERALIZED MATRIX FREEZE DRIED","SUP-ITM-10048897","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5303.77","3182.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3336.07","62.9","","3896.20","3341.38","3896.20","1 through 10","616.83","4105.12","percent of total billed charges",""
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","3047.00","1828.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","2126.81","69.8","","2052.12","2052.12","2052.12","1 through 10","374.81","2589.95","percent of total billed charges",""
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","3047.00","1828.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2444.27","","Case rate ($2,444.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2384.66","2384.66","2384.66","1 through 10","374.81","2589.95","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","3047.00","1828.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1052.50","","Case rate ($1,052.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1026.84","924.17","1679.97","1 through 10","374.81","2589.95","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","3047.00","1828.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","374.81","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","376.38","374.85","382.50","25","374.81","2589.95","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","3047.00","1828.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1975.68","","Case rate ($1,975.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1891.57","1702.41","4652.02","12","374.81","2589.95","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","3047.00","1828.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","393.93","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","387.68","386.10","387.68","13","374.81","2589.95","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","3047.00","1828.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","376.38","374.85","376.38","29","374.81","2589.95","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","3047.00","1828.20","MEDICARE [2001]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","382.50","360.01","382.50","117","374.81","2589.95","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","3047.00","1828.20","TRICARE [160005]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","382.50","382.50","382.50","1 through 10","374.81","2589.95","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","3047.00","1828.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","376.38","374.85","382.50","56","374.81","2589.95","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","both","","","3047.00","1828.20","WELLSENSE NH [1050]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","395.20","395.20","790.40","1 through 10","374.81","2589.95","other","OPPS APC"
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","outpatient","","","3047.00","1828.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","439.38","14.42","","363.38","363.38","423.95","11","354.37","2358.38","percent of total billed charges",""
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","outpatient","","","3047.00","1828.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","354.37","11.63","","404.84","347.26","742.50","1 through 10","354.37","2358.38","percent of total billed charges",""
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","outpatient","","","3047.00","1828.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2215.78","72.72","","2137.97","2137.97","12383.49","1 through 10","354.37","2358.38","percent of total billed charges",""
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","outpatient","","","3047.00","1828.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1916.56","62.9","","1852.20","1852.20","1852.20","1 through 10","354.37","2358.38","percent of total billed charges",""
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","outpatient","","","3047.00","1828.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2358.38","77.4","","2278.50","2278.50","2278.50","1 through 10","354.37","2358.38","percent of total billed charges",""
"Mlc Device(S) for Imrt","PX-33000026","CDM","77338","CPT","0333","RC","","","","outpatient","","","3047.00","1828.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","354.37","11.63","","599.76","347.26","612.00","1 through 10","354.37","2358.38","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","325.00","195.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","226.85","69.8","","219.17","219.17","219.17","21","184.93","276.25","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","325.00","195.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","184.93","56.9","","557.62","178.67","934.65","79","184.93","276.25","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","outpatient","","","325.00","195.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","46.87","14.42","","45.28","38.81","45.28","1 through 10","37.8","251.55","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","outpatient","","","325.00","195.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","37.80","11.63","","43.24","37.09","111.26","50","37.8","251.55","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","outpatient","","","325.00","195.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","142.09","43.72","","137.28","137.28","137.28","1 through 10","37.8","251.55","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","outpatient","","","325.00","195.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","236.34","72.72","","228.34","228.34","913.36","34","37.8","251.55","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","outpatient","","","325.00","195.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","204.43","62.9","","395.64","197.82","759.24","57","37.8","251.55","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","outpatient","","","325.00","195.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","251.55","77.4","","243.35","243.35","243.35","11","37.8","251.55","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","outpatient","","","325.00","195.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","37.80","11.63","","37.09","37.09","37.09","18","37.8","251.55","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","365.00","219.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","254.77","69.8","","245.70","235.92","245.70","1 through 10","207.69","310.25","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","365.00","219.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","207.69","56.9","","200.29","200.29","1144.83","46","207.69","310.25","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","365.00","219.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","310.25","85","","23.56","23.56","23.56","1 through 10","207.69","310.25","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","365.00","219.00","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","327.00","327.00","327.00","1 through 10","207.69","310.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","outpatient","","","365.00","219.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","52.63","14.42","","50.76","43.51","50.76","1 through 10","42.45","282.51","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","outpatient","","","365.00","219.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","42.45","11.63","","48.47","41.58","124.74","30","42.45","282.51","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","outpatient","","","365.00","219.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","229.15","62.78","","220.99","220.99","220.99","1 through 10","42.45","282.51","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","outpatient","","","365.00","219.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","159.58","43.72","","461.67","153.89","461.67","1 through 10","42.45","282.51","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","outpatient","","","365.00","219.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","265.43","72.72","","255.97","255.97","1023.88","29","42.45","282.51","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","outpatient","","","365.00","219.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","229.59","62.9","","426.28","221.76","852.56","40","42.45","282.51","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","outpatient","","","365.00","219.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","282.51","77.4","","272.80","272.80","272.80","1 through 10","42.45","282.51","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","outpatient","","","365.00","219.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","42.45","11.63","","41.58","41.58","41.58","12","42.45","282.51","percent of total billed charges",""
"Molecular Path Procedure Level 3","PX-31000004","CDM","81402","CPT","0310","RC","","","","outpatient","","","689.00","413.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","501.04","72.72","","484.32","484.32","484.32","1 through 10","80.13","533.29","percent of total billed charges",""
"Molecular Path Procedure Level 4","PX-31000005","CDM","81403","CPT","0310","RC","","","","outpatient","","","1942.00","1165.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","225.85","11.63","","1878.00","1878.00","1878.00","1 through 10","225.85","1503.11","percent of total billed charges",""
"Molecular Path Procedure Level 5","PX-31000006","CDM","81404","CPT","0310","RC","","","","outpatient","","","3159.00","1895.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","367.39","11.63","","3055.00","3055.00","3055.00","1 through 10","367.39","2445.07","percent of total billed charges",""
"Molecular Path Procedure Level 6","PX-31000007","CDM","81405","CPT","0310","RC","","","","outpatient","","","3159.00","1895.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","367.39","11.63","","3055.00","3055.00","3055.00","1 through 10","367.39","2445.07","percent of total billed charges",""
"Molecular Path Procedure Level 7","PX-31000008","CDM","81406","CPT","0310","RC","","","","outpatient","","","1977.00","1186.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","229.93","11.63","","1912.00","1912.00","1912.00","1 through 10","229.93","1530.2","percent of total billed charges",""
"Mononuclear Cell Antigen Qn","PX-30000850","CDM","86356","CPT","0302","RC","","","","both","","","187.00","112.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","130.53","69.8","","126.34","113.85","126.34","1 through 10","17.41","158.95","percent of total billed charges",""
"Mononuclear Cell Antigen Qn","PX-30000850","CDM","86356","CPT","0302","RC","","","","outpatient","","","187.00","112.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","135.99","72.72","","131.62","131.62","394.86","27","13.33","144.74","percent of total billed charges",""
"Mononuclear Cell Antigen Qn","PX-30000850","CDM","86356","CPT","0302","RC","","","","outpatient","","","187.00","112.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","99.52","53.22","","96.49","96.49","96.49","1 through 10","13.33","144.74","percent of total billed charges",""
"Mononuclear Cell Antigen Qn","PX-30000850","CDM","86356","CPT","0302","RC","","","","outpatient","","","187.00","112.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","117.62","62.9","","114.03","114.03","114.03","1 through 10","13.33","144.74","percent of total billed charges",""
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","3579.00","2147.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","3542.81","","Case rate ($3,542.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3456.41","3456.41","3456.41","1 through 10","543.26","3542.81","other","OPPS APC"
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","3579.00","2147.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1525.53","","Case rate ($1,525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1488.34","1461.75","3454.00","1 through 10","543.26","3542.81","other","OPPS APC"
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","3579.00","2147.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","2863.62","","Case rate ($2,863.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2793.76","2793.76","2793.76","1 through 10","543.26","3542.81","other","OPPS APC"
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","3579.00","2147.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2036.45","56.9","","1965.33","1965.33","1965.33","1 through 10","543.26","3542.81","percent of total billed charges",""
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","3579.00","2147.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","570.98","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","559.62","559.62","559.62","1 through 10","543.26","3542.81","other","OPPS APC"
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","3579.00","2147.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","554.35","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","554.41","543.32","554.41","1 through 10","543.26","3542.81","other","OPPS APC"
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","3579.00","2147.40","MEDICARE [2001]","HB WDH MEDICARE","554.35","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","554.41","522.23","554.41","13","543.26","3542.81","other","OPPS APC"
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","both","","","3579.00","2147.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","554.35","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","543.83","543.83","543.83","1 through 10","543.26","3542.81","other","OPPS APC"
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","outpatient","","","3579.00","2147.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","516.09","14.42","","498.07","498.07","498.07","1 through 10","416.24","2770.15","percent of total billed charges",""
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","outpatient","","","3579.00","2147.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2602.65","72.72","","2511.75","2511.75","2511.75","1 through 10","416.24","2770.15","percent of total billed charges",""
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","outpatient","","","3579.00","2147.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2602.65","72.72","","2511.75","2511.75","2511.75","1 through 10","416.24","2770.15","percent of total billed charges",""
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","outpatient","","","3579.00","2147.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2251.19","62.9","","2176.02","2176.02","2176.02","1 through 10","416.24","2770.15","percent of total billed charges",""
"Motility Study Esophagus","PX-75000309","CDM","91010","CPT","0750","RC","","","","outpatient","","","3579.00","2147.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2770.15","77.4","","2676.85","2676.85","2676.85","1 through 10","416.24","2770.15","percent of total billed charges",""
"Mpl Gene Analysis Common Variants","PX-31001135","CDM","81338","CPT","0310","RC","","","","both","","","1576.00","945.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","1100.05","69.8","","1063.75","1063.75","1063.75","1 through 10","97.71","1339.6","percent of total billed charges",""
"Mpl Gene Analysis Common Variants","PX-31001135","CDM","81338","CPT","0310","RC","","","","both","","","1576.00","945.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","896.74","56.9","","867.16","867.16","867.16","1 through 10","97.71","1339.6","percent of total billed charges",""
"Mpl Gene Analysis Common Variants","PX-31001135","CDM","81338","CPT","0310","RC","","","","outpatient","","","1576.00","945.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","227.26","14.42","","133.94","133.94","133.94","1 through 10","183.29","1219.82","percent of total billed charges",""
"Mpl Gene Analysis Common Variants","PX-31001135","CDM","81338","CPT","0310","RC","","","","outpatient","","","1576.00","945.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","183.29","11.63","","132.64","132.64","132.64","1 through 10","183.29","1219.82","percent of total billed charges",""
"Mra Abdomen W&W/O Cont","PX-61000123","CDM","C8902","HCPCS","0618","RC","","","","both","","","9402.00","5641.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1026.79","","Case rate ($1,026.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2397.80","2397.80","2397.80","1 through 10","365.65","7991.7","other","OPPS APC"
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","outpatient","","","9381.00","5628.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1352.74","14.42","","1308.33","1308.33","1308.33","1 through 10","1091.01","7260.89","percent of total billed charges",""
"Mra Chest W&W/O Contrast","PX-61000105","CDM","C8911","HCPCS","0618","RC","","","","both","","","9291.00","5574.60","MEDICARE [2001]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","373.16","373.16","1 through 10","365.65","7897.35","other","OPPS APC"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","6710.00","4026.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","247.49","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","252.57","252.57","252.57","1 through 10","247.49","5703.5","other","OPPS APC"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","6710.00","4026.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1304.55","","Case rate ($1,304.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","678.03","678.03","678.03","1 through 10","247.49","5703.5","other","OPPS APC"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","6710.00","4026.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3817.99","56.9","","3684.28","3684.28","3684.28","1 through 10","247.49","5703.5","percent of total billed charges",""
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","6710.00","4026.00","MEDICARE [2001]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","893.19","893.19","893.19","1 through 10","247.49","5703.5","other","OPPS APC"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","6710.00","4026.00","TRICARE [160005]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","1 through 10","247.49","5703.5","other","OPPS APC"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","6710.00","4026.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","278.12","248.53","879.43","1 through 10","247.49","5703.5","other","OPPS APC"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","outpatient","","","6710.00","4026.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","4708.62","2354.31","4708.62","1 through 10","780.37","5193.54","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","outpatient","","","6710.00","4026.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4220.59","62.9","","4079.25","4079.25","4079.25","1 through 10","780.37","5193.54","percent of total billed charges",""
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","outpatient","","","6710.00","4026.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5193.54","77.4","","5018.13","5018.13","5018.13","1 through 10","780.37","5193.54","percent of total billed charges",""
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","both","","","10354.00","6212.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5891.43","56.9","","5684.88","196.49","5684.88","1 through 10","365.65","8800.9","percent of total billed charges",""
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","both","","","10354.00","6212.40","MEDICARE [2001]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","373.16","373.16","1 through 10","365.65","8800.9","other","OPPS APC"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","both","","","10354.00","6212.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.40","365.70","369.40","1 through 10","365.65","8800.9","other","OPPS APC"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","outpatient","","","10354.00","6212.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1204.17","11.63","","2523.25","2523.25","2523.25","1 through 10","1204.17","8014","percent of total billed charges",""
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","outpatient","","","10354.00","6212.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","4368.07","4368.07","4368.07","1 through 10","1204.17","8014","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","outpatient","","","10354.00","6212.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","7265.46","7265.46","7265.46","1 through 10","1204.17","8014","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","outpatient","","","10354.00","6212.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6512.67","62.9","","6294.33","6294.33","6294.33","1 through 10","1204.17","8014","percent of total billed charges",""
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","outpatient","","","10354.00","6212.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8014.00","77.4","","7743.03","7743.03","7743.03","1 through 10","1204.17","8014","percent of total billed charges",""
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","outpatient","","","10354.00","6212.40","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","7265.46","7265.46","7265.46","1 through 10","1204.17","8014","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","outpatient","","","7135.00","4281.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","2503.39","2503.39","2503.39","1 through 10","829.8","5522.49","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Mra Neck W/O Cont","PX-61000084","CDM","70547","CPT","0615","RC","","","","outpatient","","","6740.00","4044.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","4729.71","4729.71","4729.71","1 through 10","783.86","5216.76","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0610","RC","","","","outpatient","","","8886.00","5331.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1281.36","14.42","","1236.52","1059.87","1236.52","11","1281.36","1281.36","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","8886.00","5331.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","5985.35","5742.60","5985.35","1 through 10","365.65","7553.1","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","8886.00","5331.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2384.56","","Case rate ($2,384.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2326.40","2326.40","2435.72","25","365.65","7553.1","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","8886.00","5331.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1026.79","","Case rate ($1,026.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1001.76","1001.76","1048.83","39","365.65","7553.1","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","8886.00","5331.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","365.65","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","365.70","365.70","373.16","64","365.65","7553.1","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","8886.00","5331.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1927.41","","Case rate ($1,927.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1880.39","1048.83","1880.39","29","365.65","7553.1","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","8886.00","5331.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5056.13","56.9","","4879.18","4879.18","4879.18","37","365.65","7553.1","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","8886.00","5331.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","384.31","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","383.16","379.33","384.35","19","365.65","7553.1","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","8886.00","5331.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","367.19","367.19","373.16","73","365.65","7553.1","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","8886.00","5331.60","MEDICARE [2001]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","373.16","373.16","162","365.65","7553.1","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","8886.00","5331.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","7553.10","85","","610.94","610.94","610.94","1 through 10","365.65","7553.1","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","8886.00","5331.60","TRICARE [160005]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","373.16","373.16","1 through 10","365.65","7553.1","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","8886.00","5331.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.70","365.70","373.16","92","365.65","7553.1","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","8886.00","5331.60","WELLPOINT [1015]","HB WDH ANTHEM PPO","1927.41","","Case rate ($1,927.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1968.75","1880.39","1968.75","1 through 10","365.65","7553.1","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","8886.00","5331.60","WELLSENSE NH [1050]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","386.98","383.98","386.98","13","365.65","7553.1","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","8886.00","5331.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1033.44","11.63","","1180.78","1012.85","2165.64","20","1033.44","6877.76","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","8886.00","5331.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5578.63","62.78","","5383.39","5383.39","5383.39","1 through 10","1033.44","6877.76","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","8886.00","5331.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3884.96","43.72","","3748.99","3748.99","3748.99","1 through 10","1033.44","6877.76","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","8886.00","5331.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6461.90","72.72","","6235.74","6235.74","6235.74","30","1033.44","6877.76","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","8886.00","5331.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6461.90","72.72","","6235.74","6235.74","6235.74","1 through 10","1033.44","6877.76","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","8886.00","5331.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4729.13","53.22","","4571.33","4571.33","4571.33","1 through 10","1033.44","6877.76","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","8886.00","5331.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5589.29","62.9","","5402.25","5402.25","5402.25","30","1033.44","6877.76","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","8886.00","5331.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6877.76","77.4","","6645.63","6645.62","6645.63","15","1033.44","6877.76","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","8886.00","5331.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","6461.90","72.72","","6235.74","6235.74","6235.74","1 through 10","1033.44","6877.76","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","8886.00","5331.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1033.44","11.63","","1012.85","589.90","1012.85","1 through 10","1033.44","6877.76","percent of total billed charges",""
"MRI Abdomen W/Cont","PX-61000066","CDM","74182","CPT","0614","RC","","","","both","","","8362.00","5017.20","MEDICARE [2001]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","373.16","373.16","1 through 10","365.65","7107.7","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0610","RC","","","","outpatient","","","5253.00","3151.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","757.48","14.42","","730.95","730.95","730.95","1 through 10","757.48","757.48","percent of total billed charges",""
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","5253.00","3151.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","496.65","496.65","496.65","1 through 10","247.49","4465.05","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","5253.00","3151.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1613.96","","Case rate ($1,613.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1574.60","1574.60","1574.60","1 through 10","247.49","4465.05","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","5253.00","3151.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","694.97","","Case rate ($694.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","678.03","678.03","5069.00","1 through 10","247.49","4465.05","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","5253.00","3151.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","247.49","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","247.52","238.75","252.57","1 through 10","247.49","4465.05","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","5253.00","3151.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1304.55","","Case rate ($1,304.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1254.41","1254.41","5069.00","1 through 10","247.49","4465.05","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","5253.00","3151.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2988.96","56.9","","2884.26","2884.26","2884.26","1 through 10","247.49","4465.05","percent of total billed charges",""
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","5253.00","3151.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","260.12","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","260.15","254.95","260.15","1 through 10","247.49","4465.05","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","5253.00","3151.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","248.53","252.57","1 through 10","247.49","4465.05","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","5253.00","3151.80","MEDICARE [2001]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","238.75","252.57","17","247.49","4465.05","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","5253.00","3151.80","TRICARE [160005]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","1 through 10","247.49","4465.05","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","5253.00","3151.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","251.62","248.53","251.62","1 through 10","247.49","4465.05","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","outpatient","","","5253.00","3151.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","610.92","11.63","","698.00","598.73","1351.70","1 through 10","610.92","4065.82","percent of total billed charges",""
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","outpatient","","","5253.00","3151.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3819.98","72.72","","3686.18","3686.18","3686.18","1 through 10","610.92","4065.82","percent of total billed charges",""
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","outpatient","","","5253.00","3151.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3304.14","62.9","","3193.47","3193.47","6131.96","1 through 10","610.92","4065.82","percent of total billed charges",""
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","outpatient","","","5253.00","3151.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4065.82","77.4","","3928.47","3928.47","3928.47","1 through 10","610.92","4065.82","percent of total billed charges",""
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","outpatient","","","5253.00","3151.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","610.92","11.63","","598.73","598.73","598.73","1 through 10","610.92","4065.82","percent of total billed charges",""
"MRI Abdomen W/O Cont|REDUCED SERVICES","PX-61000065","CDM","74181","CPT","0614","RC","","","52","both","","","5253.00","3151.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","260.12","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","130.08","130.08","130.08","1 through 10","247.49","260.12","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","7879.00","4727.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","5306.89","5300.15","5306.89","1 through 10","365.65","6697.15","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","7879.00","4727.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2384.56","","Case rate ($2,384.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2326.40","2326.40","5526.94","38","365.65","6697.15","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","7879.00","4727.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1026.79","","Case rate ($1,026.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1001.76","1001.76","1048.83","84","365.65","6697.15","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","7879.00","4727.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","365.65","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","373.16","365.70","374.71","74","365.65","6697.15","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","7879.00","4727.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1927.41","","Case rate ($1,927.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1880.39","1001.76","4500.91","56","365.65","6697.15","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","7879.00","4727.40","CHAMPVA [160001]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","373.16","373.16","1 through 10","365.65","6697.15","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","7879.00","4727.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4483.15","56.9","","4326.11","4326.11","4326.11","60","365.65","6697.15","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","7879.00","4727.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","384.31","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","383.16","376.66","384.35","35","365.65","6697.15","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","7879.00","4727.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","367.19","367.19","836.66","57","365.65","6697.15","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","7879.00","4727.40","MEDICARE [2001]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","373.16","374.71","208","365.65","6697.15","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","7879.00","4727.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","6697.15","85","","580.38","580.38","580.38","1 through 10","365.65","6697.15","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","7879.00","4727.40","TRICARE [160005]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","337.13","893.19","14","365.65","6697.15","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","7879.00","4727.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","368.70","365.70","373.16","119","365.65","6697.15","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","7879.00","4727.40","WELLPOINT [1015]","HB WDH ANTHEM PPO","1927.41","","Case rate ($1,927.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1880.39","1880.39","1880.39","1 through 10","365.65","6697.15","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","7879.00","4727.40","WELLSENSE NH [1050]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","386.98","386.98","386.98","1 through 10","365.65","6697.15","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","7879.00","4727.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1136.15","14.42","","1096.35","939.73","1096.35","30","916.33","6098.35","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","7879.00","4727.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","916.33","11.63","","1046.93","597.06","1920.16","46","916.33","6098.35","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","7879.00","4727.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","","","Payment is accumulated by procedure count. Procedure 1, 62.78% of billed. Procedures 2 - 9999, 31.39% of billed.","4773.16","4773.16","4773.16","1 through 10","916.33","6098.35","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","7879.00","4727.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","3324.03","1662.02","3324.03","1 through 10","916.33","6098.35","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","7879.00","4727.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","5528.90","2764.45","5528.90","57","916.33","6098.35","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","7879.00","4727.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4193.20","53.22","","4053.16","4053.16","4053.16","1 through 10","916.33","6098.35","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","7879.00","4727.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4955.89","62.9","","4789.89","4789.89","17873.40","66","916.33","6098.35","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","7879.00","4727.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6098.35","77.4","","5892.33","5892.32","5892.33","21","916.33","6098.35","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","7879.00","4727.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","916.33","11.63","","898.04","597.06","2694.12","34","916.33","6098.35","percent of total billed charges",""
"MRI Brain W/Cont","PX-61000017","CDM","70552","CPT","0611","RC","","","","both","","","6916.00","4149.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","365.65","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","372.20","372.20","372.20","1 through 10","365.65","5878.6","other","OPPS APC"
"MRI Brain W/Cont","PX-61000017","CDM","70552","CPT","0611","RC","","","","both","","","6916.00","4149.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3935.20","56.9","","3797.51","3797.51","3797.51","1 through 10","365.65","5878.6","percent of total billed charges",""
"MRI Brain W/Cont","PX-61000017","CDM","70552","CPT","0611","RC","","","","both","","","6916.00","4149.60","MEDICARE [2001]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","373.16","373.16","1 through 10","365.65","5878.6","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0610","RC","","","","inpatient","","","4674.00","2804.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3592.44","76.86","","2841.30","2841.30","2841.30","1 through 10","3094.19","3592.44","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4674.00","2804.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","3147.98","3147.98","3147.98","1 through 10","247.49","3972.9","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4674.00","2804.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1613.96","","Case rate ($1,613.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1574.60","1551.94","7038.74","14","247.49","3972.9","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4674.00","2804.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","694.97","","Case rate ($694.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","678.03","678.03","1515.45","45","247.49","3972.9","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4674.00","2804.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","247.49","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","247.52","247.52","405.88","31","247.49","3972.9","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4674.00","2804.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1304.55","","Case rate ($1,304.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1272.72","678.03","4500.91","23","247.49","3972.9","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4674.00","2804.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2659.51","56.9","","2566.19","2566.19","7698.57","32","247.49","3972.9","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4674.00","2804.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","260.12","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","260.15","254.95","260.15","18","247.49","3972.9","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4674.00","2804.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","248.53","248.53","252.57","51","247.49","3972.9","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4674.00","2804.40","MEDICARE [2001]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","757.71","105","247.49","3972.9","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4674.00","2804.40","TRICARE [160005]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","1 through 10","247.49","3972.9","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4674.00","2804.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.52","237.48","553.23","61","247.49","3972.9","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4674.00","2804.40","WELLSENSE NH [1050]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","262.90","262.90","262.90","1 through 10","247.49","3972.9","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4674.00","2804.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","673.99","14.42","","650.34","557.44","650.34","1 through 10","543.59","3617.68","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4674.00","2804.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","543.59","11.63","","621.03","532.71","1598.13","58","543.59","3617.68","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4674.00","2804.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","","","Payment is accumulated by procedure count. Procedure 1, 62.78% of billed. Procedures 2 - 9999, 31.39% of billed.","2831.38","2831.38","2831.38","1 through 10","543.59","3617.68","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4674.00","2804.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","1971.77","1971.77","1971.77","1 through 10","543.59","3617.68","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4674.00","2804.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3279.67","1639.84","3279.67","28","543.59","3617.68","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4674.00","2804.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2939.95","62.9","","2841.30","2841.30","2841.30","31","543.59","3617.68","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4674.00","2804.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3617.68","77.4","","3495.25","3495.25","3495.25","16","543.59","3617.68","percent of total billed charges",""
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4674.00","2804.40","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3279.67","1639.84","3279.67","1 through 10","543.59","3617.68","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4674.00","2804.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","543.59","11.63","","532.71","532.71","1598.13","21","543.59","3617.68","percent of total billed charges",""
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","12137.00","7282.20","CHAMPVA [160001]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","365.21","365.21","365.21","1 through 10","365.65","10316.45","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","12137.00","7282.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","384.31","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","383.16","381.27","384.35","1 through 10","365.65","10316.45","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","12137.00","7282.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","367.19","367.19","373.16","25","365.65","10316.45","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","12137.00","7282.20","MEDICARE [2001]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","373.16","373.16","1 through 10","365.65","10316.45","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","12137.00","7282.20","TRICARE [160005]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","207.81","373.16","1 through 10","365.65","10316.45","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","12137.00","7282.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.40","365.70","373.16","32","365.65","10316.45","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","12137.00","7282.20","WELLSENSE NH [1050]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","383.98","383.98","383.98","1 through 10","365.65","10316.45","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","outpatient","","","12137.00","7282.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1411.53","11.63","","1188.18","588.70","1188.18","1 through 10","1411.53","9394.04","percent of total billed charges",""
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","5395.00","3237.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","3765.71","69.8","","3633.79","3274.57","3633.79","1 through 10","247.49","4585.75","percent of total billed charges",""
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","5395.00","3237.00","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","257.59","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","252.57","252.57","252.57","1 through 10","247.49","4585.75","other","OPPS APC"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","outpatient","","","5395.00","3237.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3393.46","62.9","","3279.78","3279.78","3279.78","1 through 10","2871.22","4175.73","percent of total billed charges",""
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","outpatient","","","5395.00","3237.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4175.73","77.4","","4034.65","4034.65","4034.65","1 through 10","2871.22","4175.73","percent of total billed charges",""
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","7957.00","4774.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2384.56","","Case rate ($2,384.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2326.40","2326.40","2326.40","1 through 10","365.65","6763.45","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","7957.00","4774.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1026.79","","Case rate ($1,026.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2397.80","1001.76","7678.00","1 through 10","365.65","6763.45","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","7957.00","4774.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","365.65","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","365.70","365.70","373.16","1 through 10","365.65","6763.45","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","7957.00","4774.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1927.41","","Case rate ($1,927.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4500.91","1880.39","7678.00","1 through 10","365.65","6763.45","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","7957.00","4774.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4527.53","56.9","","4368.78","4368.78","7360.85","1 through 10","365.65","6763.45","percent of total billed charges",""
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","7957.00","4774.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","384.31","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","380.58","378.66","905.19","1 through 10","365.65","6763.45","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","7957.00","4774.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","367.19","893.19","1 through 10","365.65","6763.45","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","7957.00","4774.20","MEDICARE [2001]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","373.16","893.19","1 through 10","365.65","6763.45","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","7957.00","4774.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5004.95","62.9","","4837.14","4837.14","18048.08","18","365.65","6763.45","percent of total billed charges",""
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","7957.00","4774.20","TRICARE [160005]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1786.38","893.19","1786.38","1 through 10","365.65","6763.45","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","7957.00","4774.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.80","365.70","880.33","1 through 10","365.65","6763.45","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","7957.00","4774.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6158.72","77.4","","6043.67","6043.67","6043.67","1 through 10","365.65","6763.45","percent of total billed charges",""
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","7957.00","4774.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1147.40","14.42","","1107.17","949.00","1107.17","1 through 10","925.4","1147.4","percent of total billed charges",""
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","7957.00","4774.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","925.40","11.63","","906.89","528.63","1057.26","1 through 10","925.4","1147.4","percent of total billed charges",""
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","7957.00","4774.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","5583.44","2791.72","5583.44","1 through 10","925.4","1147.4","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","7957.00","4774.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","925.40","11.63","","906.89","906.89","906.89","1 through 10","925.4","1147.4","percent of total billed charges",""
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4487.00","2692.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","3022.34","3022.34","3022.34","1 through 10","247.49","3813.95","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4487.00","2692.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1613.96","","Case rate ($1,613.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1574.60","1574.60","1574.60","1 through 10","247.49","3813.95","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4487.00","2692.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","694.97","","Case rate ($694.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","678.03","668.27","1515.45","24","247.49","3813.95","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4487.00","2692.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","247.49","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","252.57","238.75","553.23","16","247.49","3813.95","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4487.00","2692.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1304.55","","Case rate ($1,304.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1272.72","1272.72","4330.00","1 through 10","247.49","3813.95","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4487.00","2692.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2553.10","56.9","","2463.77","2463.77","2463.77","1 through 10","247.49","3813.95","percent of total billed charges",""
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4487.00","2692.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","260.12","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","260.15","260.15","260.15","1 through 10","247.49","3813.95","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4487.00","2692.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","248.53","238.75","555.49","18","247.49","3813.95","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4487.00","2692.20","MEDICARE [2001]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","238.75","564.52","32","247.49","3813.95","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4487.00","2692.20","TRICARE [160005]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","564.52","1 through 10","247.49","3813.95","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4487.00","2692.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.52","247.52","564.52","33","247.49","3813.95","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","4487.00","2692.20","WELLSENSE NH [1050]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","262.90","259.90","1109.69","1 through 10","247.49","3813.95","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","4487.00","2692.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","647.03","14.42","","624.39","624.39","624.39","1 through 10","521.84","3472.94","percent of total billed charges",""
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","4487.00","2692.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","521.84","11.63","","596.24","511.44","1093.54","13","521.84","3472.94","percent of total billed charges",""
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","4487.00","2692.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","1893.08","1893.08","1893.08","1 through 10","521.84","3472.94","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","4487.00","2692.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3148.78","1574.39","3148.78","11","521.84","3472.94","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","4487.00","2692.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2822.32","62.9","","2727.90","2727.90","2727.90","27","521.84","3472.94","percent of total billed charges",""
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","4487.00","2692.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3472.94","77.4","","3355.75","3355.75","3355.75","1 through 10","521.84","3472.94","percent of total billed charges",""
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","4487.00","2692.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","521.84","11.63","","511.44","511.44","1209.75","14","521.84","3472.94","percent of total billed charges",""
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","13943.00","8365.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2384.56","","Case rate ($2,384.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2326.40","2326.40","2326.40","1 through 10","365.65","11851.55","other","OPPS APC"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","13943.00","8365.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1026.79","","Case rate ($1,026.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1001.76","1001.76","1001.76","1 through 10","365.65","11851.55","other","OPPS APC"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","13943.00","8365.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","365.65","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","370.70","367.19","370.70","1 through 10","365.65","11851.55","other","OPPS APC"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","13943.00","8365.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","367.19","367.19","367.19","1 through 10","365.65","11851.55","other","OPPS APC"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","13943.00","8365.80","MEDICARE [2001]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","373.16","373.16","1 through 10","365.65","11851.55","other","OPPS APC"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","13943.00","8365.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","367.19","366.10","367.19","1 through 10","365.65","11851.55","other","OPPS APC"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","outpatient","","","13943.00","8365.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1621.57","11.63","","1589.25","1589.25","1589.25","1 through 10","1621.57","10791.88","percent of total billed charges",""
"MRI Chest W/O Cont","PX-61000035","CDM","71550","CPT","0614","RC","","","","both","","","10222.00","6133.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","694.97","","Case rate ($694.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","678.03","678.03","678.03","1 through 10","247.49","8688.7","other","OPPS APC"
"MRI Chest W/O Cont","PX-61000035","CDM","71550","CPT","0614","RC","","","","both","","","10222.00","6133.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","247.49","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","248.53","248.53","248.53","1 through 10","247.49","8688.7","other","OPPS APC"
"MRI Chest W/O Cont","PX-61000035","CDM","71550","CPT","0614","RC","","","","both","","","10222.00","6133.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","1 through 10","247.49","8688.7","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","7935.00","4761.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2384.56","","Case rate ($2,384.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2435.72","2326.40","2435.72","1 through 10","365.65","6744.75","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","7935.00","4761.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1026.79","","Case rate ($1,026.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1001.76","1001.76","2397.80","1 through 10","365.65","6744.75","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","7935.00","4761.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","365.65","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","373.16","365.70","373.16","1 through 10","365.65","6744.75","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","7935.00","4761.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1927.41","","Case rate ($1,927.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1880.39","1001.76","7657.00","1 through 10","365.65","6744.75","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","7935.00","4761.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4515.02","56.9","","4356.83","4356.83","4356.83","1 through 10","365.65","6744.75","percent of total billed charges",""
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","7935.00","4761.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","4962.98","4962.98","4962.98","1 through 10","365.65","6744.75","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","7935.00","4761.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","384.31","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","384.23","380.26","384.35","1 through 10","365.65","6744.75","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","7935.00","4761.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","367.19","373.16","1 through 10","365.65","6744.75","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","7935.00","4761.00","MEDICARE [2001]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","373.16","1639.51","26","365.65","6744.75","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","7935.00","4761.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.40","365.70","370.70","11","365.65","6744.75","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","7935.00","4761.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1144.23","14.42","","1104.14","946.41","1104.14","1 through 10","922.84","6141.69","percent of total billed charges",""
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","7935.00","4761.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","922.84","11.63","","1054.37","527.18","1054.37","1 through 10","922.84","6141.69","percent of total billed charges",""
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","7935.00","4761.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","5568.17","5568.17","11181.79","1 through 10","922.84","6141.69","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","7935.00","4761.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4991.12","62.9","","4823.91","4823.91","4823.91","1 through 10","922.84","6141.69","percent of total billed charges",""
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","7935.00","4761.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6141.69","77.4","","5934.18","5934.18","5934.18","1 through 10","922.84","6141.69","percent of total billed charges",""
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","7935.00","4761.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","922.84","11.63","","904.41","904.41","904.41","1 through 10","922.84","6141.69","percent of total billed charges",""
"MRI L-Spine W&W/O Cont|REDUCED SERVICES","PX-61000032","CDM","72158","CPT","0612","RC","","","52","both","","","7935.00","4761.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","365.65","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.85","182.85","182.85","1 through 10","365.65","384.31","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4499.00","2699.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","3030.02","3030.02","3030.02","1 through 10","247.49","3824.15","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4499.00","2699.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1613.96","","Case rate ($1,613.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1574.60","1551.94","1574.60","17","247.49","3824.15","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4499.00","2699.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","694.97","","Case rate ($694.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","678.03","668.27","930.60","42","247.49","3824.15","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4499.00","2699.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","247.49","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","252.52","247.52","252.57","31","247.49","3824.15","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4499.00","2699.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1304.55","","Case rate ($1,304.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1272.72","678.03","4341.00","18","247.49","3824.15","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4499.00","2699.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2559.93","56.9","","2470.03","2470.03","2470.03","16","247.49","3824.15","percent of total billed charges",""
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4499.00","2699.40","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","2559.93","56.9","","2470.03","2470.03","2470.03","1 through 10","247.49","3824.15","percent of total billed charges",""
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4499.00","2699.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","260.12","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","260.15","256.59","260.15","15","247.49","3824.15","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4499.00","2699.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","248.53","248.53","252.57","64","247.49","3824.15","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4499.00","2699.40","MEDICARE [2001]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","74","247.49","3824.15","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4499.00","2699.40","TRICARE [160005]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","1 through 10","247.49","3824.15","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4499.00","2699.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.52","247.52","252.57","77","247.49","3824.15","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4499.00","2699.40","WELLPOINT [1015]","HB WDH ANTHEM PPO","1304.55","","Case rate ($1,304.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1272.72","1272.72","1272.72","1 through 10","247.49","3824.15","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","4499.00","2699.40","WELLSENSE NH [1050]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","262.90","262.90","262.90","1 through 10","247.49","3824.15","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","4499.00","2699.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","648.76","14.42","","625.97","536.55","625.97","1 through 10","523.23","3482.23","percent of total billed charges",""
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","4499.00","2699.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","523.23","11.63","","597.76","512.74","1096.32","52","523.23","3482.23","percent of total billed charges",""
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","4499.00","2699.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3156.78","3156.78","9470.34","25","523.23","3482.23","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","4499.00","2699.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2829.87","62.9","","2734.83","2734.83","2734.83","35","523.23","3482.23","percent of total billed charges",""
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","4499.00","2699.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3482.23","77.4","","3364.28","3364.28","3364.28","1 through 10","523.23","3482.23","percent of total billed charges",""
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","4499.00","2699.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","523.23","11.63","","512.74","398.05","512.74","11","523.23","3482.23","percent of total billed charges",""
"MRI Lwr Ext Joint W&W/O Cont","PX-61000064","CDM","73723","CPT","0614","RC","","","","both","","","10846.00","6507.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.70","365.70","370.02","1 through 10","365.65","9219.1","other","OPPS APC"
"MRI Lwr Ext Joint W/Cont","PX-61000063","CDM","73722","CPT","0614","RC","","","","outpatient","","","8974.00","5384.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","6297.55","6297.55","6297.55","1 through 10","1043.68","6945.88","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Lwr Ext Joint W/O Cont","PX-61000062","CDM","73721","CPT","0614","RC","","","","both","","","5068.00","3040.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","248.53","236.78","251.62","28","247.49","4307.8","other","OPPS APC"
"MRI Lwr Ext Joint W/O Cont","PX-61000062","CDM","73721","CPT","0614","RC","","","","outpatient","","","5068.00","3040.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3556.01","3423.02","5134.40","1 through 10","589.41","3922.63","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Lwr Ext Joint W/O Cont","PX-61000062","CDM","73721","CPT","0614","RC","","","","outpatient","","","5068.00","3040.80","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3789.75","3789.75","3789.75","1 through 10","589.41","3922.63","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Lwr Ext Joint W/O Cont","PX-61000062","CDM","73721","CPT","0614","RC","","","","outpatient","","","5068.00","3040.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3922.63","77.4","","3556.01","3556.01","3556.01","1 through 10","589.41","3922.63","percent of total billed charges",""
"MRI Lwr Ext W&W/O Cont","PX-61000061","CDM","73720","CPT","0614","RC","","","","both","","","8931.00","5358.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1026.79","","Case rate ($1,026.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1001.76","1001.76","1001.76","1 through 10","365.65","7591.35","other","OPPS APC"
"MRI Lwr Ext W&W/O Cont","PX-61000061","CDM","73720","CPT","0614","RC","","","","both","","","8931.00","5358.60","MEDICARE [2001]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","446.60","446.60","446.60","1 through 10","365.65","7591.35","other","OPPS APC"
"MRI Lwr Ext W&W/O Cont","PX-61000061","CDM","73720","CPT","0614","RC","","","","both","","","8931.00","5358.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.40","365.70","369.70","1 through 10","365.65","7591.35","other","OPPS APC"
"MRI Lwr Ext W/O Cont","PX-61000055","CDM","73718","CPT","0614","RC","","","","both","","","5986.00","3591.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","248.53","233.98","250.52","1 through 10","247.49","5088.1","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","8898.00","5338.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","5993.03","5993.03","5993.03","1 through 10","365.65","7563.3","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","8898.00","5338.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2384.56","","Case rate ($2,384.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2326.40","2326.40","5526.94","1 through 10","365.65","7563.3","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","8898.00","5338.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1026.79","","Case rate ($1,026.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2397.80","2379.92","10983.80","1 through 10","365.65","7563.3","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","8898.00","5338.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","365.65","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","367.19","365.70","373.16","1 through 10","365.65","7563.3","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","8898.00","5338.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1927.41","","Case rate ($1,927.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1968.75","1880.39","4500.91","1 through 10","365.65","7563.3","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","8898.00","5338.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5062.96","56.9","","4885.43","4885.43","5282.00","1 through 10","365.65","7563.3","percent of total billed charges",""
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","8898.00","5338.80","HARVARD PILGRIM [120001]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","840.25","840.25","840.25","1 through 10","365.65","7563.3","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","8898.00","5338.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","384.31","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","918.89","918.89","918.89","1 through 10","365.65","7563.3","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","8898.00","5338.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","893.19","367.19","893.19","1 through 10","365.65","7563.3","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","8898.00","5338.80","MEDICARE [2001]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","373.16","893.19","1 through 10","365.65","7563.3","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","8898.00","5338.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","836.26","369.80","878.90","1 through 10","365.65","7563.3","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","8898.00","5338.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1283.09","14.42","","1238.10","1238.10","1238.10","1 through 10","1034.84","6887.05","percent of total billed charges",""
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","8898.00","5338.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1034.84","11.63","","1014.15","1014.15","1182.29","1 through 10","1034.84","6887.05","percent of total billed charges",""
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","8898.00","5338.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","6243.74","6243.74","6243.74","1 through 10","1034.84","6887.05","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","8898.00","5338.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5596.84","62.9","","5409.18","5409.18","10818.36","1 through 10","1034.84","6887.05","percent of total billed charges",""
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","8898.00","5338.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6887.05","77.4","","6654.15","6654.15","6654.15","1 through 10","1034.84","6887.05","percent of total billed charges",""
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","8898.00","5338.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1034.84","11.63","","1014.15","1014.15","1014.15","1 through 10","1034.84","6887.05","percent of total billed charges",""
"MRI Orbit/Face/Neck W/O Cont","PX-61000009","CDM","70540","CPT","0611","RC","","","","both","","","6085.00","3651.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","260.12","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","260.15","260.15","260.15","1 through 10","247.49","5172.25","other","OPPS APC"
"MRI Orbit/Face/Neck W/O Cont","PX-61000009","CDM","70540","CPT","0611","RC","","","","both","","","6085.00","3651.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","1 through 10","247.49","5172.25","other","OPPS APC"
"MRI Orbit/Face/Neck W/O Cont","PX-61000009","CDM","70540","CPT","0611","RC","","","","both","","","6085.00","3651.00","TRICARE [160005]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","564.52","564.52","564.52","1 through 10","247.49","5172.25","other","OPPS APC"
"MRI Orbit/Face/Neck W/O Cont","PX-61000009","CDM","70540","CPT","0611","RC","","","","both","","","6085.00","3651.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","1 through 10","247.49","5172.25","other","OPPS APC"
"MRI Orbit/Face/Neck W/O Cont","PX-61000009","CDM","70540","CPT","0611","RC","","","","outpatient","","","6085.00","3651.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","707.69","11.63","","404.11","404.11","404.11","1 through 10","707.69","4709.79","percent of total billed charges",""
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0610","RC","","","","outpatient","","","8875.00","5325.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1279.78","14.42","","1234.93","1234.93","1234.93","15","1279.78","1279.78","percent of total billed charges",""
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0610","RC","","","","outpatient","","","8875.00","5325.00","PHCS MULTIPLAN [1022]","HB WDH AMERIHEALTH CARITAS","1279.78","14.42","","1234.93","1234.93","1234.93","1 through 10","1279.78","1279.78","percent of total billed charges",""
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","8875.00","5325.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2384.56","","Case rate ($2,384.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2326.40","2326.40","5568.47","23","365.65","7543.75","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","8875.00","5325.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1026.79","","Case rate ($1,026.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1001.76","1001.76","2397.80","33","365.65","7543.75","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","8875.00","5325.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","365.65","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","373.16","365.70","893.19","33","365.65","7543.75","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","8875.00","5325.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1927.41","","Case rate ($1,927.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1880.39","1001.76","4500.91","19","365.65","7543.75","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","8875.00","5325.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5049.88","56.9","","4872.92","4872.92","4872.92","21","365.65","7543.75","percent of total billed charges",""
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","8875.00","5325.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","5552.42","5552.42","5552.42","1 through 10","365.65","7543.75","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","8875.00","5325.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","384.31","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","383.16","376.66","384.35","11","365.65","7543.75","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","8875.00","5325.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","367.19","367.19","373.16","31","365.65","7543.75","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","8875.00","5325.00","MEDICARE [2001]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","373.16","374.71","61","365.65","7543.75","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","8875.00","5325.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","7543.75","85","","8082.58","610.16","8082.58","1 through 10","365.65","7543.75","percent of total billed charges",""
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","8875.00","5325.00","TRICARE [160005]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","893.19","373.16","893.19","1 through 10","365.65","7543.75","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","8875.00","5325.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","371.42","366.20","374.71","37","365.65","7543.75","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","8875.00","5325.00","WELLPOINT [1015]","HB WDH ANTHEM PPO","1927.41","","Case rate ($1,927.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1880.39","1880.39","1880.39","1 through 10","365.65","7543.75","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","8875.00","5325.00","WELLSENSE NH [1050]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","386.98","386.98","386.98","1 through 10","365.65","7543.75","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","8875.00","5325.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1032.16","11.63","","1179.26","1011.54","1179.26","1 through 10","1032.16","6869.25","percent of total billed charges",""
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","8875.00","5325.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","6227.74","3113.87","6227.74","19","1032.16","6869.25","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","8875.00","5325.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4723.28","53.22","","4565.47","4565.47","4565.47","1 through 10","1032.16","6869.25","percent of total billed charges",""
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","8875.00","5325.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5582.38","62.9","","5395.32","5395.32","5395.32","15","1032.16","6869.25","percent of total billed charges",""
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","8875.00","5325.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6869.25","77.4","","6637.10","6637.10","6637.10","1 through 10","1032.16","6869.25","percent of total billed charges",""
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","8875.00","5325.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1032.16","11.63","","1011.54","1011.54","3034.62","11","1032.16","6869.25","percent of total billed charges",""
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0610","RC","","","","outpatient","","","6061.00","3636.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","874.00","14.42","","843.43","843.43","843.43","1 through 10","874","874","percent of total billed charges",""
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","6061.00","3636.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","4082.60","4082.60","4082.60","1 through 10","247.49","5151.85","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","6061.00","3636.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","694.97","","Case rate ($694.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","678.03","668.27","678.03","1 through 10","247.49","5151.85","other","OPPS APC"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","6061.00","3636.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","247.49","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","248.11","247.52","248.20","1 through 10","247.49","5151.85","other","OPPS APC"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","6061.00","3636.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1304.55","","Case rate ($1,304.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1272.72","678.03","1272.72","1 through 10","247.49","5151.85","other","OPPS APC"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","6061.00","3636.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3448.71","56.9","","3328.08","3328.08","3328.08","1 through 10","247.49","5151.85","percent of total billed charges",""
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","6061.00","3636.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","248.53","238.75","252.57","1 through 10","247.49","5151.85","other","OPPS APC"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","6061.00","3636.60","MEDICARE [2001]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","15","247.49","5151.85","other","OPPS APC"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","6061.00","3636.60","TRICARE [160005]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","1 through 10","247.49","5151.85","other","OPPS APC"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","6061.00","3636.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.52","236.98","252.57","1 through 10","247.49","5151.85","other","OPPS APC"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","6061.00","3636.60","WELLSENSE NH [1050]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","262.90","262.90","262.90","1 through 10","247.49","5151.85","other","OPPS APC"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","6061.00","3636.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","704.89","11.63","","1477.18","805.41","1477.18","1 through 10","704.89","4691.21","percent of total billed charges",""
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","6061.00","3636.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","4253.39","4253.39","4253.39","1 through 10","704.89","4691.21","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","6061.00","3636.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3812.37","62.9","","3684.87","3684.87","3684.87","1 through 10","704.89","4691.21","percent of total billed charges",""
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","6061.00","3636.60","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","4253.39","4253.39","4253.39","1 through 10","704.89","4691.21","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","6061.00","3636.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4691.21","77.4","","4532.98","4532.98","4532.98","1 through 10","704.89","4691.21","percent of total billed charges",""
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","6061.00","3636.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","704.89","11.63","","690.86","690.86","690.86","1 through 10","704.89","4691.21","percent of total billed charges",""
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","7989.00","4793.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","5372.48","5372.48","5372.48","1 through 10","365.65","6790.65","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","7989.00","4793.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2384.56","","Case rate ($2,384.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2326.40","2326.40","2326.40","1 through 10","365.65","6790.65","other","OPPS APC"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","7989.00","4793.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1026.79","","Case rate ($1,026.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1001.76","1001.76","1001.76","1 through 10","365.65","6790.65","other","OPPS APC"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","7989.00","4793.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","365.65","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","875.33","373.16","1518.42","1 through 10","365.65","6790.65","other","OPPS APC"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","7989.00","4793.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1927.41","","Case rate ($1,927.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4500.90","1880.39","7709.00","1 through 10","365.65","6790.65","other","OPPS APC"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","7989.00","4793.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4545.74","56.9","","28837.96","4386.42","28837.96","1 through 10","365.65","6790.65","percent of total billed charges",""
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","7989.00","4793.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","367.19","367.19","367.19","1 through 10","365.65","6790.65","other","OPPS APC"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","7989.00","4793.40","MEDICARE [2001]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","373.16","373.16","1 through 10","365.65","6790.65","other","OPPS APC"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","7989.00","4793.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","368.70","367.19","875.33","1 through 10","365.65","6790.65","other","OPPS APC"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","7989.00","4793.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1152.01","14.42","","1111.64","952.83","1111.64","1 through 10","929.12","6183.49","percent of total billed charges",""
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","7989.00","4793.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","929.12","11.63","","1061.53","1061.53","1061.53","1 through 10","929.12","6183.49","percent of total billed charges",""
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","7989.00","4793.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","5605.98","5605.98","5605.98","1 through 10","929.12","6183.49","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","7989.00","4793.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5025.08","62.9","","4856.67","4856.67","18121.52","1 through 10","929.12","6183.49","percent of total billed charges",""
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","7989.00","4793.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6183.49","77.4","","5974.48","5974.48","5974.48","1 through 10","929.12","6183.49","percent of total billed charges",""
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","7989.00","4793.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","929.12","11.63","","910.55","588.10","910.55","1 through 10","929.12","6183.49","percent of total billed charges",""
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","4499.00","2699.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1613.96","","Case rate ($1,613.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1574.60","1574.60","1574.60","1 through 10","247.49","3824.15","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","4499.00","2699.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","694.97","","Case rate ($694.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","678.03","678.03","678.03","1 through 10","247.49","3824.15","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","4499.00","2699.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","247.49","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","252.57","247.52","959.68","1 through 10","247.49","3824.15","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","4499.00","2699.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1304.55","","Case rate ($1,304.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5856.45","1214.92","5856.45","1 through 10","247.49","3824.15","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","4499.00","2699.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2559.93","56.9","","2470.03","2470.03","2470.03","1 through 10","247.49","3824.15","percent of total billed charges",""
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","4499.00","2699.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","260.12","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","260.15","260.15","260.15","1 through 10","247.49","3824.15","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","4499.00","2699.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","555.49","248.53","564.52","1 through 10","247.49","3824.15","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","4499.00","2699.40","MEDICARE [2001]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","564.52","1 through 10","247.49","3824.15","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","4499.00","2699.40","TRICARE [160005]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","564.52","252.57","564.52","1 through 10","247.49","3824.15","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","4499.00","2699.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","556.23","250.52","556.93","1 through 10","247.49","3824.15","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","4499.00","2699.40","WELLPOINT [1015]","HB WDH ANTHEM PPO","1304.55","","Case rate ($1,304.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2844.65","2844.65","2844.65","1 through 10","247.49","3824.15","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","4499.00","2699.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","648.76","14.42","","625.97","625.97","625.97","1 through 10","523.23","3482.23","percent of total billed charges",""
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","4499.00","2699.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","523.23","11.63","","531.34","512.74","1096.32","1 through 10","523.23","3482.23","percent of total billed charges",""
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","4499.00","2699.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3156.78","3156.78","3156.78","1 through 10","523.23","3482.23","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","4499.00","2699.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2829.87","62.9","","2734.83","2734.83","2734.83","1 through 10","523.23","3482.23","percent of total billed charges",""
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","4499.00","2699.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3482.23","77.4","","3364.28","3364.28","3364.28","1 through 10","523.23","3482.23","percent of total billed charges",""
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","4499.00","2699.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","523.23","11.63","","512.74","512.74","512.74","1 through 10","523.23","3482.23","percent of total billed charges",""
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","both","","","7407.00","4444.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","4989.30","4989.30","4989.30","1 through 10","247.49","6295.95","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","both","","","7407.00","4444.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1613.96","","Case rate ($1,613.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1574.60","1574.60","1574.60","1 through 10","247.49","6295.95","other","OPPS APC"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","both","","","7407.00","4444.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","694.97","","Case rate ($694.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","678.03","678.03","678.03","1 through 10","247.49","6295.95","other","OPPS APC"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","both","","","7407.00","4444.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1304.55","","Case rate ($1,304.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1272.72","678.03","1272.72","1 through 10","247.49","6295.95","other","OPPS APC"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","both","","","7407.00","4444.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","248.53","248.53","248.53","1 through 10","247.49","6295.95","other","OPPS APC"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","outpatient","","","7407.00","4444.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","5198.03","5198.03","5198.03","1 through 10","861.43","5733.02","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","outpatient","","","7407.00","4444.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4659.00","62.9","","4503.24","4503.24","4503.24","1 through 10","861.43","5733.02","percent of total billed charges",""
"MRI Upr Ext Joint W&W/O","PX-61000052","CDM","73223","CPT","0614","RC","","","","both","","","10868.00","6520.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.40","365.70","370.70","1 through 10","365.65","9237.8","other","OPPS APC"
"MRI Upr Ext Joint W/O Cont","PX-61000050","CDM","73221","CPT","0614","RC","","","","both","","","5068.00","3040.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","3413.22","3413.22","3413.22","1 through 10","247.49","4307.8","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Upr Ext Joint W/O Cont","PX-61000050","CDM","73221","CPT","0614","RC","","","","both","","","5068.00","3040.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","4307.80","85","","3413.22","3413.22","3413.22","1 through 10","247.49","4307.8","percent of total billed charges",""
"MRI Upr Ext Joint W/O Cont","PX-61000050","CDM","73221","CPT","0614","RC","","","","both","","","5068.00","3040.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.52","247.52","251.22","15","247.49","4307.8","other","OPPS APC"
"MRI Upr Ext Joint W/O Cont","PX-61000050","CDM","73221","CPT","0614","RC","","","","outpatient","","","5068.00","3040.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3556.01","3556.01","3556.01","1 through 10","589.41","3922.63","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Upr Ext W&W/O Cont","PX-61000049","CDM","73220","CPT","0614","RC","","","","both","","","11710.00","7026.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.80","367.19","369.80","1 through 10","365.65","9953.5","other","OPPS APC"
"MRI Upr Ext W/O Cont","PX-61000043","CDM","73218","CPT","0614","RC","","","","both","","","8963.00","5377.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","248.53","248.53","248.53","1 through 10","247.49","7618.55","other","OPPS APC"
"MRI Upr Ext W/O Cont","PX-61000043","CDM","73218","CPT","0614","RC","","","","outpatient","","","8963.00","5377.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","6289.55","6289.55","6289.55","1 through 10","1042.4","6937.36","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Multiple Sleep Latency","PX-74000004","CDM","95805","CPT","0740","RC","","","","both","","","5746.00","3447.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","2863.62","","Case rate ($2,863.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2793.76","2793.76","2793.76","1 through 10","543.26","4884.1","other","OPPS APC"
"Multiple Sleep Latency","PX-74000004","CDM","95805","CPT","0740","RC","","","","both","","","5746.00","3447.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3269.47","56.9","","3155.10","3155.10","3155.10","1 through 10","543.26","4884.1","percent of total billed charges",""
"Multiple Sleep Latency","PX-74000004","CDM","95805","CPT","0740","RC","","","","both","","","5746.00","3447.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","554.35","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","554.41","554.41","554.41","1 through 10","543.26","4884.1","other","OPPS APC"
"Multiple Sleep Latency","PX-74000004","CDM","95805","CPT","0929","RC","","","","both","","","5746.00","3447.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1525.53","","Case rate ($1,525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1488.34","1488.34","1488.34","1 through 10","1525.53","3542.81","other","OPPS APC"
"Multiple Sleep Latency Ltd","PX-74000005","CDM","95805","CPT","0740","RC","","","","both","","","5746.00","3447.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","2863.62","","Case rate ($2,863.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2793.76","2793.76","2793.76","1 through 10","543.26","4884.1","other","OPPS APC"
"Multiple Sleep Latency Ltd","PX-74000005","CDM","95805","CPT","0740","RC","","","","both","","","5746.00","3447.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3269.47","56.9","","3155.10","3155.10","3155.10","1 through 10","543.26","4884.1","percent of total billed charges",""
"Multiple Sleep Latency Ltd","PX-74000005","CDM","95805","CPT","0740","RC","","","","both","","","5746.00","3447.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","554.35","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","554.41","554.41","554.41","1 through 10","543.26","4884.1","other","OPPS APC"
"Multiple Sleep Latency Ltd","PX-74000005","CDM","95805","CPT","0929","RC","","","","both","","","5746.00","3447.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1525.53","","Case rate ($1,525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1488.34","1488.34","1488.34","1 through 10","1525.53","3542.81","other","OPPS APC"
"Multiple Sleep Latency Ltd|REDUCED SERVICES","PX-74000005","CDM","95805","CPT","0740","RC","","","52","both","","","5746.00","3447.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","554.35","","APC Price ($554.35). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","272.50","272.50","272.50","1 through 10","543.26","570.98","other","OPPS APC"
"Multiple Sleep Latency Ltd|REDUCED SERVICES","PX-74000005","CDM","95805","CPT","0740","RC","","","52","both","","","5746.00","3447.60","MEDICARE [2001]","HB WDH MEDICARE","554.35","","APC Price ($554.35). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","277.21","277.21","277.21","1 through 10","543.26","570.98","other","OPPS APC"
"Multiple Sleep Latency|REDUCED SERVICES","PX-74000004","CDM","95805","CPT","0740","RC","","","52","both","","","5746.00","3447.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","554.35","","APC Price ($554.35). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","272.50","272.50","272.50","1 through 10","543.26","570.98","other","OPPS APC"
"Multiple Sleep Latency|REDUCED SERVICES","PX-74000004","CDM","95805","CPT","0740","RC","","","52","both","","","5746.00","3447.60","MEDICARE [2001]","HB WDH MEDICARE","554.35","","APC Price ($554.35). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","277.21","277.21","277.21","1 through 10","543.26","570.98","other","OPPS APC"
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0300","RC","","","","inpatient","","","185.00","111.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","142.19","76.86","","112.77","112.77","112.77","1 through 10","122.47","142.19","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","both","","","185.00","111.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","129.13","69.8","","124.94","112.59","124.94","1 through 10","8.48","157.25","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","outpatient","","","185.00","111.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","80.88","43.72","","78.26","78.26","78.26","1 through 10","12.16","143.19","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","outpatient","","","185.00","111.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","134.53","72.72","","130.17","130.17","130.17","24","12.16","143.19","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","outpatient","","","185.00","111.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","98.46","53.22","","95.42","95.42","95.42","1 through 10","12.16","143.19","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","outpatient","","","185.00","111.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","116.37","62.9","","112.77","112.77","216.92","35","12.16","143.19","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","outpatient","","","185.00","111.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","143.19","77.4","","138.73","138.73","138.73","11","12.16","143.19","percent of total billed charges",""
"Muscle-Specific Kinase Antibody","PX-30003823","CDM","86366","CPT","0302","RC","","","","outpatient","","","190.00","114.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","138.17","72.72","","133.80","133.80","133.80","1 through 10","22.1","147.06","percent of total billed charges",""
"Mycoplasma Antibody","PX-30000975","CDM","86738","CPT","0302","RC","","","","both","","","71.00","42.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","49.56","69.8","","48.16","48.16","48.16","1 through 10","8.61","67.73","percent of total billed charges",""
"Mycoplasma Antibody","PX-30000975","CDM","86738","CPT","0302","RC","","","","outpatient","","","71.00","42.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","44.66","62.9","","43.47","43.47","83.24","1 through 10","9.73","54.95","percent of total billed charges",""
"Myelin Basic Protein (CSF)","PX-30000580","CDM","83873","CPT","0301","RC","","","","outpatient","","","94.00","56.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","68.36","72.72","","66.18","66.18","66.18","1 through 10","16.02","68.36","percent of total billed charges",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without Cc/McC","828","MS-DRG","","","","","","","","inpatient","","","31953.94","19172.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","25493.75","","Fee schedule rate ($25,493.75). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","23399.02","23399.02","23399.02","1 through 10","3975","64744.57","case rate",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/McC","829","MS-DRG","","","","","","","","inpatient","","","52070.49","31242.29","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","24468.57","","Case rate ($24,468.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $22,618.48, add-ons for qualifying new technology services are included. If operating cost exceeds $26,536.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,560.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $22,268.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $22,173.61 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,755.52. The transfer capital threshold is the transfer adjustment factor * $1,755.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23243.99","23243.99","23243.99","1 through 10","3975","120080.32","other","Inpatient DRG"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/McC","830","MS-DRG","","","","","","","","inpatient","","","85709.72","51425.83","MEDICARE [2001]","HB WDH MEDICARE","11886.54","","Case rate ($11,886.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,005.40, add-ons for qualifying new technology services are included. If operating cost exceeds $14,923.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,641.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $10,605.57 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,560.53 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $836.09. The transfer capital threshold is the transfer adjustment factor * $836.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11508.92","11508.92","11508.92","1 through 10","3975","57190.15","other","Inpatient DRG"
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","both","","","195.00","117.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","136.11","69.8","","131.22","131.22","131.22","11","110.96","165.75","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","both","","","195.00","117.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","188.00","188.00","188.00","18","110.96","165.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","both","","","195.00","117.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","110.96","56.9","","106.97","106.97","320.91","1 through 10","110.96","165.75","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","both","","","195.00","117.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","165.75","85","","802.07","106.97","802.07","1 through 10","110.96","165.75","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","outpatient","","","195.00","117.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","28.12","14.42","","23.24","23.24","27.11","1 through 10","22.68","150.93","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","outpatient","","","195.00","117.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","22.68","11.63","","47.49","23.01","47.49","1 through 10","22.68","150.93","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","outpatient","","","195.00","117.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","85.25","43.72","","82.19","82.19","82.19","1 through 10","22.68","150.93","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","outpatient","","","195.00","117.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","141.80","72.72","","136.71","136.71","2416.48","17","22.68","150.93","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","outpatient","","","195.00","117.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","150.93","77.4","","145.70","145.69","145.70","1 through 10","22.68","150.93","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","outpatient","","","195.00","117.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","22.68","11.63","","22.21","22.21","66.63","1 through 10","22.68","150.93","percent of total billed charges",""
"Myocrd Img Pet Prfuj 1std Rest/Stress Cncrnt CT","PX-40000168","CDM","78430","CPT","0404","RC","","","","both","","","18417.00","11050.20","MEDICARE [2001]","HB WDH MEDICARE","1523.88","","APC Price ($1,523.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1524.05","1524.05","1524.05","1 through 10","1493.4","15654.45","other","OPPS APC"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","20832.00","12499.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","14540.74","69.8","","14031.20","12644.16","14031.20","1 through 10","2304.21","17707.2","percent of total billed charges",""
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","20832.00","12499.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","2398.26","","APC Price ($2,351.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","2351.50","2351.50","2351.50","1 through 10","2304.21","17707.2","other","OPPS APC"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","20832.00","12499.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","14660.09","14660.09","14660.09","1 through 10","2304.21","17707.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","20832.00","12499.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6312.68","6312.68","6312.68","1 through 10","2304.21","17707.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","20832.00","12499.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","2304.21","","APC Price ($2,351.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2304.47","2304.47","2351.50","13","2304.21","17707.2","other","OPPS APC"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","20832.00","12499.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11849.52","11849.52","11849.52","1 through 10","2304.21","17707.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","20832.00","12499.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","11853.41","56.9","","11438.04","9150.43","11438.04","1 through 10","2304.21","17707.2","percent of total billed charges",""
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","20832.00","12499.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","2421.77","","APC Price ($2,351.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2380.11","2380.11","2385.21","1 through 10","2304.21","17707.2","other","OPPS APC"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","20832.00","12499.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","2351.23","","APC Price ($2,351.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2313.88","2313.88","2313.88","11","2304.21","17707.2","other","OPPS APC"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","20832.00","12499.20","MEDICARE [2001]","HB WDH MEDICARE","2351.23","","APC Price ($2,351.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2351.50","2351.50","2351.50","67","2304.21","17707.2","other","OPPS APC"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","20832.00","12499.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","2351.23","","APC Price ($2,351.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2308.17","2304.47","2351.50","15","2304.21","17707.2","other","OPPS APC"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","both","","","20832.00","12499.20","WELLSENSE NH [1050]","HB WDH MEDICARE","2351.23","","APC Price ($2,351.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2426.70","2426.70","2426.70","1 through 10","2304.21","17707.2","other","OPPS APC"
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","outpatient","","","20832.00","12499.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","15149.03","72.72","","14618.17","14618.17","14618.17","1 through 10","2422.76","16123.97","percent of total billed charges",""
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","outpatient","","","20832.00","12499.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","15149.03","72.72","","14618.17","14618.17","14618.17","1 through 10","2422.76","16123.97","percent of total billed charges",""
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","outpatient","","","20832.00","12499.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","13103.33","62.9","","12664.26","12664.26","12664.26","1 through 10","2422.76","16123.97","percent of total billed charges",""
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","outpatient","","","20832.00","12499.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","16123.97","77.4","","15579.05","15579.05","15579.05","1 through 10","2422.76","16123.97","percent of total billed charges",""
"Myocrd Img Pet Prfuj Mlt Std Rst&Strs Cncrnt CT","PX-40000169","CDM","78431","CPT","0404","RC","","","","outpatient","","","20832.00","12499.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2422.76","11.63","","2374.37","2374.37","2374.37","1 through 10","2422.76","16123.97","percent of total billed charges",""
"Myoglobin","PX-30000581","CDM","83874","CPT","0301","RC","","","","outpatient","","","69.00","41.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","43.40","62.9","","42.21","42.21","42.21","1 through 10","15.47","53.41","percent of total billed charges",""
"NAIL BONE 1.5MM 300 INTRAMEDULLARY ELASTIC STAINLESS","SUP-ITM-10094969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1362.72","817.63","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","158.48","1158.31","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 1.5MM 300 INTRAMEDULLARY ELASTIC STAINLESS","SUP-ITM-10094969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1362.72","817.63","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","158.48","1158.31","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 1.5MM 300 INTRAMEDULLARY ELASTIC STAINLESS","SUP-ITM-10094969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1362.72","817.63","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","775.39","56.9","","812.12","238.65","1587.46","163","158.48","1158.31","percent of total billed charges",""
"NAIL BONE 1.5MM 300 INTRAMEDULLARY ELASTIC STAINLESS","SUP-ITM-10094969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1362.72","817.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","158.48","11.63","","112.68","112.68","146.99","38","158.48","1158.31","percent of total billed charges",""
"NAIL BONE 1.5MM 300 INTRAMEDULLARY ELASTIC STAINLESS","SUP-ITM-10094969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1362.72","817.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1054.75","77.4","","303.98","303.98","5854.79","1 through 10","158.48","1158.31","percent of total billed charges",""
"NAIL BONE 1.5MM 300 INTRAMEDULLARY ELASTIC STAINLESS","SUP-ITM-10094969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1362.72","817.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","158.48","11.63","","112.68","112.68","146.99","38","158.48","1054.75","percent of total billed charges",""
"NAIL BONE 1.5MM 300 INTRAMEDULLARY ELASTIC STAINLESS","SUP-ITM-10094969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1362.72","817.63","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","855.52","62.78","","780.86","208.94","10480.28","15","158.48","1054.75","percent of total billed charges",""
"NAIL BONE 1.5MM 300 INTRAMEDULLARY ELASTIC STAINLESS","SUP-ITM-10094969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1362.72","817.63","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","595.78","43.72","","179.76","179.76","179.76","1 through 10","158.48","1054.75","percent of total billed charges",""
"NAIL BONE 1.5MM 300 INTRAMEDULLARY ELASTIC STAINLESS","SUP-ITM-10094969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1362.72","817.63","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","990.97","72.72","","2355.45","298.99","3965.19","155","158.48","1054.75","percent of total billed charges",""
"NAIL BONE 1.5MM 300 INTRAMEDULLARY ELASTIC STAINLESS","SUP-ITM-10094969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1362.72","817.63","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","990.97","72.72","","3643.09","3643.09","3643.09","1 through 10","158.48","1054.75","percent of total billed charges",""
"NAIL BONE 1.5MM 300 INTRAMEDULLARY ELASTIC STAINLESS","SUP-ITM-10094969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1362.72","817.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","725.24","53.22","","554.28","554.28","554.28","16","158.48","1054.75","percent of total billed charges",""
"NAIL BONE 1.5MM 300 INTRAMEDULLARY ELASTIC STAINLESS","SUP-ITM-10094969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1362.72","817.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","857.15","62.9","","619.64","173.09","2370.64","150","158.48","1054.75","percent of total billed charges",""
"NAIL BONE 1.5MM 300 INTRAMEDULLARY ELASTIC STAINLESS","SUP-ITM-10094969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1362.72","817.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1054.75","77.4","","303.98","303.98","5854.79","1 through 10","158.48","1054.75","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","both","","","1280.98","768.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","148.98","1088.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","both","","","1280.98","768.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","148.98","1088.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","both","","","1280.98","768.59","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","728.88","56.9","","812.12","238.65","1587.46","163","148.98","1088.83","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","both","","","1280.98","768.59","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","148.98","11.63","","112.68","112.68","146.99","38","148.98","1088.83","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","both","","","1280.98","768.59","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","991.48","77.4","","303.98","303.98","5854.79","1 through 10","148.98","1088.83","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1280.98","768.59","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","148.98","11.63","","112.68","112.68","146.99","38","148.98","991.48","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1280.98","768.59","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","804.20","62.78","","780.86","208.94","10480.28","15","148.98","991.48","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1280.98","768.59","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","560.04","43.72","","179.76","179.76","179.76","1 through 10","148.98","991.48","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1280.98","768.59","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","931.53","72.72","","2355.45","298.99","3965.19","155","148.98","991.48","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1280.98","768.59","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","931.53","72.72","","3643.09","3643.09","3643.09","1 through 10","148.98","991.48","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1280.98","768.59","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","681.74","53.22","","554.28","554.28","554.28","16","148.98","991.48","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1280.98","768.59","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","805.74","62.9","","619.64","173.09","2370.64","150","148.98","991.48","percent of total billed charges",""
"NAIL BONE 1.5X20MM FIXATION BIORESORBABLE SMARTNAIL SELF REINFORCED","SUP-ITM-10007737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1280.98","768.59","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","991.48","77.4","","303.98","303.98","5854.79","1 through 10","148.98","991.48","percent of total billed charges",""
"NAIL BONE 10X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT RIGHT TITANIUM","SUP-ITM-10036887","CDM","C1713","HCPCS","0278","RC","","","","both","","","6639.65","3983.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","772.19","5643.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 10X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT RIGHT TITANIUM","SUP-ITM-10036887","CDM","C1713","HCPCS","0278","RC","","","","both","","","6639.65","3983.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","772.19","5643.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 10X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT RIGHT TITANIUM","SUP-ITM-10036887","CDM","C1713","HCPCS","0278","RC","","","","both","","","6639.65","3983.79","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3777.96","56.9","","812.12","238.65","1587.46","163","772.19","5643.7","percent of total billed charges",""
"NAIL BONE 10X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT RIGHT TITANIUM","SUP-ITM-10036887","CDM","C1713","HCPCS","0278","RC","","","","both","","","6639.65","3983.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","772.19","11.63","","112.68","112.68","146.99","38","772.19","5643.7","percent of total billed charges",""
"NAIL BONE 10X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT RIGHT TITANIUM","SUP-ITM-10036887","CDM","C1713","HCPCS","0278","RC","","","","both","","","6639.65","3983.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5139.09","77.4","","303.98","303.98","5854.79","1 through 10","772.19","5643.7","percent of total billed charges",""
"NAIL BONE 10X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT RIGHT TITANIUM","SUP-ITM-10036887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","772.19","11.63","","112.68","112.68","146.99","38","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 10X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT RIGHT TITANIUM","SUP-ITM-10036887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4168.37","62.78","","780.86","208.94","10480.28","15","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 10X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT RIGHT TITANIUM","SUP-ITM-10036887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2902.85","43.72","","179.76","179.76","179.76","1 through 10","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 10X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT RIGHT TITANIUM","SUP-ITM-10036887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4828.35","72.72","","2355.45","298.99","3965.19","155","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 10X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT RIGHT TITANIUM","SUP-ITM-10036887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4828.35","72.72","","3643.09","3643.09","3643.09","1 through 10","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 10X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT RIGHT TITANIUM","SUP-ITM-10036887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3533.62","53.22","","554.28","554.28","554.28","16","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 10X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT RIGHT TITANIUM","SUP-ITM-10036887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4176.34","62.9","","619.64","173.09","2370.64","150","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 10X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT RIGHT TITANIUM","SUP-ITM-10036887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5139.09","77.4","","303.98","303.98","5854.79","1 through 10","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","both","","","6639.65","3983.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","772.19","5643.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","both","","","6639.65","3983.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","772.19","5643.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","both","","","6639.65","3983.79","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3777.96","56.9","","812.12","238.65","1587.46","163","772.19","5643.7","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","both","","","6639.65","3983.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","772.19","11.63","","112.68","112.68","146.99","38","772.19","5643.7","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","both","","","6639.65","3983.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5139.09","77.4","","303.98","303.98","5854.79","1 through 10","772.19","5643.7","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","772.19","11.63","","112.68","112.68","146.99","38","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4168.37","62.78","","780.86","208.94","10480.28","15","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2902.85","43.72","","179.76","179.76","179.76","1 through 10","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4828.35","72.72","","2355.45","298.99","3965.19","155","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4828.35","72.72","","3643.09","3643.09","3643.09","1 through 10","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3533.62","53.22","","554.28","554.28","554.28","16","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4176.34","62.9","","619.64","173.09","2370.64","150","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 10X240MM EX HINDFOOT CANNULATED TITANIUM ARTHRODESIS LEFT","SUP-ITM-10036915","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5139.09","77.4","","303.98","303.98","5854.79","1 through 10","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 10X435MM EXPERT TITANIUM CANNULATED TIBIAL","SUP-ITM-10018780","CDM","C1713","HCPCS","0278","RC","","","","both","","","5595.25","3357.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","650.73","4755.96","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 10X435MM EXPERT TITANIUM CANNULATED TIBIAL","SUP-ITM-10018780","CDM","C1713","HCPCS","0278","RC","","","","both","","","5595.25","3357.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","650.73","4755.96","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 10X435MM EXPERT TITANIUM CANNULATED TIBIAL","SUP-ITM-10018780","CDM","C1713","HCPCS","0278","RC","","","","both","","","5595.25","3357.15","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3183.70","56.9","","812.12","238.65","1587.46","163","650.73","4755.96","percent of total billed charges",""
"NAIL BONE 10X435MM EXPERT TITANIUM CANNULATED TIBIAL","SUP-ITM-10018780","CDM","C1713","HCPCS","0278","RC","","","","both","","","5595.25","3357.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","650.73","11.63","","112.68","112.68","146.99","38","650.73","4755.96","percent of total billed charges",""
"NAIL BONE 10X435MM EXPERT TITANIUM CANNULATED TIBIAL","SUP-ITM-10018780","CDM","C1713","HCPCS","0278","RC","","","","both","","","5595.25","3357.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4330.72","77.4","","303.98","303.98","5854.79","1 through 10","650.73","4755.96","percent of total billed charges",""
"NAIL BONE 10X435MM EXPERT TITANIUM CANNULATED TIBIAL","SUP-ITM-10018780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5595.25","3357.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","650.73","11.63","","112.68","112.68","146.99","38","650.73","4330.72","percent of total billed charges",""
"NAIL BONE 10X435MM EXPERT TITANIUM CANNULATED TIBIAL","SUP-ITM-10018780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5595.25","3357.15","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3512.70","62.78","","780.86","208.94","10480.28","15","650.73","4330.72","percent of total billed charges",""
"NAIL BONE 10X435MM EXPERT TITANIUM CANNULATED TIBIAL","SUP-ITM-10018780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5595.25","3357.15","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2446.24","43.72","","179.76","179.76","179.76","1 through 10","650.73","4330.72","percent of total billed charges",""
"NAIL BONE 10X435MM EXPERT TITANIUM CANNULATED TIBIAL","SUP-ITM-10018780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5595.25","3357.15","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4068.87","72.72","","2355.45","298.99","3965.19","155","650.73","4330.72","percent of total billed charges",""
"NAIL BONE 10X435MM EXPERT TITANIUM CANNULATED TIBIAL","SUP-ITM-10018780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5595.25","3357.15","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4068.87","72.72","","3643.09","3643.09","3643.09","1 through 10","650.73","4330.72","percent of total billed charges",""
"NAIL BONE 10X435MM EXPERT TITANIUM CANNULATED TIBIAL","SUP-ITM-10018780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5595.25","3357.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2977.79","53.22","","554.28","554.28","554.28","16","650.73","4330.72","percent of total billed charges",""
"NAIL BONE 10X435MM EXPERT TITANIUM CANNULATED TIBIAL","SUP-ITM-10018780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5595.25","3357.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3519.41","62.9","","619.64","173.09","2370.64","150","650.73","4330.72","percent of total billed charges",""
"NAIL BONE 10X435MM EXPERT TITANIUM CANNULATED TIBIAL","SUP-ITM-10018780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5595.25","3357.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4330.72","77.4","","303.98","303.98","5854.79","1 through 10","650.73","4330.72","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","914.73","6685.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","914.73","6685.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4475.35","56.9","","812.12","238.65","1587.46","163","914.73","6685.5","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","914.73","11.63","","112.68","112.68","146.99","38","914.73","6685.5","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6087.73","77.4","","303.98","303.98","5854.79","1 through 10","914.73","6685.5","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","914.73","11.63","","112.68","112.68","146.99","38","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4937.83","62.78","","780.86","208.94","10480.28","15","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3438.70","43.72","","179.76","179.76","179.76","1 through 10","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5719.64","72.72","","2355.45","298.99","3965.19","155","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5719.64","72.72","","3643.09","3643.09","3643.09","1 through 10","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4185.91","53.22","","554.28","554.28","554.28","16","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4947.27","62.9","","619.64","173.09","2370.64","150","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6087.73","77.4","","303.98","303.98","5854.79","1 through 10","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.38","3624.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","702.5","5134.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.38","3624.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","702.5","5134.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.38","3624.23","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3436.98","56.9","","812.12","238.65","1587.46","163","702.5","5134.32","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.38","3624.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","702.50","11.63","","112.68","112.68","146.99","38","702.5","5134.32","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.38","3624.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4675.25","77.4","","303.98","303.98","5854.79","1 through 10","702.5","5134.32","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.38","3624.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","702.50","11.63","","112.68","112.68","146.99","38","702.5","4675.25","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.38","3624.23","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3792.15","62.78","","780.86","208.94","10480.28","15","702.5","4675.25","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.38","3624.23","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2640.85","43.72","","179.76","179.76","179.76","1 through 10","702.5","4675.25","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.38","3624.23","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4392.56","72.72","","2355.45","298.99","3965.19","155","702.5","4675.25","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.38","3624.23","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4392.56","72.72","","3643.09","3643.09","3643.09","1 through 10","702.5","4675.25","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.38","3624.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3214.69","53.22","","554.28","554.28","554.28","16","702.5","4675.25","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.38","3624.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3799.40","62.9","","619.64","173.09","2370.64","150","702.5","4675.25","percent of total billed charges",""
"NAIL BONE 11X380MM EX TITANIUM CANNULATED LATERAL ENTRY FEMORAL RECONSTRUCTION LEFT","SUP-ITM-10025092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.38","3624.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4675.25","77.4","","303.98","303.98","5854.79","1 through 10","702.5","4675.25","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","both","","","5765.73","3459.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","670.55","4900.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","both","","","5765.73","3459.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","670.55","4900.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","both","","","5765.73","3459.44","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3280.70","56.9","","812.12","238.65","1587.46","163","670.55","4900.87","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","both","","","5765.73","3459.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","670.55","11.63","","112.68","112.68","146.99","38","670.55","4900.87","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","both","","","5765.73","3459.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4462.68","77.4","","303.98","303.98","5854.79","1 through 10","670.55","4900.87","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5765.73","3459.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","670.55","11.63","","112.68","112.68","146.99","38","670.55","4462.68","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5765.73","3459.44","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3619.73","62.78","","780.86","208.94","10480.28","15","670.55","4462.68","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5765.73","3459.44","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2520.78","43.72","","179.76","179.76","179.76","1 through 10","670.55","4462.68","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5765.73","3459.44","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4192.84","72.72","","2355.45","298.99","3965.19","155","670.55","4462.68","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5765.73","3459.44","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4192.84","72.72","","3643.09","3643.09","3643.09","1 through 10","670.55","4462.68","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5765.73","3459.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3068.52","53.22","","554.28","554.28","554.28","16","670.55","4462.68","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5765.73","3459.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3626.64","62.9","","619.64","173.09","2370.64","150","670.55","4462.68","percent of total billed charges",""
"NAIL BONE 11X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018792","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5765.73","3459.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4462.68","77.4","","303.98","303.98","5854.79","1 through 10","670.55","4462.68","percent of total billed charges",""
"NAIL BONE 11X480MM 125DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164076","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","914.73","6685.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 11X480MM 125DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164076","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","914.73","6685.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 11X480MM 125DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164076","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4475.35","56.9","","812.12","238.65","1587.46","163","914.73","6685.5","percent of total billed charges",""
"NAIL BONE 11X480MM 125DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164076","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","914.73","11.63","","112.68","112.68","146.99","38","914.73","6685.5","percent of total billed charges",""
"NAIL BONE 11X480MM 125DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164076","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6087.73","77.4","","303.98","303.98","5854.79","1 through 10","914.73","6685.5","percent of total billed charges",""
"NAIL BONE 11X480MM 125DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164076","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","914.73","11.63","","112.68","112.68","146.99","38","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 11X480MM 125DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164076","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4937.83","62.78","","780.86","208.94","10480.28","15","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 11X480MM 125DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164076","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3438.70","43.72","","179.76","179.76","179.76","1 through 10","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 11X480MM 125DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164076","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5719.64","72.72","","2355.45","298.99","3965.19","155","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 11X480MM 125DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164076","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5719.64","72.72","","3643.09","3643.09","3643.09","1 through 10","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 11X480MM 125DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164076","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4185.91","53.22","","554.28","554.28","554.28","16","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 11X480MM 125DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164076","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4947.27","62.9","","619.64","173.09","2370.64","150","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 11X480MM 125DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164076","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6087.73","77.4","","303.98","303.98","5854.79","1 through 10","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 12X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036919","CDM","C1713","HCPCS","0278","RC","","","","both","","","6837.05","4102.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","795.15","5811.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 12X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036919","CDM","C1713","HCPCS","0278","RC","","","","both","","","6837.05","4102.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","795.15","5811.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 12X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036919","CDM","C1713","HCPCS","0278","RC","","","","both","","","6837.05","4102.23","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3890.28","56.9","","812.12","238.65","1587.46","163","795.15","5811.49","percent of total billed charges",""
"NAIL BONE 12X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036919","CDM","C1713","HCPCS","0278","RC","","","","both","","","6837.05","4102.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","795.15","11.63","","112.68","112.68","146.99","38","795.15","5811.49","percent of total billed charges",""
"NAIL BONE 12X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036919","CDM","C1713","HCPCS","0278","RC","","","","both","","","6837.05","4102.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5291.88","77.4","","303.98","303.98","5854.79","1 through 10","795.15","5811.49","percent of total billed charges",""
"NAIL BONE 12X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036919","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6837.05","4102.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","795.15","11.63","","112.68","112.68","146.99","38","795.15","5291.88","percent of total billed charges",""
"NAIL BONE 12X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036919","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6837.05","4102.23","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4292.30","62.78","","780.86","208.94","10480.28","15","795.15","5291.88","percent of total billed charges",""
"NAIL BONE 12X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036919","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6837.05","4102.23","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2989.16","43.72","","179.76","179.76","179.76","1 through 10","795.15","5291.88","percent of total billed charges",""
"NAIL BONE 12X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036919","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6837.05","4102.23","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4971.90","72.72","","2355.45","298.99","3965.19","155","795.15","5291.88","percent of total billed charges",""
"NAIL BONE 12X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036919","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6837.05","4102.23","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4971.90","72.72","","3643.09","3643.09","3643.09","1 through 10","795.15","5291.88","percent of total billed charges",""
"NAIL BONE 12X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036919","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6837.05","4102.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3638.68","53.22","","554.28","554.28","554.28","16","795.15","5291.88","percent of total billed charges",""
"NAIL BONE 12X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036919","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6837.05","4102.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4300.50","62.9","","619.64","173.09","2370.64","150","795.15","5291.88","percent of total billed charges",""
"NAIL BONE 12X150MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036919","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6837.05","4102.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5291.88","77.4","","303.98","303.98","5854.79","1 through 10","795.15","5291.88","percent of total billed charges",""
"NAIL BONE 12X180MM ARTHRODESIS EX CANNULATED TITANIUM HINDFOOT LEFT","SUP-ITM-10026596","CDM","C1713","HCPCS","0278","RC","","","","both","","","6639.65","3983.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","772.19","5643.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 12X180MM ARTHRODESIS EX CANNULATED TITANIUM HINDFOOT LEFT","SUP-ITM-10026596","CDM","C1713","HCPCS","0278","RC","","","","both","","","6639.65","3983.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","772.19","5643.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 12X180MM ARTHRODESIS EX CANNULATED TITANIUM HINDFOOT LEFT","SUP-ITM-10026596","CDM","C1713","HCPCS","0278","RC","","","","both","","","6639.65","3983.79","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3777.96","56.9","","812.12","238.65","1587.46","163","772.19","5643.7","percent of total billed charges",""
"NAIL BONE 12X180MM ARTHRODESIS EX CANNULATED TITANIUM HINDFOOT LEFT","SUP-ITM-10026596","CDM","C1713","HCPCS","0278","RC","","","","both","","","6639.65","3983.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","772.19","11.63","","112.68","112.68","146.99","38","772.19","5643.7","percent of total billed charges",""
"NAIL BONE 12X180MM ARTHRODESIS EX CANNULATED TITANIUM HINDFOOT LEFT","SUP-ITM-10026596","CDM","C1713","HCPCS","0278","RC","","","","both","","","6639.65","3983.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5139.09","77.4","","303.98","303.98","5854.79","1 through 10","772.19","5643.7","percent of total billed charges",""
"NAIL BONE 12X180MM ARTHRODESIS EX CANNULATED TITANIUM HINDFOOT LEFT","SUP-ITM-10026596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","772.19","11.63","","112.68","112.68","146.99","38","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 12X180MM ARTHRODESIS EX CANNULATED TITANIUM HINDFOOT LEFT","SUP-ITM-10026596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4168.37","62.78","","780.86","208.94","10480.28","15","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 12X180MM ARTHRODESIS EX CANNULATED TITANIUM HINDFOOT LEFT","SUP-ITM-10026596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2902.85","43.72","","179.76","179.76","179.76","1 through 10","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 12X180MM ARTHRODESIS EX CANNULATED TITANIUM HINDFOOT LEFT","SUP-ITM-10026596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4828.35","72.72","","2355.45","298.99","3965.19","155","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 12X180MM ARTHRODESIS EX CANNULATED TITANIUM HINDFOOT LEFT","SUP-ITM-10026596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4828.35","72.72","","3643.09","3643.09","3643.09","1 through 10","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 12X180MM ARTHRODESIS EX CANNULATED TITANIUM HINDFOOT LEFT","SUP-ITM-10026596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3533.62","53.22","","554.28","554.28","554.28","16","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 12X180MM ARTHRODESIS EX CANNULATED TITANIUM HINDFOOT LEFT","SUP-ITM-10026596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4176.34","62.9","","619.64","173.09","2370.64","150","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 12X180MM ARTHRODESIS EX CANNULATED TITANIUM HINDFOOT LEFT","SUP-ITM-10026596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5139.09","77.4","","303.98","303.98","5854.79","1 through 10","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 12X200MM 130DEG TFN ADVANCED TI CANNULATED","SUP-ITM-10164002","CDM","C1713","HCPCS","0278","RC","","","","both","","","5254.30","3152.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","611.08","4466.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 12X200MM 130DEG TFN ADVANCED TI CANNULATED","SUP-ITM-10164002","CDM","C1713","HCPCS","0278","RC","","","","both","","","5254.30","3152.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","611.08","4466.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 12X200MM 130DEG TFN ADVANCED TI CANNULATED","SUP-ITM-10164002","CDM","C1713","HCPCS","0278","RC","","","","both","","","5254.30","3152.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2989.70","56.9","","812.12","238.65","1587.46","163","611.08","4466.16","percent of total billed charges",""
"NAIL BONE 12X200MM 130DEG TFN ADVANCED TI CANNULATED","SUP-ITM-10164002","CDM","C1713","HCPCS","0278","RC","","","","both","","","5254.30","3152.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","611.08","11.63","","112.68","112.68","146.99","38","611.08","4466.16","percent of total billed charges",""
"NAIL BONE 12X200MM 130DEG TFN ADVANCED TI CANNULATED","SUP-ITM-10164002","CDM","C1713","HCPCS","0278","RC","","","","both","","","5254.30","3152.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4066.83","77.4","","303.98","303.98","5854.79","1 through 10","611.08","4466.16","percent of total billed charges",""
"NAIL BONE 12X200MM 130DEG TFN ADVANCED TI CANNULATED","SUP-ITM-10164002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","611.08","11.63","","112.68","112.68","146.99","38","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 12X200MM 130DEG TFN ADVANCED TI CANNULATED","SUP-ITM-10164002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3298.65","62.78","","780.86","208.94","10480.28","15","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 12X200MM 130DEG TFN ADVANCED TI CANNULATED","SUP-ITM-10164002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2297.18","43.72","","179.76","179.76","179.76","1 through 10","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 12X200MM 130DEG TFN ADVANCED TI CANNULATED","SUP-ITM-10164002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3820.93","72.72","","2355.45","298.99","3965.19","155","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 12X200MM 130DEG TFN ADVANCED TI CANNULATED","SUP-ITM-10164002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3820.93","72.72","","3643.09","3643.09","3643.09","1 through 10","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 12X200MM 130DEG TFN ADVANCED TI CANNULATED","SUP-ITM-10164002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2796.34","53.22","","554.28","554.28","554.28","16","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 12X200MM 130DEG TFN ADVANCED TI CANNULATED","SUP-ITM-10164002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3304.95","62.9","","619.64","173.09","2370.64","150","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 12X200MM 130DEG TFN ADVANCED TI CANNULATED","SUP-ITM-10164002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4066.83","77.4","","303.98","303.98","5854.79","1 through 10","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","both","","","6639.65","3983.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","772.19","5643.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","both","","","6639.65","3983.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","772.19","5643.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","both","","","6639.65","3983.79","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3777.96","56.9","","812.12","238.65","1587.46","163","772.19","5643.7","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","both","","","6639.65","3983.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","772.19","11.63","","112.68","112.68","146.99","38","772.19","5643.7","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","both","","","6639.65","3983.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5139.09","77.4","","303.98","303.98","5854.79","1 through 10","772.19","5643.7","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","772.19","11.63","","112.68","112.68","146.99","38","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4168.37","62.78","","780.86","208.94","10480.28","15","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2902.85","43.72","","179.76","179.76","179.76","1 through 10","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4828.35","72.72","","2355.45","298.99","3965.19","155","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4828.35","72.72","","3643.09","3643.09","3643.09","1 through 10","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3533.62","53.22","","554.28","554.28","554.28","16","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4176.34","62.9","","619.64","173.09","2370.64","150","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 12X240MM HINDFOOT ARTHRODESIS CANNULATED EXPERT LEFT TITANIUM","SUP-ITM-10036920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6639.65","3983.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5139.09","77.4","","303.98","303.98","5854.79","1 through 10","772.19","5139.09","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","914.73","6685.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","914.73","6685.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4475.35","56.9","","812.12","238.65","1587.46","163","914.73","6685.5","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","914.73","11.63","","112.68","112.68","146.99","38","914.73","6685.5","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6087.73","77.4","","303.98","303.98","5854.79","1 through 10","914.73","6685.5","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","914.73","11.63","","112.68","112.68","146.99","38","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4937.83","62.78","","780.86","208.94","10480.28","15","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3438.70","43.72","","179.76","179.76","179.76","1 through 10","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5719.64","72.72","","2355.45","298.99","3965.19","155","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5719.64","72.72","","3643.09","3643.09","3643.09","1 through 10","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4185.91","53.22","","554.28","554.28","554.28","16","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4947.27","62.9","","619.64","173.09","2370.64","150","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 12X440MM 130DEG TFN ADVANCED FEMORAL CANNULATED TI TERILE LEFT","SUP-ITM-10163984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6087.73","77.4","","303.98","303.98","5854.79","1 through 10","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.29","3624.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","702.49","5134.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.29","3624.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","702.49","5134.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.29","3624.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3436.93","56.9","","812.12","238.65","1587.46","163","702.49","5134.25","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.29","3624.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","702.49","11.63","","112.68","112.68","146.99","38","702.49","5134.25","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.29","3624.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4675.18","77.4","","303.98","303.98","5854.79","1 through 10","702.49","5134.25","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","702.49","11.63","","112.68","112.68","146.99","38","702.49","4675.18","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3792.09","62.78","","780.86","208.94","10480.28","15","702.49","4675.18","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2640.81","43.72","","179.76","179.76","179.76","1 through 10","702.49","4675.18","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4392.50","72.72","","2355.45","298.99","3965.19","155","702.49","4675.18","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4392.50","72.72","","3643.09","3643.09","3643.09","1 through 10","702.49","4675.18","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3214.64","53.22","","554.28","554.28","554.28","16","702.49","4675.18","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3799.34","62.9","","619.64","173.09","2370.64","150","702.49","4675.18","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4675.18","77.4","","303.98","303.98","5854.79","1 through 10","702.49","4675.18","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","both","","","5595.25","3357.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","650.73","4755.96","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","both","","","5595.25","3357.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","650.73","4755.96","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","both","","","5595.25","3357.15","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3183.70","56.9","","812.12","238.65","1587.46","163","650.73","4755.96","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","both","","","5595.25","3357.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","650.73","11.63","","112.68","112.68","146.99","38","650.73","4755.96","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","both","","","5595.25","3357.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4330.72","77.4","","303.98","303.98","5854.79","1 through 10","650.73","4755.96","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5595.25","3357.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","650.73","11.63","","112.68","112.68","146.99","38","650.73","4330.72","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5595.25","3357.15","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3512.70","62.78","","780.86","208.94","10480.28","15","650.73","4330.72","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5595.25","3357.15","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2446.24","43.72","","179.76","179.76","179.76","1 through 10","650.73","4330.72","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5595.25","3357.15","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4068.87","72.72","","2355.45","298.99","3965.19","155","650.73","4330.72","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5595.25","3357.15","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4068.87","72.72","","3643.09","3643.09","3643.09","1 through 10","650.73","4330.72","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5595.25","3357.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2977.79","53.22","","554.28","554.28","554.28","16","650.73","4330.72","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5595.25","3357.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3519.41","62.9","","619.64","173.09","2370.64","150","650.73","4330.72","percent of total billed charges",""
"NAIL BONE 13X285MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5595.25","3357.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4330.72","77.4","","303.98","303.98","5854.79","1 through 10","650.73","4330.72","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","914.73","6685.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","914.73","6685.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4475.35","56.9","","812.12","238.65","1587.46","163","914.73","6685.5","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","914.73","11.63","","112.68","112.68","146.99","38","914.73","6685.5","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6087.73","77.4","","303.98","303.98","5854.79","1 through 10","914.73","6685.5","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","914.73","11.63","","112.68","112.68","146.99","38","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4937.83","62.78","","780.86","208.94","10480.28","15","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3438.70","43.72","","179.76","179.76","179.76","1 through 10","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5719.64","72.72","","2355.45","298.99","3965.19","155","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5719.64","72.72","","3643.09","3643.09","3643.09","1 through 10","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4185.91","53.22","","554.28","554.28","554.28","16","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4947.27","62.9","","619.64","173.09","2370.64","150","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 14X400MM 130DEG FEMORAL TFN ADVANCED SYSTEM CANNULATED TI RIGHT","SUP-ITM-10163965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6087.73","77.4","","303.98","303.98","5854.79","1 through 10","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 14X480MM 130DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10163956","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","914.73","6685.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 14X480MM 130DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10163956","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","914.73","6685.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 14X480MM 130DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10163956","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4475.35","56.9","","812.12","238.65","1587.46","163","914.73","6685.5","percent of total billed charges",""
"NAIL BONE 14X480MM 130DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10163956","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","914.73","11.63","","112.68","112.68","146.99","38","914.73","6685.5","percent of total billed charges",""
"NAIL BONE 14X480MM 130DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10163956","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6087.73","77.4","","303.98","303.98","5854.79","1 through 10","914.73","6685.5","percent of total billed charges",""
"NAIL BONE 14X480MM 130DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10163956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","914.73","11.63","","112.68","112.68","146.99","38","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 14X480MM 130DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10163956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4937.83","62.78","","780.86","208.94","10480.28","15","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 14X480MM 130DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10163956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3438.70","43.72","","179.76","179.76","179.76","1 through 10","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 14X480MM 130DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10163956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5719.64","72.72","","2355.45","298.99","3965.19","155","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 14X480MM 130DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10163956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5719.64","72.72","","3643.09","3643.09","3643.09","1 through 10","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 14X480MM 130DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10163956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4185.91","53.22","","554.28","554.28","554.28","16","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 14X480MM 130DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10163956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4947.27","62.9","","619.64","173.09","2370.64","150","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 14X480MM 130DEG TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10163956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6087.73","77.4","","303.98","303.98","5854.79","1 through 10","914.73","6087.73","percent of total billed charges",""
"NAIL BONE 170X12MM SHORT 130DEG TFN ADVANCED FEMORAL CANNULATED TI NECK","SUP-ITM-10164003","CDM","C1713","HCPCS","0278","RC","","","","both","","","5254.30","3152.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","611.08","4466.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 170X12MM SHORT 130DEG TFN ADVANCED FEMORAL CANNULATED TI NECK","SUP-ITM-10164003","CDM","C1713","HCPCS","0278","RC","","","","both","","","5254.30","3152.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","611.08","4466.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 170X12MM SHORT 130DEG TFN ADVANCED FEMORAL CANNULATED TI NECK","SUP-ITM-10164003","CDM","C1713","HCPCS","0278","RC","","","","both","","","5254.30","3152.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2989.70","56.9","","812.12","238.65","1587.46","163","611.08","4466.16","percent of total billed charges",""
"NAIL BONE 170X12MM SHORT 130DEG TFN ADVANCED FEMORAL CANNULATED TI NECK","SUP-ITM-10164003","CDM","C1713","HCPCS","0278","RC","","","","both","","","5254.30","3152.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","611.08","11.63","","112.68","112.68","146.99","38","611.08","4466.16","percent of total billed charges",""
"NAIL BONE 170X12MM SHORT 130DEG TFN ADVANCED FEMORAL CANNULATED TI NECK","SUP-ITM-10164003","CDM","C1713","HCPCS","0278","RC","","","","both","","","5254.30","3152.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4066.83","77.4","","303.98","303.98","5854.79","1 through 10","611.08","4466.16","percent of total billed charges",""
"NAIL BONE 170X12MM SHORT 130DEG TFN ADVANCED FEMORAL CANNULATED TI NECK","SUP-ITM-10164003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","611.08","11.63","","112.68","112.68","146.99","38","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 170X12MM SHORT 130DEG TFN ADVANCED FEMORAL CANNULATED TI NECK","SUP-ITM-10164003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3298.65","62.78","","780.86","208.94","10480.28","15","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 170X12MM SHORT 130DEG TFN ADVANCED FEMORAL CANNULATED TI NECK","SUP-ITM-10164003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2297.18","43.72","","179.76","179.76","179.76","1 through 10","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 170X12MM SHORT 130DEG TFN ADVANCED FEMORAL CANNULATED TI NECK","SUP-ITM-10164003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3820.93","72.72","","2355.45","298.99","3965.19","155","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 170X12MM SHORT 130DEG TFN ADVANCED FEMORAL CANNULATED TI NECK","SUP-ITM-10164003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3820.93","72.72","","3643.09","3643.09","3643.09","1 through 10","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 170X12MM SHORT 130DEG TFN ADVANCED FEMORAL CANNULATED TI NECK","SUP-ITM-10164003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2796.34","53.22","","554.28","554.28","554.28","16","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 170X12MM SHORT 130DEG TFN ADVANCED FEMORAL CANNULATED TI NECK","SUP-ITM-10164003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3304.95","62.9","","619.64","173.09","2370.64","150","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 170X12MM SHORT 130DEG TFN ADVANCED FEMORAL CANNULATED TI NECK","SUP-ITM-10164003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4066.83","77.4","","303.98","303.98","5854.79","1 through 10","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 8.5X285MM HUMERAL CANNULATED TITANIUM MULTILOC RIGHT","SUP-ITM-10125455","CDM","C1713","HCPCS","0278","RC","","","","both","","","7208.51","4325.11","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","838.35","6127.23","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 8.5X285MM HUMERAL CANNULATED TITANIUM MULTILOC RIGHT","SUP-ITM-10125455","CDM","C1713","HCPCS","0278","RC","","","","both","","","7208.51","4325.11","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","838.35","6127.23","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 8.5X285MM HUMERAL CANNULATED TITANIUM MULTILOC RIGHT","SUP-ITM-10125455","CDM","C1713","HCPCS","0278","RC","","","","both","","","7208.51","4325.11","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4101.64","56.9","","812.12","238.65","1587.46","163","838.35","6127.23","percent of total billed charges",""
"NAIL BONE 8.5X285MM HUMERAL CANNULATED TITANIUM MULTILOC RIGHT","SUP-ITM-10125455","CDM","C1713","HCPCS","0278","RC","","","","both","","","7208.51","4325.11","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","838.35","11.63","","112.68","112.68","146.99","38","838.35","6127.23","percent of total billed charges",""
"NAIL BONE 8.5X285MM HUMERAL CANNULATED TITANIUM MULTILOC RIGHT","SUP-ITM-10125455","CDM","C1713","HCPCS","0278","RC","","","","both","","","7208.51","4325.11","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5579.39","77.4","","303.98","303.98","5854.79","1 through 10","838.35","6127.23","percent of total billed charges",""
"NAIL BONE 8.5X285MM HUMERAL CANNULATED TITANIUM MULTILOC RIGHT","SUP-ITM-10125455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7208.51","4325.11","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","838.35","11.63","","112.68","112.68","146.99","38","838.35","5579.39","percent of total billed charges",""
"NAIL BONE 8.5X285MM HUMERAL CANNULATED TITANIUM MULTILOC RIGHT","SUP-ITM-10125455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7208.51","4325.11","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4525.50","62.78","","780.86","208.94","10480.28","15","838.35","5579.39","percent of total billed charges",""
"NAIL BONE 8.5X285MM HUMERAL CANNULATED TITANIUM MULTILOC RIGHT","SUP-ITM-10125455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7208.51","4325.11","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3151.56","43.72","","179.76","179.76","179.76","1 through 10","838.35","5579.39","percent of total billed charges",""
"NAIL BONE 8.5X285MM HUMERAL CANNULATED TITANIUM MULTILOC RIGHT","SUP-ITM-10125455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7208.51","4325.11","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5242.03","72.72","","2355.45","298.99","3965.19","155","838.35","5579.39","percent of total billed charges",""
"NAIL BONE 8.5X285MM HUMERAL CANNULATED TITANIUM MULTILOC RIGHT","SUP-ITM-10125455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7208.51","4325.11","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5242.03","72.72","","3643.09","3643.09","3643.09","1 through 10","838.35","5579.39","percent of total billed charges",""
"NAIL BONE 8.5X285MM HUMERAL CANNULATED TITANIUM MULTILOC RIGHT","SUP-ITM-10125455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7208.51","4325.11","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3836.37","53.22","","554.28","554.28","554.28","16","838.35","5579.39","percent of total billed charges",""
"NAIL BONE 8.5X285MM HUMERAL CANNULATED TITANIUM MULTILOC RIGHT","SUP-ITM-10125455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7208.51","4325.11","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4534.15","62.9","","619.64","173.09","2370.64","150","838.35","5579.39","percent of total billed charges",""
"NAIL BONE 8.5X285MM HUMERAL CANNULATED TITANIUM MULTILOC RIGHT","SUP-ITM-10125455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7208.51","4325.11","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5579.39","77.4","","303.98","303.98","5854.79","1 through 10","838.35","5579.39","percent of total billed charges",""
"NAIL BONE 8MMX315 INTRAMEDULLARY TIBIAL STANDARD T2 TITANIUM","SUP-ITM-10033525","CDM","C1713","HCPCS","0278","RC","","","","both","","","11381.79","6829.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1323.7","9674.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 8MMX315 INTRAMEDULLARY TIBIAL STANDARD T2 TITANIUM","SUP-ITM-10033525","CDM","C1713","HCPCS","0278","RC","","","","both","","","11381.79","6829.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1323.7","9674.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 8MMX315 INTRAMEDULLARY TIBIAL STANDARD T2 TITANIUM","SUP-ITM-10033525","CDM","C1713","HCPCS","0278","RC","","","","both","","","11381.79","6829.07","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6476.24","56.9","","812.12","238.65","1587.46","163","1323.7","9674.52","percent of total billed charges",""
"NAIL BONE 8MMX315 INTRAMEDULLARY TIBIAL STANDARD T2 TITANIUM","SUP-ITM-10033525","CDM","C1713","HCPCS","0278","RC","","","","both","","","11381.79","6829.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1323.70","11.63","","112.68","112.68","146.99","38","1323.7","9674.52","percent of total billed charges",""
"NAIL BONE 8MMX315 INTRAMEDULLARY TIBIAL STANDARD T2 TITANIUM","SUP-ITM-10033525","CDM","C1713","HCPCS","0278","RC","","","","both","","","11381.79","6829.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8809.51","77.4","","303.98","303.98","5854.79","1 through 10","1323.7","9674.52","percent of total billed charges",""
"NAIL BONE 8MMX315 INTRAMEDULLARY TIBIAL STANDARD T2 TITANIUM","SUP-ITM-10033525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11381.79","6829.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1323.70","11.63","","112.68","112.68","146.99","38","1323.7","8809.51","percent of total billed charges",""
"NAIL BONE 8MMX315 INTRAMEDULLARY TIBIAL STANDARD T2 TITANIUM","SUP-ITM-10033525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11381.79","6829.07","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","7145.49","62.78","","780.86","208.94","10480.28","15","1323.7","8809.51","percent of total billed charges",""
"NAIL BONE 8MMX315 INTRAMEDULLARY TIBIAL STANDARD T2 TITANIUM","SUP-ITM-10033525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11381.79","6829.07","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4976.12","43.72","","179.76","179.76","179.76","1 through 10","1323.7","8809.51","percent of total billed charges",""
"NAIL BONE 8MMX315 INTRAMEDULLARY TIBIAL STANDARD T2 TITANIUM","SUP-ITM-10033525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11381.79","6829.07","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8276.84","72.72","","2355.45","298.99","3965.19","155","1323.7","8809.51","percent of total billed charges",""
"NAIL BONE 8MMX315 INTRAMEDULLARY TIBIAL STANDARD T2 TITANIUM","SUP-ITM-10033525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11381.79","6829.07","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","8276.84","72.72","","3643.09","3643.09","3643.09","1 through 10","1323.7","8809.51","percent of total billed charges",""
"NAIL BONE 8MMX315 INTRAMEDULLARY TIBIAL STANDARD T2 TITANIUM","SUP-ITM-10033525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11381.79","6829.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","6057.39","53.22","","554.28","554.28","554.28","16","1323.7","8809.51","percent of total billed charges",""
"NAIL BONE 8MMX315 INTRAMEDULLARY TIBIAL STANDARD T2 TITANIUM","SUP-ITM-10033525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11381.79","6829.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7159.15","62.9","","619.64","173.09","2370.64","150","1323.7","8809.51","percent of total billed charges",""
"NAIL BONE 8MMX315 INTRAMEDULLARY TIBIAL STANDARD T2 TITANIUM","SUP-ITM-10033525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11381.79","6829.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8809.51","77.4","","303.98","303.98","5854.79","1 through 10","1323.7","8809.51","percent of total billed charges",""
"NAIL BONE 8X130MM HUMERAL AEQUALIS CANNULATED TITANIUM LEFT","SUP-ITM-10136175","CDM","C1713","HCPCS","0278","RC","","","","both","","","9462.35","5677.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1100.47","8043","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 8X130MM HUMERAL AEQUALIS CANNULATED TITANIUM LEFT","SUP-ITM-10136175","CDM","C1713","HCPCS","0278","RC","","","","both","","","9462.35","5677.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1100.47","8043","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 8X130MM HUMERAL AEQUALIS CANNULATED TITANIUM LEFT","SUP-ITM-10136175","CDM","C1713","HCPCS","0278","RC","","","","both","","","9462.35","5677.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5384.08","56.9","","812.12","238.65","1587.46","163","1100.47","8043","percent of total billed charges",""
"NAIL BONE 8X130MM HUMERAL AEQUALIS CANNULATED TITANIUM LEFT","SUP-ITM-10136175","CDM","C1713","HCPCS","0278","RC","","","","both","","","9462.35","5677.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1100.47","11.63","","112.68","112.68","146.99","38","1100.47","8043","percent of total billed charges",""
"NAIL BONE 8X130MM HUMERAL AEQUALIS CANNULATED TITANIUM LEFT","SUP-ITM-10136175","CDM","C1713","HCPCS","0278","RC","","","","both","","","9462.35","5677.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7323.86","77.4","","303.98","303.98","5854.79","1 through 10","1100.47","8043","percent of total billed charges",""
"NAIL BONE 8X130MM HUMERAL AEQUALIS CANNULATED TITANIUM LEFT","SUP-ITM-10136175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9462.35","5677.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1100.47","11.63","","112.68","112.68","146.99","38","1100.47","7323.86","percent of total billed charges",""
"NAIL BONE 8X130MM HUMERAL AEQUALIS CANNULATED TITANIUM LEFT","SUP-ITM-10136175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9462.35","5677.41","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5940.46","62.78","","780.86","208.94","10480.28","15","1100.47","7323.86","percent of total billed charges",""
"NAIL BONE 8X130MM HUMERAL AEQUALIS CANNULATED TITANIUM LEFT","SUP-ITM-10136175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9462.35","5677.41","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4136.94","43.72","","179.76","179.76","179.76","1 through 10","1100.47","7323.86","percent of total billed charges",""
"NAIL BONE 8X130MM HUMERAL AEQUALIS CANNULATED TITANIUM LEFT","SUP-ITM-10136175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9462.35","5677.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6881.02","72.72","","2355.45","298.99","3965.19","155","1100.47","7323.86","percent of total billed charges",""
"NAIL BONE 8X130MM HUMERAL AEQUALIS CANNULATED TITANIUM LEFT","SUP-ITM-10136175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9462.35","5677.41","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6881.02","72.72","","3643.09","3643.09","3643.09","1 through 10","1100.47","7323.86","percent of total billed charges",""
"NAIL BONE 8X130MM HUMERAL AEQUALIS CANNULATED TITANIUM LEFT","SUP-ITM-10136175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9462.35","5677.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","5035.86","53.22","","554.28","554.28","554.28","16","1100.47","7323.86","percent of total billed charges",""
"NAIL BONE 8X130MM HUMERAL AEQUALIS CANNULATED TITANIUM LEFT","SUP-ITM-10136175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9462.35","5677.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5951.82","62.9","","619.64","173.09","2370.64","150","1100.47","7323.86","percent of total billed charges",""
"NAIL BONE 8X130MM HUMERAL AEQUALIS CANNULATED TITANIUM LEFT","SUP-ITM-10136175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9462.35","5677.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7323.86","77.4","","303.98","303.98","5854.79","1 through 10","1100.47","7323.86","percent of total billed charges",""
"NAIL BONE 8X220MM LONG PROXIMALIMAL HUMERAL TITANIUM T2 RIGHT","SUP-ITM-10033811","CDM","C1713","HCPCS","0278","RC","","","","both","","","11621.87","6973.12","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1351.62","9878.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 8X220MM LONG PROXIMALIMAL HUMERAL TITANIUM T2 RIGHT","SUP-ITM-10033811","CDM","C1713","HCPCS","0278","RC","","","","both","","","11621.87","6973.12","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1351.62","9878.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 8X220MM LONG PROXIMALIMAL HUMERAL TITANIUM T2 RIGHT","SUP-ITM-10033811","CDM","C1713","HCPCS","0278","RC","","","","both","","","11621.87","6973.12","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6612.84","56.9","","812.12","238.65","1587.46","163","1351.62","9878.59","percent of total billed charges",""
"NAIL BONE 8X220MM LONG PROXIMALIMAL HUMERAL TITANIUM T2 RIGHT","SUP-ITM-10033811","CDM","C1713","HCPCS","0278","RC","","","","both","","","11621.87","6973.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1351.62","11.63","","112.68","112.68","146.99","38","1351.62","9878.59","percent of total billed charges",""
"NAIL BONE 8X220MM LONG PROXIMALIMAL HUMERAL TITANIUM T2 RIGHT","SUP-ITM-10033811","CDM","C1713","HCPCS","0278","RC","","","","both","","","11621.87","6973.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8995.33","77.4","","303.98","303.98","5854.79","1 through 10","1351.62","9878.59","percent of total billed charges",""
"NAIL BONE 8X220MM LONG PROXIMALIMAL HUMERAL TITANIUM T2 RIGHT","SUP-ITM-10033811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11621.87","6973.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1351.62","11.63","","112.68","112.68","146.99","38","1351.62","8995.33","percent of total billed charges",""
"NAIL BONE 8X220MM LONG PROXIMALIMAL HUMERAL TITANIUM T2 RIGHT","SUP-ITM-10033811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11621.87","6973.12","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","7296.21","62.78","","780.86","208.94","10480.28","15","1351.62","8995.33","percent of total billed charges",""
"NAIL BONE 8X220MM LONG PROXIMALIMAL HUMERAL TITANIUM T2 RIGHT","SUP-ITM-10033811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11621.87","6973.12","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","5081.08","43.72","","179.76","179.76","179.76","1 through 10","1351.62","8995.33","percent of total billed charges",""
"NAIL BONE 8X220MM LONG PROXIMALIMAL HUMERAL TITANIUM T2 RIGHT","SUP-ITM-10033811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11621.87","6973.12","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8451.42","72.72","","2355.45","298.99","3965.19","155","1351.62","8995.33","percent of total billed charges",""
"NAIL BONE 8X220MM LONG PROXIMALIMAL HUMERAL TITANIUM T2 RIGHT","SUP-ITM-10033811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11621.87","6973.12","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","8451.42","72.72","","3643.09","3643.09","3643.09","1 through 10","1351.62","8995.33","percent of total billed charges",""
"NAIL BONE 8X220MM LONG PROXIMALIMAL HUMERAL TITANIUM T2 RIGHT","SUP-ITM-10033811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11621.87","6973.12","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","6185.16","53.22","","554.28","554.28","554.28","16","1351.62","8995.33","percent of total billed charges",""
"NAIL BONE 8X220MM LONG PROXIMALIMAL HUMERAL TITANIUM T2 RIGHT","SUP-ITM-10033811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11621.87","6973.12","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7310.16","62.9","","619.64","173.09","2370.64","150","1351.62","8995.33","percent of total billed charges",""
"NAIL BONE 8X220MM LONG PROXIMALIMAL HUMERAL TITANIUM T2 RIGHT","SUP-ITM-10033811","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11621.87","6973.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8995.33","77.4","","303.98","303.98","5854.79","1 through 10","1351.62","8995.33","percent of total billed charges",""
"NAIL BONE 9.0X290MM FEMORAL T2 HUMERAL INTRAMEDULLARY LOCKING","SUP-ITM-10033797","CDM","C1713","HCPCS","0278","RC","","","","both","","","11251.95","6751.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1308.6","9564.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 9.0X290MM FEMORAL T2 HUMERAL INTRAMEDULLARY LOCKING","SUP-ITM-10033797","CDM","C1713","HCPCS","0278","RC","","","","both","","","11251.95","6751.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1308.6","9564.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 9.0X290MM FEMORAL T2 HUMERAL INTRAMEDULLARY LOCKING","SUP-ITM-10033797","CDM","C1713","HCPCS","0278","RC","","","","both","","","11251.95","6751.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6402.36","56.9","","812.12","238.65","1587.46","163","1308.6","9564.16","percent of total billed charges",""
"NAIL BONE 9.0X290MM FEMORAL T2 HUMERAL INTRAMEDULLARY LOCKING","SUP-ITM-10033797","CDM","C1713","HCPCS","0278","RC","","","","both","","","11251.95","6751.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1308.60","11.63","","112.68","112.68","146.99","38","1308.6","9564.16","percent of total billed charges",""
"NAIL BONE 9.0X290MM FEMORAL T2 HUMERAL INTRAMEDULLARY LOCKING","SUP-ITM-10033797","CDM","C1713","HCPCS","0278","RC","","","","both","","","11251.95","6751.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8709.01","77.4","","303.98","303.98","5854.79","1 through 10","1308.6","9564.16","percent of total billed charges",""
"NAIL BONE 9.0X290MM FEMORAL T2 HUMERAL INTRAMEDULLARY LOCKING","SUP-ITM-10033797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11251.95","6751.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1308.60","11.63","","112.68","112.68","146.99","38","1308.6","8709.01","percent of total billed charges",""
"NAIL BONE 9.0X290MM FEMORAL T2 HUMERAL INTRAMEDULLARY LOCKING","SUP-ITM-10033797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11251.95","6751.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","7063.97","62.78","","780.86","208.94","10480.28","15","1308.6","8709.01","percent of total billed charges",""
"NAIL BONE 9.0X290MM FEMORAL T2 HUMERAL INTRAMEDULLARY LOCKING","SUP-ITM-10033797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11251.95","6751.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4919.35","43.72","","179.76","179.76","179.76","1 through 10","1308.6","8709.01","percent of total billed charges",""
"NAIL BONE 9.0X290MM FEMORAL T2 HUMERAL INTRAMEDULLARY LOCKING","SUP-ITM-10033797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11251.95","6751.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8182.42","72.72","","2355.45","298.99","3965.19","155","1308.6","8709.01","percent of total billed charges",""
"NAIL BONE 9.0X290MM FEMORAL T2 HUMERAL INTRAMEDULLARY LOCKING","SUP-ITM-10033797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11251.95","6751.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","8182.42","72.72","","3643.09","3643.09","3643.09","1 through 10","1308.6","8709.01","percent of total billed charges",""
"NAIL BONE 9.0X290MM FEMORAL T2 HUMERAL INTRAMEDULLARY LOCKING","SUP-ITM-10033797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11251.95","6751.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","5988.29","53.22","","554.28","554.28","554.28","16","1308.6","8709.01","percent of total billed charges",""
"NAIL BONE 9.0X290MM FEMORAL T2 HUMERAL INTRAMEDULLARY LOCKING","SUP-ITM-10033797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11251.95","6751.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7077.48","62.9","","619.64","173.09","2370.64","150","1308.6","8709.01","percent of total billed charges",""
"NAIL BONE 9.0X290MM FEMORAL T2 HUMERAL INTRAMEDULLARY LOCKING","SUP-ITM-10033797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11251.95","6751.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8709.01","77.4","","303.98","303.98","5854.79","1 through 10","1308.6","8709.01","percent of total billed charges",""
"NAIL BONE 9X200MM 135DEG TFN ADVANCED TITANIUM CANNULATED","SUP-ITM-10163898","CDM","C1713","HCPCS","0278","RC","","","","both","","","5254.30","3152.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","611.08","4466.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 9X200MM 135DEG TFN ADVANCED TITANIUM CANNULATED","SUP-ITM-10163898","CDM","C1713","HCPCS","0278","RC","","","","both","","","5254.30","3152.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","611.08","4466.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 9X200MM 135DEG TFN ADVANCED TITANIUM CANNULATED","SUP-ITM-10163898","CDM","C1713","HCPCS","0278","RC","","","","both","","","5254.30","3152.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2989.70","56.9","","812.12","238.65","1587.46","163","611.08","4466.16","percent of total billed charges",""
"NAIL BONE 9X200MM 135DEG TFN ADVANCED TITANIUM CANNULATED","SUP-ITM-10163898","CDM","C1713","HCPCS","0278","RC","","","","both","","","5254.30","3152.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","611.08","11.63","","112.68","112.68","146.99","38","611.08","4466.16","percent of total billed charges",""
"NAIL BONE 9X200MM 135DEG TFN ADVANCED TITANIUM CANNULATED","SUP-ITM-10163898","CDM","C1713","HCPCS","0278","RC","","","","both","","","5254.30","3152.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4066.83","77.4","","303.98","303.98","5854.79","1 through 10","611.08","4466.16","percent of total billed charges",""
"NAIL BONE 9X200MM 135DEG TFN ADVANCED TITANIUM CANNULATED","SUP-ITM-10163898","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","611.08","11.63","","112.68","112.68","146.99","38","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 9X200MM 135DEG TFN ADVANCED TITANIUM CANNULATED","SUP-ITM-10163898","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3298.65","62.78","","780.86","208.94","10480.28","15","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 9X200MM 135DEG TFN ADVANCED TITANIUM CANNULATED","SUP-ITM-10163898","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2297.18","43.72","","179.76","179.76","179.76","1 through 10","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 9X200MM 135DEG TFN ADVANCED TITANIUM CANNULATED","SUP-ITM-10163898","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3820.93","72.72","","2355.45","298.99","3965.19","155","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 9X200MM 135DEG TFN ADVANCED TITANIUM CANNULATED","SUP-ITM-10163898","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3820.93","72.72","","3643.09","3643.09","3643.09","1 through 10","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 9X200MM 135DEG TFN ADVANCED TITANIUM CANNULATED","SUP-ITM-10163898","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2796.34","53.22","","554.28","554.28","554.28","16","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 9X200MM 135DEG TFN ADVANCED TITANIUM CANNULATED","SUP-ITM-10163898","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3304.95","62.9","","619.64","173.09","2370.64","150","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 9X200MM 135DEG TFN ADVANCED TITANIUM CANNULATED","SUP-ITM-10163898","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.30","3152.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4066.83","77.4","","303.98","303.98","5854.79","1 through 10","611.08","4066.83","percent of total billed charges",""
"NAIL BONE 9X235MM 135DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163896","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.29","3624.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","702.49","5134.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 9X235MM 135DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163896","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.29","3624.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","702.49","5134.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 9X235MM 135DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163896","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.29","3624.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3436.93","56.9","","812.12","238.65","1587.46","163","702.49","5134.25","percent of total billed charges",""
"NAIL BONE 9X235MM 135DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163896","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.29","3624.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","702.49","11.63","","112.68","112.68","146.99","38","702.49","5134.25","percent of total billed charges",""
"NAIL BONE 9X235MM 135DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163896","CDM","C1713","HCPCS","0278","RC","","","","both","","","6040.29","3624.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4675.18","77.4","","303.98","303.98","5854.79","1 through 10","702.49","5134.25","percent of total billed charges",""
"NAIL BONE 9X235MM 135DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","702.49","11.63","","112.68","112.68","146.99","38","702.49","4675.18","percent of total billed charges",""
"NAIL BONE 9X235MM 135DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3792.09","62.78","","780.86","208.94","10480.28","15","702.49","4675.18","percent of total billed charges",""
"NAIL BONE 9X235MM 135DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2640.81","43.72","","179.76","179.76","179.76","1 through 10","702.49","4675.18","percent of total billed charges",""
"NAIL BONE 9X235MM 135DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4392.50","72.72","","2355.45","298.99","3965.19","155","702.49","4675.18","percent of total billed charges",""
"NAIL BONE 9X235MM 135DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4392.50","72.72","","3643.09","3643.09","3643.09","1 through 10","702.49","4675.18","percent of total billed charges",""
"NAIL BONE 9X235MM 135DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3214.64","53.22","","554.28","554.28","554.28","16","702.49","4675.18","percent of total billed charges",""
"NAIL BONE 9X235MM 135DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3799.34","62.9","","619.64","173.09","2370.64","150","702.49","4675.18","percent of total billed charges",""
"NAIL BONE 9X235MM 135DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6040.29","3624.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4675.18","77.4","","303.98","303.98","5854.79","1 through 10","702.49","4675.18","percent of total billed charges",""
"NAIL BONE 9X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018768","CDM","C1713","HCPCS","0278","RC","","","","both","","","5765.73","3459.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","670.55","4900.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 9X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018768","CDM","C1713","HCPCS","0278","RC","","","","both","","","5765.73","3459.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","670.55","4900.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 9X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018768","CDM","C1713","HCPCS","0278","RC","","","","both","","","5765.73","3459.44","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3280.70","56.9","","812.12","238.65","1587.46","163","670.55","4900.87","percent of total billed charges",""
"NAIL BONE 9X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018768","CDM","C1713","HCPCS","0278","RC","","","","both","","","5765.73","3459.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","670.55","11.63","","112.68","112.68","146.99","38","670.55","4900.87","percent of total billed charges",""
"NAIL BONE 9X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018768","CDM","C1713","HCPCS","0278","RC","","","","both","","","5765.73","3459.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4462.68","77.4","","303.98","303.98","5854.79","1 through 10","670.55","4900.87","percent of total billed charges",""
"NAIL BONE 9X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5765.73","3459.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","670.55","11.63","","112.68","112.68","146.99","38","670.55","4462.68","percent of total billed charges",""
"NAIL BONE 9X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5765.73","3459.44","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3619.73","62.78","","780.86","208.94","10480.28","15","670.55","4462.68","percent of total billed charges",""
"NAIL BONE 9X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5765.73","3459.44","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2520.78","43.72","","179.76","179.76","179.76","1 through 10","670.55","4462.68","percent of total billed charges",""
"NAIL BONE 9X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5765.73","3459.44","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4192.84","72.72","","2355.45","298.99","3965.19","155","670.55","4462.68","percent of total billed charges",""
"NAIL BONE 9X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5765.73","3459.44","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4192.84","72.72","","3643.09","3643.09","3643.09","1 through 10","670.55","4462.68","percent of total billed charges",""
"NAIL BONE 9X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5765.73","3459.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3068.52","53.22","","554.28","554.28","554.28","16","670.55","4462.68","percent of total billed charges",""
"NAIL BONE 9X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5765.73","3459.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3626.64","62.9","","619.64","173.09","2370.64","150","670.55","4462.68","percent of total billed charges",""
"NAIL BONE 9X435MM TIBIAL CANNULATED EX TITANIUM","SUP-ITM-10018768","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5765.73","3459.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4462.68","77.4","","303.98","303.98","5854.79","1 through 10","670.55","4462.68","percent of total billed charges",""
"NAIL BONE 9X480MM 130DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163900","CDM","C1713","HCPCS","0278","RC","","","","both","","","8292.38","4975.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","964.4","7048.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 9X480MM 130DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163900","CDM","C1713","HCPCS","0278","RC","","","","both","","","8292.38","4975.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","964.4","7048.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL BONE 9X480MM 130DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163900","CDM","C1713","HCPCS","0278","RC","","","","both","","","8292.38","4975.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4718.36","56.9","","812.12","238.65","1587.46","163","964.4","7048.52","percent of total billed charges",""
"NAIL BONE 9X480MM 130DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163900","CDM","C1713","HCPCS","0278","RC","","","","both","","","8292.38","4975.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","964.40","11.63","","112.68","112.68","146.99","38","964.4","7048.52","percent of total billed charges",""
"NAIL BONE 9X480MM 130DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163900","CDM","C1713","HCPCS","0278","RC","","","","both","","","8292.38","4975.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6418.30","77.4","","303.98","303.98","5854.79","1 through 10","964.4","7048.52","percent of total billed charges",""
"NAIL BONE 9X480MM 130DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163900","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8292.38","4975.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","964.40","11.63","","112.68","112.68","146.99","38","964.4","6418.3","percent of total billed charges",""
"NAIL BONE 9X480MM 130DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163900","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8292.38","4975.43","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5205.96","62.78","","780.86","208.94","10480.28","15","964.4","6418.3","percent of total billed charges",""
"NAIL BONE 9X480MM 130DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163900","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8292.38","4975.43","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3625.43","43.72","","179.76","179.76","179.76","1 through 10","964.4","6418.3","percent of total billed charges",""
"NAIL BONE 9X480MM 130DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163900","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8292.38","4975.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6030.22","72.72","","2355.45","298.99","3965.19","155","964.4","6418.3","percent of total billed charges",""
"NAIL BONE 9X480MM 130DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163900","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8292.38","4975.43","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6030.22","72.72","","3643.09","3643.09","3643.09","1 through 10","964.4","6418.3","percent of total billed charges",""
"NAIL BONE 9X480MM 130DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163900","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8292.38","4975.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4413.20","53.22","","554.28","554.28","554.28","16","964.4","6418.3","percent of total billed charges",""
"NAIL BONE 9X480MM 130DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163900","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8292.38","4975.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5215.91","62.9","","619.64","173.09","2370.64","150","964.4","6418.3","percent of total billed charges",""
"NAIL BONE 9X480MM 130DEG TFN ADVANCED TITANIUM CANNULATED LEFT","SUP-ITM-10163900","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8292.38","4975.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6418.30","77.4","","303.98","303.98","5854.79","1 through 10","964.4","6418.3","percent of total billed charges",""
"NAIL ELASTIC 2X440MM STAINLESS","SUP-ITM-10125723","CDM","C1713","HCPCS","0278","RC","","","","both","","","1457.32","874.39","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","169.49","1238.72","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL ELASTIC 2X440MM STAINLESS","SUP-ITM-10125723","CDM","C1713","HCPCS","0278","RC","","","","both","","","1457.32","874.39","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","169.49","1238.72","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL ELASTIC 2X440MM STAINLESS","SUP-ITM-10125723","CDM","C1713","HCPCS","0278","RC","","","","both","","","1457.32","874.39","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","829.22","56.9","","812.12","238.65","1587.46","163","169.49","1238.72","percent of total billed charges",""
"NAIL ELASTIC 2X440MM STAINLESS","SUP-ITM-10125723","CDM","C1713","HCPCS","0278","RC","","","","both","","","1457.32","874.39","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","169.49","11.63","","112.68","112.68","146.99","38","169.49","1238.72","percent of total billed charges",""
"NAIL ELASTIC 2X440MM STAINLESS","SUP-ITM-10125723","CDM","C1713","HCPCS","0278","RC","","","","both","","","1457.32","874.39","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1127.97","77.4","","303.98","303.98","5854.79","1 through 10","169.49","1238.72","percent of total billed charges",""
"NAIL ELASTIC 2X440MM STAINLESS","SUP-ITM-10125723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1457.32","874.39","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","169.49","11.63","","112.68","112.68","146.99","38","169.49","1127.97","percent of total billed charges",""
"NAIL ELASTIC 2X440MM STAINLESS","SUP-ITM-10125723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1457.32","874.39","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","914.91","62.78","","780.86","208.94","10480.28","15","169.49","1127.97","percent of total billed charges",""
"NAIL ELASTIC 2X440MM STAINLESS","SUP-ITM-10125723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1457.32","874.39","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","637.14","43.72","","179.76","179.76","179.76","1 through 10","169.49","1127.97","percent of total billed charges",""
"NAIL ELASTIC 2X440MM STAINLESS","SUP-ITM-10125723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1457.32","874.39","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1059.76","72.72","","2355.45","298.99","3965.19","155","169.49","1127.97","percent of total billed charges",""
"NAIL ELASTIC 2X440MM STAINLESS","SUP-ITM-10125723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1457.32","874.39","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1059.76","72.72","","3643.09","3643.09","3643.09","1 through 10","169.49","1127.97","percent of total billed charges",""
"NAIL ELASTIC 2X440MM STAINLESS","SUP-ITM-10125723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1457.32","874.39","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","775.59","53.22","","554.28","554.28","554.28","16","169.49","1127.97","percent of total billed charges",""
"NAIL ELASTIC 2X440MM STAINLESS","SUP-ITM-10125723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1457.32","874.39","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","916.65","62.9","","619.64","173.09","2370.64","150","169.49","1127.97","percent of total billed charges",""
"NAIL ELASTIC 2X440MM STAINLESS","SUP-ITM-10125723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1457.32","874.39","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1127.97","77.4","","303.98","303.98","5854.79","1 through 10","169.49","1127.97","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","both","","","5563.92","3338.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","647.08","4729.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","both","","","5563.92","3338.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","647.08","4729.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","both","","","5563.92","3338.35","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3165.87","56.9","","812.12","238.65","1587.46","163","647.08","4729.33","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","both","","","5563.92","3338.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","647.08","11.63","","112.68","112.68","146.99","38","647.08","4729.33","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","both","","","5563.92","3338.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4306.47","77.4","","303.98","303.98","5854.79","1 through 10","647.08","4729.33","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5563.92","3338.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","647.08","11.63","","112.68","112.68","146.99","38","647.08","4306.47","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5563.92","3338.35","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3493.03","62.78","","780.86","208.94","10480.28","15","647.08","4306.47","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5563.92","3338.35","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2432.55","43.72","","179.76","179.76","179.76","1 through 10","647.08","4306.47","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5563.92","3338.35","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4046.08","72.72","","2355.45","298.99","3965.19","155","647.08","4306.47","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5563.92","3338.35","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4046.08","72.72","","3643.09","3643.09","3643.09","1 through 10","647.08","4306.47","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5563.92","3338.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2961.12","53.22","","554.28","554.28","554.28","16","647.08","4306.47","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5563.92","3338.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3499.71","62.9","","619.64","173.09","2370.64","150","647.08","4306.47","percent of total billed charges",""
"NAIL FEMORAL 10X320MM NAIL-EX TI CANNULATED RETROGRADE ANTEGRADE INSERTION","SUP-ITM-10020799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5563.92","3338.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4306.47","77.4","","303.98","303.98","5854.79","1 through 10","647.08","4306.47","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","both","","","8348.26","5008.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","970.9","7096.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","both","","","8348.26","5008.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","970.9","7096.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","both","","","8348.26","5008.96","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4750.16","56.9","","812.12","238.65","1587.46","163","970.9","7096.02","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","both","","","8348.26","5008.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","970.90","11.63","","112.68","112.68","146.99","38","970.9","7096.02","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","both","","","8348.26","5008.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6461.55","77.4","","303.98","303.98","5854.79","1 through 10","970.9","7096.02","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8348.26","5008.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","970.90","11.63","","112.68","112.68","146.99","38","970.9","6461.55","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8348.26","5008.96","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5241.04","62.78","","780.86","208.94","10480.28","15","970.9","6461.55","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8348.26","5008.96","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3649.86","43.72","","179.76","179.76","179.76","1 through 10","970.9","6461.55","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8348.26","5008.96","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6070.85","72.72","","2355.45","298.99","3965.19","155","970.9","6461.55","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8348.26","5008.96","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6070.85","72.72","","3643.09","3643.09","3643.09","1 through 10","970.9","6461.55","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8348.26","5008.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4442.94","53.22","","554.28","554.28","554.28","16","970.9","6461.55","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8348.26","5008.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5251.06","62.9","","619.64","173.09","2370.64","150","970.9","6461.55","percent of total billed charges",""
"NAIL FEMORAL 10X340MM 10DEG BEND RETROGRADE","SUP-ITM-10296068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8348.26","5008.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6461.55","77.4","","303.98","303.98","5854.79","1 through 10","970.9","6461.55","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","914.73","6685.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","914.73","6685.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4475.35","56.9","","812.12","238.65","1587.46","163","914.73","6685.5","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","914.73","11.63","","112.68","112.68","146.99","38","914.73","6685.5","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","7865.29","4719.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6087.73","77.4","","303.98","303.98","5854.79","1 through 10","914.73","6685.5","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","914.73","11.63","","112.68","112.68","146.99","38","914.73","6087.73","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4937.83","62.78","","780.86","208.94","10480.28","15","914.73","6087.73","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3438.70","43.72","","179.76","179.76","179.76","1 through 10","914.73","6087.73","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5719.64","72.72","","2355.45","298.99","3965.19","155","914.73","6087.73","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5719.64","72.72","","3643.09","3643.09","3643.09","1 through 10","914.73","6087.73","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4185.91","53.22","","554.28","554.28","554.28","16","914.73","6087.73","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4947.27","62.9","","619.64","173.09","2370.64","150","914.73","6087.73","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7865.29","4719.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6087.73","77.4","","303.98","303.98","5854.79","1 through 10","914.73","6087.73","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296039","CDM","C1713","HCPCS","0278","RC","","","","both","","","7520.31","4512.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","874.61","6392.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL FEMORAL 11X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296039","CDM","C1713","HCPCS","0278","RC","","","","both","","","7520.31","4512.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","874.61","6392.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL FEMORAL 11X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296039","CDM","C1713","HCPCS","0278","RC","","","","both","","","7520.31","4512.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4279.06","56.9","","812.12","238.65","1587.46","163","874.61","6392.26","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296039","CDM","C1713","HCPCS","0278","RC","","","","both","","","7520.31","4512.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","874.61","11.63","","112.68","112.68","146.99","38","874.61","6392.26","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296039","CDM","C1713","HCPCS","0278","RC","","","","both","","","7520.31","4512.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5820.72","77.4","","303.98","303.98","5854.79","1 through 10","874.61","6392.26","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7520.31","4512.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","874.61","11.63","","112.68","112.68","146.99","38","874.61","5820.72","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7520.31","4512.19","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4721.25","62.78","","780.86","208.94","10480.28","15","874.61","5820.72","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7520.31","4512.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3287.88","43.72","","179.76","179.76","179.76","1 through 10","874.61","5820.72","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7520.31","4512.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5468.77","72.72","","2355.45","298.99","3965.19","155","874.61","5820.72","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7520.31","4512.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5468.77","72.72","","3643.09","3643.09","3643.09","1 through 10","874.61","5820.72","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7520.31","4512.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4002.31","53.22","","554.28","554.28","554.28","16","874.61","5820.72","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7520.31","4512.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4730.27","62.9","","619.64","173.09","2370.64","150","874.61","5820.72","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 5DEG BEND RETROGRADE","SUP-ITM-10296039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7520.31","4512.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5820.72","77.4","","303.98","303.98","5854.79","1 through 10","874.61","5820.72","percent of total billed charges",""
"NAIL FEMORAL 12X320MM RETROGRADE POLYETHYLENE INLAY 10DEG BEND TITANIUM","SUP-ITM-10288222","CDM","C1713","HCPCS","0278","RC","","","","both","","","8348.26","5008.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","970.9","7096.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL FEMORAL 12X320MM RETROGRADE POLYETHYLENE INLAY 10DEG BEND TITANIUM","SUP-ITM-10288222","CDM","C1713","HCPCS","0278","RC","","","","both","","","8348.26","5008.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","970.9","7096.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL FEMORAL 12X320MM RETROGRADE POLYETHYLENE INLAY 10DEG BEND TITANIUM","SUP-ITM-10288222","CDM","C1713","HCPCS","0278","RC","","","","both","","","8348.26","5008.96","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4750.16","56.9","","812.12","238.65","1587.46","163","970.9","7096.02","percent of total billed charges",""
"NAIL FEMORAL 12X320MM RETROGRADE POLYETHYLENE INLAY 10DEG BEND TITANIUM","SUP-ITM-10288222","CDM","C1713","HCPCS","0278","RC","","","","both","","","8348.26","5008.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","970.90","11.63","","112.68","112.68","146.99","38","970.9","7096.02","percent of total billed charges",""
"NAIL FEMORAL 12X320MM RETROGRADE POLYETHYLENE INLAY 10DEG BEND TITANIUM","SUP-ITM-10288222","CDM","C1713","HCPCS","0278","RC","","","","both","","","8348.26","5008.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6461.55","77.4","","303.98","303.98","5854.79","1 through 10","970.9","7096.02","percent of total billed charges",""
"NAIL FEMORAL 12X320MM RETROGRADE POLYETHYLENE INLAY 10DEG BEND TITANIUM","SUP-ITM-10288222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8348.26","5008.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","970.90","11.63","","112.68","112.68","146.99","38","970.9","6461.55","percent of total billed charges",""
"NAIL FEMORAL 12X320MM RETROGRADE POLYETHYLENE INLAY 10DEG BEND TITANIUM","SUP-ITM-10288222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8348.26","5008.96","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5241.04","62.78","","780.86","208.94","10480.28","15","970.9","6461.55","percent of total billed charges",""
"NAIL FEMORAL 12X320MM RETROGRADE POLYETHYLENE INLAY 10DEG BEND TITANIUM","SUP-ITM-10288222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8348.26","5008.96","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3649.86","43.72","","179.76","179.76","179.76","1 through 10","970.9","6461.55","percent of total billed charges",""
"NAIL FEMORAL 12X320MM RETROGRADE POLYETHYLENE INLAY 10DEG BEND TITANIUM","SUP-ITM-10288222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8348.26","5008.96","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6070.85","72.72","","2355.45","298.99","3965.19","155","970.9","6461.55","percent of total billed charges",""
"NAIL FEMORAL 12X320MM RETROGRADE POLYETHYLENE INLAY 10DEG BEND TITANIUM","SUP-ITM-10288222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8348.26","5008.96","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6070.85","72.72","","3643.09","3643.09","3643.09","1 through 10","970.9","6461.55","percent of total billed charges",""
"NAIL FEMORAL 12X320MM RETROGRADE POLYETHYLENE INLAY 10DEG BEND TITANIUM","SUP-ITM-10288222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8348.26","5008.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4442.94","53.22","","554.28","554.28","554.28","16","970.9","6461.55","percent of total billed charges",""
"NAIL FEMORAL 12X320MM RETROGRADE POLYETHYLENE INLAY 10DEG BEND TITANIUM","SUP-ITM-10288222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8348.26","5008.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5251.06","62.9","","619.64","173.09","2370.64","150","970.9","6461.55","percent of total billed charges",""
"NAIL FEMORAL 12X320MM RETROGRADE POLYETHYLENE INLAY 10DEG BEND TITANIUM","SUP-ITM-10288222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8348.26","5008.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6461.55","77.4","","303.98","303.98","5854.79","1 through 10","970.9","6461.55","percent of total billed charges",""
"NAIL FEMUR 11X380MM T2 LOCKING","SUP-ITM-10141231","CDM","C1713","HCPCS","0278","RC","","","","both","","","10908.20","6544.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1268.62","9271.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL FEMUR 11X380MM T2 LOCKING","SUP-ITM-10141231","CDM","C1713","HCPCS","0278","RC","","","","both","","","10908.20","6544.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1268.62","9271.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL FEMUR 11X380MM T2 LOCKING","SUP-ITM-10141231","CDM","C1713","HCPCS","0278","RC","","","","both","","","10908.20","6544.92","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6206.77","56.9","","812.12","238.65","1587.46","163","1268.62","9271.97","percent of total billed charges",""
"NAIL FEMUR 11X380MM T2 LOCKING","SUP-ITM-10141231","CDM","C1713","HCPCS","0278","RC","","","","both","","","10908.20","6544.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1268.62","11.63","","112.68","112.68","146.99","38","1268.62","9271.97","percent of total billed charges",""
"NAIL FEMUR 11X380MM T2 LOCKING","SUP-ITM-10141231","CDM","C1713","HCPCS","0278","RC","","","","both","","","10908.20","6544.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8442.95","77.4","","303.98","303.98","5854.79","1 through 10","1268.62","9271.97","percent of total billed charges",""
"NAIL FEMUR 11X380MM T2 LOCKING","SUP-ITM-10141231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10908.20","6544.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1268.62","11.63","","112.68","112.68","146.99","38","1268.62","8442.95","percent of total billed charges",""
"NAIL FEMUR 11X380MM T2 LOCKING","SUP-ITM-10141231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10908.20","6544.92","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6848.17","62.78","","780.86","208.94","10480.28","15","1268.62","8442.95","percent of total billed charges",""
"NAIL FEMUR 11X380MM T2 LOCKING","SUP-ITM-10141231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10908.20","6544.92","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4769.07","43.72","","179.76","179.76","179.76","1 through 10","1268.62","8442.95","percent of total billed charges",""
"NAIL FEMUR 11X380MM T2 LOCKING","SUP-ITM-10141231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10908.20","6544.92","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7932.44","72.72","","2355.45","298.99","3965.19","155","1268.62","8442.95","percent of total billed charges",""
"NAIL FEMUR 11X380MM T2 LOCKING","SUP-ITM-10141231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10908.20","6544.92","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7932.44","72.72","","3643.09","3643.09","3643.09","1 through 10","1268.62","8442.95","percent of total billed charges",""
"NAIL FEMUR 11X380MM T2 LOCKING","SUP-ITM-10141231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10908.20","6544.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","5805.34","53.22","","554.28","554.28","554.28","16","1268.62","8442.95","percent of total billed charges",""
"NAIL FEMUR 11X380MM T2 LOCKING","SUP-ITM-10141231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10908.20","6544.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6861.26","62.9","","619.64","173.09","2370.64","150","1268.62","8442.95","percent of total billed charges",""
"NAIL FEMUR 11X380MM T2 LOCKING","SUP-ITM-10141231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10908.20","6544.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8442.95","77.4","","303.98","303.98","5854.79","1 through 10","1268.62","8442.95","percent of total billed charges",""
"NAIL HUMERAL 4.3X26MM SCREW AEQUALIS TITANIUM DISTAL NONSTERILE","SUP-ITM-10268620","CDM","C1713","HCPCS","0278","RC","","","","both","","","2142.10","1285.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","249.13","1820.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL HUMERAL 4.3X26MM SCREW AEQUALIS TITANIUM DISTAL NONSTERILE","SUP-ITM-10268620","CDM","C1713","HCPCS","0278","RC","","","","both","","","2142.10","1285.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","249.13","1820.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL HUMERAL 4.3X26MM SCREW AEQUALIS TITANIUM DISTAL NONSTERILE","SUP-ITM-10268620","CDM","C1713","HCPCS","0278","RC","","","","both","","","2142.10","1285.26","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1218.85","56.9","","812.12","238.65","1587.46","163","249.13","1820.79","percent of total billed charges",""
"NAIL HUMERAL 4.3X26MM SCREW AEQUALIS TITANIUM DISTAL NONSTERILE","SUP-ITM-10268620","CDM","C1713","HCPCS","0278","RC","","","","both","","","2142.10","1285.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","249.13","11.63","","112.68","112.68","146.99","38","249.13","1820.79","percent of total billed charges",""
"NAIL HUMERAL 4.3X26MM SCREW AEQUALIS TITANIUM DISTAL NONSTERILE","SUP-ITM-10268620","CDM","C1713","HCPCS","0278","RC","","","","both","","","2142.10","1285.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1657.99","77.4","","303.98","303.98","5854.79","1 through 10","249.13","1820.79","percent of total billed charges",""
"NAIL HUMERAL 4.3X26MM SCREW AEQUALIS TITANIUM DISTAL NONSTERILE","SUP-ITM-10268620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2142.10","1285.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","249.13","11.63","","112.68","112.68","146.99","38","249.13","1657.99","percent of total billed charges",""
"NAIL HUMERAL 4.3X26MM SCREW AEQUALIS TITANIUM DISTAL NONSTERILE","SUP-ITM-10268620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2142.10","1285.26","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1344.81","62.78","","780.86","208.94","10480.28","15","249.13","1657.99","percent of total billed charges",""
"NAIL HUMERAL 4.3X26MM SCREW AEQUALIS TITANIUM DISTAL NONSTERILE","SUP-ITM-10268620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2142.10","1285.26","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","936.53","43.72","","179.76","179.76","179.76","1 through 10","249.13","1657.99","percent of total billed charges",""
"NAIL HUMERAL 4.3X26MM SCREW AEQUALIS TITANIUM DISTAL NONSTERILE","SUP-ITM-10268620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2142.10","1285.26","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1557.74","72.72","","2355.45","298.99","3965.19","155","249.13","1657.99","percent of total billed charges",""
"NAIL HUMERAL 4.3X26MM SCREW AEQUALIS TITANIUM DISTAL NONSTERILE","SUP-ITM-10268620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2142.10","1285.26","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1557.74","72.72","","3643.09","3643.09","3643.09","1 through 10","249.13","1657.99","percent of total billed charges",""
"NAIL HUMERAL 4.3X26MM SCREW AEQUALIS TITANIUM DISTAL NONSTERILE","SUP-ITM-10268620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2142.10","1285.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1140.03","53.22","","554.28","554.28","554.28","16","249.13","1657.99","percent of total billed charges",""
"NAIL HUMERAL 4.3X26MM SCREW AEQUALIS TITANIUM DISTAL NONSTERILE","SUP-ITM-10268620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2142.10","1285.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1347.38","62.9","","619.64","173.09","2370.64","150","249.13","1657.99","percent of total billed charges",""
"NAIL HUMERAL 4.3X26MM SCREW AEQUALIS TITANIUM DISTAL NONSTERILE","SUP-ITM-10268620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2142.10","1285.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1657.99","77.4","","303.98","303.98","5854.79","1 through 10","249.13","1657.99","percent of total billed charges",""
"NAIL HUMERAL 5X32MM SCREW AEQUALIS CANNULATED PROXIMAL NONSTERILE","SUP-ITM-10268621","CDM","C1713","HCPCS","0278","RC","","","","both","","","2784.73","1670.84","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","323.86","2367.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL HUMERAL 5X32MM SCREW AEQUALIS CANNULATED PROXIMAL NONSTERILE","SUP-ITM-10268621","CDM","C1713","HCPCS","0278","RC","","","","both","","","2784.73","1670.84","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","323.86","2367.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL HUMERAL 5X32MM SCREW AEQUALIS CANNULATED PROXIMAL NONSTERILE","SUP-ITM-10268621","CDM","C1713","HCPCS","0278","RC","","","","both","","","2784.73","1670.84","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1584.51","56.9","","812.12","238.65","1587.46","163","323.86","2367.02","percent of total billed charges",""
"NAIL HUMERAL 5X32MM SCREW AEQUALIS CANNULATED PROXIMAL NONSTERILE","SUP-ITM-10268621","CDM","C1713","HCPCS","0278","RC","","","","both","","","2784.73","1670.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","323.86","11.63","","112.68","112.68","146.99","38","323.86","2367.02","percent of total billed charges",""
"NAIL HUMERAL 5X32MM SCREW AEQUALIS CANNULATED PROXIMAL NONSTERILE","SUP-ITM-10268621","CDM","C1713","HCPCS","0278","RC","","","","both","","","2784.73","1670.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2155.38","77.4","","303.98","303.98","5854.79","1 through 10","323.86","2367.02","percent of total billed charges",""
"NAIL HUMERAL 5X32MM SCREW AEQUALIS CANNULATED PROXIMAL NONSTERILE","SUP-ITM-10268621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2784.73","1670.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","323.86","11.63","","112.68","112.68","146.99","38","323.86","2155.38","percent of total billed charges",""
"NAIL HUMERAL 5X32MM SCREW AEQUALIS CANNULATED PROXIMAL NONSTERILE","SUP-ITM-10268621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2784.73","1670.84","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1748.25","62.78","","780.86","208.94","10480.28","15","323.86","2155.38","percent of total billed charges",""
"NAIL HUMERAL 5X32MM SCREW AEQUALIS CANNULATED PROXIMAL NONSTERILE","SUP-ITM-10268621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2784.73","1670.84","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1217.48","43.72","","179.76","179.76","179.76","1 through 10","323.86","2155.38","percent of total billed charges",""
"NAIL HUMERAL 5X32MM SCREW AEQUALIS CANNULATED PROXIMAL NONSTERILE","SUP-ITM-10268621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2784.73","1670.84","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2025.06","72.72","","2355.45","298.99","3965.19","155","323.86","2155.38","percent of total billed charges",""
"NAIL HUMERAL 5X32MM SCREW AEQUALIS CANNULATED PROXIMAL NONSTERILE","SUP-ITM-10268621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2784.73","1670.84","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2025.06","72.72","","3643.09","3643.09","3643.09","1 through 10","323.86","2155.38","percent of total billed charges",""
"NAIL HUMERAL 5X32MM SCREW AEQUALIS CANNULATED PROXIMAL NONSTERILE","SUP-ITM-10268621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2784.73","1670.84","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1482.03","53.22","","554.28","554.28","554.28","16","323.86","2155.38","percent of total billed charges",""
"NAIL HUMERAL 5X32MM SCREW AEQUALIS CANNULATED PROXIMAL NONSTERILE","SUP-ITM-10268621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2784.73","1670.84","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1751.60","62.9","","619.64","173.09","2370.64","150","323.86","2155.38","percent of total billed charges",""
"NAIL HUMERAL 5X32MM SCREW AEQUALIS CANNULATED PROXIMAL NONSTERILE","SUP-ITM-10268621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2784.73","1670.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2155.38","77.4","","303.98","303.98","5854.79","1 through 10","323.86","2155.38","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","5943.38","3566.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","691.22","5051.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","5943.38","3566.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","691.22","5051.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","5943.38","3566.03","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3381.78","56.9","","812.12","238.65","1587.46","163","691.22","5051.87","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","5943.38","3566.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","691.22","11.63","","112.68","112.68","146.99","38","691.22","5051.87","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","5943.38","3566.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4600.18","77.4","","303.98","303.98","5854.79","1 through 10","691.22","5051.87","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5943.38","3566.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","691.22","11.63","","112.68","112.68","146.99","38","691.22","4600.18","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5943.38","3566.03","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3731.25","62.78","","780.86","208.94","10480.28","15","691.22","4600.18","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5943.38","3566.03","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2598.45","43.72","","179.76","179.76","179.76","1 through 10","691.22","4600.18","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5943.38","3566.03","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4322.03","72.72","","2355.45","298.99","3965.19","155","691.22","4600.18","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5943.38","3566.03","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4322.03","72.72","","3643.09","3643.09","3643.09","1 through 10","691.22","4600.18","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5943.38","3566.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3163.07","53.22","","554.28","554.28","554.28","16","691.22","4600.18","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5943.38","3566.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3738.39","62.9","","619.64","173.09","2370.64","150","691.22","4600.18","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5943.38","3566.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4600.18","77.4","","303.98","303.98","5854.79","1 through 10","691.22","4600.18","percent of total billed charges",""
"NAIL HUMERUS 8.0X150MM PROXIMALIMAL CANNULATED LEFT","SUP-ITM-10033804","CDM","C1713","HCPCS","0278","RC","","","","both","","","12789.67","7673.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1487.44","10871.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL HUMERUS 8.0X150MM PROXIMALIMAL CANNULATED LEFT","SUP-ITM-10033804","CDM","C1713","HCPCS","0278","RC","","","","both","","","12789.67","7673.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1487.44","10871.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL HUMERUS 8.0X150MM PROXIMALIMAL CANNULATED LEFT","SUP-ITM-10033804","CDM","C1713","HCPCS","0278","RC","","","","both","","","12789.67","7673.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7277.32","56.9","","812.12","238.65","1587.46","163","1487.44","10871.22","percent of total billed charges",""
"NAIL HUMERUS 8.0X150MM PROXIMALIMAL CANNULATED LEFT","SUP-ITM-10033804","CDM","C1713","HCPCS","0278","RC","","","","both","","","12789.67","7673.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1487.44","11.63","","112.68","112.68","146.99","38","1487.44","10871.22","percent of total billed charges",""
"NAIL HUMERUS 8.0X150MM PROXIMALIMAL CANNULATED LEFT","SUP-ITM-10033804","CDM","C1713","HCPCS","0278","RC","","","","both","","","12789.67","7673.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9899.20","77.4","","303.98","303.98","5854.79","1 through 10","1487.44","10871.22","percent of total billed charges",""
"NAIL HUMERUS 8.0X150MM PROXIMALIMAL CANNULATED LEFT","SUP-ITM-10033804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12789.67","7673.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1487.44","11.63","","112.68","112.68","146.99","38","1487.44","9899.2","percent of total billed charges",""
"NAIL HUMERUS 8.0X150MM PROXIMALIMAL CANNULATED LEFT","SUP-ITM-10033804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12789.67","7673.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","8029.35","62.78","","780.86","208.94","10480.28","15","1487.44","9899.2","percent of total billed charges",""
"NAIL HUMERUS 8.0X150MM PROXIMALIMAL CANNULATED LEFT","SUP-ITM-10033804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12789.67","7673.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","5591.64","43.72","","179.76","179.76","179.76","1 through 10","1487.44","9899.2","percent of total billed charges",""
"NAIL HUMERUS 8.0X150MM PROXIMALIMAL CANNULATED LEFT","SUP-ITM-10033804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12789.67","7673.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","9300.65","72.72","","2355.45","298.99","3965.19","155","1487.44","9899.2","percent of total billed charges",""
"NAIL HUMERUS 8.0X150MM PROXIMALIMAL CANNULATED LEFT","SUP-ITM-10033804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12789.67","7673.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","9300.65","72.72","","3643.09","3643.09","3643.09","1 through 10","1487.44","9899.2","percent of total billed charges",""
"NAIL HUMERUS 8.0X150MM PROXIMALIMAL CANNULATED LEFT","SUP-ITM-10033804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12789.67","7673.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","6806.66","53.22","","554.28","554.28","554.28","16","1487.44","9899.2","percent of total billed charges",""
"NAIL HUMERUS 8.0X150MM PROXIMALIMAL CANNULATED LEFT","SUP-ITM-10033804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12789.67","7673.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8044.70","62.9","","619.64","173.09","2370.64","150","1487.44","9899.2","percent of total billed charges",""
"NAIL HUMERUS 8.0X150MM PROXIMALIMAL CANNULATED LEFT","SUP-ITM-10033804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12789.67","7673.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9899.20","77.4","","303.98","303.98","5854.79","1 through 10","1487.44","9899.2","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","both","","","6294.04","3776.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","732","5349.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","both","","","6294.04","3776.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","732","5349.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","both","","","6294.04","3776.42","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3581.31","56.9","","812.12","238.65","1587.46","163","732","5349.93","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","both","","","6294.04","3776.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","732.00","11.63","","112.68","112.68","146.99","38","732","5349.93","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","both","","","6294.04","3776.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4871.59","77.4","","303.98","303.98","5854.79","1 through 10","732","5349.93","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","732.00","11.63","","112.68","112.68","146.99","38","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3951.40","62.78","","780.86","208.94","10480.28","15","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2751.75","43.72","","179.76","179.76","179.76","1 through 10","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4577.03","72.72","","2355.45","298.99","3965.19","155","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4577.03","72.72","","3643.09","3643.09","3643.09","1 through 10","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3349.69","53.22","","554.28","554.28","554.28","16","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3958.95","62.9","","619.64","173.09","2370.64","150","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 10X330MM ADVANCED","SUP-ITM-10296414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4871.59","77.4","","303.98","303.98","5854.79","1 through 10","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","629.23","4598.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","629.23","4598.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3078.53","56.9","","812.12","238.65","1587.46","163","629.23","4598.86","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","629.23","11.63","","112.68","112.68","146.99","38","629.23","4598.86","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4187.67","77.4","","303.98","303.98","5854.79","1 through 10","629.23","4598.86","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","629.23","11.63","","112.68","112.68","146.99","38","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3396.66","62.78","","780.86","208.94","10480.28","15","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2365.44","43.72","","179.76","179.76","179.76","1 through 10","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3934.46","72.72","","2355.45","298.99","3965.19","155","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3934.46","72.72","","3643.09","3643.09","3643.09","1 through 10","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2879.43","53.22","","554.28","554.28","554.28","16","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3403.15","62.9","","619.64","173.09","2370.64","150","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 11X315MM EX CANNULATED TITANIUM EXPERT FLUTED CROSS SECTION","SUP-ITM-10018425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4187.67","77.4","","303.98","303.98","5854.79","1 through 10","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","629.23","4598.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","629.23","4598.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3078.53","56.9","","812.12","238.65","1587.46","163","629.23","4598.86","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","629.23","11.63","","112.68","112.68","146.99","38","629.23","4598.86","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4187.67","77.4","","303.98","303.98","5854.79","1 through 10","629.23","4598.86","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","629.23","11.63","","112.68","112.68","146.99","38","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3396.66","62.78","","780.86","208.94","10480.28","15","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2365.44","43.72","","179.76","179.76","179.76","1 through 10","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3934.46","72.72","","2355.45","298.99","3965.19","155","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3934.46","72.72","","3643.09","3643.09","3643.09","1 through 10","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2879.43","53.22","","554.28","554.28","554.28","16","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3403.15","62.9","","619.64","173.09","2370.64","150","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 8X270MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4187.67","77.4","","303.98","303.98","5854.79","1 through 10","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 8X285MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018745","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","629.23","4598.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL TIBIAL 8X285MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018745","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","629.23","4598.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL TIBIAL 8X285MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018745","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3078.53","56.9","","812.12","238.65","1587.46","163","629.23","4598.86","percent of total billed charges",""
"NAIL TIBIAL 8X285MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018745","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","629.23","11.63","","112.68","112.68","146.99","38","629.23","4598.86","percent of total billed charges",""
"NAIL TIBIAL 8X285MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018745","CDM","C1713","HCPCS","0278","RC","","","","both","","","5410.42","3246.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4187.67","77.4","","303.98","303.98","5854.79","1 through 10","629.23","4598.86","percent of total billed charges",""
"NAIL TIBIAL 8X285MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018745","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","629.23","11.63","","112.68","112.68","146.99","38","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 8X285MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018745","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3396.66","62.78","","780.86","208.94","10480.28","15","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 8X285MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018745","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2365.44","43.72","","179.76","179.76","179.76","1 through 10","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 8X285MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018745","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3934.46","72.72","","2355.45","298.99","3965.19","155","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 8X285MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018745","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3934.46","72.72","","3643.09","3643.09","3643.09","1 through 10","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 8X285MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018745","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2879.43","53.22","","554.28","554.28","554.28","16","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 8X285MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018745","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3403.15","62.9","","619.64","173.09","2370.64","150","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 8X285MM EX CANNULATED TITANIUM EXPERT ROUND CROSS SECTION","SUP-ITM-10018745","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5410.42","3246.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4187.67","77.4","","303.98","303.98","5854.79","1 through 10","629.23","4187.67","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","both","","","6294.04","3776.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","732","5349.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","both","","","6294.04","3776.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","732","5349.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","both","","","6294.04","3776.42","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3581.31","56.9","","812.12","238.65","1587.46","163","732","5349.93","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","both","","","6294.04","3776.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","732.00","11.63","","112.68","112.68","146.99","38","732","5349.93","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","both","","","6294.04","3776.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4871.59","77.4","","303.98","303.98","5854.79","1 through 10","732","5349.93","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","732.00","11.63","","112.68","112.68","146.99","38","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3951.40","62.78","","780.86","208.94","10480.28","15","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2751.75","43.72","","179.76","179.76","179.76","1 through 10","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4577.03","72.72","","2355.45","298.99","3965.19","155","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4577.03","72.72","","3643.09","3643.09","3643.09","1 through 10","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3349.69","53.22","","554.28","554.28","554.28","16","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3958.95","62.9","","619.64","173.09","2370.64","150","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 9X300MM ADVANCED","SUP-ITM-10296431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4871.59","77.4","","303.98","303.98","5854.79","1 through 10","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","both","","","6294.04","3776.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","732","5349.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","both","","","6294.04","3776.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","732","5349.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","both","","","6294.04","3776.42","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3581.31","56.9","","812.12","238.65","1587.46","163","732","5349.93","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","both","","","6294.04","3776.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","732.00","11.63","","112.68","112.68","146.99","38","732","5349.93","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","both","","","6294.04","3776.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4871.59","77.4","","303.98","303.98","5854.79","1 through 10","732","5349.93","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","732.00","11.63","","112.68","112.68","146.99","38","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3951.40","62.78","","780.86","208.94","10480.28","15","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2751.75","43.72","","179.76","179.76","179.76","1 through 10","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4577.03","72.72","","2355.45","298.99","3965.19","155","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4577.03","72.72","","3643.09","3643.09","3643.09","1 through 10","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3349.69","53.22","","554.28","554.28","554.28","16","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3958.95","62.9","","619.64","173.09","2370.64","150","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 9X330MM ADVANCED","SUP-ITM-10296429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4871.59","77.4","","303.98","303.98","5854.79","1 through 10","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 9X345MM ADVANCED","SUP-ITM-10296428","CDM","C1713","HCPCS","0278","RC","","","","both","","","6294.04","3776.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","732","5349.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL TIBIAL 9X345MM ADVANCED","SUP-ITM-10296428","CDM","C1713","HCPCS","0278","RC","","","","both","","","6294.04","3776.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","732","5349.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NAIL TIBIAL 9X345MM ADVANCED","SUP-ITM-10296428","CDM","C1713","HCPCS","0278","RC","","","","both","","","6294.04","3776.42","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3581.31","56.9","","812.12","238.65","1587.46","163","732","5349.93","percent of total billed charges",""
"NAIL TIBIAL 9X345MM ADVANCED","SUP-ITM-10296428","CDM","C1713","HCPCS","0278","RC","","","","both","","","6294.04","3776.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","732.00","11.63","","112.68","112.68","146.99","38","732","5349.93","percent of total billed charges",""
"NAIL TIBIAL 9X345MM ADVANCED","SUP-ITM-10296428","CDM","C1713","HCPCS","0278","RC","","","","both","","","6294.04","3776.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4871.59","77.4","","303.98","303.98","5854.79","1 through 10","732","5349.93","percent of total billed charges",""
"NAIL TIBIAL 9X345MM ADVANCED","SUP-ITM-10296428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","732.00","11.63","","112.68","112.68","146.99","38","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 9X345MM ADVANCED","SUP-ITM-10296428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3951.40","62.78","","780.86","208.94","10480.28","15","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 9X345MM ADVANCED","SUP-ITM-10296428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2751.75","43.72","","179.76","179.76","179.76","1 through 10","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 9X345MM ADVANCED","SUP-ITM-10296428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4577.03","72.72","","2355.45","298.99","3965.19","155","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 9X345MM ADVANCED","SUP-ITM-10296428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4577.03","72.72","","3643.09","3643.09","3643.09","1 through 10","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 9X345MM ADVANCED","SUP-ITM-10296428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3349.69","53.22","","554.28","554.28","554.28","16","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 9X345MM ADVANCED","SUP-ITM-10296428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3958.95","62.9","","619.64","173.09","2370.64","150","732","4871.59","percent of total billed charges",""
"NAIL TIBIAL 9X345MM ADVANCED","SUP-ITM-10296428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6294.04","3776.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4871.59","77.4","","303.98","303.98","5854.79","1 through 10","732","4871.59","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0300","RC","","","","inpatient","","","481.00","288.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","369.70","76.86","","292.95","292.95","292.95","1 through 10","318.42","369.7","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","both","","","481.00","288.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","335.74","69.8","","324.57","311.31","324.57","36","25.52","408.85","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","both","","","481.00","288.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","408.85","85","","377.13","82.45","377.13","1 through 10","25.52","408.85","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","outpatient","","","481.00","288.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","301.97","62.78","","291.93","291.93","291.93","1 through 10","31.62","372.29","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","outpatient","","","481.00","288.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","210.29","43.72","","203.30","203.30","203.30","1 through 10","31.62","372.29","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","outpatient","","","481.00","288.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","349.78","72.72","","338.15","338.15","650.90","21","31.62","372.29","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","outpatient","","","481.00","288.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","349.78","72.72","","676.30","338.15","676.30","1 through 10","31.62","372.29","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","outpatient","","","481.00","288.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","302.55","62.9","","292.95","292.95","1093.84","63","31.62","372.29","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","outpatient","","","481.00","288.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","372.29","77.4","","360.38","360.37","360.38","18","31.62","372.29","percent of total billed charges",""
"Natural Killer (Nk) Cells, Total","PX-30000851","CDM","86357","CPT","0302","RC","","","","outpatient","","","357.00","214.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","259.61","72.72","","250.88","250.88","250.88","1 through 10","10.68","276.32","percent of total billed charges",""
"Needle Insertion W/O Injection 1 or 2 Muscles","PX-42000118","CDM","20560","CPT","0421","RC","","","","both","","","98.00","58.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","25.59","","APC Price ($25.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","25.19","25.19","95.00","12","25.07","163.55","other","OPPS APC"
"Needle Insertion W/O Injection 1 or 2 Muscles","PX-42000118","CDM","20560","CPT","0421","RC","","","","outpatient","","","98.00","58.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","11.40","11.63","","11.22","11.22","11.22","1 through 10","11.4","75.85","percent of total billed charges",""
"Needle Insertion W/O Injection 1 or 2 Muscles","PX-43000124","CDM","20560","CPT","0431","RC","","","","both","","","98.00","58.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","25.59","","APC Price ($25.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","25.19","25.19","95.00","12","25.07","163.55","other","OPPS APC"
"Needle Insertion W/O Injection 1 or 2 Muscles","PX-43000124","CDM","20560","CPT","0431","RC","","","","outpatient","","","98.00","58.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","11.40","11.63","","11.22","11.22","11.22","1 through 10","11.4","75.85","percent of total billed charges",""
"Needle Insertion W/O Injection 1 or 2 Muscles","PX-76002659","CDM","20560","CPT","0761","RC","","","","both","","","98.00","58.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","25.59","","APC Price ($25.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","25.19","25.19","95.00","12","25.07","163.55","other","OPPS APC"
"Needle Insertion W/O Injection 1 or 2 Muscles","PX-76002659","CDM","20560","CPT","0761","RC","","","","outpatient","","","98.00","58.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","11.40","11.63","","11.22","11.22","11.22","1 through 10","11.4","75.85","percent of total billed charges",""
"Needle Insertion W/O Injection 3 or More Muscles","PX-42000119","CDM","20561","CPT","0421","RC","","","","both","","","148.00","88.80","TRICARE [160005]","HB WDH MEDICARE","25.59","","APC Price ($25.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","143.00","143.00","143.00","1 through 10","25.07","163.55","other","OPPS APC"
"Needle Insertion W/O Injection 3 or More Muscles","PX-42000119","CDM","20561","CPT","0421","RC","","","","both","","","148.00","88.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","25.59","","APC Price ($25.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","143.00","25.59","143.00","12","25.07","163.55","other","OPPS APC"
"Needle Insertion W/O Injection 3 or More Muscles","PX-42000119","CDM","20561","CPT","0421","RC","","","","outpatient","","","148.00","88.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","17.21","11.63","","16.89","16.89","16.89","1 through 10","17.21","114.55","percent of total billed charges",""
"Needle Insertion W/O Injection 3 or More Muscles","PX-42000119","CDM","20561","CPT","0421","RC","","","","outpatient","","","148.00","88.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","17.21","11.63","","16.89","16.89","16.89","1 through 10","17.21","114.55","percent of total billed charges",""
"Needle Insertion W/O Injection 3 or More Muscles","PX-43000125","CDM","20561","CPT","0431","RC","","","","both","","","148.00","88.80","TRICARE [160005]","HB WDH MEDICARE","25.59","","APC Price ($25.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","143.00","143.00","143.00","1 through 10","25.07","163.55","other","OPPS APC"
"Needle Insertion W/O Injection 3 or More Muscles","PX-43000125","CDM","20561","CPT","0431","RC","","","","both","","","148.00","88.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","25.59","","APC Price ($25.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","143.00","25.59","143.00","12","25.07","163.55","other","OPPS APC"
"Needle Insertion W/O Injection 3 or More Muscles","PX-43000125","CDM","20561","CPT","0431","RC","","","","outpatient","","","148.00","88.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","17.21","11.63","","16.89","16.89","16.89","1 through 10","17.21","114.55","percent of total billed charges",""
"Needle Insertion W/O Injection 3 or More Muscles","PX-43000125","CDM","20561","CPT","0431","RC","","","","outpatient","","","148.00","88.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","17.21","11.63","","16.89","16.89","16.89","1 through 10","17.21","114.55","percent of total billed charges",""
"Needle Insertion W/O Injection 3 or More Muscles","PX-76002660","CDM","20561","CPT","0761","RC","","","","both","","","148.00","88.80","TRICARE [160005]","HB WDH MEDICARE","25.59","","APC Price ($25.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","143.00","143.00","143.00","1 through 10","25.07","163.55","other","OPPS APC"
"Needle Insertion W/O Injection 3 or More Muscles","PX-76002660","CDM","20561","CPT","0761","RC","","","","both","","","148.00","88.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","25.59","","APC Price ($25.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","143.00","25.59","143.00","12","25.07","163.55","other","OPPS APC"
"Needle Insertion W/O Injection 3 or More Muscles","PX-76002660","CDM","20561","CPT","0761","RC","","","","outpatient","","","148.00","88.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","17.21","11.63","","16.89","16.89","16.89","1 through 10","17.21","114.55","percent of total billed charges",""
"Needle Insertion W/O Injection 3 or More Muscles","PX-76002660","CDM","20561","CPT","0761","RC","","","","outpatient","","","148.00","88.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","17.21","11.63","","16.89","16.89","16.89","1 through 10","17.21","114.55","percent of total billed charges",""
"Neg Pressure Wound Therapy Dme </= 50 Sq Cm","PX-76001695","CDM","97605","CPT","0761","RC","","","","both","","","485.00","291.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","338.53","69.8","","326.66","326.66","326.66","1 through 10","203.44","1326.74","percent of total billed charges",""
"Neg Pressure Wound Therapy Dme </= 50 Sq Cm","PX-76001695","CDM","97605","CPT","0761","RC","","","","both","","","485.00","291.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1326.74","","Case rate ($1,326.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","490.55","490.51","490.70","1 through 10","203.44","1326.74","other","OPPS APC"
"Neg Pressure Wound Therapy Dme </= 50 Sq Cm","PX-76001695","CDM","97605","CPT","0761","RC","","","","both","","","485.00","291.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","571.29","","Case rate ($571.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","468.00","468.00","468.00","1 through 10","203.44","1326.74","other","OPPS APC"
"Neg Pressure Wound Therapy Dme </= 50 Sq Cm","PX-76001695","CDM","97605","CPT","0761","RC","","","","both","","","485.00","291.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","203.44","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","203.47","203.47","203.47","1 through 10","203.44","1326.74","other","OPPS APC"
"Neg Pressure Wound Therapy Dme </= 50 Sq Cm","PX-76001695","CDM","97605","CPT","0761","RC","","","","both","","","485.00","291.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1072.40","","Case rate ($1,072.40). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","468.00","468.00","468.00","19","203.44","1326.74","other","OPPS APC"
"Neg Pressure Wound Therapy Dme </= 50 Sq Cm","PX-76001695","CDM","97605","CPT","0761","RC","","","","both","","","485.00","291.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","275.97","56.9","","266.29","266.29","266.29","1 through 10","203.44","1326.74","percent of total billed charges",""
"Neg Pressure Wound Therapy Dme </= 50 Sq Cm","PX-76001695","CDM","97605","CPT","0761","RC","","","","both","","","485.00","291.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","213.82","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","209.57","209.57","209.57","1 through 10","203.44","1326.74","other","OPPS APC"
"Neg Pressure Wound Therapy Dme </= 50 Sq Cm","PX-76001695","CDM","97605","CPT","0761","RC","","","","both","","","485.00","291.00","MEDICARE [2001]","HB WDH MEDICARE","207.59","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.62","207.62","415.24","20","203.44","1326.74","other","OPPS APC"
"Neg Pressure Wound Therapy Dme </= 50 Sq Cm","PX-76001695","CDM","97605","CPT","0761","RC","","","","both","","","485.00","291.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","207.59","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","204.30","204.30","204.30","1 through 10","203.44","1326.74","other","OPPS APC"
"Neg Pressure Wound Therapy Dme </= 50 Sq Cm","PX-76001695","CDM","97605","CPT","0761","RC","","","","outpatient","","","485.00","291.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","56.41","11.63","","118.18","118.18","118.18","1 through 10","56.41","375.39","percent of total billed charges",""
"Neg Pressure Wound Therapy Dme </= 50 Sq Cm","PX-76001695","CDM","97605","CPT","0761","RC","","","","outpatient","","","485.00","291.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","352.69","72.72","","340.33","340.33","340.33","1 through 10","56.41","375.39","percent of total billed charges",""
"Neg Pressure Wound Therapy Dme </= 50 Sq Cm","PX-76001695","CDM","97605","CPT","0761","RC","","","","outpatient","","","485.00","291.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","305.07","62.9","","294.84","294.84","294.84","1 through 10","56.41","375.39","percent of total billed charges",""
"Neg Pressure Wound Therapy Dme > 50 Sq Cm","PX-76001696","CDM","97606","CPT","0761","RC","","","","both","","","553.00","331.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2667.66","","Case rate ($2,667.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","579.02","556.51","579.02","1 through 10","314.66","2667.66","other","OPPS APC"
"Neg Pressure Wound Therapy Dme > 50 Sq Cm","PX-76001696","CDM","97606","CPT","0761","RC","","","","both","","","553.00","331.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","429.94","","APC Price ($417.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","421.38","421.38","421.38","1 through 10","314.66","2667.66","other","OPPS APC"
"Neg Pressure Wound Therapy Dme > 50 Sq Cm","PX-76001696","CDM","97606","CPT","0761","RC","","","","both","","","553.00","331.80","MEDICARE [2001]","HB WDH MEDICARE","417.41","","APC Price ($417.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.46","417.46","417.46","1 through 10","314.66","2667.66","other","OPPS APC"
"Neg Pressure Wound Therapy Non-Dme </= 50 Sq Cm","PX-51000533","CDM","97607","CPT","0510","RC","","","","both","","","1087.00","652.20","MEDICARE [2001]","HB WDH MEDICARE","417.41","","APC Price ($417.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.46","417.46","417.46","23","409.06","2667.66","other","OPPS APC"
"Neg Pressure Wound Therapy Non-Dme </= 50 Sq Cm","PX-51000533","CDM","97607","CPT","0510","RC","","","","both","","","1087.00","652.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","417.41","","APC Price ($417.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","410.79","410.79","410.79","1 through 10","409.06","2667.66","other","OPPS APC"
"Neonate With Other Significant Problems","794","MS-DRG","","","","","","","","inpatient","","","4799.14","2879.48","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","56084.35","","Fee schedule rate ($56,084.35). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","6616.45","4407.05","17033.47","17","470.77","56084.35","case rate",""
"Neonate With Other Significant Problems","794","MS-DRG","","","","","","","","inpatient","","","4799.14","2879.48","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","22083.71","","Fee schedule rate ($22,083.71). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","2916.66","2916.66","2916.66","67","470.77","56084.35","case rate",""
"Neonate With Other Significant Problems","794","MS-DRG","","","","","","","","inpatient","","","4799.14","2879.48","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","11431.99","","Case rate ($11,665.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,801.20, add-ons for qualifying new technology services are included. If operating cost exceeds $14,719.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,624.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $10,400.51 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,356.34 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $819.93. The transfer capital threshold is the transfer adjustment factor * $819.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","1956.32","1952.39","7019.11","19","470.77","56084.35","other","Inpatient DRG"
"Neonate With Other Significant Problems","794","MS-DRG","","","","","","","","inpatient","","","4799.14","2879.48","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","44668.53","","Fee schedule rate ($44,668.53). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","4556.55","2916.66","5899.51","78","470.77","56084.35","case rate",""
"Neonate With Other Significant Problems","794","MS-DRG","","","","","","","","inpatient","","","4799.14","2879.48","CHAMPVA [160001]","HB WDH MEDICARE","11665.30","","Case rate ($11,665.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,801.20, add-ons for qualifying new technology services are included. If operating cost exceeds $14,719.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,624.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $10,400.51 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,356.34 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $819.93. The transfer capital threshold is the transfer adjustment factor * $819.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6726.06","6726.06","6726.06","1 through 10","470.77","56084.35","other","Inpatient DRG"
"Neonate With Other Significant Problems","794","MS-DRG","","","","","","","","inpatient","","","4799.14","2879.48","MARTIN'S POINT [160007]","HB WDH MEDICARE","11665.30","","Case rate ($11,665.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,801.20, add-ons for qualifying new technology services are included. If operating cost exceeds $14,719.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,624.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $10,400.51 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,356.34 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $819.93. The transfer capital threshold is the transfer adjustment factor * $819.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","2795.01","2795.01","2992.87","1 through 10","470.77","56084.35","other","Inpatient DRG"
"Neonate With Other Significant Problems","794","MS-DRG","","","","","","","","inpatient","","","4799.14","2879.48","TRICARE [160005]","HB WDH MEDICARE","11665.30","","Case rate ($11,665.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,801.20, add-ons for qualifying new technology services are included. If operating cost exceeds $14,719.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,624.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $10,400.51 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,356.34 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $819.93. The transfer capital threshold is the transfer adjustment factor * $819.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","2192.87","1819.35","2245.12","18","470.77","56084.35","other","Inpatient DRG"
"Neonate With Other Significant Problems","794","MS-DRG","","","","","","","","inpatient","","","4799.14","2879.48","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","11665.30","","Case rate ($11,665.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,801.20, add-ons for qualifying new technology services are included. If operating cost exceeds $14,719.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,624.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $10,400.51 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,356.34 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $819.93. The transfer capital threshold is the transfer adjustment factor * $819.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11583.54","11583.54","11583.54","1 through 10","470.77","56084.35","other","Inpatient DRG"
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","","","","inpatient","","","8015.00","4809.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","26966.10","","Fee schedule rate ($26,966.10). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","9216.48","9216.48","14619.01","1 through 10","1655.17","68483.78","case rate",""
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","","","","inpatient","","","8015.00","4809.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","54544.09","","Fee schedule rate ($54,544.09). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","29569.75","29569.75","29569.75","1 through 10","1655.17","68483.78","case rate",""
"Nephelometry Ea Analyte","PX-30000584","CDM","83883","CPT","0301","RC","","","","both","","","73.00","43.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","50.95","69.8","","49.56","12.94","49.56","1 through 10","8.84","70.73","percent of total billed charges",""
"Nephelometry Ea Analyte","PX-30000584","CDM","83883","CPT","0301","RC","","","","outpatient","","","73.00","43.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","53.09","72.72","","51.63","51.63","51.63","1 through 10","10.58","56.5","percent of total billed charges",""
"Nephelometry Ea Analyte","PX-30000584","CDM","83883","CPT","0301","RC","","","","outpatient","","","73.00","43.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","45.92","62.9","","44.73","44.73","44.73","12","10.58","56.5","percent of total billed charges",""
"Nervous System Neoplasms With McC","054","MS-DRG","","","","","","","","inpatient","","","41571.11","24942.67","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","11811.97","","Case rate ($12,053.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,159.08, add-ons for qualifying new technology services are included. If operating cost exceeds $15,077.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,653.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,759.90 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,714.20 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $848.26. The transfer capital threshold is the transfer adjustment factor * $848.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5992.99","5992.99","5992.99","1 through 10","3975","58022.35","other","Inpatient DRG"
"Nervous System Neoplasms With McC","054","MS-DRG","","","","","","","","inpatient","","","41571.11","24942.67","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","46212.06","","Fee schedule rate ($46,212.06). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","25701.71","25701.71","25701.71","1 through 10","3975","58022.35","case rate",""
"Nervous System Neoplasms With McC","054","MS-DRG","","","","","","","","inpatient","","","41571.11","24942.67","MARTIN'S POINT [160007]","HB WDH MEDICARE","12053.03","","Case rate ($12,053.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,159.08, add-ons for qualifying new technology services are included. If operating cost exceeds $15,077.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,653.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,759.90 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,714.20 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $848.26. The transfer capital threshold is the transfer adjustment factor * $848.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11521.20","11521.20","11521.20","1 through 10","3975","58022.35","other","Inpatient DRG"
"Nervous System Neoplasms With McC","054","MS-DRG","","","","","","","","inpatient","","","41571.11","24942.67","MEDICARE [2001]","HB WDH MEDICARE","12053.03","","Case rate ($12,053.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,159.08, add-ons for qualifying new technology services are included. If operating cost exceeds $15,077.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,653.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,759.90 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,714.20 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $848.26. The transfer capital threshold is the transfer adjustment factor * $848.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6100.56","0.05","11785.80","1 through 10","3975","58022.35","other","Inpatient DRG"
"Nervous System Neoplasms With McC","054","MS-DRG","","","","","","","","inpatient","","","41571.11","24942.67","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","12053.03","","Case rate ($12,053.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,159.08, add-ons for qualifying new technology services are included. If operating cost exceeds $15,077.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,653.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,759.90 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,714.20 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $848.26. The transfer capital threshold is the transfer adjustment factor * $848.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11550.09","11550.09","11574.09","1 through 10","3975","58022.35","other","Inpatient DRG"
"Nervous System Neoplasms Without McC","055","MS-DRG","","","","","","","","inpatient","","","40758.26","24454.96","MEDICARE [2001]","HB WDH MEDICARE","8196.31","","Case rate ($8,196.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,599.37, add-ons for qualifying new technology services are included. If operating cost exceeds $11,517.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,371.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,185.01 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,154.50 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $566.43. The transfer capital threshold is the transfer adjustment factor * $566.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8698.43","8698.43","8698.43","1 through 10","3975","38744.9","other","Inpatient DRG"
"Nervous System Neoplasms Without McC","055","MS-DRG","","","","","","","","inpatient","","","40758.26","24454.96","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8196.31","","Case rate ($8,196.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,599.37, add-ons for qualifying new technology services are included. If operating cost exceeds $11,517.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,371.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,185.01 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,154.50 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $566.43. The transfer capital threshold is the transfer adjustment factor * $566.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8525.02","8525.02","8525.02","1 through 10","3975","38744.9","other","Inpatient DRG"
"NET RETRIEVAL 3X5.5CM RESCUENET FOREIGN BODY BX/5EA","SUP-ITM-10210617","CDM","C1773","HCPCS","0272","RC","","","","both","","","604.97","362.98","AETNA [1001]","HB WDH AETNA COMMERCIAL","422.27","69.8","","421.75","101.11","421.75","1 through 10","70.36","514.22","percent of total billed charges",""
"NET RETRIEVAL 3X5.5CM RESCUENET FOREIGN BODY BX/5EA","SUP-ITM-10210617","CDM","C1773","HCPCS","0272","RC","","","","both","","","604.97","362.98","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1032.01","1032.01","1032.01","1 through 10","70.36","514.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NET RETRIEVAL 3X5.5CM RESCUENET FOREIGN BODY BX/5EA","SUP-ITM-10210617","CDM","C1773","HCPCS","0272","RC","","","","both","","","604.97","362.98","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","468.25","77.4","","468.85","468.85","468.85","1 through 10","70.36","514.22","percent of total billed charges",""
"NET RETRIEVAL 3X5.5CM RESCUENET FOREIGN BODY BX/5EA","SUP-ITM-10210617","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","604.97","362.98","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","380.53","62.9","","381.13","381.13","381.13","1 through 10","70.36","468.25","percent of total billed charges",""
"NET RETRIEVAL 3X5.5CM RESCUENET FOREIGN BODY BX/5EA","SUP-ITM-10210617","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","604.97","362.98","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","468.25","77.4","","468.85","468.85","468.85","1 through 10","70.36","468.25","percent of total billed charges",""
"Neurological Eye Disorders","123","MS-DRG","","","","","","","","inpatient","","","37670.82","22602.49","MEDICARE [2001]","HB WDH MEDICARE","6516.17","","Case rate ($6,516.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,048.61, add-ons for qualifying new technology services are included. If operating cost exceeds $9,966.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,248.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,627.65 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,603.75 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.66. The transfer capital threshold is the transfer adjustment factor * $443.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6521.58","6521.58","6521.58","1 through 10","3975","30346.88","other","Inpatient DRG"
"NEUROSTIMULATOR EXTERNAL 43X15X51MM VERIFY ENS POLYCARBONATE ABS BLEND PLASTIC RESIN","SUP-ITM-10152713","CDM","C1787","HCPCS","0270","RC","","","","both","","","2245.75","1347.45","AETNA [1001]","HB WDH AETNA COMMERCIAL","1567.53","69.8","","1412.58","1412.58","1412.58","1 through 10","261.18","1908.89","percent of total billed charges",""
"NEUROSTIMULATOR EXTERNAL 43X15X51MM VERIFY ENS POLYCARBONATE ABS BLEND PLASTIC RESIN","SUP-ITM-10152713","CDM","C1787","HCPCS","0270","RC","","","","both","","","2245.75","1347.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","18158.40","2245.75","18158.40","1 through 10","261.18","1908.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NEUROSTIMULATOR EXTERNAL 43X15X51MM VERIFY ENS POLYCARBONATE ABS BLEND PLASTIC RESIN","SUP-ITM-10152713","CDM","C1787","HCPCS","0270","RC","","","","both","","","2245.75","1347.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1277.83","56.9","","15498.18","15498.18","15498.18","1 through 10","261.18","1908.89","percent of total billed charges",""
"NEUROSTIMULATOR EXTERNAL 43X15X51MM VERIFY ENS POLYCARBONATE ABS BLEND PLASTIC RESIN","SUP-ITM-10152713","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","2245.75","1347.45","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","1633.11","72.72","","4236.03","4236.03","4236.03","1 through 10","261.18","1738.21","percent of total billed charges",""
"NEUROSTIMULATOR NON-RECHARGEABLE","SUP-ITM-10295658","CDM","C1767","HCPCS","0278","RC","","","","outpatient","","","27456.24","16473.74","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","17269.97","62.9","","79618.14","79618.14","79618.14","1 through 10","3193.16","21251.13","percent of total billed charges",""
"NEUROSTIMULATOR RECHARGEABLE R20","SUP-ITM-10311629","CDM","C1820","HCPCS","0278","RC","","","","both","","","25332.24","15199.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","52982.00","26491.00","52982.00","1 through 10","2946.14","21532.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NEUROSTIMULATOR RECHARGEABLE R20","SUP-ITM-10311629","CDM","C1820","HCPCS","0278","RC","","","","both","","","25332.24","15199.34","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","14414.04","56.9","","45220.14","36256.68","45220.14","1 through 10","2946.14","21532.4","percent of total billed charges",""
"NEUROSTIMULATOR RECHARGEABLE R20","SUP-ITM-10311629","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","25332.24","15199.34","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","18421.60","72.72","","18421.60","18421.60","18421.60","1 through 10","2946.14","19607.15","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","both","","","735.00","441.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","513.03","69.8","","496.28","302.12","496.28","1 through 10","83.39","662.22","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","both","","","735.00","441.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","624.75","85","","604.35","604.35","604.35","1 through 10","83.39","662.22","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","outpatient","","","735.00","441.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","461.43","62.78","","446.37","446.37","446.37","1 through 10","67.08","568.89","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","outpatient","","","735.00","441.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","321.34","43.72","","621.70","310.85","621.70","1 through 10","67.08","568.89","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","outpatient","","","735.00","441.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","534.49","72.72","","517.04","517.04","1551.12","26","67.08","568.89","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","outpatient","","","735.00","441.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","534.49","72.72","","517.04","517.04","517.04","1 through 10","67.08","568.89","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","outpatient","","","735.00","441.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","462.32","62.9","","447.93","447.93","447.93","28","67.08","568.89","percent of total billed charges",""
"Nfct Agent Dna/Rna Gastrointestinal Pathogen","PX-30002921","CDM","87505","CPT","0306","RC","","","","outpatient","","","735.00","441.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","568.89","77.4","","551.03","551.03","551.03","1 through 10","67.08","568.89","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","1496.00","897.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","1044.21","69.8","","1010.01","910.16","1010.01","1 through 10","92.71","1271.6","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","1496.00","897.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","851.22","56.9","","823.34","823.34","823.34","18","92.71","1271.6","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","1496.00","897.60","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","851.22","56.9","","823.34","823.34","823.34","1 through 10","92.71","1271.6","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","1496.00","897.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","1271.60","85","","1010.01","1010.01","1010.01","1 through 10","92.71","1271.6","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","1496.00","897.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","215.72","14.42","","127.07","127.07","127.07","1 through 10","173.98","1157.9","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","1496.00","897.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","173.98","11.63","","125.84","125.84","125.84","1 through 10","173.98","1157.9","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","1496.00","897.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","939.19","62.78","","908.43","908.43","908.43","1 through 10","173.98","1157.9","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","1496.00","897.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1087.89","72.72","","1052.26","1052.26","2974.97","16","173.98","1157.9","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","1496.00","897.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","940.98","62.9","","911.61","911.61","911.61","31","173.98","1157.9","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","1496.00","897.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1157.90","77.4","","1121.43","1121.41","1121.43","1 through 10","173.98","1157.9","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","1496.00","897.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","1087.89","72.72","","1052.26","1052.26","1052.26","1 through 10","173.98","1157.9","percent of total billed charges",""
"Nfct Ds Bct Vaginosis&Vaginitis Dna Vag Flu Alg","PX-31001146","CDM","81514","CPT","0310","RC","","","","both","","","2668.00","1600.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","1862.26","69.8","","1800.84","1800.84","1800.84","1 through 10","170.94","2267.8","percent of total billed charges",""
"Nfct Ds Bct Vaginosis&Vaginitis Dna Vag Flu Alg","PX-31001146","CDM","81514","CPT","0310","RC","","","","both","","","2668.00","1600.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1518.09","56.9","","1468.02","1468.02","1468.02","1 through 10","170.94","2267.8","percent of total billed charges",""
"Nfct Ds Bct Vaginosis&Vaginitis Dna Vag Flu Alg","PX-31001146","CDM","81514","CPT","0310","RC","","","","both","","","2668.00","1600.80","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","1518.09","56.9","","1468.02","1468.02","1468.02","1 through 10","170.94","2267.8","percent of total billed charges",""
"Nfct Ds Bct Vaginosis&Vaginitis Dna Vag Flu Alg","PX-31001146","CDM","81514","CPT","0310","RC","","","","outpatient","","","2668.00","1600.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","384.73","14.42","","234.31","234.31","645.00","1 through 10","310.29","2065.03","percent of total billed charges",""
"Nfct Ds Bct Vaginosis&Vaginitis Dna Vag Flu Alg","PX-31001146","CDM","81514","CPT","0310","RC","","","","outpatient","","","2668.00","1600.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","310.29","11.63","","232.04","232.04","232.04","1 through 10","310.29","2065.03","percent of total billed charges",""
"Nfct Ds Bct Vaginosis&Vaginitis Dna Vag Flu Alg","PX-31001146","CDM","81514","CPT","0310","RC","","","","outpatient","","","2668.00","1600.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1940.17","72.72","","1876.18","1876.18","2364.13","1 through 10","310.29","2065.03","percent of total billed charges",""
"Nfct Ds Bct Vaginosis&Vaginitis Dna Vag Flu Alg","PX-31001146","CDM","81514","CPT","0310","RC","","","","outpatient","","","2668.00","1600.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1940.17","72.72","","1876.18","1876.18","1876.18","1 through 10","310.29","2065.03","percent of total billed charges",""
"Nfct Ds Bct Vaginosis&Vaginitis Dna Vag Flu Alg","PX-31001146","CDM","81514","CPT","0310","RC","","","","outpatient","","","2668.00","1600.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1419.91","53.22","","4126.20","2750.80","4126.20","1 through 10","310.29","2065.03","percent of total billed charges",""
"Nfct Ds Bct Vaginosis&Vaginitis Dna Vag Flu Alg","PX-31001146","CDM","81514","CPT","0310","RC","","","","outpatient","","","2668.00","1600.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1678.17","62.9","","1625.40","1563.51","1625.40","17","310.29","2065.03","percent of total billed charges",""
"Nfct Ds Bct Vaginosis&Vaginitis Dna Vag Flu Alg","PX-31001146","CDM","81514","CPT","0310","RC","","","","outpatient","","","2668.00","1600.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2065.03","77.4","","1999.50","1999.50","1999.50","1 through 10","310.29","2065.03","percent of total billed charges",""
"Nfct Ds Bct Vaginosis&Vaginitis Dna Vag Flu Alg","PX-31001146","CDM","81514","CPT","0310","RC","","","","outpatient","","","2668.00","1600.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","310.29","11.63","","232.04","232.04","412.76","1 through 10","310.29","2065.03","percent of total billed charges",""
"Nfct Ds Rna 3 Targets Upper Respiratory Specimen","PX-30003717","CDM","0240U","CPT","0300","RC","","","","both","","","358.00","214.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","249.88","69.8","","249.88","249.88","249.88","127","203.7","304.3","percent of total billed charges",""
"Nfct Ds Rna 3 Targets Upper Respiratory Specimen","PX-30003717","CDM","0240U","CPT","0300","RC","","","","both","","","358.00","214.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","203.70","56.9","","162.46","124.63","273.18","353","203.7","304.3","percent of total billed charges",""
"Nfct Ds Rna 3 Targets Upper Respiratory Specimen","PX-30003717","CDM","0240U","CPT","0300","RC","","","","both","","","358.00","214.80","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","203.70","56.9","","264.58","141.24","264.58","1 through 10","203.7","304.3","percent of total billed charges",""
"Nfct Ds Rna 3 Targets Upper Respiratory Specimen","PX-30003717","CDM","0240U","CPT","0300","RC","","","","both","","","358.00","214.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","249.88","69.8","","232.38","232.38","232.38","1 through 10","203.7","304.3","percent of total billed charges",""
"Nfct Ds Rna 3 Targets Upper Respiratory Specimen","PX-30003717","CDM","0240U","CPT","0300","RC","","","","both","","","358.00","214.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","304.30","85","","358.00","107.70","358.00","1 through 10","203.7","304.3","percent of total billed charges",""
"Nfct Ds Rna 3 Targets Upper Respiratory Specimen","PX-30003717","CDM","0240U","CPT","0300","RC","","","","outpatient","","","358.00","214.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","41.64","11.63","","145.48","145.48","290.96","452","41.64","277.09","percent of total billed charges",""
"Nfct Ds Rna 3 Targets Upper Respiratory Specimen","PX-30003717","CDM","0240U","CPT","0300","RC","","","","outpatient","","","358.00","214.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","224.75","62.78","","224.75","224.75","224.75","15","41.64","277.09","percent of total billed charges",""
"Nfct Ds Rna 3 Targets Upper Respiratory Specimen","PX-30003717","CDM","0240U","CPT","0300","RC","","","","outpatient","","","358.00","214.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","156.52","43.72","","156.52","156.52","156.52","1 through 10","41.64","277.09","percent of total billed charges",""
"Nfct Ds Rna 3 Targets Upper Respiratory Specimen","PX-30003717","CDM","0240U","CPT","0300","RC","","","","outpatient","","","358.00","214.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","260.34","72.72","","260.34","260.34","260.34","201","41.64","277.09","percent of total billed charges",""
"Nfct Ds Rna 3 Targets Upper Respiratory Specimen","PX-30003717","CDM","0240U","CPT","0300","RC","","","","outpatient","","","358.00","214.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","260.34","72.72","","260.34","260.34","260.34","1 through 10","41.64","277.09","percent of total billed charges",""
"Nfct Ds Rna 3 Targets Upper Respiratory Specimen","PX-30003717","CDM","0240U","CPT","0300","RC","","","","outpatient","","","358.00","214.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","190.53","53.22","","190.85","190.85","322.20","1 through 10","41.64","277.09","percent of total billed charges",""
"Nfct Ds Rna 3 Targets Upper Respiratory Specimen","PX-30003717","CDM","0240U","CPT","0300","RC","","","","outpatient","","","358.00","214.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","225.18","62.9","","225.54","225.54","225.54","275","41.64","277.09","percent of total billed charges",""
"Nfct Ds Rna 3 Targets Upper Respiratory Specimen","PX-30003717","CDM","0240U","CPT","0300","RC","","","","outpatient","","","358.00","214.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","277.09","77.4","","277.45","277.45","277.45","99","41.64","277.09","percent of total billed charges",""
"Nfct Ds Rna 3 Targets Upper Respiratory Specimen","PX-30003717","CDM","0240U","CPT","0300","RC","","","","outpatient","","","358.00","214.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","260.34","72.72","","260.34","260.34","260.34","1 through 10","41.64","277.09","percent of total billed charges",""
"Nfct Ds Rna 3 Targets Upper Respiratory Specimen","PX-30003717","CDM","0240U","CPT","0300","RC","","","","outpatient","","","358.00","214.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","41.64","11.63","","224.79","224.79","224.79","1 through 10","41.64","277.09","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","286.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","333.64","69.8","","333.64","333.64","333.64","27","271.98","406.3","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","286.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","271.98","56.9","","271.98","152.26","303.81","64","271.98","406.3","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","286.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","55.59","11.63","","145.48","145.48","290.96","239","55.59","369.97","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","286.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","300.09","62.78","","300.09","300.09","300.09","1 through 10","55.59","369.97","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","286.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","347.60","72.72","","347.60","347.60","347.60","24","55.59","369.97","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","286.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","347.60","72.72","","347.60","347.60","347.60","1 through 10","55.59","369.97","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","286.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","254.39","53.22","","254.82","254.82","254.82","1 through 10","55.59","369.97","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","286.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","300.66","62.9","","301.14","301.14","301.14","78","55.59","369.97","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","286.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","369.97","77.4","","370.45","370.45","370.45","18","55.59","369.97","percent of total billed charges",""
"Nitric Oxide Test","PX-46000082","CDM","95012","CPT","0460","RC","","","","both","","","228.00","136.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","112.85","","Case rate ($112.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","110.10","110.10","110.10","1 through 10","40.19","262.09","other","OPPS APC"
"Nitric Oxide Test","PX-46000082","CDM","95012","CPT","0460","RC","","","","both","","","228.00","136.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","41.01","","APC Price ($41.01). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","40.19","40.19","40.19","1 through 10","40.19","262.09","other","OPPS APC"
"Nitric Oxide Test","PX-46000082","CDM","95012","CPT","0460","RC","","","","outpatient","","","228.00","136.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","143.41","62.9","","138.60","138.60","138.60","1 through 10","26.52","176.47","percent of total billed charges",""
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-76001526","CDM","64483","CPT","0761","RC","","","","both","","","5455.00","3273.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","919.55","911.65","1375.38","57","911.54","5944.45","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-76001526","CDM","64483","CPT","0761","RC","","","","outpatient","","","5455.00","3273.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","7659.17","3827.98","7659.43","1 through 10","634.42","4222.17","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-76001526","CDM","64483","CPT","0761","RC","","","","outpatient","","","5455.00","3273.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4222.17","77.4","","3918.02","3918.02","3918.02","1 through 10","634.42","4222.17","percent of total billed charges",""
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE","PX-76001526","CDM","64483","CPT","0761","RC","","","50","both","","","5455.00","3273.00","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","948.74","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","1395.37","1395.37","1395.37","1 through 10","911.54","958.04","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE","PX-76001526","CDM","64483","CPT","0761","RC","","","50","both","","","5455.00","3273.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","911.54","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1395.37","1367.47","2372.13","12","911.54","958.04","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE","PX-76001526","CDM","64483","CPT","0761","RC","","","50","both","","","5455.00","3273.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","958.04","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1415.28","1351.66","1422.69","1 through 10","911.54","958.04","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE","PX-76001526","CDM","64483","CPT","0761","RC","","","50","both","","","5455.00","3273.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1368.37","1367.47","1395.37","1 through 10","911.54","958.04","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE","PX-76001526","CDM","64483","CPT","0761","RC","","","50","both","","","5455.00","3273.00","MEDICARE [2001]","HB WDH MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1395.37","1395.37","1395.37","70","911.54","958.04","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE","PX-76001526","CDM","64483","CPT","0761","RC","","","50","both","","","5455.00","3273.00","TRICARE [160005]","HB WDH MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1395.37","1395.37","1395.37","1 through 10","911.54","958.04","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|BILATERAL PROCEDURE","PX-76001526","CDM","64483","CPT","0761","RC","","","50","both","","","5455.00","3273.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1395.37","1332.14","1395.37","1 through 10","911.54","958.04","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl","PX-76001529","CDM","64484","CPT","0761","RC","","","","outpatient","","","2540.00","1524.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","5613.61","1782.37","5613.61","1 through 10","295.4","1965.96","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Njx Cholangio Prq W/Img Gid Rs&I Existing Access","PX-36000374","CDM","47531","CPT","0361","RC","","","","both","","","779.00","467.40","MEDICARE [2001]","HB WDH MEDICARE","3687.02","","APC Price ($3,687.02). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3687.44","3687.44","3687.44","1 through 10","443.25","23563.47","other","OPPS APC"
"Njx Cholangio Prq W/Img Gid Rs&I Existing Access","PX-36000374","CDM","47531","CPT","0361","RC","","","","both","","","779.00","467.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","3687.02","","APC Price ($3,687.02). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3687.44","3687.44","3687.44","1 through 10","443.25","23563.47","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","5238.00","3142.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","3656.12","69.8","","3528.39","3528.39","3528.39","1 through 10","709.05","4623.96","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","5238.00","3142.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","737.99","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","723.60","723.60","723.60","1 through 10","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","5238.00","3142.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","4623.96","","Case rate ($4,623.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4511.19","4379.92","4511.19","14","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","5238.00","3142.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1991.07","","Case rate ($1,991.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1942.53","1886.00","1942.53","19","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","5238.00","3142.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","709.05","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","710.13","709.13","723.60","14","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","5238.00","3142.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","3737.50","","Case rate ($3,737.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3646.32","1942.53","3646.32","13","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","5238.00","3142.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2980.42","56.9","","2876.30","2859.25","2876.30","12","709.05","4623.96","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","5238.00","3142.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","745.22","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","741.40","736.60","1490.62","1 through 10","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","5238.00","3142.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","710.03","710.03","723.60","13","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","5238.00","3142.80","MEDICARE [2001]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","723.60","723.60","723.60","54","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","5238.00","3142.80","TRICARE [160005]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","723.60","723.60","723.60","1 through 10","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","5238.00","3142.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","717.03","712.03","723.60","31","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","5238.00","3142.80","WELLSENSE NH [1050]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","751.88","751.88","751.88","1 through 10","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","5238.00","3142.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","755.32","14.42","","728.93","624.80","728.93","1 through 10","609.18","4054.21","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","5238.00","3142.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","609.18","11.63","","696.07","597.08","1276.66","1 through 10","609.18","4054.21","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","5238.00","3142.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3676.00","3676.00","3677.72","13","609.18","4054.21","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","5238.00","3142.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3294.70","62.9","","3184.65","3184.65","3184.65","11","609.18","4054.21","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","5238.00","3142.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4054.21","77.4","","3917.63","2668.70","3917.63","1 through 10","609.18","4054.21","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","5238.00","3142.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","609.18","11.63","","597.08","597.08","597.08","1 through 10","609.18","4054.21","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","4847.00","2908.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","3383.21","69.8","","3264.55","2941.83","3264.55","1 through 10","709.05","4623.96","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","4847.00","2908.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","737.99","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","723.60","723.60","723.60","17","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","4847.00","2908.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","4623.96","","Case rate ($4,623.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4511.19","4379.92","4511.19","18","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","4847.00","2908.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1991.07","","Case rate ($1,991.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1942.53","1886.00","1942.53","18","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","4847.00","2908.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","709.05","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","709.93","709.13","723.60","26","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","4847.00","2908.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","3737.50","","Case rate ($3,737.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3646.32","1942.53","3646.32","24","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","4847.00","2908.20","CHAMPVA [160001]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","723.60","723.60","723.60","1 through 10","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","4847.00","2908.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2757.94","56.9","","2661.22","2661.21","2661.82","30","709.05","4623.96","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","4847.00","2908.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","745.22","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","741.53","730.40","745.31","18","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","4847.00","2908.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","710.03","709.13","723.60","46","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","4847.00","2908.20","MEDICARE [2001]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","723.60","723.60","723.60","189","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","4847.00","2908.20","TRICARE [160005]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","723.60","472.25","723.60","1 through 10","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","4847.00","2908.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","717.03","709.13","723.60","89","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","4847.00","2908.20","WELLPOINT [1015]","HB WDH ANTHEM PPO","3737.50","","Case rate ($3,737.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3646.32","3646.32","3646.32","1 through 10","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","4847.00","2908.20","WELLSENSE NH [1050]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","752.18","751.78","9933.10","1 through 10","709.05","4623.96","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","4847.00","2908.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","698.94","14.42","","674.42","674.42","674.42","1 through 10","563.71","3751.58","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","4847.00","2908.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","563.71","11.63","","644.02","552.43","1181.19","29","563.71","3751.58","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","4847.00","2908.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","2044.78","2044.78","2044.78","1 through 10","563.71","3751.58","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","4847.00","2908.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3401.11","3401.11","3401.63","16","563.71","3751.58","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","4847.00","2908.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","3401.11","3401.11","3401.11","1 through 10","563.71","3751.58","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","4847.00","2908.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3048.76","62.9","","2946.51","2946.51","5657.74","17","563.71","3751.58","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","4847.00","2908.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3751.58","77.4","","3624.68","1809.00","3624.68","1 through 10","563.71","3751.58","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","4847.00","2908.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","563.71","11.63","","552.43","552.43","1134.61","13","563.71","3751.58","percent of total billed charges",""
"NM Bone 3 Phase","PX-34000045","CDM","78315","CPT","0341","RC","","","","both","","","3437.00","2062.20","MEDICARE [2001]","HB WDH MEDICARE","419.82","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.86","419.86","419.86","1 through 10","411.42","2921.45","other","OPPS APC"
"NM Bone 3 Phase","PX-34000045","CDM","78315","CPT","0341","RC","","","","both","","","3437.00","2062.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","419.82","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.86","396.63","419.86","1 through 10","411.42","2921.45","other","OPPS APC"
"NM Bone Ltd","PX-34000042","CDM","78300","CPT","0341","RC","","","","both","","","2311.00","1386.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","411.42","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","413.14","413.14","413.14","1 through 10","411.42","2683.02","other","OPPS APC"
"NM Bone Ltd","PX-34000042","CDM","78300","CPT","0341","RC","","","","both","","","2311.00","1386.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","419.82","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.86","419.86","419.86","1 through 10","411.42","2683.02","other","OPPS APC"
"NM Bone Ltd","PX-34000042","CDM","78300","CPT","0341","RC","","","","both","","","2311.00","1386.60","MEDICARE [2001]","HB WDH MEDICARE","419.82","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.86","419.86","419.86","1 through 10","411.42","2683.02","other","OPPS APC"
"NM Bone Ltd","PX-34000042","CDM","78300","CPT","0341","RC","","","","outpatient","","","2311.00","1386.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1788.71","77.4","","1728.25","1728.25","1728.25","1 through 10","268.77","1788.71","percent of total billed charges",""
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","3017.00","1810.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2683.02","","Case rate ($2,683.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2617.59","2612.24","2617.59","1 through 10","411.42","2683.02","other","OPPS APC"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","3017.00","1810.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1155.31","","Case rate ($1,155.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1127.14","1124.84","1127.14","17","411.42","2683.02","other","OPPS APC"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","3017.00","1810.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","411.42","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","411.46","411.46","419.86","16","411.42","2683.02","other","OPPS APC"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","3017.00","1810.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","2168.66","","Case rate ($2,168.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2115.75","2115.75","2115.75","1 through 10","411.42","2683.02","other","OPPS APC"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","3017.00","1810.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","432.41","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","431.81","431.81","432.46","1 through 10","411.42","2683.02","other","OPPS APC"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","3017.00","1810.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","419.82","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","413.14","395.43","419.86","1 through 10","411.42","2683.02","other","OPPS APC"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","3017.00","1810.20","MEDICARE [2001]","HB WDH MEDICARE","419.82","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.86","419.86","419.86","84","411.42","2683.02","other","OPPS APC"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","3017.00","1810.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","419.82","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","415.47","411.47","419.86","17","411.42","2683.02","other","OPPS APC"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","3017.00","1810.20","WELLSENSE NH [1050]","HB WDH MEDICARE","419.82","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","433.63","433.63","433.63","1 through 10","411.42","2683.02","other","OPPS APC"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","outpatient","","","3017.00","1810.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","435.05","14.42","","419.77","359.80","419.77","1 through 10","350.88","2335.16","percent of total billed charges",""
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","outpatient","","","3017.00","1810.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","350.88","11.63","","735.17","400.84","735.17","1 through 10","350.88","2335.16","percent of total billed charges",""
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","outpatient","","","3017.00","1810.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2193.96","72.72","","2116.88","2116.88","2116.88","1 through 10","350.88","2335.16","percent of total billed charges",""
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","outpatient","","","3017.00","1810.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1897.69","62.9","","1833.93","1833.93","1833.93","1 through 10","350.88","2335.16","percent of total billed charges",""
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","outpatient","","","3017.00","1810.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2335.16","77.4","","2256.03","2256.03","2256.03","1 through 10","350.88","2335.16","percent of total billed charges",""
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","outpatient","","","3017.00","1810.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","350.88","11.63","","343.83","343.83","343.83","1 through 10","350.88","2335.16","percent of total billed charges",""
"NM Hepatobiliary System Imaging","PX-34000022","CDM","78226","CPT","0341","RC","","","","both","","","3406.00","2043.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","411.42","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","395.43","395.43","395.43","1 through 10","411.42","2895.1","other","OPPS APC"
"NM Hepatobiliary System Imaging","PX-34000022","CDM","78226","CPT","0341","RC","","","","both","","","3406.00","2043.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","2168.66","","Case rate ($2,168.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3287.00","3287.00","3287.00","1 through 10","411.42","2895.1","other","OPPS APC"
"NM Hepatobiliary System Imaging","PX-34000022","CDM","78226","CPT","0341","RC","","","","both","","","3406.00","2043.60","MEDICARE [2001]","HB WDH MEDICARE","419.82","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.86","419.86","419.86","1 through 10","411.42","2895.1","other","OPPS APC"
"NM Hepatobiliary System Imaging","PX-34000022","CDM","78226","CPT","0341","RC","","","","both","","","3406.00","2043.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","419.82","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","414.47","414.47","414.47","1 through 10","411.42","2895.1","other","OPPS APC"
"NM Hepatobiliary System Imaging","PX-34000022","CDM","78226","CPT","0341","RC","","","","outpatient","","","3406.00","2043.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","396.12","11.63","","438.31","438.31","438.31","1 through 10","396.12","2636.24","percent of total billed charges",""
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","both","","","4658.00","2794.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","3594.01","","Case rate ($3,594.01). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3506.36","3506.36","3506.36","1 through 10","551.12","3959.3","other","OPPS APC"
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","both","","","4658.00","2794.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1547.58","","Case rate ($1,547.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1509.85","1474.11","1509.85","1 through 10","551.12","3959.3","other","OPPS APC"
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","both","","","4658.00","2794.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","551.12","","APC Price ($562.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","562.43","553.43","562.43","1 through 10","551.12","3959.3","other","OPPS APC"
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","both","","","4658.00","2794.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","2905.01","","Case rate ($2,905.01). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2834.14","2834.14","2834.14","1 through 10","551.12","3959.3","other","OPPS APC"
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","both","","","4658.00","2794.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","562.36","","APC Price ($562.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","562.43","526.64","562.43","1 through 10","551.12","3959.3","other","OPPS APC"
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","both","","","4658.00","2794.80","MEDICARE [2001]","HB WDH MEDICARE","562.36","","APC Price ($562.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","562.43","526.64","562.43","1 through 10","551.12","3959.3","other","OPPS APC"
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","both","","","4658.00","2794.80","TRICARE [160005]","HB WDH MEDICARE","562.36","","APC Price ($562.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","562.43","562.43","562.43","1 through 10","551.12","3959.3","other","OPPS APC"
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","both","","","4658.00","2794.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","562.36","","APC Price ($562.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","555.29","554.89","555.29","1 through 10","551.12","3959.3","other","OPPS APC"
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","outpatient","","","4658.00","2794.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","541.73","11.63","","618.96","618.96","618.96","1 through 10","541.73","3605.29","percent of total billed charges",""
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","outpatient","","","4658.00","2794.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2924.29","62.78","","2821.96","2821.96","2821.96","1 through 10","541.73","3605.29","percent of total billed charges",""
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","outpatient","","","4658.00","2794.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3387.30","72.72","","3268.76","3268.76","11032.52","1 through 10","541.73","3605.29","percent of total billed charges",""
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","outpatient","","","4658.00","2794.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2929.88","62.9","","8495.55","2831.85","8495.55","1 through 10","541.73","3605.29","percent of total billed charges",""
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","outpatient","","","4658.00","2794.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","541.73","11.63","","881.89","881.89","881.89","1 through 10","541.73","3605.29","percent of total billed charges",""
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","5575.00","3345.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","1363.91","","APC Price ($1,363.91). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1361.39","1361.39","1361.39","1 through 10","1336.64","8716.66","other","OPPS APC"
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","5575.00","3345.00","MEDICARE [2001]","HB WDH MEDICARE","1363.91","","APC Price ($1,363.91). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1364.07","1364.07","1364.07","1 through 10","1336.64","8716.66","other","OPPS APC"
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","5575.00","3345.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1363.91","","APC Price ($1,363.91). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1364.07","1364.07","1364.07","1 through 10","1336.64","8716.66","other","OPPS APC"
"NM Intestine Mucosa/Meckels","PX-34000037","CDM","78290","CPT","0341","RC","","","","both","","","3444.00","2066.40","MEDICARE [2001]","HB WDH MEDICARE","419.82","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.86","419.86","419.86","1 through 10","411.42","2927.4","other","OPPS APC"
"NM Kidney Scan W/Flow & Function","PX-34000104","CDM","78707","CPT","0341","RC","","","","both","","","3023.00","1813.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","579.23","","APC Price ($562.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","575.71","575.71","575.71","1 through 10","551.12","3594.01","other","OPPS APC"
"NM Kidney Scan W/Flow & Function","PX-34000104","CDM","78707","CPT","0341","RC","","","","both","","","3023.00","1813.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","562.36","","APC Price ($562.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","553.43","553.43","553.43","1 through 10","551.12","3594.01","other","OPPS APC"
"NM Kidney Scan W/Flow & Function","PX-34000104","CDM","78707","CPT","0341","RC","","","","both","","","3023.00","1813.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","562.36","","APC Price ($562.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","551.19","551.19","551.19","1 through 10","551.12","3594.01","other","OPPS APC"
"NM Kidney Scan W/Flow & Function","PX-34000104","CDM","78707","CPT","0341","RC","","","","outpatient","","","3023.00","1813.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","351.57","11.63","","736.70","736.70","736.70","1 through 10","351.57","2339.8","percent of total billed charges",""
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","3837.00","2302.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","3594.01","","Case rate ($3,594.01). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3506.36","3423.36","3506.36","1 through 10","551.12","3594.01","other","OPPS APC"
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","3837.00","2302.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1547.58","","Case rate ($1,547.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1474.11","1474.11","1474.11","1 through 10","551.12","3594.01","other","OPPS APC"
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","3837.00","2302.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","551.12","","APC Price ($562.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","551.18","551.18","551.18","1 through 10","551.12","3594.01","other","OPPS APC"
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","3837.00","2302.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","2905.01","","Case rate ($2,905.01). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2834.14","2767.05","2834.14","1 through 10","551.12","3594.01","other","OPPS APC"
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","3837.00","2302.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","579.23","","APC Price ($562.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","573.51","573.51","573.51","1 through 10","551.12","3594.01","other","OPPS APC"
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","3837.00","2302.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","562.36","","APC Price ($562.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","553.43","553.43","553.43","1 through 10","551.12","3594.01","other","OPPS APC"
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","3837.00","2302.20","MEDICARE [2001]","HB WDH MEDICARE","562.36","","APC Price ($562.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","562.43","562.43","562.43","18","551.12","3594.01","other","OPPS APC"
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","3837.00","2302.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","562.36","","APC Price ($562.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","555.27","554.19","555.27","1 through 10","551.12","3594.01","other","OPPS APC"
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","3837.00","2302.20","WELLSENSE NH [1050]","HB WDH MEDICARE","562.36","","APC Price ($562.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","580.34","580.34","580.34","1 through 10","551.12","3594.01","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","8057.00","4834.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","5623.79","69.8","","5426.95","5205.68","5426.95","1 through 10","1161.82","8716.66","percent of total billed charges",""
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","8057.00","4834.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","8716.66","","Case rate ($8,716.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8504.08","8504.08","8993.40","1 through 10","1161.82","8716.66","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","8057.00","4834.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","3753.38","","Case rate ($3,753.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3661.88","3661.88","11436.88","27","1161.82","8716.66","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","8057.00","4834.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1336.64","","APC Price ($1,363.91). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1341.79","1336.79","1383.53","38","1161.82","8716.66","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","8057.00","4834.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","7045.59","","Case rate ($7,045.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6873.71","3661.88","7269.22","23","1161.82","8716.66","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","8057.00","4834.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1161.82","14.42","","1121.16","960.99","1121.16","1 through 10","1161.82","8716.66","percent of total billed charges",""
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","8057.00","4834.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","1404.83","","APC Price ($1,363.91). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1384.89","1382.69","1395.69","28","1161.82","8716.66","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","8057.00","4834.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","1363.91","","APC Price ($1,363.91). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1342.24","1342.24","1364.07","85","1161.82","8716.66","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","8057.00","4834.20","MEDICARE [2001]","HB WDH MEDICARE","1363.91","","APC Price ($1,363.91). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1364.07","1364.07","1383.53","242","1161.82","8716.66","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","8057.00","4834.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5067.85","62.9","","4898.25","4898.25","18812.04","39","1161.82","8716.66","percent of total billed charges",""
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","8057.00","4834.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","6848.45","85","","1936.94","1936.94","1936.94","1 through 10","1161.82","8716.66","percent of total billed charges",""
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","8057.00","4834.20","TRICARE [160005]","HB WDH MEDICARE","1363.91","","APC Price ($1,363.91). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1364.07","1364.07","1364.07","1 through 10","1161.82","8716.66","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","8057.00","4834.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1363.91","","APC Price ($1,363.91). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1340.89","1336.79","1364.07","105","1161.82","8716.66","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","8057.00","4834.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6236.12","77.4","","6025.63","6025.63","6025.63","1 through 10","1161.82","8716.66","percent of total billed charges",""
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","8057.00","4834.20","WELLPOINT [1015]","HB WDH ANTHEM PPO","7045.59","","Case rate ($7,045.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6873.71","6873.71","6873.71","1 through 10","1161.82","8716.66","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","8057.00","4834.20","WELLSENSE NH [1050]","HB WDH MEDICARE","1363.91","","APC Price ($1,363.91). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1410.62","1410.62","4231.86","22","1161.82","8716.66","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","outpatient","","","8057.00","4834.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","937.03","11.63","","1070.62","918.36","2755.08","15","937.03","5859.05","percent of total billed charges",""
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","outpatient","","","8057.00","4834.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5058.18","62.78","","4881.15","4881.15","4881.15","1 through 10","937.03","5859.05","percent of total billed charges",""
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","outpatient","","","8057.00","4834.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3522.52","43.72","","3399.23","3399.23","3399.23","1 through 10","937.03","5859.05","percent of total billed charges",""
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","outpatient","","","8057.00","4834.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5859.05","72.72","","5653.98","5653.98","5653.98","1 through 10","937.03","5859.05","percent of total billed charges",""
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","outpatient","","","8057.00","4834.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5859.05","72.72","","11307.96","11307.96","11307.96","1 through 10","937.03","5859.05","percent of total billed charges",""
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","outpatient","","","8057.00","4834.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","937.03","11.63","","918.36","918.36","2149.77","14","937.03","5859.05","percent of total billed charges",""
"NM Pulmonary Perfusion Quan Diff","PX-34000088","CDM","78597","CPT","0341","RC","","","","both","","","2424.00","1454.40","MEDICARE [2001]","HB WDH MEDICARE","419.82","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.86","419.86","419.86","1 through 10","411.42","2683.02","other","OPPS APC"
"NM Pulmonary Vent/Perfusion Img","PX-34000066","CDM","78582","CPT","0341","RC","","","","both","","","3268.00","1960.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","2281.06","69.8","","2201.49","2201.49","2201.49","1 through 10","551.12","3594.01","percent of total billed charges",""
"NM Pulmonary Vent/Perfusion Img","PX-34000066","CDM","78582","CPT","0341","RC","","","","both","","","3268.00","1960.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1547.58","","Case rate ($1,547.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1509.85","1509.85","1509.85","1 through 10","551.12","3594.01","other","OPPS APC"
"NM Pulmonary Vent/Perfusion Img","PX-34000066","CDM","78582","CPT","0341","RC","","","","both","","","3268.00","1960.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","551.12","","APC Price ($562.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","553.43","553.43","553.43","1 through 10","551.12","3594.01","other","OPPS APC"
"NM Pulmonary Vent/Perfusion Img","PX-34000066","CDM","78582","CPT","0341","RC","","","","both","","","3268.00","1960.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","562.36","","APC Price ($562.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","553.43","551.18","553.43","1 through 10","551.12","3594.01","other","OPPS APC"
"NM Pulmonary Vent/Perfusion Img","PX-34000066","CDM","78582","CPT","0341","RC","","","","both","","","3268.00","1960.80","MEDICARE [2001]","HB WDH MEDICARE","562.36","","APC Price ($562.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","562.43","562.43","562.43","1 through 10","551.12","3594.01","other","OPPS APC"
"NM Pulmonary Vent/Perfusion Img","PX-34000066","CDM","78582","CPT","0341","RC","","","","both","","","3268.00","1960.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","562.36","","APC Price ($562.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","553.44","519.61","562.43","1 through 10","551.12","3594.01","other","OPPS APC"
"NM Pulmonary Vent/Perfusion Img","PX-34000066","CDM","78582","CPT","0341","RC","","","","both","","","3268.00","1960.80","WELLSENSE NH [1050]","HB WDH MEDICARE","562.36","","APC Price ($562.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","580.34","580.34","580.34","1 through 10","551.12","3594.01","other","OPPS APC"
"NM Pulmonary Vent/Perfusion Img","PX-34000066","CDM","78582","CPT","0341","RC","","","","outpatient","","","3268.00","1960.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","380.07","11.63","","434.31","434.31","434.31","1 through 10","380.07","2529.43","percent of total billed charges",""
"NM Pulmonary Vent/Perfusion Img","PX-34000066","CDM","78582","CPT","0341","RC","","","","outpatient","","","3268.00","1960.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2055.57","62.9","","1987.02","1987.02","1987.02","1 through 10","380.07","2529.43","percent of total billed charges",""
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-34000134","CDM","78014","CPT","0341","RC","","","","both","","","2511.00","1506.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2683.02","","Case rate ($2,683.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2617.59","2617.59","2617.59","1 through 10","411.42","2683.02","other","OPPS APC"
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-34000134","CDM","78014","CPT","0341","RC","","","","both","","","2511.00","1506.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1155.31","","Case rate ($1,155.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1127.14","1127.14","1127.14","1 through 10","411.42","2683.02","other","OPPS APC"
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-34000134","CDM","78014","CPT","0341","RC","","","","both","","","2511.00","1506.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","411.42","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","419.86","419.86","419.86","1 through 10","411.42","2683.02","other","OPPS APC"
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-34000134","CDM","78014","CPT","0341","RC","","","","both","","","2511.00","1506.60","HARVARD PILGRIM [120001]","HB WDH MEDICARE","419.82","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","395.02","395.02","395.02","1 through 10","411.42","2683.02","other","OPPS APC"
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-34000134","CDM","78014","CPT","0341","RC","","","","both","","","2511.00","1506.60","MEDICARE [2001]","HB WDH MEDICARE","419.82","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.86","419.86","419.86","1 through 10","411.42","2683.02","other","OPPS APC"
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-34000134","CDM","78014","CPT","0341","RC","","","","both","","","2511.00","1506.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","419.82","","APC Price ($419.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","415.17","415.17","415.17","1 through 10","411.42","2683.02","other","OPPS APC"
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-34000134","CDM","78014","CPT","0341","RC","","","","outpatient","","","2511.00","1506.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","292.03","11.63","","286.19","286.19","286.19","1 through 10","292.03","1943.51","percent of total billed charges",""
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-34000134","CDM","78014","CPT","0341","RC","","","","outpatient","","","2511.00","1506.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1943.51","77.4","","1877.83","1877.83","1877.83","1 through 10","292.03","1943.51","percent of total billed charges",""
"NM Thyroid Uptake Single/Multiple","PX-34000135","CDM","78012","CPT","0341","RC","","","","both","","","2314.00","1388.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1155.31","","Case rate ($1,155.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1127.14","1127.14","1127.14","1 through 10","411.42","2683.02","other","OPPS APC"
"NM Thyroid Uptake Single/Multiple","PX-34000135","CDM","78012","CPT","0341","RC","","","","outpatient","","","2314.00","1388.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","269.12","11.63","","666.88","666.88","666.88","1 through 10","269.12","1791.04","percent of total billed charges",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","","","","inpatient","","","64274.23","38564.54","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","17891.70","","Case rate ($17,891.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $16,548.10, add-ons for qualifying new technology services are included. If operating cost exceeds $20,466.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,079.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $16,171.91 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $16,103.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,274.92. The transfer capital threshold is the transfer adjustment factor * $1,274.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16500.21","16500.21","16500.21","1 through 10","3975","87206.43","other","Inpatient DRG"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC","097","MS-DRG","","","","","","","","inpatient","","","103284.84","61970.90","MARTIN'S POINT [160007]","HB WDH MEDICARE","27903.34","","Case rate ($27,903.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $25,788.74, add-ons for qualifying new technology services are included. If operating cost exceeds $29,706.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,811.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $25,451.96 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $25,343.87 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,006.51. The transfer capital threshold is the transfer adjustment factor * $2,006.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27064.32","27064.32","27064.32","1 through 10","4637","137248.76","other","Inpatient DRG"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/McC","099","MS-DRG","","","","","","","","inpatient","","","30605.36","18363.22","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","41233.42","","Fee schedule rate ($41,233.42). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","29743.07","29743.07","29743.07","1 through 10","3975","51771.34","case rate",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","","","","inpatient","","","36764.10","22058.46","MEDICARE [2001]","HB WDH MEDICARE","12940.23","","Case rate ($12,940.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,977.95, add-ons for qualifying new technology services are included. If operating cost exceeds $15,896.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,718.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,582.27 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,533.08 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $913.09. The transfer capital threshold is the transfer adjustment factor * $913.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13427.59","13427.59","13427.59","1 through 10","3975","62456.96","other","Inpatient DRG"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","987","MS-DRG","","","","","","","","inpatient","","","91256.82","54754.09","MARTIN'S POINT [160007]","HB WDH MEDICARE","26509.07","","Case rate ($26,509.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $24,501.83, add-ons for qualifying new technology services are included. If operating cost exceeds $28,420.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,709.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $24,159.56 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $24,056.96 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,904.63. The transfer capital threshold is the transfer adjustment factor * $1,904.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","32872.49","32872.49","32872.49","1 through 10","3975","130279.54","other","Inpatient DRG"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","987","MS-DRG","","","","","","","","inpatient","","","91256.82","54754.09","MEDICARE [2001]","HB WDH MEDICARE","26509.07","","Case rate ($26,509.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $24,501.83, add-ons for qualifying new technology services are included. If operating cost exceeds $28,420.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,709.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $24,159.56 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $24,056.96 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,904.63. The transfer capital threshold is the transfer adjustment factor * $1,904.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26874.62","26874.62","26874.62","1 through 10","3975","130279.54","other","Inpatient DRG"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","both","","","1.00","0.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","0.70","69.8","","0.70","0.63","0.70","56","0.53","0.85","percent of total billed charges",""
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","both","","","1.00","0.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","46.62","0.71","46.62","18","0.53","0.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","both","","","1.00","0.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","43.71","26.22","43.71","52","0.53","0.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","both","","","1.00","0.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","30.24","26.22","50.40","42","0.53","0.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","both","","","1.00","0.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","0.57","56.9","","761.55","761.55","761.55","1 through 10","0.53","0.85","percent of total billed charges",""
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","both","","","1.00","0.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","0.53","53.22","","0.54","0.54","0.54","1 through 10","0.53","0.85","percent of total billed charges",""
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","both","","","1.00","0.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","0.63","62.9","","0.63","0.63","2.52","99","0.53","0.85","percent of total billed charges",""
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","both","","","1.00","0.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","0.77","77.4","","0.78","0.78","1.55","20","0.53","0.85","percent of total billed charges",""
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","both","","","1.00","0.60","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","30.24","30.24","30.24","1 through 10","0.53","0.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.60","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","10.20","","APC Price ($10). Final payment is multiplied by 102%.","10.00","6.00","10.00","44","9.8","10.3","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","9.80","","APC Price ($10). Final payment is multiplied by 98%.","10.00","6.00","17.00","15","9.8","10.3","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","10.30","","APC Price ($10). Final payment is multiplied by 103%.","10.10","6.06","175.20","1 through 10","9.8","10.3","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","10.00","","APC Price ($10).","9.84","5.88","10.00","154","9.8","10.3","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.60","MEDICARE [2001]","HB WDH MEDICARE","10.00","","APC Price ($10).","10.00","6.00","10.00","446","9.8","10.3","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.60","TRICARE [160005]","HB WDH MEDICARE","10.00","","APC Price ($10).","12.00","12.00","12.00","1 through 10","9.8","10.3","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","10.00","","APC Price ($10).","9.80","5.88","10.00","195","9.8","10.3","other","OPPS APC"
"Non-Malignant Breast Disorders With Cc/McC","600","MS-DRG","","","","","","","","inpatient","","","39426.98","23656.19","MEDICARE [2001]","HB WDH MEDICARE","8363.56","","Case rate ($8,363.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,753.74, add-ons for qualifying new technology services are included. If operating cost exceeds $11,671.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,383.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,340.04 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,308.87 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $578.65. The transfer capital threshold is the transfer adjustment factor * $578.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7681.68","7681.68","7681.68","1 through 10","3975","39580.9","other","Inpatient DRG"
"Non-Malignant Breast Disorders Without Cc/McC","601","MS-DRG","","","","","","","","inpatient","","","11878.43","7127.06","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","5044.34","","Case rate ($5,044.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $4,690.13, add-ons for qualifying new technology services are included. If operating cost exceeds $8,608.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,141.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,263.37 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,245.26 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $336.10. The transfer capital threshold is the transfer adjustment factor * $336.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7544.34","7544.34","7544.34","1 through 10","3975","22990.06","other","Inpatient DRG"
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","205.00","123.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","143.09","69.8","","138.20","138.20","138.21","20","18.78","1358.06","percent of total billed charges",""
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","205.00","123.00","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","216.74","","APC Price ($212.49). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","28.55","28.55","28.55","1 through 10","18.78","1358.06","other","OPPS APC"
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","205.00","123.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1358.06","","Case rate ($1,358.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1324.94","1324.94","1324.94","1 through 10","18.78","1358.06","other","OPPS APC"
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","205.00","123.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","584.78","","Case rate ($584.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","385.00","27.69","570.52","1 through 10","18.78","1358.06","other","OPPS APC"
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","205.00","123.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1097.71","","Case rate ($1,097.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","198.00","198.00","198.00","1 through 10","18.78","1358.06","other","OPPS APC"
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","205.00","123.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","116.65","56.9","","112.66","33.54","198.00","42","18.78","1358.06","percent of total billed charges",""
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","205.00","123.00","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","116.65","56.9","","78.11","78.11","78.11","1 through 10","18.78","1358.06","percent of total billed charges",""
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","205.00","123.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","212.49","","APC Price ($212.49). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.48","208.48","208.48","1 through 10","18.78","1358.06","other","OPPS APC"
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","205.00","123.00","MEDICARE [2001]","HB WDH MEDICARE","212.49","","APC Price ($212.49). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","212.52","212.52","212.52","1 through 10","18.78","1358.06","other","OPPS APC"
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","205.00","123.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","128.95","62.9","","239.62","124.74","465.88","54","18.78","1358.06","percent of total billed charges",""
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","205.00","123.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","212.49","","APC Price ($212.49). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","212.23","212.23","212.23","1 through 10","18.78","1358.06","other","OPPS APC"
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","205.00","123.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","158.67","77.4","","153.45","153.45","153.45","1 through 10","18.78","1358.06","percent of total billed charges",""
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","outpatient","","","205.00","123.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","29.56","14.42","","28.55","28.55","28.55","24","23.84","29.56","percent of total billed charges",""
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","outpatient","","","205.00","123.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","23.84","11.63","","27.27","23.39","50.01","93","23.84","29.56","percent of total billed charges",""
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","outpatient","","","205.00","123.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","23.84","11.63","","23.39","23.39","396.00","30","23.84","29.56","percent of total billed charges",""
"Normal Newborn","795","MS-DRG","","","","","","","","inpatient","","","4381.35","2628.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","7592.42","","Fee schedule rate ($7,592.42). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","4290.31","2630.67","6872.26","20","1108","7592.42","case rate",""
"Normal Newborn","795","MS-DRG","","","","","","","","inpatient","","","4381.35","2628.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","2989.58","","Fee schedule rate ($2,989.58). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","2916.66","2535.94","2916.66","84","1108","7592.42","case rate",""
"Normal Newborn","795","MS-DRG","","","","","","","","inpatient","","","4381.35","2628.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1924.56","","Case rate ($1,963.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $1,846.86, add-ons for qualifying new technology services are included. If operating cost exceeds $5,765.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $47,916.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $1,407.97 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $1,401.99 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $111.00. The transfer capital threshold is the transfer adjustment factor * $111.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","1952.39","1952.39","1956.32","22","1108","7592.42","other","Inpatient DRG"
"Normal Newborn","795","MS-DRG","","","","","","","","inpatient","","","4381.35","2628.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","6047.00","","Fee schedule rate ($6,047.00). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","4184.87","2593.87","5217.75","88","1108","7592.42","case rate",""
"Normal Newborn","795","MS-DRG","","","","","","","","inpatient","","","4381.35","2628.81","MARTIN'S POINT [160007]","HB WDH MEDICARE","1963.84","","Case rate ($1,963.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $1,846.86, add-ons for qualifying new technology services are included. If operating cost exceeds $5,765.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $47,916.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $1,407.97 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $1,401.99 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $111.00. The transfer capital threshold is the transfer adjustment factor * $111.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","2049.34","2049.34","2049.34","1 through 10","1108","7592.42","other","Inpatient DRG"
"Normal Newborn","795","MS-DRG","","","","","","","","inpatient","","","4381.35","2628.81","TRICARE [160005]","HB WDH MEDICARE","1963.84","","Case rate ($1,963.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $1,846.86, add-ons for qualifying new technology services are included. If operating cost exceeds $5,765.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $47,916.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $1,407.97 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $1,401.99 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $111.00. The transfer capital threshold is the transfer adjustment factor * $111.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1240.01","1115.11","1249.33","19","1108","7592.42","other","Inpatient DRG"
"Normal Newborn","795","MS-DRG","","","","","","","","inpatient","","","4381.35","2628.81","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1963.84","","Case rate ($1,963.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $1,846.86, add-ons for qualifying new technology services are included. If operating cost exceeds $5,765.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $47,916.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $1,407.97 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $1,401.99 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $111.00. The transfer capital threshold is the transfer adjustment factor * $111.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1956.32","1956.32","1956.32","1 through 10","1108","7592.42","other","Inpatient DRG"
"Normal Newborn","795","MS-DRG","","","","","","","","inpatient","","","4381.35","2628.81","WELLPOINT [1015]","HB WDH ANTHEM PPO","6047.00","","Fee schedule rate ($6,047.00). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","4676.95","4676.95","4676.95","1 through 10","1108","7592.42","case rate",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","both","","","273.00","163.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","190.55","69.8","","184.27","29.69","184.27","1 through 10","22.81","232.05","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","both","","","273.00","163.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","190.55","69.8","","184.27","184.27","184.27","1 through 10","22.81","232.05","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","outpatient","","","273.00","163.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","119.36","43.72","","115.42","115.42","115.42","1 through 10","31.56","211.3","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","outpatient","","","273.00","163.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","198.53","72.72","","191.98","191.98","191.98","11","31.56","211.3","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","outpatient","","","273.00","163.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","145.29","53.22","","140.74","140.74","140.74","1 through 10","31.56","211.3","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","outpatient","","","273.00","163.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","171.72","62.9","","498.96","166.32","498.96","1 through 10","31.56","211.3","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","outpatient","","","273.00","163.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","211.30","77.4","","204.60","204.60","204.60","1 through 10","31.56","211.3","percent of total billed charges",""
"Nucleic Acid Amp Borrelia","PX-30001265","CDM","87476","CPT","0300","RC","","","","inpatient","","","188.00","112.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","144.50","76.86","","114.66","114.66","114.66","1 through 10","124.46","144.5","percent of total billed charges",""
"Nucleic Acid Amp Borrelia","PX-30001265","CDM","87476","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","118.03","62.78","","114.26","114.26","114.26","1 through 10","24.28","145.51","percent of total billed charges",""
"Nucleic Acid Amp Borrelia","PX-30001265","CDM","87476","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Nucleic Acid Amp Borrelia","PX-30001265","CDM","87476","CPT","0306","RC","","","","outpatient","","","188.00","112.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","118.25","62.9","","427.92","114.66","427.92","1 through 10","24.28","145.51","percent of total billed charges",""
"Nucleic Acid Amp Borrelia","PX-30001265","CDM","87476","CPT","0306","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","145.51","77.4","","141.04","141.04","141.04","1 through 10","24.28","145.51","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","both","","","227.00","136.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","158.45","69.8","","153.56","138.38","153.56","18","22.81","192.95","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","both","","","227.00","136.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","192.95","85","","153.56","153.56","153.56","1 through 10","22.81","192.95","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","outpatient","","","227.00","136.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","142.51","62.78","","138.12","138.12","138.12","1 through 10","24.28","175.7","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","outpatient","","","227.00","136.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","165.07","72.72","","159.98","159.98","220.00","47","24.28","175.7","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","outpatient","","","227.00","136.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","165.07","72.72","","159.98","159.98","159.98","1 through 10","24.28","175.7","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","outpatient","","","227.00","136.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","142.78","62.9","","138.60","138.60","138.60","123","24.28","175.7","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","outpatient","","","227.00","136.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","175.70","77.4","","170.50","170.50","170.50","24","24.28","175.7","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","outpatient","","","227.00","136.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","165.07","72.72","","159.98","159.98","159.98","1 through 10","24.28","175.7","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","both","","","302.00","181.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","210.80","69.8","","203.82","183.67","203.82","171","22.81","256.7","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","both","","","302.00","181.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","210.80","69.8","","203.82","203.82","203.82","1 through 10","22.81","256.7","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","both","","","302.00","181.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","256.70","85","","203.82","31.58","203.82","1 through 10","22.81","256.7","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","outpatient","","","302.00","181.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","189.60","62.78","","183.32","183.32","183.32","1 through 10","24.28","233.75","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","outpatient","","","302.00","181.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","132.03","43.72","","127.66","127.66","127.66","15","24.28","233.75","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","outpatient","","","302.00","181.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","160.72","53.22","","155.67","155.67","311.34","14","24.28","233.75","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","outpatient","","","302.00","181.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","189.96","62.9","","183.96","183.96","183.96","292","24.28","233.75","percent of total billed charges",""
"Nucleic Acid Amp Chlamydia Trach","PX-30001275","CDM","87491","CPT","0306","RC","","","","outpatient","","","302.00","181.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","233.75","77.4","","226.30","226.30","226.30","141","24.28","233.75","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","both","","","188.00","112.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","131.22","69.8","","127.04","114.48","508.14","20","22.81","180.59","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","118.03","62.78","","114.26","114.26","114.26","1 through 10","24.28","145.51","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","82.19","43.72","","79.57","79.57","79.57","1 through 10","24.28","145.51","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","529.40","79","24.28","145.51","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","118.25","62.9","","114.66","114.66","114.66","231","24.28","145.51","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","145.51","77.4","","141.05","141.05","564.20","57","24.28","145.51","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Nucleic Acid Amp Multi Org","PX-30001347","CDM","87801","CPT","0306","RC","","","","both","","","808.00","484.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","563.98","69.8","","545.14","491.25","545.14","15","45.63","686.8","percent of total billed charges",""
"Nucleic Acid Amp Multi Org","PX-30001347","CDM","87801","CPT","0306","RC","","","","both","","","808.00","484.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","686.80","85","","545.14","545.14","545.14","1 through 10","45.63","686.8","percent of total billed charges",""
"Nucleic Acid Amp Multi Org","PX-30001347","CDM","87801","CPT","0306","RC","","","","outpatient","","","808.00","484.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","507.26","62.78","","1470.93","490.31","1470.93","1 through 10","31.21","625.39","percent of total billed charges",""
"Nucleic Acid Amp Multi Org","PX-30001347","CDM","87801","CPT","0306","RC","","","","outpatient","","","808.00","484.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","353.26","43.72","","341.45","341.45","341.45","1 through 10","31.21","625.39","percent of total billed charges",""
"Nucleic Acid Amp Multi Org","PX-30001347","CDM","87801","CPT","0306","RC","","","","outpatient","","","808.00","484.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","587.58","72.72","","567.94","567.94","567.94","40","31.21","625.39","percent of total billed charges",""
"Nucleic Acid Amp Multi Org","PX-30001347","CDM","87801","CPT","0306","RC","","","","outpatient","","","808.00","484.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","587.58","72.72","","567.94","567.94","1135.88","1 through 10","31.21","625.39","percent of total billed charges",""
"Nucleic Acid Amp Multi Org","PX-30001347","CDM","87801","CPT","0306","RC","","","","outpatient","","","808.00","484.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","430.02","53.22","","416.35","416.35","416.35","1 through 10","31.21","625.39","percent of total billed charges",""
"Nucleic Acid Amp Multi Org","PX-30001347","CDM","87801","CPT","0306","RC","","","","outpatient","","","808.00","484.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","508.23","62.9","","492.03","492.03","1476.09","66","31.21","625.39","percent of total billed charges",""
"Nucleic Acid Amp Multi Org","PX-30001347","CDM","87801","CPT","0306","RC","","","","outpatient","","","808.00","484.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","625.39","77.4","","605.28","605.28","605.28","14","31.21","625.39","percent of total billed charges",""
"Nucleic Acid Amp Multi Org","PX-30001347","CDM","87801","CPT","0306","RC","","","","outpatient","","","808.00","484.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","587.58","72.72","","567.94","567.94","567.94","1 through 10","31.21","625.39","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","both","","","302.00","181.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","210.80","69.8","","203.82","183.67","203.82","170","22.81","256.7","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","both","","","302.00","181.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","210.80","69.8","","203.82","203.82","203.82","1 through 10","22.81","256.7","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","both","","","302.00","181.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","256.70","85","","110.96","31.58","203.82","1 through 10","22.81","256.7","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","outpatient","","","302.00","181.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","189.60","62.78","","183.32","183.32","183.32","1 through 10","24.28","233.75","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","outpatient","","","302.00","181.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","132.03","43.72","","127.66","127.66","127.66","15","24.28","233.75","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","outpatient","","","302.00","181.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","160.72","53.22","","155.67","155.67","311.34","14","24.28","233.75","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","outpatient","","","302.00","181.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","189.96","62.9","","183.96","183.96","183.96","292","24.28","233.75","percent of total billed charges",""
"Nucleic Acid Amp N Gonorrhoeae","PX-30001330","CDM","87591","CPT","0306","RC","","","","outpatient","","","302.00","181.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","233.75","77.4","","226.30","226.30","226.30","142","24.28","233.75","percent of total billed charges",""
"Nucleic Acid Amp Probe Clostridium","PX-30001277","CDM","87493","CPT","0300","RC","","","","inpatient","","","302.00","181.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","232.12","76.86","","176.57","176.57","176.57","1 through 10","199.92","232.12","percent of total billed charges",""
"Nucleic Acid Amp Probe Clostridium","PX-30001277","CDM","87493","CPT","0306","RC","","","","both","","","302.00","181.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","210.80","69.8","","203.82","203.82","203.82","1 through 10","24.23","256.7","percent of total billed charges",""
"Nucleic Acid Amp Probe Clostridium","PX-30001277","CDM","87493","CPT","0306","RC","","","","outpatient","","","302.00","181.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","132.03","43.72","","382.98","127.66","382.98","1 through 10","24.28","233.75","percent of total billed charges",""
"Nucleic Acid Amp Probe Clostridium","PX-30001277","CDM","87493","CPT","0306","RC","","","","outpatient","","","302.00","181.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","219.61","72.72","","212.34","212.34","212.34","1 through 10","24.28","233.75","percent of total billed charges",""
"Nucleic Acid Amp Probe Clostridium","PX-30001277","CDM","87493","CPT","0306","RC","","","","outpatient","","","302.00","181.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","189.96","62.9","","183.96","183.96","353.14","1 through 10","24.28","233.75","percent of total billed charges",""
"Nucleic Acid Amp Probe Clostridium","PX-30001277","CDM","87493","CPT","0306","RC","","","","outpatient","","","302.00","181.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","233.75","77.4","","226.30","226.28","226.30","1 through 10","24.28","233.75","percent of total billed charges",""
"Nucleic Acid Amp Probe Cmv","PX-30001280","CDM","87496","CPT","0306","RC","","","","both","","","255.00","153.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","177.99","69.8","","172.41","172.41","172.41","1 through 10","22.81","216.75","percent of total billed charges",""
"Nucleic Acid Amp Probe Cmv","PX-30001280","CDM","87496","CPT","0306","RC","","","","outpatient","","","255.00","153.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","160.40","62.9","","622.44","155.61","622.44","14","24.28","197.37","percent of total billed charges",""
"Nucleic Acid Amp Probe Gardnerella","PX-30001288","CDM","87511","CPT","0306","RC","","","","both","","","192.00","115.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","134.02","69.8","","129.83","116.99","129.83","1 through 10","22.81","180.59","percent of total billed charges",""
"Nucleic Acid Amp Probe Gardnerella","PX-30001288","CDM","87511","CPT","0306","RC","","","","outpatient","","","192.00","115.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","139.62","72.72","","135.26","135.26","135.26","12","24.28","148.61","percent of total billed charges",""
"Nucleic Acid Amp Probe Gardnerella","PX-30001288","CDM","87511","CPT","0306","RC","","","","outpatient","","","192.00","115.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","139.62","72.72","","135.26","135.26","135.26","1 through 10","24.28","148.61","percent of total billed charges",""
"Nucleic Acid Amp Probe Gardnerella","PX-30001288","CDM","87511","CPT","0306","RC","","","","outpatient","","","192.00","115.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","120.77","62.9","","117.18","117.18","117.18","23","24.28","148.61","percent of total billed charges",""
"Nucleic Acid Amp Probe Gardnerella","PX-30001288","CDM","87511","CPT","0306","RC","","","","outpatient","","","192.00","115.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","148.61","77.4","","144.15","144.15","144.15","1 through 10","24.28","148.61","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0300","RC","","","","inpatient","","","246.00","147.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","189.08","76.86","","149.31","149.31","149.31","1 through 10","162.85","189.08","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","both","","","246.00","147.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","171.71","69.8","","165.43","149.08","165.43","16","22.81","209.1","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","outpatient","","","246.00","147.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","154.44","62.78","","148.79","148.79","148.79","1 through 10","24.28","190.4","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","outpatient","","","246.00","147.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","178.89","72.72","","172.35","172.35","517.04","19","24.28","190.4","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","outpatient","","","246.00","147.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","130.92","53.22","","252.69","252.69","252.69","1 through 10","24.28","190.4","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","outpatient","","","246.00","147.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","154.73","62.9","","149.31","149.31","286.29","65","24.28","190.4","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","outpatient","","","246.00","147.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","190.40","77.4","","183.68","183.68","367.35","13","24.28","190.4","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","outpatient","","","246.00","147.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","178.89","72.72","","172.35","172.35","172.35","1 through 10","24.28","190.4","percent of total billed charges",""
"Nucleic Acid Amp Strep A","PX-30001339","CDM","87651","CPT","0306","RC","","","","both","","","274.00","164.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","191.25","69.8","","184.27","184.27","184.27","129","35.09","232.9","percent of total billed charges",""
"Nucleic Acid Amp Strep A","PX-30001339","CDM","87651","CPT","0306","RC","","","","both","","","274.00","164.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","232.90","85","","224.40","49.13","224.40","1 through 10","35.09","232.9","percent of total billed charges",""
"Nucleic Acid Amp Strep A","PX-30001339","CDM","87651","CPT","0306","RC","","","","outpatient","","","274.00","164.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","172.02","62.78","","165.74","165.74","165.74","12","31.21","212.08","percent of total billed charges",""
"Nucleic Acid Amp Strep A","PX-30001339","CDM","87651","CPT","0306","RC","","","","outpatient","","","274.00","164.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","119.79","43.72","","115.42","115.42","115.42","1 through 10","31.21","212.08","percent of total billed charges",""
"Nucleic Acid Amp Strep A","PX-30001339","CDM","87651","CPT","0306","RC","","","","outpatient","","","274.00","164.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","199.25","72.72","","191.98","191.98","191.98","197","31.21","212.08","percent of total billed charges",""
"Nucleic Acid Amp Strep A","PX-30001339","CDM","87651","CPT","0306","RC","","","","outpatient","","","274.00","164.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","199.25","72.72","","191.98","191.98","191.98","17","31.21","212.08","percent of total billed charges",""
"Nucleic Acid Amp Strep A","PX-30001339","CDM","87651","CPT","0306","RC","","","","outpatient","","","274.00","164.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","145.82","53.22","","140.74","140.74","237.60","1 through 10","31.21","212.08","percent of total billed charges",""
"Nucleic Acid Amp Strep A","PX-30001339","CDM","87651","CPT","0306","RC","","","","outpatient","","","274.00","164.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","172.35","62.9","","166.32","166.32","166.32","262","31.21","212.08","percent of total billed charges",""
"Nucleic Acid Amp Strep A","PX-30001339","CDM","87651","CPT","0306","RC","","","","outpatient","","","274.00","164.40","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","199.25","72.72","","191.98","191.98","191.98","1 through 10","31.21","212.08","percent of total billed charges",""
"Nucleic Acid Amp Strep A","PX-30001339","CDM","87651","CPT","0306","RC","","","","outpatient","","","274.00","164.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","212.08","77.4","","204.60","204.60","204.60","103","31.21","212.08","percent of total billed charges",""
"Nucleic Acid Amp Strep A","PX-30001339","CDM","87651","CPT","0306","RC","","","","outpatient","","","274.00","164.40","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","199.25","72.72","","191.98","191.98","191.98","1 through 10","31.21","212.08","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","both","","","245.00","147.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","171.01","69.8","","165.43","165.43","165.43","1 through 10","22.81","208.25","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","outpatient","","","245.00","147.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","153.81","62.78","","148.79","148.79","148.79","1 through 10","24.28","189.63","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","outpatient","","","245.00","147.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","178.16","72.72","","172.35","172.35","174.32","1 through 10","24.28","189.63","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","outpatient","","","245.00","147.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","154.11","62.9","","149.31","149.31","149.31","25","24.28","189.63","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","outpatient","","","245.00","147.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","189.63","77.4","","183.68","183.68","183.68","1 through 10","24.28","189.63","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","outpatient","","","245.00","147.00","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","178.16","72.72","","172.35","172.35","172.35","1 through 10","24.28","189.63","percent of total billed charges",""
"Nucleic Acid Direct Candida","PX-30001267","CDM","87480","CPT","0306","RC","","","","both","","","141.00","84.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","98.42","69.8","","94.93","85.54","94.93","62","13.03","119.85","percent of total billed charges",""
"Nucleic Acid Direct Candida","PX-30001267","CDM","87480","CPT","0306","RC","","","","both","","","141.00","84.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","119.85","85","","94.93","28.07","94.93","1 through 10","13.03","119.85","percent of total billed charges",""
"Nucleic Acid Direct Candida","PX-30001267","CDM","87480","CPT","0306","RC","","","","outpatient","","","141.00","84.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","88.52","62.78","","85.38","85.38","85.38","1 through 10","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Direct Candida","PX-30001267","CDM","87480","CPT","0306","RC","","","","outpatient","","","141.00","84.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","61.65","43.72","","59.46","59.46","59.46","11","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Direct Candida","PX-30001267","CDM","87480","CPT","0306","RC","","","","outpatient","","","141.00","84.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","102.54","72.72","","98.90","98.90","98.90","91","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Direct Candida","PX-30001267","CDM","87480","CPT","0306","RC","","","","outpatient","","","141.00","84.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","102.54","72.72","","98.90","98.90","98.90","1 through 10","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Direct Candida","PX-30001267","CDM","87480","CPT","0306","RC","","","","outpatient","","","141.00","84.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","75.04","53.22","","72.50","72.50","72.50","1 through 10","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Direct Candida","PX-30001267","CDM","87480","CPT","0306","RC","","","","outpatient","","","141.00","84.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","88.69","62.9","","85.68","85.68","85.68","111","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Direct Candida","PX-30001267","CDM","87480","CPT","0306","RC","","","","outpatient","","","141.00","84.60","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","102.54","72.72","","98.90","98.90","98.90","1 through 10","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Direct Candida","PX-30001267","CDM","87480","CPT","0306","RC","","","","outpatient","","","141.00","84.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","109.13","77.4","","105.40","105.40","105.40","46","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Direct Candida","PX-30001267","CDM","87480","CPT","0306","RC","","","","outpatient","","","141.00","84.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","102.54","72.72","","98.90","98.90","98.90","1 through 10","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Direct Gardnerella","PX-30001287","CDM","87510","CPT","0306","RC","","","","both","","","141.00","84.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","98.42","69.8","","94.93","85.54","94.93","62","13.03","119.85","percent of total billed charges",""
"Nucleic Acid Direct Gardnerella","PX-30001287","CDM","87510","CPT","0306","RC","","","","both","","","141.00","84.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","119.85","85","","94.93","28.07","94.93","1 through 10","13.03","119.85","percent of total billed charges",""
"Nucleic Acid Direct Gardnerella","PX-30001287","CDM","87510","CPT","0306","RC","","","","outpatient","","","141.00","84.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","88.52","62.78","","85.38","85.38","85.38","1 through 10","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Direct Gardnerella","PX-30001287","CDM","87510","CPT","0306","RC","","","","outpatient","","","141.00","84.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","61.65","43.72","","59.46","59.46","59.46","11","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Direct Gardnerella","PX-30001287","CDM","87510","CPT","0306","RC","","","","outpatient","","","141.00","84.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","102.54","72.72","","98.90","98.90","98.90","92","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Direct Gardnerella","PX-30001287","CDM","87510","CPT","0306","RC","","","","outpatient","","","141.00","84.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","102.54","72.72","","98.90","98.90","98.90","1 through 10","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Direct Gardnerella","PX-30001287","CDM","87510","CPT","0306","RC","","","","outpatient","","","141.00","84.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","75.04","53.22","","72.50","72.50","72.50","1 through 10","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Direct Gardnerella","PX-30001287","CDM","87510","CPT","0306","RC","","","","outpatient","","","141.00","84.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","88.69","62.9","","85.68","85.68","85.68","111","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Direct Gardnerella","PX-30001287","CDM","87510","CPT","0306","RC","","","","outpatient","","","141.00","84.60","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","102.54","72.72","","98.90","98.90","98.90","1 through 10","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Direct Gardnerella","PX-30001287","CDM","87510","CPT","0306","RC","","","","outpatient","","","141.00","84.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","109.13","77.4","","105.40","105.40","105.40","44","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Direct Gardnerella","PX-30001287","CDM","87510","CPT","0306","RC","","","","outpatient","","","141.00","84.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","102.54","72.72","","98.90","98.90","98.90","1 through 10","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Genotype Hepatitis C","PX-30001361","CDM","87902","CPT","0306","RC","","","","both","","","1391.00","834.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","970.92","69.8","","938.81","938.81","938.81","1 through 10","167.34","1328.92","percent of total billed charges",""
"Nucleic Acid Genotype Hepatitis C","PX-30001361","CDM","87902","CPT","0306","RC","","","","outpatient","","","1391.00","834.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","874.94","62.9","","847.35","847.35","847.35","1 through 10","76.65","1076.63","percent of total billed charges",""
"Nucleic Acid Genotype Hiv 1","PX-30001360","CDM","87901","CPT","0306","RC","","","","outpatient","","","1391.00","834.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1011.54","72.72","","978.08","978.08","978.08","1 through 10","76.65","1076.63","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","both","","","299.00","179.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","208.70","69.8","","201.72","201.72","201.72","1 through 10","27.85","254.15","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","outpatient","","","299.00","179.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","130.72","43.72","","126.35","126.35","126.35","1 through 10","51.91","231.43","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","outpatient","","","299.00","179.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","217.43","72.72","","210.16","210.16","210.16","11","51.91","231.43","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","outpatient","","","299.00","179.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","159.13","53.22","","154.07","154.07","154.07","1 through 10","51.91","231.43","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","outpatient","","","299.00","179.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","188.07","62.9","","364.14","182.07","728.28","113","51.91","231.43","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","outpatient","","","299.00","179.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","231.43","77.4","","223.96","214.95","223.98","1 through 10","51.91","231.43","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","both","","","290.00","174.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","202.42","69.8","","195.44","176.12","195.44","1 through 10","27.85","246.5","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","outpatient","","","290.00","174.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","210.89","72.72","","203.62","203.62","203.62","1 through 10","39.91","224.46","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","outpatient","","","290.00","174.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","154.34","53.22","","149.27","149.27","149.27","1 through 10","39.91","224.46","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","outpatient","","","290.00","174.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","182.41","62.9","","176.40","176.40","529.20","1 through 10","39.91","224.46","percent of total billed charges",""
"Nucleic Acid Qn Herpes 6","PX-30001306","CDM","87533","CPT","0306","RC","","","","outpatient","","","363.00","217.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","228.33","62.9","","221.13","221.13","221.13","1 through 10","38.46","280.96","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","outpatient","","","230.00","138.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","100.56","43.72","","97.06","97.06","97.06","1 through 10","51.91","178.02","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","outpatient","","","230.00","138.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","167.26","72.72","","161.44","161.44","484.32","15","51.91","178.02","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","outpatient","","","230.00","138.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","122.41","53.22","","118.35","118.35","118.35","1 through 10","51.91","178.02","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","outpatient","","","230.00","138.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","144.67","62.9","","139.86","139.86","419.58","44","51.91","178.02","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","outpatient","","","230.00","138.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","178.02","77.4","","172.05","172.05","172.05","1 through 10","51.91","178.02","percent of total billed charges",""
"Nucleic Acid Qn Trichomon","PX-30001342","CDM","87660","CPT","0306","RC","","","","both","","","141.00","84.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","98.42","69.8","","94.93","85.54","94.93","62","13.03","119.85","percent of total billed charges",""
"Nucleic Acid Qn Trichomon","PX-30001342","CDM","87660","CPT","0306","RC","","","","both","","","141.00","84.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","119.85","85","","94.93","28.07","94.93","1 through 10","13.03","119.85","percent of total billed charges",""
"Nucleic Acid Qn Trichomon","PX-30001342","CDM","87660","CPT","0306","RC","","","","outpatient","","","141.00","84.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","88.52","62.78","","85.38","85.38","85.38","1 through 10","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Qn Trichomon","PX-30001342","CDM","87660","CPT","0306","RC","","","","outpatient","","","141.00","84.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","61.65","43.72","","59.46","59.46","59.46","11","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Qn Trichomon","PX-30001342","CDM","87660","CPT","0306","RC","","","","outpatient","","","141.00","84.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","102.54","72.72","","98.90","98.90","284.58","104","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Qn Trichomon","PX-30001342","CDM","87660","CPT","0306","RC","","","","outpatient","","","141.00","84.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","102.54","72.72","","98.90","98.90","98.90","1 through 10","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Qn Trichomon","PX-30001342","CDM","87660","CPT","0306","RC","","","","outpatient","","","141.00","84.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","75.04","53.22","","72.50","72.50","72.50","1 through 10","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Qn Trichomon","PX-30001342","CDM","87660","CPT","0306","RC","","","","outpatient","","","141.00","84.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","88.69","62.9","","85.68","85.68","85.68","111","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Qn Trichomon","PX-30001342","CDM","87660","CPT","0306","RC","","","","outpatient","","","141.00","84.60","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","102.54","72.72","","98.90","98.90","98.90","1 through 10","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Qn Trichomon","PX-30001342","CDM","87660","CPT","0306","RC","","","","outpatient","","","141.00","84.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","109.13","77.4","","105.40","105.40","105.40","46","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Qn Trichomon","PX-30001342","CDM","87660","CPT","0306","RC","","","","outpatient","","","141.00","84.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","102.54","72.72","","98.90","98.90","98.90","1 through 10","18.68","109.13","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","both","","","299.00","179.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","208.70","69.8","","201.72","48.83","201.72","1 through 10","27.85","254.15","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","outpatient","","","299.00","179.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","217.43","72.72","","210.16","210.16","210.16","1 through 10","39.91","231.43","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","outpatient","","","299.00","179.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","188.07","62.9","","546.21","182.07","546.21","19","39.91","231.43","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","outpatient","","","299.00","179.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","231.43","77.4","","223.98","51.24","223.98","1 through 10","39.91","231.43","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","both","","","460.00","276.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","321.08","69.8","","310.61","310.61","310.61","1 through 10","55.32","439.47","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","outpatient","","","460.00","276.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","334.51","72.72","","323.60","323.60","323.60","1 through 10","52.36","356.04","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","outpatient","","","460.00","276.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","244.81","53.22","","237.23","237.23","237.23","1 through 10","52.36","356.04","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","outpatient","","","460.00","276.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","289.34","62.9","","280.35","280.35","841.05","1 through 10","52.36","356.04","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","outpatient","","","460.00","276.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","356.04","77.4","","344.88","344.88","344.88","1 through 10","52.36","356.04","percent of total billed charges",""
"Nucleic Acid Rev Trans/Amp Probe En","PX-30001282","CDM","87498","CPT","0300","RC","","","","inpatient","","","287.00","172.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","220.59","76.86","","175.14","175.14","175.14","1 through 10","189.99","220.59","percent of total billed charges",""
"Nucleic Acid Rev Trans/Amp Probe En","PX-30001282","CDM","87498","CPT","0306","RC","","","","outpatient","","","287.00","172.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","180.52","62.9","","175.14","175.14","175.14","1 through 10","31.56","222.14","percent of total billed charges",""
"Nucleic Acid Staph a Amplified Prob","PX-30001336","CDM","87640","CPT","0306","RC","","","","both","","","302.00","181.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","210.80","69.8","","203.82","203.82","203.82","1 through 10","22.81","256.7","percent of total billed charges",""
"Nucleic Acid Staph a Amplified Prob","PX-30001336","CDM","87640","CPT","0306","RC","","","","both","","","302.00","181.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","210.80","69.8","","203.82","203.82","203.82","1 through 10","22.81","256.7","percent of total billed charges",""
"Nucleic Acid Staph a Amplified Prob","PX-30001336","CDM","87640","CPT","0306","RC","","","","outpatient","","","302.00","181.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","189.60","62.78","","183.32","183.32","183.32","1 through 10","31.56","233.75","percent of total billed charges",""
"Nucleic Acid Staph a Amplified Prob","PX-30001336","CDM","87640","CPT","0306","RC","","","","outpatient","","","302.00","181.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","219.61","72.72","","212.34","100.82","212.34","1 through 10","31.56","233.75","percent of total billed charges",""
"Nucleic Acid Staph a Amplified Prob","PX-30001336","CDM","87640","CPT","0306","RC","","","","outpatient","","","302.00","181.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","189.96","62.9","","183.96","183.96","183.96","25","31.56","233.75","percent of total billed charges",""
"Nucleic Acid Staph a Amplified Prob","PX-30001336","CDM","87640","CPT","0306","RC","","","","outpatient","","","302.00","181.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","233.75","77.4","","226.30","226.30","226.30","1 through 10","31.56","233.75","percent of total billed charges",""
"Nucleic Acid Staph a Amplified Prob","PX-30001336","CDM","87640","CPT","0306","RC","","","","outpatient","","","302.00","181.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","219.61","72.72","","212.34","212.34","212.34","1 through 10","31.56","233.75","percent of total billed charges",""
"Nucleotidase 5","PX-30000588","CDM","83915","CPT","0301","RC","","","","both","","","60.00","36.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","41.88","69.8","","40.48","40.48","40.48","1 through 10","7.25","57.21","percent of total billed charges",""
"Nucleotidase 5","PX-30000588","CDM","83915","CPT","0301","RC","","","","outpatient","","","60.00","36.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","43.63","72.72","","42.18","42.18","42.18","1 through 10","13.36","46.44","percent of total billed charges",""
"Nucleotidase 5","PX-30000588","CDM","83915","CPT","0301","RC","","","","outpatient","","","60.00","36.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","37.74","62.9","","36.54","36.54","36.54","1 through 10","13.36","46.44","percent of total billed charges",""
"Nucleotidase 5","PX-30000588","CDM","83915","CPT","0301","RC","","","","outpatient","","","60.00","36.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","46.44","77.4","","44.95","44.95","44.95","1 through 10","13.36","46.44","percent of total billed charges",""
"NUT BONE 5MM TI SCREW SELF TAPPING","SUP-ITM-10040396","CDM","C1713","HCPCS","0278","RC","","","","both","","","887.17","532.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","103.18","754.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NUT BONE 5MM TI SCREW SELF TAPPING","SUP-ITM-10040396","CDM","C1713","HCPCS","0278","RC","","","","both","","","887.17","532.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","103.18","754.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NUT BONE 5MM TI SCREW SELF TAPPING","SUP-ITM-10040396","CDM","C1713","HCPCS","0278","RC","","","","both","","","887.17","532.30","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","504.80","56.9","","812.12","238.65","1587.46","163","103.18","754.09","percent of total billed charges",""
"NUT BONE 5MM TI SCREW SELF TAPPING","SUP-ITM-10040396","CDM","C1713","HCPCS","0278","RC","","","","both","","","887.17","532.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","103.18","11.63","","112.68","112.68","146.99","38","103.18","754.09","percent of total billed charges",""
"NUT BONE 5MM TI SCREW SELF TAPPING","SUP-ITM-10040396","CDM","C1713","HCPCS","0278","RC","","","","both","","","887.17","532.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","686.67","77.4","","303.98","303.98","5854.79","1 through 10","103.18","754.09","percent of total billed charges",""
"NUT BONE 5MM TI SCREW SELF TAPPING","SUP-ITM-10040396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","887.17","532.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","103.18","11.63","","112.68","112.68","146.99","38","103.18","686.67","percent of total billed charges",""
"NUT BONE 5MM TI SCREW SELF TAPPING","SUP-ITM-10040396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","887.17","532.30","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","556.97","62.78","","780.86","208.94","10480.28","15","103.18","686.67","percent of total billed charges",""
"NUT BONE 5MM TI SCREW SELF TAPPING","SUP-ITM-10040396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","887.17","532.30","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","387.87","43.72","","179.76","179.76","179.76","1 through 10","103.18","686.67","percent of total billed charges",""
"NUT BONE 5MM TI SCREW SELF TAPPING","SUP-ITM-10040396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","887.17","532.30","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","645.15","72.72","","2355.45","298.99","3965.19","155","103.18","686.67","percent of total billed charges",""
"NUT BONE 5MM TI SCREW SELF TAPPING","SUP-ITM-10040396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","887.17","532.30","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","645.15","72.72","","3643.09","3643.09","3643.09","1 through 10","103.18","686.67","percent of total billed charges",""
"NUT BONE 5MM TI SCREW SELF TAPPING","SUP-ITM-10040396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","887.17","532.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","472.15","53.22","","554.28","554.28","554.28","16","103.18","686.67","percent of total billed charges",""
"NUT BONE 5MM TI SCREW SELF TAPPING","SUP-ITM-10040396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","887.17","532.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","558.03","62.9","","619.64","173.09","2370.64","150","103.18","686.67","percent of total billed charges",""
"NUT BONE 5MM TI SCREW SELF TAPPING","SUP-ITM-10040396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","887.17","532.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","686.67","77.4","","303.98","303.98","5854.79","1 through 10","103.18","686.67","percent of total billed charges",""
"NUT WASHER 5MM TRIGEN STABLE","SUP-ITM-10014537","CDM","C1713","HCPCS","0278","RC","","","","both","","","4042.35","2425.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","470.13","3436","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NUT WASHER 5MM TRIGEN STABLE","SUP-ITM-10014537","CDM","C1713","HCPCS","0278","RC","","","","both","","","4042.35","2425.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","470.13","3436","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"NUT WASHER 5MM TRIGEN STABLE","SUP-ITM-10014537","CDM","C1713","HCPCS","0278","RC","","","","both","","","4042.35","2425.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2300.10","56.9","","812.12","238.65","1587.46","163","470.13","3436","percent of total billed charges",""
"NUT WASHER 5MM TRIGEN STABLE","SUP-ITM-10014537","CDM","C1713","HCPCS","0278","RC","","","","both","","","4042.35","2425.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","470.13","11.63","","112.68","112.68","146.99","38","470.13","3436","percent of total billed charges",""
"NUT WASHER 5MM TRIGEN STABLE","SUP-ITM-10014537","CDM","C1713","HCPCS","0278","RC","","","","both","","","4042.35","2425.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3128.78","77.4","","303.98","303.98","5854.79","1 through 10","470.13","3436","percent of total billed charges",""
"NUT WASHER 5MM TRIGEN STABLE","SUP-ITM-10014537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4042.35","2425.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","470.13","11.63","","112.68","112.68","146.99","38","470.13","3128.78","percent of total billed charges",""
"NUT WASHER 5MM TRIGEN STABLE","SUP-ITM-10014537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4042.35","2425.41","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2537.79","62.78","","780.86","208.94","10480.28","15","470.13","3128.78","percent of total billed charges",""
"NUT WASHER 5MM TRIGEN STABLE","SUP-ITM-10014537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4042.35","2425.41","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1767.32","43.72","","179.76","179.76","179.76","1 through 10","470.13","3128.78","percent of total billed charges",""
"NUT WASHER 5MM TRIGEN STABLE","SUP-ITM-10014537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4042.35","2425.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2939.60","72.72","","2355.45","298.99","3965.19","155","470.13","3128.78","percent of total billed charges",""
"NUT WASHER 5MM TRIGEN STABLE","SUP-ITM-10014537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4042.35","2425.41","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2939.60","72.72","","3643.09","3643.09","3643.09","1 through 10","470.13","3128.78","percent of total billed charges",""
"NUT WASHER 5MM TRIGEN STABLE","SUP-ITM-10014537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4042.35","2425.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2151.34","53.22","","554.28","554.28","554.28","16","470.13","3128.78","percent of total billed charges",""
"NUT WASHER 5MM TRIGEN STABLE","SUP-ITM-10014537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4042.35","2425.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2542.64","62.9","","619.64","173.09","2370.64","150","470.13","3128.78","percent of total billed charges",""
"NUT WASHER 5MM TRIGEN STABLE","SUP-ITM-10014537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4042.35","2425.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3128.78","77.4","","303.98","303.98","5854.79","1 through 10","470.13","3128.78","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","both","","","136.00","81.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","94.93","69.8","","82.40","78.52","91.44","100","31.82","115.6","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","both","","","136.00","81.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","77.38","56.9","","74.54","74.54","111.35","249","31.82","115.6","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","both","","","136.00","81.60","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","77.38","56.9","","74.54","74.54","74.54","1 through 10","31.82","115.6","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","both","","","136.00","81.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","115.60","85","","96.16","96.16","96.16","1 through 10","31.82","115.6","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","outpatient","","","136.00","81.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","19.61","14.42","","18.89","16.19","18.89","52","15.82","105.26","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","outpatient","","","136.00","81.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","15.82","11.63","","33.08","15.47","33.09","160","15.82","105.26","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","outpatient","","","136.00","81.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","85.38","62.78","","82.24","82.24","82.24","11","15.82","105.26","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","outpatient","","","136.00","81.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","59.46","43.72","","171.82","57.27","171.82","19","15.82","105.26","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","outpatient","","","136.00","81.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","98.90","72.72","","95.26","95.26","95.26","210","15.82","105.26","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","outpatient","","","136.00","81.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","98.90","72.72","","95.26","95.26","95.26","1 through 10","15.82","105.26","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","outpatient","","","136.00","81.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","72.38","53.22","","82.53","82.53","82.53","1 through 10","15.82","105.26","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","outpatient","","","136.00","81.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","85.54","62.9","","82.53","82.53","82.53","230","15.82","105.26","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","outpatient","","","136.00","81.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","105.26","77.4","","101.53","101.53","101.53","57","15.82","105.26","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","outpatient","","","136.00","81.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","15.82","11.63","","15.47","15.47","15.47","115","15.82","105.26","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","both","","","115.00","69.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","80.27","69.8","","69.82","66.93","77.48","167","26.89","97.75","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","both","","","115.00","69.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","65.44","56.9","","63.16","63.16","94.35","536","26.89","97.75","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","outpatient","","","115.00","69.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","16.58","14.42","","16.01","13.72","32.01","55","13.37","89.01","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","outpatient","","","115.00","69.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","13.37","11.63","","15.29","13.11","28.04","253","13.37","89.01","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","outpatient","","","115.00","69.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","72.20","62.78","","69.69","69.69","69.69","22","13.37","89.01","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","outpatient","","","115.00","69.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","50.28","43.72","","48.53","48.53","48.53","1 through 10","13.37","89.01","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","outpatient","","","115.00","69.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","83.63","72.72","","80.72","80.72","80.72","389","13.37","89.01","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","outpatient","","","115.00","69.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","83.63","72.72","","80.72","80.72","80.72","11","13.37","89.01","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","outpatient","","","115.00","69.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","72.34","62.9","","69.93","69.93","69.93","522","13.37","89.01","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","outpatient","","","115.00","69.00","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","83.63","72.72","","86.03","86.03","86.03","1 through 10","13.37","89.01","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","outpatient","","","115.00","69.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","89.01","77.4","","86.03","86.03","86.03","128","13.37","89.01","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","outpatient","","","115.00","69.00","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","83.63","72.72","","80.72","80.72","80.72","1 through 10","13.37","89.01","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","outpatient","","","115.00","69.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","13.37","11.63","","13.11","13.11","13.11","191","13.37","89.01","percent of total billed charges",""
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","","","","inpatient","","","46928.11","28156.87","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","48433.53","","Fee schedule rate ($48,433.53). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","47154.77","47154.77","47154.77","1 through 10","11428.75","60811.56","case rate",""
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","","","","inpatient","","","46928.11","28156.87","MEDICARE [2001]","HB WDH MEDICARE","12611.05","","Case rate ($12,611.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,674.12, add-ons for qualifying new technology services are included. If operating cost exceeds $15,592.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,694.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $11,277.14 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,229.25 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $889.04. The transfer capital threshold is the transfer adjustment factor * $889.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12526.43","12495.04","12527.27","1 through 10","11428.75","60811.56","other","Inpatient DRG"
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","","","","inpatient","","","46928.11","28156.87","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","12611.05","","Case rate ($12,611.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,674.12, add-ons for qualifying new technology services are included. If operating cost exceeds $15,592.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,694.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $11,277.14 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,229.25 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $889.04. The transfer capital threshold is the transfer adjustment factor * $889.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12283.91","12283.91","12283.91","1 through 10","11428.75","60811.56","other","Inpatient DRG"
"O.R. Procedures For Obesity Without Cc/McC","621","MS-DRG","","","","","","","","inpatient","","","47120.33","28272.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","12150.64","","Case rate ($11,912.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,029.26, add-ons for qualifying new technology services are included. If operating cost exceeds $14,947.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,643.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $10,629.53 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,584.39 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $837.98. The transfer capital threshold is the transfer adjustment factor * $837.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","11474.84","11474.84","11474.84","1 through 10","10772.43","57319.35","other","Inpatient DRG"
"O.R. Procedures For Obesity Without Cc/McC","621","MS-DRG","","","","","","","","inpatient","","","47120.33","28272.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","22570.01","","Fee schedule rate ($22,570.01). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","21339.25","21339.25","21339.25","1 through 10","10772.43","57319.35","case rate",""
"O.R. Procedures For Obesity Without Cc/McC","621","MS-DRG","","","","","","","","inpatient","","","47120.33","28272.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","11674.14","","Case rate ($11,912.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,029.26, add-ons for qualifying new technology services are included. If operating cost exceeds $14,947.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,643.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $10,629.53 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,584.39 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $837.98. The transfer capital threshold is the transfer adjustment factor * $837.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11307.08","11307.08","11307.08","1 through 10","10772.43","57319.35","other","Inpatient DRG"
"O.R. Procedures For Obesity Without Cc/McC","621","MS-DRG","","","","","","","","inpatient","","","47120.33","28272.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","45652.15","","Fee schedule rate ($45,652.15). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","40114.93","35961.70","47154.77","1 through 10","10772.43","57319.35","case rate",""
"O.R. Procedures For Obesity Without Cc/McC","621","MS-DRG","","","","","","","","inpatient","","","47120.33","28272.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","11912.39","","Case rate ($11,912.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,029.26, add-ons for qualifying new technology services are included. If operating cost exceeds $14,947.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,643.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $10,629.53 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,584.39 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $837.98. The transfer capital threshold is the transfer adjustment factor * $837.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17684.94","17684.94","17684.94","1 through 10","10772.43","57319.35","other","Inpatient DRG"
"O.R. Procedures For Obesity Without Cc/McC","621","MS-DRG","","","","","","","","inpatient","","","47120.33","28272.20","MEDICARE [2001]","HB WDH MEDICARE","11912.39","","Case rate ($11,912.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,029.26, add-ons for qualifying new technology services are included. If operating cost exceeds $14,947.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,643.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $10,629.53 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,584.39 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $837.98. The transfer capital threshold is the transfer adjustment factor * $837.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11503.63","11474.89","11503.63","1 through 10","10772.43","57319.35","other","Inpatient DRG"
"O.R. Procedures For Obesity Without Cc/McC","621","MS-DRG","","","","","","","","inpatient","","","47120.33","28272.20","TRICARE [160005]","HB WDH MEDICARE","11912.39","","Case rate ($11,912.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,029.26, add-ons for qualifying new technology services are included. If operating cost exceeds $14,947.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,643.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $10,629.53 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,584.39 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $837.98. The transfer capital threshold is the transfer adjustment factor * $837.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16884.94","16884.94","16884.94","1 through 10","10772.43","57319.35","other","Inpatient DRG"
"O.R. Procedures For Obesity Without Cc/McC","621","MS-DRG","","","","","","","","inpatient","","","47120.33","28272.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","11912.39","","Case rate ($11,912.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,029.26, add-ons for qualifying new technology services are included. If operating cost exceeds $14,947.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,643.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $10,629.53 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,584.39 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $837.98. The transfer capital threshold is the transfer adjustment factor * $837.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11283.00","11281.26","11503.63","1 through 10","10772.43","57319.35","other","Inpatient DRG"
"O.R. Procedures For Obesity Without Cc/McC","621","MS-DRG","","","","","","","","inpatient","","","47120.33","28272.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","30907.12","","Fee schedule rate ($30,907.12). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","29079.59","29079.59","29079.59","1 through 10","10772.43","57319.35","case rate",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","","","","inpatient","","","131638.48","78983.09","MARTIN'S POINT [160007]","HB WDH MEDICARE","18211.00","","Case rate ($18,211). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $16,842.81, add-ons for qualifying new technology services are included. If operating cost exceeds $20,760.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,103.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $16,467.88 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $16,397.94 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,298.25. The transfer capital threshold is the transfer adjustment factor * $1,298.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Includes an additional $800 of payment.","9082.96","9082.96","9082.96","1 through 10","3975","88802.43","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","","","","inpatient","","","92941.50","55764.90","MEDICARE [2001]","HB WDH MEDICARE","29827.51","","Case rate ($29,827.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $27,564.73, add-ons for qualifying new technology services are included. If operating cost exceeds $31,482.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,952.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $27,235.53 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $27,119.86 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,147.12. The transfer capital threshold is the transfer adjustment factor * $2,147.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","0.05","1 through 10","3975","146866.59","other","Inpatient DRG"
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","57.17","57.17","57.17","296","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","504.00","81.00","4032.00","22","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","84.00","81.00","84.00","192","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3734.60","","Case rate ($3,734.60).","790.78","143.39","2862.64","506","73.95","3975.19","case rate",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","3734.60","","Case rate ($3,734.60).","406.27","406.27","406.27","1 through 10","73.95","3975.19","case rate",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","66.87","76.86","","52.92","4.41","102.16","224","57.59","66.87","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","12.55","14.42","","12.11","10.38","12.11","2994","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.12","11.63","","19.84","9.92","29.77","9624","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","46.30","53.22","","13.27","13.27","44.78","82","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","54.72","62.9","","158.76","7.06","1273.48","7625","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","67.34","77.4","","65.10","61.08","84.00","707","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.12","11.63","","9.92","9.92","29.77","3584","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","57.17","57.17","57.17","296","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","504.00","81.00","4032.00","22","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","84.00","81.00","84.00","192","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3734.60","","Case rate ($3,734.60).","790.78","143.39","2862.64","506","73.95","3975.19","case rate",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","3734.60","","Case rate ($3,734.60).","406.27","406.27","406.27","1 through 10","73.95","3975.19","case rate",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","66.87","76.86","","52.92","4.41","102.16","224","57.59","66.87","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","12.55","14.42","","12.11","10.38","12.11","2994","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.12","11.63","","19.84","9.92","29.77","9624","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","46.30","53.22","","13.27","13.27","44.78","82","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","54.72","62.9","","158.76","7.06","1273.48","7625","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","67.34","77.4","","65.10","61.08","84.00","707","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.12","11.63","","9.92","9.92","29.77","3584","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","57.17","57.17","57.17","296","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","504.00","81.00","4032.00","22","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","84.00","81.00","84.00","192","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3734.60","","Case rate ($3,734.60).","790.78","143.39","2862.64","506","73.95","3975.19","case rate",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","3734.60","","Case rate ($3,734.60).","406.27","406.27","406.27","1 through 10","73.95","3975.19","case rate",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","66.87","76.86","","52.92","4.41","102.16","224","57.59","66.87","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","12.55","14.42","","12.11","10.38","12.11","2994","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.12","11.63","","19.84","9.92","29.77","9624","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","46.30","53.22","","13.27","13.27","44.78","82","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","54.72","62.9","","158.76","7.06","1273.48","7625","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","67.34","77.4","","65.10","61.08","84.00","707","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.12","11.63","","9.92","9.92","29.77","3584","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","57.17","57.17","57.17","296","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","504.00","81.00","4032.00","22","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","84.00","81.00","84.00","192","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3734.60","","Case rate ($3,734.60).","790.78","143.39","2862.64","506","73.95","3975.19","case rate",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","3734.60","","Case rate ($3,734.60).","406.27","406.27","406.27","1 through 10","73.95","3975.19","case rate",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","66.87","76.86","","52.92","4.41","102.16","224","57.59","66.87","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","12.55","14.42","","12.11","10.38","12.11","2994","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.12","11.63","","19.84","9.92","29.77","9624","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","46.30","53.22","","13.27","13.27","44.78","82","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","54.72","62.9","","158.76","7.06","1273.48","7625","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","67.34","77.4","","65.10","61.08","84.00","707","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.12","11.63","","9.92","9.92","29.77","3584","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","57.17","57.17","57.17","296","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","504.00","81.00","4032.00","22","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","84.00","81.00","84.00","192","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3734.60","","Case rate ($3,734.60).","790.78","143.39","2862.64","506","73.95","3975.19","case rate",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","3734.60","","Case rate ($3,734.60).","406.27","406.27","406.27","1 through 10","73.95","3975.19","case rate",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","66.87","76.86","","52.92","4.41","102.16","224","57.59","66.87","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","12.55","14.42","","12.11","10.38","12.11","2994","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.12","11.63","","19.84","9.92","29.77","9624","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","46.30","53.22","","13.27","13.27","44.78","82","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","54.72","62.9","","158.76","7.06","1273.48","7625","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","67.34","77.4","","65.10","61.08","84.00","707","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.12","11.63","","9.92","9.92","29.77","3584","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","57.17","57.17","57.17","296","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","504.00","81.00","4032.00","22","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","84.00","81.00","84.00","192","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3734.60","","Case rate ($3,734.60).","790.78","143.39","2862.64","506","73.95","3975.19","case rate",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","3734.60","","Case rate ($3,734.60).","406.27","406.27","406.27","1 through 10","73.95","3975.19","case rate",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","66.87","76.86","","52.92","4.41","102.16","224","57.59","66.87","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","12.55","14.42","","12.11","10.38","12.11","2994","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.12","11.63","","19.84","9.92","29.77","9624","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","46.30","53.22","","13.27","13.27","44.78","82","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","54.72","62.9","","158.76","7.06","1273.48","7625","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","67.34","77.4","","65.10","61.08","84.00","707","10.12","67.34","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.12","11.63","","9.92","9.92","29.77","3584","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","57.17","57.17","57.17","296","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","504.00","81.00","4032.00","22","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","84.00","81.00","84.00","192","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3734.60","","Case rate ($3,734.60).","790.78","143.39","2862.64","506","73.95","3975.19","case rate",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","3734.60","","Case rate ($3,734.60).","406.27","406.27","406.27","1 through 10","73.95","3975.19","case rate",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","66.87","76.86","","52.92","4.41","102.16","224","57.59","66.87","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","12.55","14.42","","12.11","10.38","12.11","2994","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.12","11.63","","19.84","9.92","29.77","9624","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","46.30","53.22","","13.27","13.27","44.78","82","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","54.72","62.9","","158.76","7.06","1273.48","7625","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","67.34","77.4","","65.10","61.08","84.00","707","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.12","11.63","","9.92","9.92","29.77","3584","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","57.17","57.17","57.17","296","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","504.00","81.00","4032.00","22","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","84.00","81.00","84.00","192","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3734.60","","Case rate ($3,734.60).","790.78","143.39","2862.64","506","73.95","3975.19","case rate",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","3734.60","","Case rate ($3,734.60).","406.27","406.27","406.27","1 through 10","73.95","3975.19","case rate",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","66.87","76.86","","52.92","4.41","102.16","224","57.59","66.87","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","12.55","14.42","","12.11","10.38","12.11","2994","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.12","11.63","","19.84","9.92","29.77","9624","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","46.30","53.22","","13.27","13.27","44.78","82","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","54.72","62.9","","158.76","7.06","1273.48","7625","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","67.34","77.4","","65.10","61.08","84.00","707","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.12","11.63","","9.92","9.92","29.77","3584","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","57.17","57.17","57.17","296","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","504.00","81.00","4032.00","22","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","84.00","81.00","84.00","192","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3734.60","","Case rate ($3,734.60).","790.78","143.39","2862.64","506","73.95","3975.19","case rate",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","3734.60","","Case rate ($3,734.60).","406.27","406.27","406.27","1 through 10","73.95","3975.19","case rate",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","66.87","76.86","","52.92","4.41","102.16","224","57.59","66.87","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","12.55","14.42","","12.11","10.38","12.11","2994","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.12","11.63","","19.84","9.92","29.77","9624","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","46.30","53.22","","13.27","13.27","44.78","82","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","54.72","62.9","","158.76","7.06","1273.48","7625","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","67.34","77.4","","65.10","61.08","84.00","707","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.12","11.63","","9.92","9.92","29.77","3584","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","57.17","57.17","57.17","296","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","504.00","81.00","4032.00","22","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","84.00","81.00","84.00","192","73.95","3975.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3734.60","","Case rate ($3,734.60).","790.78","143.39","2862.64","506","73.95","3975.19","case rate",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","both","","","87.00","52.20","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","3734.60","","Case rate ($3,734.60).","406.27","406.27","406.27","1 through 10","73.95","3975.19","case rate",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","66.87","76.86","","52.92","4.41","102.16","224","57.59","66.87","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","12.55","14.42","","12.11","10.38","12.11","2994","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.12","11.63","","19.84","9.92","29.77","9624","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","46.30","53.22","","13.27","13.27","44.78","82","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","54.72","62.9","","158.76","7.06","1273.48","7625","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","67.34","77.4","","65.10","61.08","84.00","707","10.12","67.34","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","87.00","52.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","10.12","11.63","","9.92","9.92","29.77","3584","10.12","67.34","percent of total billed charges",""
"Occult Blood Feces Cancer Screen","PX-30000328","CDM","82270","CPT","0301","RC","","","","both","","","53.00","31.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","36.99","69.8","","32.08","32.08","35.60","1 through 10","2.85","45.05","percent of total billed charges",""
"Occult Blood Feces Cancer Screen","PX-30000328","CDM","82270","CPT","0301","RC","","","","both","","","53.00","31.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","45.05","85","","16.84","16.84","16.84","1 through 10","2.85","45.05","percent of total billed charges",""
"Occult Blood Feces Cancer Screen","PX-30000328","CDM","82270","CPT","0301","RC","","","","outpatient","","","53.00","31.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","23.17","43.72","","22.30","22.30","22.30","1 through 10","3.01","41.02","percent of total billed charges",""
"Occult Blood Feces Cancer Screen","PX-30000328","CDM","82270","CPT","0301","RC","","","","outpatient","","","53.00","31.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","38.54","72.72","","1149.79","37.09","1149.79","41","3.01","41.02","percent of total billed charges",""
"Occult Blood Feces Cancer Screen","PX-30000328","CDM","82270","CPT","0301","RC","","","","outpatient","","","53.00","31.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","33.34","62.9","","32.13","32.13","32.13","1 through 10","3.01","41.02","percent of total billed charges",""
"Occult Blood Feces Cancer Screen","PX-30000328","CDM","82270","CPT","0301","RC","","","","outpatient","","","53.00","31.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","41.02","77.4","","39.53","39.53","39.53","1 through 10","3.01","41.02","percent of total billed charges",""
"Occult Blood Feces Cancer Screen","PX-30000328","CDM","82270","CPT","0301","RC","","","","outpatient","","","53.00","31.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","38.54","72.72","","37.09","37.09","37.09","1 through 10","3.01","41.02","percent of total billed charges",""
"Occult Blood Feces Immunoassay Ql","PX-30000331","CDM","82274","CPT","0301","RC","","","","outpatient","","","240.00","144.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","150.96","62.9","","146.16","146.16","146.16","1 through 10","12.99","185.76","percent of total billed charges",""
"Occupational Ther Re-Eval Est Plan Care 30 Mins","PX-43000112","CDM","97168","CPT","0434","RC","","","","both","","","383.00","229.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","70.50","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($70.50). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($51.11). Each line will be capped at the line billed amount.","69.59","69.59","69.59","1 through 10","70.5","326.66","fee schedule",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","both","","","570.00","342.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","397.86","69.8","","383.90","345.95","383.90","24","101.8","484.5","percent of total billed charges",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","both","","","570.00","342.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","397.86","69.8","","383.90","294.00","383.90","1 through 10","101.8","484.5","percent of total billed charges",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","both","","","570.00","342.00","TRICARE [160005]","HB WDH MEDICARE","101.80","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($101.80). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($76.21). Each line will be capped at the line billed amount.","102.15","102.15","102.15","1 through 10","101.8","484.5","fee schedule",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","both","","","570.00","342.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","101.80","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($101.80). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($76.21). Each line will be capped at the line billed amount.","100.11","99.77","100.66","305","101.8","484.5","fee schedule",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","outpatient","","","570.00","342.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","414.50","72.72","","399.96","399.96","527.95","12","66.29","441.18","percent of total billed charges",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","outpatient","","","570.00","342.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","358.53","62.9","","346.50","346.50","346.50","57","66.29","441.18","percent of total billed charges",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","outpatient","","","570.00","342.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","66.29","11.63","","64.96","64.96","324.80","21","66.29","441.18","percent of total billed charges",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","both","","","570.00","342.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","397.86","69.8","","383.90","345.95","383.90","1 through 10","101.8","484.5","percent of total billed charges",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","both","","","570.00","342.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","484.50","85","","75.44","75.44","75.44","1 through 10","101.8","484.5","percent of total billed charges",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","both","","","570.00","342.00","TRICARE [160005]","HB WDH MEDICARE","101.80","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($101.80). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($76.21). Each line will be capped at the line billed amount.","102.15","102.15","102.15","1 through 10","101.8","484.5","fee schedule",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","both","","","570.00","342.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","101.80","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($101.80). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($76.21). Each line will be capped at the line billed amount.","100.52","100.11","101.06","38","101.8","484.5","fee schedule",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","outpatient","","","570.00","342.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","414.50","72.72","","399.96","399.96","527.95","1 through 10","66.29","441.18","percent of total billed charges",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","outpatient","","","570.00","342.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","358.53","62.9","","346.50","346.50","346.50","11","66.29","441.18","percent of total billed charges",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","outpatient","","","570.00","342.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","66.29","11.63","","64.96","64.96","64.96","1 through 10","66.29","441.18","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","176.00","105.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","122.85","69.8","","117.96","23.17","117.96","415","109.14","149.6","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","176.00","105.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","131.95","","APC Price ($134.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28.75","28.75","28.75","62","109.14","149.6","other","OPPS APC"
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","176.00","105.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","122.85","69.8","","109.70","109.69","117.96","1 through 10","109.14","149.6","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","176.00","105.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","149.60","85","","168.31","47.42","169.00","32","109.14","149.6","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","outpatient","","","176.00","105.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","25.38","14.42","","24.37","18.03","24.37","549","20.47","136.22","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","outpatient","","","176.00","105.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.47","11.63","","23.27","17.21","42.68","1030","20.47","136.22","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","outpatient","","","176.00","105.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","93.67","53.22","","90.09","66.64","90.09","1 through 10","20.47","136.22","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","outpatient","","","176.00","105.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","110.70","62.9","","106.47","78.75","106.47","609","20.47","136.22","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","outpatient","","","176.00","105.60","PHCS MULTIPLAN [1022]","HB WDH AMERIHEALTH CARITAS","25.38","14.42","","24.37","24.37","24.37","1 through 10","20.47","136.22","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","outpatient","","","176.00","105.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.47","11.63","","19.96","14.77","19.96","380","20.47","136.22","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","both","","","315.00","189.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","219.87","69.8","","157.75","157.75","157.75","363","131.95","267.75","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","both","","","315.00","189.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","131.95","","APC Price ($134.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","51.98","51.98","51.98","401","131.95","267.75","other","OPPS APC"
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","both","","","315.00","189.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","219.87","69.8","","157.75","140.85","226.00","1 through 10","131.95","267.75","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","both","","","315.00","189.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","267.75","85","","125.00","50.06","192.10","14","131.95","267.75","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","outpatient","","","315.00","189.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","45.42","14.42","","32.59","27.93","32.59","345","36.63","243.81","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","outpatient","","","315.00","189.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","36.63","11.63","","31.12","26.69","57.08","1318","36.63","243.81","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","outpatient","","","315.00","189.00","INTERNATIONAL COMMERCIAL [140001]","HB WDH UNITED HMO / PPO / INDEM","243.81","77.4","","175.15","168.39","175.15","1 through 10","36.63","243.81","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","outpatient","","","315.00","189.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","167.64","53.22","","120.48","120.48","240.96","15","36.63","243.81","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","outpatient","","","315.00","189.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","198.14","62.9","","142.38","142.38","142.38","730","36.63","243.81","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","outpatient","","","315.00","189.00","PHCS MULTIPLAN [1022]","HB WDH AMERIHEALTH CARITAS","45.42","14.42","","32.59","32.59","32.59","1 through 10","36.63","243.81","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000081","CDM","99212","CPT","0510","RC","","","","outpatient","","","315.00","189.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","36.63","11.63","","26.69","26.69","26.69","463","36.63","243.81","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","507.00","304.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","353.89","69.8","","251.28","251.28","339.23","280","131.95","596.49","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","507.00","304.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","131.95","","APC Price ($134.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.80","82.80","82.80","257","131.95","596.49","other","OPPS APC"
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","507.00","304.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","353.89","69.8","","251.28","233.67","306.00","1 through 10","131.95","596.49","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","both","","","507.00","304.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","430.95","85","","306.00","108.30","445.63","1 through 10","131.95","596.49","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","outpatient","","","507.00","304.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","73.11","14.42","","51.91","44.50","51.91","193","58.96","392.42","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","outpatient","","","507.00","304.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","58.96","11.63","","49.57","42.52","90.92","690","58.96","392.42","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","outpatient","","","507.00","304.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","269.83","53.22","","191.92","191.92","575.76","1 through 10","58.96","392.42","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","outpatient","","","507.00","304.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","318.90","62.9","","226.80","226.80","306.18","574","58.96","392.42","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","outpatient","","","507.00","304.20","PHCS MULTIPLAN [1022]","HB WDH AMERIHEALTH CARITAS","73.11","14.42","","51.91","51.91","51.91","1 through 10","58.96","392.42","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000082","CDM","99213","CPT","0510","RC","","","","outpatient","","","507.00","304.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","58.96","11.63","","42.52","42.52","42.52","250","58.96","392.42","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","both","","","781.00","468.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","545.14","69.8","","387.39","310.11","387.39","1 through 10","131.95","1003.45","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","both","","","781.00","468.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","131.95","","APC Price ($134.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","127.65","127.65","207.68","1 through 10","131.95","1003.45","other","OPPS APC"
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","outpatient","","","781.00","468.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","112.62","14.42","","68.60","68.60","80.03","1 through 10","90.83","604.49","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","outpatient","","","781.00","468.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","90.83","11.63","","76.42","65.56","140.17","23","90.83","604.49","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","outpatient","","","781.00","468.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","491.25","62.9","","349.65","349.65","349.65","1 through 10","90.83","604.49","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000083","CDM","99214","CPT","0510","RC","","","","outpatient","","","781.00","468.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","90.83","11.63","","65.56","65.56","65.56","1 through 10","90.83","604.49","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","1104.00","662.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","770.59","69.8","","545.84","545.84","545.84","1 through 10","131.95","1664.9","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","outpatient","","","1104.00","662.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","159.20","14.42","","130.77","130.77","130.77","1 through 10","128.4","854.5","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","outpatient","","","1104.00","662.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","128.40","11.63","","129.50","124.97","129.50","1 through 10","128.4","854.5","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","outpatient","","","1104.00","662.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","694.42","62.9","","666.54","666.54","666.54","1 through 10","128.4","854.5","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","outpatient","","","1104.00","662.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","128.40","11.63","","92.37","92.37","92.37","1 through 10","128.4","854.5","percent of total billed charges",""
"Oligoclonal Bands","PX-30000589","CDM","83916","CPT","0301","RC","","","","both","","","153.00","91.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","106.79","69.8","","103.30","103.30","103.30","1 through 10","17.8","130.05","percent of total billed charges",""
"Oligoclonal Bands","PX-30000589","CDM","83916","CPT","0301","RC","","","","outpatient","","","153.00","91.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","111.26","72.72","","107.63","107.63","107.63","1 through 10","18.74","118.42","percent of total billed charges",""
"Oligoclonal Bands","PX-30000589","CDM","83916","CPT","0301","RC","","","","outpatient","","","153.00","91.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","111.26","72.72","","107.63","107.63","107.63","1 through 10","18.74","118.42","percent of total billed charges",""
"Oligoclonal Bands","PX-30000589","CDM","83916","CPT","0301","RC","","","","outpatient","","","153.00","91.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","96.24","62.9","","346.88","93.24","346.88","1 through 10","18.74","118.42","percent of total billed charges",""
"Open/Perq Place Stent Same","PX-76001941","CDM","37238","CPT","0761","RC","","","","both","","","28107.00","16864.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","11848.17","","APC Price ($11,848.17). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11620.24","11620.24","11620.24","1 through 10","11611.21","75720.79","other","OPPS APC"
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","both","","","94.00","56.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","65.61","69.8","","63.52","57.24","63.52","1 through 10","13.79","88.81","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","outpatient","","","94.00","56.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","59.01","62.78","","57.13","57.13","57.13","1 through 10","15.34","72.76","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","outpatient","","","94.00","56.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","68.36","72.72","","66.18","66.18","66.18","1 through 10","15.34","72.76","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","outpatient","","","94.00","56.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","50.03","53.22","","48.51","48.51","48.51","1 through 10","15.34","72.76","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","outpatient","","","94.00","56.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","59.13","62.9","","57.33","57.33","171.99","11","15.34","72.76","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","outpatient","","","94.00","56.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","72.76","77.4","","70.53","70.53","70.53","1 through 10","15.34","72.76","percent of total billed charges",""
"Organic Acids Total Qn","PX-30000590","CDM","83918","CPT","0301","RC","","","","outpatient","","","326.00","195.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","205.05","62.9","","198.45","198.45","198.45","1 through 10","15.34","252.32","percent of total billed charges",""
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","33728.86","20237.32","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","12929.96","","Case rate ($12,676.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,734.46, add-ons for qualifying new technology services are included. If operating cost exceeds $15,652.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,698.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,337.74 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,289.59 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $893.81. The transfer capital threshold is the transfer adjustment factor * $893.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","8509.99","8509.99","8509.99","1 through 10","3975","61138.36","other","Inpatient DRG"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","33728.86","20237.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","12422.90","","Case rate ($12,676.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,734.46, add-ons for qualifying new technology services are included. If operating cost exceeds $15,652.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,698.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,337.74 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,289.59 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $893.81. The transfer capital threshold is the transfer adjustment factor * $893.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13080.22","13080.22","13080.22","1 through 10","3975","61138.36","other","Inpatient DRG"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","33728.86","20237.32","MARTIN'S POINT [160007]","HB WDH MEDICARE","12676.43","","Case rate ($12,676.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,734.46, add-ons for qualifying new technology services are included. If operating cost exceeds $15,652.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,698.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,337.74 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,289.59 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $893.81. The transfer capital threshold is the transfer adjustment factor * $893.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Includes an additional $800 of payment.","13379.51","13379.51","13379.51","1 through 10","3975","61138.36","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","33728.86","20237.32","MEDICARE [2001]","HB WDH MEDICARE","12676.43","","Case rate ($12,676.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,734.46, add-ons for qualifying new technology services are included. If operating cost exceeds $15,652.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,698.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $11,337.74 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,289.59 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $893.81. The transfer capital threshold is the transfer adjustment factor * $893.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Includes an additional $800 of payment.","13047.38","11198.80","13080.22","1 through 10","3975","61138.36","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Orthotics Mgmt & Trainj Initial Enctr Ea 15 Mins","PX-42000108","CDM","97760","CPT","0421","RC","","","","both","","","288.00","172.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","194.04","194.04","194.04","1 through 10","46.79","244.8","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Orthotics Mgmt & Trainj Initial Enctr Ea 15 Mins","PX-42000108","CDM","97760","CPT","0421","RC","","","","both","","","288.00","172.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","46.79","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($46.79). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($31.57). Each line will be capped at the line billed amount.","32.26","31.15","45.86","22","46.79","244.8","fee schedule",""
"Orthotics Mgmt & Trainj Initial Enctr Ea 15 Mins","PX-42000108","CDM","97760","CPT","0421","RC","","","","outpatient","","","288.00","172.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","181.15","62.9","","175.14","175.14","175.14","27","33.49","222.91","percent of total billed charges",""
"Orthotics Mgmt & Trainj Initial Enctr Ea 15 Mins","PX-42000108","CDM","97760","CPT","0421","RC","","","","outpatient","","","288.00","172.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","222.91","77.4","","215.45","215.45","215.45","1 through 10","33.49","222.91","percent of total billed charges",""
"Orthotics Mgmt & Trainj Initial Enctr Ea 15 Mins","PX-42000108","CDM","97760","CPT","0421","RC","","","","outpatient","","","288.00","172.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","33.49","11.63","","32.83","32.83","32.83","1 through 10","33.49","222.91","percent of total billed charges",""
"Orthotics Mgmt & Trainj Initial Enctr Ea 15 Mins","PX-43000115","CDM","97760","CPT","0431","RC","","","","both","","","288.00","172.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","194.04","194.04","194.04","1 through 10","46.79","244.8","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Orthotics Mgmt & Trainj Initial Enctr Ea 15 Mins","PX-43000115","CDM","97760","CPT","0431","RC","","","","both","","","288.00","172.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","46.79","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($46.79). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($31.57). Each line will be capped at the line billed amount.","32.26","31.15","45.86","22","46.79","244.8","fee schedule",""
"Orthotics Mgmt & Trainj Initial Enctr Ea 15 Mins","PX-43000115","CDM","97760","CPT","0431","RC","","","","outpatient","","","288.00","172.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","181.15","62.9","","175.14","175.14","175.14","27","33.49","222.91","percent of total billed charges",""
"Orthotics Mgmt & Trainj Initial Enctr Ea 15 Mins","PX-43000115","CDM","97760","CPT","0431","RC","","","","outpatient","","","288.00","172.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","222.91","77.4","","215.45","215.45","215.45","1 through 10","33.49","222.91","percent of total billed charges",""
"Orthotics Mgmt & Trainj Initial Enctr Ea 15 Mins","PX-43000115","CDM","97760","CPT","0431","RC","","","","outpatient","","","288.00","172.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","33.49","11.63","","32.83","32.83","32.83","1 through 10","33.49","222.91","percent of total billed charges",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-42000107","CDM","97763","CPT","0421","RC","","","","both","","","215.00","129.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","150.07","69.8","","144.49","144.49","239.57","1 through 10","51.16","240.42","percent of total billed charges",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-42000107","CDM","97763","CPT","0421","RC","","","","both","","","215.00","129.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","150.07","69.8","","288.97","288.97","288.97","1 through 10","51.16","240.42","percent of total billed charges",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-42000107","CDM","97763","CPT","0421","RC","","","","both","","","215.00","129.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","51.16","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($51.16). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($33.43). Each line will be capped at the line billed amount.","43.48","37.34","50.45","34","51.16","240.42","fee schedule",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-42000107","CDM","97763","CPT","0421","RC","","","","outpatient","","","215.00","129.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","135.24","62.9","","130.41","130.41","130.41","34","94","166.41","percent of total billed charges",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-43000114","CDM","97763","CPT","0431","RC","","","","both","","","215.00","129.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","150.07","69.8","","144.49","144.49","239.57","1 through 10","51.16","240.42","percent of total billed charges",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-43000114","CDM","97763","CPT","0431","RC","","","","both","","","215.00","129.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","150.07","69.8","","288.97","288.97","288.97","1 through 10","51.16","240.42","percent of total billed charges",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-43000114","CDM","97763","CPT","0431","RC","","","","both","","","215.00","129.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","51.16","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($51.16). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($33.43). Each line will be capped at the line billed amount.","43.48","37.34","50.45","34","51.16","240.42","fee schedule",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-43000114","CDM","97763","CPT","0431","RC","","","","outpatient","","","215.00","129.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","135.24","62.9","","130.41","130.41","130.41","34","94","166.41","percent of total billed charges",""
"Osmolality Blood","PX-30000594","CDM","83930","CPT","0301","RC","","","","both","","","95.00","57.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","66.31","69.8","","64.22","64.22","64.22","1 through 10","4.3","80.75","percent of total billed charges",""
"Osmolality Blood","PX-30000594","CDM","83930","CPT","0301","RC","","","","both","","","95.00","57.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","59.76","62.9","","57.96","57.96","57.96","1 through 10","4.3","80.75","percent of total billed charges",""
"Osmolality Blood","PX-30000594","CDM","83930","CPT","0301","RC","","","","both","","","95.00","57.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","73.53","77.4","","71.30","71.30","71.30","1 through 10","4.3","80.75","percent of total billed charges",""
"Osmolality Blood","PX-30000594","CDM","83930","CPT","0301","RC","","","","outpatient","","","95.00","57.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","41.53","43.72","","120.66","120.66","120.66","1 through 10","6.16","69.08","percent of total billed charges",""
"Osmolality Blood","PX-30000594","CDM","83930","CPT","0301","RC","","","","outpatient","","","95.00","57.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","69.08","72.72","","66.90","66.90","66.90","11","6.16","69.08","percent of total billed charges",""
"Osmolality Urine","PX-30000595","CDM","83935","CPT","0301","RC","","","","both","","","97.00","58.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","67.71","69.8","","65.61","65.61","65.61","1 through 10","4.43","82.45","percent of total billed charges",""
"Osmolality Urine","PX-30000595","CDM","83935","CPT","0301","RC","","","","outpatient","","","97.00","58.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","42.41","43.72","","123.30","123.30","123.30","1 through 10","6.35","75.08","percent of total billed charges",""
"Osmolality Urine","PX-30000595","CDM","83935","CPT","0301","RC","","","","outpatient","","","97.00","58.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","70.54","72.72","","68.36","68.36","68.36","12","6.35","75.08","percent of total billed charges",""
"Osmolality Urine","PX-30000595","CDM","83935","CPT","0301","RC","","","","outpatient","","","97.00","58.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","61.01","62.9","","59.22","59.22","59.22","1 through 10","6.35","75.08","percent of total billed charges",""
"Osmolality Urine","PX-30000595","CDM","83935","CPT","0301","RC","","","","outpatient","","","97.00","58.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","75.08","77.4","","72.85","72.85","72.85","1 through 10","6.35","75.08","percent of total billed charges",""
"OSSICLE PISTON .6X4.75MM STAPES ANGULAR TI","SUP-ITM-10232137","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","2875.39","1725.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1808.62","62.9","","2038.65","2038.65","2038.65","1 through 10","1530.28","2225.55","percent of total billed charges",""
"OSSICLE PLESTER 3.25MM ANGULAR TI PARTIAL","SUP-ITM-10232190","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","3110.26","1866.16","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1956.35","62.9","","2038.65","2038.65","2038.65","1 through 10","1655.28","2407.34","percent of total billed charges",""
"Osteocalcin","PX-30000596","CDM","83937","CPT","0301","RC","","","","both","","","344.00","206.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","240.11","69.8","","209.46","209.46","209.46","1 through 10","19.4","292.4","percent of total billed charges",""
"Osteomyelitis With Cc","540","MS-DRG","","","","","","","","inpatient","","","25127.85","15076.71","MEDICARE [2001]","HB WDH MEDICARE","10299.90","","Case rate ($10,299.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,540.96, add-ons for qualifying new technology services are included. If operating cost exceeds $13,459.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,525.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $9,134.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,096.09 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $720.15. The transfer capital threshold is the transfer adjustment factor * $720.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5094.72","5094.72","5094.72","1 through 10","3975","49259.53","other","Inpatient DRG"
"Osteomyelitis With McC","539","MS-DRG","","","","","","","","inpatient","","","63180.13","37908.08","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","15419.39","","Case rate ($15,419.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,266.19, add-ons for qualifying new technology services are included. If operating cost exceeds $18,184.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,899.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $13,880.26 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,821.31 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,094.25. The transfer capital threshold is the transfer adjustment factor * $1,094.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Includes an additional $800 of payment.","15744.69","15744.69","15744.69","1 through 10","3975","74848.8","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Ot Debr/Rem Tiss Addl 20 Sq Cm/Part","PX-43000040","CDM","97598","CPT","0431","RC","","","","outpatient","","","182.00","109.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","26.24","14.42","","25.38","25.38","25.38","1 through 10","21.17","140.87","percent of total billed charges",""
"Ot Debr/Rem Tiss Addl 20 Sq Cm/Part","PX-43000040","CDM","97598","CPT","0431","RC","","","","outpatient","","","182.00","109.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","21.17","11.63","","44.45","44.45","44.45","22","21.17","140.87","percent of total billed charges",""
"Ot Debr/Rem Tiss Addl 20 Sq Cm/Part","PX-43000040","CDM","97598","CPT","0431","RC","","","","outpatient","","","182.00","109.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","21.17","11.63","","20.79","20.79","20.79","12","21.17","140.87","percent of total billed charges",""
"Ot Debride/Rem Dev Tiss <20 Sq Cm","PX-43000039","CDM","97597","CPT","0431","RC","","","","both","","","768.00","460.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","536.06","69.8","","517.22","517.22","517.22","13","34.05","652.8","percent of total billed charges",""
"Ot Debride/Rem Dev Tiss <20 Sq Cm","PX-43000039","CDM","97597","CPT","0431","RC","","","","outpatient","","","768.00","460.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","110.75","14.42","","106.85","91.59","106.85","24","89.32","594.43","percent of total billed charges",""
"Ot Debride/Rem Dev Tiss <20 Sq Cm","PX-43000039","CDM","97597","CPT","0431","RC","","","","outpatient","","","768.00","460.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","89.32","11.63","","102.04","87.53","187.14","49","89.32","594.43","percent of total billed charges",""
"Ot Debride/Rem Dev Tiss <20 Sq Cm","PX-43000039","CDM","97597","CPT","0431","RC","","","","outpatient","","","768.00","460.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","482.15","62.78","","465.20","465.20","465.20","1 through 10","89.32","594.43","percent of total billed charges",""
"Ot Debride/Rem Dev Tiss <20 Sq Cm","PX-43000039","CDM","97597","CPT","0431","RC","","","","outpatient","","","768.00","460.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","558.49","72.72","","538.86","538.86","555.48","34","89.32","594.43","percent of total billed charges",""
"Ot Debride/Rem Dev Tiss <20 Sq Cm","PX-43000039","CDM","97597","CPT","0431","RC","","","","outpatient","","","768.00","460.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","483.07","62.9","","466.83","466.83","466.83","53","89.32","594.43","percent of total billed charges",""
"Ot Debride/Rem Dev Tiss <20 Sq Cm","PX-43000039","CDM","97597","CPT","0431","RC","","","","outpatient","","","768.00","460.80","PHCS MULTIPLAN [1022]","HB WDH AMERIHEALTH CARITAS","110.75","14.42","","106.85","106.85","106.85","1 through 10","89.32","594.43","percent of total billed charges",""
"Ot Debride/Rem Dev Tiss <20 Sq Cm","PX-43000039","CDM","97597","CPT","0431","RC","","","","outpatient","","","768.00","460.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","594.43","77.4","","538.86","503.72","739.84","1 through 10","89.32","594.43","percent of total billed charges",""
"Ot Debride/Rem Dev Tiss <20 Sq Cm","PX-43000039","CDM","97597","CPT","0431","RC","","","","outpatient","","","768.00","460.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","89.32","11.63","","87.53","87.53","437.65","35","89.32","594.43","percent of total billed charges",""
"Ot E-Stim Unattended Other","PX-43000054","CDM","G0283","HCPCS","0431","RC","","","","both","","","85.00","51.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","12.43","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($12.43). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($9.25). Each line will be capped at the line billed amount.","9.15","9.11","9.29","17","5","157.54","fee schedule",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","182.00","109.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","194.66","110.70","216.02","3550","29.13","157.54","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","182.00","109.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","114.19","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($32.11). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($23.78). Each line will be capped at the line billed amount. Final payment is multiplied by 355.62%.","84.78","76.47","88.94","19","29.13","157.54","fee schedule",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","182.00","109.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","114.24","114.24","368.54","59","29.13","157.54","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","182.00","109.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","154.70","85","","100.00","33.76","368.54","26","29.13","157.54","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","182.00","109.20","TRICARE [160005]","HB WDH MEDICARE","29.13","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($29.13). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($21.94). Each line will be capped at the line billed amount.","29.23","29.23","87.69","969","29.13","157.54","fee schedule",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","182.00","109.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","29.13","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($29.13). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($21.94). Each line will be capped at the line billed amount.","24.12","21.76","25.60","7502","29.13","157.54","fee schedule",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","outpatient","","","182.00","109.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","132.35","72.72","","383.96","255.97","383.96","176","21.17","140.87","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","outpatient","","","182.00","109.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","132.35","72.72","","255.97","255.97","383.96","1 through 10","21.17","140.87","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","outpatient","","","182.00","109.20","INTERNATIONAL COMMERCIAL [140001]","HB WDH UNITED HMO / PPO / INDEM","140.87","77.4","","409.20","136.40","409.20","18","21.17","140.87","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","outpatient","","","182.00","109.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","96.86","53.22","","93.83","93.83","93.83","39","21.17","140.87","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","outpatient","","","182.00","109.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","114.48","62.9","","110.88","110.88","110.88","5182","21.17","140.87","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","outpatient","","","182.00","109.20","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","132.35","72.72","","136.40","136.40","136.40","1 through 10","21.17","140.87","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","outpatient","","","182.00","109.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","140.87","77.4","","127.99","127.99","136.40","49","21.17","140.87","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","outpatient","","","182.00","109.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","21.17","11.63","","20.79","20.79","20.79","809","21.17","140.87","percent of total billed charges",""
"Ot Home Instruction/Program 15min","PX-43000034","CDM","97535","CPT","0431","RC","","","","both","","","145.00","87.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","97.72","71.56","169.28","15","32.47","157.54","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Ot Home Instruction/Program 15min","PX-43000034","CDM","97535","CPT","0431","RC","","","","both","","","145.00","87.00","TRICARE [160005]","HB WDH MEDICARE","32.47","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($32.47). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($23.61). Each line will be capped at the line billed amount.","32.57","32.57","32.57","1 through 10","32.47","157.54","fee schedule",""
"Ot Home Instruction/Program 15min","PX-43000034","CDM","97535","CPT","0431","RC","","","","both","","","145.00","87.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","32.47","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($32.47). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($23.61). Each line will be capped at the line billed amount.","23.34","23.14","32.05","38","32.47","157.54","fee schedule",""
"Ot Home Instruction/Program 15min","PX-43000034","CDM","97535","CPT","0431","RC","","","","outpatient","","","145.00","87.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","105.44","72.72","","203.62","101.81","203.62","1 through 10","16.86","112.23","percent of total billed charges",""
"Ot Home Instruction/Program 15min","PX-43000034","CDM","97535","CPT","0431","RC","","","","outpatient","","","145.00","87.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","91.21","62.9","","88.20","88.20","88.20","29","16.86","112.23","percent of total billed charges",""
"Ot Home Instruction/Program 15min","PX-43000034","CDM","97535","CPT","0431","RC","","","","outpatient","","","145.00","87.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16.86","11.63","","16.54","16.53","82.65","21","16.86","112.23","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","both","","","168.00","100.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","86.16","77.64","180.53","1238","27.48","157.54","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","both","","","168.00","100.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","107.65","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($30.27). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($22.53). Each line will be capped at the line billed amount. Final payment is multiplied by 355.62%.","72.48","72.48","72.48","1 through 10","27.48","157.54","fee schedule",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","both","","","168.00","100.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","105.15","105.15","105.15","24","27.48","157.54","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","both","","","168.00","100.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","142.80","85","","38.85","31.44","333.63","11","27.48","157.54","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","both","","","168.00","100.80","TRICARE [160005]","HB WDH MEDICARE","27.48","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($27.48). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($20.79). Each line will be capped at the line billed amount.","27.58","27.34","55.16","390","27.48","157.54","fee schedule",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","both","","","168.00","100.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","27.48","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($27.48). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($20.79). Each line will be capped at the line billed amount.","20.48","18.16","22.75","2463","27.48","157.54","fee schedule",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","outpatient","","","168.00","100.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","122.17","72.72","","353.42","235.61","353.42","65","19.54","130.03","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","outpatient","","","168.00","100.80","INTERNATIONAL COMMERCIAL [140001]","HB WDH UNITED HMO / PPO / INDEM","130.03","77.4","","125.55","125.55","125.55","1 through 10","19.54","130.03","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","outpatient","","","168.00","100.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","89.41","53.22","","86.36","86.36","86.36","23","19.54","130.03","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","outpatient","","","168.00","100.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","105.67","62.9","","102.06","102.06","102.06","2475","19.54","130.03","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","outpatient","","","168.00","100.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","130.03","77.4","","117.81","117.81","117.81","1 through 10","19.54","130.03","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","outpatient","","","168.00","100.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","19.54","11.63","","19.14","19.14","19.14","267","19.54","130.03","percent of total billed charges",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","both","","","209.00","125.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","222.67","127.06","247.82","115","32.4","177.65","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","both","","","209.00","125.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","127.06","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($35.73). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($26.43). Each line will be capped at the line billed amount. Final payment is multiplied by 355.62%.","98.90","98.90","112.83","1 through 10","32.4","177.65","fee schedule",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","both","","","209.00","125.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","177.65","85","","281.99","171.70","281.99","1 through 10","32.4","177.65","percent of total billed charges",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","both","","","209.00","125.40","TRICARE [160005]","HB WDH MEDICARE","32.40","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($32.40). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($24.38). Each line will be capped at the line billed amount.","32.51","32.51","65.02","12","32.4","177.65","fee schedule",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","both","","","209.00","125.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","32.40","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($32.40). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($24.38). Each line will be capped at the line billed amount.","27.86","26.15","31.87","1004","32.4","177.65","fee schedule",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","outpatient","","","209.00","125.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","151.98","72.72","","440.68","293.79","440.68","15","24.31","161.77","percent of total billed charges",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","outpatient","","","209.00","125.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","111.23","53.22","","107.69","107.69","107.69","1 through 10","24.31","161.77","percent of total billed charges",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","outpatient","","","209.00","125.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","131.46","62.9","","127.26","127.26","127.26","318","24.31","161.77","percent of total billed charges",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","outpatient","","","209.00","125.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","24.31","11.63","","23.86","23.86","23.86","61","24.31","161.77","percent of total billed charges",""
"Ot Orthotic Mngmnt/Fit/Tran 15 Min","PX-43000046","CDM","97760","CPT","0431","RC","","","","both","","","288.00","172.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","194.04","194.04","194.04","1 through 10","46.79","244.8","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Ot Orthotic Mngmnt/Fit/Tran 15 Min","PX-43000046","CDM","97760","CPT","0431","RC","","","","both","","","288.00","172.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","46.79","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($46.79). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($31.57). Each line will be capped at the line billed amount.","32.26","31.15","45.86","22","46.79","244.8","fee schedule",""
"Ot Orthotic Mngmnt/Fit/Tran 15 Min","PX-43000046","CDM","97760","CPT","0431","RC","","","","outpatient","","","288.00","172.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","181.15","62.9","","175.14","175.14","175.14","27","33.49","222.91","percent of total billed charges",""
"Ot Orthotic Mngmnt/Fit/Tran 15 Min","PX-43000046","CDM","97760","CPT","0431","RC","","","","outpatient","","","288.00","172.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","222.91","77.4","","215.45","215.45","215.45","1 through 10","33.49","222.91","percent of total billed charges",""
"Ot Orthotic Mngmnt/Fit/Tran 15 Min","PX-43000046","CDM","97760","CPT","0431","RC","","","","outpatient","","","288.00","172.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","33.49","11.63","","32.83","32.83","32.83","1 through 10","33.49","222.91","percent of total billed charges",""
"Ot Paraffin Bath Therapy","PX-43000012","CDM","97018","CPT","0431","RC","","","","both","","","31.00","18.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6.23","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($6.23). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($4.22). Each line will be capped at the line billed amount.","4.24","4.24","4.24","1 through 10","6.23","157.54","fee schedule",""
"Ot Paraffin Bath Therapy","PX-43000012","CDM","97018","CPT","0431","RC","","","","outpatient","","","31.00","18.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","3.61","11.63","","3.54","3.54","3.54","1 through 10","3.61","23.99","percent of total billed charges",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","both","","","240.00","144.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","248.75","115.02","276.96","418","35.16","204","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","both","","","240.00","144.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","139.15","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($39.13). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($27.12). Each line will be capped at the line billed amount. Final payment is multiplied by 355.62%.","122.33","122.33","122.33","1 through 10","35.16","204","fee schedule",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","both","","","240.00","144.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","161.94","124.00","161.94","1 through 10","35.16","204","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","both","","","240.00","144.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","204.00","85","","161.94","35.75","369.98","1 through 10","35.16","204","percent of total billed charges",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","both","","","240.00","144.00","TRICARE [160005]","HB WDH MEDICARE","35.16","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($35.16). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($24.79). Each line will be capped at the line billed amount.","35.26","35.26","70.52","89","35.16","204","fee schedule",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","both","","","240.00","144.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","35.16","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($35.16). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($24.79). Each line will be capped at the line billed amount.","27.98","24.89","34.56","1257","35.16","204","fee schedule",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","outpatient","","","240.00","144.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","34.61","14.42","","32.48","32.48","32.48","1 through 10","27.91","185.76","percent of total billed charges",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","outpatient","","","240.00","144.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","174.53","72.72","","506.13","168.71","506.13","25","27.91","185.76","percent of total billed charges",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","outpatient","","","240.00","144.00","INTERNATIONAL COMMERCIAL [140001]","HB WDH UNITED HMO / PPO / INDEM","185.76","77.4","","232.00","179.80","359.60","1 through 10","27.91","185.76","percent of total billed charges",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","outpatient","","","240.00","144.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","127.73","53.22","","123.68","123.68","123.68","1 through 10","27.91","185.76","percent of total billed charges",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","outpatient","","","240.00","144.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","150.96","62.9","","146.16","146.16","146.16","740","27.91","185.76","percent of total billed charges",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","outpatient","","","240.00","144.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","27.91","11.63","","27.40","27.40","27.41","126","27.91","185.76","percent of total billed charges",""
"Ot Ultrasound 15 Min","PX-43000020","CDM","97035","CPT","0431","RC","","","","both","","","82.00","49.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","41.68","37.56","55.14","37","14.06","157.54","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Ot Ultrasound 15 Min","PX-43000020","CDM","97035","CPT","0431","RC","","","","both","","","82.00","49.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","69.70","85","","18.94","12.17","18.94","1 through 10","14.06","157.54","percent of total billed charges",""
"Ot Ultrasound 15 Min","PX-43000020","CDM","97035","CPT","0431","RC","","","","both","","","82.00","49.20","TRICARE [160005]","HB WDH MEDICARE","14.06","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($14.06). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($10.55). Each line will be capped at the line billed amount.","14.11","14.11","14.11","1 through 10","14.06","157.54","fee schedule",""
"Ot Ultrasound 15 Min","PX-43000020","CDM","97035","CPT","0431","RC","","","","both","","","82.00","49.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","14.06","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($14.06). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($10.55). Each line will be capped at the line billed amount.","10.59","10.41","10.73","47","14.06","157.54","fee schedule",""
"Ot Ultrasound 15 Min","PX-43000020","CDM","97035","CPT","0431","RC","","","","outpatient","","","82.00","49.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","51.58","62.9","","49.77","49.77","49.77","34","9.54","63.47","percent of total billed charges",""
"Ot Ultrasound 15 Min","PX-43000020","CDM","97035","CPT","0431","RC","","","","outpatient","","","82.00","49.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","9.54","11.63","","9.33","9.33","9.33","1 through 10","9.54","63.47","percent of total billed charges",""
"Ot Whirlpool","PX-43000013","CDM","97022","CPT","0431","RC","","","","both","","","78.00","46.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","35.99","32.43","52.35","17","15.78","157.54","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Ot Whirlpool","PX-43000013","CDM","97022","CPT","0431","RC","","","","both","","","78.00","46.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","52.35","52.35","52.35","1 through 10","15.78","157.54","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Ot Whirlpool","PX-43000013","CDM","97022","CPT","0431","RC","","","","both","","","78.00","46.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","15.78","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($15.78). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($10.77). Each line will be capped at the line billed amount.","10.81","10.60","11.64","39","15.78","157.54","fee schedule",""
"Ot Whirlpool","PX-43000013","CDM","97022","CPT","0431","RC","","","","outpatient","","","78.00","46.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","49.06","62.9","","47.25","47.25","47.25","48","9.07","60.37","percent of total billed charges",""
"Ot Whirlpool","PX-43000013","CDM","97022","CPT","0431","RC","","","","outpatient","","","78.00","46.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","9.07","11.63","","8.86","8.86","8.86","1 through 10","9.07","60.37","percent of total billed charges",""
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/McC","819","MS-DRG","","","","","","","","inpatient","","","41719.84","25031.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","26025.11","","Fee schedule rate ($26,025.11). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","24108.87","24108.87","24108.87","1 through 10","3975","32676.29","case rate",""
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","","","","inpatient","","","6922.73","4153.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","4153.00","","Per diem ($4,153). If length of stay < 2.6, first 1 days paid at a per diem of $4,153 instead.","4604.25","4604.25","4604.25","1 through 10","3975","14651.8","per diem","Estimated amount calculated based on 1 day length of stay."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","","","","inpatient","","","6922.73","4153.64","MEDICARE [2001]","HB WDH MEDICARE","5930.79","","Case rate ($5,930.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,508.31, add-ons for qualifying new technology services are included. If operating cost exceeds $9,426.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,205.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,085.04 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,063.44 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.88. The transfer capital threshold is the transfer adjustment factor * $400.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","0.05","1 through 10","3975","14651.8","other","Inpatient DRG"
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","","","","inpatient","","","6922.73","4153.64","WELLPOINT [1015]","HB WDH ANTHEM PPO","8400.00","","Per diem ($8,400). If length of stay < 2.6, first 1 days paid at a per diem of $8,400 instead.","7834.94","7834.94","7834.94","1 through 10","3975","14651.8","per diem","Estimated amount calculated based on 1 day length of stay."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC","833","MS-DRG","","","","","","","","inpatient","","","4114.03","2468.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","19870.25","","Fee schedule rate ($19,870.25). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","4232.12","4232.12","4232.12","1 through 10","3734.36","19870.25","case rate",""
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC","833","MS-DRG","","","","","","","","inpatient","","","4114.03","2468.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","4331.80","","Case rate ($4,420.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $4,114.05, add-ons for qualifying new technology services are included. If operating cost exceeds $8,032.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,095.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,684.82 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $3,669.17 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $290.49. The transfer capital threshold is the transfer adjustment factor * $290.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5979.25","5979.25","5979.25","1 through 10","3734.36","19870.25","other","Inpatient DRG"
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC","833","MS-DRG","","","","","","","","inpatient","","","4114.03","2468.42","TRICARE [160005]","HB WDH MEDICARE","4420.20","","Case rate ($4,420.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $4,114.05, add-ons for qualifying new technology services are included. If operating cost exceeds $8,032.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,095.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $3,684.82 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $3,669.17 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $290.49. The transfer capital threshold is the transfer adjustment factor * $290.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","2559.24","2559.24","2559.24","1 through 10","3734.36","19870.25","other","Inpatient DRG"
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","","","","inpatient","","","39081.45","23448.87","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","15351.91","","Fee schedule rate ($15,351.91). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","15384.75","15384.75","15384.75","1 through 10","3975","38988.1","case rate",""
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","","","","inpatient","","","39081.45","23448.87","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","8080.06","","Case rate ($8,244.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,644.28, add-ons for qualifying new technology services are included. If operating cost exceeds $11,562.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,375.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,230.11 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,199.41 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.99. The transfer capital threshold is the transfer adjustment factor * $569.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8249.41","8249.41","8249.41","1 through 10","3975","38988.1","other","Inpatient DRG"
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","","","","inpatient","","","39081.45","23448.87","MEDICARE [2001]","HB WDH MEDICARE","8244.96","","Case rate ($8,244.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,644.28, add-ons for qualifying new technology services are included. If operating cost exceeds $11,562.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,375.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,230.11 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,199.41 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.99. The transfer capital threshold is the transfer adjustment factor * $569.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8397.05","7674.18","8417.77","1 through 10","3975","38988.1","other","Inpatient DRG"
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","","","","inpatient","","","39081.45","23448.87","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8244.96","","Case rate ($8,244.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,644.28, add-ons for qualifying new technology services are included. If operating cost exceeds $11,562.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,375.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,230.11 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,199.41 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.99. The transfer capital threshold is the transfer adjustment factor * $569.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8397.05","8397.05","8397.05","1 through 10","3975","38988.1","other","Inpatient DRG"
"Other Cerebrovascular Disorders With McC","070","MS-DRG","","","","","","","","inpatient","","","41713.41","25028.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","12839.37","","Case rate ($13,101.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,126.71, add-ons for qualifying new technology services are included. If operating cost exceeds $16,044.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,729.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,731.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,681.84 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $924.87. The transfer capital threshold is the transfer adjustment factor * $924.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","23060.50","23060.50","23060.50","1 through 10","3975","63262.57","other","Inpatient DRG"
"Other Cerebrovascular Disorders With McC","070","MS-DRG","","","","","","","","inpatient","","","41713.41","25028.05","MEDICARE [2001]","HB WDH MEDICARE","13101.40","","Case rate ($13,101.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,126.71, add-ons for qualifying new technology services are included. If operating cost exceeds $16,044.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,729.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,731.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,681.84 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $924.87. The transfer capital threshold is the transfer adjustment factor * $924.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11854.12","11854.12","11854.12","1 through 10","3975","63262.57","other","Inpatient DRG"
"Other Cerebrovascular Disorders With McC","070","MS-DRG","","","","","","","","inpatient","","","41713.41","25028.05","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","13101.40","","Case rate ($13,101.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,126.71, add-ons for qualifying new technology services are included. If operating cost exceeds $16,044.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,729.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,731.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,681.84 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $924.87. The transfer capital threshold is the transfer adjustment factor * $924.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13565.00","13565.00","13565.00","1 through 10","3975","63262.57","other","Inpatient DRG"
"Other Cerebrovascular Disorders With McC","070","MS-DRG","","","","","","","","inpatient","","","41713.41","25028.05","WELLSENSE NH [1050]","HB WDH MEDICARE","13101.40","","Case rate ($13,101.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,126.71, add-ons for qualifying new technology services are included. If operating cost exceeds $16,044.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,729.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $11,731.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,681.84 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $924.87. The transfer capital threshold is the transfer adjustment factor * $924.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9300.37","9300.37","9300.37","1 through 10","3975","63262.57","other","Inpatient DRG"
"Other Cerebrovascular Disorders Without Cc/McC","072","MS-DRG","","","","","","","","inpatient","","","27246.45","16347.87","MEDICARE [2001]","HB WDH MEDICARE","6193.83","","Case rate ($6,193.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,751.10, add-ons for qualifying new technology services are included. If operating cost exceeds $9,669.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,225.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,328.86 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,306.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $420.10. The transfer capital threshold is the transfer adjustment factor * $420.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5604.30","5604.30","5604.30","1 through 10","3975","28735.68","other","Inpatient DRG"
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","","","","inpatient","","","38062.62","22837.57","MEDICARE [2001]","HB WDH MEDICARE","7768.29","","Case rate ($7,768.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,204.31, add-ons for qualifying new technology services are included. If operating cost exceeds $11,122.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,340.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,788.27 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,759.44 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $535.16. The transfer capital threshold is the transfer adjustment factor * $535.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7724.79","7705.87","7724.79","12","3975","36605.5","other","Inpatient DRG"
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","","","","inpatient","","","38062.62","22837.57","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7768.29","","Case rate ($7,768.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,204.31, add-ons for qualifying new technology services are included. If operating cost exceeds $11,122.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,340.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,788.27 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,759.44 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $535.16. The transfer capital threshold is the transfer adjustment factor * $535.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7567.55","7567.55","7567.55","1 through 10","3975","36605.5","other","Inpatient DRG"
"Other Circulatory System Diagnoses With McC","314","MS-DRG","","","","","","","","inpatient","","","45356.21","27213.73","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","16623.42","","Case rate ($16,297.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,076.65, add-ons for qualifying new technology services are included. If operating cost exceeds $18,994.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,963.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,694.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,631.77 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.42. The transfer capital threshold is the transfer adjustment factor * $1,158.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","16736.49","16736.49","16736.49","1 through 10","3975","42339.15","other","Inpatient DRG"
"Other Circulatory System Diagnoses With McC","314","MS-DRG","","","","","","","","inpatient","","","45356.21","27213.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","15971.52","","Case rate ($16,297.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,076.65, add-ons for qualifying new technology services are included. If operating cost exceeds $18,994.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,963.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,694.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,631.77 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.42. The transfer capital threshold is the transfer adjustment factor * $1,158.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6944.12","6944.12","6944.12","1 through 10","3975","42339.15","other","Inpatient DRG"
"Other Circulatory System Diagnoses With McC","314","MS-DRG","","","","","","","","inpatient","","","45356.21","27213.73","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","16786.39","","Case rate ($16,297.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,076.65, add-ons for qualifying new technology services are included. If operating cost exceeds $18,994.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,963.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,694.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,631.77 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.42. The transfer capital threshold is the transfer adjustment factor * $1,158.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","16287.14","16287.14","16287.14","1 through 10","3975","42339.15","other","Inpatient DRG"
"Other Circulatory System Diagnoses With McC","314","MS-DRG","","","","","","","","inpatient","","","45356.21","27213.73","MARTIN'S POINT [160007]","HB WDH MEDICARE","16297.47","","Case rate ($16,297.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,076.65, add-ons for qualifying new technology services are included. If operating cost exceeds $18,994.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,963.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,694.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,631.77 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.42. The transfer capital threshold is the transfer adjustment factor * $1,158.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15789.14","15789.14","15789.14","1 through 10","3975","42339.15","other","Inpatient DRG"
"Other Circulatory System Diagnoses With McC","314","MS-DRG","","","","","","","","inpatient","","","45356.21","27213.73","MEDICARE [2001]","HB WDH MEDICARE","16297.47","","Case rate ($16,297.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,076.65, add-ons for qualifying new technology services are included. If operating cost exceeds $18,994.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,963.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,694.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,631.77 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.42. The transfer capital threshold is the transfer adjustment factor * $1,158.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16694.15","0.05","16736.49","11","3975","42339.15","other","Inpatient DRG"
"Other Circulatory System Diagnoses With McC","314","MS-DRG","","","","","","","","inpatient","","","45356.21","27213.73","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","16297.47","","Case rate ($16,297.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,076.65, add-ons for qualifying new technology services are included. If operating cost exceeds $18,994.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,963.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,694.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,631.77 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,158.42. The transfer capital threshold is the transfer adjustment factor * $1,158.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","50929.99","50929.99","50929.99","1 through 10","3975","42339.15","other","Inpatient DRG"
"Other Circulatory System Diagnoses Without Cc/McC","316","MS-DRG","","","","","","","","inpatient","","","54588.78","32753.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","10206.18","","Fee schedule rate ($10,206.18). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","9966.00","9966.00","9966.00","1 through 10","4637","25919.87","case rate",""
"Other Circulatory System Diagnoses Without Cc/McC","316","MS-DRG","","","","","","","","inpatient","","","54588.78","32753.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","20643.95","","Fee schedule rate ($20,643.95). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","9966.00","9966.00","9966.00","1 through 10","4637","25919.87","case rate",""
"Other Circulatory System Diagnoses Without Cc/McC","316","MS-DRG","","","","","","","","inpatient","","","54588.78","32753.27","MEDICARE [2001]","HB WDH MEDICARE","5630.48","","Case rate ($5,630.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,231.14, add-ons for qualifying new technology services are included. If operating cost exceeds $9,149.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,183.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,806.68 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,786.27 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $378.94. The transfer capital threshold is the transfer adjustment factor * $378.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5609.56","5609.56","5609.56","1 through 10","4637","25919.87","other","Inpatient DRG"
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","","","","inpatient","","","79278.18","47566.91","MARTIN'S POINT [160007]","HB WDH MEDICARE","25841.56","","Case rate ($25,841.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $23,885.74, add-ons for qualifying new technology services are included. If operating cost exceeds $27,803.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,660.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $23,540.85 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $23,440.87 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,855.85. The transfer capital threshold is the transfer adjustment factor * $1,855.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26400.77","26400.77","26400.77","1 through 10","3975","126943.13","other","Inpatient DRG"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","23714.88","14228.93","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","7709.63","","Case rate ($7,558.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,010.64, add-ons for qualifying new technology services are included. If operating cost exceeds $10,928.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,324.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,593.78 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,565.77 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.82. The transfer capital threshold is the transfer adjustment factor * $519.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","7547.42","7547.42","7547.42","1 through 10","3975","35556.69","other","Inpatient DRG"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","23714.88","14228.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","14000.77","","Fee schedule rate ($14,000.77). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","13741.03","13741.03","13741.03","1 through 10","3975","35556.69","case rate",""
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","23714.88","14228.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","7407.29","","Case rate ($7,558.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,010.64, add-ons for qualifying new technology services are included. If operating cost exceeds $10,928.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,324.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,593.78 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,565.77 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.82. The transfer capital threshold is the transfer adjustment factor * $519.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7547.42","7547.42","7547.42","1 through 10","3975","35556.69","other","Inpatient DRG"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","23714.88","14228.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","28319.22","","Fee schedule rate ($28,319.22). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","27793.85","27793.85","27793.85","1 through 10","3975","35556.69","case rate",""
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","23714.88","14228.93","MARTIN'S POINT [160007]","HB WDH MEDICARE","7558.46","","Case rate ($7,558.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,010.64, add-ons for qualifying new technology services are included. If operating cost exceeds $10,928.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,324.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,593.78 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,565.77 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.82. The transfer capital threshold is the transfer adjustment factor * $519.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5496.17","5496.17","5496.17","1 through 10","3975","35556.69","other","Inpatient DRG"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","23714.88","14228.93","MEDICARE [2001]","HB WDH MEDICARE","7558.46","","Case rate ($7,558.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,010.64, add-ons for qualifying new technology services are included. If operating cost exceeds $10,928.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,324.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,593.78 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,565.77 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.82. The transfer capital threshold is the transfer adjustment factor * $519.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7547.42","0.05","7565.92","23","3975","35556.69","other","Inpatient DRG"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","23714.88","14228.93","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7558.46","","Case rate ($7,558.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,010.64, add-ons for qualifying new technology services are included. If operating cost exceeds $10,928.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,324.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,593.78 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,565.77 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $519.82. The transfer capital threshold is the transfer adjustment factor * $519.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7565.92","2770.94","7566.41","1 through 10","3975","35556.69","other","Inpatient DRG"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","23714.88","14228.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","19172.49","","Fee schedule rate ($19,172.49). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","19287.24","19287.24","19287.24","1 through 10","3975","35556.69","case rate",""
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","44230.57","26538.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","14470.00","","Per diem ($14,470). If length of stay < 4.2, first 1 days paid at a per diem of $14,470 instead.","42512.25","42512.25","42512.25","1 through 10","3975","32473.15","per diem","Estimated amount calculated based on 4 day length of stay."
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","44230.57","26538.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","11525.00","","Per diem ($11,525). If length of stay < 4.2, first 1 days paid at a per diem of $11,525 instead.","25673.88","25673.88","25673.88","1 through 10","3975","32473.15","per diem","Estimated amount calculated based on 4 day length of stay."
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","44230.57","26538.34","MARTIN'S POINT [160007]","HB WDH MEDICARE","12603.44","","Case rate ($12,603.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,667.10, add-ons for qualifying new technology services are included. If operating cost exceeds $15,585.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,693.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $11,270.09 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,222.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.48. The transfer capital threshold is the transfer adjustment factor * $888.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14324.99","14324.99","14324.99","1 through 10","3975","32473.15","other","Inpatient DRG"
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","44230.57","26538.34","MEDICARE [2001]","HB WDH MEDICARE","12603.44","","Case rate ($12,603.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,667.10, add-ons for qualifying new technology services are included. If operating cost exceeds $15,585.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,693.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $11,270.09 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,222.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.48. The transfer capital threshold is the transfer adjustment factor * $888.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12940.24","0.05","12972.79","22","3975","32473.15","other","Inpatient DRG"
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","44230.57","26538.34","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","12603.44","","Case rate ($12,603.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,667.10, add-ons for qualifying new technology services are included. If operating cost exceeds $15,585.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,693.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $11,270.09 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,222.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.48. The transfer capital threshold is the transfer adjustment factor * $888.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12973.66","12973.66","15006.73","1 through 10","3975","32473.15","other","Inpatient DRG"
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","44230.57","26538.34","WELLSENSE NH [1050]","HB WDH MEDICARE","12603.44","","Case rate ($12,603.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,667.10, add-ons for qualifying new technology services are included. If operating cost exceeds $15,585.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,693.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $11,270.09 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,222.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $888.48. The transfer capital threshold is the transfer adjustment factor * $888.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13345.10","13345.10","13345.10","1 through 10","3975","32473.15","other","Inpatient DRG"
"Other Digestive System Diagnoses Without Cc/McC","395","MS-DRG","","","","","","","","inpatient","","","30527.98","18316.79","MEDICARE [2001]","HB WDH MEDICARE","5378.85","","Case rate ($5,378.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $4,998.88, add-ons for qualifying new technology services are included. If operating cost exceeds $8,917.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,165.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,573.43 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,554.01 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.55. The transfer capital threshold is the transfer adjustment factor * $360.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5246.78","5246.78","5246.78","1 through 10","3975","24662.06","other","Inpatient DRG"
"Other Digestive System Diagnoses Without Cc/McC","395","MS-DRG","","","","","","","","inpatient","","","30527.98","18316.79","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","5378.85","","Case rate ($5,378.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $4,998.88, add-ons for qualifying new technology services are included. If operating cost exceeds $8,917.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,165.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,573.43 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,554.01 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $360.55. The transfer capital threshold is the transfer adjustment factor * $360.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5259.29","5259.29","5259.29","1 through 10","3975","24662.06","other","Inpatient DRG"
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","","","","inpatient","","","50896.49","30537.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","34796.18","","Fee schedule rate ($34,796.18). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","32874.53","32874.53","32874.53","1 through 10","3975","88369.23","case rate",""
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","","","","inpatient","","","50896.49","30537.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","17761.83","","Case rate ($18,124.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $16,762.82, add-ons for qualifying new technology services are included. If operating cost exceeds $20,681.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,096.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $16,387.55 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $16,317.95 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,291.92. The transfer capital threshold is the transfer adjustment factor * $1,291.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","17481.67","17481.67","17481.67","1 through 10","3975","88369.23","other","Inpatient DRG"
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","","","","inpatient","","","50896.49","30537.89","MEDICARE [2001]","HB WDH MEDICARE","18124.32","","Case rate ($18,124.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $16,762.82, add-ons for qualifying new technology services are included. If operating cost exceeds $20,681.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,096.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $16,387.55 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $16,317.95 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,291.92. The transfer capital threshold is the transfer adjustment factor * $1,291.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","0.05","1 through 10","3975","88369.23","other","Inpatient DRG"
"Other Digestive System O.R. Procedures With McC","356","MS-DRG","","","","","","","","inpatient","","","161428.38","96857.03","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","34856.08","","Case rate ($33,840.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $31,268.99, add-ons for qualifying new technology services are included. If operating cost exceeds $35,187.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,245.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $30,955.59 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $30,824.12 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,440.39. The transfer capital threshold is the transfer adjustment factor * $2,440.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","4873.18","4873.18","4873.18","1 through 10","3975","166926.84","other","Inpatient DRG"
"Other Digestive System O.R. Procedures With McC","356","MS-DRG","","","","","","","","inpatient","","","161428.38","96857.03","MEDICARE [2001]","HB WDH MEDICARE","33840.85","","Case rate ($33,840.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $31,268.99, add-ons for qualifying new technology services are included. If operating cost exceeds $35,187.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,245.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $30,955.59 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $30,824.12 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,440.39. The transfer capital threshold is the transfer adjustment factor * $2,440.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","39860.30","39860.30","39860.30","1 through 10","3975","166926.84","other","Inpatient DRG"
"Other Digestive System O.R. Procedures Without Cc/McC","358","MS-DRG","","","","","","","","inpatient","","","52492.36","31495.42","MEDICARE [2001]","HB WDH MEDICARE","11072.30","","Case rate ($11,072.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,253.88, add-ons for qualifying new technology services are included. If operating cost exceeds $14,172.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,581.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $9,850.85 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,809.01 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.59. The transfer capital threshold is the transfer adjustment factor * $776.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10669.77","10669.77","10669.77","1 through 10","3975","53120.34","other","Inpatient DRG"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","36156.00","21693.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","15307.03","","Fee schedule rate ($15,307.03). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","5151.60","5151.60","5151.60","1 through 10","3975","38874.1","case rate",""
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","36156.00","21693.60","MEDICARE [2001]","HB WDH MEDICARE","8222.18","","Case rate ($8,222.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,623.23, add-ons for qualifying new technology services are included. If operating cost exceeds $11,541.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,373.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,208.97 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,178.35 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $568.32. The transfer capital threshold is the transfer adjustment factor * $568.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8433.27","2662.62","8454.08","17","3975","38874.1","other","Inpatient DRG"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","36156.00","21693.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8222.18","","Case rate ($8,222.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,623.23, add-ons for qualifying new technology services are included. If operating cost exceeds $11,541.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,373.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,208.97 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,178.35 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $568.32. The transfer capital threshold is the transfer adjustment factor * $568.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8298.80","5677.16","8433.27","1 through 10","3975","38874.1","other","Inpatient DRG"
"Other Disorders Of Nervous System With McC","091","MS-DRG","","","","","","","","inpatient","","","52889.11","31733.47","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","14072.18","","Case rate ($13,796.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,768.06, add-ons for qualifying new technology services are included. If operating cost exceeds $16,686.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,780.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,375.75 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,323.19 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $975.65. The transfer capital threshold is the transfer adjustment factor * $975.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","57968.85","57968.85","57968.85","1 through 10","3975","66735.78","other","Inpatient DRG"
"Other Disorders Of Nervous System With McC","091","MS-DRG","","","","","","","","inpatient","","","52889.11","31733.47","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","14210.14","","Case rate ($13,796.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,768.06, add-ons for qualifying new technology services are included. If operating cost exceeds $16,686.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,780.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,375.75 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,323.19 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $975.65. The transfer capital threshold is the transfer adjustment factor * $975.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","45052.68","45052.68","45052.68","1 through 10","3975","66735.78","other","Inpatient DRG"
"Other Disorders Of Nervous System With McC","091","MS-DRG","","","","","","","","inpatient","","","52889.11","31733.47","MARTIN'S POINT [160007]","HB WDH MEDICARE","13796.25","","Case rate ($13,796.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,768.06, add-ons for qualifying new technology services are included. If operating cost exceeds $16,686.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,780.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,375.75 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,323.19 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $975.65. The transfer capital threshold is the transfer adjustment factor * $975.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16422.23","16422.23","16422.23","1 through 10","3975","66735.78","other","Inpatient DRG"
"Other Disorders Of Nervous System With McC","091","MS-DRG","","","","","","","","inpatient","","","52889.11","31733.47","MEDICARE [2001]","HB WDH MEDICARE","13796.25","","Case rate ($13,796.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,768.06, add-ons for qualifying new technology services are included. If operating cost exceeds $16,686.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,780.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,375.75 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,323.19 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $975.65. The transfer capital threshold is the transfer adjustment factor * $975.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14199.59","0.05","14236.38","14","3975","66735.78","other","Inpatient DRG"
"Other Disorders Of Nervous System With McC","091","MS-DRG","","","","","","","","inpatient","","","52889.11","31733.47","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","13796.25","","Case rate ($13,796.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,768.06, add-ons for qualifying new technology services are included. If operating cost exceeds $16,686.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,780.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,375.75 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,323.19 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $975.65. The transfer capital threshold is the transfer adjustment factor * $975.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12484.25","12484.25","12484.25","1 through 10","3975","66735.78","other","Inpatient DRG"
"Other Disorders Of Nervous System Without Cc/McC","093","MS-DRG","","","","","","","","inpatient","","","39319.38","23591.63","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","24100.24","","Fee schedule rate ($24,100.24). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","23305.74","23305.74","23305.74","1 through 10","3975","30259.48","case rate",""
"Other Disorders Of The Eye Without McC","125","MS-DRG","","","","","","","","inpatient","","","33663.66","20198.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","23237.68","","Fee schedule rate ($23,237.68). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","12053.51","12053.51","12053.51","1 through 10","3975","29176.48","case rate",""
"Other Disorders Of The Eye Without McC","125","MS-DRG","","","","","","","","inpatient","","","33663.66","20198.20","MEDICARE [2001]","HB WDH MEDICARE","6282.01","","Case rate ($6,282.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,832.49, add-ons for qualifying new technology services are included. If operating cost exceeds $9,750.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,231.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,410.60 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,387.63 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $426.55. The transfer capital threshold is the transfer adjustment factor * $426.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6675.15","895.32","6691.39","1 through 10","3975","29176.48","other","Inpatient DRG"
"Other Ear, Nose, Mouth And Throat Diagnoses With McC","154","MS-DRG","","","","","","","","inpatient","","","52912.87","31747.72","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","12701.21","","Case rate ($12,331.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,415.89, add-ons for qualifying new technology services are included. If operating cost exceeds $15,334.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,673.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,017.82 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,971.02 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $868.59. The transfer capital threshold is the transfer adjustment factor * $868.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","12353.28","12353.28","12353.28","1 through 10","3975","59413.16","other","Inpatient DRG"
"Other Ear, Nose, Mouth And Throat Diagnoses With McC","154","MS-DRG","","","","","","","","inpatient","","","52912.87","31747.72","MEDICARE [2001]","HB WDH MEDICARE","12331.27","","Case rate ($12,331.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,415.89, add-ons for qualifying new technology services are included. If operating cost exceeds $15,334.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,673.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,017.82 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,971.02 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $868.59. The transfer capital threshold is the transfer adjustment factor * $868.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12716.13","12716.13","12716.13","1 through 10","3975","59413.16","other","Inpatient DRG"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","","","","inpatient","","","50313.66","30188.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","16668.87","","Case rate ($17,009.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,733.43, add-ons for qualifying new technology services are included. If operating cost exceeds $19,651.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,015.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $15,353.77 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,288.56 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.42. The transfer capital threshold is the transfer adjustment factor * $1,210.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14167.33","14167.33","14167.33","1 through 10","3975","82794.62","other","Inpatient DRG"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","","","","inpatient","","","50313.66","30188.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","17009.05","","Case rate ($17,009.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,733.43, add-ons for qualifying new technology services are included. If operating cost exceeds $19,651.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,015.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $15,353.77 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,288.56 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.42. The transfer capital threshold is the transfer adjustment factor * $1,210.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13881.04","13881.04","13881.04","1 through 10","3975","82794.62","other","Inpatient DRG"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","","","","inpatient","","","50313.66","30188.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","17009.05","","Case rate ($17,009.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,733.43, add-ons for qualifying new technology services are included. If operating cost exceeds $19,651.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,015.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $15,353.77 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,288.56 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.42. The transfer capital threshold is the transfer adjustment factor * $1,210.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11218.07","11218.07","11218.07","1 through 10","3975","82794.62","other","Inpatient DRG"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","","","","inpatient","","","50313.66","30188.20","WELLSENSE NH [1050]","HB WDH MEDICARE","17009.05","","Case rate ($17,009.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,733.43, add-ons for qualifying new technology services are included. If operating cost exceeds $19,651.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,015.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $15,353.77 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,288.56 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,210.42. The transfer capital threshold is the transfer adjustment factor * $1,210.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17928.46","17928.46","17928.46","1 through 10","3975","82794.62","other","Inpatient DRG"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With McC","628","MS-DRG","","","","","","","","inpatient","","","56407.03","33844.22","MEDICARE [2001]","HB WDH MEDICARE","28777.63","","Case rate ($28,777.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $26,595.70, add-ons for qualifying new technology services are included. If operating cost exceeds $30,513.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,875.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $26,262.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $26,150.82 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,070.40. The transfer capital threshold is the transfer adjustment factor * $2,070.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","30217.30","30217.30","30294.88","1 through 10","3975","141618.77","other","Inpatient DRG"
"Other Factors Influencing Health Status","951","MS-DRG","","","","","","","","inpatient","","","4603.39","2762.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","16827.50","","Fee schedule rate ($16,827.50). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","3226.63","3226.63","3226.63","1 through 10","3970.75","21128.06","case rate",""
"Other Factors Influencing Health Status","951","MS-DRG","","","","","","","","inpatient","","","4603.39","2762.03","MEDICARE [2001]","HB WDH MEDICARE","4671.81","","Case rate ($4,671.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $4,346.30, add-ons for qualifying new technology services are included. If operating cost exceeds $8,264.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,113.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $3,918.07 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $3,901.43 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $308.88. The transfer capital threshold is the transfer adjustment factor * $308.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1095.27","1095.27","1095.27","1 through 10","3970.75","21128.06","other","Inpatient DRG"
"Other Heart Assist System Implant","215","MS-DRG","","","","","","","","inpatient","","","157813.13","94687.88","MEDICARE [2001]","HB WDH MEDICARE","76142.31","","Case rate ($76,142.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $70,312.78, add-ons for qualifying new technology services are included. If operating cost exceeds $74,230.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $53,336.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $70,165.90 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $69,867.91 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,531.55. The transfer capital threshold is the transfer adjustment factor * $5,531.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","40330.36","40330.36","68518.57","1 through 10","4637","202172.9","other","Inpatient DRG"
"Other Hepatobiliary Or Pancreas O.R. Procedures With McC","423","MS-DRG","","","","","","","","inpatient","","","94614.68","56768.81","MEDICARE [2001]","HB WDH MEDICARE","32017.79","","Case rate ($32,017.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $29,586.32, add-ons for qualifying new technology services are included. If operating cost exceeds $33,504.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,112.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.1. The base transfer operating payment is the transfer adjustment factor * $29,265.74 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $29,141.45 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,307.17. The transfer capital threshold is the transfer adjustment factor * $2,307.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","31215.56","31215.56","31215.56","1 through 10","3975","157814.42","other","Inpatient DRG"
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","","","","inpatient","","","44763.94","26858.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","39181.90","","Fee schedule rate ($39,181.90). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","38930.64","38930.64","38930.64","1 through 10","3975","39181.9","case rate",""
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","","","","inpatient","","","44763.94","26858.36","MEDICARE [2001]","HB WDH MEDICARE","8283.74","","Case rate ($8,283.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,680.06, add-ons for qualifying new technology services are included. If operating cost exceeds $11,598.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,377.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,266.05 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,235.19 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $572.82. The transfer capital threshold is the transfer adjustment factor * $572.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8368.37","5105.44","8389.02","1 through 10","3975","39181.9","other","Inpatient DRG"
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","","","","inpatient","","","44763.94","26858.36","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8283.74","","Case rate ($8,283.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,680.06, add-ons for qualifying new technology services are included. If operating cost exceeds $11,598.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,377.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,266.05 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,235.19 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $572.82. The transfer capital threshold is the transfer adjustment factor * $572.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8224.71","8224.71","8224.71","1 through 10","3975","39181.9","other","Inpatient DRG"
"Other Infectious And Parasitic Diseases Diagnoses With McC","867","MS-DRG","","","","","","","","inpatient","","","39394.30","23636.58","MEDICARE [2001]","HB WDH MEDICARE","16358.27","","Case rate ($16,358.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,132.77, add-ons for qualifying new technology services are included. If operating cost exceeds $19,050.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,967.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $14,750.55 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,687.91 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,162.86. The transfer capital threshold is the transfer adjustment factor * $1,162.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16624.73","16624.73","16624.73","1 through 10","3975","79541.81","other","Inpatient DRG"
"Other Infectious And Parasitic Diseases Diagnoses With McC","867","MS-DRG","","","","","","","","inpatient","","","39394.30","23636.58","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","16358.27","","Case rate ($16,358.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,132.77, add-ons for qualifying new technology services are included. If operating cost exceeds $19,050.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,967.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $14,750.55 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,687.91 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,162.86. The transfer capital threshold is the transfer adjustment factor * $1,162.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16367.40","16367.40","16367.40","1 through 10","3975","79541.81","other","Inpatient DRG"
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/McC","869","MS-DRG","","","","","","","","inpatient","","","72129.31","43277.59","MEDICARE [2001]","HB WDH MEDICARE","5992.37","","Case rate ($5,992.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,565.15, add-ons for qualifying new technology services are included. If operating cost exceeds $9,483.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,210.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,142.12 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,120.28 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $405.38. The transfer capital threshold is the transfer adjustment factor * $405.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5888.71","5888.71","5888.71","1 through 10","3975","27728.67","other","Inpatient DRG"
"Other Injury, Poisoning And Toxic Effect Diagnoses With McC","922","MS-DRG","","","","","","","","inpatient","","","28326.65","16995.99","MARTIN'S POINT [160007]","HB WDH MEDICARE","13744.57","","Case rate ($13,744.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,720.34, add-ons for qualifying new technology services are included. If operating cost exceeds $16,638.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,776.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $12,327.83 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,275.48 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.87. The transfer capital threshold is the transfer adjustment factor * $971.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5644.97","5644.97","5644.97","1 through 10","3975","66477.37","other","Inpatient DRG"
"Other Injury, Poisoning And Toxic Effect Diagnoses With McC","922","MS-DRG","","","","","","","","inpatient","","","28326.65","16995.99","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","13744.57","","Case rate ($13,744.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,720.34, add-ons for qualifying new technology services are included. If operating cost exceeds $16,638.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,776.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $12,327.83 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,275.48 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.87. The transfer capital threshold is the transfer adjustment factor * $971.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12971.83","12971.83","12971.83","1 through 10","3975","66477.37","other","Inpatient DRG"
"Other Injury, Poisoning And Toxic Effect Diagnoses Without McC","923","MS-DRG","","","","","","","","inpatient","","","18259.38","10955.63","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8181.87","","Case rate ($8,181.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,586.04, add-ons for qualifying new technology services are included. If operating cost exceeds $11,504.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,370.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,171.62 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,141.16 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $565.38. The transfer capital threshold is the transfer adjustment factor * $565.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8140.50","8140.50","8140.50","1 through 10","3975","38672.7","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","28091.36","16854.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","7998.12","","Case rate ($8,161.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,567.09, add-ons for qualifying new technology services are included. If operating cost exceeds $11,485.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,368.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,152.60 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,122.22 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.88. The transfer capital threshold is the transfer adjustment factor * $563.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8140.50","8140.50","8140.50","1 through 10","3975","38570.1","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","28091.36","16854.82","MARTIN'S POINT [160007]","HB WDH MEDICARE","8161.35","","Case rate ($8,161.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,567.09, add-ons for qualifying new technology services are included. If operating cost exceeds $11,485.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,368.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,152.60 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,122.22 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.88. The transfer capital threshold is the transfer adjustment factor * $563.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8025.29","8025.29","8025.29","1 through 10","3975","38570.1","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","28091.36","16854.82","MEDICARE [2001]","HB WDH MEDICARE","8161.35","","Case rate ($8,161.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,567.09, add-ons for qualifying new technology services are included. If operating cost exceeds $11,485.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,368.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,152.60 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,122.22 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.88. The transfer capital threshold is the transfer adjustment factor * $563.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8140.50","0.05","8160.55","29","3975","38570.1","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","28091.36","16854.82","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8161.35","","Case rate ($8,161.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,567.09, add-ons for qualifying new technology services are included. If operating cost exceeds $11,485.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,368.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $7,152.60 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,122.22 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.88. The transfer capital threshold is the transfer adjustment factor * $563.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8011.89","8011.89","8011.89","1 through 10","3975","38570.1","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","41963.28","25177.97","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","13282.79","","Case rate ($13,022.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,053.74, add-ons for qualifying new technology services are included. If operating cost exceeds $15,971.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,724.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,658.38 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,608.87 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $919.09. The transfer capital threshold is the transfer adjustment factor * $919.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","13128.11","13128.11","13128.11","1 through 10","3975","62867.37","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","41963.28","25177.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","62867.37","","Fee schedule rate ($62,867.37). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","54237.82","54237.82","54237.82","1 through 10","3975","62867.37","case rate",""
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","41963.28","25177.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","24754.59","","Fee schedule rate ($24,754.59). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","24537.66","24537.66","24537.66","1 through 10","3975","62867.37","case rate",""
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","41963.28","25177.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","12761.89","","Case rate ($13,022.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,053.74, add-ons for qualifying new technology services are included. If operating cost exceeds $15,971.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,724.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,658.38 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,608.87 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $919.09. The transfer capital threshold is the transfer adjustment factor * $919.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12899.07","12899.07","12899.07","1 through 10","3975","62867.37","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","41963.28","25177.97","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","13413.01","","Case rate ($13,022.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,053.74, add-ons for qualifying new technology services are included. If operating cost exceeds $15,971.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,724.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,658.38 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,608.87 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $919.09. The transfer capital threshold is the transfer adjustment factor * $919.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","12712.81","12712.81","12712.81","1 through 10","3975","62867.37","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","41963.28","25177.97","MARTIN'S POINT [160007]","HB WDH MEDICARE","13022.34","","Case rate ($13,022.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,053.74, add-ons for qualifying new technology services are included. If operating cost exceeds $15,971.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,724.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,658.38 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,608.87 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $919.09. The transfer capital threshold is the transfer adjustment factor * $919.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12920.85","12920.85","12920.85","1 through 10","3975","62867.37","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","41963.28","25177.97","MEDICARE [2001]","HB WDH MEDICARE","13022.34","","Case rate ($13,022.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,053.74, add-ons for qualifying new technology services are included. If operating cost exceeds $15,971.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,724.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,658.38 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,608.87 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $919.09. The transfer capital threshold is the transfer adjustment factor * $919.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13128.11","0.05","13161.16","41","3975","62867.37","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","41963.28","25177.97","TRICARE [160005]","HB WDH MEDICARE","13022.34","","Case rate ($13,022.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,053.74, add-ons for qualifying new technology services are included. If operating cost exceeds $15,971.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,724.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,658.38 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,608.87 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $919.09. The transfer capital threshold is the transfer adjustment factor * $919.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13471.10","13471.10","13471.10","1 through 10","3975","62867.37","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","41963.28","25177.97","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","13022.34","","Case rate ($13,022.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,053.74, add-ons for qualifying new technology services are included. If operating cost exceeds $15,971.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,724.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $11,658.38 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,608.87 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $919.09. The transfer capital threshold is the transfer adjustment factor * $919.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12897.94","8234.67","13161.16","1 through 10","3975","62867.37","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","41963.28","25177.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","33898.66","","Fee schedule rate ($33,898.66). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","33438.14","33438.14","33438.14","1 through 10","3975","62867.37","case rate",""
"Other Kidney And Urinary Tract Diagnoses Without Cc/McC","700","MS-DRG","","","","","","","","inpatient","","","10927.82","6556.69","MEDICARE [2001]","HB WDH MEDICARE","5689.78","","Case rate ($5,689.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,285.87, add-ons for qualifying new technology services are included. If operating cost exceeds $9,204.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,188.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $4,861.65 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,841.00 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $383.27. The transfer capital threshold is the transfer adjustment factor * $383.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5696.55","5696.55","5696.55","1 through 10","3975","26216.27","other","Inpatient DRG"
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","","","","inpatient","","","72434.60","43460.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","70778.38","","Fee schedule rate ($70,778.38). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","68160.35","68160.35","68160.35","1 through 10","3975","88867.03","case rate",""
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","","","","inpatient","","","72434.60","43460.76","MEDICARE [2001]","HB WDH MEDICARE","18223.92","","Case rate ($18,223.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $16,854.74, add-ons for qualifying new technology services are included. If operating cost exceeds $20,772.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,104.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $16,479.86 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $16,409.87 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,299.19. The transfer capital threshold is the transfer adjustment factor * $1,299.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","17909.54","1 through 10","3975","88867.03","other","Inpatient DRG"
"Other Kidney And Urinary Tract Procedures With McC","673","MS-DRG","","","","","","","","inpatient","","","125423.61","75254.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","127162.60","","Fee schedule rate ($127,162.60). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","74327.58","74327.58","74327.58","1 through 10","3975","159661.22","case rate",""
"Other Kidney And Urinary Tract Procedures With McC","673","MS-DRG","","","","","","","","inpatient","","","125423.61","75254.17","MEDICARE [2001]","HB WDH MEDICARE","32387.25","","Case rate ($32,387.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $29,927.34, add-ons for qualifying new technology services are included. If operating cost exceeds $33,845.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,139.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $29,608.22 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $29,482.48 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,334.17. The transfer capital threshold is the transfer adjustment factor * $2,334.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","32140.03","32140.03","32140.03","1 through 10","3975","159661.22","other","Inpatient DRG"
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","","","","inpatient","","","101014.92","60608.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","135139.76","","Fee schedule rate ($135,139.76). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","34512.20","34512.20","34512.20","1 through 10","3975","135139.76","case rate",""
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","","","","inpatient","","","101014.92","60608.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","107632.42","","Fee schedule rate ($107,632.42). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","101703.14","101703.14","211660.10","1 through 10","3975","135139.76","case rate",""
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","","","","inpatient","","","101014.92","60608.95","MARTIN'S POINT [160007]","HB WDH MEDICARE","27481.41","","Case rate ($27,481.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $25,399.30, add-ons for qualifying new technology services are included. If operating cost exceeds $29,317.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,780.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $25,060.86 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $24,954.43 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,975.68. The transfer capital threshold is the transfer adjustment factor * $1,975.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","25913.53","25913.53","32379.91","1 through 10","3975","135139.76","other","Inpatient DRG"
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","","","","inpatient","","","101014.92","60608.95","MEDICARE [2001]","HB WDH MEDICARE","27481.41","","Case rate ($27,481.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $25,399.30, add-ons for qualifying new technology services are included. If operating cost exceeds $29,317.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,780.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $25,060.86 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $24,954.43 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,975.68. The transfer capital threshold is the transfer adjustment factor * $1,975.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","26434.72","26434.72","29582.21","1 through 10","3975","135139.76","other","Inpatient DRG"
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","","","","inpatient","","","101014.92","60608.95","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","27481.41","","Case rate ($27,481.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $25,399.30, add-ons for qualifying new technology services are included. If operating cost exceeds $29,317.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,780.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $25,060.86 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $24,954.43 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,975.68. The transfer capital threshold is the transfer adjustment factor * $1,975.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","26434.72","26434.72","26434.72","1 through 10","3975","135139.76","other","Inpatient DRG"
"Other Major Cardiovascular Procedures With McC","270","MS-DRG","","","","","","","","inpatient","","","142468.48","85481.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","159688.70","","Fee schedule rate ($159,688.70). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","101464.71","101464.71","166862.75","1 through 10","3975","200499.93","case rate",""
"Other Major Cardiovascular Procedures With McC","270","MS-DRG","","","","","","","","inpatient","","","142468.48","85481.09","MARTIN'S POINT [160007]","HB WDH MEDICARE","40557.60","","Case rate ($40,557.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $37,468.48, add-ons for qualifying new technology services are included. If operating cost exceeds $41,386.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,736.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $37,181.51 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $37,023.61 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,931.21. The transfer capital threshold is the transfer adjustment factor * $2,931.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","19243.16","19243.16","19243.16","1 through 10","3975","200499.93","other","Inpatient DRG"
"Other Major Cardiovascular Procedures With McC","270","MS-DRG","","","","","","","","inpatient","","","142468.48","85481.09","MEDICARE [2001]","HB WDH MEDICARE","40557.60","","Case rate ($40,557.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $37,468.48, add-ons for qualifying new technology services are included. If operating cost exceeds $41,386.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,736.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $37,181.51 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $37,023.61 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,931.21. The transfer capital threshold is the transfer adjustment factor * $2,931.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","39176.16","0.05","39277.08","1 through 10","3975","200499.93","other","Inpatient DRG"
"Other Major Cardiovascular Procedures With McC","270","MS-DRG","","","","","","","","inpatient","","","142468.48","85481.09","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","40557.60","","Case rate ($40,557.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $37,468.48, add-ons for qualifying new technology services are included. If operating cost exceeds $41,386.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,736.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $37,181.51 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $37,023.61 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,931.21. The transfer capital threshold is the transfer adjustment factor * $2,931.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","42066.21","42066.21","42066.21","1 through 10","3975","200499.93","other","Inpatient DRG"
"Other Major Cardiovascular Procedures Without Cc/McC","272","MS-DRG","","","","","","","","inpatient","","","87585.87","52551.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","77267.26","","Fee schedule rate ($77,267.26). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","73882.70","73882.70","73882.70","1 through 10","3975","97014.26","case rate",""
"Other Major Cardiovascular Procedures Without Cc/McC","272","MS-DRG","","","","","","","","inpatient","","","87585.87","52551.52","MARTIN'S POINT [160007]","HB WDH MEDICARE","19853.89","","Case rate ($19,853.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $18,359.18, add-ons for qualifying new technology services are included. If operating cost exceeds $22,277.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,223.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $17,990.71 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,914.31 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,418.30. The transfer capital threshold is the transfer adjustment factor * $1,418.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","19003.00","19003.00","19003.00","1 through 10","3975","97014.26","other","Inpatient DRG"
"Other Major Cardiovascular Procedures Without Cc/McC","272","MS-DRG","","","","","","","","inpatient","","","87585.87","52551.52","MEDICARE [2001]","HB WDH MEDICARE","19853.89","","Case rate ($19,853.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $18,359.18, add-ons for qualifying new technology services are included. If operating cost exceeds $22,277.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,223.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $17,990.71 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,914.31 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,418.30. The transfer capital threshold is the transfer adjustment factor * $1,418.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","0.05","0.05","0.05","1 through 10","3975","97014.26","other","Inpatient DRG"
"Other Major Cardiovascular Procedures Without Cc/McC","272","MS-DRG","","","","","","","","inpatient","","","87585.87","52551.52","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","19853.89","","Case rate ($19,853.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $18,359.18, add-ons for qualifying new technology services are included. If operating cost exceeds $22,277.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,223.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $17,990.71 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,914.31 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,418.30. The transfer capital threshold is the transfer adjustment factor * $1,418.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","19374.49","19374.49","19374.49","1 through 10","3975","97014.26","other","Inpatient DRG"
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","","","","inpatient","","","36289.14","21773.48","MEDICARE [2001]","HB WDH MEDICARE","12096.36","","Case rate ($12,096.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,199.07, add-ons for qualifying new technology services are included. If operating cost exceeds $15,117.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,656.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,800.07 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,754.20 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $851.43. The transfer capital threshold is the transfer adjustment factor * $851.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11793.36","11793.36","11793.36","1 through 10","3975","58238.95","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","","","","inpatient","","","37151.83","22291.10","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","8009.74","","Case rate ($7,852.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,282.20, add-ons for qualifying new technology services are included. If operating cost exceeds $11,200.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,346.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,866.49 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,837.33 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $541.32. The transfer capital threshold is the transfer adjustment factor * $541.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","8138.94","8138.94","8138.94","1 through 10","3975","37027.3","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","","","","inpatient","","","37151.83","22291.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","7695.64","","Case rate ($7,852.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,282.20, add-ons for qualifying new technology services are included. If operating cost exceeds $11,200.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,346.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,866.49 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,837.33 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $541.32. The transfer capital threshold is the transfer adjustment factor * $541.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8009.73","8009.73","8009.73","1 through 10","3975","37027.3","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","","","","inpatient","","","37151.83","22291.10","MEDICARE [2001]","HB WDH MEDICARE","7852.69","","Case rate ($7,852.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,282.20, add-ons for qualifying new technology services are included. If operating cost exceeds $11,200.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,346.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,866.49 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,837.33 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $541.32. The transfer capital threshold is the transfer adjustment factor * $541.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8138.99","8138.99","8159.04","1 through 10","3975","37027.3","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","","","","inpatient","","","37151.83","22291.10","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7852.69","","Case rate ($7,852.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,282.20, add-ons for qualifying new technology services are included. If operating cost exceeds $11,200.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,346.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,866.49 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,837.33 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $541.32. The transfer capital threshold is the transfer adjustment factor * $541.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8035.66","8035.66","8035.66","1 through 10","3975","37027.3","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses With McC","564","MS-DRG","","","","","","","","inpatient","","","45914.79","27548.87","MEDICARE [2001]","HB WDH MEDICARE","12180.00","","Case rate ($12,180). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,276.26, add-ons for qualifying new technology services are included. If operating cost exceeds $15,194.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,662.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,877.58 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,831.39 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $857.54. The transfer capital threshold is the transfer adjustment factor * $857.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12316.13","12285.28","12316.13","1 through 10","3975","58656.95","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses With McC","564","MS-DRG","","","","","","","","inpatient","","","45914.79","27548.87","TRICARE [160005]","HB WDH MEDICARE","12180.00","","Case rate ($12,180). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,276.26, add-ons for qualifying new technology services are included. If operating cost exceeds $15,194.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,662.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $10,877.58 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,831.39 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $857.54. The transfer capital threshold is the transfer adjustment factor * $857.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17453.97","17453.97","17453.97","1 through 10","3975","58656.95","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With McC","515","MS-DRG","","","","","","","","inpatient","","","29009.11","17405.47","MEDICARE [2001]","HB WDH MEDICARE","24673.09","","Case rate ($24,673.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $22,807.24, add-ons for qualifying new technology services are included. If operating cost exceeds $26,725.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,575.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,457.74 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $22,362.36 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,770.46. The transfer capital threshold is the transfer adjustment factor * $1,770.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7325.15","7325.15","7325.15","1 through 10","3975","64708.73","other","Inpatient DRG"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","","","","inpatient","","","41928.91","25157.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","36844.95","","Fee schedule rate ($36,844.95). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","35290.78","35290.78","35290.78","1 through 10","3975","46261.32","case rate",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With McC","843","MS-DRG","","","","","","","","inpatient","","","65171.94","39103.16","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","15298.01","","Case rate ($15,610.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,442.31, add-ons for qualifying new technology services are included. If operating cost exceeds $18,360.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,913.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $14,057.14 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,997.44 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,108.20. The transfer capital threshold is the transfer adjustment factor * $1,108.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","25042.36","25042.36","25042.36","1 through 10","3975","75802.6","other","Inpatient DRG"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With McC","843","MS-DRG","","","","","","","","inpatient","","","65171.94","39103.16","MARTIN'S POINT [160007]","HB WDH MEDICARE","15610.21","","Case rate ($15,610.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,442.31, add-ons for qualifying new technology services are included. If operating cost exceeds $18,360.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,913.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $14,057.14 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,997.44 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,108.20. The transfer capital threshold is the transfer adjustment factor * $1,108.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Includes an additional $800 of payment.","14807.88","14807.88","14807.88","1 through 10","3975","75802.6","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With McC","843","MS-DRG","","","","","","","","inpatient","","","65171.94","39103.16","MEDICARE [2001]","HB WDH MEDICARE","15610.21","","Case rate ($15,610.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,442.31, add-ons for qualifying new technology services are included. If operating cost exceeds $18,360.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,913.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $14,057.14 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,997.44 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,108.20. The transfer capital threshold is the transfer adjustment factor * $1,108.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Includes an additional $800 of payment.","14768.02","14768.02","14768.02","1 through 10","3975","75802.6","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","","","","inpatient","","","82499.01","49499.41","MEDICARE [2001]","HB WDH MEDICARE","15613.25","","Case rate ($15,613.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,445.12, add-ons for qualifying new technology services are included. If operating cost exceeds $18,363.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,913.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $14,059.96 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,000.25 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,108.42. The transfer capital threshold is the transfer adjustment factor * $1,108.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15704.59","15704.59","15704.59","1 through 10","3975","75817.8","other","Inpatient DRG"
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","","","","inpatient","","","82499.01","49499.41","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","15613.25","","Case rate ($15,613.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,445.12, add-ons for qualifying new technology services are included. If operating cost exceeds $18,363.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,913.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $14,059.96 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,000.25 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,108.42. The transfer capital threshold is the transfer adjustment factor * $1,108.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15414.20","15414.20","15414.20","1 through 10","3975","75817.8","other","Inpatient DRG"
"Other O.R. Procedures For Injuries With McC","907","MS-DRG","","","","","","","","inpatient","","","94083.83","56450.30","MEDICARE [2001]","HB WDH MEDICARE","29632.90","","Case rate ($29,632.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $27,385.10, add-ons for qualifying new technology services are included. If operating cost exceeds $31,303.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,937.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $27,055.13 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $26,940.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,132.90. The transfer capital threshold is the transfer adjustment factor * $2,132.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","30582.36","30582.36","30582.36","1 through 10","3975","145893.78","other","Inpatient DRG"
"Other O.R. Procedures For Injuries Without Cc/McC","909","MS-DRG","","","","","","","","inpatient","","","47808.98","28685.39","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","39729.23","","Fee schedule rate ($39,729.23). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","34805.44","34805.44","34805.44","1 through 10","3975","49882.73","case rate",""
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","","","","inpatient","","","167575.59","100545.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","31831.15","","Case rate ($32,480.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $30,013.65, add-ons for qualifying new technology services are included. If operating cost exceeds $33,931.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,146.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $29,694.90 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $29,568.79 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,341.01. The transfer capital threshold is the transfer adjustment factor * $2,341.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","736.70","736.70","736.70","1 through 10","3975","160128.62","other","Inpatient DRG"
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","","","","inpatient","","","10514.96","6308.98","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","14577.04","","Case rate ($14,577.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,488.71, add-ons for qualifying new technology services are included. If operating cost exceeds $17,406.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,837.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $13,099.47 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,043.83 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,032.70. The transfer capital threshold is the transfer adjustment factor * $1,032.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10020.00","10020.00","10020.00","1 through 10","3975","70638.39","other","Inpatient DRG"
"Other O.R. Procedures Of The Blood And Blood Forming Organs With McC","802","MS-DRG","","","","","","","","inpatient","","","51884.82","31130.89","MEDICARE [2001]","HB WDH MEDICARE","30733.74","","Case rate ($30,733.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $28,401.15, add-ons for qualifying new technology services are included. If operating cost exceeds $32,319.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,018.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $28,075.52 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $27,956.29 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,213.34. The transfer capital threshold is the transfer adjustment factor * $2,213.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","0.05","1 through 10","3975","151396.2","other","Inpatient DRG"
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","33767.18","20260.31","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","14652.23","","Case rate ($14,364.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,292.93, add-ons for qualifying new technology services are included. If operating cost exceeds $17,211.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,822.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,902.86 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,848.06 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.20. The transfer capital threshold is the transfer adjustment factor * $1,017.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","6775.04","6775.04","6775.04","1 through 10","3975","69578.18","other","Inpatient DRG"
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","33767.18","20260.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","55415.73","","Fee schedule rate ($55,415.73). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","27557.97","27557.97","27557.97","1 through 10","3975","69578.18","case rate",""
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","33767.18","20260.31","MARTIN'S POINT [160007]","HB WDH MEDICARE","14364.93","","Case rate ($14,364.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,292.93, add-ons for qualifying new technology services are included. If operating cost exceeds $17,211.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,822.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,902.86 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,848.06 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.20. The transfer capital threshold is the transfer adjustment factor * $1,017.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15158.42","15158.42","15158.42","1 through 10","3975","69578.18","other","Inpatient DRG"
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","33767.18","20260.31","MEDICARE [2001]","HB WDH MEDICARE","14364.93","","Case rate ($14,364.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,292.93, add-ons for qualifying new technology services are included. If operating cost exceeds $17,211.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,822.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,902.86 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,848.06 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.20. The transfer capital threshold is the transfer adjustment factor * $1,017.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","14726.40","1 through 10","3975","69578.18","other","Inpatient DRG"
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","33767.18","20260.31","TRICARE [160005]","HB WDH MEDICARE","14364.93","","Case rate ($14,364.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,292.93, add-ons for qualifying new technology services are included. If operating cost exceeds $17,211.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,822.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,902.86 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,848.06 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.20. The transfer capital threshold is the transfer adjustment factor * $1,017.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5567.81","5567.81","5567.81","1 through 10","3975","69578.18","other","Inpatient DRG"
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","33767.18","20260.31","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","14364.93","","Case rate ($14,364.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,292.93, add-ons for qualifying new technology services are included. If operating cost exceeds $17,211.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,822.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $12,902.86 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,848.06 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,017.20. The transfer capital threshold is the transfer adjustment factor * $1,017.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14405.54","6057.39","14689.29","1 through 10","3975","69578.18","other","Inpatient DRG"
"Other Respiratory System Diagnoses Without McC","206","MS-DRG","","","","","","","","inpatient","","","44952.64","26971.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","14081.57","","Fee schedule rate ($14,081.57). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","13222.80","13222.80","13222.80","1 through 10","3975","35761.89","case rate",""
"Other Respiratory System Diagnoses Without McC","206","MS-DRG","","","","","","","","inpatient","","","44952.64","26971.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","7447.53","","Case rate ($7,599.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,048.54, add-ons for qualifying new technology services are included. If operating cost exceeds $10,966.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,327.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,631.83 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,603.67 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $522.82. The transfer capital threshold is the transfer adjustment factor * $522.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7133.97","7133.97","7133.97","1 through 10","3975","35761.89","other","Inpatient DRG"
"Other Respiratory System Diagnoses Without McC","206","MS-DRG","","","","","","","","inpatient","","","44952.64","26971.58","MEDICARE [2001]","HB WDH MEDICARE","7599.52","","Case rate ($7,599.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,048.54, add-ons for qualifying new technology services are included. If operating cost exceeds $10,966.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,327.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,631.83 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,603.67 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $522.82. The transfer capital threshold is the transfer adjustment factor * $522.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","7297.37","1 through 10","3975","35761.89","other","Inpatient DRG"
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","","","","inpatient","","","43562.43","26137.46","MEDICARE [2001]","HB WDH MEDICARE","14155.12","","Case rate ($14,155.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,099.27, add-ons for qualifying new technology services are included. If operating cost exceeds $17,017.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,806.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $12,708.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,654.39 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,001.87. The transfer capital threshold is the transfer adjustment factor * $1,001.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","0.05","1 through 10","3975","68529.38","other","Inpatient DRG"
"Other Respiratory System O.R. Procedures Without Cc/McC","168","MS-DRG","","","","","","","","inpatient","","","41317.85","24790.71","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","11049.51","","Case rate ($10,832.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,032.85, add-ons for qualifying new technology services are included. If operating cost exceeds $13,951.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,564.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $9,628.87 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,587.98 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.09. The transfer capital threshold is the transfer adjustment factor * $759.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","10687.35","10687.35","10687.35","1 through 10","3975","51923.34","other","Inpatient DRG"
"Other Respiratory System O.R. Procedures Without Cc/McC","168","MS-DRG","","","","","","","","inpatient","","","41317.85","24790.71","MEDICARE [2001]","HB WDH MEDICARE","10832.85","","Case rate ($10,832.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,032.85, add-ons for qualifying new technology services are included. If operating cost exceeds $13,951.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,564.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $9,628.87 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,587.98 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $759.09. The transfer capital threshold is the transfer adjustment factor * $759.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10687.35","10687.35","10687.35","1 through 10","3975","51923.34","other","Inpatient DRG"
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","","","","inpatient","","","63923.11","38353.87","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","13310.25","","Case rate ($13,581.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,570.19, add-ons for qualifying new technology services are included. If operating cost exceeds $16,488.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,765.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $12,177.03 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,125.31 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.98. The transfer capital threshold is the transfer adjustment factor * $959.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13580.12","13580.12","13580.12","1 through 10","3975","65664.17","other","Inpatient DRG"
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","","","","inpatient","","","63923.11","38353.87","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","13989.35","","Case rate ($13,581.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,570.19, add-ons for qualifying new technology services are included. If operating cost exceeds $16,488.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,765.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $12,177.03 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,125.31 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.98. The transfer capital threshold is the transfer adjustment factor * $959.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","63227.83","63227.83","63227.83","1 through 10","3975","65664.17","other","Inpatient DRG"
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","","","","inpatient","","","63923.11","38353.87","MARTIN'S POINT [160007]","HB WDH MEDICARE","13581.89","","Case rate ($13,581.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,570.19, add-ons for qualifying new technology services are included. If operating cost exceeds $16,488.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,765.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $12,177.03 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,125.31 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.98. The transfer capital threshold is the transfer adjustment factor * $959.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9814.47","9814.47","9814.47","1 through 10","3975","65664.17","other","Inpatient DRG"
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","","","","inpatient","","","63923.11","38353.87","MEDICARE [2001]","HB WDH MEDICARE","13581.89","","Case rate ($13,581.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,570.19, add-ons for qualifying new technology services are included. If operating cost exceeds $16,488.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,765.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $12,177.03 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,125.31 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $959.98. The transfer capital threshold is the transfer adjustment factor * $959.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13823.06","13823.06","13857.91","1 through 10","3975","65664.17","other","Inpatient DRG"
"Other Skin, Subcutaneous Tissue And Breast Procedures With McC","579","MS-DRG","","","","","","","","inpatient","","","54196.17","32517.70","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","25817.32","","Case rate ($25,065.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $23,169.31, add-ons for qualifying new technology services are included. If operating cost exceeds $27,087.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,604.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $22,821.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $22,724.44 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,799.13. The transfer capital threshold is the transfer adjustment factor * $1,799.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","24704.58","24704.58","24704.58","1 through 10","3975","123063.32","other","Inpatient DRG"
"Other Skin, Subcutaneous Tissue And Breast Procedures With McC","579","MS-DRG","","","","","","","","inpatient","","","54196.17","32517.70","MEDICARE [2001]","HB WDH MEDICARE","25065.36","","Case rate ($25,065.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $23,169.31, add-ons for qualifying new technology services are included. If operating cost exceeds $27,087.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,604.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $22,821.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $22,724.44 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,799.13. The transfer capital threshold is the transfer adjustment factor * $1,799.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25038.79","25038.79","25038.79","1 through 10","3975","123063.32","other","Inpatient DRG"
"Other Skin, Subcutaneous Tissue And Breast Procedures With McC","579","MS-DRG","","","","","","","","inpatient","","","54196.17","32517.70","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","25065.36","","Case rate ($25,065.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $23,169.31, add-ons for qualifying new technology services are included. If operating cost exceeds $27,087.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,604.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $22,821.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $22,724.44 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,799.13. The transfer capital threshold is the transfer adjustment factor * $1,799.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9866.34","9866.34","9866.34","1 through 10","3975","123063.32","other","Inpatient DRG"
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","","","","inpatient","","","87699.74","52619.84","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","20581.32","","Case rate ($20,177.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $18,658.11, add-ons for qualifying new technology services are included. If operating cost exceeds $22,576.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,246.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $18,290.91 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $18,213.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,441.97. The transfer capital threshold is the transfer adjustment factor * $1,441.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","19708.55","19708.55","19708.55","1 through 10","18536.81","98633.06","other","Inpatient DRG"
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","","","","inpatient","","","87699.74","52619.84","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","19774.20","","Case rate ($20,177.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $18,658.11, add-ons for qualifying new technology services are included. If operating cost exceeds $22,576.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,246.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $18,290.91 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $18,213.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,441.97. The transfer capital threshold is the transfer adjustment factor * $1,441.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21856.92","21856.92","21856.92","1 through 10","18536.81","98633.06","other","Inpatient DRG"
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","","","","inpatient","","","87699.74","52619.84","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","78556.56","","Fee schedule rate ($78,556.56). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","75382.68","75382.68","156097.72","1 through 10","18536.81","98633.06","case rate",""
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","","","","inpatient","","","87699.74","52619.84","MARTIN'S POINT [160007]","HB WDH MEDICARE","20177.76","","Case rate ($20,177.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $18,658.11, add-ons for qualifying new technology services are included. If operating cost exceeds $22,576.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,246.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $18,290.91 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $18,213.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,441.97. The transfer capital threshold is the transfer adjustment factor * $1,441.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19378.61","19378.61","19378.61","1 through 10","18536.81","98633.06","other","Inpatient DRG"
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","","","","inpatient","","","87699.74","52619.84","MEDICARE [2001]","HB WDH MEDICARE","20177.76","","Case rate ($20,177.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $18,658.11, add-ons for qualifying new technology services are included. If operating cost exceeds $22,576.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,246.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $18,290.91 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $18,213.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,441.97. The transfer capital threshold is the transfer adjustment factor * $1,441.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","19708.60","19708.60","19758.79","1 through 10","18536.81","98633.06","other","Inpatient DRG"
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","","","","inpatient","","","87699.74","52619.84","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","20177.76","","Case rate ($20,177.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $18,658.11, add-ons for qualifying new technology services are included. If operating cost exceeds $22,576.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,246.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $18,290.91 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $18,213.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,441.97. The transfer capital threshold is the transfer adjustment factor * $1,441.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","19708.60","1 through 10","18536.81","98633.06","other","Inpatient DRG"
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","","","","inpatient","","","87699.74","52619.84","WELLSENSE NH [1050]","HB WDH MEDICARE","20177.76","","Case rate ($20,177.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $18,658.11, add-ons for qualifying new technology services are included. If operating cost exceeds $22,576.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,246.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $18,290.91 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $18,213.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,441.97. The transfer capital threshold is the transfer adjustment factor * $1,441.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20339.20","20339.20","20339.20","1 through 10","18536.81","98633.06","other","Inpatient DRG"
"Other Vascular Procedures With McC","252","MS-DRG","","","","","","","","inpatient","","","103421.39","62052.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","105574.38","","Fee schedule rate ($105,574.38). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","101289.76","101289.76","101289.76","1 through 10","24912.15","132555.75","case rate",""
"Other Vascular Procedures With McC","252","MS-DRG","","","","","","","","inpatient","","","103421.39","62052.83","MARTIN'S POINT [160007]","HB WDH MEDICARE","26964.44","","Case rate ($26,964.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $24,922.14, add-ons for qualifying new technology services are included. If operating cost exceeds $28,840.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,742.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $24,581.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $24,477.28 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,937.90. The transfer capital threshold is the transfer adjustment factor * $1,937.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9145.76","9145.76","9145.76","1 through 10","24912.15","132555.75","other","Inpatient DRG"
"Other Vascular Procedures With McC","252","MS-DRG","","","","","","","","inpatient","","","103421.39","62052.83","MEDICARE [2001]","HB WDH MEDICARE","26964.44","","Case rate ($26,964.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $24,922.14, add-ons for qualifying new technology services are included. If operating cost exceeds $28,840.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,742.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $24,581.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $24,477.28 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,937.90. The transfer capital threshold is the transfer adjustment factor * $1,937.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1744.43","860.77","26329.09","1 through 10","24912.15","132555.75","other","Inpatient DRG"
"Other Vascular Procedures With McC","252","MS-DRG","","","","","","","","inpatient","","","103421.39","62052.83","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","26964.44","","Case rate ($26,964.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $24,922.14, add-ons for qualifying new technology services are included. If operating cost exceeds $28,840.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,742.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $24,581.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $24,477.28 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,937.90. The transfer capital threshold is the transfer adjustment factor * $1,937.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25872.36","25872.36","25901.96","1 through 10","24912.15","132555.75","other","Inpatient DRG"
"Other Vascular Procedures Without Cc/McC","254","MS-DRG","","","","","","","","inpatient","","","97942.65","58765.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","13710.34","","Case rate ($13,990.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,947, add-ons for qualifying new technology services are included. If operating cost exceeds $16,865.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,794.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $12,555.45 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,502.13 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $989.81. The transfer capital threshold is the transfer adjustment factor * $989.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","13372.09","13372.09","13372.09","1 through 10","12724.24","67704.78","other","Inpatient DRG"
"Other Vascular Procedures Without Cc/McC","254","MS-DRG","","","","","","","","inpatient","","","97942.65","58765.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","53923.65","","Fee schedule rate ($53,923.65). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","51654.70","51654.70","51654.70","1 through 10","12724.24","67704.78","case rate",""
"Other Vascular Procedures Without Cc/McC","254","MS-DRG","","","","","","","","inpatient","","","97942.65","58765.59","MEDICARE [2001]","HB WDH MEDICARE","13990.14","","Case rate ($13,990.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,947, add-ons for qualifying new technology services are included. If operating cost exceeds $16,865.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,794.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $12,555.45 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,502.13 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $989.81. The transfer capital threshold is the transfer adjustment factor * $989.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13644.99","13644.99","13644.99","1 through 10","12724.24","67704.78","other","Inpatient DRG"
"Other Vascular Procedures Without Cc/McC","254","MS-DRG","","","","","","","","inpatient","","","97942.65","58765.59","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","13990.14","","Case rate ($13,990.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,947, add-ons for qualifying new technology services are included. If operating cost exceeds $16,865.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,794.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $12,555.45 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,502.13 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $989.81. The transfer capital threshold is the transfer adjustment factor * $989.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13680.29","13680.29","13680.29","1 through 10","12724.24","67704.78","other","Inpatient DRG"
"Otitis Media And Uri With McC","152","MS-DRG","","","","","","","","inpatient","","","30494.35","18296.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","44923.72","","Fee schedule rate ($44,923.72). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","29931.99","29931.99","29931.99","1 through 10","3975","44923.72","case rate",""
"Otitis Media And Uri With McC","152","MS-DRG","","","","","","","","inpatient","","","30494.35","18296.61","MEDICARE [2001]","HB WDH MEDICARE","9432.46","","Case rate ($9,432.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,740.32, add-ons for qualifying new technology services are included. If operating cost exceeds $12,658.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,461.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,330.84 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,295.46 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $656.76. The transfer capital threshold is the transfer adjustment factor * $656.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9007.48","9007.48","9007.48","1 through 10","3975","44923.72","other","Inpatient DRG"
"Otitis Media And Uri Without McC","153","MS-DRG","","","","","","","","inpatient","","","12535.88","7521.53","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","28051.67","","Fee schedule rate ($28,051.67). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","11992.66","11992.66","11992.66","1 through 10","3975","28051.67","case rate",""
"Otitis Media And Uri Without McC","153","MS-DRG","","","","","","","","inpatient","","","12535.88","7521.53","MEDICARE [2001]","HB WDH MEDICARE","6056.99","","Case rate ($6,056.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,624.80, add-ons for qualifying new technology services are included. If operating cost exceeds $9,542.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,215.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,202.02 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,179.92 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $410.10. The transfer capital threshold is the transfer adjustment factor * $410.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5828.95","834.67","5828.95","1 through 10","3975","28051.67","other","Inpatient DRG"
"PACK CATHETER 160F BALLOON ENDOSCOPIC PULMONARY ULTRASONIC BFUC PK/20EA","SUP-ITM-10020936","CDM","C1726","HCPCS","0272","RC","","","","both","","","197.43","118.46","AETNA [1001]","HB WDH AETNA COMMERCIAL","137.81","69.8","","166.96","137.81","825.49","1 through 10","22.96","167.82","percent of total billed charges",""
"PACK CATHETER 160F BALLOON ENDOSCOPIC PULMONARY ULTRASONIC BFUC PK/20EA","SUP-ITM-10020936","CDM","C1726","HCPCS","0272","RC","","","","both","","","197.43","118.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1716.86","1716.86","1716.86","1 through 10","22.96","167.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PACK CATHETER 160F BALLOON ENDOSCOPIC PULMONARY ULTRASONIC BFUC PK/20EA","SUP-ITM-10020936","CDM","C1726","HCPCS","0272","RC","","","","both","","","197.43","118.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","4281.09","1182.65","4281.09","1 through 10","22.96","167.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PACK CATHETER 160F BALLOON ENDOSCOPIC PULMONARY ULTRASONIC BFUC PK/20EA","SUP-ITM-10020936","CDM","C1726","HCPCS","0272","RC","","","","both","","","197.43","118.46","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","22.96","11.63","","262.01","27.19","426.66","1 through 10","22.96","167.82","percent of total billed charges",""
"PACK CATHETER 160F BALLOON ENDOSCOPIC PULMONARY ULTRASONIC BFUC PK/20EA","SUP-ITM-10020936","CDM","C1726","HCPCS","0272","RC","","","","both","","","197.43","118.46","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","152.81","77.4","","1411.46","916.55","1411.46","1 through 10","22.96","167.82","percent of total billed charges",""
"PACK CATHETER 160F BALLOON ENDOSCOPIC PULMONARY ULTRASONIC BFUC PK/20EA","SUP-ITM-10020936","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","197.43","118.46","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","22.96","11.63","","262.01","27.19","426.66","1 through 10","22.96","152.81","percent of total billed charges",""
"PACK CATHETER 160F BALLOON ENDOSCOPIC PULMONARY ULTRASONIC BFUC PK/20EA","SUP-ITM-10020936","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","197.43","118.46","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","86.32","43.72","","517.05","517.05","517.05","1 through 10","22.96","152.81","percent of total billed charges",""
"PACK CATHETER 160F BALLOON ENDOSCOPIC PULMONARY ULTRASONIC BFUC PK/20EA","SUP-ITM-10020936","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","197.43","118.46","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","143.57","72.72","","1556.61","860.02","1914.17","1 through 10","22.96","152.81","percent of total billed charges",""
"PACK CATHETER 160F BALLOON ENDOSCOPIC PULMONARY ULTRASONIC BFUC PK/20EA","SUP-ITM-10020936","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","197.43","118.46","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","124.18","62.9","","1348.55","745.07","1348.55","19","22.96","152.81","percent of total billed charges",""
"PACK CATHETER 160F BALLOON ENDOSCOPIC PULMONARY ULTRASONIC BFUC PK/20EA","SUP-ITM-10020936","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","197.43","118.46","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","152.81","77.4","","1411.46","916.55","1411.46","1 through 10","22.96","152.81","percent of total billed charges",""
"PACK CATHETER 160F BALLOON ENDOSCOPIC PULMONARY ULTRASONIC BFUC PK/20EA","SUP-ITM-10020936","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","197.43","118.46","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","143.57","72.72","","860.02","860.02","860.02","1 through 10","22.96","152.81","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.75","103.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","20.09","146.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.75","103.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","98.29","56.9","","2911.53","1863.86","5209.05","65","20.09","146.84","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.75","103.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.09","11.63","","400.94","400.94","400.94","1 through 10","20.09","146.84","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.75","103.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","133.71","77.4","","5214.50","5214.50","16415.28","1 through 10","20.09","146.84","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.09","11.63","","400.94","400.94","400.94","1 through 10","20.09","133.71","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","75.53","43.72","","1543.33","1543.33","1671.61","1 through 10","20.09","133.71","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","125.62","72.72","","3700.21","2382.07","6427.18","53","20.09","133.71","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","125.62","72.72","","12685.80","12685.80","12685.80","1 through 10","20.09","133.71","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","108.66","62.9","","3408.87","2784.05","9859.40","46","20.09","133.71","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","133.71","77.4","","5214.50","5214.50","16415.28","1 through 10","20.09","133.71","percent of total billed charges",""
"Pad Rehab per Session","PX-48000022","CDM","93668","CPT","0480","RC","","","","both","","","371.00","222.60","MEDICARE [2001]","HB WDH MEDICARE","62.06","","APC Price ($62.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.21","186.21","186.21","1 through 10","60.82","396.58","other","OPPS APC"
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","both","","","200.00","120.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","139.60","69.8","","134.71","14.76","134.71","17","11.23","170","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","inpatient","","","200.00","120.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","153.72","76.86","","121.59","121.59","121.59","1 through 10","132.4","153.72","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","145.44","72.72","","140.35","140.35","140.35","16","12.06","154.8","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","145.44","72.72","","140.35","140.35","140.35","1 through 10","12.06","154.8","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","106.44","53.22","","102.89","102.89","102.89","1 through 10","12.06","154.8","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","125.80","62.9","","243.18","121.59","364.77","19","12.06","154.8","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","154.80","77.4","","149.58","138.91","149.58","12","12.06","154.8","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0311","RC","","","","both","","","166.00","99.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","25.07","","APC Price ($25.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","25.59","25.59","25.59","1 through 10","25.07","26.35","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0311","RC","","","","both","","","166.00","99.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","26.35","","APC Price ($25.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","25.83","25.83","25.83","1 through 10","25.07","26.35","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0311","RC","","","","both","","","166.00","99.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","25.59","","APC Price ($25.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","25.59","25.59","25.59","1 through 10","25.07","26.35","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0311","RC","","","","both","","","166.00","99.60","MEDICARE [2001]","HB WDH MEDICARE","25.59","","APC Price ($25.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","160.00","25.59","160.00","1 through 10","25.07","26.35","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0311","RC","","","","both","","","166.00","99.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","25.59","","APC Price ($25.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","25.08","25.08","25.08","1 through 10","25.07","26.35","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0311","RC","","","","both","","","166.00","99.60","WELLSENSE NH [1050]","HB WDH MEDICARE","25.59","","APC Price ($25.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","26.53","26.53","26.53","1 through 10","25.07","26.35","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","both","","","166.00","99.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","115.87","69.8","","111.68","111.68","111.68","1 through 10","70.42","163.55","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","both","","","166.00","99.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","163.55","","Case rate ($163.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","159.56","159.56","159.56","1 through 10","70.42","163.55","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","both","","","166.00","99.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","70.42","","Case rate ($70.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","68.71","68.71","73.09","1 through 10","70.42","163.55","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","both","","","166.00","99.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","132.20","","Case rate ($132.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","128.97","128.97","128.97","1 through 10","70.42","163.55","other","OPPS APC"
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","both","","","166.00","99.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","94.45","56.9","","91.04","91.04","91.04","1 through 10","70.42","163.55","percent of total billed charges",""
"Pap Smear Screening","PX-92000093","CDM","Q0091","HCPCS","0923","RC","","","","outpatient","","","166.00","99.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","19.31","11.63","","22.03","22.03","22.03","1 through 10","19.31","128.48","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","both","","","585.00","351.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","408.33","69.8","","395.07","47.04","395.07","52","26.83","497.25","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","outpatient","","","585.00","351.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","367.26","62.78","","355.33","355.33","355.33","1 through 10","38.45","452.79","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","outpatient","","","585.00","351.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","255.76","43.72","","247.46","247.46","247.46","1 through 10","38.45","452.79","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","outpatient","","","585.00","351.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","425.41","72.72","","411.60","411.60","411.60","82","38.45","452.79","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","outpatient","","","585.00","351.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","425.41","72.72","","411.60","411.60","411.60","1 through 10","38.45","452.79","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","outpatient","","","585.00","351.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","311.34","53.22","","301.73","301.73","301.73","1 through 10","38.45","452.79","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","outpatient","","","585.00","351.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","367.97","62.9","","356.58","356.58","684.84","120","38.45","452.79","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","outpatient","","","585.00","351.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","452.79","77.4","","438.65","438.65","438.65","39","38.45","452.79","percent of total billed charges",""
"Parathyroid Spect","PX-34000130","CDM","78071","CPT","0341","RC","","","","both","","","3455.00","2073.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1155.31","","Case rate ($1,155.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1127.14","1127.14","1127.14","1 through 10","411.42","2936.75","other","OPPS APC"
"Paring/Cutting Lesn Benign 1","PX-76000028","CDM","11055","CPT","0761","RC","","","","both","","","265.00","159.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","150.79","56.9","","145.66","145.66","145.66","1 through 10","150.79","1326.74","percent of total billed charges",""
"Paring/Cutting Lesn Benign 1","PX-76000028","CDM","11055","CPT","0761","RC","","","","both","","","265.00","159.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","213.82","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","213.85","213.85","213.85","1 through 10","150.79","1326.74","other","OPPS APC"
"Paring/Cutting Lesn Benign 1","PX-76000028","CDM","11055","CPT","0761","RC","","","","both","","","265.00","159.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","207.59","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","204.37","204.37","204.37","1 through 10","150.79","1326.74","other","OPPS APC"
"Paring/Cutting Lesn Benign 1","PX-76000028","CDM","11055","CPT","0761","RC","","","","both","","","265.00","159.00","MEDICARE [2001]","HB WDH MEDICARE","207.59","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.62","207.62","207.62","1 through 10","150.79","1326.74","other","OPPS APC"
"Paring/Cutting Lesn Benign 1","PX-76000028","CDM","11055","CPT","0761","RC","","","","both","","","265.00","159.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","207.59","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.47","203.47","203.47","1 through 10","150.79","1326.74","other","OPPS APC"
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","both","","","92.00","55.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","64.22","69.8","","62.12","59.33","62.12","38","3.91","78.2","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","both","","","92.00","55.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","64.22","69.8","","62.12","62.12","62.12","1 through 10","3.91","78.2","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","outpatient","","","92.00","55.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","57.76","62.78","","55.87","55.87","55.87","1 through 10","5.59","71.21","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","outpatient","","","92.00","55.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","40.22","43.72","","38.91","38.91","38.91","1 through 10","5.59","71.21","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","outpatient","","","92.00","55.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","66.90","72.72","","64.72","64.72","129.44","58","5.59","71.21","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","outpatient","","","92.00","55.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","66.90","72.72","","64.72","64.72","64.72","1 through 10","5.59","71.21","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","outpatient","","","92.00","55.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","57.87","62.9","","56.07","56.07","56.07","63","5.59","71.21","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","outpatient","","","92.00","55.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","71.21","77.4","","68.98","68.96","68.98","37","5.59","71.21","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","outpatient","","","92.00","55.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","66.90","72.72","","64.72","64.72","64.72","1 through 10","5.59","71.21","percent of total billed charges",""
"Parvovirus Antibody","PX-30000980","CDM","86747","CPT","0302","RC","","","","outpatient","","","81.00","48.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","35.41","43.72","","34.10","34.10","34.10","1 through 10","11.16","62.69","percent of total billed charges",""
"Parvovirus Antibody","PX-30000980","CDM","86747","CPT","0302","RC","","","","outpatient","","","81.00","48.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","58.90","72.72","","56.72","56.72","56.72","11","11.16","62.69","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","both","","","967.40","580.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","112.51","822.29","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","both","","","967.40","580.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","112.51","822.29","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","both","","","967.40","580.44","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","550.45","56.9","","812.12","238.65","1587.46","163","112.51","822.29","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","both","","","967.40","580.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","112.51","11.63","","112.68","112.68","146.99","38","112.51","822.29","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","both","","","967.40","580.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","748.77","77.4","","303.98","303.98","5854.79","1 through 10","112.51","822.29","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","967.40","580.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","112.51","11.63","","112.68","112.68","146.99","38","112.51","748.77","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","967.40","580.44","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","607.33","62.78","","780.86","208.94","10480.28","15","112.51","748.77","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","967.40","580.44","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","422.95","43.72","","179.76","179.76","179.76","1 through 10","112.51","748.77","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","967.40","580.44","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","703.49","72.72","","2355.45","298.99","3965.19","155","112.51","748.77","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","967.40","580.44","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","703.49","72.72","","3643.09","3643.09","3643.09","1 through 10","112.51","748.77","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","967.40","580.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","514.85","53.22","","554.28","554.28","554.28","16","112.51","748.77","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","967.40","580.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","608.49","62.9","","619.64","173.09","2370.64","150","112.51","748.77","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE LEFT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","967.40","580.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","748.77","77.4","","303.98","303.98","5854.79","1 through 10","112.51","748.77","percent of total billed charges",""
"PATCH SYNTHETIC 4.3 XCM SM ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041542","CDM","C1781","HCPCS","0278","RC","","","","both","","","2268.93","1361.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","263.88","1928.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PATCH SYNTHETIC 4.3 XCM SM ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041542","CDM","C1781","HCPCS","0278","RC","","","","both","","","2268.93","1361.36","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1291.02","56.9","","1333.47","776.80","2316.37","34","263.88","1928.59","percent of total billed charges",""
"PATCH SYNTHETIC 4.3 XCM SM ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041542","CDM","C1781","HCPCS","0278","RC","","","","both","","","2268.93","1361.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","263.88","11.63","","348.38","187.99","380.51","1 through 10","263.88","1928.59","percent of total billed charges",""
"PATCH SYNTHETIC 4.3 XCM SM ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041542","CDM","C1781","HCPCS","0278","RC","","","","both","","","2268.93","1361.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1427.16","62.9","","1793.12","860.08","3673.04","20","263.88","1928.59","percent of total billed charges",""
"PATCH SYNTHETIC 4.3 XCM SM ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041542","CDM","C1781","HCPCS","0278","RC","","","","both","","","2268.93","1361.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1756.15","77.4","","1107.52","186.36","4312.65","1 through 10","263.88","1928.59","percent of total billed charges",""
"PATCH SYNTHETIC 4.3 XCM SM ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041542","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2268.93","1361.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","263.88","11.63","","348.38","187.99","380.51","1 through 10","263.88","1649.97","percent of total billed charges",""
"PATCH SYNTHETIC 4.3 XCM SM ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041542","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2268.93","1361.36","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1424.43","62.78","","9719.10","2943.96","9719.10","1 through 10","263.88","1649.97","percent of total billed charges",""
"PATCH SYNTHETIC 4.3 XCM SM ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041542","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2268.93","1361.36","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1649.97","72.72","","2009.48","1217.35","3752.64","17","263.88","1649.97","percent of total billed charges",""
"PATCH SYNTHETIC 6.4 XCM MD ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041541","CDM","C1781","HCPCS","0278","RC","","","","both","","","2713.63","1628.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","315.6","2306.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PATCH SYNTHETIC 6.4 XCM MD ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041541","CDM","C1781","HCPCS","0278","RC","","","","both","","","2713.63","1628.18","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1544.06","56.9","","1333.47","776.80","2316.37","34","315.6","2306.59","percent of total billed charges",""
"PATCH SYNTHETIC 6.4 XCM MD ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041541","CDM","C1781","HCPCS","0278","RC","","","","both","","","2713.63","1628.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","315.60","11.63","","348.38","187.99","380.51","1 through 10","315.6","2306.59","percent of total billed charges",""
"PATCH SYNTHETIC 6.4 XCM MD ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041541","CDM","C1781","HCPCS","0278","RC","","","","both","","","2713.63","1628.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1706.87","62.9","","1793.12","860.08","3673.04","20","315.6","2306.59","percent of total billed charges",""
"PATCH SYNTHETIC 6.4 XCM MD ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041541","CDM","C1781","HCPCS","0278","RC","","","","both","","","2713.63","1628.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2100.35","77.4","","1107.52","186.36","4312.65","1 through 10","315.6","2306.59","percent of total billed charges",""
"PATCH SYNTHETIC 6.4 XCM MD ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041541","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2713.63","1628.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","315.60","11.63","","348.38","187.99","380.51","1 through 10","315.6","1973.35","percent of total billed charges",""
"PATCH SYNTHETIC 6.4 XCM MD ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041541","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2713.63","1628.18","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1703.62","62.78","","9719.10","2943.96","9719.10","1 through 10","315.6","1973.35","percent of total billed charges",""
"PATCH SYNTHETIC 6.4 XCM MD ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041541","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2713.63","1628.18","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1973.35","72.72","","2009.48","1217.35","3752.64","17","315.6","1973.35","percent of total billed charges",""
"PATCH TAPERED .45MM 8CM XW.8 GRAFT TISSUE VASCULAR XENOSURE BIOLOGIC","SUP-ITM-10091806","CDM","C1781","HCPCS","0278","RC","","","","both","","","1022.68","613.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","118.94","869.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PATCH TAPERED .45MM 8CM XW.8 GRAFT TISSUE VASCULAR XENOSURE BIOLOGIC","SUP-ITM-10091806","CDM","C1781","HCPCS","0278","RC","","","","both","","","1022.68","613.61","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","581.90","56.9","","1333.47","776.80","2316.37","34","118.94","869.28","percent of total billed charges",""
"PATCH TAPERED .45MM 8CM XW.8 GRAFT TISSUE VASCULAR XENOSURE BIOLOGIC","SUP-ITM-10091806","CDM","C1781","HCPCS","0278","RC","","","","both","","","1022.68","613.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","118.94","11.63","","348.38","187.99","380.51","1 through 10","118.94","869.28","percent of total billed charges",""
"PATCH TAPERED .45MM 8CM XW.8 GRAFT TISSUE VASCULAR XENOSURE BIOLOGIC","SUP-ITM-10091806","CDM","C1781","HCPCS","0278","RC","","","","both","","","1022.68","613.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","643.27","62.9","","1793.12","860.08","3673.04","20","118.94","869.28","percent of total billed charges",""
"PATCH TAPERED .45MM 8CM XW.8 GRAFT TISSUE VASCULAR XENOSURE BIOLOGIC","SUP-ITM-10091806","CDM","C1781","HCPCS","0278","RC","","","","both","","","1022.68","613.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","791.55","77.4","","1107.52","186.36","4312.65","1 through 10","118.94","869.28","percent of total billed charges",""
"PATCH TAPERED .45MM 8CM XW.8 GRAFT TISSUE VASCULAR XENOSURE BIOLOGIC","SUP-ITM-10091806","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1022.68","613.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","118.94","11.63","","348.38","187.99","380.51","1 through 10","118.94","743.69","percent of total billed charges",""
"PATCH TAPERED .45MM 8CM XW.8 GRAFT TISSUE VASCULAR XENOSURE BIOLOGIC","SUP-ITM-10091806","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1022.68","613.61","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","642.04","62.78","","9719.10","2943.96","9719.10","1 through 10","118.94","743.69","percent of total billed charges",""
"PATCH TAPERED .45MM 8CM XW.8 GRAFT TISSUE VASCULAR XENOSURE BIOLOGIC","SUP-ITM-10091806","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1022.68","613.61","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","743.69","72.72","","2009.48","1217.35","3752.64","17","118.94","743.69","percent of total billed charges",""
"PATCH VASCULAR 0.3X3IN 6 XW. KNITTED NON VELOUR ULTRA THIN TAPERED END HEMASHIELD FINESSE COLLAGEN POLYESTER IMPLANTAB","SUP-ITM-10005075","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","620.79","372.47","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","451.44","72.72","","4588.52","4588.52","4588.52","1 through 10","72.2","480.49","percent of total billed charges",""
"PATCH VASCULAR 8X0.8CM VASCU GUARD BOVINE PERICARDIUM IMPLANTABLE","SUP-ITM-10008770","CDM","C1768","HCPCS","0278","RC","","","","outpatient","","","1617.29","970.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1176.09","72.72","","4588.52","4588.52","4588.52","1 through 10","188.09","1251.78","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","both","","","7901.96","4741.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","919","6716.67","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","both","","","7901.96","4741.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","919","6716.67","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","both","","","7901.96","4741.18","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4496.22","56.9","","812.12","238.65","1587.46","163","919","6716.67","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","both","","","7901.96","4741.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","919.00","11.63","","112.68","112.68","146.99","38","919","6716.67","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","both","","","7901.96","4741.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6116.12","77.4","","303.98","303.98","5854.79","1 through 10","919","6716.67","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7901.96","4741.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","919.00","11.63","","112.68","112.68","146.99","38","919","6116.12","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7901.96","4741.18","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4960.85","62.78","","780.86","208.94","10480.28","15","919","6116.12","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7901.96","4741.18","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3454.74","43.72","","179.76","179.76","179.76","1 through 10","919","6116.12","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7901.96","4741.18","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5746.31","72.72","","2355.45","298.99","3965.19","155","919","6116.12","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7901.96","4741.18","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5746.31","72.72","","3643.09","3643.09","3643.09","1 through 10","919","6116.12","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7901.96","4741.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4205.42","53.22","","554.28","554.28","554.28","16","919","6116.12","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7901.96","4741.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4970.33","62.9","","619.64","173.09","2370.64","150","919","6116.12","percent of total billed charges",""
"PATELLA PLATE 2.7 LOCKING VA ANTERIOR 3-HOLE STANDARD SS","SUP-ITM-10287980","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7901.96","4741.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6116.12","77.4","","303.98","303.98","5854.79","1 through 10","919","6116.12","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","both","","","7901.96","4741.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","919","6716.67","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","both","","","7901.96","4741.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","919","6716.67","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","both","","","7901.96","4741.18","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4496.22","56.9","","812.12","238.65","1587.46","163","919","6716.67","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","both","","","7901.96","4741.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","919.00","11.63","","112.68","112.68","146.99","38","919","6716.67","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","both","","","7901.96","4741.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6116.12","77.4","","303.98","303.98","5854.79","1 through 10","919","6716.67","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7901.96","4741.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","919.00","11.63","","112.68","112.68","146.99","38","919","6116.12","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7901.96","4741.18","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4960.85","62.78","","780.86","208.94","10480.28","15","919","6116.12","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7901.96","4741.18","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3454.74","43.72","","179.76","179.76","179.76","1 through 10","919","6116.12","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7901.96","4741.18","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5746.31","72.72","","2355.45","298.99","3965.19","155","919","6116.12","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7901.96","4741.18","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5746.31","72.72","","3643.09","3643.09","3643.09","1 through 10","919","6116.12","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7901.96","4741.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4205.42","53.22","","554.28","554.28","554.28","16","919","6116.12","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7901.96","4741.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4970.33","62.9","","619.64","173.09","2370.64","150","919","6116.12","percent of total billed charges",""
"PATELLA PLATE 2.7MM SM 3-HOLE VARIABLE ANGLE LOCKING ANTERIOR SS","SUP-ITM-10285902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7901.96","4741.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6116.12","77.4","","303.98","303.98","5854.79","1 through 10","919","6116.12","percent of total billed charges",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","","","","inpatient","","","30768.43","18461.06","MARTIN'S POINT [160007]","HB WDH MEDICARE","8260.17","","Case rate ($8,260.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,658.30, add-ons for qualifying new technology services are included. If operating cost exceeds $11,576.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,376.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,244.20 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,213.44 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $571.10. The transfer capital threshold is the transfer adjustment factor * $571.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10266.52","10266.52","10266.52","1 through 10","3975","39064.1","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","","","","inpatient","","","30768.43","18461.06","MEDICARE [2001]","HB WDH MEDICARE","8260.17","","Case rate ($8,260.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,658.30, add-ons for qualifying new technology services are included. If operating cost exceeds $11,576.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,376.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,244.20 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,213.44 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $571.10. The transfer capital threshold is the transfer adjustment factor * $571.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8449.87","0.05","8470.73","15","3975","39064.1","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","","","","inpatient","","","30768.43","18461.06","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8260.17","","Case rate ($8,260.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,658.30, add-ons for qualifying new technology services are included. If operating cost exceeds $11,576.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,376.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,244.20 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,213.44 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $571.10. The transfer capital threshold is the transfer adjustment factor * $571.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8301.32","8301.32","8301.32","1 through 10","3975","39064.1","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","","","","inpatient","","","30768.43","18461.06","WELLSENSE NH [1050]","HB WDH MEDICARE","8260.17","","Case rate ($8,260.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,658.30, add-ons for qualifying new technology services are included. If operating cost exceeds $11,576.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,376.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $7,244.20 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,213.44 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $571.10. The transfer capital threshold is the transfer adjustment factor * $571.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8716.94","8716.94","8716.94","1 through 10","3975","39064.1","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC","542","MS-DRG","","","","","","","","inpatient","","","48690.46","29214.28","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","14290.81","","Case rate ($13,874.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,840.33, add-ons for qualifying new technology services are included. If operating cost exceeds $16,758.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,786.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $12,448.33 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,395.47 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $981.37. The transfer capital threshold is the transfer adjustment factor * $981.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","14774.55","14774.55","14774.55","1 through 10","3975","67127.18","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC","542","MS-DRG","","","","","","","","inpatient","","","48690.46","29214.28","MEDICARE [2001]","HB WDH MEDICARE","13874.57","","Case rate ($13,874.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,840.33, add-ons for qualifying new technology services are included. If operating cost exceeds $16,758.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,786.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $12,448.33 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,395.47 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $981.37. The transfer capital threshold is the transfer adjustment factor * $981.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14011.45","0.05","14554.68","1 through 10","3975","67127.18","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC","542","MS-DRG","","","","","","","","inpatient","","","48690.46","29214.28","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","13874.57","","Case rate ($13,874.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,840.33, add-ons for qualifying new technology services are included. If operating cost exceeds $16,758.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,786.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $12,448.33 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,395.47 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $981.37. The transfer capital threshold is the transfer adjustment factor * $981.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","0.05","1 through 10","3975","67127.18","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/McC","544","MS-DRG","","","","","","","","inpatient","","","30185.78","18111.47","MEDICARE [2001]","HB WDH MEDICARE","6181.68","","Case rate ($6,181.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,739.87, add-ons for qualifying new technology services are included. If operating cost exceeds $9,658.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,224.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,317.58 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,295.00 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $419.21. The transfer capital threshold is the transfer adjustment factor * $419.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","1915.97","1915.97","4830.89","1 through 10","3975","28674.88","other","Inpatient DRG"
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.65","476.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","92.42","675.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.65","476.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","92.42","675.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.65","476.79","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","452.16","56.9","","812.12","238.65","1587.46","163","92.42","675.45","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.65","476.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","92.42","11.63","","112.68","112.68","146.99","38","92.42","675.45","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.65","476.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","615.06","77.4","","303.98","303.98","5854.79","1 through 10","92.42","675.45","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","92.42","11.63","","112.68","112.68","146.99","38","92.42","615.06","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","498.88","62.78","","780.86","208.94","10480.28","15","92.42","615.06","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","347.42","43.72","","179.76","179.76","179.76","1 through 10","92.42","615.06","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","577.87","72.72","","2355.45","298.99","3965.19","155","92.42","615.06","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","577.87","72.72","","3643.09","3643.09","3643.09","1 through 10","92.42","615.06","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","422.91","53.22","","554.28","554.28","554.28","16","92.42","615.06","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","499.83","62.9","","619.64","173.09","2370.64","150","92.42","615.06","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","615.06","77.4","","303.98","303.98","5854.79","1 through 10","92.42","615.06","percent of total billed charges",""
"PEG BONE 2.0X16MM TITANIUM LOCKING","SUP-ITM-10133295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1302.05","781.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","151.43","1106.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PEG BONE 2.0X16MM TITANIUM LOCKING","SUP-ITM-10133295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1302.05","781.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","151.43","1106.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PEG BONE 2.0X16MM TITANIUM LOCKING","SUP-ITM-10133295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1302.05","781.23","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","740.87","56.9","","812.12","238.65","1587.46","163","151.43","1106.74","percent of total billed charges",""
"PEG BONE 2.0X16MM TITANIUM LOCKING","SUP-ITM-10133295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1302.05","781.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","151.43","11.63","","112.68","112.68","146.99","38","151.43","1106.74","percent of total billed charges",""
"PEG BONE 2.0X16MM TITANIUM LOCKING","SUP-ITM-10133295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1302.05","781.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1007.79","77.4","","303.98","303.98","5854.79","1 through 10","151.43","1106.74","percent of total billed charges",""
"PEG BONE 2.0X16MM TITANIUM LOCKING","SUP-ITM-10133295","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","151.43","11.63","","112.68","112.68","146.99","38","151.43","1007.79","percent of total billed charges",""
"PEG BONE 2.0X16MM TITANIUM LOCKING","SUP-ITM-10133295","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","817.43","62.78","","780.86","208.94","10480.28","15","151.43","1007.79","percent of total billed charges",""
"PEG BONE 2.0X16MM TITANIUM LOCKING","SUP-ITM-10133295","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","569.26","43.72","","179.76","179.76","179.76","1 through 10","151.43","1007.79","percent of total billed charges",""
"PEG BONE 2.0X16MM TITANIUM LOCKING","SUP-ITM-10133295","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","946.85","72.72","","2355.45","298.99","3965.19","155","151.43","1007.79","percent of total billed charges",""
"PEG BONE 2.0X16MM TITANIUM LOCKING","SUP-ITM-10133295","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","946.85","72.72","","3643.09","3643.09","3643.09","1 through 10","151.43","1007.79","percent of total billed charges",""
"PEG BONE 2.0X16MM TITANIUM LOCKING","SUP-ITM-10133295","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","692.95","53.22","","554.28","554.28","554.28","16","151.43","1007.79","percent of total billed charges",""
"PEG BONE 2.0X16MM TITANIUM LOCKING","SUP-ITM-10133295","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","818.99","62.9","","619.64","173.09","2370.64","150","151.43","1007.79","percent of total billed charges",""
"PEG BONE 2.0X16MM TITANIUM LOCKING","SUP-ITM-10133295","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1007.79","77.4","","303.98","303.98","5854.79","1 through 10","151.43","1007.79","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.65","476.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","92.42","675.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.65","476.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","92.42","675.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.65","476.79","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","452.16","56.9","","812.12","238.65","1587.46","163","92.42","675.45","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.65","476.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","92.42","11.63","","112.68","112.68","146.99","38","92.42","675.45","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.65","476.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","615.06","77.4","","303.98","303.98","5854.79","1 through 10","92.42","675.45","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","92.42","11.63","","112.68","112.68","146.99","38","92.42","615.06","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","498.88","62.78","","780.86","208.94","10480.28","15","92.42","615.06","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","347.42","43.72","","179.76","179.76","179.76","1 through 10","92.42","615.06","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","577.87","72.72","","2355.45","298.99","3965.19","155","92.42","615.06","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","577.87","72.72","","3643.09","3643.09","3643.09","1 through 10","92.42","615.06","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","422.91","53.22","","554.28","554.28","554.28","16","92.42","615.06","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","499.83","62.9","","619.64","173.09","2370.64","150","92.42","615.06","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","615.06","77.4","","303.98","303.98","5854.79","1 through 10","92.42","615.06","percent of total billed charges",""
"PEG BONE 22X2.0MM FIXATION VARIAX TITANIUM LOCKING","SUP-ITM-10133296","CDM","C1713","HCPCS","0278","RC","","","","both","","","1302.05","781.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","151.43","1106.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PEG BONE 22X2.0MM FIXATION VARIAX TITANIUM LOCKING","SUP-ITM-10133296","CDM","C1713","HCPCS","0278","RC","","","","both","","","1302.05","781.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","151.43","1106.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PEG BONE 22X2.0MM FIXATION VARIAX TITANIUM LOCKING","SUP-ITM-10133296","CDM","C1713","HCPCS","0278","RC","","","","both","","","1302.05","781.23","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","740.87","56.9","","812.12","238.65","1587.46","163","151.43","1106.74","percent of total billed charges",""
"PEG BONE 22X2.0MM FIXATION VARIAX TITANIUM LOCKING","SUP-ITM-10133296","CDM","C1713","HCPCS","0278","RC","","","","both","","","1302.05","781.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","151.43","11.63","","112.68","112.68","146.99","38","151.43","1106.74","percent of total billed charges",""
"PEG BONE 22X2.0MM FIXATION VARIAX TITANIUM LOCKING","SUP-ITM-10133296","CDM","C1713","HCPCS","0278","RC","","","","both","","","1302.05","781.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1007.79","77.4","","303.98","303.98","5854.79","1 through 10","151.43","1106.74","percent of total billed charges",""
"PEG BONE 22X2.0MM FIXATION VARIAX TITANIUM LOCKING","SUP-ITM-10133296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","151.43","11.63","","112.68","112.68","146.99","38","151.43","1007.79","percent of total billed charges",""
"PEG BONE 22X2.0MM FIXATION VARIAX TITANIUM LOCKING","SUP-ITM-10133296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","817.43","62.78","","780.86","208.94","10480.28","15","151.43","1007.79","percent of total billed charges",""
"PEG BONE 22X2.0MM FIXATION VARIAX TITANIUM LOCKING","SUP-ITM-10133296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","569.26","43.72","","179.76","179.76","179.76","1 through 10","151.43","1007.79","percent of total billed charges",""
"PEG BONE 22X2.0MM FIXATION VARIAX TITANIUM LOCKING","SUP-ITM-10133296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","946.85","72.72","","2355.45","298.99","3965.19","155","151.43","1007.79","percent of total billed charges",""
"PEG BONE 22X2.0MM FIXATION VARIAX TITANIUM LOCKING","SUP-ITM-10133296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","946.85","72.72","","3643.09","3643.09","3643.09","1 through 10","151.43","1007.79","percent of total billed charges",""
"PEG BONE 22X2.0MM FIXATION VARIAX TITANIUM LOCKING","SUP-ITM-10133296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","692.95","53.22","","554.28","554.28","554.28","16","151.43","1007.79","percent of total billed charges",""
"PEG BONE 22X2.0MM FIXATION VARIAX TITANIUM LOCKING","SUP-ITM-10133296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","818.99","62.9","","619.64","173.09","2370.64","150","151.43","1007.79","percent of total billed charges",""
"PEG BONE 22X2.0MM FIXATION VARIAX TITANIUM LOCKING","SUP-ITM-10133296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1007.79","77.4","","303.98","303.98","5854.79","1 through 10","151.43","1007.79","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","both","","","718.64","431.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","83.58","610.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","both","","","718.64","431.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","83.58","610.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","both","","","718.64","431.18","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","408.91","56.9","","812.12","238.65","1587.46","163","83.58","610.84","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","both","","","718.64","431.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","83.58","11.63","","112.68","112.68","146.99","38","83.58","610.84","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","both","","","718.64","431.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","556.23","77.4","","303.98","303.98","5854.79","1 through 10","83.58","610.84","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","83.58","11.63","","112.68","112.68","146.99","38","83.58","556.23","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","451.16","62.78","","780.86","208.94","10480.28","15","83.58","556.23","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","314.19","43.72","","179.76","179.76","179.76","1 through 10","83.58","556.23","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","522.60","72.72","","2355.45","298.99","3965.19","155","83.58","556.23","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","522.60","72.72","","3643.09","3643.09","3643.09","1 through 10","83.58","556.23","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","382.46","53.22","","554.28","554.28","554.28","16","83.58","556.23","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","452.02","62.9","","619.64","173.09","2370.64","150","83.58","556.23","percent of total billed charges",""
"PEG BONE L14X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","556.23","77.4","","303.98","303.98","5854.79","1 through 10","83.58","556.23","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","both","","","4195.54","2517.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","487.94","3566.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","both","","","4195.54","2517.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","487.94","3566.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","both","","","4195.54","2517.32","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2387.26","56.9","","812.12","238.65","1587.46","163","487.94","3566.21","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","both","","","4195.54","2517.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","487.94","11.63","","112.68","112.68","146.99","38","487.94","3566.21","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","both","","","4195.54","2517.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3247.35","77.4","","303.98","303.98","5854.79","1 through 10","487.94","3566.21","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4195.54","2517.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","487.94","11.63","","112.68","112.68","146.99","38","487.94","3247.35","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4195.54","2517.32","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2633.96","62.78","","780.86","208.94","10480.28","15","487.94","3247.35","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4195.54","2517.32","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1834.29","43.72","","179.76","179.76","179.76","1 through 10","487.94","3247.35","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4195.54","2517.32","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3051.00","72.72","","2355.45","298.99","3965.19","155","487.94","3247.35","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4195.54","2517.32","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3051.00","72.72","","3643.09","3643.09","3643.09","1 through 10","487.94","3247.35","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4195.54","2517.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2232.87","53.22","","554.28","554.28","554.28","16","487.94","3247.35","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4195.54","2517.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2638.99","62.9","","619.64","173.09","2370.64","150","487.94","3247.35","percent of total billed charges",""
"PELVIS PLATE 3.5X118MM 10 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004250","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4195.54","2517.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3247.35","77.4","","303.98","303.98","5854.79","1 through 10","487.94","3247.35","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","both","","","4394.97","2636.98","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","511.14","3735.72","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","both","","","4394.97","2636.98","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","511.14","3735.72","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","both","","","4394.97","2636.98","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2500.74","56.9","","812.12","238.65","1587.46","163","511.14","3735.72","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","both","","","4394.97","2636.98","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","511.14","11.63","","112.68","112.68","146.99","38","511.14","3735.72","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","both","","","4394.97","2636.98","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3401.71","77.4","","303.98","303.98","5854.79","1 through 10","511.14","3735.72","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4394.97","2636.98","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","511.14","11.63","","112.68","112.68","146.99","38","511.14","3401.71","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4394.97","2636.98","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2759.16","62.78","","780.86","208.94","10480.28","15","511.14","3401.71","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4394.97","2636.98","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1921.48","43.72","","179.76","179.76","179.76","1 through 10","511.14","3401.71","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4394.97","2636.98","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3196.02","72.72","","2355.45","298.99","3965.19","155","511.14","3401.71","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4394.97","2636.98","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3196.02","72.72","","3643.09","3643.09","3643.09","1 through 10","511.14","3401.71","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4394.97","2636.98","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2339.00","53.22","","554.28","554.28","554.28","16","511.14","3401.71","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4394.97","2636.98","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2764.44","62.9","","619.64","173.09","2370.64","150","511.14","3401.71","percent of total billed charges",""
"PELVIS PLATE 3.5X142MM 12 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004251","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4394.97","2636.98","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3401.71","77.4","","303.98","303.98","5854.79","1 through 10","511.14","3401.71","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","both","","","5274.47","3164.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","613.42","4483.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","both","","","5274.47","3164.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","613.42","4483.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","both","","","5274.47","3164.68","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3001.17","56.9","","812.12","238.65","1587.46","163","613.42","4483.3","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","both","","","5274.47","3164.68","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","613.42","11.63","","112.68","112.68","146.99","38","613.42","4483.3","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","both","","","5274.47","3164.68","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4082.44","77.4","","303.98","303.98","5854.79","1 through 10","613.42","4483.3","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5274.47","3164.68","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","613.42","11.63","","112.68","112.68","146.99","38","613.42","4082.44","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5274.47","3164.68","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3311.31","62.78","","780.86","208.94","10480.28","15","613.42","4082.44","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5274.47","3164.68","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2306.00","43.72","","179.76","179.76","179.76","1 through 10","613.42","4082.44","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5274.47","3164.68","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3835.59","72.72","","2355.45","298.99","3965.19","155","613.42","4082.44","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5274.47","3164.68","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3835.59","72.72","","3643.09","3643.09","3643.09","1 through 10","613.42","4082.44","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5274.47","3164.68","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2807.07","53.22","","554.28","554.28","554.28","16","613.42","4082.44","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5274.47","3164.68","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3317.64","62.9","","619.64","173.09","2370.64","150","613.42","4082.44","percent of total billed charges",""
"PELVIS PLATE 3.5X190MM 16 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5274.47","3164.68","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4082.44","77.4","","303.98","303.98","5854.79","1 through 10","613.42","4082.44","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","both","","","3694.43","2216.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","429.66","3140.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","both","","","3694.43","2216.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","429.66","3140.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","both","","","3694.43","2216.66","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2102.13","56.9","","812.12","238.65","1587.46","163","429.66","3140.27","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","both","","","3694.43","2216.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","429.66","11.63","","112.68","112.68","146.99","38","429.66","3140.27","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","both","","","3694.43","2216.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2859.49","77.4","","303.98","303.98","5854.79","1 through 10","429.66","3140.27","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3694.43","2216.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","429.66","11.63","","112.68","112.68","146.99","38","429.66","2859.49","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3694.43","2216.66","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2319.36","62.78","","780.86","208.94","10480.28","15","429.66","2859.49","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3694.43","2216.66","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1615.20","43.72","","179.76","179.76","179.76","1 through 10","429.66","2859.49","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3694.43","2216.66","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2686.59","72.72","","2355.45","298.99","3965.19","155","429.66","2859.49","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3694.43","2216.66","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2686.59","72.72","","3643.09","3643.09","3643.09","1 through 10","429.66","2859.49","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3694.43","2216.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1966.18","53.22","","554.28","554.28","554.28","16","429.66","2859.49","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3694.43","2216.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2323.80","62.9","","619.64","173.09","2370.64","150","429.66","2859.49","percent of total billed charges",""
"PELVIS PLATE 3.5X70MM 6 HOLE BONE LCP SS CURVED LOW PROFILE RECONSTRUCTION","SUP-ITM-10004248","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3694.43","2216.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2859.49","77.4","","303.98","303.98","5854.79","1 through 10","429.66","2859.49","percent of total billed charges",""
"Percutaneous And Other Intracardiac Procedures With McC","273","MS-DRG","","","","","","","","inpatient","","","179961.90","107977.14","MEDICARE [2001]","HB WDH MEDICARE","25469.80","","Case rate ($25,469.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $23,542.61, add-ons for qualifying new technology services are included. If operating cost exceeds $27,460.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,633.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $23,196.25 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $23,097.74 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,828.68. The transfer capital threshold is the transfer adjustment factor * $1,828.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","29950.19","29950.19","29950.19","1 through 10","4637","125084.93","other","Inpatient DRG"
"Percutaneous And Other Intracardiac Procedures With McC","273","MS-DRG","","","","","","","","inpatient","","","179961.90","107977.14","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","25469.80","","Case rate ($25,469.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $23,542.61, add-ons for qualifying new technology services are included. If operating cost exceeds $27,460.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,633.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $23,196.25 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $23,097.74 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,828.68. The transfer capital threshold is the transfer adjustment factor * $1,828.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26338.20","26338.20","26338.20","1 through 10","4637","125084.93","other","Inpatient DRG"
"Percutaneous And Other Intracardiac Procedures Without McC","274","MS-DRG","","","","","","","","inpatient","","","159070.26","95442.16","MEDICARE [2001]","HB WDH MEDICARE","25469.80","","Case rate ($25,469.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $23,542.61, add-ons for qualifying new technology services are included. If operating cost exceeds $27,460.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,633.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $23,196.25 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $23,097.74 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,828.68. The transfer capital threshold is the transfer adjustment factor * $1,828.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24055.82","24055.82","24055.82","1 through 10","3975","125084.93","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices","321","MS-DRG","","","","","","","","inpatient","","","147128.28","88276.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","40711.00","","Fee schedule rate ($40,711.00). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","41557.38","41557.38","41557.38","1 through 10","3975","103390.67","case rate",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices","321","MS-DRG","","","","","","","","inpatient","","","147128.28","88276.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","20706.97","","Case rate ($21,129.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $19,536.62, add-ons for qualifying new technology services are included. If operating cost exceeds $23,454.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,316.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $19,173.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $19,091.76 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,511.52. The transfer capital threshold is the transfer adjustment factor * $1,511.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","21575.34","21575.34","21575.34","1 through 10","3975","103390.67","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices","321","MS-DRG","","","","","","","","inpatient","","","147128.28","88276.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","82345.77","","Fee schedule rate ($82,345.77). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","102360.52","102360.52","102360.52","1 through 10","3975","103390.67","case rate",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices","321","MS-DRG","","","","","","","","inpatient","","","147128.28","88276.97","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","21763.45","","Case rate ($21,129.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $19,536.62, add-ons for qualifying new technology services are included. If operating cost exceeds $23,454.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,316.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $19,173.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $19,091.76 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,511.52. The transfer capital threshold is the transfer adjustment factor * $1,511.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","19360.69","19360.69","19360.69","1 through 10","3975","103390.67","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices","321","MS-DRG","","","","","","","","inpatient","","","147128.28","88276.97","MARTIN'S POINT [160007]","HB WDH MEDICARE","21129.56","","Case rate ($21,129.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $19,536.62, add-ons for qualifying new technology services are included. If operating cost exceeds $23,454.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,316.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $19,173.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $19,091.76 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,511.52. The transfer capital threshold is the transfer adjustment factor * $1,511.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","218188.39","218188.39","218188.39","1 through 10","3975","103390.67","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices","321","MS-DRG","","","","","","","","inpatient","","","147128.28","88276.97","MEDICARE [2001]","HB WDH MEDICARE","21129.56","","Case rate ($21,129.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $19,536.62, add-ons for qualifying new technology services are included. If operating cost exceeds $23,454.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,316.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $19,173.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $19,091.76 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,511.52. The transfer capital threshold is the transfer adjustment factor * $1,511.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21981.45","0.05","21982.93","30","3975","103390.67","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices","321","MS-DRG","","","","","","","","inpatient","","","147128.28","88276.97","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","21129.56","","Case rate ($21,129.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $19,536.62, add-ons for qualifying new technology services are included. If operating cost exceeds $23,454.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,316.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $19,173.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $19,091.76 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,511.52. The transfer capital threshold is the transfer adjustment factor * $1,511.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21581.33","1148.79","27118.20","1 through 10","3975","103390.67","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices","321","MS-DRG","","","","","","","","inpatient","","","147128.28","88276.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","55749.19","","Fee schedule rate ($55,749.19). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","56631.39","56631.39","56631.39","1 through 10","3975","103390.67","case rate",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC","322","MS-DRG","","","","","","","","inpatient","","","116649.82","69989.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","66994.18","","Fee schedule rate ($66,994.18). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","67072.96","67072.96","67072.96","1 through 10","3975","66994.18","case rate",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC","322","MS-DRG","","","","","","","","inpatient","","","116649.82","69989.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","26379.56","","Fee schedule rate ($26,379.56). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","26410.57","26410.57","26410.57","1 through 10","3975","66994.18","case rate",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC","322","MS-DRG","","","","","","","","inpatient","","","116649.82","69989.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","13570.99","","Case rate ($13,847.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,815.77, add-ons for qualifying new technology services are included. If operating cost exceeds $16,733.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,784.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,423.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,370.91 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $979.42. The transfer capital threshold is the transfer adjustment factor * $979.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","204014.74","204014.74","204014.74","1 through 10","3975","66994.18","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC","322","MS-DRG","","","","","","","","inpatient","","","116649.82","69989.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","53357.69","","Fee schedule rate ($53,357.69). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","53420.42","53420.42","53420.42","1 through 10","3975","66994.18","case rate",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC","322","MS-DRG","","","","","","","","inpatient","","","116649.82","69989.89","MARTIN'S POINT [160007]","HB WDH MEDICARE","13847.95","","Case rate ($13,847.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,815.77, add-ons for qualifying new technology services are included. If operating cost exceeds $16,733.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,784.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,423.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,370.91 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $979.42. The transfer capital threshold is the transfer adjustment factor * $979.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13856.64","13829.29","24524.85","1 through 10","3975","66994.18","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC","322","MS-DRG","","","","","","","","inpatient","","","116649.82","69989.89","MEDICARE [2001]","HB WDH MEDICARE","13847.95","","Case rate ($13,847.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,815.77, add-ons for qualifying new technology services are included. If operating cost exceeds $16,733.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,784.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,423.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,370.91 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $979.42. The transfer capital threshold is the transfer adjustment factor * $979.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14096.21","0.05","14131.78","22","3975","66994.18","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC","322","MS-DRG","","","","","","","","inpatient","","","116649.82","69989.89","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","13847.95","","Case rate ($13,847.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,815.77, add-ons for qualifying new technology services are included. If operating cost exceeds $16,733.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,784.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,423.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,370.91 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $979.42. The transfer capital threshold is the transfer adjustment factor * $979.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13864.95","13849.15","14131.78","1 through 10","3975","66994.18","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC","322","MS-DRG","","","","","","","","inpatient","","","116649.82","69989.89","WELLSENSE NH [1050]","HB WDH MEDICARE","13847.95","","Case rate ($13,847.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,815.77, add-ons for qualifying new technology services are included. If operating cost exceeds $16,733.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,784.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $12,423.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,370.91 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $979.42. The transfer capital threshold is the transfer adjustment factor * $979.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16927.06","16927.06","16927.06","1 through 10","3975","66994.18","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With McC","250","MS-DRG","","","","","","","","inpatient","","","140204.85","84122.91","MEDICARE [2001]","HB WDH MEDICARE","17037.19","","Case rate ($17,037.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,759.40, add-ons for qualifying new technology services are included. If operating cost exceeds $19,677.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,017.49, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $15,379.84 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,314.52 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,212.47. The transfer capital threshold is the transfer adjustment factor * $1,212.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17894.65","17894.65","21113.50","1 through 10","3975","82935.22","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without McC","251","MS-DRG","","","","","","","","inpatient","","","113305.85","67983.51","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","12042.84","","Case rate ($11,806.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,931.72, add-ons for qualifying new technology services are included. If operating cost exceeds $14,849.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,635.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,531.58 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,486.85 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $830.26. The transfer capital threshold is the transfer adjustment factor * $830.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","12235.48","12235.48","12235.48","1 through 10","10673.17","56791.15","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without McC","251","MS-DRG","","","","","","","","inpatient","","","113305.85","67983.51","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","12160.91","","Case rate ($11,806.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,931.72, add-ons for qualifying new technology services are included. If operating cost exceeds $14,849.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,635.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,531.58 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,486.85 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $830.26. The transfer capital threshold is the transfer adjustment factor * $830.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","2397.11","2397.11","2397.11","1 through 10","10673.17","56791.15","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without McC","251","MS-DRG","","","","","","","","inpatient","","","113305.85","67983.51","MEDICARE [2001]","HB WDH MEDICARE","11806.71","","Case rate ($11,806.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,931.72, add-ons for qualifying new technology services are included. If operating cost exceeds $14,849.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,635.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,531.58 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,486.85 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $830.26. The transfer capital threshold is the transfer adjustment factor * $830.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12266.20","12266.20","12266.20","1 through 10","10673.17","56791.15","other","Inpatient DRG"
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without McC","251","MS-DRG","","","","","","","","inpatient","","","113305.85","67983.51","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","11806.71","","Case rate ($11,806.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,931.72, add-ons for qualifying new technology services are included. If operating cost exceeds $14,849.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,635.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $10,531.58 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,486.85 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $830.26. The transfer capital threshold is the transfer adjustment factor * $830.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11998.28","11998.28","11998.28","1 through 10","10673.17","56791.15","other","Inpatient DRG"
"Percutaneous Coronary Lithotripsy With Other Intervention","PX-48000482","CDM","92972","CPT","0481","RC","","","","outpatient","","","41998.00","25198.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","4884.37","11.63","","5138.01","4786.89","5138.01","1 through 10","4884.37","32506.45","percent of total billed charges",""
"Peri-Px Dev Eval & Prog Sing/Dual/Multi Lead Dfb","PX-48000013","CDM","93287","CPT","0480","RC","","","","outpatient","","","355.00","213.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","258.16","72.72","","249.43","249.43","249.43","1 through 10","41.29","274.77","percent of total billed charges",""
"Pericardiocentesis W/Img Guidance When Performed","PX-36000457","CDM","33016","CPT","0361","RC","","","","both","","","8767.00","5260.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","8383.83","","Case rate ($8,383.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4357.42","4357.42","4357.42","1 through 10","1590.51","10372.29","other","OPPS APC"
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","","","","inpatient","","","23200.50","13920.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","8389.25","","Case rate ($8,560.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,935.48, add-ons for qualifying new technology services are included. If operating cost exceeds $11,853.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,398.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,522.56 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,490.61 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $593.04. The transfer capital threshold is the transfer adjustment factor * $593.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5557.05","5557.05","5557.05","1 through 10","3975","40565.11","other","Inpatient DRG"
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","","","","inpatient","","","23200.50","13920.30","MEDICARE [2001]","HB WDH MEDICARE","8560.46","","Case rate ($8,560.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,935.48, add-ons for qualifying new technology services are included. If operating cost exceeds $11,853.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,398.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,522.56 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,490.61 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $593.04. The transfer capital threshold is the transfer adjustment factor * $593.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8262.13","0.05","8523.06","1 through 10","3975","40565.11","other","Inpatient DRG"
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","","","","inpatient","","","23200.50","13920.30","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8560.46","","Case rate ($8,560.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,935.48, add-ons for qualifying new technology services are included. If operating cost exceeds $11,853.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,398.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,522.56 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,490.61 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $593.04. The transfer capital threshold is the transfer adjustment factor * $593.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8412.72","8412.72","8412.72","1 through 10","3975","40565.11","other","Inpatient DRG"
"Peripheral Vascular Disorders With McC","299","MS-DRG","","","","","","","","inpatient","","","34543.46","20726.08","MARTIN'S POINT [160007]","HB WDH MEDICARE","12857.37","","Case rate ($12,857.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,901.47, add-ons for qualifying new technology services are included. If operating cost exceeds $15,819.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,712.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,505.46 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,456.60 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $907.04. The transfer capital threshold is the transfer adjustment factor * $907.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9982.78","9982.78","9982.78","1 through 10","3975","62042.76","other","Inpatient DRG"
"Peripheral Vascular Disorders With McC","299","MS-DRG","","","","","","","","inpatient","","","34543.46","20726.08","MEDICARE [2001]","HB WDH MEDICARE","12857.37","","Case rate ($12,857.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,901.47, add-ons for qualifying new technology services are included. If operating cost exceeds $15,819.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,712.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,505.46 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,456.60 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $907.04. The transfer capital threshold is the transfer adjustment factor * $907.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12682.29","572.91","12682.29","1 through 10","3975","62042.76","other","Inpatient DRG"
"Peripheral Vascular Disorders With McC","299","MS-DRG","","","","","","","","inpatient","","","34543.46","20726.08","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","12857.37","","Case rate ($12,857.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,901.47, add-ons for qualifying new technology services are included. If operating cost exceeds $15,819.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,712.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,505.46 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,456.60 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $907.04. The transfer capital threshold is the transfer adjustment factor * $907.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9622.92","9622.92","9622.92","1 through 10","3975","62042.76","other","Inpatient DRG"
"Peripheral Vascular Disorders Without Cc/McC","301","MS-DRG","","","","","","","","inpatient","","","27132.60","16279.56","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","5916.35","","Case rate ($5,916.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,494.98, add-ons for qualifying new technology services are included. If operating cost exceeds $9,413.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,204.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,071.65 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,050.11 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $399.82. The transfer capital threshold is the transfer adjustment factor * $399.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5827.78","5827.78","5827.78","1 through 10","3975","27348.67","other","Inpatient DRG"
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","","","","inpatient","","","66745.27","40047.16","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","32898.88","","Fee schedule rate ($32,898.88). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","47029.70","47029.70","47029.70","1 through 10","3975","83550.82","case rate",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures With McC","040","MS-DRG","","","","","","","","inpatient","","","130540.06","78324.04","MEDICARE [2001]","HB WDH MEDICARE","29799.40","","Case rate ($29,799.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $27,538.77, add-ons for qualifying new technology services are included. If operating cost exceeds $31,456.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,950.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $27,209.46 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $27,093.90 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,145.06. The transfer capital threshold is the transfer adjustment factor * $2,145.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","24903.65","24903.65","24903.65","1 through 10","8024","78400.12","other","Inpatient DRG"
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","","","","inpatient","","","88975.55","53385.33","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","31552.23","","Fee schedule rate ($31,552.23). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","30835.20","30835.20","30835.20","1 through 10","3975","80130.81","case rate",""
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","","","","inpatient","","","88975.55","53385.33","MEDICARE [2001]","HB WDH MEDICARE","16476.13","","Case rate ($16,476.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,241.54, add-ons for qualifying new technology services are included. If operating cost exceeds $19,159.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,976.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $14,859.78 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,796.67 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,171.47. The transfer capital threshold is the transfer adjustment factor * $1,171.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","16383.27","16383.27","16383.27","1 through 10","3975","80130.81","other","Inpatient DRG"
"Peritoneal Adhesiolysis With McC","335","MS-DRG","","","","","","","","inpatient","","","119545.02","71727.01","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","28420.18","","Case rate ($27,592.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $25,501.75, add-ons for qualifying new technology services are included. If operating cost exceeds $29,419.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,788.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $25,163.75 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $25,056.88 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,983.79. The transfer capital threshold is the transfer adjustment factor * $1,983.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","27447.84","27447.84","27447.84","1 through 10","3975","135694.56","other","Inpatient DRG"
"Peritoneal Adhesiolysis With McC","335","MS-DRG","","","","","","","","inpatient","","","119545.02","71727.01","MEDICARE [2001]","HB WDH MEDICARE","27592.41","","Case rate ($27,592.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $25,501.75, add-ons for qualifying new technology services are included. If operating cost exceeds $29,419.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,788.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $25,163.75 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $25,056.88 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,983.79. The transfer capital threshold is the transfer adjustment factor * $1,983.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27785.37","27785.37","27785.37","1 through 10","3975","135694.56","other","Inpatient DRG"
"Peritoneal Adhesiolysis With McC","335","MS-DRG","","","","","","","","inpatient","","","119545.02","71727.01","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","27592.41","","Case rate ($27,592.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $25,501.75, add-ons for qualifying new technology services are included. If operating cost exceeds $29,419.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,788.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $25,163.75 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $25,056.88 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,983.79. The transfer capital threshold is the transfer adjustment factor * $1,983.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27856.60","27856.60","27856.60","1 through 10","3975","135694.56","other","Inpatient DRG"
"Peritoneal Adhesiolysis Without Cc/McC","337","MS-DRG","","","","","","","","inpatient","","","60776.86","36466.12","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","46457.20","","Fee schedule rate ($46,457.20). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","43685.11","43685.11","43685.11","1 through 10","3975","58330.15","case rate",""
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","","","","inpatient","","","108968.01","65380.81","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","16977.80","","Case rate ($16,644.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,397.32, add-ons for qualifying new technology services are included. If operating cost exceeds $19,315.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,988.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $15,016.22 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,952.45 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,183.81. The transfer capital threshold is the transfer adjustment factor * $1,183.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.","17487.71","17487.71","17487.71","1 through 10","15218.1","80974.41","other","Inpatient DRG"
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","","","","inpatient","","","108968.01","65380.81","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","17144.25","","Case rate ($16,644.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,397.32, add-ons for qualifying new technology services are included. If operating cost exceeds $19,315.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,988.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $15,016.22 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,952.45 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,183.81. The transfer capital threshold is the transfer adjustment factor * $1,183.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","81879.63","81879.63","81879.63","1 through 10","15218.1","80974.41","other","Inpatient DRG"
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","","","","inpatient","","","108968.01","65380.81","MARTIN'S POINT [160007]","HB WDH MEDICARE","16644.90","","Case rate ($16,644.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,397.32, add-ons for qualifying new technology services are included. If operating cost exceeds $19,315.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,988.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $15,016.22 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,952.45 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,183.81. The transfer capital threshold is the transfer adjustment factor * $1,183.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","17145.46","17145.46","17145.46","1 through 10","15218.1","80974.41","other","Inpatient DRG"
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","","","","inpatient","","","108968.01","65380.81","MEDICARE [2001]","HB WDH MEDICARE","16644.90","","Case rate ($16,644.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,397.32, add-ons for qualifying new technology services are included. If operating cost exceeds $19,315.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,988.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $15,016.22 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,952.45 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,183.81. The transfer capital threshold is the transfer adjustment factor * $1,183.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","17443.42","0.05","17487.71","12","15218.1","80974.41","other","Inpatient DRG"
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","","","","inpatient","","","108968.01","65380.81","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","16644.90","","Case rate ($16,644.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,397.32, add-ons for qualifying new technology services are included. If operating cost exceeds $19,315.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,988.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $15,016.22 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,952.45 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,183.81. The transfer capital threshold is the transfer adjustment factor * $1,183.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","17443.42","2666.98","17487.71","1 through 10","15218.1","80974.41","other","Inpatient DRG"
"Permanent Cardiac Pacemaker Implant With McC","242","MS-DRG","","","","","","","","inpatient","","","128158.04","76894.82","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","25212.29","","Case rate ($24,717.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $22,848.63, add-ons for qualifying new technology services are included. If operating cost exceeds $26,766.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,578.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $22,499.32 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $22,403.76 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,773.74. The transfer capital threshold is the transfer adjustment factor * $1,773.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.","26107.79","26107.79","26107.79","1 through 10","22801.8","121326.72","other","Inpatient DRG"
"Permanent Cardiac Pacemaker Implant With McC","242","MS-DRG","","","","","","","","inpatient","","","128158.04","76894.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","24223.57","","Case rate ($24,717.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $22,848.63, add-ons for qualifying new technology services are included. If operating cost exceeds $26,766.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,578.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $22,499.32 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $22,403.76 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,773.74. The transfer capital threshold is the transfer adjustment factor * $1,773.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","25583.90","25583.90","25583.90","1 through 10","22801.8","121326.72","other","Inpatient DRG"
"Permanent Cardiac Pacemaker Implant With McC","242","MS-DRG","","","","","","","","inpatient","","","128158.04","76894.82","MEDICARE [2001]","HB WDH MEDICARE","24717.93","","Case rate ($24,717.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $22,848.63, add-ons for qualifying new technology services are included. If operating cost exceeds $26,766.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,578.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $22,499.32 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $22,403.76 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,773.74. The transfer capital threshold is the transfer adjustment factor * $1,773.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Includes an additional $800 of payment.","26106.02","26106.02","26106.02","1 through 10","22801.8","121326.72","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Permanent Cardiac Pacemaker Implant With McC","242","MS-DRG","","","","","","","","inpatient","","","128158.04","76894.82","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","24717.93","","Case rate ($24,717.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $22,848.63, add-ons for qualifying new technology services are included. If operating cost exceeds $26,766.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,578.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $22,499.32 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $22,403.76 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,773.74. The transfer capital threshold is the transfer adjustment factor * $1,773.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Includes an additional $800 of payment.","25623.40","25623.40","25623.40","1 through 10","22801.8","121326.72","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Permanent Cardiac Pacemaker Implant Without Cc/McC","244","MS-DRG","","","","","","","","inpatient","","","114625.06","68775.04","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","13902.54","","Case rate ($14,186.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,128.03, add-ons for qualifying new technology services are included. If operating cost exceeds $17,046.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,809.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $12,737.26 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,683.16 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.15. The transfer capital threshold is the transfer adjustment factor * $1,004.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","14062.25","14062.25","14062.25","1 through 10","12908.5","68685.18","other","Inpatient DRG"
"Permanent Cardiac Pacemaker Implant Without Cc/McC","244","MS-DRG","","","","","","","","inpatient","","","114625.06","68775.04","MEDICARE [2001]","HB WDH MEDICARE","14186.27","","Case rate ($14,186.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,128.03, add-ons for qualifying new technology services are included. If operating cost exceeds $17,046.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,809.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $12,737.26 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,683.16 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.15. The transfer capital threshold is the transfer adjustment factor * $1,004.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","14062.25","14062.25","14097.73","1 through 10","12908.5","68685.18","other","Inpatient DRG"
"Perq Device Breast 1st Imag","PX-76001936","CDM","19281","CPT","0761","RC","","","","both","","","4957.00","2974.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1692.76","","APC Price ($1,692.76). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1551.26","1551.26","1551.26","1 through 10","1658.91","10818.29","other","OPPS APC"
"Perq Device Breast Ea Imag, US Guidance","PX-76001938","CDM","19285","CPT","0761","RC","","","","both","","","4155.00","2493.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","2900.19","69.8","","2798.28","2798.28","2798.28","1 through 10","599.15","4697.85","percent of total billed charges",""
"Perq Device Breast Ea Imag, US Guidance","PX-76001938","CDM","19285","CPT","0761","RC","","","","both","","","4155.00","2493.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","735.08","","APC Price ($735.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","726.37","674.56","728.47","1 through 10","599.15","4697.85","other","OPPS APC"
"Perq Replacement Gtube Not Req Revj Gstrst Trc","PX-75000480","CDM","43762","CPT","0750","RC","","","","both","","","1054.00","632.40","MEDICARE [2001]","HB WDH MEDICARE","254.10","","APC Price ($254.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","254.13","254.13","254.13","1 through 10","249.01","1623.9","other","OPPS APC"
"Perq Sft Tiss Loc Device Plmt 1st Les W/Gdnce","PX-76002177","CDM","10035","CPT","0761","RC","","","","both","","","4226.00","2535.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","2949.75","69.8","","2846.44","2653.10","2846.44","1 through 10","720.38","4697.85","percent of total billed charges",""
"Perq Tcat Plmt Ntrac St 1 Les 1+C Segments","PX-48000238","CDM","92928","CPT","0481","RC","","","","both","","","58181.00","34908.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","11848.17","","APC Price ($11,848.17). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11713.35","11612.54","16422.71","16","11611.21","75720.79","other","OPPS APC"
"Perq Tcat Plmt Ntrac St 1 Les 1+C Segments","PX-48000238","CDM","92928","CPT","0481","RC","","","","outpatient","","","58181.00","34908.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","42309.22","72.72","","40827.19","40827.19","40827.19","1 through 10","6766.45","45032.09","percent of total billed charges",""
"Perq Tcat Ther Rx Dlvr Ntrac Rx Balo 1 Maj C Art","PX-48000549","CDM","0913T","CPT","0481","RC","","","","both","","","41998.00","25198.80","MEDICARE [2001]","HB WDH MEDICARE","5956.72","","APC Price ($5,956.72). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","17872.20","5957.40","17872.20","1 through 10","5837.59","38068.95","other","OPPS APC"
"Perq Thrmbc/Nfs Dial Circuit Trluml Balo Angiop","PX-36000411","CDM","36905","CPT","0361","RC","","","","both","","","43619.00","26171.40","MEDICARE [2001]","HB WDH MEDICARE","11848.17","","APC Price ($11,848.17). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","35548.59","21437.82","35548.59","1 through 10","6289.86","75720.79","other","OPPS APC"
"Perq Trluml C Angioplasty 1 Maj C Art&/Branches","PX-48000234","CDM","92920","CPT","0481","RC","","","","both","","","41998.00","25198.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","5956.72","","APC Price ($5,956.72). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","12846.24","5846.16","12846.24","1 through 10","5837.59","38068.95","other","OPPS APC"
"Perq Trluml C Athrc St Angiop 1 Maj C Art&/Brnch","PX-48000240","CDM","92933","CPT","0481","RC","","","","both","","","11556.00","6933.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","18760.46","","APC Price ($18,760.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","18396.27","18396.27","18396.27","1 through 10","6575.36","119896.73","other","OPPS APC"
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","both","","","8319.00","4991.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","4193.60","","Case rate ($4,193.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4266.65","4266.65","4266.65","1 through 10","1493.4","9738.99","other","OPPS APC"
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","both","","","8319.00","4991.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1493.40","","APC Price ($1,523.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1501.47","1501.47","1501.47","1 through 10","1493.4","9738.99","other","OPPS APC"
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","both","","","8319.00","4991.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","1523.88","","APC Price ($1,523.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1499.67","1499.67","1499.67","1 through 10","1493.4","9738.99","other","OPPS APC"
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","both","","","8319.00","4991.40","MEDICARE [2001]","HB WDH MEDICARE","1523.88","","APC Price ($1,523.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1524.05","1524.05","1524.32","1 through 10","1493.4","9738.99","other","OPPS APC"
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","both","","","8319.00","4991.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1523.88","","APC Price ($1,523.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1524.32","1524.32","1524.32","1 through 10","1493.4","9738.99","other","OPPS APC"
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","both","","","8319.00","4991.40","WELLSENSE NH [1050]","HB WDH MEDICARE","1523.88","","APC Price ($1,523.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1575.24","1575.24","1575.24","1 through 10","1493.4","9738.99","other","OPPS APC"
"Pet Brain Imaging Metabolic Eval","PX-40000102","CDM","78608","CPT","0404","RC","","","","outpatient","","","8319.00","4991.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5232.65","62.9","","5057.64","5057.64","5057.64","1 through 10","967.5","6438.91","percent of total billed charges",""
"Pet Brain Imaging Metabolic Eval|REDUCED SERVICES","PX-40000102","CDM","78608","CPT","0404","RC","","","52","both","","","8319.00","4991.40","MEDICARE [2001]","HB WDH MEDICARE","1523.88","","APC Price ($1,523.88). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","762.03","762.03","762.03","1 through 10","1493.4","1569.59","other","OPPS APC"
"Pet W/CT Tumor Imaging Limited Area","PX-40000107","CDM","78814","CPT","0404","RC","","","","both","","","9969.00","5981.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","9738.99","","Case rate ($9,738.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9501.48","9501.48","9501.48","1 through 10","1493.4","9738.99","other","OPPS APC"
"Pet W/CT Tumor Imaging Limited Area","PX-40000107","CDM","78814","CPT","0404","RC","","","","both","","","9969.00","5981.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","7871.93","","Case rate ($7,871.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7679.89","7679.89","7679.89","1 through 10","1493.4","9738.99","other","OPPS APC"
"Pet W/CT Tumor Imaging Limited Area","PX-40000107","CDM","78814","CPT","0404","RC","","","","both","","","9969.00","5981.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","1569.59","","APC Price ($1,523.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1549.97","1549.97","1549.97","1 through 10","1493.4","9738.99","other","OPPS APC"
"Pet W/CT Tumor Imaging Limited Area","PX-40000107","CDM","78814","CPT","0404","RC","","","","both","","","9969.00","5981.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","1523.88","","APC Price ($1,523.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1499.67","1493.83","1499.67","1 through 10","1493.4","9738.99","other","OPPS APC"
"Pet W/CT Tumor Imaging Limited Area","PX-40000107","CDM","78814","CPT","0404","RC","","","","both","","","9969.00","5981.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1523.88","","APC Price ($1,523.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1524.05","1524.05","1524.05","1 through 10","1493.4","9738.99","other","OPPS APC"
"Pet W/CT Tumor Imaging Limited Area","PX-40000107","CDM","78814","CPT","0404","RC","","","","outpatient","","","9969.00","5981.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7249.46","72.72","","6995.66","6995.66","6995.66","1 through 10","1159.39","7716.01","percent of total billed charges",""
"Pet W/CT Tumor Imaging Limited Area","PX-40000107","CDM","78814","CPT","0404","RC","","","","outpatient","","","9969.00","5981.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6270.50","62.9","","6060.60","6060.60","6060.60","1 through 10","1159.39","7716.01","percent of total billed charges",""
"Pet W/CT Tumor Imaging Limited Area","PX-40000107","CDM","78814","CPT","0404","RC","","","","outpatient","","","9969.00","5981.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7716.01","77.4","","7455.50","7455.50","7455.50","1 through 10","1159.39","7716.01","percent of total billed charges",""
"Pet W/CT Tumor Imaging Limited Area","PX-40000107","CDM","78814","CPT","0404","RC","","","","outpatient","","","9969.00","5981.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1159.39","11.63","","2438.48","2438.48","2438.48","1 through 10","1159.39","7716.01","percent of total billed charges",""
"Pet W/CT Tumor Imaging Whole Body","PX-40000109","CDM","78816","CPT","0404","RC","","","","both","","","13212.00","7927.20","MEDICARE [2001]","HB WDH MEDICARE","1523.88","","APC Price ($1,523.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1524.32","1524.32","1524.32","1 through 10","1493.4","11230.2","other","OPPS APC"
"Pet W/CT Tumor Imaging Whole Body","PX-40000109","CDM","78816","CPT","0404","RC","","","","both","","","13212.00","7927.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1523.88","","APC Price ($1,523.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1496.57","1493.57","1498.84","1 through 10","1493.4","11230.2","other","OPPS APC"
"Pet W/CT Tumor Skull to Mid-Thigh","PX-40000108","CDM","78815","CPT","0404","RC","","","","both","","","13212.00","7927.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","9221.98","69.8","","8898.80","8898.80","8898.80","1 through 10","1493.4","11230.2","percent of total billed charges",""
"Pet W/CT Tumor Skull to Mid-Thigh","PX-40000108","CDM","78815","CPT","0404","RC","","","","both","","","13212.00","7927.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","9738.99","","Case rate ($9,738.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9501.48","9501.48","9501.48","1 through 10","1493.4","11230.2","other","OPPS APC"
"Pet W/CT Tumor Skull to Mid-Thigh","PX-40000108","CDM","78815","CPT","0404","RC","","","","both","","","13212.00","7927.20","MEDICARE [2001]","HB WDH MEDICARE","1523.88","","APC Price ($1,523.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1524.05","1524.05","1524.05","1 through 10","1493.4","11230.2","other","OPPS APC"
"Pet W/CT Tumor Skull to Mid-Thigh","PX-40000108","CDM","78815","CPT","0404","RC","","","","both","","","13212.00","7927.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","11230.20","85","","2133.67","2133.67","2133.67","1 through 10","1493.4","11230.2","percent of total billed charges",""
"Pet W/CT Tumor Skull to Mid-Thigh","PX-40000108","CDM","78815","CPT","0404","RC","","","","both","","","13212.00","7927.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1523.88","","APC Price ($1,523.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1496.57","1493.57","1499.67","100","1493.4","11230.2","other","OPPS APC"
"Pet W/CT Tumor Skull to Mid-Thigh","PX-40000108","CDM","78815","CPT","0404","RC","","","","outpatient","","","13212.00","7927.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","9607.77","72.72","","10015.32","9271.07","10015.32","1 through 10","1536.56","10226.09","percent of total billed charges",""
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","884.00","530.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","860.68","","Case rate ($860.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","839.69","809.02","839.69","1 through 10","131.98","860.68","other","OPPS APC"
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","884.00","530.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","370.61","","Case rate ($370.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","361.57","348.37","361.57","13","131.98","860.68","other","OPPS APC"
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","884.00","530.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","131.98","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","134.69","132.00","134.69","32","131.98","860.68","other","OPPS APC"
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","884.00","530.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","695.68","","Case rate ($695.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","361.57","361.57","678.71","23","131.98","860.68","other","OPPS APC"
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","884.00","530.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","503.00","56.9","","485.36","485.36","485.36","1 through 10","131.98","860.68","percent of total billed charges",""
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","884.00","530.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","138.71","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","127.63","127.53","138.73","1 through 10","131.98","860.68","other","OPPS APC"
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","884.00","530.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","132.40","122.34","132.40","16","131.98","860.68","other","OPPS APC"
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","884.00","530.40","MEDICARE [2001]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","134.69","134.69","134.69","77","131.98","860.68","other","OPPS APC"
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","884.00","530.40","TRICARE [160005]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","134.69","134.69","134.69","1 through 10","131.98","860.68","other","OPPS APC"
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","884.00","530.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","134.69","134.69","134.69","22","131.98","860.68","other","OPPS APC"
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","outpatient","","","884.00","530.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","127.47","14.42","","123.00","105.43","123.00","1 through 10","102.81","684.22","percent of total billed charges",""
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","outpatient","","","884.00","530.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","102.81","11.63","","117.46","100.76","302.28","1 through 10","102.81","684.22","percent of total billed charges",""
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","outpatient","","","884.00","530.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","556.04","62.9","","537.39","537.39","537.39","1 through 10","102.81","684.22","percent of total billed charges",""
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","outpatient","","","884.00","530.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","684.22","77.4","","661.08","661.08","661.08","1 through 10","102.81","684.22","percent of total billed charges",""
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","outpatient","","","884.00","530.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","102.81","11.63","","215.50","100.76","426.68","1 through 10","102.81","684.22","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","both","","","73.00","43.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","50.95","69.8","","44.66","5.90","49.56","1 through 10","3.37","62.05","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","outpatient","","","73.00","43.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","53.09","72.72","","51.63","51.63","51.63","12","4.82","56.5","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","outpatient","","","73.00","43.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","45.92","62.9","","44.73","44.73","85.76","14","4.82","56.5","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","outpatient","","","73.00","43.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","56.50","77.4","","55.03","55.03","55.03","1 through 10","4.82","56.5","percent of total billed charges",""
"Phosphatase Alkaline Isoenzyme","PX-30000615","CDM","84080","CPT","0301","RC","","","","both","","","86.00","51.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","60.03","69.8","","57.93","52.21","57.93","1 through 10","9.61","76.77","percent of total billed charges",""
"Phosphatase Alkaline Isoenzyme","PX-30000615","CDM","84080","CPT","0301","RC","","","","outpatient","","","86.00","51.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","62.54","72.72","","60.36","60.36","60.36","1 through 10","13.78","66.56","percent of total billed charges",""
"Phosphatase Alkaline Isoenzyme","PX-30000615","CDM","84080","CPT","0301","RC","","","","outpatient","","","86.00","51.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","54.09","62.9","","52.29","52.29","52.29","1 through 10","13.78","66.56","percent of total billed charges",""
"Phosphatase Alkaline Isoenzyme","PX-30000615","CDM","84080","CPT","0301","RC","","","","outpatient","","","86.00","51.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","66.56","77.4","","64.33","64.33","64.33","1 through 10","13.78","66.56","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","68.00","40.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","47.46","69.8","","46.07","46.07","46.07","102","3.08","57.8","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","68.00","40.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","57.80","85","","56.10","56.10","56.10","1 through 10","3.08","57.8","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","outpatient","","","68.00","40.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","42.69","62.78","","41.43","41.43","41.43","1 through 10","4.42","52.63","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","outpatient","","","68.00","40.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","29.73","43.72","","28.86","28.86","86.58","14","4.42","52.63","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","outpatient","","","68.00","40.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","49.45","72.72","","48.00","48.00","48.00","148","4.42","52.63","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","outpatient","","","68.00","40.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","49.45","72.72","","48.00","48.00","48.00","1 through 10","4.42","52.63","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","outpatient","","","68.00","40.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","36.19","53.22","","35.18","35.18","35.18","15","4.42","52.63","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","outpatient","","","68.00","40.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","42.77","62.9","","41.58","41.58","166.32","207","4.42","52.63","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","outpatient","","","68.00","40.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","52.63","77.4","","51.15","51.15","51.15","66","4.42","52.63","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","outpatient","","","68.00","40.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","49.45","72.72","","48.00","48.00","48.00","1 through 10","4.42","52.63","percent of total billed charges",""
"Phosphorus Urine","PX-30000620","CDM","84105","CPT","0301","RC","","","","both","","","73.00","43.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","50.95","69.8","","49.56","49.56","49.56","1 through 10","3.76","62.05","percent of total billed charges",""
"Phosphorus Urine","PX-30000620","CDM","84105","CPT","0301","RC","","","","outpatient","","","73.00","43.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","53.09","72.72","","51.63","51.63","51.63","1 through 10","6.2","56.5","percent of total billed charges",""
"Phys/Qhp Svcs OP Pulm Rehab W/Cont Oximtry Mntr","PX-94000057","CDM","94626","CPT","0948","RC","","","","both","","","358.00","214.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","63.30","","APC Price ($62.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","59.60","59.60","59.60","1 through 10","60.82","396.58","other","OPPS APC"
"Phys/Qhp Svcs OP Pulm Rehab W/Cont Oximtry Mntr","PX-94000057","CDM","94626","CPT","0948","RC","","","","both","","","358.00","214.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","170.77","","Case rate ($170.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","166.60","166.60","166.81","17","60.82","396.58","other","OPPS APC"
"Phys/Qhp Svcs OP Pulm Rehab W/Cont Oximtry Mntr","PX-94000057","CDM","94626","CPT","0948","RC","","","","both","","","358.00","214.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","60.82","","APC Price ($62.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","60.83","60.83","60.83","30","60.82","396.58","other","OPPS APC"
"Phys/Qhp Svcs OP Pulm Rehab W/Cont Oximtry Mntr","PX-94000057","CDM","94626","CPT","0948","RC","","","","both","","","358.00","214.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","320.55","","Case rate ($320.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","312.73","312.73","312.73","17","60.82","396.58","other","OPPS APC"
"Phys/Qhp Svcs OP Pulm Rehab W/Cont Oximtry Mntr","PX-94000057","CDM","94626","CPT","0948","RC","","","","both","","","358.00","214.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","203.70","56.9","","196.31","196.31","196.31","15","60.82","396.58","percent of total billed charges",""
"Phys/Qhp Svcs OP Pulm Rehab W/Cont Oximtry Mntr","PX-94000057","CDM","94626","CPT","0948","RC","","","","both","","","358.00","214.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","63.92","","APC Price ($62.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","63.93","62.95","63.93","1 through 10","60.82","396.58","other","OPPS APC"
"Phys/Qhp Svcs OP Pulm Rehab W/Cont Oximtry Mntr","PX-94000057","CDM","94626","CPT","0948","RC","","","","both","","","358.00","214.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","62.06","","APC Price ($62.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","60.83","60.83","62.07","124","60.82","396.58","other","OPPS APC"
"Phys/Qhp Svcs OP Pulm Rehab W/Cont Oximtry Mntr","PX-94000057","CDM","94626","CPT","0948","RC","","","","both","","","358.00","214.80","MEDICARE [2001]","HB WDH MEDICARE","62.06","","APC Price ($62.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.07","59.60","62.07","146","60.82","396.58","other","OPPS APC"
"Phys/Qhp Svcs OP Pulm Rehab W/Cont Oximtry Mntr","PX-94000057","CDM","94626","CPT","0948","RC","","","","both","","","358.00","214.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","62.06","","APC Price ($62.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.07","59.60","62.07","113","60.82","396.58","other","OPPS APC"
"Phys/Qhp Svcs OP Pulm Rehab W/Cont Oximtry Mntr","PX-94000057","CDM","94626","CPT","0948","RC","","","","both","","","358.00","214.80","WELLSENSE NH [1050]","HB WDH MEDICARE","62.06","","APC Price ($62.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","64.47","64.47","64.47","16","60.82","396.58","other","OPPS APC"
"Phys/Qhp Svcs OP Pulm Rehab W/Cont Oximtry Mntr","PX-94000057","CDM","94626","CPT","0948","RC","","","","outpatient","","","358.00","214.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","51.62","14.42","","49.75","49.75","49.75","19","41.64","277.09","percent of total billed charges",""
"Phys/Qhp Svcs OP Pulm Rehab W/Cont Oximtry Mntr","PX-94000057","CDM","94626","CPT","0948","RC","","","","outpatient","","","358.00","214.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","41.64","11.63","","40.75","40.75","40.75","16","41.64","277.09","percent of total billed charges",""
"Phys/Qhp Svcs OP Pulm Rehab W/Cont Oximtry Mntr","PX-94000057","CDM","94626","CPT","0948","RC","","","","outpatient","","","358.00","214.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","260.34","72.72","","250.88","250.88","250.88","1 through 10","41.64","277.09","percent of total billed charges",""
"Physical Therapy Evaluation, High Complexity","PX-42000100","CDM","97163","CPT","0424","RC","","","","both","","","519.00","311.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","362.26","69.8","","315.13","315.13","315.13","1 through 10","99.12","456.5","percent of total billed charges",""
"Physical Therapy Evaluation, High Complexity","PX-42000100","CDM","97163","CPT","0424","RC","","","","both","","","519.00","311.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","441.15","85","","425.85","425.85","425.85","1 through 10","99.12","456.5","percent of total billed charges",""
"Physical Therapy Evaluation, High Complexity","PX-42000100","CDM","97163","CPT","0424","RC","","","","both","","","519.00","311.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","99.12","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($99.12). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($74.88). Each line will be capped at the line billed amount.","97.68","97.14","99.80","25","99.12","456.5","fee schedule",""
"Physical Therapy Evaluation, High Complexity","PX-42000100","CDM","97163","CPT","0424","RC","","","","outpatient","","","519.00","311.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","377.42","72.72","","364.33","364.33","364.33","1 through 10","60.36","401.71","percent of total billed charges",""
"Physical Therapy Evaluation, High Complexity","PX-42000100","CDM","97163","CPT","0424","RC","","","","outpatient","","","519.00","311.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","326.45","62.9","","315.63","315.63","315.63","1 through 10","60.36","401.71","percent of total billed charges",""
"Physical Therapy Evaluation, High Complexity","PX-42000100","CDM","97163","CPT","0424","RC","","","","outpatient","","","519.00","311.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","60.36","11.63","","59.18","59.18","59.18","1 through 10","60.36","401.71","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","529.00","317.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","369.24","69.8","","355.98","320.79","355.98","186","99.12","456.5","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","529.00","317.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","301.00","56.9","","157.54","117.12","157.54","1 through 10","99.12","456.5","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","529.00","317.40","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","369.24","69.8","","331.04","272.00","355.98","1 through 10","99.12","456.5","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","529.00","317.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","449.65","85","","355.98","201.47","355.98","1 through 10","99.12","456.5","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","529.00","317.40","TRICARE [160005]","HB WDH MEDICARE","99.12","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($99.12). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($74.88). Each line will be capped at the line billed amount.","99.47","99.47","101.68","62","99.12","456.5","fee schedule",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","529.00","317.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","99.12","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($99.12). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($74.88). Each line will be capped at the line billed amount.","97.54","73.72","99.65","516","99.12","456.5","fee schedule",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","outpatient","","","529.00","317.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","384.69","72.72","","474.31","370.87","539.58","48","61.52","409.45","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","outpatient","","","529.00","317.40","INTERNATIONAL COMMERCIAL [140001]","HB WDH UNITED HMO / PPO / INDEM","409.45","77.4","","395.25","395.25","395.25","1 through 10","61.52","409.45","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","outpatient","","","529.00","317.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","281.53","53.22","","271.88","271.88","271.88","1 through 10","61.52","409.45","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","outpatient","","","529.00","317.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","332.74","62.9","","321.30","321.30","321.30","335","61.52","409.45","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","outpatient","","","529.00","317.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","409.45","77.4","","370.87","370.87","370.87","1 through 10","61.52","409.45","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","outpatient","","","529.00","317.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","61.52","11.63","","60.24","60.24","301.20","43","61.52","409.45","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","both","","","519.00","311.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","362.26","69.8","","349.70","315.13","349.70","65","99.12","456.5","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","both","","","519.00","311.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","295.31","56.9","","152.58","152.58","152.58","1 through 10","99.12","456.5","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","both","","","519.00","311.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","441.15","85","","152.52","152.52","152.52","1 through 10","99.12","456.5","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","both","","","519.00","311.40","TRICARE [160005]","HB WDH MEDICARE","99.12","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($99.12). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($74.88). Each line will be capped at the line billed amount.","99.47","99.47","101.68","22","99.12","456.5","fee schedule",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","both","","","519.00","311.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","99.12","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($99.12). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($74.88). Each line will be capped at the line billed amount.","97.64","73.72","99.65","361","99.12","456.5","fee schedule",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","outpatient","","","519.00","311.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","377.42","72.72","","492.32","364.33","533.04","13","60.36","401.71","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","outpatient","","","519.00","311.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","276.21","53.22","","267.08","267.08","267.08","1 through 10","60.36","401.71","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","outpatient","","","519.00","311.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","326.45","62.9","","315.63","315.63","315.63","147","60.36","401.71","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","outpatient","","","519.00","311.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","401.71","77.4","","364.33","364.32","388.28","1 through 10","60.36","401.71","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","outpatient","","","519.00","311.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","60.36","11.63","","59.18","59.18","59.18","30","60.36","401.71","percent of total billed charges",""
"Physical Therapy Re-Eval Est Plan Care 20 Mins","PX-42000103","CDM","97164","CPT","0424","RC","","","","both","","","352.00","211.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","245.70","69.8","","237.32","237.32","237.32","1 through 10","68.54","317.34","percent of total billed charges",""
"Physical Therapy Re-Eval Est Plan Care 20 Mins","PX-42000103","CDM","97164","CPT","0424","RC","","","","outpatient","","","352.00","211.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","221.41","62.9","","214.20","214.20","214.20","1 through 10","40.94","272.45","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","both","","","2169.74","1301.84","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","252.34","1844.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","both","","","2169.74","1301.84","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","252.34","1844.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","both","","","2169.74","1301.84","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1234.58","56.9","","812.12","238.65","1587.46","163","252.34","1844.28","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","both","","","2169.74","1301.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","252.34","11.63","","112.68","112.68","146.99","38","252.34","1844.28","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","both","","","2169.74","1301.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1679.38","77.4","","303.98","303.98","5854.79","1 through 10","252.34","1844.28","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2169.74","1301.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","252.34","11.63","","112.68","112.68","146.99","38","252.34","1679.38","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2169.74","1301.84","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1362.16","62.78","","780.86","208.94","10480.28","15","252.34","1679.38","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2169.74","1301.84","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","948.61","43.72","","179.76","179.76","179.76","1 through 10","252.34","1679.38","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2169.74","1301.84","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1577.83","72.72","","2355.45","298.99","3965.19","155","252.34","1679.38","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2169.74","1301.84","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1577.83","72.72","","3643.09","3643.09","3643.09","1 through 10","252.34","1679.38","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2169.74","1301.84","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1154.74","53.22","","554.28","554.28","554.28","16","252.34","1679.38","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2169.74","1301.84","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1364.77","62.9","","619.64","173.09","2370.64","150","252.34","1679.38","percent of total billed charges",""
"PIN AXIS 2.5MMX45 INTERNAL JOINT STABILIZER ELBOW","SUP-ITM-10170023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2169.74","1301.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1679.38","77.4","","303.98","303.98","5854.79","1 through 10","252.34","1679.38","percent of total billed charges",""
"PIN BONE 1.8X8MM BUTTRESS VARIABLE ANGLE LOCKING T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10096175","CDM","C1713","HCPCS","0278","RC","","","","both","","","716.43","429.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","83.32","608.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 1.8X8MM BUTTRESS VARIABLE ANGLE LOCKING T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10096175","CDM","C1713","HCPCS","0278","RC","","","","both","","","716.43","429.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","83.32","608.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 1.8X8MM BUTTRESS VARIABLE ANGLE LOCKING T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10096175","CDM","C1713","HCPCS","0278","RC","","","","both","","","716.43","429.86","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","407.65","56.9","","812.12","238.65","1587.46","163","83.32","608.97","percent of total billed charges",""
"PIN BONE 1.8X8MM BUTTRESS VARIABLE ANGLE LOCKING T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10096175","CDM","C1713","HCPCS","0278","RC","","","","both","","","716.43","429.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","83.32","11.63","","112.68","112.68","146.99","38","83.32","608.97","percent of total billed charges",""
"PIN BONE 1.8X8MM BUTTRESS VARIABLE ANGLE LOCKING T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10096175","CDM","C1713","HCPCS","0278","RC","","","","both","","","716.43","429.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","554.52","77.4","","303.98","303.98","5854.79","1 through 10","83.32","608.97","percent of total billed charges",""
"PIN BONE 1.8X8MM BUTTRESS VARIABLE ANGLE LOCKING T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10096175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","716.43","429.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","83.32","11.63","","112.68","112.68","146.99","38","83.32","554.52","percent of total billed charges",""
"PIN BONE 1.8X8MM BUTTRESS VARIABLE ANGLE LOCKING T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10096175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","716.43","429.86","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","449.77","62.78","","780.86","208.94","10480.28","15","83.32","554.52","percent of total billed charges",""
"PIN BONE 1.8X8MM BUTTRESS VARIABLE ANGLE LOCKING T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10096175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","716.43","429.86","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","313.22","43.72","","179.76","179.76","179.76","1 through 10","83.32","554.52","percent of total billed charges",""
"PIN BONE 1.8X8MM BUTTRESS VARIABLE ANGLE LOCKING T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10096175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","716.43","429.86","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","520.99","72.72","","2355.45","298.99","3965.19","155","83.32","554.52","percent of total billed charges",""
"PIN BONE 1.8X8MM BUTTRESS VARIABLE ANGLE LOCKING T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10096175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","716.43","429.86","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","520.99","72.72","","3643.09","3643.09","3643.09","1 through 10","83.32","554.52","percent of total billed charges",""
"PIN BONE 1.8X8MM BUTTRESS VARIABLE ANGLE LOCKING T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10096175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","716.43","429.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","381.28","53.22","","554.28","554.28","554.28","16","83.32","554.52","percent of total billed charges",""
"PIN BONE 1.8X8MM BUTTRESS VARIABLE ANGLE LOCKING T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10096175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","716.43","429.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","450.63","62.9","","619.64","173.09","2370.64","150","83.32","554.52","percent of total billed charges",""
"PIN BONE 1.8X8MM BUTTRESS VARIABLE ANGLE LOCKING T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10096175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","716.43","429.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","554.52","77.4","","303.98","303.98","5854.79","1 through 10","83.32","554.52","percent of total billed charges",""
"PIN BONE 10MM 3.0X60 HALF APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034407","CDM","C1713","HCPCS","0278","RC","","","","both","","","325.53","195.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","37.86","276.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 10MM 3.0X60 HALF APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034407","CDM","C1713","HCPCS","0278","RC","","","","both","","","325.53","195.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","37.86","276.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 10MM 3.0X60 HALF APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034407","CDM","C1713","HCPCS","0278","RC","","","","both","","","325.53","195.32","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","185.23","56.9","","812.12","238.65","1587.46","163","37.86","276.7","percent of total billed charges",""
"PIN BONE 10MM 3.0X60 HALF APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034407","CDM","C1713","HCPCS","0278","RC","","","","both","","","325.53","195.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","37.86","11.63","","112.68","112.68","146.99","38","37.86","276.7","percent of total billed charges",""
"PIN BONE 10MM 3.0X60 HALF APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034407","CDM","C1713","HCPCS","0278","RC","","","","both","","","325.53","195.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","251.96","77.4","","303.98","303.98","5854.79","1 through 10","37.86","276.7","percent of total billed charges",""
"PIN BONE 10MM 3.0X60 HALF APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","325.53","195.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","37.86","11.63","","112.68","112.68","146.99","38","37.86","251.96","percent of total billed charges",""
"PIN BONE 10MM 3.0X60 HALF APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","325.53","195.32","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","204.37","62.78","","780.86","208.94","10480.28","15","37.86","251.96","percent of total billed charges",""
"PIN BONE 10MM 3.0X60 HALF APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","325.53","195.32","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","142.32","43.72","","179.76","179.76","179.76","1 through 10","37.86","251.96","percent of total billed charges",""
"PIN BONE 10MM 3.0X60 HALF APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","325.53","195.32","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","236.73","72.72","","2355.45","298.99","3965.19","155","37.86","251.96","percent of total billed charges",""
"PIN BONE 10MM 3.0X60 HALF APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","325.53","195.32","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","236.73","72.72","","3643.09","3643.09","3643.09","1 through 10","37.86","251.96","percent of total billed charges",""
"PIN BONE 10MM 3.0X60 HALF APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","325.53","195.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","173.25","53.22","","554.28","554.28","554.28","16","37.86","251.96","percent of total billed charges",""
"PIN BONE 10MM 3.0X60 HALF APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","325.53","195.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","204.76","62.9","","619.64","173.09","2370.64","150","37.86","251.96","percent of total billed charges",""
"PIN BONE 10MM 3.0X60 HALF APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","325.53","195.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","251.96","77.4","","303.98","303.98","5854.79","1 through 10","37.86","251.96","percent of total billed charges",""
"PIN BONE 10MM 4X90 FIXATION EXTERNAL APEX HALF BLUNT THREAD SS","SUP-ITM-10034377","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.52","585.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","113.57","830.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 10MM 4X90 FIXATION EXTERNAL APEX HALF BLUNT THREAD SS","SUP-ITM-10034377","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.52","585.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","113.57","830.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 10MM 4X90 FIXATION EXTERNAL APEX HALF BLUNT THREAD SS","SUP-ITM-10034377","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.52","585.91","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","555.64","56.9","","812.12","238.65","1587.46","163","113.57","830.04","percent of total billed charges",""
"PIN BONE 10MM 4X90 FIXATION EXTERNAL APEX HALF BLUNT THREAD SS","SUP-ITM-10034377","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.52","585.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","113.57","11.63","","112.68","112.68","146.99","38","113.57","830.04","percent of total billed charges",""
"PIN BONE 10MM 4X90 FIXATION EXTERNAL APEX HALF BLUNT THREAD SS","SUP-ITM-10034377","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.52","585.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","755.83","77.4","","303.98","303.98","5854.79","1 through 10","113.57","830.04","percent of total billed charges",""
"PIN BONE 10MM 4X90 FIXATION EXTERNAL APEX HALF BLUNT THREAD SS","SUP-ITM-10034377","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","976.52","585.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","113.57","11.63","","112.68","112.68","146.99","38","113.57","755.83","percent of total billed charges",""
"PIN BONE 10MM 4X90 FIXATION EXTERNAL APEX HALF BLUNT THREAD SS","SUP-ITM-10034377","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","976.52","585.91","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","613.06","62.78","","780.86","208.94","10480.28","15","113.57","755.83","percent of total billed charges",""
"PIN BONE 10MM 4X90 FIXATION EXTERNAL APEX HALF BLUNT THREAD SS","SUP-ITM-10034377","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","976.52","585.91","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","426.93","43.72","","179.76","179.76","179.76","1 through 10","113.57","755.83","percent of total billed charges",""
"PIN BONE 10MM 4X90 FIXATION EXTERNAL APEX HALF BLUNT THREAD SS","SUP-ITM-10034377","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","976.52","585.91","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","710.13","72.72","","2355.45","298.99","3965.19","155","113.57","755.83","percent of total billed charges",""
"PIN BONE 10MM 4X90 FIXATION EXTERNAL APEX HALF BLUNT THREAD SS","SUP-ITM-10034377","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","976.52","585.91","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","710.13","72.72","","3643.09","3643.09","3643.09","1 through 10","113.57","755.83","percent of total billed charges",""
"PIN BONE 10MM 4X90 FIXATION EXTERNAL APEX HALF BLUNT THREAD SS","SUP-ITM-10034377","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","976.52","585.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","519.70","53.22","","554.28","554.28","554.28","16","113.57","755.83","percent of total billed charges",""
"PIN BONE 10MM 4X90 FIXATION EXTERNAL APEX HALF BLUNT THREAD SS","SUP-ITM-10034377","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","976.52","585.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","614.23","62.9","","619.64","173.09","2370.64","150","113.57","755.83","percent of total billed charges",""
"PIN BONE 10MM 4X90 FIXATION EXTERNAL APEX HALF BLUNT THREAD SS","SUP-ITM-10034377","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","976.52","585.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","755.83","77.4","","303.98","303.98","5854.79","1 through 10","113.57","755.83","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","both","","","1028.28","616.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","119.59","874.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","both","","","1028.28","616.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","119.59","874.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","both","","","1028.28","616.97","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","585.09","56.9","","812.12","238.65","1587.46","163","119.59","874.04","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","both","","","1028.28","616.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","119.59","11.63","","112.68","112.68","146.99","38","119.59","874.04","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","both","","","1028.28","616.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","795.89","77.4","","303.98","303.98","5854.79","1 through 10","119.59","874.04","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","119.59","11.63","","112.68","112.68","146.99","38","119.59","795.89","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","645.55","62.78","","780.86","208.94","10480.28","15","119.59","795.89","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","449.56","43.72","","179.76","179.76","179.76","1 through 10","119.59","795.89","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","747.77","72.72","","2355.45","298.99","3965.19","155","119.59","795.89","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","747.77","72.72","","3643.09","3643.09","3643.09","1 through 10","119.59","795.89","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","547.25","53.22","","554.28","554.28","554.28","16","119.59","795.89","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","646.79","62.9","","619.64","173.09","2370.64","150","119.59","795.89","percent of total billed charges",""
"PIN BONE 12MM 1.65X45 HALF SS APEX SELF DRILLING TAPG THREAD","SUP-ITM-10034411","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","795.89","77.4","","303.98","303.98","5854.79","1 through 10","119.59","795.89","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.41","807.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","156.59","1144.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.41","807.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","156.59","1144.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.41","807.85","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","766.11","56.9","","812.12","238.65","1587.46","163","156.59","1144.45","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.41","807.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","156.59","11.63","","112.68","112.68","146.99","38","156.59","1144.45","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.41","807.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1042.12","77.4","","303.98","303.98","5854.79","1 through 10","156.59","1144.45","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","156.59","11.63","","112.68","112.68","146.99","38","156.59","1042.12","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","845.28","62.78","","780.86","208.94","10480.28","15","156.59","1042.12","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","588.65","43.72","","179.76","179.76","179.76","1 through 10","156.59","1042.12","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","979.11","72.72","","2355.45","298.99","3965.19","155","156.59","1042.12","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","979.11","72.72","","3643.09","3643.09","3643.09","1 through 10","156.59","1042.12","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","716.56","53.22","","554.28","554.28","554.28","16","156.59","1042.12","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","846.89","62.9","","619.64","173.09","2370.64","150","156.59","1042.12","percent of total billed charges",""
"PIN BONE 20MM 4X90 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034365","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1042.12","77.4","","303.98","303.98","5854.79","1 through 10","156.59","1042.12","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.97","277.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","53.84","393.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.97","277.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","53.84","393.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.97","277.78","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","263.43","56.9","","812.12","238.65","1587.46","163","53.84","393.52","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.97","277.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","53.84","11.63","","112.68","112.68","146.99","38","53.84","393.52","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.97","277.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","358.34","77.4","","303.98","303.98","5854.79","1 through 10","53.84","393.52","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.97","277.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","53.84","11.63","","112.68","112.68","146.99","38","53.84","358.34","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.97","277.78","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","290.65","62.78","","780.86","208.94","10480.28","15","53.84","358.34","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.97","277.78","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","202.41","43.72","","179.76","179.76","179.76","1 through 10","53.84","358.34","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.97","277.78","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","336.67","72.72","","2355.45","298.99","3965.19","155","53.84","358.34","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.97","277.78","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","336.67","72.72","","3643.09","3643.09","3643.09","1 through 10","53.84","358.34","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.97","277.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","246.39","53.22","","554.28","554.28","554.28","16","53.84","358.34","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.97","277.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","291.21","62.9","","619.64","173.09","2370.64","150","53.84","358.34","percent of total billed charges",""
"PIN BONE 230MMX2.4 GUIDE RICHARDS SS CANNULATED THREADED TIP BX/6","SUP-ITM-10027148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.97","277.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","358.34","77.4","","303.98","303.98","5854.79","1 through 10","53.84","358.34","percent of total billed charges",""
"PIN BONE 35MM 4.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/1EA","SUP-ITM-10034369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.41","807.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","156.59","1144.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 35MM 4.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/1EA","SUP-ITM-10034369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.41","807.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","156.59","1144.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 35MM 4.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/1EA","SUP-ITM-10034369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.41","807.85","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","766.11","56.9","","812.12","238.65","1587.46","163","156.59","1144.45","percent of total billed charges",""
"PIN BONE 35MM 4.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/1EA","SUP-ITM-10034369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.41","807.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","156.59","11.63","","112.68","112.68","146.99","38","156.59","1144.45","percent of total billed charges",""
"PIN BONE 35MM 4.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/1EA","SUP-ITM-10034369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.41","807.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1042.12","77.4","","303.98","303.98","5854.79","1 through 10","156.59","1144.45","percent of total billed charges",""
"PIN BONE 35MM 4.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/1EA","SUP-ITM-10034369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","156.59","11.63","","112.68","112.68","146.99","38","156.59","1042.12","percent of total billed charges",""
"PIN BONE 35MM 4.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/1EA","SUP-ITM-10034369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","845.28","62.78","","780.86","208.94","10480.28","15","156.59","1042.12","percent of total billed charges",""
"PIN BONE 35MM 4.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/1EA","SUP-ITM-10034369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","588.65","43.72","","179.76","179.76","179.76","1 through 10","156.59","1042.12","percent of total billed charges",""
"PIN BONE 35MM 4.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/1EA","SUP-ITM-10034369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","979.11","72.72","","2355.45","298.99","3965.19","155","156.59","1042.12","percent of total billed charges",""
"PIN BONE 35MM 4.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/1EA","SUP-ITM-10034369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","979.11","72.72","","3643.09","3643.09","3643.09","1 through 10","156.59","1042.12","percent of total billed charges",""
"PIN BONE 35MM 4.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/1EA","SUP-ITM-10034369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","716.56","53.22","","554.28","554.28","554.28","16","156.59","1042.12","percent of total billed charges",""
"PIN BONE 35MM 4.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/1EA","SUP-ITM-10034369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","846.89","62.9","","619.64","173.09","2370.64","150","156.59","1042.12","percent of total billed charges",""
"PIN BONE 35MM 4.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/1EA","SUP-ITM-10034369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1042.12","77.4","","303.98","303.98","5854.79","1 through 10","156.59","1042.12","percent of total billed charges",""
"PIN BONE 35MM 5.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034322","CDM","C1713","HCPCS","0278","RC","","","","both","","","1664.55","998.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","193.59","1414.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 35MM 5.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034322","CDM","C1713","HCPCS","0278","RC","","","","both","","","1664.55","998.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","193.59","1414.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 35MM 5.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034322","CDM","C1713","HCPCS","0278","RC","","","","both","","","1664.55","998.73","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","947.13","56.9","","812.12","238.65","1587.46","163","193.59","1414.87","percent of total billed charges",""
"PIN BONE 35MM 5.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034322","CDM","C1713","HCPCS","0278","RC","","","","both","","","1664.55","998.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","193.59","11.63","","112.68","112.68","146.99","38","193.59","1414.87","percent of total billed charges",""
"PIN BONE 35MM 5.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034322","CDM","C1713","HCPCS","0278","RC","","","","both","","","1664.55","998.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1288.36","77.4","","303.98","303.98","5854.79","1 through 10","193.59","1414.87","percent of total billed charges",""
"PIN BONE 35MM 5.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1664.55","998.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","193.59","11.63","","112.68","112.68","146.99","38","193.59","1288.36","percent of total billed charges",""
"PIN BONE 35MM 5.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1664.55","998.73","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1045.00","62.78","","780.86","208.94","10480.28","15","193.59","1288.36","percent of total billed charges",""
"PIN BONE 35MM 5.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1664.55","998.73","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","727.74","43.72","","179.76","179.76","179.76","1 through 10","193.59","1288.36","percent of total billed charges",""
"PIN BONE 35MM 5.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1664.55","998.73","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1210.46","72.72","","2355.45","298.99","3965.19","155","193.59","1288.36","percent of total billed charges",""
"PIN BONE 35MM 5.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1664.55","998.73","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1210.46","72.72","","3643.09","3643.09","3643.09","1 through 10","193.59","1288.36","percent of total billed charges",""
"PIN BONE 35MM 5.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1664.55","998.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","885.87","53.22","","554.28","554.28","554.28","16","193.59","1288.36","percent of total billed charges",""
"PIN BONE 35MM 5.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1664.55","998.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1047.00","62.9","","619.64","173.09","2370.64","150","193.59","1288.36","percent of total billed charges",""
"PIN BONE 35MM 5.0X120 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1664.55","998.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1288.36","77.4","","303.98","303.98","5854.79","1 through 10","193.59","1288.36","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","1001.95","601.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","116.53","851.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","1001.95","601.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","116.53","851.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","1001.95","601.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","570.11","56.9","","812.12","238.65","1587.46","163","116.53","851.66","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","1001.95","601.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","116.53","11.63","","112.68","112.68","146.99","38","116.53","851.66","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","1001.95","601.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","775.51","77.4","","303.98","303.98","5854.79","1 through 10","116.53","851.66","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1001.95","601.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","116.53","11.63","","112.68","112.68","146.99","38","116.53","775.51","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1001.95","601.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","629.02","62.78","","780.86","208.94","10480.28","15","116.53","775.51","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1001.95","601.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","438.05","43.72","","179.76","179.76","179.76","1 through 10","116.53","775.51","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1001.95","601.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","728.62","72.72","","2355.45","298.99","3965.19","155","116.53","775.51","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1001.95","601.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","728.62","72.72","","3643.09","3643.09","3643.09","1 through 10","116.53","775.51","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1001.95","601.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","533.24","53.22","","554.28","554.28","554.28","16","116.53","775.51","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1001.95","601.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","630.23","62.9","","619.64","173.09","2370.64","150","116.53","775.51","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1001.95","601.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","775.51","77.4","","303.98","303.98","5854.79","1 through 10","116.53","775.51","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.41","807.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","156.59","1144.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.41","807.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","156.59","1144.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.41","807.85","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","766.11","56.9","","812.12","238.65","1587.46","163","156.59","1144.45","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.41","807.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","156.59","11.63","","112.68","112.68","146.99","38","156.59","1144.45","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","both","","","1346.41","807.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1042.12","77.4","","303.98","303.98","5854.79","1 through 10","156.59","1144.45","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","156.59","11.63","","112.68","112.68","146.99","38","156.59","1042.12","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","845.28","62.78","","780.86","208.94","10480.28","15","156.59","1042.12","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","588.65","43.72","","179.76","179.76","179.76","1 through 10","156.59","1042.12","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","979.11","72.72","","2355.45","298.99","3965.19","155","156.59","1042.12","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","979.11","72.72","","3643.09","3643.09","3643.09","1 through 10","156.59","1042.12","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","716.56","53.22","","554.28","554.28","554.28","16","156.59","1042.12","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","846.89","62.9","","619.64","173.09","2370.64","150","156.59","1042.12","percent of total billed charges",""
"PIN BONE 40MM 4.0X150 EXTERNAL FIXATION APEX SS HALF SELF DRILLING TAPG THREAD","SUP-ITM-10034371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1346.41","807.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1042.12","77.4","","303.98","303.98","5854.79","1 through 10","156.59","1042.12","percent of total billed charges",""
"PIN BONE 4MM 3X20 65 EXTERNAL FIXATION JET SS HALF SHANK","SUP-ITM-10062667","CDM","C1713","HCPCS","0278","RC","","","","both","","","1692.95","1015.77","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","196.89","1439.01","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 4MM 3X20 65 EXTERNAL FIXATION JET SS HALF SHANK","SUP-ITM-10062667","CDM","C1713","HCPCS","0278","RC","","","","both","","","1692.95","1015.77","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","196.89","1439.01","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 4MM 3X20 65 EXTERNAL FIXATION JET SS HALF SHANK","SUP-ITM-10062667","CDM","C1713","HCPCS","0278","RC","","","","both","","","1692.95","1015.77","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","963.29","56.9","","812.12","238.65","1587.46","163","196.89","1439.01","percent of total billed charges",""
"PIN BONE 4MM 3X20 65 EXTERNAL FIXATION JET SS HALF SHANK","SUP-ITM-10062667","CDM","C1713","HCPCS","0278","RC","","","","both","","","1692.95","1015.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","196.89","11.63","","112.68","112.68","146.99","38","196.89","1439.01","percent of total billed charges",""
"PIN BONE 4MM 3X20 65 EXTERNAL FIXATION JET SS HALF SHANK","SUP-ITM-10062667","CDM","C1713","HCPCS","0278","RC","","","","both","","","1692.95","1015.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1310.34","77.4","","303.98","303.98","5854.79","1 through 10","196.89","1439.01","percent of total billed charges",""
"PIN BONE 4MM 3X20 65 EXTERNAL FIXATION JET SS HALF SHANK","SUP-ITM-10062667","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1692.95","1015.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","196.89","11.63","","112.68","112.68","146.99","38","196.89","1310.34","percent of total billed charges",""
"PIN BONE 4MM 3X20 65 EXTERNAL FIXATION JET SS HALF SHANK","SUP-ITM-10062667","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1692.95","1015.77","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1062.83","62.78","","780.86","208.94","10480.28","15","196.89","1310.34","percent of total billed charges",""
"PIN BONE 4MM 3X20 65 EXTERNAL FIXATION JET SS HALF SHANK","SUP-ITM-10062667","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1692.95","1015.77","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","740.16","43.72","","179.76","179.76","179.76","1 through 10","196.89","1310.34","percent of total billed charges",""
"PIN BONE 4MM 3X20 65 EXTERNAL FIXATION JET SS HALF SHANK","SUP-ITM-10062667","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1692.95","1015.77","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1231.11","72.72","","2355.45","298.99","3965.19","155","196.89","1310.34","percent of total billed charges",""
"PIN BONE 4MM 3X20 65 EXTERNAL FIXATION JET SS HALF SHANK","SUP-ITM-10062667","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1692.95","1015.77","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1231.11","72.72","","3643.09","3643.09","3643.09","1 through 10","196.89","1310.34","percent of total billed charges",""
"PIN BONE 4MM 3X20 65 EXTERNAL FIXATION JET SS HALF SHANK","SUP-ITM-10062667","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1692.95","1015.77","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","900.99","53.22","","554.28","554.28","554.28","16","196.89","1310.34","percent of total billed charges",""
"PIN BONE 4MM 3X20 65 EXTERNAL FIXATION JET SS HALF SHANK","SUP-ITM-10062667","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1692.95","1015.77","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1064.87","62.9","","619.64","173.09","2370.64","150","196.89","1310.34","percent of total billed charges",""
"PIN BONE 4MM 3X20 65 EXTERNAL FIXATION JET SS HALF SHANK","SUP-ITM-10062667","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1692.95","1015.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1310.34","77.4","","303.98","303.98","5854.79","1 through 10","196.89","1310.34","percent of total billed charges",""
"PIN BONE 4X15 95MM JET EXTERNAL FIXATION HALF SS","SUP-ITM-10062684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1865.70","1119.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","216.98","1585.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 4X15 95MM JET EXTERNAL FIXATION HALF SS","SUP-ITM-10062684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1865.70","1119.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","216.98","1585.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 4X15 95MM JET EXTERNAL FIXATION HALF SS","SUP-ITM-10062684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1865.70","1119.42","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1061.58","56.9","","812.12","238.65","1587.46","163","216.98","1585.85","percent of total billed charges",""
"PIN BONE 4X15 95MM JET EXTERNAL FIXATION HALF SS","SUP-ITM-10062684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1865.70","1119.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","216.98","11.63","","112.68","112.68","146.99","38","216.98","1585.85","percent of total billed charges",""
"PIN BONE 4X15 95MM JET EXTERNAL FIXATION HALF SS","SUP-ITM-10062684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1865.70","1119.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1444.05","77.4","","303.98","303.98","5854.79","1 through 10","216.98","1585.85","percent of total billed charges",""
"PIN BONE 4X15 95MM JET EXTERNAL FIXATION HALF SS","SUP-ITM-10062684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1865.70","1119.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","216.98","11.63","","112.68","112.68","146.99","38","216.98","1444.05","percent of total billed charges",""
"PIN BONE 4X15 95MM JET EXTERNAL FIXATION HALF SS","SUP-ITM-10062684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1865.70","1119.42","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1171.29","62.78","","780.86","208.94","10480.28","15","216.98","1444.05","percent of total billed charges",""
"PIN BONE 4X15 95MM JET EXTERNAL FIXATION HALF SS","SUP-ITM-10062684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1865.70","1119.42","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","815.68","43.72","","179.76","179.76","179.76","1 through 10","216.98","1444.05","percent of total billed charges",""
"PIN BONE 4X15 95MM JET EXTERNAL FIXATION HALF SS","SUP-ITM-10062684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1865.70","1119.42","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1356.74","72.72","","2355.45","298.99","3965.19","155","216.98","1444.05","percent of total billed charges",""
"PIN BONE 4X15 95MM JET EXTERNAL FIXATION HALF SS","SUP-ITM-10062684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1865.70","1119.42","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1356.74","72.72","","3643.09","3643.09","3643.09","1 through 10","216.98","1444.05","percent of total billed charges",""
"PIN BONE 4X15 95MM JET EXTERNAL FIXATION HALF SS","SUP-ITM-10062684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1865.70","1119.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","992.93","53.22","","554.28","554.28","554.28","16","216.98","1444.05","percent of total billed charges",""
"PIN BONE 4X15 95MM JET EXTERNAL FIXATION HALF SS","SUP-ITM-10062684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1865.70","1119.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1173.53","62.9","","619.64","173.09","2370.64","150","216.98","1444.05","percent of total billed charges",""
"PIN BONE 4X15 95MM JET EXTERNAL FIXATION HALF SS","SUP-ITM-10062684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1865.70","1119.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1444.05","77.4","","303.98","303.98","5854.79","1 through 10","216.98","1444.05","percent of total billed charges",""
"PIN BONE 4X200 5 35THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1553.58","932.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","180.68","1320.54","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 4X200 5 35THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1553.58","932.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","180.68","1320.54","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 4X200 5 35THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1553.58","932.15","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","883.99","56.9","","812.12","238.65","1587.46","163","180.68","1320.54","percent of total billed charges",""
"PIN BONE 4X200 5 35THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1553.58","932.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","180.68","11.63","","112.68","112.68","146.99","38","180.68","1320.54","percent of total billed charges",""
"PIN BONE 4X200 5 35THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1553.58","932.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1202.47","77.4","","303.98","303.98","5854.79","1 through 10","180.68","1320.54","percent of total billed charges",""
"PIN BONE 4X200 5 35THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1553.58","932.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","180.68","11.63","","112.68","112.68","146.99","38","180.68","1202.47","percent of total billed charges",""
"PIN BONE 4X200 5 35THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1553.58","932.15","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","975.34","62.78","","780.86","208.94","10480.28","15","180.68","1202.47","percent of total billed charges",""
"PIN BONE 4X200 5 35THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1553.58","932.15","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","679.23","43.72","","179.76","179.76","179.76","1 through 10","180.68","1202.47","percent of total billed charges",""
"PIN BONE 4X200 5 35THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1553.58","932.15","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1129.76","72.72","","2355.45","298.99","3965.19","155","180.68","1202.47","percent of total billed charges",""
"PIN BONE 4X200 5 35THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1553.58","932.15","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1129.76","72.72","","3643.09","3643.09","3643.09","1 through 10","180.68","1202.47","percent of total billed charges",""
"PIN BONE 4X200 5 35THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1553.58","932.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","826.82","53.22","","554.28","554.28","554.28","16","180.68","1202.47","percent of total billed charges",""
"PIN BONE 4X200 5 35THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1553.58","932.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","977.20","62.9","","619.64","173.09","2370.64","150","180.68","1202.47","percent of total billed charges",""
"PIN BONE 4X200 5 35THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1553.58","932.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1202.47","77.4","","303.98","303.98","5854.79","1 through 10","180.68","1202.47","percent of total billed charges",""
"PIN BONE 4X200 5 50THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034392","CDM","C1713","HCPCS","0278","RC","","","","both","","","517.84","310.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","60.22","440.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 4X200 5 50THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034392","CDM","C1713","HCPCS","0278","RC","","","","both","","","517.84","310.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","60.22","440.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 4X200 5 50THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034392","CDM","C1713","HCPCS","0278","RC","","","","both","","","517.84","310.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","294.65","56.9","","812.12","238.65","1587.46","163","60.22","440.16","percent of total billed charges",""
"PIN BONE 4X200 5 50THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034392","CDM","C1713","HCPCS","0278","RC","","","","both","","","517.84","310.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","60.22","11.63","","112.68","112.68","146.99","38","60.22","440.16","percent of total billed charges",""
"PIN BONE 4X200 5 50THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034392","CDM","C1713","HCPCS","0278","RC","","","","both","","","517.84","310.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","400.81","77.4","","303.98","303.98","5854.79","1 through 10","60.22","440.16","percent of total billed charges",""
"PIN BONE 4X200 5 50THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","517.84","310.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","60.22","11.63","","112.68","112.68","146.99","38","60.22","400.81","percent of total billed charges",""
"PIN BONE 4X200 5 50THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","517.84","310.70","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","325.10","62.78","","780.86","208.94","10480.28","15","60.22","400.81","percent of total billed charges",""
"PIN BONE 4X200 5 50THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","517.84","310.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","226.40","43.72","","179.76","179.76","179.76","1 through 10","60.22","400.81","percent of total billed charges",""
"PIN BONE 4X200 5 50THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","517.84","310.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","376.57","72.72","","2355.45","298.99","3965.19","155","60.22","400.81","percent of total billed charges",""
"PIN BONE 4X200 5 50THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","517.84","310.70","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","376.57","72.72","","3643.09","3643.09","3643.09","1 through 10","60.22","400.81","percent of total billed charges",""
"PIN BONE 4X200 5 50THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","517.84","310.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","275.59","53.22","","554.28","554.28","554.28","16","60.22","400.81","percent of total billed charges",""
"PIN BONE 4X200 5 50THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","517.84","310.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","325.72","62.9","","619.64","173.09","2370.64","150","60.22","400.81","percent of total billed charges",""
"PIN BONE 4X200 5 50THR TRANSFIXING APEX SS THREAD","SUP-ITM-10034392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","517.84","310.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","400.81","77.4","","303.98","303.98","5854.79","1 through 10","60.22","400.81","percent of total billed charges",""
"PIN BONE 5.0X30MM SHORT EXTERNAL FIXATION JET SS TITANIUM NITRIDE THREADED TAPERED HALF","SUP-ITM-10062703","CDM","C1713","HCPCS","0278","RC","","","","both","","","2625.80","1575.48","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","305.38","2231.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 5.0X30MM SHORT EXTERNAL FIXATION JET SS TITANIUM NITRIDE THREADED TAPERED HALF","SUP-ITM-10062703","CDM","C1713","HCPCS","0278","RC","","","","both","","","2625.80","1575.48","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","305.38","2231.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 5.0X30MM SHORT EXTERNAL FIXATION JET SS TITANIUM NITRIDE THREADED TAPERED HALF","SUP-ITM-10062703","CDM","C1713","HCPCS","0278","RC","","","","both","","","2625.80","1575.48","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1494.08","56.9","","812.12","238.65","1587.46","163","305.38","2231.93","percent of total billed charges",""
"PIN BONE 5.0X30MM SHORT EXTERNAL FIXATION JET SS TITANIUM NITRIDE THREADED TAPERED HALF","SUP-ITM-10062703","CDM","C1713","HCPCS","0278","RC","","","","both","","","2625.80","1575.48","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","305.38","11.63","","112.68","112.68","146.99","38","305.38","2231.93","percent of total billed charges",""
"PIN BONE 5.0X30MM SHORT EXTERNAL FIXATION JET SS TITANIUM NITRIDE THREADED TAPERED HALF","SUP-ITM-10062703","CDM","C1713","HCPCS","0278","RC","","","","both","","","2625.80","1575.48","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2032.37","77.4","","303.98","303.98","5854.79","1 through 10","305.38","2231.93","percent of total billed charges",""
"PIN BONE 5.0X30MM SHORT EXTERNAL FIXATION JET SS TITANIUM NITRIDE THREADED TAPERED HALF","SUP-ITM-10062703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2625.80","1575.48","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","305.38","11.63","","112.68","112.68","146.99","38","305.38","2032.37","percent of total billed charges",""
"PIN BONE 5.0X30MM SHORT EXTERNAL FIXATION JET SS TITANIUM NITRIDE THREADED TAPERED HALF","SUP-ITM-10062703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2625.80","1575.48","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1648.48","62.78","","780.86","208.94","10480.28","15","305.38","2032.37","percent of total billed charges",""
"PIN BONE 5.0X30MM SHORT EXTERNAL FIXATION JET SS TITANIUM NITRIDE THREADED TAPERED HALF","SUP-ITM-10062703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2625.80","1575.48","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1148.00","43.72","","179.76","179.76","179.76","1 through 10","305.38","2032.37","percent of total billed charges",""
"PIN BONE 5.0X30MM SHORT EXTERNAL FIXATION JET SS TITANIUM NITRIDE THREADED TAPERED HALF","SUP-ITM-10062703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2625.80","1575.48","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1909.48","72.72","","2355.45","298.99","3965.19","155","305.38","2032.37","percent of total billed charges",""
"PIN BONE 5.0X30MM SHORT EXTERNAL FIXATION JET SS TITANIUM NITRIDE THREADED TAPERED HALF","SUP-ITM-10062703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2625.80","1575.48","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1909.48","72.72","","3643.09","3643.09","3643.09","1 through 10","305.38","2032.37","percent of total billed charges",""
"PIN BONE 5.0X30MM SHORT EXTERNAL FIXATION JET SS TITANIUM NITRIDE THREADED TAPERED HALF","SUP-ITM-10062703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2625.80","1575.48","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1397.45","53.22","","554.28","554.28","554.28","16","305.38","2032.37","percent of total billed charges",""
"PIN BONE 5.0X30MM SHORT EXTERNAL FIXATION JET SS TITANIUM NITRIDE THREADED TAPERED HALF","SUP-ITM-10062703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2625.80","1575.48","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1651.63","62.9","","619.64","173.09","2370.64","150","305.38","2032.37","percent of total billed charges",""
"PIN BONE 5.0X30MM SHORT EXTERNAL FIXATION JET SS TITANIUM NITRIDE THREADED TAPERED HALF","SUP-ITM-10062703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2625.80","1575.48","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2032.37","77.4","","303.98","303.98","5854.79","1 through 10","305.38","2032.37","percent of total billed charges",""
"PIN BONE 5/32X9IN STEINMANN SS SMOOTH TROCAR POINT TYPE D BX/6EA","SUP-ITM-10062393","CDM","C1713","HCPCS","0278","RC","","","","both","","","559.71","335.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","65.09","475.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 5/32X9IN STEINMANN SS SMOOTH TROCAR POINT TYPE D BX/6EA","SUP-ITM-10062393","CDM","C1713","HCPCS","0278","RC","","","","both","","","559.71","335.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","65.09","475.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 5/32X9IN STEINMANN SS SMOOTH TROCAR POINT TYPE D BX/6EA","SUP-ITM-10062393","CDM","C1713","HCPCS","0278","RC","","","","both","","","559.71","335.83","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","318.47","56.9","","812.12","238.65","1587.46","163","65.09","475.75","percent of total billed charges",""
"PIN BONE 5/32X9IN STEINMANN SS SMOOTH TROCAR POINT TYPE D BX/6EA","SUP-ITM-10062393","CDM","C1713","HCPCS","0278","RC","","","","both","","","559.71","335.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","65.09","11.63","","112.68","112.68","146.99","38","65.09","475.75","percent of total billed charges",""
"PIN BONE 5/32X9IN STEINMANN SS SMOOTH TROCAR POINT TYPE D BX/6EA","SUP-ITM-10062393","CDM","C1713","HCPCS","0278","RC","","","","both","","","559.71","335.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","433.22","77.4","","303.98","303.98","5854.79","1 through 10","65.09","475.75","percent of total billed charges",""
"PIN BONE 5/32X9IN STEINMANN SS SMOOTH TROCAR POINT TYPE D BX/6EA","SUP-ITM-10062393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","559.71","335.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","65.09","11.63","","112.68","112.68","146.99","38","65.09","433.22","percent of total billed charges",""
"PIN BONE 5/32X9IN STEINMANN SS SMOOTH TROCAR POINT TYPE D BX/6EA","SUP-ITM-10062393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","559.71","335.83","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","351.39","62.78","","780.86","208.94","10480.28","15","65.09","433.22","percent of total billed charges",""
"PIN BONE 5/32X9IN STEINMANN SS SMOOTH TROCAR POINT TYPE D BX/6EA","SUP-ITM-10062393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","559.71","335.83","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","244.71","43.72","","179.76","179.76","179.76","1 through 10","65.09","433.22","percent of total billed charges",""
"PIN BONE 5/32X9IN STEINMANN SS SMOOTH TROCAR POINT TYPE D BX/6EA","SUP-ITM-10062393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","559.71","335.83","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","407.02","72.72","","2355.45","298.99","3965.19","155","65.09","433.22","percent of total billed charges",""
"PIN BONE 5/32X9IN STEINMANN SS SMOOTH TROCAR POINT TYPE D BX/6EA","SUP-ITM-10062393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","559.71","335.83","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","407.02","72.72","","3643.09","3643.09","3643.09","1 through 10","65.09","433.22","percent of total billed charges",""
"PIN BONE 5/32X9IN STEINMANN SS SMOOTH TROCAR POINT TYPE D BX/6EA","SUP-ITM-10062393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","559.71","335.83","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","297.88","53.22","","554.28","554.28","554.28","16","65.09","433.22","percent of total billed charges",""
"PIN BONE 5/32X9IN STEINMANN SS SMOOTH TROCAR POINT TYPE D BX/6EA","SUP-ITM-10062393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","559.71","335.83","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","352.06","62.9","","619.64","173.09","2370.64","150","65.09","433.22","percent of total billed charges",""
"PIN BONE 5/32X9IN STEINMANN SS SMOOTH TROCAR POINT TYPE D BX/6EA","SUP-ITM-10062393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","559.71","335.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","433.22","77.4","","303.98","303.98","5854.79","1 through 10","65.09","433.22","percent of total billed charges",""
"PIN BONE 50MM 4X180 FIXATION EXTERNAL APEX HALF SELF DRILLING TAPG THREAD SS","SUP-ITM-10034375","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.80","269.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","52.2","381.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 50MM 4X180 FIXATION EXTERNAL APEX HALF SELF DRILLING TAPG THREAD SS","SUP-ITM-10034375","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.80","269.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","52.2","381.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 50MM 4X180 FIXATION EXTERNAL APEX HALF SELF DRILLING TAPG THREAD SS","SUP-ITM-10034375","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.80","269.28","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","255.37","56.9","","812.12","238.65","1587.46","163","52.2","381.48","percent of total billed charges",""
"PIN BONE 50MM 4X180 FIXATION EXTERNAL APEX HALF SELF DRILLING TAPG THREAD SS","SUP-ITM-10034375","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.80","269.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","52.20","11.63","","112.68","112.68","146.99","38","52.2","381.48","percent of total billed charges",""
"PIN BONE 50MM 4X180 FIXATION EXTERNAL APEX HALF SELF DRILLING TAPG THREAD SS","SUP-ITM-10034375","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.80","269.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","347.37","77.4","","303.98","303.98","5854.79","1 through 10","52.2","381.48","percent of total billed charges",""
"PIN BONE 50MM 4X180 FIXATION EXTERNAL APEX HALF SELF DRILLING TAPG THREAD SS","SUP-ITM-10034375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.80","269.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","52.20","11.63","","112.68","112.68","146.99","38","52.2","347.37","percent of total billed charges",""
"PIN BONE 50MM 4X180 FIXATION EXTERNAL APEX HALF SELF DRILLING TAPG THREAD SS","SUP-ITM-10034375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.80","269.28","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","281.76","62.78","","780.86","208.94","10480.28","15","52.2","347.37","percent of total billed charges",""
"PIN BONE 50MM 4X180 FIXATION EXTERNAL APEX HALF SELF DRILLING TAPG THREAD SS","SUP-ITM-10034375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.80","269.28","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","196.22","43.72","","179.76","179.76","179.76","1 through 10","52.2","347.37","percent of total billed charges",""
"PIN BONE 50MM 4X180 FIXATION EXTERNAL APEX HALF SELF DRILLING TAPG THREAD SS","SUP-ITM-10034375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.80","269.28","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","326.37","72.72","","2355.45","298.99","3965.19","155","52.2","347.37","percent of total billed charges",""
"PIN BONE 50MM 4X180 FIXATION EXTERNAL APEX HALF SELF DRILLING TAPG THREAD SS","SUP-ITM-10034375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.80","269.28","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","326.37","72.72","","3643.09","3643.09","3643.09","1 through 10","52.2","347.37","percent of total billed charges",""
"PIN BONE 50MM 4X180 FIXATION EXTERNAL APEX HALF SELF DRILLING TAPG THREAD SS","SUP-ITM-10034375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.80","269.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","238.85","53.22","","554.28","554.28","554.28","16","52.2","347.37","percent of total billed charges",""
"PIN BONE 50MM 4X180 FIXATION EXTERNAL APEX HALF SELF DRILLING TAPG THREAD SS","SUP-ITM-10034375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.80","269.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","282.30","62.9","","619.64","173.09","2370.64","150","52.2","347.37","percent of total billed charges",""
"PIN BONE 50MM 4X180 FIXATION EXTERNAL APEX HALF SELF DRILLING TAPG THREAD SS","SUP-ITM-10034375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.80","269.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","347.37","77.4","","303.98","303.98","5854.79","1 through 10","52.2","347.37","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","1664.55","998.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","193.59","1414.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","1664.55","998.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","193.59","1414.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","1664.55","998.73","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","947.13","56.9","","812.12","238.65","1587.46","163","193.59","1414.87","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","1664.55","998.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","193.59","11.63","","112.68","112.68","146.99","38","193.59","1414.87","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","1664.55","998.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1288.36","77.4","","303.98","303.98","5854.79","1 through 10","193.59","1414.87","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1664.55","998.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","193.59","11.63","","112.68","112.68","146.99","38","193.59","1288.36","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1664.55","998.73","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1045.00","62.78","","780.86","208.94","10480.28","15","193.59","1288.36","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1664.55","998.73","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","727.74","43.72","","179.76","179.76","179.76","1 through 10","193.59","1288.36","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1664.55","998.73","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1210.46","72.72","","2355.45","298.99","3965.19","155","193.59","1288.36","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1664.55","998.73","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1210.46","72.72","","3643.09","3643.09","3643.09","1 through 10","193.59","1288.36","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1664.55","998.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","885.87","53.22","","554.28","554.28","554.28","16","193.59","1288.36","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1664.55","998.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1047.00","62.9","","619.64","173.09","2370.64","150","193.59","1288.36","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1664.55","998.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1288.36","77.4","","303.98","303.98","5854.79","1 through 10","193.59","1288.36","percent of total billed charges",""
"PIN BONE 50MM 5.0X300 TRANSFIXING APEX TITANIUM THREAD","SUP-ITM-10137786","CDM","C1713","HCPCS","0278","RC","","","","both","","","1745.88","1047.53","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","203.05","1484","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 50MM 5.0X300 TRANSFIXING APEX TITANIUM THREAD","SUP-ITM-10137786","CDM","C1713","HCPCS","0278","RC","","","","both","","","1745.88","1047.53","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","203.05","1484","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 50MM 5.0X300 TRANSFIXING APEX TITANIUM THREAD","SUP-ITM-10137786","CDM","C1713","HCPCS","0278","RC","","","","both","","","1745.88","1047.53","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","993.41","56.9","","812.12","238.65","1587.46","163","203.05","1484","percent of total billed charges",""
"PIN BONE 50MM 5.0X300 TRANSFIXING APEX TITANIUM THREAD","SUP-ITM-10137786","CDM","C1713","HCPCS","0278","RC","","","","both","","","1745.88","1047.53","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","203.05","11.63","","112.68","112.68","146.99","38","203.05","1484","percent of total billed charges",""
"PIN BONE 50MM 5.0X300 TRANSFIXING APEX TITANIUM THREAD","SUP-ITM-10137786","CDM","C1713","HCPCS","0278","RC","","","","both","","","1745.88","1047.53","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1351.31","77.4","","303.98","303.98","5854.79","1 through 10","203.05","1484","percent of total billed charges",""
"PIN BONE 50MM 5.0X300 TRANSFIXING APEX TITANIUM THREAD","SUP-ITM-10137786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1745.88","1047.53","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","203.05","11.63","","112.68","112.68","146.99","38","203.05","1351.31","percent of total billed charges",""
"PIN BONE 50MM 5.0X300 TRANSFIXING APEX TITANIUM THREAD","SUP-ITM-10137786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1745.88","1047.53","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1096.06","62.78","","780.86","208.94","10480.28","15","203.05","1351.31","percent of total billed charges",""
"PIN BONE 50MM 5.0X300 TRANSFIXING APEX TITANIUM THREAD","SUP-ITM-10137786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1745.88","1047.53","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","763.30","43.72","","179.76","179.76","179.76","1 through 10","203.05","1351.31","percent of total billed charges",""
"PIN BONE 50MM 5.0X300 TRANSFIXING APEX TITANIUM THREAD","SUP-ITM-10137786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1745.88","1047.53","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1269.60","72.72","","2355.45","298.99","3965.19","155","203.05","1351.31","percent of total billed charges",""
"PIN BONE 50MM 5.0X300 TRANSFIXING APEX TITANIUM THREAD","SUP-ITM-10137786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1745.88","1047.53","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1269.60","72.72","","3643.09","3643.09","3643.09","1 through 10","203.05","1351.31","percent of total billed charges",""
"PIN BONE 50MM 5.0X300 TRANSFIXING APEX TITANIUM THREAD","SUP-ITM-10137786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1745.88","1047.53","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","929.16","53.22","","554.28","554.28","554.28","16","203.05","1351.31","percent of total billed charges",""
"PIN BONE 50MM 5.0X300 TRANSFIXING APEX TITANIUM THREAD","SUP-ITM-10137786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1745.88","1047.53","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1098.16","62.9","","619.64","173.09","2370.64","150","203.05","1351.31","percent of total billed charges",""
"PIN BONE 50MM 5.0X300 TRANSFIXING APEX TITANIUM THREAD","SUP-ITM-10137786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1745.88","1047.53","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1351.31","77.4","","303.98","303.98","5854.79","1 through 10","203.05","1351.31","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.85","218.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","42.43","310.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.85","218.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","42.43","310.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.85","218.91","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","207.60","56.9","","812.12","238.65","1587.46","163","42.43","310.12","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.85","218.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","42.43","11.63","","112.68","112.68","146.99","38","42.43","310.12","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.85","218.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","282.39","77.4","","303.98","303.98","5854.79","1 through 10","42.43","310.12","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.85","218.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","42.43","11.63","","112.68","112.68","146.99","38","42.43","282.39","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.85","218.91","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","229.05","62.78","","780.86","208.94","10480.28","15","42.43","282.39","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.85","218.91","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","159.51","43.72","","179.76","179.76","179.76","1 through 10","42.43","282.39","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.85","218.91","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","265.32","72.72","","2355.45","298.99","3965.19","155","42.43","282.39","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.85","218.91","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","265.32","72.72","","3643.09","3643.09","3643.09","1 through 10","42.43","282.39","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.85","218.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","194.17","53.22","","554.28","554.28","554.28","16","42.43","282.39","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.85","218.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","229.49","62.9","","619.64","173.09","2370.64","150","42.43","282.39","percent of total billed charges",""
"PIN BONE 5X180MM STEINMANN SS","SUP-ITM-10038587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.85","218.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","282.39","77.4","","303.98","303.98","5854.79","1 through 10","42.43","282.39","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.71","368.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","71.49","522.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.71","368.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","71.49","522.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.71","368.83","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","349.77","56.9","","812.12","238.65","1587.46","163","71.49","522.5","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.71","368.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.49","11.63","","112.68","112.68","146.99","38","71.49","522.5","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.71","368.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","475.79","77.4","","303.98","303.98","5854.79","1 through 10","71.49","522.5","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.71","368.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.49","11.63","","112.68","112.68","146.99","38","71.49","475.79","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.71","368.83","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","385.91","62.78","","780.86","208.94","10480.28","15","71.49","475.79","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.71","368.83","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","268.75","43.72","","179.76","179.76","179.76","1 through 10","71.49","475.79","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.71","368.83","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","447.02","72.72","","2355.45","298.99","3965.19","155","71.49","475.79","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.71","368.83","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","447.02","72.72","","3643.09","3643.09","3643.09","1 through 10","71.49","475.79","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.71","368.83","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","327.15","53.22","","554.28","554.28","554.28","16","71.49","475.79","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.71","368.83","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","386.65","62.9","","619.64","173.09","2370.64","150","71.49","475.79","percent of total billed charges",""
"PIN BONE 5X225MM STEINMANN SS CENTRAL THREAD","SUP-ITM-10038600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.71","368.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","475.79","77.4","","303.98","303.98","5854.79","1 through 10","71.49","475.79","percent of total billed charges",""
"PIN BONE 5X250MM STEINMANN SS","SUP-ITM-10038589","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.85","218.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","42.43","310.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 5X250MM STEINMANN SS","SUP-ITM-10038589","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.85","218.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","42.43","310.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 5X250MM STEINMANN SS","SUP-ITM-10038589","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.85","218.91","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","207.60","56.9","","812.12","238.65","1587.46","163","42.43","310.12","percent of total billed charges",""
"PIN BONE 5X250MM STEINMANN SS","SUP-ITM-10038589","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.85","218.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","42.43","11.63","","112.68","112.68","146.99","38","42.43","310.12","percent of total billed charges",""
"PIN BONE 5X250MM STEINMANN SS","SUP-ITM-10038589","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.85","218.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","282.39","77.4","","303.98","303.98","5854.79","1 through 10","42.43","310.12","percent of total billed charges",""
"PIN BONE 5X250MM STEINMANN SS","SUP-ITM-10038589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.85","218.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","42.43","11.63","","112.68","112.68","146.99","38","42.43","282.39","percent of total billed charges",""
"PIN BONE 5X250MM STEINMANN SS","SUP-ITM-10038589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.85","218.91","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","229.05","62.78","","780.86","208.94","10480.28","15","42.43","282.39","percent of total billed charges",""
"PIN BONE 5X250MM STEINMANN SS","SUP-ITM-10038589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.85","218.91","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","159.51","43.72","","179.76","179.76","179.76","1 through 10","42.43","282.39","percent of total billed charges",""
"PIN BONE 5X250MM STEINMANN SS","SUP-ITM-10038589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.85","218.91","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","265.32","72.72","","2355.45","298.99","3965.19","155","42.43","282.39","percent of total billed charges",""
"PIN BONE 5X250MM STEINMANN SS","SUP-ITM-10038589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.85","218.91","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","265.32","72.72","","3643.09","3643.09","3643.09","1 through 10","42.43","282.39","percent of total billed charges",""
"PIN BONE 5X250MM STEINMANN SS","SUP-ITM-10038589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.85","218.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","194.17","53.22","","554.28","554.28","554.28","16","42.43","282.39","percent of total billed charges",""
"PIN BONE 5X250MM STEINMANN SS","SUP-ITM-10038589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.85","218.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","229.49","62.9","","619.64","173.09","2370.64","150","42.43","282.39","percent of total billed charges",""
"PIN BONE 5X250MM STEINMANN SS","SUP-ITM-10038589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.85","218.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","282.39","77.4","","303.98","303.98","5854.79","1 through 10","42.43","282.39","percent of total billed charges",""
"PIN BONE 5X30 175MM SHORT EXTERNAL FIXATION JET SS THREADED TAPERED HALF","SUP-ITM-10062700","CDM","C1713","HCPCS","0278","RC","","","","both","","","2383.95","1430.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","277.25","2026.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 5X30 175MM SHORT EXTERNAL FIXATION JET SS THREADED TAPERED HALF","SUP-ITM-10062700","CDM","C1713","HCPCS","0278","RC","","","","both","","","2383.95","1430.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","277.25","2026.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 5X30 175MM SHORT EXTERNAL FIXATION JET SS THREADED TAPERED HALF","SUP-ITM-10062700","CDM","C1713","HCPCS","0278","RC","","","","both","","","2383.95","1430.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1356.47","56.9","","812.12","238.65","1587.46","163","277.25","2026.36","percent of total billed charges",""
"PIN BONE 5X30 175MM SHORT EXTERNAL FIXATION JET SS THREADED TAPERED HALF","SUP-ITM-10062700","CDM","C1713","HCPCS","0278","RC","","","","both","","","2383.95","1430.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","277.25","11.63","","112.68","112.68","146.99","38","277.25","2026.36","percent of total billed charges",""
"PIN BONE 5X30 175MM SHORT EXTERNAL FIXATION JET SS THREADED TAPERED HALF","SUP-ITM-10062700","CDM","C1713","HCPCS","0278","RC","","","","both","","","2383.95","1430.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1845.18","77.4","","303.98","303.98","5854.79","1 through 10","277.25","2026.36","percent of total billed charges",""
"PIN BONE 5X30 175MM SHORT EXTERNAL FIXATION JET SS THREADED TAPERED HALF","SUP-ITM-10062700","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2383.95","1430.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","277.25","11.63","","112.68","112.68","146.99","38","277.25","1845.18","percent of total billed charges",""
"PIN BONE 5X30 175MM SHORT EXTERNAL FIXATION JET SS THREADED TAPERED HALF","SUP-ITM-10062700","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2383.95","1430.37","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1496.64","62.78","","780.86","208.94","10480.28","15","277.25","1845.18","percent of total billed charges",""
"PIN BONE 5X30 175MM SHORT EXTERNAL FIXATION JET SS THREADED TAPERED HALF","SUP-ITM-10062700","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2383.95","1430.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1042.26","43.72","","179.76","179.76","179.76","1 through 10","277.25","1845.18","percent of total billed charges",""
"PIN BONE 5X30 175MM SHORT EXTERNAL FIXATION JET SS THREADED TAPERED HALF","SUP-ITM-10062700","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2383.95","1430.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1733.61","72.72","","2355.45","298.99","3965.19","155","277.25","1845.18","percent of total billed charges",""
"PIN BONE 5X30 175MM SHORT EXTERNAL FIXATION JET SS THREADED TAPERED HALF","SUP-ITM-10062700","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2383.95","1430.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1733.61","72.72","","3643.09","3643.09","3643.09","1 through 10","277.25","1845.18","percent of total billed charges",""
"PIN BONE 5X30 175MM SHORT EXTERNAL FIXATION JET SS THREADED TAPERED HALF","SUP-ITM-10062700","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2383.95","1430.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1268.74","53.22","","554.28","554.28","554.28","16","277.25","1845.18","percent of total billed charges",""
"PIN BONE 5X30 175MM SHORT EXTERNAL FIXATION JET SS THREADED TAPERED HALF","SUP-ITM-10062700","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2383.95","1430.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1499.50","62.9","","619.64","173.09","2370.64","150","277.25","1845.18","percent of total billed charges",""
"PIN BONE 5X30 175MM SHORT EXTERNAL FIXATION JET SS THREADED TAPERED HALF","SUP-ITM-10062700","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2383.95","1430.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1845.18","77.4","","303.98","303.98","5854.79","1 through 10","277.25","1845.18","percent of total billed charges",""
"PIN BONE 60MM 5.0X200 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034330","CDM","C1713","HCPCS","0278","RC","","","","both","","","1442.60","865.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","167.77","1226.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 60MM 5.0X200 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034330","CDM","C1713","HCPCS","0278","RC","","","","both","","","1442.60","865.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","167.77","1226.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 60MM 5.0X200 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034330","CDM","C1713","HCPCS","0278","RC","","","","both","","","1442.60","865.56","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","820.84","56.9","","812.12","238.65","1587.46","163","167.77","1226.21","percent of total billed charges",""
"PIN BONE 60MM 5.0X200 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034330","CDM","C1713","HCPCS","0278","RC","","","","both","","","1442.60","865.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","167.77","11.63","","112.68","112.68","146.99","38","167.77","1226.21","percent of total billed charges",""
"PIN BONE 60MM 5.0X200 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034330","CDM","C1713","HCPCS","0278","RC","","","","both","","","1442.60","865.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1116.57","77.4","","303.98","303.98","5854.79","1 through 10","167.77","1226.21","percent of total billed charges",""
"PIN BONE 60MM 5.0X200 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034330","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1442.60","865.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","167.77","11.63","","112.68","112.68","146.99","38","167.77","1116.57","percent of total billed charges",""
"PIN BONE 60MM 5.0X200 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034330","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1442.60","865.56","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","905.66","62.78","","780.86","208.94","10480.28","15","167.77","1116.57","percent of total billed charges",""
"PIN BONE 60MM 5.0X200 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034330","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1442.60","865.56","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","630.70","43.72","","179.76","179.76","179.76","1 through 10","167.77","1116.57","percent of total billed charges",""
"PIN BONE 60MM 5.0X200 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034330","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1442.60","865.56","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1049.06","72.72","","2355.45","298.99","3965.19","155","167.77","1116.57","percent of total billed charges",""
"PIN BONE 60MM 5.0X200 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034330","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1442.60","865.56","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1049.06","72.72","","3643.09","3643.09","3643.09","1 through 10","167.77","1116.57","percent of total billed charges",""
"PIN BONE 60MM 5.0X200 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034330","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1442.60","865.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","767.75","53.22","","554.28","554.28","554.28","16","167.77","1116.57","percent of total billed charges",""
"PIN BONE 60MM 5.0X200 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034330","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1442.60","865.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","907.40","62.9","","619.64","173.09","2370.64","150","167.77","1116.57","percent of total billed charges",""
"PIN BONE 60MM 5.0X200 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD","SUP-ITM-10034330","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1442.60","865.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1116.57","77.4","","303.98","303.98","5854.79","1 through 10","167.77","1116.57","percent of total billed charges",""
"PIN BONE 7X50 375MM EXTERNAL FIXATION JET SS TRACTION THREADED TAPERED","SUP-ITM-10062725","CDM","C1713","HCPCS","0278","RC","","","","both","","","4629.70","2777.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","538.43","3935.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 7X50 375MM EXTERNAL FIXATION JET SS TRACTION THREADED TAPERED","SUP-ITM-10062725","CDM","C1713","HCPCS","0278","RC","","","","both","","","4629.70","2777.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","538.43","3935.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BONE 7X50 375MM EXTERNAL FIXATION JET SS TRACTION THREADED TAPERED","SUP-ITM-10062725","CDM","C1713","HCPCS","0278","RC","","","","both","","","4629.70","2777.82","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2634.30","56.9","","812.12","238.65","1587.46","163","538.43","3935.25","percent of total billed charges",""
"PIN BONE 7X50 375MM EXTERNAL FIXATION JET SS TRACTION THREADED TAPERED","SUP-ITM-10062725","CDM","C1713","HCPCS","0278","RC","","","","both","","","4629.70","2777.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","538.43","11.63","","112.68","112.68","146.99","38","538.43","3935.25","percent of total billed charges",""
"PIN BONE 7X50 375MM EXTERNAL FIXATION JET SS TRACTION THREADED TAPERED","SUP-ITM-10062725","CDM","C1713","HCPCS","0278","RC","","","","both","","","4629.70","2777.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3583.39","77.4","","303.98","303.98","5854.79","1 through 10","538.43","3935.25","percent of total billed charges",""
"PIN BONE 7X50 375MM EXTERNAL FIXATION JET SS TRACTION THREADED TAPERED","SUP-ITM-10062725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4629.70","2777.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","538.43","11.63","","112.68","112.68","146.99","38","538.43","3583.39","percent of total billed charges",""
"PIN BONE 7X50 375MM EXTERNAL FIXATION JET SS TRACTION THREADED TAPERED","SUP-ITM-10062725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4629.70","2777.82","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2906.53","62.78","","780.86","208.94","10480.28","15","538.43","3583.39","percent of total billed charges",""
"PIN BONE 7X50 375MM EXTERNAL FIXATION JET SS TRACTION THREADED TAPERED","SUP-ITM-10062725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4629.70","2777.82","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2024.10","43.72","","179.76","179.76","179.76","1 through 10","538.43","3583.39","percent of total billed charges",""
"PIN BONE 7X50 375MM EXTERNAL FIXATION JET SS TRACTION THREADED TAPERED","SUP-ITM-10062725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4629.70","2777.82","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3366.72","72.72","","2355.45","298.99","3965.19","155","538.43","3583.39","percent of total billed charges",""
"PIN BONE 7X50 375MM EXTERNAL FIXATION JET SS TRACTION THREADED TAPERED","SUP-ITM-10062725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4629.70","2777.82","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3366.72","72.72","","3643.09","3643.09","3643.09","1 through 10","538.43","3583.39","percent of total billed charges",""
"PIN BONE 7X50 375MM EXTERNAL FIXATION JET SS TRACTION THREADED TAPERED","SUP-ITM-10062725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4629.70","2777.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2463.93","53.22","","554.28","554.28","554.28","16","538.43","3583.39","percent of total billed charges",""
"PIN BONE 7X50 375MM EXTERNAL FIXATION JET SS TRACTION THREADED TAPERED","SUP-ITM-10062725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4629.70","2777.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2912.08","62.9","","619.64","173.09","2370.64","150","538.43","3583.39","percent of total billed charges",""
"PIN BONE 7X50 375MM EXTERNAL FIXATION JET SS TRACTION THREADED TAPERED","SUP-ITM-10062725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4629.70","2777.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3583.39","77.4","","303.98","303.98","5854.79","1 through 10","538.43","3583.39","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","both","","","647.88","388.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","75.35","550.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","both","","","647.88","388.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","75.35","550.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","both","","","647.88","388.73","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","368.64","56.9","","812.12","238.65","1587.46","163","75.35","550.7","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","both","","","647.88","388.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","75.35","11.63","","112.68","112.68","146.99","38","75.35","550.7","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","both","","","647.88","388.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","501.46","77.4","","303.98","303.98","5854.79","1 through 10","75.35","550.7","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","75.35","11.63","","112.68","112.68","146.99","38","75.35","501.46","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","406.74","62.78","","780.86","208.94","10480.28","15","75.35","501.46","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","283.25","43.72","","179.76","179.76","179.76","1 through 10","75.35","501.46","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","471.14","72.72","","2355.45","298.99","3965.19","155","75.35","501.46","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","471.14","72.72","","3643.09","3643.09","3643.09","1 through 10","75.35","501.46","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","344.80","53.22","","554.28","554.28","554.28","16","75.35","501.46","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","407.52","62.9","","619.64","173.09","2370.64","150","75.35","501.46","percent of total billed charges",""
"PIN BUTTRESS 1.8X30MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095244","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","501.46","77.4","","303.98","303.98","5854.79","1 through 10","75.35","501.46","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","both","","","647.88","388.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","75.35","550.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","both","","","647.88","388.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","75.35","550.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","both","","","647.88","388.73","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","368.64","56.9","","812.12","238.65","1587.46","163","75.35","550.7","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","both","","","647.88","388.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","75.35","11.63","","112.68","112.68","146.99","38","75.35","550.7","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","both","","","647.88","388.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","501.46","77.4","","303.98","303.98","5854.79","1 through 10","75.35","550.7","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","75.35","11.63","","112.68","112.68","146.99","38","75.35","501.46","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","406.74","62.78","","780.86","208.94","10480.28","15","75.35","501.46","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","283.25","43.72","","179.76","179.76","179.76","1 through 10","75.35","501.46","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","471.14","72.72","","2355.45","298.99","3965.19","155","75.35","501.46","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","471.14","72.72","","3643.09","3643.09","3643.09","1 through 10","75.35","501.46","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","344.80","53.22","","554.28","554.28","554.28","16","75.35","501.46","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","407.52","62.9","","619.64","173.09","2370.64","150","75.35","501.46","percent of total billed charges",""
"PIN BUTTRESS 10X1.8MM SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10095235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","501.46","77.4","","303.98","303.98","5854.79","1 through 10","75.35","501.46","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","1538.17","922.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","178.89","1307.44","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","1538.17","922.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","178.89","1307.44","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","1538.17","922.90","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","875.22","56.9","","812.12","238.65","1587.46","163","178.89","1307.44","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","1538.17","922.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","178.89","11.63","","112.68","112.68","146.99","38","178.89","1307.44","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","1538.17","922.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1190.54","77.4","","303.98","303.98","5854.79","1 through 10","178.89","1307.44","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1538.17","922.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","178.89","11.63","","112.68","112.68","146.99","38","178.89","1190.54","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1538.17","922.90","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","965.66","62.78","","780.86","208.94","10480.28","15","178.89","1190.54","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1538.17","922.90","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","672.49","43.72","","179.76","179.76","179.76","1 through 10","178.89","1190.54","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1538.17","922.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1118.56","72.72","","2355.45","298.99","3965.19","155","178.89","1190.54","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1538.17","922.90","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1118.56","72.72","","3643.09","3643.09","3643.09","1 through 10","178.89","1190.54","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1538.17","922.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","818.61","53.22","","554.28","554.28","554.28","16","178.89","1190.54","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1538.17","922.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","967.51","62.9","","619.64","173.09","2370.64","150","178.89","1190.54","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1538.17","922.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1190.54","77.4","","303.98","303.98","5854.79","1 through 10","178.89","1190.54","percent of total billed charges",""
"PIN DRILL 4X2.7MM SHORT EXTERNAL FIXATION DEVICE SS GRADUATED HALF","SUP-ITM-10062669","CDM","C1713","HCPCS","0278","RC","","","","both","","","3316.80","1990.08","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","385.74","2819.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN DRILL 4X2.7MM SHORT EXTERNAL FIXATION DEVICE SS GRADUATED HALF","SUP-ITM-10062669","CDM","C1713","HCPCS","0278","RC","","","","both","","","3316.80","1990.08","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","385.74","2819.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN DRILL 4X2.7MM SHORT EXTERNAL FIXATION DEVICE SS GRADUATED HALF","SUP-ITM-10062669","CDM","C1713","HCPCS","0278","RC","","","","both","","","3316.80","1990.08","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1887.26","56.9","","812.12","238.65","1587.46","163","385.74","2819.28","percent of total billed charges",""
"PIN DRILL 4X2.7MM SHORT EXTERNAL FIXATION DEVICE SS GRADUATED HALF","SUP-ITM-10062669","CDM","C1713","HCPCS","0278","RC","","","","both","","","3316.80","1990.08","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","385.74","11.63","","112.68","112.68","146.99","38","385.74","2819.28","percent of total billed charges",""
"PIN DRILL 4X2.7MM SHORT EXTERNAL FIXATION DEVICE SS GRADUATED HALF","SUP-ITM-10062669","CDM","C1713","HCPCS","0278","RC","","","","both","","","3316.80","1990.08","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2567.20","77.4","","303.98","303.98","5854.79","1 through 10","385.74","2819.28","percent of total billed charges",""
"PIN DRILL 4X2.7MM SHORT EXTERNAL FIXATION DEVICE SS GRADUATED HALF","SUP-ITM-10062669","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3316.80","1990.08","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","385.74","11.63","","112.68","112.68","146.99","38","385.74","2567.2","percent of total billed charges",""
"PIN DRILL 4X2.7MM SHORT EXTERNAL FIXATION DEVICE SS GRADUATED HALF","SUP-ITM-10062669","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3316.80","1990.08","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2082.29","62.78","","780.86","208.94","10480.28","15","385.74","2567.2","percent of total billed charges",""
"PIN DRILL 4X2.7MM SHORT EXTERNAL FIXATION DEVICE SS GRADUATED HALF","SUP-ITM-10062669","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3316.80","1990.08","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1450.10","43.72","","179.76","179.76","179.76","1 through 10","385.74","2567.2","percent of total billed charges",""
"PIN DRILL 4X2.7MM SHORT EXTERNAL FIXATION DEVICE SS GRADUATED HALF","SUP-ITM-10062669","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3316.80","1990.08","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2411.98","72.72","","2355.45","298.99","3965.19","155","385.74","2567.2","percent of total billed charges",""
"PIN DRILL 4X2.7MM SHORT EXTERNAL FIXATION DEVICE SS GRADUATED HALF","SUP-ITM-10062669","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3316.80","1990.08","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2411.98","72.72","","3643.09","3643.09","3643.09","1 through 10","385.74","2567.2","percent of total billed charges",""
"PIN DRILL 4X2.7MM SHORT EXTERNAL FIXATION DEVICE SS GRADUATED HALF","SUP-ITM-10062669","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3316.80","1990.08","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1765.20","53.22","","554.28","554.28","554.28","16","385.74","2567.2","percent of total billed charges",""
"PIN DRILL 4X2.7MM SHORT EXTERNAL FIXATION DEVICE SS GRADUATED HALF","SUP-ITM-10062669","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3316.80","1990.08","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2086.27","62.9","","619.64","173.09","2370.64","150","385.74","2567.2","percent of total billed charges",""
"PIN DRILL 4X2.7MM SHORT EXTERNAL FIXATION DEVICE SS GRADUATED HALF","SUP-ITM-10062669","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3316.80","1990.08","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2567.20","77.4","","303.98","303.98","5854.79","1 through 10","385.74","2567.2","percent of total billed charges",""
"PIN EXTERNAL 50MM 5X200 FIXATION APEX SS HALF BLUNT SELF DRILLING TAPG THREAD","SUP-ITM-10034348","CDM","C1713","HCPCS","0278","RC","","","","both","","","554.87","332.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","64.53","471.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN EXTERNAL 50MM 5X200 FIXATION APEX SS HALF BLUNT SELF DRILLING TAPG THREAD","SUP-ITM-10034348","CDM","C1713","HCPCS","0278","RC","","","","both","","","554.87","332.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","64.53","471.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN EXTERNAL 50MM 5X200 FIXATION APEX SS HALF BLUNT SELF DRILLING TAPG THREAD","SUP-ITM-10034348","CDM","C1713","HCPCS","0278","RC","","","","both","","","554.87","332.92","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","315.72","56.9","","812.12","238.65","1587.46","163","64.53","471.64","percent of total billed charges",""
"PIN EXTERNAL 50MM 5X200 FIXATION APEX SS HALF BLUNT SELF DRILLING TAPG THREAD","SUP-ITM-10034348","CDM","C1713","HCPCS","0278","RC","","","","both","","","554.87","332.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","64.53","11.63","","112.68","112.68","146.99","38","64.53","471.64","percent of total billed charges",""
"PIN EXTERNAL 50MM 5X200 FIXATION APEX SS HALF BLUNT SELF DRILLING TAPG THREAD","SUP-ITM-10034348","CDM","C1713","HCPCS","0278","RC","","","","both","","","554.87","332.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","429.47","77.4","","303.98","303.98","5854.79","1 through 10","64.53","471.64","percent of total billed charges",""
"PIN EXTERNAL 50MM 5X200 FIXATION APEX SS HALF BLUNT SELF DRILLING TAPG THREAD","SUP-ITM-10034348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","554.87","332.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","64.53","11.63","","112.68","112.68","146.99","38","64.53","429.47","percent of total billed charges",""
"PIN EXTERNAL 50MM 5X200 FIXATION APEX SS HALF BLUNT SELF DRILLING TAPG THREAD","SUP-ITM-10034348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","554.87","332.92","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","348.35","62.78","","780.86","208.94","10480.28","15","64.53","429.47","percent of total billed charges",""
"PIN EXTERNAL 50MM 5X200 FIXATION APEX SS HALF BLUNT SELF DRILLING TAPG THREAD","SUP-ITM-10034348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","554.87","332.92","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","242.59","43.72","","179.76","179.76","179.76","1 through 10","64.53","429.47","percent of total billed charges",""
"PIN EXTERNAL 50MM 5X200 FIXATION APEX SS HALF BLUNT SELF DRILLING TAPG THREAD","SUP-ITM-10034348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","554.87","332.92","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","403.50","72.72","","2355.45","298.99","3965.19","155","64.53","429.47","percent of total billed charges",""
"PIN EXTERNAL 50MM 5X200 FIXATION APEX SS HALF BLUNT SELF DRILLING TAPG THREAD","SUP-ITM-10034348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","554.87","332.92","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","403.50","72.72","","3643.09","3643.09","3643.09","1 through 10","64.53","429.47","percent of total billed charges",""
"PIN EXTERNAL 50MM 5X200 FIXATION APEX SS HALF BLUNT SELF DRILLING TAPG THREAD","SUP-ITM-10034348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","554.87","332.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","295.30","53.22","","554.28","554.28","554.28","16","64.53","429.47","percent of total billed charges",""
"PIN EXTERNAL 50MM 5X200 FIXATION APEX SS HALF BLUNT SELF DRILLING TAPG THREAD","SUP-ITM-10034348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","554.87","332.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","349.01","62.9","","619.64","173.09","2370.64","150","64.53","429.47","percent of total billed charges",""
"PIN EXTERNAL 50MM 5X200 FIXATION APEX SS HALF BLUNT SELF DRILLING TAPG THREAD","SUP-ITM-10034348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","554.87","332.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","429.47","77.4","","303.98","303.98","5854.79","1 through 10","64.53","429.47","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.12","675.67","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","130.97","957.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.12","675.67","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","130.97","957.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.12","675.67","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","640.76","56.9","","812.12","238.65","1587.46","163","130.97","957.2","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.12","675.67","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","130.97","11.63","","112.68","112.68","146.99","38","130.97","957.2","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.12","675.67","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","871.62","77.4","","303.98","303.98","5854.79","1 through 10","130.97","957.2","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.12","675.67","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","130.97","11.63","","112.68","112.68","146.99","38","130.97","871.62","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.12","675.67","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","706.98","62.78","","780.86","208.94","10480.28","15","130.97","871.62","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.12","675.67","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","492.34","43.72","","179.76","179.76","179.76","1 through 10","130.97","871.62","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.12","675.67","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","818.91","72.72","","2355.45","298.99","3965.19","155","130.97","871.62","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.12","675.67","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","818.91","72.72","","3643.09","3643.09","3643.09","1 through 10","130.97","871.62","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.12","675.67","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","599.32","53.22","","554.28","554.28","554.28","16","130.97","871.62","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.12","675.67","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","708.33","62.9","","619.64","173.09","2370.64","150","130.97","871.62","percent of total billed charges",""
"PIN POSITIONING 5MM VA LF SS STERILE DISPOSABLE","SUP-ITM-10294961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.12","675.67","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","871.62","77.4","","303.98","303.98","5854.79","1 through 10","130.97","871.62","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","184.27","110.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","21.43","156.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","184.27","110.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","21.43","156.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","184.27","110.56","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","104.85","56.9","","812.12","238.65","1587.46","163","21.43","156.63","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","184.27","110.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","21.43","11.63","","112.68","112.68","146.99","38","21.43","156.63","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","184.27","110.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","142.62","77.4","","303.98","303.98","5854.79","1 through 10","21.43","156.63","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","184.27","110.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","21.43","11.63","","112.68","112.68","146.99","38","21.43","142.62","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","184.27","110.56","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","115.68","62.78","","780.86","208.94","10480.28","15","21.43","142.62","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","184.27","110.56","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","80.56","43.72","","179.76","179.76","179.76","1 through 10","21.43","142.62","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","184.27","110.56","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","134.00","72.72","","2355.45","298.99","3965.19","155","21.43","142.62","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","184.27","110.56","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","134.00","72.72","","3643.09","3643.09","3643.09","1 through 10","21.43","142.62","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","184.27","110.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","98.07","53.22","","554.28","554.28","554.28","16","21.43","142.62","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","184.27","110.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","115.91","62.9","","619.64","173.09","2370.64","150","21.43","142.62","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","184.27","110.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","142.62","77.4","","303.98","303.98","5854.79","1 through 10","21.43","142.62","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.92","370.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","71.75","524.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.92","370.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","71.75","524.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.92","370.15","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","351.03","56.9","","812.12","238.65","1587.46","163","71.75","524.38","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.92","370.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.75","11.63","","112.68","112.68","146.99","38","71.75","524.38","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.92","370.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","477.50","77.4","","303.98","303.98","5854.79","1 through 10","71.75","524.38","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.92","370.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.75","11.63","","112.68","112.68","146.99","38","71.75","477.5","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.92","370.15","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","387.30","62.78","","780.86","208.94","10480.28","15","71.75","477.5","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.92","370.15","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","269.72","43.72","","179.76","179.76","179.76","1 through 10","71.75","477.5","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.92","370.15","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","448.62","72.72","","2355.45","298.99","3965.19","155","71.75","477.5","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.92","370.15","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","448.62","72.72","","3643.09","3643.09","3643.09","1 through 10","71.75","477.5","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.92","370.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","328.32","53.22","","554.28","554.28","554.28","16","71.75","477.5","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.92","370.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","388.04","62.9","","619.64","173.09","2370.64","150","71.75","477.5","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.92","370.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","477.50","77.4","","303.98","303.98","5854.79","1 through 10","71.75","477.5","percent of total billed charges",""
"PIN TRANSFIXING 15MM 2X36 BONE APEX TITANIUM HALF BLUNT SELF TAPG THREAD","SUP-ITM-10143312","CDM","C1713","HCPCS","0278","RC","","","","both","","","440.17","264.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","51.19","374.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN TRANSFIXING 15MM 2X36 BONE APEX TITANIUM HALF BLUNT SELF TAPG THREAD","SUP-ITM-10143312","CDM","C1713","HCPCS","0278","RC","","","","both","","","440.17","264.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","51.19","374.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PIN TRANSFIXING 15MM 2X36 BONE APEX TITANIUM HALF BLUNT SELF TAPG THREAD","SUP-ITM-10143312","CDM","C1713","HCPCS","0278","RC","","","","both","","","440.17","264.10","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","250.46","56.9","","812.12","238.65","1587.46","163","51.19","374.14","percent of total billed charges",""
"PIN TRANSFIXING 15MM 2X36 BONE APEX TITANIUM HALF BLUNT SELF TAPG THREAD","SUP-ITM-10143312","CDM","C1713","HCPCS","0278","RC","","","","both","","","440.17","264.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","51.19","11.63","","112.68","112.68","146.99","38","51.19","374.14","percent of total billed charges",""
"PIN TRANSFIXING 15MM 2X36 BONE APEX TITANIUM HALF BLUNT SELF TAPG THREAD","SUP-ITM-10143312","CDM","C1713","HCPCS","0278","RC","","","","both","","","440.17","264.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","340.69","77.4","","303.98","303.98","5854.79","1 through 10","51.19","374.14","percent of total billed charges",""
"PIN TRANSFIXING 15MM 2X36 BONE APEX TITANIUM HALF BLUNT SELF TAPG THREAD","SUP-ITM-10143312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","440.17","264.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","51.19","11.63","","112.68","112.68","146.99","38","51.19","340.69","percent of total billed charges",""
"PIN TRANSFIXING 15MM 2X36 BONE APEX TITANIUM HALF BLUNT SELF TAPG THREAD","SUP-ITM-10143312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","440.17","264.10","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","276.34","62.78","","780.86","208.94","10480.28","15","51.19","340.69","percent of total billed charges",""
"PIN TRANSFIXING 15MM 2X36 BONE APEX TITANIUM HALF BLUNT SELF TAPG THREAD","SUP-ITM-10143312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","440.17","264.10","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","192.44","43.72","","179.76","179.76","179.76","1 through 10","51.19","340.69","percent of total billed charges",""
"PIN TRANSFIXING 15MM 2X36 BONE APEX TITANIUM HALF BLUNT SELF TAPG THREAD","SUP-ITM-10143312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","440.17","264.10","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","320.09","72.72","","2355.45","298.99","3965.19","155","51.19","340.69","percent of total billed charges",""
"PIN TRANSFIXING 15MM 2X36 BONE APEX TITANIUM HALF BLUNT SELF TAPG THREAD","SUP-ITM-10143312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","440.17","264.10","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","320.09","72.72","","3643.09","3643.09","3643.09","1 through 10","51.19","340.69","percent of total billed charges",""
"PIN TRANSFIXING 15MM 2X36 BONE APEX TITANIUM HALF BLUNT SELF TAPG THREAD","SUP-ITM-10143312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","440.17","264.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","234.26","53.22","","554.28","554.28","554.28","16","51.19","340.69","percent of total billed charges",""
"PIN TRANSFIXING 15MM 2X36 BONE APEX TITANIUM HALF BLUNT SELF TAPG THREAD","SUP-ITM-10143312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","440.17","264.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","276.87","62.9","","619.64","173.09","2370.64","150","51.19","340.69","percent of total billed charges",""
"PIN TRANSFIXING 15MM 2X36 BONE APEX TITANIUM HALF BLUNT SELF TAPG THREAD","SUP-ITM-10143312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","440.17","264.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","340.69","77.4","","303.98","303.98","5854.79","1 through 10","51.19","340.69","percent of total billed charges",""
"Pinworm Exam Cellophane Tape Prep","PX-30001180","CDM","87172","CPT","0306","RC","","","","both","","","36.00","21.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","25.13","69.8","","24.43","22.02","24.43","1 through 10","2.78","30.6","percent of total billed charges",""
"PISTON EAR .6X4.5MM SCHUKNECHT STAINLESS STEEL FLUOROPLASTIC STERILE","SUP-ITM-10027199","CDM","L8613","HCPCS","0278","RC","","","","outpatient","","","626.60","375.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","394.13","62.9","","2038.65","2038.65","2038.65","1 through 10","333.48","484.99","percent of total billed charges",""
"PISTON EAR .6X5MM SCHUKNECHT SS FLUOROPLASTIC","SUP-ITM-10274220","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.52","383.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","74.38","543.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PISTON EAR .6X5MM SCHUKNECHT SS FLUOROPLASTIC","SUP-ITM-10274220","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.52","383.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","74.38","543.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PISTON EAR .6X5MM SCHUKNECHT SS FLUOROPLASTIC","SUP-ITM-10274220","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.52","383.71","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","363.89","56.9","","812.12","238.65","1587.46","163","74.38","543.59","percent of total billed charges",""
"PISTON EAR .6X5MM SCHUKNECHT SS FLUOROPLASTIC","SUP-ITM-10274220","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.52","383.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","74.38","11.63","","112.68","112.68","146.99","38","74.38","543.59","percent of total billed charges",""
"PISTON EAR .6X5MM SCHUKNECHT SS FLUOROPLASTIC","SUP-ITM-10274220","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.52","383.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","494.99","77.4","","303.98","303.98","5854.79","1 through 10","74.38","543.59","percent of total billed charges",""
"PISTON EAR .6X5MM SCHUKNECHT SS FLUOROPLASTIC","SUP-ITM-10274220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","639.52","383.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","74.38","11.63","","112.68","112.68","146.99","38","74.38","494.99","percent of total billed charges",""
"PISTON EAR .6X5MM SCHUKNECHT SS FLUOROPLASTIC","SUP-ITM-10274220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","639.52","383.71","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","401.49","62.78","","780.86","208.94","10480.28","15","74.38","494.99","percent of total billed charges",""
"PISTON EAR .6X5MM SCHUKNECHT SS FLUOROPLASTIC","SUP-ITM-10274220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","639.52","383.71","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","279.60","43.72","","179.76","179.76","179.76","1 through 10","74.38","494.99","percent of total billed charges",""
"PISTON EAR .6X5MM SCHUKNECHT SS FLUOROPLASTIC","SUP-ITM-10274220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","639.52","383.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","465.06","72.72","","2355.45","298.99","3965.19","155","74.38","494.99","percent of total billed charges",""
"PISTON EAR .6X5MM SCHUKNECHT SS FLUOROPLASTIC","SUP-ITM-10274220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","639.52","383.71","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","465.06","72.72","","3643.09","3643.09","3643.09","1 through 10","74.38","494.99","percent of total billed charges",""
"PISTON EAR .6X5MM SCHUKNECHT SS FLUOROPLASTIC","SUP-ITM-10274220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","639.52","383.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","340.35","53.22","","554.28","554.28","554.28","16","74.38","494.99","percent of total billed charges",""
"PISTON EAR .6X5MM SCHUKNECHT SS FLUOROPLASTIC","SUP-ITM-10274220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","639.52","383.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","402.26","62.9","","619.64","173.09","2370.64","150","74.38","494.99","percent of total billed charges",""
"PISTON EAR .6X5MM SCHUKNECHT SS FLUOROPLASTIC","SUP-ITM-10274220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","639.52","383.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","494.99","77.4","","303.98","303.98","5854.79","1 through 10","74.38","494.99","percent of total billed charges",""
"PISTON EAR 4.5MM SHEA CUP STAPEDECTOMY","SUP-ITM-10295660","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","1037.40","622.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","652.52","62.9","","2038.65","2038.65","2038.65","1 through 10","552.1","802.95","percent of total billed charges",""
"PISTON EAR 4MM STAPES SHEA CUP RT SM FLUOROPLASTIC","SUP-ITM-10237277","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","1039.61","623.77","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","653.91","62.9","","2038.65","2038.65","2038.65","1 through 10","553.28","804.66","percent of total billed charges",""
"PISTON STAPES .4MM","SUP-ITM-10237282","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","462.97","277.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","291.21","62.9","","2038.65","2038.65","2038.65","1 through 10","246.39","358.34","percent of total billed charges",""
"Place Cath Renal 1st Order Unilat","PX-76001053","CDM","36251","CPT","0361","RC","","","","both","","","11428.00","6856.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","3288.38","","APC Price ($3,288.38). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3225.99","3225.99","3225.99","1 through 10","3222.61","21015.78","other","OPPS APC"
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9085.00","5451.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","6341.33","69.8","","6119.37","6119.37","6119.37","1 through 10","1400.91","9135.87","percent of total billed charges",""
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9085.00","5451.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","9135.87","","Case rate ($9,135.87). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8387.87","8198.31","8913.06","12","1400.91","9135.87","other","OPPS APC"
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9085.00","5451.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","3933.90","","Case rate ($3,933.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3837.99","3837.99","3837.99","1 through 10","1400.91","9135.87","other","OPPS APC"
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9085.00","5451.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1400.91","","APC Price ($1,429.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1429.67","1401.08","2430.44","24","1400.91","9135.87","other","OPPS APC"
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9085.00","5451.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","7384.44","","Case rate ($7,384.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6483.86","6384.10","7204.29","1 through 10","1400.91","9135.87","other","OPPS APC"
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9085.00","5451.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","1472.39","","APC Price ($1,429.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1449.00","1449.00","1449.00","1 through 10","1400.91","9135.87","other","OPPS APC"
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9085.00","5451.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","1429.50","","APC Price ($1,429.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1406.80","1401.08","1429.67","17","1400.91","9135.87","other","OPPS APC"
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9085.00","5451.00","MEDICARE [2001]","HB WDH MEDICARE","1429.50","","APC Price ($1,429.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1429.67","1429.67","1429.67","65","1400.91","9135.87","other","OPPS APC"
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9085.00","5451.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1429.50","","APC Price ($1,429.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1401.08","1323.07","1408.37","16","1400.91","9135.87","other","OPPS APC"
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","both","","","9085.00","5451.00","WELLSENSE NH [1050]","HB WDH MEDICARE","1429.50","","APC Price ($1,429.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1477.13","1477.13","1477.13","1 through 10","1400.91","9135.87","other","OPPS APC"
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","outpatient","","","9085.00","5451.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1310.06","14.42","","1264.20","1264.20","1264.20","1 through 10","1056.59","7031.79","percent of total billed charges",""
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","outpatient","","","9085.00","5451.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1056.59","11.63","","1073.08","1035.52","1207.22","1 through 10","1056.59","7031.79","percent of total billed charges",""
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","outpatient","","","9085.00","5451.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5703.56","62.78","","5503.92","5503.92","5503.92","1 through 10","1056.59","7031.79","percent of total billed charges",""
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","outpatient","","","9085.00","5451.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6606.61","72.72","","6375.36","5770.44","6375.36","11","1056.59","7031.79","percent of total billed charges",""
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","outpatient","","","9085.00","5451.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5714.47","62.9","","5523.21","5523.21","5523.21","1 through 10","1056.59","7031.79","percent of total billed charges",""
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","outpatient","","","9085.00","5451.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7031.79","77.4","","6375.36","6375.36","6375.36","1 through 10","1056.59","7031.79","percent of total billed charges",""
"Plan Rad 3d W/ Dose Vol Histogram","PX-33000010","CDM","77295","CPT","0333","RC","","","","outpatient","","","9085.00","5451.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1056.59","11.63","","2241.72","1035.52","2241.72","1 through 10","1056.59","7031.79","percent of total billed charges",""
"PLASMA DISTAL 14MMX127 STEM HIP MODULAR POROUS STRAIGHT","SUP-ITM-10035064","CDM","C1776","HCPCS","0278","RC","","","","both","","","11344.15","6806.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1319.32","9642.53","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLASMA DISTAL 14MMX127 STEM HIP MODULAR POROUS STRAIGHT","SUP-ITM-10035064","CDM","C1776","HCPCS","0278","RC","","","","both","","","11344.15","6806.49","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6454.82","56.9","","2911.53","1863.86","5209.05","65","1319.32","9642.53","percent of total billed charges",""
"PLASMA DISTAL 14MMX127 STEM HIP MODULAR POROUS STRAIGHT","SUP-ITM-10035064","CDM","C1776","HCPCS","0278","RC","","","","both","","","11344.15","6806.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1319.32","11.63","","400.94","400.94","400.94","1 through 10","1319.32","9642.53","percent of total billed charges",""
"PLASMA DISTAL 14MMX127 STEM HIP MODULAR POROUS STRAIGHT","SUP-ITM-10035064","CDM","C1776","HCPCS","0278","RC","","","","both","","","11344.15","6806.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8780.37","77.4","","5214.50","5214.50","16415.28","1 through 10","1319.32","9642.53","percent of total billed charges",""
"PLASMA DISTAL 14MMX127 STEM HIP MODULAR POROUS STRAIGHT","SUP-ITM-10035064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11344.15","6806.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1319.32","11.63","","400.94","400.94","400.94","1 through 10","1319.32","8780.37","percent of total billed charges",""
"PLASMA DISTAL 14MMX127 STEM HIP MODULAR POROUS STRAIGHT","SUP-ITM-10035064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11344.15","6806.49","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4959.66","43.72","","1543.33","1543.33","1671.61","1 through 10","1319.32","8780.37","percent of total billed charges",""
"PLASMA DISTAL 14MMX127 STEM HIP MODULAR POROUS STRAIGHT","SUP-ITM-10035064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11344.15","6806.49","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8249.47","72.72","","3700.21","2382.07","6427.18","53","1319.32","8780.37","percent of total billed charges",""
"PLASMA DISTAL 14MMX127 STEM HIP MODULAR POROUS STRAIGHT","SUP-ITM-10035064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11344.15","6806.49","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","8249.47","72.72","","12685.80","12685.80","12685.80","1 through 10","1319.32","8780.37","percent of total billed charges",""
"PLASMA DISTAL 14MMX127 STEM HIP MODULAR POROUS STRAIGHT","SUP-ITM-10035064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11344.15","6806.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7135.47","62.9","","3408.87","2784.05","9859.40","46","1319.32","8780.37","percent of total billed charges",""
"PLASMA DISTAL 14MMX127 STEM HIP MODULAR POROUS STRAIGHT","SUP-ITM-10035064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11344.15","6806.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8780.37","77.4","","5214.50","5214.50","16415.28","1 through 10","1319.32","8780.37","percent of total billed charges",""
"Plasma Frozen 8 to 24","PX-39000032","CDM","P9059","HCPCS","0390","RC","","","","both","","","480.00","288.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","273.12","56.9","","263.45","263.45","263.45","1 through 10","69.67","474.7","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","both","","","3817.15","2290.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","443.93","3244.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","both","","","3817.15","2290.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","443.93","3244.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","both","","","3817.15","2290.29","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2171.96","56.9","","812.12","238.65","1587.46","163","443.93","3244.58","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","both","","","3817.15","2290.29","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","443.93","11.63","","112.68","112.68","146.99","38","443.93","3244.58","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","both","","","3817.15","2290.29","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2954.47","77.4","","303.98","303.98","5854.79","1 through 10","443.93","3244.58","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3817.15","2290.29","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","443.93","11.63","","112.68","112.68","146.99","38","443.93","2954.47","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3817.15","2290.29","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2396.41","62.78","","780.86","208.94","10480.28","15","443.93","2954.47","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3817.15","2290.29","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1668.86","43.72","","179.76","179.76","179.76","1 through 10","443.93","2954.47","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3817.15","2290.29","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2775.83","72.72","","2355.45","298.99","3965.19","155","443.93","2954.47","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3817.15","2290.29","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2775.83","72.72","","3643.09","3643.09","3643.09","1 through 10","443.93","2954.47","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3817.15","2290.29","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2031.49","53.22","","554.28","554.28","554.28","16","443.93","2954.47","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3817.15","2290.29","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2400.99","62.9","","619.64","173.09","2370.64","150","443.93","2954.47","percent of total billed charges",""
"PLATE ANKLE 105MM 5 HOLE 2.7MM VA LCP SS DISTAL LATERAL FIBULA RIGHT","SUP-ITM-10124975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3817.15","2290.29","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2954.47","77.4","","303.98","303.98","5854.79","1 through 10","443.93","2954.47","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","6279.44","3767.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","730.3","5337.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","6279.44","3767.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","730.3","5337.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","6279.44","3767.66","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3573.00","56.9","","812.12","238.65","1587.46","163","730.3","5337.52","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","6279.44","3767.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","730.30","11.63","","112.68","112.68","146.99","38","730.3","5337.52","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","6279.44","3767.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4860.29","77.4","","303.98","303.98","5854.79","1 through 10","730.3","5337.52","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6279.44","3767.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","730.30","11.63","","112.68","112.68","146.99","38","730.3","4860.29","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6279.44","3767.66","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3942.23","62.78","","780.86","208.94","10480.28","15","730.3","4860.29","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6279.44","3767.66","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2745.37","43.72","","179.76","179.76","179.76","1 through 10","730.3","4860.29","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6279.44","3767.66","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4566.41","72.72","","2355.45","298.99","3965.19","155","730.3","4860.29","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6279.44","3767.66","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4566.41","72.72","","3643.09","3643.09","3643.09","1 through 10","730.3","4860.29","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6279.44","3767.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3341.92","53.22","","554.28","554.28","554.28","16","730.3","4860.29","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6279.44","3767.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3949.77","62.9","","619.64","173.09","2370.64","150","730.3","4860.29","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6279.44","3767.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4860.29","77.4","","303.98","303.98","5854.79","1 through 10","730.3","4860.29","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","both","","","6544.88","3926.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","761.17","5563.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","both","","","6544.88","3926.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","761.17","5563.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","both","","","6544.88","3926.93","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3724.04","56.9","","812.12","238.65","1587.46","163","761.17","5563.15","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","both","","","6544.88","3926.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","761.17","11.63","","112.68","112.68","146.99","38","761.17","5563.15","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","both","","","6544.88","3926.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5065.74","77.4","","303.98","303.98","5854.79","1 through 10","761.17","5563.15","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6544.88","3926.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","761.17","11.63","","112.68","112.68","146.99","38","761.17","5065.74","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6544.88","3926.93","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4108.88","62.78","","780.86","208.94","10480.28","15","761.17","5065.74","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6544.88","3926.93","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2861.42","43.72","","179.76","179.76","179.76","1 through 10","761.17","5065.74","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6544.88","3926.93","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4759.44","72.72","","2355.45","298.99","3965.19","155","761.17","5065.74","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6544.88","3926.93","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4759.44","72.72","","3643.09","3643.09","3643.09","1 through 10","761.17","5065.74","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6544.88","3926.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3483.19","53.22","","554.28","554.28","554.28","16","761.17","5065.74","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6544.88","3926.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4116.73","62.9","","619.64","173.09","2370.64","150","761.17","5065.74","percent of total billed charges",""
"PLATE ANKLE 112MM 6 HOLE 2.7/3.5MM VA LCP SS ANTEROLATERAL DISTAL TIBIA LEFT","SUP-ITM-10124953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6544.88","3926.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5065.74","77.4","","303.98","303.98","5854.79","1 through 10","761.17","5065.74","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","both","","","6832.10","4099.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","794.57","5807.29","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","both","","","6832.10","4099.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","794.57","5807.29","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","both","","","6832.10","4099.26","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3887.46","56.9","","812.12","238.65","1587.46","163","794.57","5807.29","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","both","","","6832.10","4099.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","794.57","11.63","","112.68","112.68","146.99","38","794.57","5807.29","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","both","","","6832.10","4099.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5288.05","77.4","","303.98","303.98","5854.79","1 through 10","794.57","5807.29","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6832.10","4099.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","794.57","11.63","","112.68","112.68","146.99","38","794.57","5288.05","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6832.10","4099.26","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4289.19","62.78","","780.86","208.94","10480.28","15","794.57","5288.05","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6832.10","4099.26","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2986.99","43.72","","179.76","179.76","179.76","1 through 10","794.57","5288.05","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6832.10","4099.26","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4968.30","72.72","","2355.45","298.99","3965.19","155","794.57","5288.05","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6832.10","4099.26","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4968.30","72.72","","3643.09","3643.09","3643.09","1 through 10","794.57","5288.05","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6832.10","4099.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3636.04","53.22","","554.28","554.28","554.28","16","794.57","5288.05","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6832.10","4099.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4297.39","62.9","","619.64","173.09","2370.64","150","794.57","5288.05","percent of total billed charges",""
"PLATE ANKLE 142MM 8 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE ANTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6832.10","4099.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5288.05","77.4","","303.98","303.98","5854.79","1 through 10","794.57","5288.05","percent of total billed charges",""
"PLATE ANKLE 172MM 8 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124985","CDM","C1713","HCPCS","0278","RC","","","","both","","","7059.42","4235.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","821.01","6000.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 172MM 8 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124985","CDM","C1713","HCPCS","0278","RC","","","","both","","","7059.42","4235.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","821.01","6000.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 172MM 8 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124985","CDM","C1713","HCPCS","0278","RC","","","","both","","","7059.42","4235.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4016.81","56.9","","812.12","238.65","1587.46","163","821.01","6000.51","percent of total billed charges",""
"PLATE ANKLE 172MM 8 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124985","CDM","C1713","HCPCS","0278","RC","","","","both","","","7059.42","4235.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","821.01","11.63","","112.68","112.68","146.99","38","821.01","6000.51","percent of total billed charges",""
"PLATE ANKLE 172MM 8 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124985","CDM","C1713","HCPCS","0278","RC","","","","both","","","7059.42","4235.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5463.99","77.4","","303.98","303.98","5854.79","1 through 10","821.01","6000.51","percent of total billed charges",""
"PLATE ANKLE 172MM 8 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7059.42","4235.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","821.01","11.63","","112.68","112.68","146.99","38","821.01","5463.99","percent of total billed charges",""
"PLATE ANKLE 172MM 8 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7059.42","4235.65","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4431.90","62.78","","780.86","208.94","10480.28","15","821.01","5463.99","percent of total billed charges",""
"PLATE ANKLE 172MM 8 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7059.42","4235.65","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3086.38","43.72","","179.76","179.76","179.76","1 through 10","821.01","5463.99","percent of total billed charges",""
"PLATE ANKLE 172MM 8 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7059.42","4235.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5133.61","72.72","","2355.45","298.99","3965.19","155","821.01","5463.99","percent of total billed charges",""
"PLATE ANKLE 172MM 8 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7059.42","4235.65","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5133.61","72.72","","3643.09","3643.09","3643.09","1 through 10","821.01","5463.99","percent of total billed charges",""
"PLATE ANKLE 172MM 8 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7059.42","4235.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3757.02","53.22","","554.28","554.28","554.28","16","821.01","5463.99","percent of total billed charges",""
"PLATE ANKLE 172MM 8 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7059.42","4235.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4440.38","62.9","","619.64","173.09","2370.64","150","821.01","5463.99","percent of total billed charges",""
"PLATE ANKLE 172MM 8 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7059.42","4235.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5463.99","77.4","","303.98","303.98","5854.79","1 through 10","821.01","5463.99","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","both","","","6892.58","4135.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","801.61","5858.69","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","both","","","6892.58","4135.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","801.61","5858.69","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","both","","","6892.58","4135.55","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3921.88","56.9","","812.12","238.65","1587.46","163","801.61","5858.69","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","both","","","6892.58","4135.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","801.61","11.63","","112.68","112.68","146.99","38","801.61","5858.69","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","both","","","6892.58","4135.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5334.86","77.4","","303.98","303.98","5854.79","1 through 10","801.61","5858.69","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6892.58","4135.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","801.61","11.63","","112.68","112.68","146.99","38","801.61","5334.86","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6892.58","4135.55","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4327.16","62.78","","780.86","208.94","10480.28","15","801.61","5334.86","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6892.58","4135.55","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3013.44","43.72","","179.76","179.76","179.76","1 through 10","801.61","5334.86","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6892.58","4135.55","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5012.28","72.72","","2355.45","298.99","3965.19","155","801.61","5334.86","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6892.58","4135.55","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5012.28","72.72","","3643.09","3643.09","3643.09","1 through 10","801.61","5334.86","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6892.58","4135.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3668.23","53.22","","554.28","554.28","554.28","16","801.61","5334.86","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6892.58","4135.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4335.43","62.9","","619.64","173.09","2370.64","150","801.61","5334.86","percent of total billed charges",""
"PLATE ANKLE 2.7/3.5X172MM 10 HOLE TIBIA VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124956","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6892.58","4135.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5334.86","77.4","","303.98","303.98","5854.79","1 through 10","801.61","5334.86","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","6477.56","3886.54","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","753.34","5505.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","6477.56","3886.54","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","753.34","5505.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","6477.56","3886.54","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3685.73","56.9","","812.12","238.65","1587.46","163","753.34","5505.93","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","6477.56","3886.54","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","753.34","11.63","","112.68","112.68","146.99","38","753.34","5505.93","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","6477.56","3886.54","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5013.63","77.4","","303.98","303.98","5854.79","1 through 10","753.34","5505.93","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6477.56","3886.54","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","753.34","11.63","","112.68","112.68","146.99","38","753.34","5013.63","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6477.56","3886.54","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4066.61","62.78","","780.86","208.94","10480.28","15","753.34","5013.63","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6477.56","3886.54","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2831.99","43.72","","179.76","179.76","179.76","1 through 10","753.34","5013.63","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6477.56","3886.54","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4710.48","72.72","","2355.45","298.99","3965.19","155","753.34","5013.63","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6477.56","3886.54","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4710.48","72.72","","3643.09","3643.09","3643.09","1 through 10","753.34","5013.63","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6477.56","3886.54","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3447.36","53.22","","554.28","554.28","554.28","16","753.34","5013.63","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6477.56","3886.54","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4074.39","62.9","","619.64","173.09","2370.64","150","753.34","5013.63","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6477.56","3886.54","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5013.63","77.4","","303.98","303.98","5854.79","1 through 10","753.34","5013.63","percent of total billed charges",""
"PLATE ANKLE 232MM 12 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124939","CDM","C1713","HCPCS","0278","RC","","","","both","","","7562.02","4537.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","879.46","6427.72","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 232MM 12 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124939","CDM","C1713","HCPCS","0278","RC","","","","both","","","7562.02","4537.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","879.46","6427.72","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 232MM 12 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124939","CDM","C1713","HCPCS","0278","RC","","","","both","","","7562.02","4537.21","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4302.79","56.9","","812.12","238.65","1587.46","163","879.46","6427.72","percent of total billed charges",""
"PLATE ANKLE 232MM 12 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124939","CDM","C1713","HCPCS","0278","RC","","","","both","","","7562.02","4537.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","879.46","11.63","","112.68","112.68","146.99","38","879.46","6427.72","percent of total billed charges",""
"PLATE ANKLE 232MM 12 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124939","CDM","C1713","HCPCS","0278","RC","","","","both","","","7562.02","4537.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5853.00","77.4","","303.98","303.98","5854.79","1 through 10","879.46","6427.72","percent of total billed charges",""
"PLATE ANKLE 232MM 12 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7562.02","4537.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","879.46","11.63","","112.68","112.68","146.99","38","879.46","5853","percent of total billed charges",""
"PLATE ANKLE 232MM 12 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7562.02","4537.21","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4747.44","62.78","","780.86","208.94","10480.28","15","879.46","5853","percent of total billed charges",""
"PLATE ANKLE 232MM 12 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7562.02","4537.21","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3306.12","43.72","","179.76","179.76","179.76","1 through 10","879.46","5853","percent of total billed charges",""
"PLATE ANKLE 232MM 12 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7562.02","4537.21","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5499.10","72.72","","2355.45","298.99","3965.19","155","879.46","5853","percent of total billed charges",""
"PLATE ANKLE 232MM 12 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7562.02","4537.21","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5499.10","72.72","","3643.09","3643.09","3643.09","1 through 10","879.46","5853","percent of total billed charges",""
"PLATE ANKLE 232MM 12 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7562.02","4537.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4024.51","53.22","","554.28","554.28","554.28","16","879.46","5853","percent of total billed charges",""
"PLATE ANKLE 232MM 12 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7562.02","4537.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4756.51","62.9","","619.64","173.09","2370.64","150","879.46","5853","percent of total billed charges",""
"PLATE ANKLE 232MM 12 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7562.02","4537.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5853.00","77.4","","303.98","303.98","5854.79","1 through 10","879.46","5853","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124944","CDM","C1713","HCPCS","0278","RC","","","","both","","","8644.40","5186.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1005.34","7347.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124944","CDM","C1713","HCPCS","0278","RC","","","","both","","","8644.40","5186.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1005.34","7347.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124944","CDM","C1713","HCPCS","0278","RC","","","","both","","","8644.40","5186.64","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4918.66","56.9","","812.12","238.65","1587.46","163","1005.34","7347.74","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124944","CDM","C1713","HCPCS","0278","RC","","","","both","","","8644.40","5186.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1005.34","11.63","","112.68","112.68","146.99","38","1005.34","7347.74","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124944","CDM","C1713","HCPCS","0278","RC","","","","both","","","8644.40","5186.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6690.77","77.4","","303.98","303.98","5854.79","1 through 10","1005.34","7347.74","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8644.40","5186.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1005.34","11.63","","112.68","112.68","146.99","38","1005.34","6690.77","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8644.40","5186.64","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5426.95","62.78","","780.86","208.94","10480.28","15","1005.34","6690.77","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8644.40","5186.64","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3779.33","43.72","","179.76","179.76","179.76","1 through 10","1005.34","6690.77","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8644.40","5186.64","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6286.21","72.72","","2355.45","298.99","3965.19","155","1005.34","6690.77","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8644.40","5186.64","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6286.21","72.72","","3643.09","3643.09","3643.09","1 through 10","1005.34","6690.77","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8644.40","5186.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4600.55","53.22","","554.28","554.28","554.28","16","1005.34","6690.77","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8644.40","5186.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5437.33","62.9","","619.64","173.09","2370.64","150","1005.34","6690.77","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8644.40","5186.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6690.77","77.4","","303.98","303.98","5854.79","1 through 10","1005.34","6690.77","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","both","","","8644.40","5186.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1005.34","7347.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","both","","","8644.40","5186.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1005.34","7347.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","both","","","8644.40","5186.64","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4918.66","56.9","","812.12","238.65","1587.46","163","1005.34","7347.74","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","both","","","8644.40","5186.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1005.34","11.63","","112.68","112.68","146.99","38","1005.34","7347.74","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","both","","","8644.40","5186.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6690.77","77.4","","303.98","303.98","5854.79","1 through 10","1005.34","7347.74","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8644.40","5186.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1005.34","11.63","","112.68","112.68","146.99","38","1005.34","6690.77","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8644.40","5186.64","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5426.95","62.78","","780.86","208.94","10480.28","15","1005.34","6690.77","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8644.40","5186.64","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3779.33","43.72","","179.76","179.76","179.76","1 through 10","1005.34","6690.77","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8644.40","5186.64","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6286.21","72.72","","2355.45","298.99","3965.19","155","1005.34","6690.77","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8644.40","5186.64","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6286.21","72.72","","3643.09","3643.09","3643.09","1 through 10","1005.34","6690.77","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8644.40","5186.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4600.55","53.22","","554.28","554.28","554.28","16","1005.34","6690.77","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8644.40","5186.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5437.33","62.9","","619.64","173.09","2370.64","150","1005.34","6690.77","percent of total billed charges",""
"PLATE ANKLE 292MM 16 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8644.40","5186.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6690.77","77.4","","303.98","303.98","5854.79","1 through 10","1005.34","6690.77","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","1273.24","763.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","148.08","1082.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","1273.24","763.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","148.08","1082.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","1273.24","763.94","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","724.47","56.9","","812.12","238.65","1587.46","163","148.08","1082.25","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","1273.24","763.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","148.08","11.63","","112.68","112.68","146.99","38","148.08","1082.25","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","1273.24","763.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","985.49","77.4","","303.98","303.98","5854.79","1 through 10","148.08","1082.25","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1273.24","763.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","148.08","11.63","","112.68","112.68","146.99","38","148.08","985.49","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1273.24","763.94","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","799.34","62.78","","780.86","208.94","10480.28","15","148.08","985.49","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1273.24","763.94","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","556.66","43.72","","179.76","179.76","179.76","1 through 10","148.08","985.49","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1273.24","763.94","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","925.90","72.72","","2355.45","298.99","3965.19","155","148.08","985.49","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1273.24","763.94","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","925.90","72.72","","3643.09","3643.09","3643.09","1 through 10","148.08","985.49","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1273.24","763.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","677.62","53.22","","554.28","554.28","554.28","16","148.08","985.49","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1273.24","763.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","800.87","62.9","","619.64","173.09","2370.64","150","148.08","985.49","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1273.24","763.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","985.49","77.4","","303.98","303.98","5854.79","1 through 10","148.08","985.49","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","both","","","5208.69","3125.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","605.77","4427.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","both","","","5208.69","3125.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","605.77","4427.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","both","","","5208.69","3125.21","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2963.74","56.9","","812.12","238.65","1587.46","163","605.77","4427.39","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","both","","","5208.69","3125.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","605.77","11.63","","112.68","112.68","146.99","38","605.77","4427.39","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","both","","","5208.69","3125.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4031.53","77.4","","303.98","303.98","5854.79","1 through 10","605.77","4427.39","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5208.69","3125.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","605.77","11.63","","112.68","112.68","146.99","38","605.77","4031.53","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5208.69","3125.21","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3270.02","62.78","","780.86","208.94","10480.28","15","605.77","4031.53","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5208.69","3125.21","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2277.24","43.72","","179.76","179.76","179.76","1 through 10","605.77","4031.53","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5208.69","3125.21","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3787.76","72.72","","2355.45","298.99","3965.19","155","605.77","4031.53","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5208.69","3125.21","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3787.76","72.72","","3643.09","3643.09","3643.09","1 through 10","605.77","4031.53","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5208.69","3125.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2772.06","53.22","","554.28","554.28","554.28","16","605.77","4031.53","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5208.69","3125.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3276.27","62.9","","619.64","173.09","2370.64","150","605.77","4031.53","percent of total billed charges",""
"PLATE ANKLE 72MM 4 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5208.69","3125.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4031.53","77.4","","303.98","303.98","5854.79","1 through 10","605.77","4031.53","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","both","","","5419.65","3251.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","630.31","4606.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","both","","","5419.65","3251.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","630.31","4606.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","both","","","5419.65","3251.79","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3083.78","56.9","","812.12","238.65","1587.46","163","630.31","4606.7","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","both","","","5419.65","3251.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","630.31","11.63","","112.68","112.68","146.99","38","630.31","4606.7","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","both","","","5419.65","3251.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4194.81","77.4","","303.98","303.98","5854.79","1 through 10","630.31","4606.7","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5419.65","3251.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","630.31","11.63","","112.68","112.68","146.99","38","630.31","4194.81","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5419.65","3251.79","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3402.46","62.78","","780.86","208.94","10480.28","15","630.31","4194.81","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5419.65","3251.79","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2369.47","43.72","","179.76","179.76","179.76","1 through 10","630.31","4194.81","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5419.65","3251.79","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3941.17","72.72","","2355.45","298.99","3965.19","155","630.31","4194.81","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5419.65","3251.79","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3941.17","72.72","","3643.09","3643.09","3643.09","1 through 10","630.31","4194.81","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5419.65","3251.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2884.34","53.22","","554.28","554.28","554.28","16","630.31","4194.81","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5419.65","3251.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3408.96","62.9","","619.64","173.09","2370.64","150","630.31","4194.81","percent of total billed charges",""
"PLATE ANKLE 90 MM6 HOLE 2.7MM VA LCP SS L SHAPE POSTEROLATERAL DISTAL TIBIA RIGHT","SUP-ITM-10124968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5419.65","3251.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4194.81","77.4","","303.98","303.98","5854.79","1 through 10","630.31","4194.81","percent of total billed charges",""
"PLATE BONE 1.2MM UPPERFACE CURVED TITANIUM 10 HOLE","SUP-ITM-10042320","CDM","C1713","HCPCS","0278","RC","","","","both","","","1517.24","910.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","176.46","1289.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 1.2MM UPPERFACE CURVED TITANIUM 10 HOLE","SUP-ITM-10042320","CDM","C1713","HCPCS","0278","RC","","","","both","","","1517.24","910.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","176.46","1289.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 1.2MM UPPERFACE CURVED TITANIUM 10 HOLE","SUP-ITM-10042320","CDM","C1713","HCPCS","0278","RC","","","","both","","","1517.24","910.34","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","863.31","56.9","","812.12","238.65","1587.46","163","176.46","1289.65","percent of total billed charges",""
"PLATE BONE 1.2MM UPPERFACE CURVED TITANIUM 10 HOLE","SUP-ITM-10042320","CDM","C1713","HCPCS","0278","RC","","","","both","","","1517.24","910.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","176.46","11.63","","112.68","112.68","146.99","38","176.46","1289.65","percent of total billed charges",""
"PLATE BONE 1.2MM UPPERFACE CURVED TITANIUM 10 HOLE","SUP-ITM-10042320","CDM","C1713","HCPCS","0278","RC","","","","both","","","1517.24","910.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1174.34","77.4","","303.98","303.98","5854.79","1 through 10","176.46","1289.65","percent of total billed charges",""
"PLATE BONE 1.2MM UPPERFACE CURVED TITANIUM 10 HOLE","SUP-ITM-10042320","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1517.24","910.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","176.46","11.63","","112.68","112.68","146.99","38","176.46","1174.34","percent of total billed charges",""
"PLATE BONE 1.2MM UPPERFACE CURVED TITANIUM 10 HOLE","SUP-ITM-10042320","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1517.24","910.34","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","952.52","62.78","","780.86","208.94","10480.28","15","176.46","1174.34","percent of total billed charges",""
"PLATE BONE 1.2MM UPPERFACE CURVED TITANIUM 10 HOLE","SUP-ITM-10042320","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1517.24","910.34","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","663.34","43.72","","179.76","179.76","179.76","1 through 10","176.46","1174.34","percent of total billed charges",""
"PLATE BONE 1.2MM UPPERFACE CURVED TITANIUM 10 HOLE","SUP-ITM-10042320","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1517.24","910.34","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1103.34","72.72","","2355.45","298.99","3965.19","155","176.46","1174.34","percent of total billed charges",""
"PLATE BONE 1.2MM UPPERFACE CURVED TITANIUM 10 HOLE","SUP-ITM-10042320","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1517.24","910.34","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1103.34","72.72","","3643.09","3643.09","3643.09","1 through 10","176.46","1174.34","percent of total billed charges",""
"PLATE BONE 1.2MM UPPERFACE CURVED TITANIUM 10 HOLE","SUP-ITM-10042320","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1517.24","910.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","807.48","53.22","","554.28","554.28","554.28","16","176.46","1174.34","percent of total billed charges",""
"PLATE BONE 1.2MM UPPERFACE CURVED TITANIUM 10 HOLE","SUP-ITM-10042320","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1517.24","910.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","954.34","62.9","","619.64","173.09","2370.64","150","176.46","1174.34","percent of total billed charges",""
"PLATE BONE 1.2MM UPPERFACE CURVED TITANIUM 10 HOLE","SUP-ITM-10042320","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1517.24","910.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1174.34","77.4","","303.98","303.98","5854.79","1 through 10","176.46","1174.34","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","both","","","2375.17","1425.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","276.23","2018.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","both","","","2375.17","1425.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","276.23","2018.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","both","","","2375.17","1425.10","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1351.47","56.9","","812.12","238.65","1587.46","163","276.23","2018.89","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","both","","","2375.17","1425.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","276.23","11.63","","112.68","112.68","146.99","38","276.23","2018.89","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","both","","","2375.17","1425.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1838.38","77.4","","303.98","303.98","5854.79","1 through 10","276.23","2018.89","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2375.17","1425.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","276.23","11.63","","112.68","112.68","146.99","38","276.23","1838.38","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2375.17","1425.10","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1491.13","62.78","","780.86","208.94","10480.28","15","276.23","1838.38","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2375.17","1425.10","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1038.42","43.72","","179.76","179.76","179.76","1 through 10","276.23","1838.38","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2375.17","1425.10","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1727.22","72.72","","2355.45","298.99","3965.19","155","276.23","1838.38","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2375.17","1425.10","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1727.22","72.72","","3643.09","3643.09","3643.09","1 through 10","276.23","1838.38","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2375.17","1425.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1264.07","53.22","","554.28","554.28","554.28","16","276.23","1838.38","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2375.17","1425.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1493.98","62.9","","619.64","173.09","2370.64","150","276.23","1838.38","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2375.17","1425.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1838.38","77.4","","303.98","303.98","5854.79","1 through 10","276.23","1838.38","percent of total billed charges",""
"PLATE BONE 1.7MM UPPERFACE ORBITAL WITH BAR TITANIUM 4 HOLE","SUP-ITM-10042321","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.09","441.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","85.49","624.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 1.7MM UPPERFACE ORBITAL WITH BAR TITANIUM 4 HOLE","SUP-ITM-10042321","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.09","441.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","85.49","624.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 1.7MM UPPERFACE ORBITAL WITH BAR TITANIUM 4 HOLE","SUP-ITM-10042321","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.09","441.05","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","418.27","56.9","","812.12","238.65","1587.46","163","85.49","624.83","percent of total billed charges",""
"PLATE BONE 1.7MM UPPERFACE ORBITAL WITH BAR TITANIUM 4 HOLE","SUP-ITM-10042321","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.09","441.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","85.49","11.63","","112.68","112.68","146.99","38","85.49","624.83","percent of total billed charges",""
"PLATE BONE 1.7MM UPPERFACE ORBITAL WITH BAR TITANIUM 4 HOLE","SUP-ITM-10042321","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.09","441.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","568.96","77.4","","303.98","303.98","5854.79","1 through 10","85.49","624.83","percent of total billed charges",""
"PLATE BONE 1.7MM UPPERFACE ORBITAL WITH BAR TITANIUM 4 HOLE","SUP-ITM-10042321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.09","441.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","85.49","11.63","","112.68","112.68","146.99","38","85.49","568.96","percent of total billed charges",""
"PLATE BONE 1.7MM UPPERFACE ORBITAL WITH BAR TITANIUM 4 HOLE","SUP-ITM-10042321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.09","441.05","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","461.49","62.78","","780.86","208.94","10480.28","15","85.49","568.96","percent of total billed charges",""
"PLATE BONE 1.7MM UPPERFACE ORBITAL WITH BAR TITANIUM 4 HOLE","SUP-ITM-10042321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.09","441.05","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","321.38","43.72","","179.76","179.76","179.76","1 through 10","85.49","568.96","percent of total billed charges",""
"PLATE BONE 1.7MM UPPERFACE ORBITAL WITH BAR TITANIUM 4 HOLE","SUP-ITM-10042321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.09","441.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","534.56","72.72","","2355.45","298.99","3965.19","155","85.49","568.96","percent of total billed charges",""
"PLATE BONE 1.7MM UPPERFACE ORBITAL WITH BAR TITANIUM 4 HOLE","SUP-ITM-10042321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.09","441.05","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","534.56","72.72","","3643.09","3643.09","3643.09","1 through 10","85.49","568.96","percent of total billed charges",""
"PLATE BONE 1.7MM UPPERFACE ORBITAL WITH BAR TITANIUM 4 HOLE","SUP-ITM-10042321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.09","441.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","391.21","53.22","","554.28","554.28","554.28","16","85.49","568.96","percent of total billed charges",""
"PLATE BONE 1.7MM UPPERFACE ORBITAL WITH BAR TITANIUM 4 HOLE","SUP-ITM-10042321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.09","441.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","462.37","62.9","","619.64","173.09","2370.64","150","85.49","568.96","percent of total billed charges",""
"PLATE BONE 1.7MM UPPERFACE ORBITAL WITH BAR TITANIUM 4 HOLE","SUP-ITM-10042321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.09","441.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","568.96","77.4","","303.98","303.98","5854.79","1 through 10","85.49","568.96","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1013.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","196.54","1436.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1013.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","196.54","1436.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1013.99","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","961.60","56.9","","812.12","238.65","1587.46","163","196.54","1436.48","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1013.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","196.54","11.63","","112.68","112.68","146.99","38","196.54","1436.48","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","1689.98","1013.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1308.04","77.4","","303.98","303.98","5854.79","1 through 10","196.54","1436.48","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1689.98","1013.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","196.54","11.63","","112.68","112.68","146.99","38","196.54","1308.04","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1689.98","1013.99","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1060.97","62.78","","780.86","208.94","10480.28","15","196.54","1308.04","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1689.98","1013.99","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","738.86","43.72","","179.76","179.76","179.76","1 through 10","196.54","1308.04","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1689.98","1013.99","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1228.95","72.72","","2355.45","298.99","3965.19","155","196.54","1308.04","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1689.98","1013.99","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1228.95","72.72","","3643.09","3643.09","3643.09","1 through 10","196.54","1308.04","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1689.98","1013.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","899.41","53.22","","554.28","554.28","554.28","16","196.54","1308.04","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1689.98","1013.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1063.00","62.9","","619.64","173.09","2370.64","150","196.54","1308.04","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1689.98","1013.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1308.04","77.4","","303.98","303.98","5854.79","1 through 10","196.54","1308.04","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","2710.10","1626.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","315.18","2303.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","2710.10","1626.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","315.18","2303.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","2710.10","1626.06","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1542.05","56.9","","812.12","238.65","1587.46","163","315.18","2303.59","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","2710.10","1626.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","315.18","11.63","","112.68","112.68","146.99","38","315.18","2303.59","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","2710.10","1626.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2097.62","77.4","","303.98","303.98","5854.79","1 through 10","315.18","2303.59","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2710.10","1626.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","315.18","11.63","","112.68","112.68","146.99","38","315.18","2097.62","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2710.10","1626.06","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1701.40","62.78","","780.86","208.94","10480.28","15","315.18","2097.62","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2710.10","1626.06","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1184.86","43.72","","179.76","179.76","179.76","1 through 10","315.18","2097.62","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2710.10","1626.06","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1970.78","72.72","","2355.45","298.99","3965.19","155","315.18","2097.62","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2710.10","1626.06","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1970.78","72.72","","3643.09","3643.09","3643.09","1 through 10","315.18","2097.62","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2710.10","1626.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1442.32","53.22","","554.28","554.28","554.28","16","315.18","2097.62","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2710.10","1626.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1704.65","62.9","","619.64","173.09","2370.64","150","315.18","2097.62","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2710.10","1626.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2097.62","77.4","","303.98","303.98","5854.79","1 through 10","315.18","2097.62","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","935.75","561.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","108.83","795.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","935.75","561.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","108.83","795.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","935.75","561.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","532.44","56.9","","812.12","238.65","1587.46","163","108.83","795.39","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","935.75","561.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","108.83","11.63","","112.68","112.68","146.99","38","108.83","795.39","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","935.75","561.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","724.27","77.4","","303.98","303.98","5854.79","1 through 10","108.83","795.39","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","935.75","561.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","108.83","11.63","","112.68","112.68","146.99","38","108.83","724.27","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","935.75","561.45","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","587.46","62.78","","780.86","208.94","10480.28","15","108.83","724.27","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","935.75","561.45","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","409.11","43.72","","179.76","179.76","179.76","1 through 10","108.83","724.27","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","935.75","561.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","680.48","72.72","","2355.45","298.99","3965.19","155","108.83","724.27","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","935.75","561.45","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","680.48","72.72","","3643.09","3643.09","3643.09","1 through 10","108.83","724.27","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","935.75","561.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","498.01","53.22","","554.28","554.28","554.28","16","108.83","724.27","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","935.75","561.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","588.59","62.9","","619.64","173.09","2370.64","150","108.83","724.27","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","935.75","561.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","724.27","77.4","","303.98","303.98","5854.79","1 through 10","108.83","724.27","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","940.87","564.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","109.42","799.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","940.87","564.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","109.42","799.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","940.87","564.52","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","535.36","56.9","","812.12","238.65","1587.46","163","109.42","799.74","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","940.87","564.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","109.42","11.63","","112.68","112.68","146.99","38","109.42","799.74","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","940.87","564.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","728.23","77.4","","303.98","303.98","5854.79","1 through 10","109.42","799.74","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","940.87","564.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","109.42","11.63","","112.68","112.68","146.99","38","109.42","728.23","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","940.87","564.52","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","590.68","62.78","","780.86","208.94","10480.28","15","109.42","728.23","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","940.87","564.52","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","411.35","43.72","","179.76","179.76","179.76","1 through 10","109.42","728.23","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","940.87","564.52","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","684.20","72.72","","2355.45","298.99","3965.19","155","109.42","728.23","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","940.87","564.52","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","684.20","72.72","","3643.09","3643.09","3643.09","1 through 10","109.42","728.23","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","940.87","564.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","500.73","53.22","","554.28","554.28","554.28","16","109.42","728.23","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","940.87","564.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","591.81","62.9","","619.64","173.09","2370.64","150","109.42","728.23","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","940.87","564.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","728.23","77.4","","303.98","303.98","5854.79","1 through 10","109.42","728.23","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","1797.36","1078.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","209.03","1527.76","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","1797.36","1078.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","209.03","1527.76","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","1797.36","1078.42","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1022.70","56.9","","812.12","238.65","1587.46","163","209.03","1527.76","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","1797.36","1078.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","209.03","11.63","","112.68","112.68","146.99","38","209.03","1527.76","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","1797.36","1078.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1391.16","77.4","","303.98","303.98","5854.79","1 through 10","209.03","1527.76","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1797.36","1078.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","209.03","11.63","","112.68","112.68","146.99","38","209.03","1391.16","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1797.36","1078.42","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1128.38","62.78","","780.86","208.94","10480.28","15","209.03","1391.16","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1797.36","1078.42","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","785.81","43.72","","179.76","179.76","179.76","1 through 10","209.03","1391.16","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1797.36","1078.42","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1307.04","72.72","","2355.45","298.99","3965.19","155","209.03","1391.16","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1797.36","1078.42","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1307.04","72.72","","3643.09","3643.09","3643.09","1 through 10","209.03","1391.16","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1797.36","1078.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","956.55","53.22","","554.28","554.28","554.28","16","209.03","1391.16","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1797.36","1078.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1130.54","62.9","","619.64","173.09","2370.64","150","209.03","1391.16","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1797.36","1078.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1391.16","77.4","","303.98","303.98","5854.79","1 through 10","209.03","1391.16","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","2252.45","1351.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","261.96","1914.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","2252.45","1351.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","261.96","1914.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","2252.45","1351.47","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1281.64","56.9","","812.12","238.65","1587.46","163","261.96","1914.58","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","2252.45","1351.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","261.96","11.63","","112.68","112.68","146.99","38","261.96","1914.58","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","2252.45","1351.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1743.40","77.4","","303.98","303.98","5854.79","1 through 10","261.96","1914.58","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2252.45","1351.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","261.96","11.63","","112.68","112.68","146.99","38","261.96","1743.4","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2252.45","1351.47","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1414.09","62.78","","780.86","208.94","10480.28","15","261.96","1743.4","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2252.45","1351.47","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","984.77","43.72","","179.76","179.76","179.76","1 through 10","261.96","1743.4","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2252.45","1351.47","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1637.98","72.72","","2355.45","298.99","3965.19","155","261.96","1743.4","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2252.45","1351.47","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1637.98","72.72","","3643.09","3643.09","3643.09","1 through 10","261.96","1743.4","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2252.45","1351.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1198.75","53.22","","554.28","554.28","554.28","16","261.96","1743.4","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2252.45","1351.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1416.79","62.9","","619.64","173.09","2370.64","150","261.96","1743.4","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2252.45","1351.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1743.40","77.4","","303.98","303.98","5854.79","1 through 10","261.96","1743.4","percent of total billed charges",""
"PLATE BONE 14 HOLE FRACTURE MANDIBLE UNIVERSAL CMF PLATING","SUP-ITM-10042351","CDM","C1713","HCPCS","0278","RC","","","","both","","","4119.13","2471.48","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","479.05","3501.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 14 HOLE FRACTURE MANDIBLE UNIVERSAL CMF PLATING","SUP-ITM-10042351","CDM","C1713","HCPCS","0278","RC","","","","both","","","4119.13","2471.48","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","479.05","3501.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 14 HOLE FRACTURE MANDIBLE UNIVERSAL CMF PLATING","SUP-ITM-10042351","CDM","C1713","HCPCS","0278","RC","","","","both","","","4119.13","2471.48","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2343.78","56.9","","812.12","238.65","1587.46","163","479.05","3501.26","percent of total billed charges",""
"PLATE BONE 14 HOLE FRACTURE MANDIBLE UNIVERSAL CMF PLATING","SUP-ITM-10042351","CDM","C1713","HCPCS","0278","RC","","","","both","","","4119.13","2471.48","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","479.05","11.63","","112.68","112.68","146.99","38","479.05","3501.26","percent of total billed charges",""
"PLATE BONE 14 HOLE FRACTURE MANDIBLE UNIVERSAL CMF PLATING","SUP-ITM-10042351","CDM","C1713","HCPCS","0278","RC","","","","both","","","4119.13","2471.48","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3188.21","77.4","","303.98","303.98","5854.79","1 through 10","479.05","3501.26","percent of total billed charges",""
"PLATE BONE 14 HOLE FRACTURE MANDIBLE UNIVERSAL CMF PLATING","SUP-ITM-10042351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4119.13","2471.48","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","479.05","11.63","","112.68","112.68","146.99","38","479.05","3188.21","percent of total billed charges",""
"PLATE BONE 14 HOLE FRACTURE MANDIBLE UNIVERSAL CMF PLATING","SUP-ITM-10042351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4119.13","2471.48","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2585.99","62.78","","780.86","208.94","10480.28","15","479.05","3188.21","percent of total billed charges",""
"PLATE BONE 14 HOLE FRACTURE MANDIBLE UNIVERSAL CMF PLATING","SUP-ITM-10042351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4119.13","2471.48","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1800.88","43.72","","179.76","179.76","179.76","1 through 10","479.05","3188.21","percent of total billed charges",""
"PLATE BONE 14 HOLE FRACTURE MANDIBLE UNIVERSAL CMF PLATING","SUP-ITM-10042351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4119.13","2471.48","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2995.43","72.72","","2355.45","298.99","3965.19","155","479.05","3188.21","percent of total billed charges",""
"PLATE BONE 14 HOLE FRACTURE MANDIBLE UNIVERSAL CMF PLATING","SUP-ITM-10042351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4119.13","2471.48","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2995.43","72.72","","3643.09","3643.09","3643.09","1 through 10","479.05","3188.21","percent of total billed charges",""
"PLATE BONE 14 HOLE FRACTURE MANDIBLE UNIVERSAL CMF PLATING","SUP-ITM-10042351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4119.13","2471.48","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2192.20","53.22","","554.28","554.28","554.28","16","479.05","3188.21","percent of total billed charges",""
"PLATE BONE 14 HOLE FRACTURE MANDIBLE UNIVERSAL CMF PLATING","SUP-ITM-10042351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4119.13","2471.48","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2590.93","62.9","","619.64","173.09","2370.64","150","479.05","3188.21","percent of total billed charges",""
"PLATE BONE 14 HOLE FRACTURE MANDIBLE UNIVERSAL CMF PLATING","SUP-ITM-10042351","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4119.13","2471.48","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3188.21","77.4","","303.98","303.98","5854.79","1 through 10","479.05","3188.21","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","958.76","575.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","111.5","814.95","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","958.76","575.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","111.5","814.95","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","958.76","575.26","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","545.53","56.9","","812.12","238.65","1587.46","163","111.5","814.95","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","958.76","575.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","111.50","11.63","","112.68","112.68","146.99","38","111.5","814.95","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","958.76","575.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","742.08","77.4","","303.98","303.98","5854.79","1 through 10","111.5","814.95","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","958.76","575.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","111.50","11.63","","112.68","112.68","146.99","38","111.5","742.08","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","958.76","575.26","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","601.91","62.78","","780.86","208.94","10480.28","15","111.5","742.08","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","958.76","575.26","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","419.17","43.72","","179.76","179.76","179.76","1 through 10","111.5","742.08","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","958.76","575.26","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","697.21","72.72","","2355.45","298.99","3965.19","155","111.5","742.08","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","958.76","575.26","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","697.21","72.72","","3643.09","3643.09","3643.09","1 through 10","111.5","742.08","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","958.76","575.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","510.25","53.22","","554.28","554.28","554.28","16","111.5","742.08","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","958.76","575.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","603.06","62.9","","619.64","173.09","2370.64","150","111.5","742.08","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","958.76","575.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","742.08","77.4","","303.98","303.98","5854.79","1 through 10","111.5","742.08","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","both","","","981.77","589.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","114.18","834.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","both","","","981.77","589.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","114.18","834.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","both","","","981.77","589.06","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","558.63","56.9","","812.12","238.65","1587.46","163","114.18","834.5","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","both","","","981.77","589.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","114.18","11.63","","112.68","112.68","146.99","38","114.18","834.5","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","both","","","981.77","589.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","759.89","77.4","","303.98","303.98","5854.79","1 through 10","114.18","834.5","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","114.18","11.63","","112.68","112.68","146.99","38","114.18","759.89","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","616.36","62.78","","780.86","208.94","10480.28","15","114.18","759.89","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","429.23","43.72","","179.76","179.76","179.76","1 through 10","114.18","759.89","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","713.94","72.72","","2355.45","298.99","3965.19","155","114.18","759.89","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","713.94","72.72","","3643.09","3643.09","3643.09","1 through 10","114.18","759.89","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","522.50","53.22","","554.28","554.28","554.28","16","114.18","759.89","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","617.53","62.9","","619.64","173.09","2370.64","150","114.18","759.89","percent of total billed charges",""
"PLATE BONE 145X3.5MM 12 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","759.89","77.4","","303.98","303.98","5854.79","1 through 10","114.18","759.89","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","both","","","19634.40","11780.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","2283.48","16689.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","both","","","19634.40","11780.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","2283.48","16689.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","both","","","19634.40","11780.64","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","11171.97","56.9","","812.12","238.65","1587.46","163","2283.48","16689.24","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","both","","","19634.40","11780.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2283.48","11.63","","112.68","112.68","146.99","38","2283.48","16689.24","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","both","","","19634.40","11780.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","15197.03","77.4","","303.98","303.98","5854.79","1 through 10","2283.48","16689.24","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19634.40","11780.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2283.48","11.63","","112.68","112.68","146.99","38","2283.48","15197.03","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19634.40","11780.64","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","12326.48","62.78","","780.86","208.94","10480.28","15","2283.48","15197.03","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19634.40","11780.64","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","8584.16","43.72","","179.76","179.76","179.76","1 through 10","2283.48","15197.03","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19634.40","11780.64","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","14278.14","72.72","","2355.45","298.99","3965.19","155","2283.48","15197.03","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19634.40","11780.64","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","14278.14","72.72","","3643.09","3643.09","3643.09","1 through 10","2283.48","15197.03","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19634.40","11780.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","10449.43","53.22","","554.28","554.28","554.28","16","2283.48","15197.03","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19634.40","11780.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","12350.04","62.9","","619.64","173.09","2370.64","150","2283.48","15197.03","percent of total billed charges",""
"PLATE BONE 2 ANATOMIC LAPIPLASTY SYSTEM TRIPLANAR","SUP-ITM-10240804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19634.40","11780.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","15197.03","77.4","","303.98","303.98","5854.79","1 through 10","2283.48","15197.03","percent of total billed charges",""
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 4 HOLE","SUP-ITM-10042348","CDM","C1713","HCPCS","0278","RC","","","","both","","","2443.65","1466.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","284.2","2077.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 4 HOLE","SUP-ITM-10042348","CDM","C1713","HCPCS","0278","RC","","","","both","","","2443.65","1466.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","284.2","2077.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 4 HOLE","SUP-ITM-10042348","CDM","C1713","HCPCS","0278","RC","","","","both","","","2443.65","1466.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1390.44","56.9","","812.12","238.65","1587.46","163","284.2","2077.1","percent of total billed charges",""
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 4 HOLE","SUP-ITM-10042348","CDM","C1713","HCPCS","0278","RC","","","","both","","","2443.65","1466.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","284.20","11.63","","112.68","112.68","146.99","38","284.2","2077.1","percent of total billed charges",""
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 4 HOLE","SUP-ITM-10042348","CDM","C1713","HCPCS","0278","RC","","","","both","","","2443.65","1466.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1891.39","77.4","","303.98","303.98","5854.79","1 through 10","284.2","2077.1","percent of total billed charges",""
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 4 HOLE","SUP-ITM-10042348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2443.65","1466.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","284.20","11.63","","112.68","112.68","146.99","38","284.2","1891.39","percent of total billed charges",""
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 4 HOLE","SUP-ITM-10042348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2443.65","1466.19","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1534.12","62.78","","780.86","208.94","10480.28","15","284.2","1891.39","percent of total billed charges",""
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 4 HOLE","SUP-ITM-10042348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2443.65","1466.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1068.36","43.72","","179.76","179.76","179.76","1 through 10","284.2","1891.39","percent of total billed charges",""
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 4 HOLE","SUP-ITM-10042348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2443.65","1466.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1777.02","72.72","","2355.45","298.99","3965.19","155","284.2","1891.39","percent of total billed charges",""
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 4 HOLE","SUP-ITM-10042348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2443.65","1466.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1777.02","72.72","","3643.09","3643.09","3643.09","1 through 10","284.2","1891.39","percent of total billed charges",""
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 4 HOLE","SUP-ITM-10042348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2443.65","1466.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1300.51","53.22","","554.28","554.28","554.28","16","284.2","1891.39","percent of total billed charges",""
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 4 HOLE","SUP-ITM-10042348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2443.65","1466.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1537.06","62.9","","619.64","173.09","2370.64","150","284.2","1891.39","percent of total billed charges",""
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 4 HOLE","SUP-ITM-10042348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2443.65","1466.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1891.39","77.4","","303.98","303.98","5854.79","1 through 10","284.2","1891.39","percent of total billed charges",""
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 6 HOLE 55-15506","SUP-ITM-10042349","CDM","C1713","HCPCS","0278","RC","","","","both","","","2863.90","1718.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","333.07","2434.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 6 HOLE 55-15506","SUP-ITM-10042349","CDM","C1713","HCPCS","0278","RC","","","","both","","","2863.90","1718.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","333.07","2434.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 6 HOLE 55-15506","SUP-ITM-10042349","CDM","C1713","HCPCS","0278","RC","","","","both","","","2863.90","1718.34","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1629.56","56.9","","812.12","238.65","1587.46","163","333.07","2434.32","percent of total billed charges",""
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 6 HOLE 55-15506","SUP-ITM-10042349","CDM","C1713","HCPCS","0278","RC","","","","both","","","2863.90","1718.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","333.07","11.63","","112.68","112.68","146.99","38","333.07","2434.32","percent of total billed charges",""
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 6 HOLE 55-15506","SUP-ITM-10042349","CDM","C1713","HCPCS","0278","RC","","","","both","","","2863.90","1718.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2216.66","77.4","","303.98","303.98","5854.79","1 through 10","333.07","2434.32","percent of total billed charges",""
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 6 HOLE 55-15506","SUP-ITM-10042349","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2863.90","1718.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","333.07","11.63","","112.68","112.68","146.99","38","333.07","2216.66","percent of total billed charges",""
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 6 HOLE 55-15506","SUP-ITM-10042349","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2863.90","1718.34","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1797.96","62.78","","780.86","208.94","10480.28","15","333.07","2216.66","percent of total billed charges",""
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 6 HOLE 55-15506","SUP-ITM-10042349","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2863.90","1718.34","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1252.10","43.72","","179.76","179.76","179.76","1 through 10","333.07","2216.66","percent of total billed charges",""
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 6 HOLE 55-15506","SUP-ITM-10042349","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2863.90","1718.34","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2082.63","72.72","","2355.45","298.99","3965.19","155","333.07","2216.66","percent of total billed charges",""
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 6 HOLE 55-15506","SUP-ITM-10042349","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2863.90","1718.34","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2082.63","72.72","","3643.09","3643.09","3643.09","1 through 10","333.07","2216.66","percent of total billed charges",""
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 6 HOLE 55-15506","SUP-ITM-10042349","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2863.90","1718.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1524.17","53.22","","554.28","554.28","554.28","16","333.07","2216.66","percent of total billed charges",""
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 6 HOLE 55-15506","SUP-ITM-10042349","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2863.90","1718.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1801.39","62.9","","619.64","173.09","2370.64","150","333.07","2216.66","percent of total billed charges",""
"PLATE BONE 2.3MM MANDIBLE WITH BAR UNIVERSAL 6 HOLE 55-15506","SUP-ITM-10042349","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2863.90","1718.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2216.66","77.4","","303.98","303.98","5854.79","1 through 10","333.07","2216.66","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","both","","","5144.08","3086.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","598.26","4372.47","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","both","","","5144.08","3086.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","598.26","4372.47","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","both","","","5144.08","3086.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2926.98","56.9","","812.12","238.65","1587.46","163","598.26","4372.47","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","both","","","5144.08","3086.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","598.26","11.63","","112.68","112.68","146.99","38","598.26","4372.47","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","both","","","5144.08","3086.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3981.52","77.4","","303.98","303.98","5854.79","1 through 10","598.26","4372.47","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5144.08","3086.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","598.26","11.63","","112.68","112.68","146.99","38","598.26","3981.52","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5144.08","3086.45","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3229.45","62.78","","780.86","208.94","10480.28","15","598.26","3981.52","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5144.08","3086.45","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2248.99","43.72","","179.76","179.76","179.76","1 through 10","598.26","3981.52","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5144.08","3086.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3740.77","72.72","","2355.45","298.99","3965.19","155","598.26","3981.52","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5144.08","3086.45","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3740.77","72.72","","3643.09","3643.09","3643.09","1 through 10","598.26","3981.52","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5144.08","3086.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2737.68","53.22","","554.28","554.28","554.28","16","598.26","3981.52","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5144.08","3086.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3235.63","62.9","","619.64","173.09","2370.64","150","598.26","3981.52","percent of total billed charges",""
"PLATE BONE 2.4/2.7X62MM LONG LCP SS COMPRESSION LOCKING VARIABLE ANGLE L FUSION RIGHT","SUP-ITM-10092003","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5144.08","3086.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3981.52","77.4","","303.98","303.98","5854.79","1 through 10","598.26","3981.52","percent of total billed charges",""
"PLATE BONE 4 HOLE MINI FRACTURE MANDIBLE UNIVERSAL CMF","SUP-ITM-10042339","CDM","C1713","HCPCS","0278","RC","","","","both","","","603.82","362.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","70.22","513.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 4 HOLE MINI FRACTURE MANDIBLE UNIVERSAL CMF","SUP-ITM-10042339","CDM","C1713","HCPCS","0278","RC","","","","both","","","603.82","362.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","70.22","513.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 4 HOLE MINI FRACTURE MANDIBLE UNIVERSAL CMF","SUP-ITM-10042339","CDM","C1713","HCPCS","0278","RC","","","","both","","","603.82","362.29","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","343.57","56.9","","812.12","238.65","1587.46","163","70.22","513.25","percent of total billed charges",""
"PLATE BONE 4 HOLE MINI FRACTURE MANDIBLE UNIVERSAL CMF","SUP-ITM-10042339","CDM","C1713","HCPCS","0278","RC","","","","both","","","603.82","362.29","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","70.22","11.63","","112.68","112.68","146.99","38","70.22","513.25","percent of total billed charges",""
"PLATE BONE 4 HOLE MINI FRACTURE MANDIBLE UNIVERSAL CMF","SUP-ITM-10042339","CDM","C1713","HCPCS","0278","RC","","","","both","","","603.82","362.29","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","467.36","77.4","","303.98","303.98","5854.79","1 through 10","70.22","513.25","percent of total billed charges",""
"PLATE BONE 4 HOLE MINI FRACTURE MANDIBLE UNIVERSAL CMF","SUP-ITM-10042339","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","603.82","362.29","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","70.22","11.63","","112.68","112.68","146.99","38","70.22","467.36","percent of total billed charges",""
"PLATE BONE 4 HOLE MINI FRACTURE MANDIBLE UNIVERSAL CMF","SUP-ITM-10042339","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","603.82","362.29","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","379.08","62.78","","780.86","208.94","10480.28","15","70.22","467.36","percent of total billed charges",""
"PLATE BONE 4 HOLE MINI FRACTURE MANDIBLE UNIVERSAL CMF","SUP-ITM-10042339","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","603.82","362.29","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","263.99","43.72","","179.76","179.76","179.76","1 through 10","70.22","467.36","percent of total billed charges",""
"PLATE BONE 4 HOLE MINI FRACTURE MANDIBLE UNIVERSAL CMF","SUP-ITM-10042339","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","603.82","362.29","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","439.10","72.72","","2355.45","298.99","3965.19","155","70.22","467.36","percent of total billed charges",""
"PLATE BONE 4 HOLE MINI FRACTURE MANDIBLE UNIVERSAL CMF","SUP-ITM-10042339","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","603.82","362.29","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","439.10","72.72","","3643.09","3643.09","3643.09","1 through 10","70.22","467.36","percent of total billed charges",""
"PLATE BONE 4 HOLE MINI FRACTURE MANDIBLE UNIVERSAL CMF","SUP-ITM-10042339","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","603.82","362.29","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","321.35","53.22","","554.28","554.28","554.28","16","70.22","467.36","percent of total billed charges",""
"PLATE BONE 4 HOLE MINI FRACTURE MANDIBLE UNIVERSAL CMF","SUP-ITM-10042339","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","603.82","362.29","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","379.80","62.9","","619.64","173.09","2370.64","150","70.22","467.36","percent of total billed charges",""
"PLATE BONE 4 HOLE MINI FRACTURE MANDIBLE UNIVERSAL CMF","SUP-ITM-10042339","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","603.82","362.29","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","467.36","77.4","","303.98","303.98","5854.79","1 through 10","70.22","467.36","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.09","1165.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","225.98","1651.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.09","1165.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","225.98","1651.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.09","1165.85","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1105.62","56.9","","812.12","238.65","1587.46","163","225.98","1651.63","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.09","1165.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","225.98","11.63","","112.68","112.68","146.99","38","225.98","1651.63","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.09","1165.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1503.95","77.4","","303.98","303.98","5854.79","1 through 10","225.98","1651.63","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1943.09","1165.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","225.98","11.63","","112.68","112.68","146.99","38","225.98","1503.95","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1943.09","1165.85","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1219.87","62.78","","780.86","208.94","10480.28","15","225.98","1503.95","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1943.09","1165.85","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","849.52","43.72","","179.76","179.76","179.76","1 through 10","225.98","1503.95","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1943.09","1165.85","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1413.02","72.72","","2355.45","298.99","3965.19","155","225.98","1503.95","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1943.09","1165.85","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1413.02","72.72","","3643.09","3643.09","3643.09","1 through 10","225.98","1503.95","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1943.09","1165.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1034.11","53.22","","554.28","554.28","554.28","16","225.98","1503.95","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1943.09","1165.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1222.20","62.9","","619.64","173.09","2370.64","150","225.98","1503.95","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1943.09","1165.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1503.95","77.4","","303.98","303.98","5854.79","1 through 10","225.98","1503.95","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.03","934.22","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","181.08","1323.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.03","934.22","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","181.08","1323.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.03","934.22","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","885.95","56.9","","812.12","238.65","1587.46","163","181.08","1323.48","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.03","934.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","181.08","11.63","","112.68","112.68","146.99","38","181.08","1323.48","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","both","","","1557.03","934.22","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1205.14","77.4","","303.98","303.98","5854.79","1 through 10","181.08","1323.48","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.03","934.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","181.08","11.63","","112.68","112.68","146.99","38","181.08","1205.14","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.03","934.22","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","977.50","62.78","","780.86","208.94","10480.28","15","181.08","1205.14","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.03","934.22","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","680.73","43.72","","179.76","179.76","179.76","1 through 10","181.08","1205.14","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.03","934.22","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1132.27","72.72","","2355.45","298.99","3965.19","155","181.08","1205.14","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.03","934.22","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1132.27","72.72","","3643.09","3643.09","3643.09","1 through 10","181.08","1205.14","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.03","934.22","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","828.65","53.22","","554.28","554.28","554.28","16","181.08","1205.14","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.03","934.22","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","979.37","62.9","","619.64","173.09","2370.64","150","181.08","1205.14","percent of total billed charges",""
"PLATE BONE 64X3.5MM 5 HOLE COMPRESSION LC DCP SS","SUP-ITM-10006736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1557.03","934.22","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1205.14","77.4","","303.98","303.98","5854.79","1 through 10","181.08","1205.14","percent of total billed charges",""
"PLATE BONE LEFT RADIAL PROTEAN COLUMN FRAGMENT","SUP-ITM-10266661","CDM","C1713","HCPCS","0278","RC","","","","both","","","5262.25","3157.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","612","4472.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE LEFT RADIAL PROTEAN COLUMN FRAGMENT","SUP-ITM-10266661","CDM","C1713","HCPCS","0278","RC","","","","both","","","5262.25","3157.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","612","4472.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE LEFT RADIAL PROTEAN COLUMN FRAGMENT","SUP-ITM-10266661","CDM","C1713","HCPCS","0278","RC","","","","both","","","5262.25","3157.35","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2994.22","56.9","","812.12","238.65","1587.46","163","612","4472.91","percent of total billed charges",""
"PLATE BONE LEFT RADIAL PROTEAN COLUMN FRAGMENT","SUP-ITM-10266661","CDM","C1713","HCPCS","0278","RC","","","","both","","","5262.25","3157.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","612.00","11.63","","112.68","112.68","146.99","38","612","4472.91","percent of total billed charges",""
"PLATE BONE LEFT RADIAL PROTEAN COLUMN FRAGMENT","SUP-ITM-10266661","CDM","C1713","HCPCS","0278","RC","","","","both","","","5262.25","3157.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4072.98","77.4","","303.98","303.98","5854.79","1 through 10","612","4472.91","percent of total billed charges",""
"PLATE BONE LEFT RADIAL PROTEAN COLUMN FRAGMENT","SUP-ITM-10266661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5262.25","3157.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","612.00","11.63","","112.68","112.68","146.99","38","612","4072.98","percent of total billed charges",""
"PLATE BONE LEFT RADIAL PROTEAN COLUMN FRAGMENT","SUP-ITM-10266661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5262.25","3157.35","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3303.64","62.78","","780.86","208.94","10480.28","15","612","4072.98","percent of total billed charges",""
"PLATE BONE LEFT RADIAL PROTEAN COLUMN FRAGMENT","SUP-ITM-10266661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5262.25","3157.35","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2300.66","43.72","","179.76","179.76","179.76","1 through 10","612","4072.98","percent of total billed charges",""
"PLATE BONE LEFT RADIAL PROTEAN COLUMN FRAGMENT","SUP-ITM-10266661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5262.25","3157.35","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3826.71","72.72","","2355.45","298.99","3965.19","155","612","4072.98","percent of total billed charges",""
"PLATE BONE LEFT RADIAL PROTEAN COLUMN FRAGMENT","SUP-ITM-10266661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5262.25","3157.35","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3826.71","72.72","","3643.09","3643.09","3643.09","1 through 10","612","4072.98","percent of total billed charges",""
"PLATE BONE LEFT RADIAL PROTEAN COLUMN FRAGMENT","SUP-ITM-10266661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5262.25","3157.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2800.57","53.22","","554.28","554.28","554.28","16","612","4072.98","percent of total billed charges",""
"PLATE BONE LEFT RADIAL PROTEAN COLUMN FRAGMENT","SUP-ITM-10266661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5262.25","3157.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3309.96","62.9","","619.64","173.09","2370.64","150","612","4072.98","percent of total billed charges",""
"PLATE BONE LEFT RADIAL PROTEAN COLUMN FRAGMENT","SUP-ITM-10266661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5262.25","3157.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4072.98","77.4","","303.98","303.98","5854.79","1 through 10","612","4072.98","percent of total billed charges",""
"PLATE BONE MIDFOOT STAINLESS STEEL 2 HOLE","SUP-ITM-10267719","CDM","C1713","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","642.91","4698.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE MIDFOOT STAINLESS STEEL 2 HOLE","SUP-ITM-10267719","CDM","C1713","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","642.91","4698.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE BONE MIDFOOT STAINLESS STEEL 2 HOLE","SUP-ITM-10267719","CDM","C1713","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3145.43","56.9","","812.12","238.65","1587.46","163","642.91","4698.8","percent of total billed charges",""
"PLATE BONE MIDFOOT STAINLESS STEEL 2 HOLE","SUP-ITM-10267719","CDM","C1713","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","642.91","11.63","","112.68","112.68","146.99","38","642.91","4698.8","percent of total billed charges",""
"PLATE BONE MIDFOOT STAINLESS STEEL 2 HOLE","SUP-ITM-10267719","CDM","C1713","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4278.67","77.4","","303.98","303.98","5854.79","1 through 10","642.91","4698.8","percent of total billed charges",""
"PLATE BONE MIDFOOT STAINLESS STEEL 2 HOLE","SUP-ITM-10267719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","642.91","11.63","","112.68","112.68","146.99","38","642.91","4278.67","percent of total billed charges",""
"PLATE BONE MIDFOOT STAINLESS STEEL 2 HOLE","SUP-ITM-10267719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3470.48","62.78","","780.86","208.94","10480.28","15","642.91","4278.67","percent of total billed charges",""
"PLATE BONE MIDFOOT STAINLESS STEEL 2 HOLE","SUP-ITM-10267719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2416.84","43.72","","179.76","179.76","179.76","1 through 10","642.91","4278.67","percent of total billed charges",""
"PLATE BONE MIDFOOT STAINLESS STEEL 2 HOLE","SUP-ITM-10267719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4019.96","72.72","","2355.45","298.99","3965.19","155","642.91","4278.67","percent of total billed charges",""
"PLATE BONE MIDFOOT STAINLESS STEEL 2 HOLE","SUP-ITM-10267719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4019.96","72.72","","3643.09","3643.09","3643.09","1 through 10","642.91","4278.67","percent of total billed charges",""
"PLATE BONE MIDFOOT STAINLESS STEEL 2 HOLE","SUP-ITM-10267719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2942.00","53.22","","554.28","554.28","554.28","16","642.91","4278.67","percent of total billed charges",""
"PLATE BONE MIDFOOT STAINLESS STEEL 2 HOLE","SUP-ITM-10267719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3477.11","62.9","","619.64","173.09","2370.64","150","642.91","4278.67","percent of total billed charges",""
"PLATE BONE MIDFOOT STAINLESS STEEL 2 HOLE","SUP-ITM-10267719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4278.67","77.4","","303.98","303.98","5854.79","1 through 10","642.91","4278.67","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","both","","","5481.56","3288.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","637.51","4659.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","both","","","5481.56","3288.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","637.51","4659.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","both","","","5481.56","3288.94","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3119.01","56.9","","812.12","238.65","1587.46","163","637.51","4659.33","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","both","","","5481.56","3288.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","637.51","11.63","","112.68","112.68","146.99","38","637.51","4659.33","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","both","","","5481.56","3288.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4242.73","77.4","","303.98","303.98","5854.79","1 through 10","637.51","4659.33","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5481.56","3288.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","637.51","11.63","","112.68","112.68","146.99","38","637.51","4242.73","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5481.56","3288.94","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3441.32","62.78","","780.86","208.94","10480.28","15","637.51","4242.73","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5481.56","3288.94","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2396.54","43.72","","179.76","179.76","179.76","1 through 10","637.51","4242.73","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5481.56","3288.94","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3986.19","72.72","","2355.45","298.99","3965.19","155","637.51","4242.73","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5481.56","3288.94","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3986.19","72.72","","3643.09","3643.09","3643.09","1 through 10","637.51","4242.73","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5481.56","3288.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2917.29","53.22","","554.28","554.28","554.28","16","637.51","4242.73","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5481.56","3288.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3447.90","62.9","","619.64","173.09","2370.64","150","637.51","4242.73","percent of total billed charges",""
"PLATE CALCANEAL 1.2X70MM UNIVERSAL DCP SS","SUP-ITM-10003838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5481.56","3288.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4242.73","77.4","","303.98","303.98","5854.79","1 through 10","637.51","4242.73","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING LEFT","SUP-ITM-10164579","CDM","C1713","HCPCS","0278","RC","","","","both","","","4811.71","2887.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","559.6","4089.95","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING LEFT","SUP-ITM-10164579","CDM","C1713","HCPCS","0278","RC","","","","both","","","4811.71","2887.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","559.6","4089.95","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING LEFT","SUP-ITM-10164579","CDM","C1713","HCPCS","0278","RC","","","","both","","","4811.71","2887.03","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2737.86","56.9","","812.12","238.65","1587.46","163","559.6","4089.95","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING LEFT","SUP-ITM-10164579","CDM","C1713","HCPCS","0278","RC","","","","both","","","4811.71","2887.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","559.60","11.63","","112.68","112.68","146.99","38","559.6","4089.95","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING LEFT","SUP-ITM-10164579","CDM","C1713","HCPCS","0278","RC","","","","both","","","4811.71","2887.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3724.26","77.4","","303.98","303.98","5854.79","1 through 10","559.6","4089.95","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING LEFT","SUP-ITM-10164579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4811.71","2887.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","559.60","11.63","","112.68","112.68","146.99","38","559.6","3724.26","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING LEFT","SUP-ITM-10164579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4811.71","2887.03","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3020.79","62.78","","780.86","208.94","10480.28","15","559.6","3724.26","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING LEFT","SUP-ITM-10164579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4811.71","2887.03","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2103.68","43.72","","179.76","179.76","179.76","1 through 10","559.6","3724.26","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING LEFT","SUP-ITM-10164579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4811.71","2887.03","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3499.08","72.72","","2355.45","298.99","3965.19","155","559.6","3724.26","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING LEFT","SUP-ITM-10164579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4811.71","2887.03","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3499.08","72.72","","3643.09","3643.09","3643.09","1 through 10","559.6","3724.26","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING LEFT","SUP-ITM-10164579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4811.71","2887.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2560.79","53.22","","554.28","554.28","554.28","16","559.6","3724.26","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING LEFT","SUP-ITM-10164579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4811.71","2887.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3026.57","62.9","","619.64","173.09","2370.64","150","559.6","3724.26","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING LEFT","SUP-ITM-10164579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4811.71","2887.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3724.26","77.4","","303.98","303.98","5854.79","1 through 10","559.6","3724.26","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING TAB LEFT","SUP-ITM-10164575","CDM","C1713","HCPCS","0278","RC","","","","both","","","5115.96","3069.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","594.99","4348.57","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING TAB LEFT","SUP-ITM-10164575","CDM","C1713","HCPCS","0278","RC","","","","both","","","5115.96","3069.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","594.99","4348.57","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING TAB LEFT","SUP-ITM-10164575","CDM","C1713","HCPCS","0278","RC","","","","both","","","5115.96","3069.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2910.98","56.9","","812.12","238.65","1587.46","163","594.99","4348.57","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING TAB LEFT","SUP-ITM-10164575","CDM","C1713","HCPCS","0278","RC","","","","both","","","5115.96","3069.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","594.99","11.63","","112.68","112.68","146.99","38","594.99","4348.57","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING TAB LEFT","SUP-ITM-10164575","CDM","C1713","HCPCS","0278","RC","","","","both","","","5115.96","3069.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3959.75","77.4","","303.98","303.98","5854.79","1 through 10","594.99","4348.57","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING TAB LEFT","SUP-ITM-10164575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5115.96","3069.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","594.99","11.63","","112.68","112.68","146.99","38","594.99","3959.75","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING TAB LEFT","SUP-ITM-10164575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5115.96","3069.58","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3211.80","62.78","","780.86","208.94","10480.28","15","594.99","3959.75","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING TAB LEFT","SUP-ITM-10164575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5115.96","3069.58","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2236.70","43.72","","179.76","179.76","179.76","1 through 10","594.99","3959.75","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING TAB LEFT","SUP-ITM-10164575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5115.96","3069.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3720.33","72.72","","2355.45","298.99","3965.19","155","594.99","3959.75","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING TAB LEFT","SUP-ITM-10164575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5115.96","3069.58","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3720.33","72.72","","3643.09","3643.09","3643.09","1 through 10","594.99","3959.75","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING TAB LEFT","SUP-ITM-10164575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5115.96","3069.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2722.71","53.22","","554.28","554.28","554.28","16","594.99","3959.75","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING TAB LEFT","SUP-ITM-10164575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5115.96","3069.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3217.94","62.9","","619.64","173.09","2370.64","150","594.99","3959.75","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP LOCKING TAB LEFT","SUP-ITM-10164575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5115.96","3069.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3959.75","77.4","","303.98","303.98","5854.79","1 through 10","594.99","3959.75","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP SS RIGHT","SUP-ITM-10164580","CDM","C1713","HCPCS","0278","RC","","","","both","","","4811.71","2887.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","559.6","4089.95","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CALCANEAL 2.7X64MM MED VA LCP SS RIGHT","SUP-ITM-10164580","CDM","C1713","HCPCS","0278","RC","","","","both","","","4811.71","2887.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","559.6","4089.95","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CALCANEAL 2.7X64MM MED VA LCP SS RIGHT","SUP-ITM-10164580","CDM","C1713","HCPCS","0278","RC","","","","both","","","4811.71","2887.03","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2737.86","56.9","","812.12","238.65","1587.46","163","559.6","4089.95","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP SS RIGHT","SUP-ITM-10164580","CDM","C1713","HCPCS","0278","RC","","","","both","","","4811.71","2887.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","559.60","11.63","","112.68","112.68","146.99","38","559.6","4089.95","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP SS RIGHT","SUP-ITM-10164580","CDM","C1713","HCPCS","0278","RC","","","","both","","","4811.71","2887.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3724.26","77.4","","303.98","303.98","5854.79","1 through 10","559.6","4089.95","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP SS RIGHT","SUP-ITM-10164580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4811.71","2887.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","559.60","11.63","","112.68","112.68","146.99","38","559.6","3724.26","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP SS RIGHT","SUP-ITM-10164580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4811.71","2887.03","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3020.79","62.78","","780.86","208.94","10480.28","15","559.6","3724.26","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP SS RIGHT","SUP-ITM-10164580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4811.71","2887.03","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2103.68","43.72","","179.76","179.76","179.76","1 through 10","559.6","3724.26","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP SS RIGHT","SUP-ITM-10164580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4811.71","2887.03","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3499.08","72.72","","2355.45","298.99","3965.19","155","559.6","3724.26","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP SS RIGHT","SUP-ITM-10164580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4811.71","2887.03","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3499.08","72.72","","3643.09","3643.09","3643.09","1 through 10","559.6","3724.26","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP SS RIGHT","SUP-ITM-10164580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4811.71","2887.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2560.79","53.22","","554.28","554.28","554.28","16","559.6","3724.26","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP SS RIGHT","SUP-ITM-10164580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4811.71","2887.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3026.57","62.9","","619.64","173.09","2370.64","150","559.6","3724.26","percent of total billed charges",""
"PLATE CALCANEAL 2.7X64MM MED VA LCP SS RIGHT","SUP-ITM-10164580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4811.71","2887.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3724.26","77.4","","303.98","303.98","5854.79","1 through 10","559.6","3724.26","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP LOCKING TAB RIGHT","SUP-ITM-10164574","CDM","C1713","HCPCS","0278","RC","","","","both","","","5115.96","3069.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","594.99","4348.57","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CALCANEAL 2.7X70MM LG VA LCP LOCKING TAB RIGHT","SUP-ITM-10164574","CDM","C1713","HCPCS","0278","RC","","","","both","","","5115.96","3069.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","594.99","4348.57","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CALCANEAL 2.7X70MM LG VA LCP LOCKING TAB RIGHT","SUP-ITM-10164574","CDM","C1713","HCPCS","0278","RC","","","","both","","","5115.96","3069.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2910.98","56.9","","812.12","238.65","1587.46","163","594.99","4348.57","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP LOCKING TAB RIGHT","SUP-ITM-10164574","CDM","C1713","HCPCS","0278","RC","","","","both","","","5115.96","3069.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","594.99","11.63","","112.68","112.68","146.99","38","594.99","4348.57","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP LOCKING TAB RIGHT","SUP-ITM-10164574","CDM","C1713","HCPCS","0278","RC","","","","both","","","5115.96","3069.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3959.75","77.4","","303.98","303.98","5854.79","1 through 10","594.99","4348.57","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP LOCKING TAB RIGHT","SUP-ITM-10164574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5115.96","3069.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","594.99","11.63","","112.68","112.68","146.99","38","594.99","3959.75","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP LOCKING TAB RIGHT","SUP-ITM-10164574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5115.96","3069.58","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3211.80","62.78","","780.86","208.94","10480.28","15","594.99","3959.75","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP LOCKING TAB RIGHT","SUP-ITM-10164574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5115.96","3069.58","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2236.70","43.72","","179.76","179.76","179.76","1 through 10","594.99","3959.75","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP LOCKING TAB RIGHT","SUP-ITM-10164574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5115.96","3069.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3720.33","72.72","","2355.45","298.99","3965.19","155","594.99","3959.75","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP LOCKING TAB RIGHT","SUP-ITM-10164574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5115.96","3069.58","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3720.33","72.72","","3643.09","3643.09","3643.09","1 through 10","594.99","3959.75","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP LOCKING TAB RIGHT","SUP-ITM-10164574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5115.96","3069.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2722.71","53.22","","554.28","554.28","554.28","16","594.99","3959.75","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP LOCKING TAB RIGHT","SUP-ITM-10164574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5115.96","3069.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3217.94","62.9","","619.64","173.09","2370.64","150","594.99","3959.75","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP LOCKING TAB RIGHT","SUP-ITM-10164574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5115.96","3069.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3959.75","77.4","","303.98","303.98","5854.79","1 through 10","594.99","3959.75","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","both","","","4847.50","2908.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","563.76","4120.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","both","","","4847.50","2908.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","563.76","4120.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","both","","","4847.50","2908.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2758.23","56.9","","812.12","238.65","1587.46","163","563.76","4120.38","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","both","","","4847.50","2908.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","563.76","11.63","","112.68","112.68","146.99","38","563.76","4120.38","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","both","","","4847.50","2908.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3751.97","77.4","","303.98","303.98","5854.79","1 through 10","563.76","4120.38","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4847.50","2908.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","563.76","11.63","","112.68","112.68","146.99","38","563.76","3751.97","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4847.50","2908.50","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3043.26","62.78","","780.86","208.94","10480.28","15","563.76","3751.97","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4847.50","2908.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2119.33","43.72","","179.76","179.76","179.76","1 through 10","563.76","3751.97","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4847.50","2908.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3525.10","72.72","","2355.45","298.99","3965.19","155","563.76","3751.97","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4847.50","2908.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3525.10","72.72","","3643.09","3643.09","3643.09","1 through 10","563.76","3751.97","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4847.50","2908.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2579.84","53.22","","554.28","554.28","554.28","16","563.76","3751.97","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4847.50","2908.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3049.08","62.9","","619.64","173.09","2370.64","150","563.76","3751.97","percent of total billed charges",""
"PLATE CALCANEAL 2.7X70MM LG VA LCP SS VARIABLE ANGLE LOCKING LEFT","SUP-ITM-10164577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4847.50","2908.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3751.97","77.4","","303.98","303.98","5854.79","1 through 10","563.76","3751.97","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","both","","","5445.77","3267.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","633.34","4628.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","both","","","5445.77","3267.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","633.34","4628.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","both","","","5445.77","3267.46","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3098.64","56.9","","812.12","238.65","1587.46","163","633.34","4628.9","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","both","","","5445.77","3267.46","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","633.34","11.63","","112.68","112.68","146.99","38","633.34","4628.9","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","both","","","5445.77","3267.46","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4215.03","77.4","","303.98","303.98","5854.79","1 through 10","633.34","4628.9","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5445.77","3267.46","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","633.34","11.63","","112.68","112.68","146.99","38","633.34","4215.03","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5445.77","3267.46","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3418.85","62.78","","780.86","208.94","10480.28","15","633.34","4215.03","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5445.77","3267.46","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2380.89","43.72","","179.76","179.76","179.76","1 through 10","633.34","4215.03","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5445.77","3267.46","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3960.16","72.72","","2355.45","298.99","3965.19","155","633.34","4215.03","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5445.77","3267.46","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3960.16","72.72","","3643.09","3643.09","3643.09","1 through 10","633.34","4215.03","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5445.77","3267.46","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2898.24","53.22","","554.28","554.28","554.28","16","633.34","4215.03","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5445.77","3267.46","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3425.39","62.9","","619.64","173.09","2370.64","150","633.34","4215.03","percent of total billed charges",""
"PLATE CALCANEAL 60MM LCP SS LOCKING MINI","SUP-ITM-10003839","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5445.77","3267.46","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4215.03","77.4","","303.98","303.98","5854.79","1 through 10","633.34","4215.03","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","both","","","5525.03","3315.02","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","642.56","4696.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","both","","","5525.03","3315.02","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","642.56","4696.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","both","","","5525.03","3315.02","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3143.74","56.9","","812.12","238.65","1587.46","163","642.56","4696.28","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","both","","","5525.03","3315.02","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","642.56","11.63","","112.68","112.68","146.99","38","642.56","4696.28","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","both","","","5525.03","3315.02","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4276.37","77.4","","303.98","303.98","5854.79","1 through 10","642.56","4696.28","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5525.03","3315.02","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","642.56","11.63","","112.68","112.68","146.99","38","642.56","4276.37","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5525.03","3315.02","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3468.61","62.78","","780.86","208.94","10480.28","15","642.56","4276.37","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5525.03","3315.02","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2415.54","43.72","","179.76","179.76","179.76","1 through 10","642.56","4276.37","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5525.03","3315.02","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4017.80","72.72","","2355.45","298.99","3965.19","155","642.56","4276.37","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5525.03","3315.02","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4017.80","72.72","","3643.09","3643.09","3643.09","1 through 10","642.56","4276.37","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5525.03","3315.02","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2940.42","53.22","","554.28","554.28","554.28","16","642.56","4276.37","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5525.03","3315.02","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3475.24","62.9","","619.64","173.09","2370.64","150","642.56","4276.37","percent of total billed charges",""
"PLATE CALCANEAL 87MM LCP SS Y SHAPE","SUP-ITM-10003837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5525.03","3315.02","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4276.37","77.4","","303.98","303.98","5854.79","1 through 10","642.56","4276.37","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","5621.70","3373.02","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","653.8","4778.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","5621.70","3373.02","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","653.8","4778.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","5621.70","3373.02","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3198.75","56.9","","812.12","238.65","1587.46","163","653.8","4778.45","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","5621.70","3373.02","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","653.80","11.63","","112.68","112.68","146.99","38","653.8","4778.45","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","5621.70","3373.02","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4351.20","77.4","","303.98","303.98","5854.79","1 through 10","653.8","4778.45","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5621.70","3373.02","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","653.80","11.63","","112.68","112.68","146.99","38","653.8","4351.2","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5621.70","3373.02","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3529.30","62.78","","780.86","208.94","10480.28","15","653.8","4351.2","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5621.70","3373.02","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2457.81","43.72","","179.76","179.76","179.76","1 through 10","653.8","4351.2","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5621.70","3373.02","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4088.10","72.72","","2355.45","298.99","3965.19","155","653.8","4351.2","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5621.70","3373.02","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4088.10","72.72","","3643.09","3643.09","3643.09","1 through 10","653.8","4351.2","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5621.70","3373.02","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2991.87","53.22","","554.28","554.28","554.28","16","653.8","4351.2","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5621.70","3373.02","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3536.05","62.9","","619.64","173.09","2370.64","150","653.8","4351.2","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5621.70","3373.02","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4351.20","77.4","","303.98","303.98","5854.79","1 through 10","653.8","4351.2","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","both","","","5254.02","3152.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","611.04","4465.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","both","","","5254.02","3152.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","611.04","4465.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","both","","","5254.02","3152.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2989.54","56.9","","0.63","0.63","0.63","1 through 10","611.04","4465.92","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","both","","","5254.02","3152.41","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","757.63","14.42","","317.14","317.14","317.14","1 through 10","611.04","4465.92","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5254.02","3152.41","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","757.63","14.42","","317.14","317.14","317.14","1 through 10","611.04","4066.61","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5254.02","3152.41","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3298.47","62.78","","1125.09","1125.09","1125.09","1 through 10","611.04","4066.61","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5254.02","3152.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3820.72","72.72","","4732.50","1617.43","14180.40","1 through 10","611.04","4066.61","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5254.02","3152.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3304.78","62.9","","3896.20","3341.38","3896.20","1 through 10","611.04","4066.61","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","5254.02","3152.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","611.04","4465.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","5254.02","3152.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","611.04","4465.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","5254.02","3152.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2989.54","56.9","","812.12","238.65","1587.46","163","611.04","4465.92","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","5254.02","3152.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","611.04","11.63","","112.68","112.68","146.99","38","611.04","4465.92","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","5254.02","3152.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4066.61","77.4","","303.98","303.98","5854.79","1 through 10","611.04","4465.92","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.02","3152.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","611.04","11.63","","112.68","112.68","146.99","38","611.04","4066.61","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.02","3152.41","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3298.47","62.78","","780.86","208.94","10480.28","15","611.04","4066.61","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.02","3152.41","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2297.06","43.72","","179.76","179.76","179.76","1 through 10","611.04","4066.61","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.02","3152.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3820.72","72.72","","2355.45","298.99","3965.19","155","611.04","4066.61","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.02","3152.41","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3820.72","72.72","","3643.09","3643.09","3643.09","1 through 10","611.04","4066.61","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.02","3152.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2796.19","53.22","","554.28","554.28","554.28","16","611.04","4066.61","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.02","3152.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3304.78","62.9","","619.64","173.09","2370.64","150","611.04","4066.61","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5254.02","3152.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4066.61","77.4","","303.98","303.98","5854.79","1 through 10","611.04","4066.61","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","5389.52","3233.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","626.8","4581.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","5389.52","3233.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","626.8","4581.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","5389.52","3233.71","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3066.64","56.9","","812.12","238.65","1587.46","163","626.8","4581.09","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","5389.52","3233.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","626.80","11.63","","112.68","112.68","146.99","38","626.8","4581.09","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","5389.52","3233.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4171.49","77.4","","303.98","303.98","5854.79","1 through 10","626.8","4581.09","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5389.52","3233.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","626.80","11.63","","112.68","112.68","146.99","38","626.8","4171.49","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5389.52","3233.71","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3383.54","62.78","","780.86","208.94","10480.28","15","626.8","4171.49","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5389.52","3233.71","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2356.30","43.72","","179.76","179.76","179.76","1 through 10","626.8","4171.49","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5389.52","3233.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3919.26","72.72","","2355.45","298.99","3965.19","155","626.8","4171.49","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5389.52","3233.71","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3919.26","72.72","","3643.09","3643.09","3643.09","1 through 10","626.8","4171.49","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5389.52","3233.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2868.30","53.22","","554.28","554.28","554.28","16","626.8","4171.49","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5389.52","3233.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3390.01","62.9","","619.64","173.09","2370.64","150","626.8","4171.49","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5389.52","3233.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4171.49","77.4","","303.98","303.98","5854.79","1 through 10","626.8","4171.49","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","5532.70","3319.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","643.45","4702.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","5532.70","3319.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","643.45","4702.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","5532.70","3319.62","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3148.11","56.9","","812.12","238.65","1587.46","163","643.45","4702.8","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","5532.70","3319.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","643.45","11.63","","112.68","112.68","146.99","38","643.45","4702.8","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","5532.70","3319.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4282.31","77.4","","303.98","303.98","5854.79","1 through 10","643.45","4702.8","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5532.70","3319.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","643.45","11.63","","112.68","112.68","146.99","38","643.45","4282.31","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5532.70","3319.62","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3473.43","62.78","","780.86","208.94","10480.28","15","643.45","4282.31","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5532.70","3319.62","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2418.90","43.72","","179.76","179.76","179.76","1 through 10","643.45","4282.31","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5532.70","3319.62","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4023.38","72.72","","2355.45","298.99","3965.19","155","643.45","4282.31","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5532.70","3319.62","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4023.38","72.72","","3643.09","3643.09","3643.09","1 through 10","643.45","4282.31","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5532.70","3319.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2944.50","53.22","","554.28","554.28","554.28","16","643.45","4282.31","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5532.70","3319.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3480.07","62.9","","619.64","173.09","2370.64","150","643.45","4282.31","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5532.70","3319.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4282.31","77.4","","303.98","303.98","5854.79","1 through 10","643.45","4282.31","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","5029.03","3017.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","584.88","4274.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","5029.03","3017.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","584.88","4274.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","5029.03","3017.42","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2861.52","56.9","","812.12","238.65","1587.46","163","584.88","4274.68","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","5029.03","3017.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","584.88","11.63","","112.68","112.68","146.99","38","584.88","4274.68","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","5029.03","3017.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3892.47","77.4","","303.98","303.98","5854.79","1 through 10","584.88","4274.68","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5029.03","3017.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","584.88","11.63","","112.68","112.68","146.99","38","584.88","3892.47","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5029.03","3017.42","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3157.23","62.78","","780.86","208.94","10480.28","15","584.88","3892.47","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5029.03","3017.42","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2198.69","43.72","","179.76","179.76","179.76","1 through 10","584.88","3892.47","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5029.03","3017.42","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3657.11","72.72","","2355.45","298.99","3965.19","155","584.88","3892.47","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5029.03","3017.42","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3657.11","72.72","","3643.09","3643.09","3643.09","1 through 10","584.88","3892.47","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5029.03","3017.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2676.45","53.22","","554.28","554.28","554.28","16","584.88","3892.47","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5029.03","3017.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3163.26","62.9","","619.64","173.09","2370.64","150","584.88","3892.47","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5029.03","3017.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3892.47","77.4","","303.98","303.98","5854.79","1 through 10","584.88","3892.47","percent of total billed charges",""
"PLATE CLAVICLE 3.5X79MM 6 HOLE LCP STAINLESS STEEL MEDIAL ANTERIOR","SUP-ITM-10095077","CDM","C1713","HCPCS","0278","RC","","","","both","","","5532.70","3319.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","643.45","4702.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CLAVICLE 3.5X79MM 6 HOLE LCP STAINLESS STEEL MEDIAL ANTERIOR","SUP-ITM-10095077","CDM","C1713","HCPCS","0278","RC","","","","both","","","5532.70","3319.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","643.45","4702.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CLAVICLE 3.5X79MM 6 HOLE LCP STAINLESS STEEL MEDIAL ANTERIOR","SUP-ITM-10095077","CDM","C1713","HCPCS","0278","RC","","","","both","","","5532.70","3319.62","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3148.11","56.9","","812.12","238.65","1587.46","163","643.45","4702.8","percent of total billed charges",""
"PLATE CLAVICLE 3.5X79MM 6 HOLE LCP STAINLESS STEEL MEDIAL ANTERIOR","SUP-ITM-10095077","CDM","C1713","HCPCS","0278","RC","","","","both","","","5532.70","3319.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","643.45","11.63","","112.68","112.68","146.99","38","643.45","4702.8","percent of total billed charges",""
"PLATE CLAVICLE 3.5X79MM 6 HOLE LCP STAINLESS STEEL MEDIAL ANTERIOR","SUP-ITM-10095077","CDM","C1713","HCPCS","0278","RC","","","","both","","","5532.70","3319.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4282.31","77.4","","303.98","303.98","5854.79","1 through 10","643.45","4702.8","percent of total billed charges",""
"PLATE CLAVICLE 3.5X79MM 6 HOLE LCP STAINLESS STEEL MEDIAL ANTERIOR","SUP-ITM-10095077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5532.70","3319.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","643.45","11.63","","112.68","112.68","146.99","38","643.45","4282.31","percent of total billed charges",""
"PLATE CLAVICLE 3.5X79MM 6 HOLE LCP STAINLESS STEEL MEDIAL ANTERIOR","SUP-ITM-10095077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5532.70","3319.62","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3473.43","62.78","","780.86","208.94","10480.28","15","643.45","4282.31","percent of total billed charges",""
"PLATE CLAVICLE 3.5X79MM 6 HOLE LCP STAINLESS STEEL MEDIAL ANTERIOR","SUP-ITM-10095077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5532.70","3319.62","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2418.90","43.72","","179.76","179.76","179.76","1 through 10","643.45","4282.31","percent of total billed charges",""
"PLATE CLAVICLE 3.5X79MM 6 HOLE LCP STAINLESS STEEL MEDIAL ANTERIOR","SUP-ITM-10095077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5532.70","3319.62","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4023.38","72.72","","2355.45","298.99","3965.19","155","643.45","4282.31","percent of total billed charges",""
"PLATE CLAVICLE 3.5X79MM 6 HOLE LCP STAINLESS STEEL MEDIAL ANTERIOR","SUP-ITM-10095077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5532.70","3319.62","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4023.38","72.72","","3643.09","3643.09","3643.09","1 through 10","643.45","4282.31","percent of total billed charges",""
"PLATE CLAVICLE 3.5X79MM 6 HOLE LCP STAINLESS STEEL MEDIAL ANTERIOR","SUP-ITM-10095077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5532.70","3319.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2944.50","53.22","","554.28","554.28","554.28","16","643.45","4282.31","percent of total billed charges",""
"PLATE CLAVICLE 3.5X79MM 6 HOLE LCP STAINLESS STEEL MEDIAL ANTERIOR","SUP-ITM-10095077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5532.70","3319.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3480.07","62.9","","619.64","173.09","2370.64","150","643.45","4282.31","percent of total billed charges",""
"PLATE CLAVICLE 3.5X79MM 6 HOLE LCP STAINLESS STEEL MEDIAL ANTERIOR","SUP-ITM-10095077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5532.70","3319.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4282.31","77.4","","303.98","303.98","5854.79","1 through 10","643.45","4282.31","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","5108.29","3064.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","594.09","4342.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","5108.29","3064.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","594.09","4342.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","5108.29","3064.97","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2906.62","56.9","","812.12","238.65","1587.46","163","594.09","4342.05","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","5108.29","3064.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","594.09","11.63","","112.68","112.68","146.99","38","594.09","4342.05","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","5108.29","3064.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3953.82","77.4","","303.98","303.98","5854.79","1 through 10","594.09","4342.05","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5108.29","3064.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","594.09","11.63","","112.68","112.68","146.99","38","594.09","3953.82","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5108.29","3064.97","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3206.98","62.78","","780.86","208.94","10480.28","15","594.09","3953.82","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5108.29","3064.97","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2233.34","43.72","","179.76","179.76","179.76","1 through 10","594.09","3953.82","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5108.29","3064.97","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3714.75","72.72","","2355.45","298.99","3965.19","155","594.09","3953.82","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5108.29","3064.97","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3714.75","72.72","","3643.09","3643.09","3643.09","1 through 10","594.09","3953.82","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5108.29","3064.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2718.63","53.22","","554.28","554.28","554.28","16","594.09","3953.82","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5108.29","3064.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3213.11","62.9","","619.64","173.09","2370.64","150","594.09","3953.82","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5108.29","3064.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3953.82","77.4","","303.98","303.98","5854.79","1 through 10","594.09","3953.82","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","5197.77","3118.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","604.5","4418.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","5197.77","3118.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","604.5","4418.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","5197.77","3118.66","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2957.53","56.9","","812.12","238.65","1587.46","163","604.5","4418.1","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","5197.77","3118.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","604.50","11.63","","112.68","112.68","146.99","38","604.5","4418.1","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","5197.77","3118.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4023.07","77.4","","303.98","303.98","5854.79","1 through 10","604.5","4418.1","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5197.77","3118.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","604.50","11.63","","112.68","112.68","146.99","38","604.5","4023.07","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5197.77","3118.66","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3263.16","62.78","","780.86","208.94","10480.28","15","604.5","4023.07","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5197.77","3118.66","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2272.47","43.72","","179.76","179.76","179.76","1 through 10","604.5","4023.07","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5197.77","3118.66","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3779.82","72.72","","2355.45","298.99","3965.19","155","604.5","4023.07","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5197.77","3118.66","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3779.82","72.72","","3643.09","3643.09","3643.09","1 through 10","604.5","4023.07","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5197.77","3118.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2766.25","53.22","","554.28","554.28","554.28","16","604.5","4023.07","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5197.77","3118.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3269.40","62.9","","619.64","173.09","2370.64","150","604.5","4023.07","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5197.77","3118.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4023.07","77.4","","303.98","303.98","5854.79","1 through 10","604.5","4023.07","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIA 0.85MM TITAN BARRIER TITANIUM MESH ORBITAL FLOOR FAN STERILE","SUP-ITM-10215476","CDM","C1781","HCPCS","0278","RC","","","","both","","","6596.62","3957.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","767.19","5607.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CRANIOMAXILLOFACIA 0.85MM TITAN BARRIER TITANIUM MESH ORBITAL FLOOR FAN STERILE","SUP-ITM-10215476","CDM","C1781","HCPCS","0278","RC","","","","both","","","6596.62","3957.97","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3753.48","56.9","","1333.47","776.80","2316.37","34","767.19","5607.13","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIA 0.85MM TITAN BARRIER TITANIUM MESH ORBITAL FLOOR FAN STERILE","SUP-ITM-10215476","CDM","C1781","HCPCS","0278","RC","","","","both","","","6596.62","3957.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","767.19","11.63","","348.38","187.99","380.51","1 through 10","767.19","5607.13","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIA 0.85MM TITAN BARRIER TITANIUM MESH ORBITAL FLOOR FAN STERILE","SUP-ITM-10215476","CDM","C1781","HCPCS","0278","RC","","","","both","","","6596.62","3957.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4149.27","62.9","","1793.12","860.08","3673.04","20","767.19","5607.13","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIA 0.85MM TITAN BARRIER TITANIUM MESH ORBITAL FLOOR FAN STERILE","SUP-ITM-10215476","CDM","C1781","HCPCS","0278","RC","","","","both","","","6596.62","3957.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5105.78","77.4","","1107.52","186.36","4312.65","1 through 10","767.19","5607.13","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIA 0.85MM TITAN BARRIER TITANIUM MESH ORBITAL FLOOR FAN STERILE","SUP-ITM-10215476","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6596.62","3957.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","767.19","11.63","","348.38","187.99","380.51","1 through 10","767.19","4797.06","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIA 0.85MM TITAN BARRIER TITANIUM MESH ORBITAL FLOOR FAN STERILE","SUP-ITM-10215476","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6596.62","3957.97","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4141.36","62.78","","9719.10","2943.96","9719.10","1 through 10","767.19","4797.06","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIA 0.85MM TITAN BARRIER TITANIUM MESH ORBITAL FLOOR FAN STERILE","SUP-ITM-10215476","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6596.62","3957.97","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4797.06","72.72","","2009.48","1217.35","3752.64","17","767.19","4797.06","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","both","","","986.47","591.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","114.73","838.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","both","","","986.47","591.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","114.73","838.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","both","","","986.47","591.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","561.30","56.9","","812.12","238.65","1587.46","163","114.73","838.5","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","both","","","986.47","591.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","114.73","11.63","","112.68","112.68","146.99","38","114.73","838.5","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","both","","","986.47","591.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","763.53","77.4","","303.98","303.98","5854.79","1 through 10","114.73","838.5","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","986.47","591.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","114.73","11.63","","112.68","112.68","146.99","38","114.73","763.53","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","986.47","591.88","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","619.31","62.78","","780.86","208.94","10480.28","15","114.73","763.53","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","986.47","591.88","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","431.28","43.72","","179.76","179.76","179.76","1 through 10","114.73","763.53","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","986.47","591.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","717.36","72.72","","2355.45","298.99","3965.19","155","114.73","763.53","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","986.47","591.88","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","717.36","72.72","","3643.09","3643.09","3643.09","1 through 10","114.73","763.53","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","986.47","591.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","525.00","53.22","","554.28","554.28","554.28","16","114.73","763.53","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","986.47","591.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","620.49","62.9","","619.64","173.09","2370.64","150","114.73","763.53","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 1.3X35MM 9 HOLE ORBITAL RIM ADAPTION TITANIUM","SUP-ITM-10002345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","986.47","591.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","763.53","77.4","","303.98","303.98","5854.79","1 through 10","114.73","763.53","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.99","1771.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","343.43","2510.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.99","1771.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","343.43","2510.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.99","1771.79","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1680.25","56.9","","812.12","238.65","1587.46","163","343.43","2510.04","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.99","1771.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","343.43","11.63","","112.68","112.68","146.99","38","343.43","2510.04","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.99","1771.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2285.61","77.4","","303.98","303.98","5854.79","1 through 10","343.43","2510.04","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2952.99","1771.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","343.43","11.63","","112.68","112.68","146.99","38","343.43","2285.61","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2952.99","1771.79","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1853.89","62.78","","780.86","208.94","10480.28","15","343.43","2285.61","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2952.99","1771.79","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1291.05","43.72","","179.76","179.76","179.76","1 through 10","343.43","2285.61","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2952.99","1771.79","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2147.41","72.72","","2355.45","298.99","3965.19","155","343.43","2285.61","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2952.99","1771.79","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2147.41","72.72","","3643.09","3643.09","3643.09","1 through 10","343.43","2285.61","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2952.99","1771.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1571.58","53.22","","554.28","554.28","554.28","16","343.43","2285.61","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2952.99","1771.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1857.43","62.9","","619.64","173.09","2370.64","150","343.43","2285.61","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2952.99","1771.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2285.61","77.4","","303.98","303.98","5854.79","1 through 10","343.43","2285.61","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","5588.95","3353.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","649.99","4750.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","5588.95","3353.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","649.99","4750.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","5588.95","3353.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3180.11","56.9","","812.12","238.65","1587.46","163","649.99","4750.61","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","5588.95","3353.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","649.99","11.63","","112.68","112.68","146.99","38","649.99","4750.61","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","5588.95","3353.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4325.85","77.4","","303.98","303.98","5854.79","1 through 10","649.99","4750.61","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5588.95","3353.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","649.99","11.63","","112.68","112.68","146.99","38","649.99","4325.85","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5588.95","3353.37","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3508.74","62.78","","780.86","208.94","10480.28","15","649.99","4325.85","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5588.95","3353.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2443.49","43.72","","179.76","179.76","179.76","1 through 10","649.99","4325.85","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5588.95","3353.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4064.28","72.72","","2355.45","298.99","3965.19","155","649.99","4325.85","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5588.95","3353.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4064.28","72.72","","3643.09","3643.09","3643.09","1 through 10","649.99","4325.85","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5588.95","3353.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2974.44","53.22","","554.28","554.28","554.28","16","649.99","4325.85","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5588.95","3353.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3515.45","62.9","","619.64","173.09","2370.64","150","649.99","4325.85","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5588.95","3353.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4325.85","77.4","","303.98","303.98","5854.79","1 through 10","649.99","4325.85","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","5982.68","3589.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","695.79","5085.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","5982.68","3589.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","695.79","5085.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","5982.68","3589.61","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3404.14","56.9","","812.12","238.65","1587.46","163","695.79","5085.28","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","5982.68","3589.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","695.79","11.63","","112.68","112.68","146.99","38","695.79","5085.28","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","5982.68","3589.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4630.59","77.4","","303.98","303.98","5854.79","1 through 10","695.79","5085.28","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","695.79","11.63","","112.68","112.68","146.99","38","695.79","4630.59","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3755.93","62.78","","780.86","208.94","10480.28","15","695.79","4630.59","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2615.63","43.72","","179.76","179.76","179.76","1 through 10","695.79","4630.59","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4350.60","72.72","","2355.45","298.99","3965.19","155","695.79","4630.59","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4350.60","72.72","","3643.09","3643.09","3643.09","1 through 10","695.79","4630.59","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3183.98","53.22","","554.28","554.28","554.28","16","695.79","4630.59","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3763.11","62.9","","619.64","173.09","2370.64","150","695.79","4630.59","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5982.68","3589.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4630.59","77.4","","303.98","303.98","5854.79","1 through 10","695.79","4630.59","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.02","2545.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","493.46","3606.57","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.02","2545.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","493.46","3606.57","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.02","2545.81","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2414.28","56.9","","812.12","238.65","1587.46","163","493.46","3606.57","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.02","2545.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","493.46","11.63","","112.68","112.68","146.99","38","493.46","3606.57","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.02","2545.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3284.10","77.4","","303.98","303.98","5854.79","1 through 10","493.46","3606.57","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4243.02","2545.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","493.46","11.63","","112.68","112.68","146.99","38","493.46","3284.1","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4243.02","2545.81","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2663.77","62.78","","780.86","208.94","10480.28","15","493.46","3284.1","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4243.02","2545.81","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1855.05","43.72","","179.76","179.76","179.76","1 through 10","493.46","3284.1","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4243.02","2545.81","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3085.52","72.72","","2355.45","298.99","3965.19","155","493.46","3284.1","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4243.02","2545.81","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3085.52","72.72","","3643.09","3643.09","3643.09","1 through 10","493.46","3284.1","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4243.02","2545.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2258.14","53.22","","554.28","554.28","554.28","16","493.46","3284.1","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4243.02","2545.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2668.86","62.9","","619.64","173.09","2370.64","150","493.46","3284.1","percent of total billed charges",""
"PLATE FEMORAL 1HOLE NECK SYSTEM","SUP-ITM-10296783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4243.02","2545.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3284.10","77.4","","303.98","303.98","5854.79","1 through 10","493.46","3284.1","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","both","","","7045.21","4227.13","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","819.36","5988.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","both","","","7045.21","4227.13","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","819.36","5988.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","both","","","7045.21","4227.13","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4008.72","56.9","","812.12","238.65","1587.46","163","819.36","5988.43","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","both","","","7045.21","4227.13","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","819.36","11.63","","112.68","112.68","146.99","38","819.36","5988.43","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","both","","","7045.21","4227.13","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5452.99","77.4","","303.98","303.98","5854.79","1 through 10","819.36","5988.43","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7045.21","4227.13","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","819.36","11.63","","112.68","112.68","146.99","38","819.36","5452.99","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7045.21","4227.13","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4422.98","62.78","","780.86","208.94","10480.28","15","819.36","5452.99","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7045.21","4227.13","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3080.17","43.72","","179.76","179.76","179.76","1 through 10","819.36","5452.99","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7045.21","4227.13","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5123.28","72.72","","2355.45","298.99","3965.19","155","819.36","5452.99","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7045.21","4227.13","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5123.28","72.72","","3643.09","3643.09","3643.09","1 through 10","819.36","5452.99","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7045.21","4227.13","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3749.46","53.22","","554.28","554.28","554.28","16","819.36","5452.99","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7045.21","4227.13","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4431.44","62.9","","619.64","173.09","2370.64","150","819.36","5452.99","percent of total billed charges",""
"PLATE FEMORAL 4.5X349MM 14 HOLE PROXIMAL HOOK LCP","SUP-ITM-10024440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7045.21","4227.13","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5452.99","77.4","","303.98","303.98","5854.79","1 through 10","819.36","5452.99","percent of total billed charges",""
"PLATE FEMUR 113.5MM 4 HOLE TI TOMOFIX MEDIAL DISTAL RIGHT","SUP-ITM-10164399","CDM","C1713","HCPCS","0278","RC","","","","both","","","5641.28","3384.77","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","656.08","4795.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FEMUR 113.5MM 4 HOLE TI TOMOFIX MEDIAL DISTAL RIGHT","SUP-ITM-10164399","CDM","C1713","HCPCS","0278","RC","","","","both","","","5641.28","3384.77","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","656.08","4795.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FEMUR 113.5MM 4 HOLE TI TOMOFIX MEDIAL DISTAL RIGHT","SUP-ITM-10164399","CDM","C1713","HCPCS","0278","RC","","","","both","","","5641.28","3384.77","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3209.89","56.9","","812.12","238.65","1587.46","163","656.08","4795.09","percent of total billed charges",""
"PLATE FEMUR 113.5MM 4 HOLE TI TOMOFIX MEDIAL DISTAL RIGHT","SUP-ITM-10164399","CDM","C1713","HCPCS","0278","RC","","","","both","","","5641.28","3384.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","656.08","11.63","","112.68","112.68","146.99","38","656.08","4795.09","percent of total billed charges",""
"PLATE FEMUR 113.5MM 4 HOLE TI TOMOFIX MEDIAL DISTAL RIGHT","SUP-ITM-10164399","CDM","C1713","HCPCS","0278","RC","","","","both","","","5641.28","3384.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4366.35","77.4","","303.98","303.98","5854.79","1 through 10","656.08","4795.09","percent of total billed charges",""
"PLATE FEMUR 113.5MM 4 HOLE TI TOMOFIX MEDIAL DISTAL RIGHT","SUP-ITM-10164399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5641.28","3384.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","656.08","11.63","","112.68","112.68","146.99","38","656.08","4366.35","percent of total billed charges",""
"PLATE FEMUR 113.5MM 4 HOLE TI TOMOFIX MEDIAL DISTAL RIGHT","SUP-ITM-10164399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5641.28","3384.77","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3541.60","62.78","","780.86","208.94","10480.28","15","656.08","4366.35","percent of total billed charges",""
"PLATE FEMUR 113.5MM 4 HOLE TI TOMOFIX MEDIAL DISTAL RIGHT","SUP-ITM-10164399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5641.28","3384.77","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2466.37","43.72","","179.76","179.76","179.76","1 through 10","656.08","4366.35","percent of total billed charges",""
"PLATE FEMUR 113.5MM 4 HOLE TI TOMOFIX MEDIAL DISTAL RIGHT","SUP-ITM-10164399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5641.28","3384.77","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4102.34","72.72","","2355.45","298.99","3965.19","155","656.08","4366.35","percent of total billed charges",""
"PLATE FEMUR 113.5MM 4 HOLE TI TOMOFIX MEDIAL DISTAL RIGHT","SUP-ITM-10164399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5641.28","3384.77","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4102.34","72.72","","3643.09","3643.09","3643.09","1 through 10","656.08","4366.35","percent of total billed charges",""
"PLATE FEMUR 113.5MM 4 HOLE TI TOMOFIX MEDIAL DISTAL RIGHT","SUP-ITM-10164399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5641.28","3384.77","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3002.29","53.22","","554.28","554.28","554.28","16","656.08","4366.35","percent of total billed charges",""
"PLATE FEMUR 113.5MM 4 HOLE TI TOMOFIX MEDIAL DISTAL RIGHT","SUP-ITM-10164399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5641.28","3384.77","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3548.37","62.9","","619.64","173.09","2370.64","150","656.08","4366.35","percent of total billed charges",""
"PLATE FEMUR 113.5MM 4 HOLE TI TOMOFIX MEDIAL DISTAL RIGHT","SUP-ITM-10164399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5641.28","3384.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4366.35","77.4","","303.98","303.98","5854.79","1 through 10","656.08","4366.35","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5M SM 5 HOLE HOOK VA-LCP PPFX PROXIMAL STAINLESS STEEL RIGHT","SUP-ITM-10297820","CDM","C1713","HCPCS","0278","RC","","","","both","","","12070.29","7242.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1403.77","10259.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FEMUR 3.5/4.5M SM 5 HOLE HOOK VA-LCP PPFX PROXIMAL STAINLESS STEEL RIGHT","SUP-ITM-10297820","CDM","C1713","HCPCS","0278","RC","","","","both","","","12070.29","7242.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1403.77","10259.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FEMUR 3.5/4.5M SM 5 HOLE HOOK VA-LCP PPFX PROXIMAL STAINLESS STEEL RIGHT","SUP-ITM-10297820","CDM","C1713","HCPCS","0278","RC","","","","both","","","12070.29","7242.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6868.00","56.9","","812.12","238.65","1587.46","163","1403.77","10259.75","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5M SM 5 HOLE HOOK VA-LCP PPFX PROXIMAL STAINLESS STEEL RIGHT","SUP-ITM-10297820","CDM","C1713","HCPCS","0278","RC","","","","both","","","12070.29","7242.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1403.77","11.63","","112.68","112.68","146.99","38","1403.77","10259.75","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5M SM 5 HOLE HOOK VA-LCP PPFX PROXIMAL STAINLESS STEEL RIGHT","SUP-ITM-10297820","CDM","C1713","HCPCS","0278","RC","","","","both","","","12070.29","7242.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9342.40","77.4","","303.98","303.98","5854.79","1 through 10","1403.77","10259.75","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5M SM 5 HOLE HOOK VA-LCP PPFX PROXIMAL STAINLESS STEEL RIGHT","SUP-ITM-10297820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12070.29","7242.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1403.77","11.63","","112.68","112.68","146.99","38","1403.77","9342.4","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5M SM 5 HOLE HOOK VA-LCP PPFX PROXIMAL STAINLESS STEEL RIGHT","SUP-ITM-10297820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12070.29","7242.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","7577.73","62.78","","780.86","208.94","10480.28","15","1403.77","9342.4","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5M SM 5 HOLE HOOK VA-LCP PPFX PROXIMAL STAINLESS STEEL RIGHT","SUP-ITM-10297820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12070.29","7242.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","5277.13","43.72","","179.76","179.76","179.76","1 through 10","1403.77","9342.4","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5M SM 5 HOLE HOOK VA-LCP PPFX PROXIMAL STAINLESS STEEL RIGHT","SUP-ITM-10297820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12070.29","7242.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8777.51","72.72","","2355.45","298.99","3965.19","155","1403.77","9342.4","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5M SM 5 HOLE HOOK VA-LCP PPFX PROXIMAL STAINLESS STEEL RIGHT","SUP-ITM-10297820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12070.29","7242.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","8777.51","72.72","","3643.09","3643.09","3643.09","1 through 10","1403.77","9342.4","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5M SM 5 HOLE HOOK VA-LCP PPFX PROXIMAL STAINLESS STEEL RIGHT","SUP-ITM-10297820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12070.29","7242.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","6423.81","53.22","","554.28","554.28","554.28","16","1403.77","9342.4","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5M SM 5 HOLE HOOK VA-LCP PPFX PROXIMAL STAINLESS STEEL RIGHT","SUP-ITM-10297820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12070.29","7242.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7592.21","62.9","","619.64","173.09","2370.64","150","1403.77","9342.4","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5M SM 5 HOLE HOOK VA-LCP PPFX PROXIMAL STAINLESS STEEL RIGHT","SUP-ITM-10297820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12070.29","7242.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9342.40","77.4","","303.98","303.98","5854.79","1 through 10","1403.77","9342.4","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","both","","","11212.81","6727.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1304.05","9530.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","both","","","11212.81","6727.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1304.05","9530.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","both","","","11212.81","6727.69","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6380.09","56.9","","812.12","238.65","1587.46","163","1304.05","9530.89","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","both","","","11212.81","6727.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1304.05","11.63","","112.68","112.68","146.99","38","1304.05","9530.89","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","both","","","11212.81","6727.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8678.71","77.4","","303.98","303.98","5854.79","1 through 10","1304.05","9530.89","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11212.81","6727.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1304.05","11.63","","112.68","112.68","146.99","38","1304.05","8678.71","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11212.81","6727.69","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","7039.40","62.78","","780.86","208.94","10480.28","15","1304.05","8678.71","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11212.81","6727.69","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4902.24","43.72","","179.76","179.76","179.76","1 through 10","1304.05","8678.71","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11212.81","6727.69","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8153.96","72.72","","2355.45","298.99","3965.19","155","1304.05","8678.71","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11212.81","6727.69","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","8153.96","72.72","","3643.09","3643.09","3643.09","1 through 10","1304.05","8678.71","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11212.81","6727.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","5967.46","53.22","","554.28","554.28","554.28","16","1304.05","8678.71","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11212.81","6727.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7052.86","62.9","","619.64","173.09","2370.64","150","1304.05","8678.71","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 7 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297801","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11212.81","6727.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8678.71","77.4","","303.98","303.98","5854.79","1 through 10","1304.05","8678.71","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","both","","","10541.81","6325.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1226.01","8960.54","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","both","","","10541.81","6325.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1226.01","8960.54","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","both","","","10541.81","6325.09","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5998.29","56.9","","812.12","238.65","1587.46","163","1226.01","8960.54","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","both","","","10541.81","6325.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1226.01","11.63","","112.68","112.68","146.99","38","1226.01","8960.54","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","both","","","10541.81","6325.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8159.36","77.4","","303.98","303.98","5854.79","1 through 10","1226.01","8960.54","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10541.81","6325.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1226.01","11.63","","112.68","112.68","146.99","38","1226.01","8159.36","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10541.81","6325.09","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6618.15","62.78","","780.86","208.94","10480.28","15","1226.01","8159.36","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10541.81","6325.09","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4608.88","43.72","","179.76","179.76","179.76","1 through 10","1226.01","8159.36","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10541.81","6325.09","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7666.00","72.72","","2355.45","298.99","3965.19","155","1226.01","8159.36","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10541.81","6325.09","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7666.00","72.72","","3643.09","3643.09","3643.09","1 through 10","1226.01","8159.36","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10541.81","6325.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","5610.35","53.22","","554.28","554.28","554.28","16","1226.01","8159.36","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10541.81","6325.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6630.80","62.9","","619.64","173.09","2370.64","150","1226.01","8159.36","percent of total billed charges",""
"PLATE FEMUR 3.5/4.5MM 9 HOLE VA-LCP PPFX STAINLESS STEEL PROXIMAL LEFT","SUP-ITM-10297797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10541.81","6325.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8159.36","77.4","","303.98","303.98","5854.79","1 through 10","1226.01","8159.36","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","both","","","6282.30","3769.38","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","730.63","5339.96","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","both","","","6282.30","3769.38","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","730.63","5339.96","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","both","","","6282.30","3769.38","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3574.63","56.9","","812.12","238.65","1587.46","163","730.63","5339.96","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","both","","","6282.30","3769.38","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","730.63","11.63","","112.68","112.68","146.99","38","730.63","5339.96","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","both","","","6282.30","3769.38","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4862.50","77.4","","303.98","303.98","5854.79","1 through 10","730.63","5339.96","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6282.30","3769.38","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","730.63","11.63","","112.68","112.68","146.99","38","730.63","4862.5","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6282.30","3769.38","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3944.03","62.78","","780.86","208.94","10480.28","15","730.63","4862.5","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6282.30","3769.38","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2746.62","43.72","","179.76","179.76","179.76","1 through 10","730.63","4862.5","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6282.30","3769.38","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4568.49","72.72","","2355.45","298.99","3965.19","155","730.63","4862.5","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6282.30","3769.38","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4568.49","72.72","","3643.09","3643.09","3643.09","1 through 10","730.63","4862.5","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6282.30","3769.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3343.44","53.22","","554.28","554.28","554.28","16","730.63","4862.5","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6282.30","3769.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3951.57","62.9","","619.64","173.09","2370.64","150","730.63","4862.5","percent of total billed charges",""
"PLATE FEMUR 3.5MM 4HOLE VA-LOCKING PPFX STAINLESS STEEL SPANNING ATTACHMENT DISTAL LEFT","SUP-ITM-10297789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6282.30","3769.38","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4862.50","77.4","","303.98","303.98","5854.79","1 through 10","730.63","4862.5","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE LOCKING COMPRESSION DISTAL TITANIUM RIGHT","SUP-ITM-10040393","CDM","C1713","HCPCS","0278","RC","","","","both","","","7800.69","4680.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","907.22","6630.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FEMUR 316MM 13 HOLE LOCKING COMPRESSION DISTAL TITANIUM RIGHT","SUP-ITM-10040393","CDM","C1713","HCPCS","0278","RC","","","","both","","","7800.69","4680.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","907.22","6630.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FEMUR 316MM 13 HOLE LOCKING COMPRESSION DISTAL TITANIUM RIGHT","SUP-ITM-10040393","CDM","C1713","HCPCS","0278","RC","","","","both","","","7800.69","4680.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4438.59","56.9","","812.12","238.65","1587.46","163","907.22","6630.59","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE LOCKING COMPRESSION DISTAL TITANIUM RIGHT","SUP-ITM-10040393","CDM","C1713","HCPCS","0278","RC","","","","both","","","7800.69","4680.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","907.22","11.63","","112.68","112.68","146.99","38","907.22","6630.59","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE LOCKING COMPRESSION DISTAL TITANIUM RIGHT","SUP-ITM-10040393","CDM","C1713","HCPCS","0278","RC","","","","both","","","7800.69","4680.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6037.73","77.4","","303.98","303.98","5854.79","1 through 10","907.22","6630.59","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE LOCKING COMPRESSION DISTAL TITANIUM RIGHT","SUP-ITM-10040393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7800.69","4680.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","907.22","11.63","","112.68","112.68","146.99","38","907.22","6037.73","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE LOCKING COMPRESSION DISTAL TITANIUM RIGHT","SUP-ITM-10040393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7800.69","4680.41","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4897.27","62.78","","780.86","208.94","10480.28","15","907.22","6037.73","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE LOCKING COMPRESSION DISTAL TITANIUM RIGHT","SUP-ITM-10040393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7800.69","4680.41","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3410.46","43.72","","179.76","179.76","179.76","1 through 10","907.22","6037.73","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE LOCKING COMPRESSION DISTAL TITANIUM RIGHT","SUP-ITM-10040393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7800.69","4680.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5672.66","72.72","","2355.45","298.99","3965.19","155","907.22","6037.73","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE LOCKING COMPRESSION DISTAL TITANIUM RIGHT","SUP-ITM-10040393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7800.69","4680.41","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5672.66","72.72","","3643.09","3643.09","3643.09","1 through 10","907.22","6037.73","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE LOCKING COMPRESSION DISTAL TITANIUM RIGHT","SUP-ITM-10040393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7800.69","4680.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4151.53","53.22","","554.28","554.28","554.28","16","907.22","6037.73","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE LOCKING COMPRESSION DISTAL TITANIUM RIGHT","SUP-ITM-10040393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7800.69","4680.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4906.63","62.9","","619.64","173.09","2370.64","150","907.22","6037.73","percent of total billed charges",""
"PLATE FEMUR 316MM 13 HOLE LOCKING COMPRESSION DISTAL TITANIUM RIGHT","SUP-ITM-10040393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7800.69","4680.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6037.73","77.4","","303.98","303.98","5854.79","1 through 10","907.22","6037.73","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","both","","","6413.54","3848.12","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","745.89","5451.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","both","","","6413.54","3848.12","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","745.89","5451.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","both","","","6413.54","3848.12","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3649.30","56.9","","812.12","238.65","1587.46","163","745.89","5451.51","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","both","","","6413.54","3848.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","745.89","11.63","","112.68","112.68","146.99","38","745.89","5451.51","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","both","","","6413.54","3848.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4964.08","77.4","","303.98","303.98","5854.79","1 through 10","745.89","5451.51","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6413.54","3848.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","745.89","11.63","","112.68","112.68","146.99","38","745.89","4964.08","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6413.54","3848.12","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4026.42","62.78","","780.86","208.94","10480.28","15","745.89","4964.08","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6413.54","3848.12","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2804.00","43.72","","179.76","179.76","179.76","1 through 10","745.89","4964.08","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6413.54","3848.12","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4663.93","72.72","","2355.45","298.99","3965.19","155","745.89","4964.08","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6413.54","3848.12","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4663.93","72.72","","3643.09","3643.09","3643.09","1 through 10","745.89","4964.08","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6413.54","3848.12","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3413.29","53.22","","554.28","554.28","554.28","16","745.89","4964.08","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6413.54","3848.12","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4034.12","62.9","","619.64","173.09","2370.64","150","745.89","4964.08","percent of total billed charges",""
"PLATE FEMUR 4.5X241MM 8 HOLE LEG LCP SS LOCKING COMPRESSION HOOK PROXIMAL","SUP-ITM-10022696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6413.54","3848.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4964.08","77.4","","303.98","303.98","5854.79","1 through 10","745.89","4964.08","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","both","","","6743.73","4046.24","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","784.3","5732.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","both","","","6743.73","4046.24","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","784.3","5732.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","both","","","6743.73","4046.24","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3837.18","56.9","","812.12","238.65","1587.46","163","784.3","5732.17","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","both","","","6743.73","4046.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","784.30","11.63","","112.68","112.68","146.99","38","784.3","5732.17","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","both","","","6743.73","4046.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5219.65","77.4","","303.98","303.98","5854.79","1 through 10","784.3","5732.17","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6743.73","4046.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","784.30","11.63","","112.68","112.68","146.99","38","784.3","5219.65","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6743.73","4046.24","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4233.71","62.78","","780.86","208.94","10480.28","15","784.3","5219.65","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6743.73","4046.24","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2948.36","43.72","","179.76","179.76","179.76","1 through 10","784.3","5219.65","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6743.73","4046.24","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4904.04","72.72","","2355.45","298.99","3965.19","155","784.3","5219.65","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6743.73","4046.24","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4904.04","72.72","","3643.09","3643.09","3643.09","1 through 10","784.3","5219.65","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6743.73","4046.24","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3589.01","53.22","","554.28","554.28","554.28","16","784.3","5219.65","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6743.73","4046.24","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4241.81","62.9","","619.64","173.09","2370.64","150","784.3","5219.65","percent of total billed charges",""
"PLATE FEMUR 4.5X277MM 10 HOLE HOOK PROXIMAL LCP SYNTHES","SUP-ITM-10022697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6743.73","4046.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5219.65","77.4","","303.98","303.98","5854.79","1 through 10","784.3","5219.65","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","both","","","2534.04","1520.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","294.71","2153.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","both","","","2534.04","1520.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","294.71","2153.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","both","","","2534.04","1520.42","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1441.87","56.9","","812.12","238.65","1587.46","163","294.71","2153.93","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","both","","","2534.04","1520.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","294.71","11.63","","112.68","112.68","146.99","38","294.71","2153.93","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","both","","","2534.04","1520.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1961.35","77.4","","303.98","303.98","5854.79","1 through 10","294.71","2153.93","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2534.04","1520.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","294.71","11.63","","112.68","112.68","146.99","38","294.71","1961.35","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2534.04","1520.42","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1590.87","62.78","","780.86","208.94","10480.28","15","294.71","1961.35","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2534.04","1520.42","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1107.88","43.72","","179.76","179.76","179.76","1 through 10","294.71","1961.35","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2534.04","1520.42","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1842.75","72.72","","2355.45","298.99","3965.19","155","294.71","1961.35","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2534.04","1520.42","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1842.75","72.72","","3643.09","3643.09","3643.09","1 through 10","294.71","1961.35","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2534.04","1520.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1348.62","53.22","","554.28","554.28","554.28","16","294.71","1961.35","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2534.04","1520.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1593.91","62.9","","619.64","173.09","2370.64","150","294.71","1961.35","percent of total billed charges",""
"PLATE FIBULA 2.7/3.5X73MM 3 HOLE DISTAL LCP SS RIGHT","SUP-ITM-10091116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2534.04","1520.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1961.35","77.4","","303.98","303.98","5854.79","1 through 10","294.71","1961.35","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","both","","","4233.90","2540.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","492.4","3598.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","both","","","4233.90","2540.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","492.4","3598.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","both","","","4233.90","2540.34","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2409.09","56.9","","812.12","238.65","1587.46","163","492.4","3598.82","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","both","","","4233.90","2540.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","492.40","11.63","","112.68","112.68","146.99","38","492.4","3598.82","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","both","","","4233.90","2540.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3277.04","77.4","","303.98","303.98","5854.79","1 through 10","492.4","3598.82","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4233.90","2540.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","492.40","11.63","","112.68","112.68","146.99","38","492.4","3277.04","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4233.90","2540.34","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2658.04","62.78","","780.86","208.94","10480.28","15","492.4","3277.04","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4233.90","2540.34","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1851.06","43.72","","179.76","179.76","179.76","1 through 10","492.4","3277.04","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4233.90","2540.34","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3078.89","72.72","","2355.45","298.99","3965.19","155","492.4","3277.04","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4233.90","2540.34","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3078.89","72.72","","3643.09","3643.09","3643.09","1 through 10","492.4","3277.04","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4233.90","2540.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2253.28","53.22","","554.28","554.28","554.28","16","492.4","3277.04","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4233.90","2540.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2663.12","62.9","","619.64","173.09","2370.64","150","492.4","3277.04","percent of total billed charges",""
"PLATE FIBULA 2.7X131MM 7 HOLE DISTAL VA LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10124979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4233.90","2540.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3277.04","77.4","","303.98","303.98","5854.79","1 through 10","492.4","3277.04","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","both","","","4755.46","2853.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","553.06","4042.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","both","","","4755.46","2853.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","553.06","4042.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","both","","","4755.46","2853.28","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2705.86","56.9","","812.12","238.65","1587.46","163","553.06","4042.14","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","both","","","4755.46","2853.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","553.06","11.63","","112.68","112.68","146.99","38","553.06","4042.14","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","both","","","4755.46","2853.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3680.73","77.4","","303.98","303.98","5854.79","1 through 10","553.06","4042.14","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4755.46","2853.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","553.06","11.63","","112.68","112.68","146.99","38","553.06","3680.73","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4755.46","2853.28","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2985.48","62.78","","780.86","208.94","10480.28","15","553.06","3680.73","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4755.46","2853.28","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2079.09","43.72","","179.76","179.76","179.76","1 through 10","553.06","3680.73","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4755.46","2853.28","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3458.17","72.72","","2355.45","298.99","3965.19","155","553.06","3680.73","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4755.46","2853.28","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3458.17","72.72","","3643.09","3643.09","3643.09","1 through 10","553.06","3680.73","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4755.46","2853.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2530.86","53.22","","554.28","554.28","554.28","16","553.06","3680.73","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4755.46","2853.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2991.18","62.9","","619.64","173.09","2370.64","150","553.06","3680.73","percent of total billed charges",""
"PLATE FUSION 2.4 2.7X38MM SHORT CLOVERLEAF VA LCP FIRST TMT RT","SUP-ITM-10091977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4755.46","2853.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3680.73","77.4","","303.98","303.98","5854.79","1 through 10","553.06","3680.73","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","both","","","1889.40","1133.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","219.74","1605.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","both","","","1889.40","1133.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","219.74","1605.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","both","","","1889.40","1133.64","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1075.07","56.9","","812.12","238.65","1587.46","163","219.74","1605.99","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","both","","","1889.40","1133.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","219.74","11.63","","112.68","112.68","146.99","38","219.74","1605.99","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","both","","","1889.40","1133.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1462.40","77.4","","303.98","303.98","5854.79","1 through 10","219.74","1605.99","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1889.40","1133.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","219.74","11.63","","112.68","112.68","146.99","38","219.74","1462.4","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1889.40","1133.64","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1186.17","62.78","","780.86","208.94","10480.28","15","219.74","1462.4","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1889.40","1133.64","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","826.05","43.72","","179.76","179.76","179.76","1 through 10","219.74","1462.4","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1889.40","1133.64","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1373.97","72.72","","2355.45","298.99","3965.19","155","219.74","1462.4","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1889.40","1133.64","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1373.97","72.72","","3643.09","3643.09","3643.09","1 through 10","219.74","1462.4","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1889.40","1133.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1005.54","53.22","","554.28","554.28","554.28","16","219.74","1462.4","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1889.40","1133.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1188.43","62.9","","619.64","173.09","2370.64","150","219.74","1462.4","percent of total billed charges",""
"PLATE HAND 23X1.3MM 6 HOLE STRAIGHT MODULAR SYSTEM TITANIUM","SUP-ITM-10002358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1889.40","1133.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1462.40","77.4","","303.98","303.98","5854.79","1 through 10","219.74","1462.4","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","both","","","1886.84","1132.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","219.44","1603.81","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","both","","","1886.84","1132.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","219.44","1603.81","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","both","","","1886.84","1132.10","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1073.61","56.9","","812.12","238.65","1587.46","163","219.44","1603.81","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","both","","","1886.84","1132.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","219.44","11.63","","112.68","112.68","146.99","38","219.44","1603.81","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","both","","","1886.84","1132.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1460.41","77.4","","303.98","303.98","5854.79","1 through 10","219.44","1603.81","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1886.84","1132.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","219.44","11.63","","112.68","112.68","146.99","38","219.44","1460.41","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1886.84","1132.10","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1184.56","62.78","","780.86","208.94","10480.28","15","219.44","1460.41","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1886.84","1132.10","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","824.93","43.72","","179.76","179.76","179.76","1 through 10","219.44","1460.41","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1886.84","1132.10","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1372.11","72.72","","2355.45","298.99","3965.19","155","219.44","1460.41","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1886.84","1132.10","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1372.11","72.72","","3643.09","3643.09","3643.09","1 through 10","219.44","1460.41","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1886.84","1132.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1004.18","53.22","","554.28","554.28","554.28","16","219.44","1460.41","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1886.84","1132.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1186.82","62.9","","619.64","173.09","2370.64","150","219.44","1460.41","percent of total billed charges",""
"PLATE HAND 24X2MM 4 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10006279","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1886.84","1132.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1460.41","77.4","","303.98","303.98","5854.79","1 through 10","219.44","1460.41","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","2224.33","1334.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","258.69","1890.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","2224.33","1334.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","258.69","1890.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","2224.33","1334.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1265.64","56.9","","812.12","238.65","1587.46","163","258.69","1890.68","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","2224.33","1334.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","258.69","11.63","","112.68","112.68","146.99","38","258.69","1890.68","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","2224.33","1334.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1721.63","77.4","","303.98","303.98","5854.79","1 through 10","258.69","1890.68","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2224.33","1334.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","258.69","11.63","","112.68","112.68","146.99","38","258.69","1721.63","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2224.33","1334.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1396.43","62.78","","780.86","208.94","10480.28","15","258.69","1721.63","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2224.33","1334.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","972.48","43.72","","179.76","179.76","179.76","1 through 10","258.69","1721.63","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2224.33","1334.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1617.53","72.72","","2355.45","298.99","3965.19","155","258.69","1721.63","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2224.33","1334.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1617.53","72.72","","3643.09","3643.09","3643.09","1 through 10","258.69","1721.63","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2224.33","1334.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1183.79","53.22","","554.28","554.28","554.28","16","258.69","1721.63","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2224.33","1334.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1399.10","62.9","","619.64","173.09","2370.64","150","258.69","1721.63","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2224.33","1334.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1721.63","77.4","","303.98","303.98","5854.79","1 through 10","258.69","1721.63","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","3423.42","2054.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","398.14","2909.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","3423.42","2054.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","398.14","2909.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","3423.42","2054.05","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1947.93","56.9","","812.12","238.65","1587.46","163","398.14","2909.91","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","3423.42","2054.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","398.14","11.63","","112.68","112.68","146.99","38","398.14","2909.91","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","3423.42","2054.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2649.73","77.4","","303.98","303.98","5854.79","1 through 10","398.14","2909.91","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3423.42","2054.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","398.14","11.63","","112.68","112.68","146.99","38","398.14","2649.73","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3423.42","2054.05","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2149.22","62.78","","780.86","208.94","10480.28","15","398.14","2649.73","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3423.42","2054.05","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1496.72","43.72","","179.76","179.76","179.76","1 through 10","398.14","2649.73","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3423.42","2054.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2489.51","72.72","","2355.45","298.99","3965.19","155","398.14","2649.73","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3423.42","2054.05","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2489.51","72.72","","3643.09","3643.09","3643.09","1 through 10","398.14","2649.73","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3423.42","2054.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1821.94","53.22","","554.28","554.28","554.28","16","398.14","2649.73","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3423.42","2054.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2153.33","62.9","","619.64","173.09","2370.64","150","398.14","2649.73","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3423.42","2054.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2649.73","77.4","","303.98","303.98","5854.79","1 through 10","398.14","2649.73","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","3699.54","2219.72","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","430.26","3144.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","3699.54","2219.72","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","430.26","3144.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","3699.54","2219.72","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2105.04","56.9","","812.12","238.65","1587.46","163","430.26","3144.61","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","3699.54","2219.72","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","430.26","11.63","","112.68","112.68","146.99","38","430.26","3144.61","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","3699.54","2219.72","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2863.44","77.4","","303.98","303.98","5854.79","1 through 10","430.26","3144.61","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3699.54","2219.72","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","430.26","11.63","","112.68","112.68","146.99","38","430.26","2863.44","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3699.54","2219.72","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2322.57","62.78","","780.86","208.94","10480.28","15","430.26","2863.44","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3699.54","2219.72","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1617.44","43.72","","179.76","179.76","179.76","1 through 10","430.26","2863.44","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3699.54","2219.72","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2690.31","72.72","","2355.45","298.99","3965.19","155","430.26","2863.44","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3699.54","2219.72","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2690.31","72.72","","3643.09","3643.09","3643.09","1 through 10","430.26","2863.44","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3699.54","2219.72","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1968.90","53.22","","554.28","554.28","554.28","16","430.26","2863.44","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3699.54","2219.72","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2327.01","62.9","","619.64","173.09","2370.64","150","430.26","2863.44","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3699.54","2219.72","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2863.44","77.4","","303.98","303.98","5854.79","1 through 10","430.26","2863.44","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","both","","","2037.69","1222.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","236.98","1732.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","both","","","2037.69","1222.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","236.98","1732.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","both","","","2037.69","1222.61","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1159.45","56.9","","812.12","238.65","1587.46","163","236.98","1732.04","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","both","","","2037.69","1222.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","236.98","11.63","","112.68","112.68","146.99","38","236.98","1732.04","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","both","","","2037.69","1222.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1577.17","77.4","","303.98","303.98","5854.79","1 through 10","236.98","1732.04","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2037.69","1222.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","236.98","11.63","","112.68","112.68","146.99","38","236.98","1577.17","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2037.69","1222.61","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1279.26","62.78","","780.86","208.94","10480.28","15","236.98","1577.17","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2037.69","1222.61","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","890.88","43.72","","179.76","179.76","179.76","1 through 10","236.98","1577.17","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2037.69","1222.61","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1481.81","72.72","","2355.45","298.99","3965.19","155","236.98","1577.17","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2037.69","1222.61","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1481.81","72.72","","3643.09","3643.09","3643.09","1 through 10","236.98","1577.17","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2037.69","1222.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1084.46","53.22","","554.28","554.28","554.28","16","236.98","1577.17","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2037.69","1222.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1281.71","62.9","","619.64","173.09","2370.64","150","236.98","1577.17","percent of total billed charges",""
"PLATE HAND 71X2MM 12 HOLE MODULAR SYSTEM STRAIGHT TITANIUM","SUP-ITM-10006480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2037.69","1222.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1577.17","77.4","","303.98","303.98","5854.79","1 through 10","236.98","1577.17","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10038274","CDM","C1713","HCPCS","0278","RC","","","","both","","","5264.25","3158.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","612.23","4474.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HIP 270MM 16 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10038274","CDM","C1713","HCPCS","0278","RC","","","","both","","","5264.25","3158.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","612.23","4474.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HIP 270MM 16 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10038274","CDM","C1713","HCPCS","0278","RC","","","","both","","","5264.25","3158.55","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2995.36","56.9","","812.12","238.65","1587.46","163","612.23","4474.61","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10038274","CDM","C1713","HCPCS","0278","RC","","","","both","","","5264.25","3158.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","612.23","11.63","","112.68","112.68","146.99","38","612.23","4474.61","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10038274","CDM","C1713","HCPCS","0278","RC","","","","both","","","5264.25","3158.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4074.53","77.4","","303.98","303.98","5854.79","1 through 10","612.23","4474.61","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10038274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5264.25","3158.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","612.23","11.63","","112.68","112.68","146.99","38","612.23","4074.53","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10038274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5264.25","3158.55","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3304.90","62.78","","780.86","208.94","10480.28","15","612.23","4074.53","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10038274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5264.25","3158.55","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2301.53","43.72","","179.76","179.76","179.76","1 through 10","612.23","4074.53","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10038274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5264.25","3158.55","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3828.16","72.72","","2355.45","298.99","3965.19","155","612.23","4074.53","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10038274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5264.25","3158.55","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3828.16","72.72","","3643.09","3643.09","3643.09","1 through 10","612.23","4074.53","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10038274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5264.25","3158.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2801.63","53.22","","554.28","554.28","554.28","16","612.23","4074.53","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10038274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5264.25","3158.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3311.21","62.9","","619.64","173.09","2370.64","150","612.23","4074.53","percent of total billed charges",""
"PLATE HIP 270MM 16 HOLE 135DEG DHS SS COMPRESSION STD BARREL","SUP-ITM-10038274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5264.25","3158.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4074.53","77.4","","303.98","303.98","5854.79","1 through 10","612.23","4074.53","percent of total billed charges",""
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10038270","CDM","C1713","HCPCS","0278","RC","","","","both","","","2983.67","1790.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","347","2536.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10038270","CDM","C1713","HCPCS","0278","RC","","","","both","","","2983.67","1790.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","347","2536.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10038270","CDM","C1713","HCPCS","0278","RC","","","","both","","","2983.67","1790.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1697.71","56.9","","812.12","238.65","1587.46","163","347","2536.12","percent of total billed charges",""
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10038270","CDM","C1713","HCPCS","0278","RC","","","","both","","","2983.67","1790.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","347.00","11.63","","112.68","112.68","146.99","38","347","2536.12","percent of total billed charges",""
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10038270","CDM","C1713","HCPCS","0278","RC","","","","both","","","2983.67","1790.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2309.36","77.4","","303.98","303.98","5854.79","1 through 10","347","2536.12","percent of total billed charges",""
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10038270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2983.67","1790.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","347.00","11.63","","112.68","112.68","146.99","38","347","2309.36","percent of total billed charges",""
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10038270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2983.67","1790.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1873.15","62.78","","780.86","208.94","10480.28","15","347","2309.36","percent of total billed charges",""
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10038270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2983.67","1790.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1304.46","43.72","","179.76","179.76","179.76","1 through 10","347","2309.36","percent of total billed charges",""
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10038270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2983.67","1790.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2169.72","72.72","","2355.45","298.99","3965.19","155","347","2309.36","percent of total billed charges",""
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10038270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2983.67","1790.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2169.72","72.72","","3643.09","3643.09","3643.09","1 through 10","347","2309.36","percent of total billed charges",""
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10038270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2983.67","1790.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1587.91","53.22","","554.28","554.28","554.28","16","347","2309.36","percent of total billed charges",""
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10038270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2983.67","1790.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1876.73","62.9","","619.64","173.09","2370.64","150","347","2309.36","percent of total billed charges",""
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10038270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2983.67","1790.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2309.36","77.4","","303.98","303.98","5854.79","1 through 10","347","2309.36","percent of total billed charges",""
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10029026","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.80","1969.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","381.79","2790.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10029026","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.80","1969.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","381.79","2790.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10029026","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.80","1969.68","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1867.91","56.9","","812.12","238.65","1587.46","163","381.79","2790.38","percent of total billed charges",""
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10029026","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.80","1969.68","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","381.79","11.63","","112.68","112.68","146.99","38","381.79","2790.38","percent of total billed charges",""
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10029026","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.80","1969.68","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2540.89","77.4","","303.98","303.98","5854.79","1 through 10","381.79","2790.38","percent of total billed charges",""
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10029026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.80","1969.68","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","381.79","11.63","","112.68","112.68","146.99","38","381.79","2540.89","percent of total billed charges",""
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10029026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.80","1969.68","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2060.94","62.78","","780.86","208.94","10480.28","15","381.79","2540.89","percent of total billed charges",""
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10029026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.80","1969.68","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1435.24","43.72","","179.76","179.76","179.76","1 through 10","381.79","2540.89","percent of total billed charges",""
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10029026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.80","1969.68","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2387.25","72.72","","2355.45","298.99","3965.19","155","381.79","2540.89","percent of total billed charges",""
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10029026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.80","1969.68","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2387.25","72.72","","3643.09","3643.09","3643.09","1 through 10","381.79","2540.89","percent of total billed charges",""
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10029026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.80","1969.68","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1747.11","53.22","","554.28","554.28","554.28","16","381.79","2540.89","percent of total billed charges",""
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10029026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.80","1969.68","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2064.88","62.9","","619.64","173.09","2370.64","150","381.79","2540.89","percent of total billed charges",""
"PLATE HIP 62MM 3 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL STERILE","SUP-ITM-10029026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.80","1969.68","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2540.89","77.4","","303.98","303.98","5854.79","1 through 10","381.79","2540.89","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","6174.43","3704.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","718.09","5248.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","6174.43","3704.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","718.09","5248.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","6174.43","3704.66","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3513.25","56.9","","812.12","238.65","1587.46","163","718.09","5248.27","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","6174.43","3704.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","718.09","11.63","","112.68","112.68","146.99","38","718.09","5248.27","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","6174.43","3704.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4779.01","77.4","","303.98","303.98","5854.79","1 through 10","718.09","5248.27","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6174.43","3704.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","718.09","11.63","","112.68","112.68","146.99","38","718.09","4779.01","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6174.43","3704.66","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3876.31","62.78","","780.86","208.94","10480.28","15","718.09","4779.01","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6174.43","3704.66","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2699.46","43.72","","179.76","179.76","179.76","1 through 10","718.09","4779.01","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6174.43","3704.66","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4490.05","72.72","","2355.45","298.99","3965.19","155","718.09","4779.01","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6174.43","3704.66","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4490.05","72.72","","3643.09","3643.09","3643.09","1 through 10","718.09","4779.01","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6174.43","3704.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3286.03","53.22","","554.28","554.28","554.28","16","718.09","4779.01","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6174.43","3704.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3883.72","62.9","","619.64","173.09","2370.64","150","718.09","4779.01","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6174.43","3704.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4779.01","77.4","","303.98","303.98","5854.79","1 through 10","718.09","4779.01","percent of total billed charges",""
"PLATE HUMERUS 3.5X109MM 3 HOLE LCP TITANIUM PROXIMAL RIGHT PERIARTIC","SUP-ITM-10097609","CDM","C1713","HCPCS","0278","RC","","","","both","","","9011.45","5406.87","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1048.03","7659.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HUMERUS 3.5X109MM 3 HOLE LCP TITANIUM PROXIMAL RIGHT PERIARTIC","SUP-ITM-10097609","CDM","C1713","HCPCS","0278","RC","","","","both","","","9011.45","5406.87","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1048.03","7659.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HUMERUS 3.5X109MM 3 HOLE LCP TITANIUM PROXIMAL RIGHT PERIARTIC","SUP-ITM-10097609","CDM","C1713","HCPCS","0278","RC","","","","both","","","9011.45","5406.87","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5127.52","56.9","","812.12","238.65","1587.46","163","1048.03","7659.73","percent of total billed charges",""
"PLATE HUMERUS 3.5X109MM 3 HOLE LCP TITANIUM PROXIMAL RIGHT PERIARTIC","SUP-ITM-10097609","CDM","C1713","HCPCS","0278","RC","","","","both","","","9011.45","5406.87","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1048.03","11.63","","112.68","112.68","146.99","38","1048.03","7659.73","percent of total billed charges",""
"PLATE HUMERUS 3.5X109MM 3 HOLE LCP TITANIUM PROXIMAL RIGHT PERIARTIC","SUP-ITM-10097609","CDM","C1713","HCPCS","0278","RC","","","","both","","","9011.45","5406.87","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6974.86","77.4","","303.98","303.98","5854.79","1 through 10","1048.03","7659.73","percent of total billed charges",""
"PLATE HUMERUS 3.5X109MM 3 HOLE LCP TITANIUM PROXIMAL RIGHT PERIARTIC","SUP-ITM-10097609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9011.45","5406.87","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1048.03","11.63","","112.68","112.68","146.99","38","1048.03","6974.86","percent of total billed charges",""
"PLATE HUMERUS 3.5X109MM 3 HOLE LCP TITANIUM PROXIMAL RIGHT PERIARTIC","SUP-ITM-10097609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9011.45","5406.87","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5657.39","62.78","","780.86","208.94","10480.28","15","1048.03","6974.86","percent of total billed charges",""
"PLATE HUMERUS 3.5X109MM 3 HOLE LCP TITANIUM PROXIMAL RIGHT PERIARTIC","SUP-ITM-10097609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9011.45","5406.87","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3939.81","43.72","","179.76","179.76","179.76","1 through 10","1048.03","6974.86","percent of total billed charges",""
"PLATE HUMERUS 3.5X109MM 3 HOLE LCP TITANIUM PROXIMAL RIGHT PERIARTIC","SUP-ITM-10097609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9011.45","5406.87","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6553.13","72.72","","2355.45","298.99","3965.19","155","1048.03","6974.86","percent of total billed charges",""
"PLATE HUMERUS 3.5X109MM 3 HOLE LCP TITANIUM PROXIMAL RIGHT PERIARTIC","SUP-ITM-10097609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9011.45","5406.87","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6553.13","72.72","","3643.09","3643.09","3643.09","1 through 10","1048.03","6974.86","percent of total billed charges",""
"PLATE HUMERUS 3.5X109MM 3 HOLE LCP TITANIUM PROXIMAL RIGHT PERIARTIC","SUP-ITM-10097609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9011.45","5406.87","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4795.89","53.22","","554.28","554.28","554.28","16","1048.03","6974.86","percent of total billed charges",""
"PLATE HUMERUS 3.5X109MM 3 HOLE LCP TITANIUM PROXIMAL RIGHT PERIARTIC","SUP-ITM-10097609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9011.45","5406.87","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5668.20","62.9","","619.64","173.09","2370.64","150","1048.03","6974.86","percent of total billed charges",""
"PLATE HUMERUS 3.5X109MM 3 HOLE LCP TITANIUM PROXIMAL RIGHT PERIARTIC","SUP-ITM-10097609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9011.45","5406.87","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6974.86","77.4","","303.98","303.98","5854.79","1 through 10","1048.03","6974.86","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","6119.44","3671.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","711.69","5201.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","6119.44","3671.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","711.69","5201.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","6119.44","3671.66","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3481.96","56.9","","812.12","238.65","1587.46","163","711.69","5201.52","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","6119.44","3671.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","711.69","11.63","","112.68","112.68","146.99","38","711.69","5201.52","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","6119.44","3671.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4736.45","77.4","","303.98","303.98","5854.79","1 through 10","711.69","5201.52","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6119.44","3671.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","711.69","11.63","","112.68","112.68","146.99","38","711.69","4736.45","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6119.44","3671.66","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3841.78","62.78","","780.86","208.94","10480.28","15","711.69","4736.45","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6119.44","3671.66","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2675.42","43.72","","179.76","179.76","179.76","1 through 10","711.69","4736.45","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6119.44","3671.66","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4450.06","72.72","","2355.45","298.99","3965.19","155","711.69","4736.45","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6119.44","3671.66","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4450.06","72.72","","3643.09","3643.09","3643.09","1 through 10","711.69","4736.45","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6119.44","3671.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3256.77","53.22","","554.28","554.28","554.28","16","711.69","4736.45","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6119.44","3671.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3849.13","62.9","","619.64","173.09","2370.64","150","711.69","4736.45","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6119.44","3671.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4736.45","77.4","","303.98","303.98","5854.79","1 through 10","711.69","4736.45","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2309.18","1385.51","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","268.56","1962.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2309.18","1385.51","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","268.56","1962.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2309.18","1385.51","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1313.92","56.9","","812.12","238.65","1587.46","163","268.56","1962.8","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2309.18","1385.51","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","268.56","11.63","","112.68","112.68","146.99","38","268.56","1962.8","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2309.18","1385.51","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1787.31","77.4","","303.98","303.98","5854.79","1 through 10","268.56","1962.8","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2309.18","1385.51","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","268.56","11.63","","112.68","112.68","146.99","38","268.56","1787.31","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2309.18","1385.51","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1449.70","62.78","","780.86","208.94","10480.28","15","268.56","1787.31","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2309.18","1385.51","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1009.57","43.72","","179.76","179.76","179.76","1 through 10","268.56","1787.31","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2309.18","1385.51","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1679.24","72.72","","2355.45","298.99","3965.19","155","268.56","1787.31","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2309.18","1385.51","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1679.24","72.72","","3643.09","3643.09","3643.09","1 through 10","268.56","1787.31","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2309.18","1385.51","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1228.95","53.22","","554.28","554.28","554.28","16","268.56","1787.31","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2309.18","1385.51","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1452.47","62.9","","619.64","173.09","2370.64","150","268.56","1787.31","percent of total billed charges",""
"PLATE MAXILLOMANDIBULAR SM 9 HOLE SMARTLOCK HYBRID","SUP-ITM-10118293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2309.18","1385.51","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1787.31","77.4","","303.98","303.98","5854.79","1 through 10","268.56","1787.31","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X112MM 8 HOLE METAPHYSL LCP SS","SUP-ITM-10029054","CDM","C1713","HCPCS","0278","RC","","","","both","","","4568.82","2741.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","531.35","3883.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE METAPHYSEAL 3.5X112MM 8 HOLE METAPHYSL LCP SS","SUP-ITM-10029054","CDM","C1713","HCPCS","0278","RC","","","","both","","","4568.82","2741.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","531.35","3883.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE METAPHYSEAL 3.5X112MM 8 HOLE METAPHYSL LCP SS","SUP-ITM-10029054","CDM","C1713","HCPCS","0278","RC","","","","both","","","4568.82","2741.29","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2599.66","56.9","","812.12","238.65","1587.46","163","531.35","3883.5","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X112MM 8 HOLE METAPHYSL LCP SS","SUP-ITM-10029054","CDM","C1713","HCPCS","0278","RC","","","","both","","","4568.82","2741.29","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","531.35","11.63","","112.68","112.68","146.99","38","531.35","3883.5","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X112MM 8 HOLE METAPHYSL LCP SS","SUP-ITM-10029054","CDM","C1713","HCPCS","0278","RC","","","","both","","","4568.82","2741.29","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3536.27","77.4","","303.98","303.98","5854.79","1 through 10","531.35","3883.5","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X112MM 8 HOLE METAPHYSL LCP SS","SUP-ITM-10029054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4568.82","2741.29","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","531.35","11.63","","112.68","112.68","146.99","38","531.35","3536.27","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X112MM 8 HOLE METAPHYSL LCP SS","SUP-ITM-10029054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4568.82","2741.29","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2868.31","62.78","","780.86","208.94","10480.28","15","531.35","3536.27","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X112MM 8 HOLE METAPHYSL LCP SS","SUP-ITM-10029054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4568.82","2741.29","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1997.49","43.72","","179.76","179.76","179.76","1 through 10","531.35","3536.27","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X112MM 8 HOLE METAPHYSL LCP SS","SUP-ITM-10029054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4568.82","2741.29","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3322.45","72.72","","2355.45","298.99","3965.19","155","531.35","3536.27","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X112MM 8 HOLE METAPHYSL LCP SS","SUP-ITM-10029054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4568.82","2741.29","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3322.45","72.72","","3643.09","3643.09","3643.09","1 through 10","531.35","3536.27","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X112MM 8 HOLE METAPHYSL LCP SS","SUP-ITM-10029054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4568.82","2741.29","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2431.53","53.22","","554.28","554.28","554.28","16","531.35","3536.27","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X112MM 8 HOLE METAPHYSL LCP SS","SUP-ITM-10029054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4568.82","2741.29","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2873.79","62.9","","619.64","173.09","2370.64","150","531.35","3536.27","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X112MM 8 HOLE METAPHYSL LCP SS","SUP-ITM-10029054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4568.82","2741.29","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3536.27","77.4","","303.98","303.98","5854.79","1 through 10","531.35","3536.27","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","4648.08","2788.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","540.57","3950.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","4648.08","2788.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","540.57","3950.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","4648.08","2788.85","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2644.76","56.9","","812.12","238.65","1587.46","163","540.57","3950.87","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","4648.08","2788.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","540.57","11.63","","112.68","112.68","146.99","38","540.57","3950.87","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","4648.08","2788.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3597.61","77.4","","303.98","303.98","5854.79","1 through 10","540.57","3950.87","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4648.08","2788.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","540.57","11.63","","112.68","112.68","146.99","38","540.57","3597.61","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4648.08","2788.85","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2918.06","62.78","","780.86","208.94","10480.28","15","540.57","3597.61","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4648.08","2788.85","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2032.14","43.72","","179.76","179.76","179.76","1 through 10","540.57","3597.61","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4648.08","2788.85","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3380.08","72.72","","2355.45","298.99","3965.19","155","540.57","3597.61","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4648.08","2788.85","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3380.08","72.72","","3643.09","3643.09","3643.09","1 through 10","540.57","3597.61","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4648.08","2788.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2473.71","53.22","","554.28","554.28","554.28","16","540.57","3597.61","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4648.08","2788.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2923.64","62.9","","619.64","173.09","2370.64","150","540.57","3597.61","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4648.08","2788.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3597.61","77.4","","303.98","303.98","5854.79","1 through 10","540.57","3597.61","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","both","","","6200.00","3720.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","721.06","5270","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","both","","","6200.00","3720.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","721.06","5270","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","both","","","6200.00","3720.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3527.80","56.9","","812.12","238.65","1587.46","163","721.06","5270","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","both","","","6200.00","3720.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","721.06","11.63","","112.68","112.68","146.99","38","721.06","5270","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","both","","","6200.00","3720.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4798.80","77.4","","303.98","303.98","5854.79","1 through 10","721.06","5270","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6200.00","3720.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","721.06","11.63","","112.68","112.68","146.99","38","721.06","4798.8","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6200.00","3720.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3892.36","62.78","","780.86","208.94","10480.28","15","721.06","4798.8","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6200.00","3720.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2710.64","43.72","","179.76","179.76","179.76","1 through 10","721.06","4798.8","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6200.00","3720.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4508.64","72.72","","2355.45","298.99","3965.19","155","721.06","4798.8","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6200.00","3720.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4508.64","72.72","","3643.09","3643.09","3643.09","1 through 10","721.06","4798.8","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6200.00","3720.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3299.64","53.22","","554.28","554.28","554.28","16","721.06","4798.8","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6200.00","3720.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3899.80","62.9","","619.64","173.09","2370.64","150","721.06","4798.8","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X164MM 12 HOLE METAPHYSL LCP SS","SUP-ITM-10029058","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6200.00","3720.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4798.80","77.4","","303.98","303.98","5854.79","1 through 10","721.06","4798.8","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","both","","","4801.48","2880.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","558.41","4081.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","both","","","4801.48","2880.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","558.41","4081.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","both","","","4801.48","2880.89","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2732.04","56.9","","812.12","238.65","1587.46","163","558.41","4081.26","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","both","","","4801.48","2880.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","558.41","11.63","","112.68","112.68","146.99","38","558.41","4081.26","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","both","","","4801.48","2880.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3716.35","77.4","","303.98","303.98","5854.79","1 through 10","558.41","4081.26","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4801.48","2880.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","558.41","11.63","","112.68","112.68","146.99","38","558.41","3716.35","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4801.48","2880.89","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3014.37","62.78","","780.86","208.94","10480.28","15","558.41","3716.35","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4801.48","2880.89","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2099.21","43.72","","179.76","179.76","179.76","1 through 10","558.41","3716.35","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4801.48","2880.89","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3491.64","72.72","","2355.45","298.99","3965.19","155","558.41","3716.35","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4801.48","2880.89","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3491.64","72.72","","3643.09","3643.09","3643.09","1 through 10","558.41","3716.35","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4801.48","2880.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2555.35","53.22","","554.28","554.28","554.28","16","558.41","3716.35","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4801.48","2880.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3020.13","62.9","","619.64","173.09","2370.64","150","558.41","3716.35","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X208MM 11 HOLE LCP SS","SUP-ITM-10029057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4801.48","2880.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3716.35","77.4","","303.98","303.98","5854.79","1 through 10","558.41","3716.35","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X216MM 16 HOLE LCP SS","SUP-ITM-10029084","CDM","C1713","HCPCS","0278","RC","","","","both","","","6532.37","3919.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","759.71","5552.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE METAPHYSEAL 3.5X216MM 16 HOLE LCP SS","SUP-ITM-10029084","CDM","C1713","HCPCS","0278","RC","","","","both","","","6532.37","3919.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","759.71","5552.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE METAPHYSEAL 3.5X216MM 16 HOLE LCP SS","SUP-ITM-10029084","CDM","C1713","HCPCS","0278","RC","","","","both","","","6532.37","3919.42","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3716.92","56.9","","812.12","238.65","1587.46","163","759.71","5552.51","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X216MM 16 HOLE LCP SS","SUP-ITM-10029084","CDM","C1713","HCPCS","0278","RC","","","","both","","","6532.37","3919.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","759.71","11.63","","112.68","112.68","146.99","38","759.71","5552.51","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X216MM 16 HOLE LCP SS","SUP-ITM-10029084","CDM","C1713","HCPCS","0278","RC","","","","both","","","6532.37","3919.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5056.05","77.4","","303.98","303.98","5854.79","1 through 10","759.71","5552.51","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X216MM 16 HOLE LCP SS","SUP-ITM-10029084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6532.37","3919.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","759.71","11.63","","112.68","112.68","146.99","38","759.71","5056.05","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X216MM 16 HOLE LCP SS","SUP-ITM-10029084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6532.37","3919.42","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4101.02","62.78","","780.86","208.94","10480.28","15","759.71","5056.05","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X216MM 16 HOLE LCP SS","SUP-ITM-10029084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6532.37","3919.42","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2855.95","43.72","","179.76","179.76","179.76","1 through 10","759.71","5056.05","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X216MM 16 HOLE LCP SS","SUP-ITM-10029084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6532.37","3919.42","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4750.34","72.72","","2355.45","298.99","3965.19","155","759.71","5056.05","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X216MM 16 HOLE LCP SS","SUP-ITM-10029084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6532.37","3919.42","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4750.34","72.72","","3643.09","3643.09","3643.09","1 through 10","759.71","5056.05","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X216MM 16 HOLE LCP SS","SUP-ITM-10029084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6532.37","3919.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3476.53","53.22","","554.28","554.28","554.28","16","759.71","5056.05","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X216MM 16 HOLE LCP SS","SUP-ITM-10029084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6532.37","3919.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4108.86","62.9","","619.64","173.09","2370.64","150","759.71","5056.05","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X216MM 16 HOLE LCP SS","SUP-ITM-10029084","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6532.37","3919.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5056.05","77.4","","303.98","303.98","5854.79","1 through 10","759.71","5056.05","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","both","","","6396.86","3838.12","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","743.95","5437.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","both","","","6396.86","3838.12","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","743.95","5437.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","both","","","6396.86","3838.12","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3639.81","56.9","","812.12","238.65","1587.46","163","743.95","5437.33","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","both","","","6396.86","3838.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","743.95","11.63","","112.68","112.68","146.99","38","743.95","5437.33","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","both","","","6396.86","3838.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4951.17","77.4","","303.98","303.98","5854.79","1 through 10","743.95","5437.33","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6396.86","3838.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","743.95","11.63","","112.68","112.68","146.99","38","743.95","4951.17","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6396.86","3838.12","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4015.95","62.78","","780.86","208.94","10480.28","15","743.95","4951.17","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6396.86","3838.12","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2796.71","43.72","","179.76","179.76","179.76","1 through 10","743.95","4951.17","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6396.86","3838.12","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4651.80","72.72","","2355.45","298.99","3965.19","155","743.95","4951.17","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6396.86","3838.12","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4651.80","72.72","","3643.09","3643.09","3643.09","1 through 10","743.95","4951.17","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6396.86","3838.12","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3404.41","53.22","","554.28","554.28","554.28","16","743.95","4951.17","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6396.86","3838.12","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4023.62","62.9","","619.64","173.09","2370.64","150","743.95","4951.17","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X242MM 18 HOLE LCP SS","SUP-ITM-10029085","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6396.86","3838.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4951.17","77.4","","303.98","303.98","5854.79","1 through 10","743.95","4951.17","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","both","","","4417.98","2650.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","513.81","3755.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","both","","","4417.98","2650.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","513.81","3755.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","both","","","4417.98","2650.79","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2513.83","56.9","","812.12","238.65","1587.46","163","513.81","3755.28","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","both","","","4417.98","2650.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","513.81","11.63","","112.68","112.68","146.99","38","513.81","3755.28","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","both","","","4417.98","2650.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3419.52","77.4","","303.98","303.98","5854.79","1 through 10","513.81","3755.28","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4417.98","2650.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","513.81","11.63","","112.68","112.68","146.99","38","513.81","3419.52","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4417.98","2650.79","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2773.61","62.78","","780.86","208.94","10480.28","15","513.81","3419.52","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4417.98","2650.79","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1931.54","43.72","","179.76","179.76","179.76","1 through 10","513.81","3419.52","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4417.98","2650.79","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3212.76","72.72","","2355.45","298.99","3965.19","155","513.81","3419.52","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4417.98","2650.79","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3212.76","72.72","","3643.09","3643.09","3643.09","1 through 10","513.81","3419.52","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4417.98","2650.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2351.25","53.22","","554.28","554.28","554.28","16","513.81","3419.52","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4417.98","2650.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2778.91","62.9","","619.64","173.09","2370.64","150","513.81","3419.52","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X86MM 6 HOLE METAPHYSL LCP SS","SUP-ITM-10029572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4417.98","2650.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3419.52","77.4","","303.98","303.98","5854.79","1 through 10","513.81","3419.52","percent of total billed charges",""
"PLATE MIDFACE .6X1.7MM UNIVERSAL 4 HOLE CURVED WITH BAR TITANIUM","SUP-ITM-10042331","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.75","819.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","158.84","1160.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE MIDFACE .6X1.7MM UNIVERSAL 4 HOLE CURVED WITH BAR TITANIUM","SUP-ITM-10042331","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.75","819.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","158.84","1160.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE MIDFACE .6X1.7MM UNIVERSAL 4 HOLE CURVED WITH BAR TITANIUM","SUP-ITM-10042331","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.75","819.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","777.11","56.9","","812.12","238.65","1587.46","163","158.84","1160.89","percent of total billed charges",""
"PLATE MIDFACE .6X1.7MM UNIVERSAL 4 HOLE CURVED WITH BAR TITANIUM","SUP-ITM-10042331","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.75","819.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","158.84","11.63","","112.68","112.68","146.99","38","158.84","1160.89","percent of total billed charges",""
"PLATE MIDFACE .6X1.7MM UNIVERSAL 4 HOLE CURVED WITH BAR TITANIUM","SUP-ITM-10042331","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.75","819.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1057.09","77.4","","303.98","303.98","5854.79","1 through 10","158.84","1160.89","percent of total billed charges",""
"PLATE MIDFACE .6X1.7MM UNIVERSAL 4 HOLE CURVED WITH BAR TITANIUM","SUP-ITM-10042331","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.75","819.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","158.84","11.63","","112.68","112.68","146.99","38","158.84","1057.09","percent of total billed charges",""
"PLATE MIDFACE .6X1.7MM UNIVERSAL 4 HOLE CURVED WITH BAR TITANIUM","SUP-ITM-10042331","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.75","819.45","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","857.42","62.78","","780.86","208.94","10480.28","15","158.84","1057.09","percent of total billed charges",""
"PLATE MIDFACE .6X1.7MM UNIVERSAL 4 HOLE CURVED WITH BAR TITANIUM","SUP-ITM-10042331","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.75","819.45","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","597.11","43.72","","179.76","179.76","179.76","1 through 10","158.84","1057.09","percent of total billed charges",""
"PLATE MIDFACE .6X1.7MM UNIVERSAL 4 HOLE CURVED WITH BAR TITANIUM","SUP-ITM-10042331","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.75","819.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","993.17","72.72","","2355.45","298.99","3965.19","155","158.84","1057.09","percent of total billed charges",""
"PLATE MIDFACE .6X1.7MM UNIVERSAL 4 HOLE CURVED WITH BAR TITANIUM","SUP-ITM-10042331","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.75","819.45","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","993.17","72.72","","3643.09","3643.09","3643.09","1 through 10","158.84","1057.09","percent of total billed charges",""
"PLATE MIDFACE .6X1.7MM UNIVERSAL 4 HOLE CURVED WITH BAR TITANIUM","SUP-ITM-10042331","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.75","819.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","726.85","53.22","","554.28","554.28","554.28","16","158.84","1057.09","percent of total billed charges",""
"PLATE MIDFACE .6X1.7MM UNIVERSAL 4 HOLE CURVED WITH BAR TITANIUM","SUP-ITM-10042331","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.75","819.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","859.06","62.9","","619.64","173.09","2370.64","150","158.84","1057.09","percent of total billed charges",""
"PLATE MIDFACE .6X1.7MM UNIVERSAL 4 HOLE CURVED WITH BAR TITANIUM","SUP-ITM-10042331","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.75","819.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1057.09","77.4","","303.98","303.98","5854.79","1 through 10","158.84","1057.09","percent of total billed charges",""
"PLATE MIDFACE .6X1.7MM UNIVERSAL 8 HOLE 2 TITANIUM STRAIGHT","SUP-ITM-10042326","CDM","C1713","HCPCS","0278","RC","","","","both","","","1693.12","1015.87","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","196.91","1439.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE MIDFACE .6X1.7MM UNIVERSAL 8 HOLE 2 TITANIUM STRAIGHT","SUP-ITM-10042326","CDM","C1713","HCPCS","0278","RC","","","","both","","","1693.12","1015.87","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","196.91","1439.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE MIDFACE .6X1.7MM UNIVERSAL 8 HOLE 2 TITANIUM STRAIGHT","SUP-ITM-10042326","CDM","C1713","HCPCS","0278","RC","","","","both","","","1693.12","1015.87","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","963.39","56.9","","812.12","238.65","1587.46","163","196.91","1439.15","percent of total billed charges",""
"PLATE MIDFACE .6X1.7MM UNIVERSAL 8 HOLE 2 TITANIUM STRAIGHT","SUP-ITM-10042326","CDM","C1713","HCPCS","0278","RC","","","","both","","","1693.12","1015.87","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","196.91","11.63","","112.68","112.68","146.99","38","196.91","1439.15","percent of total billed charges",""
"PLATE MIDFACE .6X1.7MM UNIVERSAL 8 HOLE 2 TITANIUM STRAIGHT","SUP-ITM-10042326","CDM","C1713","HCPCS","0278","RC","","","","both","","","1693.12","1015.87","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1310.47","77.4","","303.98","303.98","5854.79","1 through 10","196.91","1439.15","percent of total billed charges",""
"PLATE MIDFACE .6X1.7MM UNIVERSAL 8 HOLE 2 TITANIUM STRAIGHT","SUP-ITM-10042326","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1693.12","1015.87","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","196.91","11.63","","112.68","112.68","146.99","38","196.91","1310.47","percent of total billed charges",""
"PLATE MIDFACE .6X1.7MM UNIVERSAL 8 HOLE 2 TITANIUM STRAIGHT","SUP-ITM-10042326","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1693.12","1015.87","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1062.94","62.78","","780.86","208.94","10480.28","15","196.91","1310.47","percent of total billed charges",""
"PLATE MIDFACE .6X1.7MM UNIVERSAL 8 HOLE 2 TITANIUM STRAIGHT","SUP-ITM-10042326","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1693.12","1015.87","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","740.23","43.72","","179.76","179.76","179.76","1 through 10","196.91","1310.47","percent of total billed charges",""
"PLATE MIDFACE .6X1.7MM UNIVERSAL 8 HOLE 2 TITANIUM STRAIGHT","SUP-ITM-10042326","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1693.12","1015.87","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1231.24","72.72","","2355.45","298.99","3965.19","155","196.91","1310.47","percent of total billed charges",""
"PLATE MIDFACE .6X1.7MM UNIVERSAL 8 HOLE 2 TITANIUM STRAIGHT","SUP-ITM-10042326","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1693.12","1015.87","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1231.24","72.72","","3643.09","3643.09","3643.09","1 through 10","196.91","1310.47","percent of total billed charges",""
"PLATE MIDFACE .6X1.7MM UNIVERSAL 8 HOLE 2 TITANIUM STRAIGHT","SUP-ITM-10042326","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1693.12","1015.87","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","901.08","53.22","","554.28","554.28","554.28","16","196.91","1310.47","percent of total billed charges",""
"PLATE MIDFACE .6X1.7MM UNIVERSAL 8 HOLE 2 TITANIUM STRAIGHT","SUP-ITM-10042326","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1693.12","1015.87","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1064.97","62.9","","619.64","173.09","2370.64","150","196.91","1310.47","percent of total billed charges",""
"PLATE MIDFACE .6X1.7MM UNIVERSAL 8 HOLE 2 TITANIUM STRAIGHT","SUP-ITM-10042326","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1693.12","1015.87","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1310.47","77.4","","303.98","303.98","5854.79","1 through 10","196.91","1310.47","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","both","","","4028.23","2416.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","468.48","3424","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","both","","","4028.23","2416.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","468.48","3424","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","both","","","4028.23","2416.94","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2292.06","56.9","","812.12","238.65","1587.46","163","468.48","3424","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","both","","","4028.23","2416.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","468.48","11.63","","112.68","112.68","146.99","38","468.48","3424","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","both","","","4028.23","2416.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3117.85","77.4","","303.98","303.98","5854.79","1 through 10","468.48","3424","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4028.23","2416.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","468.48","11.63","","112.68","112.68","146.99","38","468.48","3117.85","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4028.23","2416.94","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2528.92","62.78","","780.86","208.94","10480.28","15","468.48","3117.85","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4028.23","2416.94","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1761.14","43.72","","179.76","179.76","179.76","1 through 10","468.48","3117.85","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4028.23","2416.94","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2929.33","72.72","","2355.45","298.99","3965.19","155","468.48","3117.85","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4028.23","2416.94","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2929.33","72.72","","3643.09","3643.09","3643.09","1 through 10","468.48","3117.85","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4028.23","2416.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2143.82","53.22","","554.28","554.28","554.28","16","468.48","3117.85","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4028.23","2416.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2533.76","62.9","","619.64","173.09","2370.64","150","468.48","3117.85","percent of total billed charges",""
"PLATE MIDFACE 0.6X1.7MM UNIVERSAL 24 HOLE BONE 2 TITANIUM STRAIGHT MID FACE","SUP-ITM-10042327","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4028.23","2416.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3117.85","77.4","","303.98","303.98","5854.79","1 through 10","468.48","3117.85","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","5509.69","3305.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","640.78","4683.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","5509.69","3305.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","640.78","4683.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","5509.69","3305.81","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3135.01","56.9","","812.12","238.65","1587.46","163","640.78","4683.24","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","5509.69","3305.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","640.78","11.63","","112.68","112.68","146.99","38","640.78","4683.24","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","5509.69","3305.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4264.50","77.4","","303.98","303.98","5854.79","1 through 10","640.78","4683.24","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5509.69","3305.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","640.78","11.63","","112.68","112.68","146.99","38","640.78","4264.5","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5509.69","3305.81","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3458.98","62.78","","780.86","208.94","10480.28","15","640.78","4264.5","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5509.69","3305.81","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2408.84","43.72","","179.76","179.76","179.76","1 through 10","640.78","4264.5","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5509.69","3305.81","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4006.65","72.72","","2355.45","298.99","3965.19","155","640.78","4264.5","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5509.69","3305.81","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4006.65","72.72","","3643.09","3643.09","3643.09","1 through 10","640.78","4264.5","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5509.69","3305.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2932.26","53.22","","554.28","554.28","554.28","16","640.78","4264.5","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5509.69","3305.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3465.60","62.9","","619.64","173.09","2370.64","150","640.78","4264.5","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5509.69","3305.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4264.50","77.4","","303.98","303.98","5854.79","1 through 10","640.78","4264.5","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","both","","","5865.07","3519.04","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","682.11","4985.31","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","both","","","5865.07","3519.04","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","682.11","4985.31","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","both","","","5865.07","3519.04","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3337.22","56.9","","812.12","238.65","1587.46","163","682.11","4985.31","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","both","","","5865.07","3519.04","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","682.11","11.63","","112.68","112.68","146.99","38","682.11","4985.31","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","both","","","5865.07","3519.04","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4539.56","77.4","","303.98","303.98","5854.79","1 through 10","682.11","4985.31","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5865.07","3519.04","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","682.11","11.63","","112.68","112.68","146.99","38","682.11","4539.56","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5865.07","3519.04","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3682.09","62.78","","780.86","208.94","10480.28","15","682.11","4539.56","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5865.07","3519.04","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2564.21","43.72","","179.76","179.76","179.76","1 through 10","682.11","4539.56","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5865.07","3519.04","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4265.08","72.72","","2355.45","298.99","3965.19","155","682.11","4539.56","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5865.07","3519.04","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4265.08","72.72","","3643.09","3643.09","3643.09","1 through 10","682.11","4539.56","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5865.07","3519.04","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3121.39","53.22","","554.28","554.28","554.28","16","682.11","4539.56","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5865.07","3519.04","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3689.13","62.9","","619.64","173.09","2370.64","150","682.11","4539.56","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X169MM 8 HOLE VA LCP SS RIGHT","SUP-ITM-10114054","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5865.07","3519.04","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4539.56","77.4","","303.98","303.98","5854.79","1 through 10","682.11","4539.56","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","5366.51","3219.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","624.13","4561.53","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","5366.51","3219.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","624.13","4561.53","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","5366.51","3219.91","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3053.54","56.9","","812.12","238.65","1587.46","163","624.13","4561.53","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","5366.51","3219.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","624.13","11.63","","112.68","112.68","146.99","38","624.13","4561.53","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","5366.51","3219.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4153.68","77.4","","303.98","303.98","5854.79","1 through 10","624.13","4561.53","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5366.51","3219.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","624.13","11.63","","112.68","112.68","146.99","38","624.13","4153.68","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5366.51","3219.91","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3369.09","62.78","","780.86","208.94","10480.28","15","624.13","4153.68","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5366.51","3219.91","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2346.24","43.72","","179.76","179.76","179.76","1 through 10","624.13","4153.68","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5366.51","3219.91","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3902.53","72.72","","2355.45","298.99","3965.19","155","624.13","4153.68","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5366.51","3219.91","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3902.53","72.72","","3643.09","3643.09","3643.09","1 through 10","624.13","4153.68","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5366.51","3219.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2856.06","53.22","","554.28","554.28","554.28","16","624.13","4153.68","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5366.51","3219.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3375.53","62.9","","619.64","173.09","2370.64","150","624.13","4153.68","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5366.51","3219.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4153.68","77.4","","303.98","303.98","5854.79","1 through 10","624.13","4153.68","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","6264.84","3758.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","728.6","5325.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","6264.84","3758.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","728.6","5325.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","6264.84","3758.90","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3564.69","56.9","","812.12","238.65","1587.46","163","728.6","5325.11","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","6264.84","3758.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","728.60","11.63","","112.68","112.68","146.99","38","728.6","5325.11","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","6264.84","3758.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4848.99","77.4","","303.98","303.98","5854.79","1 through 10","728.6","5325.11","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6264.84","3758.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","728.60","11.63","","112.68","112.68","146.99","38","728.6","4848.99","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6264.84","3758.90","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3933.07","62.78","","780.86","208.94","10480.28","15","728.6","4848.99","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6264.84","3758.90","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2738.99","43.72","","179.76","179.76","179.76","1 through 10","728.6","4848.99","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6264.84","3758.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4555.79","72.72","","2355.45","298.99","3965.19","155","728.6","4848.99","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6264.84","3758.90","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4555.79","72.72","","3643.09","3643.09","3643.09","1 through 10","728.6","4848.99","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6264.84","3758.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3334.15","53.22","","554.28","554.28","554.28","16","728.6","4848.99","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6264.84","3758.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3940.58","62.9","","619.64","173.09","2370.64","150","728.6","4848.99","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6264.84","3758.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4848.99","77.4","","303.98","303.98","5854.79","1 through 10","728.6","4848.99","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10024519","CDM","C1713","HCPCS","0278","RC","","","","both","","","6356.60","3813.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","739.27","5403.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10024519","CDM","C1713","HCPCS","0278","RC","","","","both","","","6356.60","3813.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","739.27","5403.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10024519","CDM","C1713","HCPCS","0278","RC","","","","both","","","6356.60","3813.96","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3616.91","56.9","","812.12","238.65","1587.46","163","739.27","5403.11","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10024519","CDM","C1713","HCPCS","0278","RC","","","","both","","","6356.60","3813.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","739.27","11.63","","112.68","112.68","146.99","38","739.27","5403.11","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10024519","CDM","C1713","HCPCS","0278","RC","","","","both","","","6356.60","3813.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4920.01","77.4","","303.98","303.98","5854.79","1 through 10","739.27","5403.11","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10024519","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6356.60","3813.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","739.27","11.63","","112.68","112.68","146.99","38","739.27","4920.01","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10024519","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6356.60","3813.96","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3990.67","62.78","","780.86","208.94","10480.28","15","739.27","4920.01","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10024519","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6356.60","3813.96","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2779.11","43.72","","179.76","179.76","179.76","1 through 10","739.27","4920.01","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10024519","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6356.60","3813.96","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4622.52","72.72","","2355.45","298.99","3965.19","155","739.27","4920.01","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10024519","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6356.60","3813.96","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4622.52","72.72","","3643.09","3643.09","3643.09","1 through 10","739.27","4920.01","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10024519","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6356.60","3813.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3382.98","53.22","","554.28","554.28","554.28","16","739.27","4920.01","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10024519","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6356.60","3813.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3998.30","62.9","","619.64","173.09","2370.64","150","739.27","4920.01","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10024519","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6356.60","3813.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4920.01","77.4","","303.98","303.98","5854.79","1 through 10","739.27","4920.01","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL STERILE","SUP-ITM-10036547","CDM","C1713","HCPCS","0278","RC","","","","both","","","6990.60","4194.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","813.01","5942.01","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL STERILE","SUP-ITM-10036547","CDM","C1713","HCPCS","0278","RC","","","","both","","","6990.60","4194.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","813.01","5942.01","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL STERILE","SUP-ITM-10036547","CDM","C1713","HCPCS","0278","RC","","","","both","","","6990.60","4194.36","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3977.65","56.9","","812.12","238.65","1587.46","163","813.01","5942.01","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL STERILE","SUP-ITM-10036547","CDM","C1713","HCPCS","0278","RC","","","","both","","","6990.60","4194.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","813.01","11.63","","112.68","112.68","146.99","38","813.01","5942.01","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL STERILE","SUP-ITM-10036547","CDM","C1713","HCPCS","0278","RC","","","","both","","","6990.60","4194.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5410.72","77.4","","303.98","303.98","5854.79","1 through 10","813.01","5942.01","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL STERILE","SUP-ITM-10036547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6990.60","4194.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","813.01","11.63","","112.68","112.68","146.99","38","813.01","5410.72","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL STERILE","SUP-ITM-10036547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6990.60","4194.36","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4388.70","62.78","","780.86","208.94","10480.28","15","813.01","5410.72","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL STERILE","SUP-ITM-10036547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6990.60","4194.36","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3056.29","43.72","","179.76","179.76","179.76","1 through 10","813.01","5410.72","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL STERILE","SUP-ITM-10036547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6990.60","4194.36","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5083.56","72.72","","2355.45","298.99","3965.19","155","813.01","5410.72","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL STERILE","SUP-ITM-10036547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6990.60","4194.36","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5083.56","72.72","","3643.09","3643.09","3643.09","1 through 10","813.01","5410.72","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL STERILE","SUP-ITM-10036547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6990.60","4194.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3720.40","53.22","","554.28","554.28","554.28","16","813.01","5410.72","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL STERILE","SUP-ITM-10036547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6990.60","4194.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4397.09","62.9","","619.64","173.09","2370.64","150","813.01","5410.72","percent of total billed charges",""
"PLATE RADIUS 154MM 9 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL STERILE","SUP-ITM-10036547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6990.60","4194.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5410.72","77.4","","303.98","303.98","5854.79","1 through 10","813.01","5410.72","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","both","","","4185.80","2511.48","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","486.81","3557.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","both","","","4185.80","2511.48","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","486.81","3557.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","both","","","4185.80","2511.48","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2381.72","56.9","","812.12","238.65","1587.46","163","486.81","3557.93","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","both","","","4185.80","2511.48","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","486.81","11.63","","112.68","112.68","146.99","38","486.81","3557.93","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","both","","","4185.80","2511.48","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3239.81","77.4","","303.98","303.98","5854.79","1 through 10","486.81","3557.93","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4185.80","2511.48","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","486.81","11.63","","112.68","112.68","146.99","38","486.81","3239.81","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4185.80","2511.48","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2627.85","62.78","","780.86","208.94","10480.28","15","486.81","3239.81","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4185.80","2511.48","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1830.03","43.72","","179.76","179.76","179.76","1 through 10","486.81","3239.81","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4185.80","2511.48","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3043.91","72.72","","2355.45","298.99","3965.19","155","486.81","3239.81","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4185.80","2511.48","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3043.91","72.72","","3643.09","3643.09","3643.09","1 through 10","486.81","3239.81","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4185.80","2511.48","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2227.68","53.22","","554.28","554.28","554.28","16","486.81","3239.81","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4185.80","2511.48","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2632.87","62.9","","619.64","173.09","2370.64","150","486.81","3239.81","percent of total billed charges",""
"PLATE RADIUS 2.4MM 6 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4185.80","2511.48","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3239.81","77.4","","303.98","303.98","5854.79","1 through 10","486.81","3239.81","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095967","CDM","C1713","HCPCS","0278","RC","","","","both","","","4070.82","2442.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","473.44","3460.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095967","CDM","C1713","HCPCS","0278","RC","","","","both","","","4070.82","2442.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","473.44","3460.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095967","CDM","C1713","HCPCS","0278","RC","","","","both","","","4070.82","2442.49","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2316.30","56.9","","812.12","238.65","1587.46","163","473.44","3460.2","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095967","CDM","C1713","HCPCS","0278","RC","","","","both","","","4070.82","2442.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","473.44","11.63","","112.68","112.68","146.99","38","473.44","3460.2","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095967","CDM","C1713","HCPCS","0278","RC","","","","both","","","4070.82","2442.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3150.81","77.4","","303.98","303.98","5854.79","1 through 10","473.44","3460.2","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4070.82","2442.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","473.44","11.63","","112.68","112.68","146.99","38","473.44","3150.81","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4070.82","2442.49","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2555.66","62.78","","780.86","208.94","10480.28","15","473.44","3150.81","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4070.82","2442.49","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1779.76","43.72","","179.76","179.76","179.76","1 through 10","473.44","3150.81","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4070.82","2442.49","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2960.30","72.72","","2355.45","298.99","3965.19","155","473.44","3150.81","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4070.82","2442.49","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2960.30","72.72","","3643.09","3643.09","3643.09","1 through 10","473.44","3150.81","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4070.82","2442.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2166.49","53.22","","554.28","554.28","554.28","16","473.44","3150.81","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4070.82","2442.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2560.55","62.9","","619.64","173.09","2370.64","150","473.44","3150.81","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 2 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4070.82","2442.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3150.81","77.4","","303.98","303.98","5854.79","1 through 10","473.44","3150.81","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","5176.21","3105.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","601.99","4399.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","5176.21","3105.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","601.99","4399.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","5176.21","3105.73","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2945.26","56.9","","812.12","238.65","1587.46","163","601.99","4399.78","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","5176.21","3105.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","601.99","11.63","","112.68","112.68","146.99","38","601.99","4399.78","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","5176.21","3105.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4006.39","77.4","","303.98","303.98","5854.79","1 through 10","601.99","4399.78","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5176.21","3105.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","601.99","11.63","","112.68","112.68","146.99","38","601.99","4006.39","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5176.21","3105.73","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3249.62","62.78","","780.86","208.94","10480.28","15","601.99","4006.39","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5176.21","3105.73","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2263.04","43.72","","179.76","179.76","179.76","1 through 10","601.99","4006.39","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5176.21","3105.73","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3764.14","72.72","","2355.45","298.99","3965.19","155","601.99","4006.39","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5176.21","3105.73","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3764.14","72.72","","3643.09","3643.09","3643.09","1 through 10","601.99","4006.39","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5176.21","3105.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2754.78","53.22","","554.28","554.28","554.28","16","601.99","4006.39","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5176.21","3105.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3255.84","62.9","","619.64","173.09","2370.64","150","601.99","4006.39","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5176.21","3105.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4006.39","77.4","","303.98","303.98","5854.79","1 through 10","601.99","4006.39","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095979","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.77","2649.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","513.55","3753.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095979","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.77","2649.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","513.55","3753.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095979","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.77","2649.46","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2512.57","56.9","","812.12","238.65","1587.46","163","513.55","3753.4","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095979","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.77","2649.46","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","513.55","11.63","","112.68","112.68","146.99","38","513.55","3753.4","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095979","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.77","2649.46","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3417.81","77.4","","303.98","303.98","5854.79","1 through 10","513.55","3753.4","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4415.77","2649.46","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","513.55","11.63","","112.68","112.68","146.99","38","513.55","3417.81","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4415.77","2649.46","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2772.22","62.78","","780.86","208.94","10480.28","15","513.55","3417.81","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4415.77","2649.46","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1930.57","43.72","","179.76","179.76","179.76","1 through 10","513.55","3417.81","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4415.77","2649.46","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3211.15","72.72","","2355.45","298.99","3965.19","155","513.55","3417.81","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4415.77","2649.46","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3211.15","72.72","","3643.09","3643.09","3643.09","1 through 10","513.55","3417.81","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4415.77","2649.46","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2350.07","53.22","","554.28","554.28","554.28","16","513.55","3417.81","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4415.77","2649.46","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2777.52","62.9","","619.64","173.09","2370.64","150","513.55","3417.81","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 7 HOLE HEAD 4 SHAFT VOLAR VA LCP TITANIUM COMPRESSION RIGHT","SUP-ITM-10095979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4415.77","2649.46","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3417.81","77.4","","303.98","303.98","5854.79","1 through 10","513.55","3417.81","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","5369.69","3221.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","624.49","4564.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","5369.69","3221.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","624.49","4564.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","5369.69","3221.81","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3055.35","56.9","","812.12","238.65","1587.46","163","624.49","4564.24","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","5369.69","3221.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","624.49","11.63","","112.68","112.68","146.99","38","624.49","4564.24","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","5369.69","3221.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4156.14","77.4","","303.98","303.98","5854.79","1 through 10","624.49","4564.24","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5369.69","3221.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","624.49","11.63","","112.68","112.68","146.99","38","624.49","4156.14","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5369.69","3221.81","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3371.09","62.78","","780.86","208.94","10480.28","15","624.49","4156.14","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5369.69","3221.81","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2347.63","43.72","","179.76","179.76","179.76","1 through 10","624.49","4156.14","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5369.69","3221.81","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3904.84","72.72","","2355.45","298.99","3965.19","155","624.49","4156.14","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5369.69","3221.81","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3904.84","72.72","","3643.09","3643.09","3643.09","1 through 10","624.49","4156.14","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5369.69","3221.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2857.75","53.22","","554.28","554.28","554.28","16","624.49","4156.14","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5369.69","3221.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3377.54","62.9","","619.64","173.09","2370.64","150","624.49","4156.14","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5369.69","3221.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4156.14","77.4","","303.98","303.98","5854.79","1 through 10","624.49","4156.14","percent of total billed charges",""
"PLATE RADIUS 2.4X37MM 2X3 HOLE 90DEG DORSAL DISTAL VARIABLE ANGLE LOCKING COMPRESSION","SUP-ITM-10096088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3847.83","2308.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","447.5","3270.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 2.4X37MM 2X3 HOLE 90DEG DORSAL DISTAL VARIABLE ANGLE LOCKING COMPRESSION","SUP-ITM-10096088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3847.83","2308.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","447.5","3270.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 2.4X37MM 2X3 HOLE 90DEG DORSAL DISTAL VARIABLE ANGLE LOCKING COMPRESSION","SUP-ITM-10096088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3847.83","2308.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2189.42","56.9","","812.12","238.65","1587.46","163","447.5","3270.66","percent of total billed charges",""
"PLATE RADIUS 2.4X37MM 2X3 HOLE 90DEG DORSAL DISTAL VARIABLE ANGLE LOCKING COMPRESSION","SUP-ITM-10096088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3847.83","2308.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","447.50","11.63","","112.68","112.68","146.99","38","447.5","3270.66","percent of total billed charges",""
"PLATE RADIUS 2.4X37MM 2X3 HOLE 90DEG DORSAL DISTAL VARIABLE ANGLE LOCKING COMPRESSION","SUP-ITM-10096088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3847.83","2308.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2978.22","77.4","","303.98","303.98","5854.79","1 through 10","447.5","3270.66","percent of total billed charges",""
"PLATE RADIUS 2.4X37MM 2X3 HOLE 90DEG DORSAL DISTAL VARIABLE ANGLE LOCKING COMPRESSION","SUP-ITM-10096088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3847.83","2308.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","447.50","11.63","","112.68","112.68","146.99","38","447.5","2978.22","percent of total billed charges",""
"PLATE RADIUS 2.4X37MM 2X3 HOLE 90DEG DORSAL DISTAL VARIABLE ANGLE LOCKING COMPRESSION","SUP-ITM-10096088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3847.83","2308.70","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2415.67","62.78","","780.86","208.94","10480.28","15","447.5","2978.22","percent of total billed charges",""
"PLATE RADIUS 2.4X37MM 2X3 HOLE 90DEG DORSAL DISTAL VARIABLE ANGLE LOCKING COMPRESSION","SUP-ITM-10096088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3847.83","2308.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1682.27","43.72","","179.76","179.76","179.76","1 through 10","447.5","2978.22","percent of total billed charges",""
"PLATE RADIUS 2.4X37MM 2X3 HOLE 90DEG DORSAL DISTAL VARIABLE ANGLE LOCKING COMPRESSION","SUP-ITM-10096088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3847.83","2308.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2798.14","72.72","","2355.45","298.99","3965.19","155","447.5","2978.22","percent of total billed charges",""
"PLATE RADIUS 2.4X37MM 2X3 HOLE 90DEG DORSAL DISTAL VARIABLE ANGLE LOCKING COMPRESSION","SUP-ITM-10096088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3847.83","2308.70","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2798.14","72.72","","3643.09","3643.09","3643.09","1 through 10","447.5","2978.22","percent of total billed charges",""
"PLATE RADIUS 2.4X37MM 2X3 HOLE 90DEG DORSAL DISTAL VARIABLE ANGLE LOCKING COMPRESSION","SUP-ITM-10096088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3847.83","2308.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2047.82","53.22","","554.28","554.28","554.28","16","447.5","2978.22","percent of total billed charges",""
"PLATE RADIUS 2.4X37MM 2X3 HOLE 90DEG DORSAL DISTAL VARIABLE ANGLE LOCKING COMPRESSION","SUP-ITM-10096088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3847.83","2308.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2420.29","62.9","","619.64","173.09","2370.64","150","447.5","2978.22","percent of total billed charges",""
"PLATE RADIUS 2.4X37MM 2X3 HOLE 90DEG DORSAL DISTAL VARIABLE ANGLE LOCKING COMPRESSION","SUP-ITM-10096088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3847.83","2308.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2978.22","77.4","","303.98","303.98","5854.79","1 through 10","447.5","2978.22","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM DISTAL 3X3 HOLE LCP T SHAPE","SUP-ITM-10016924","CDM","C1713","HCPCS","0278","RC","","","","both","","","3913.20","2347.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","455.11","3326.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 2.4X40MM DISTAL 3X3 HOLE LCP T SHAPE","SUP-ITM-10016924","CDM","C1713","HCPCS","0278","RC","","","","both","","","3913.20","2347.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","455.11","3326.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 2.4X40MM DISTAL 3X3 HOLE LCP T SHAPE","SUP-ITM-10016924","CDM","C1713","HCPCS","0278","RC","","","","both","","","3913.20","2347.92","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2226.61","56.9","","812.12","238.65","1587.46","163","455.11","3326.22","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM DISTAL 3X3 HOLE LCP T SHAPE","SUP-ITM-10016924","CDM","C1713","HCPCS","0278","RC","","","","both","","","3913.20","2347.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","455.11","11.63","","112.68","112.68","146.99","38","455.11","3326.22","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM DISTAL 3X3 HOLE LCP T SHAPE","SUP-ITM-10016924","CDM","C1713","HCPCS","0278","RC","","","","both","","","3913.20","2347.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3028.82","77.4","","303.98","303.98","5854.79","1 through 10","455.11","3326.22","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM DISTAL 3X3 HOLE LCP T SHAPE","SUP-ITM-10016924","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3913.20","2347.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","455.11","11.63","","112.68","112.68","146.99","38","455.11","3028.82","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM DISTAL 3X3 HOLE LCP T SHAPE","SUP-ITM-10016924","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3913.20","2347.92","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2456.71","62.78","","780.86","208.94","10480.28","15","455.11","3028.82","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM DISTAL 3X3 HOLE LCP T SHAPE","SUP-ITM-10016924","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3913.20","2347.92","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1710.85","43.72","","179.76","179.76","179.76","1 through 10","455.11","3028.82","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM DISTAL 3X3 HOLE LCP T SHAPE","SUP-ITM-10016924","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3913.20","2347.92","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2845.68","72.72","","2355.45","298.99","3965.19","155","455.11","3028.82","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM DISTAL 3X3 HOLE LCP T SHAPE","SUP-ITM-10016924","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3913.20","2347.92","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2845.68","72.72","","3643.09","3643.09","3643.09","1 through 10","455.11","3028.82","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM DISTAL 3X3 HOLE LCP T SHAPE","SUP-ITM-10016924","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3913.20","2347.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2082.61","53.22","","554.28","554.28","554.28","16","455.11","3028.82","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM DISTAL 3X3 HOLE LCP T SHAPE","SUP-ITM-10016924","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3913.20","2347.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2461.40","62.9","","619.64","173.09","2370.64","150","455.11","3028.82","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM DISTAL 3X3 HOLE LCP T SHAPE","SUP-ITM-10016924","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3913.20","2347.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3028.82","77.4","","303.98","303.98","5854.79","1 through 10","455.11","3028.82","percent of total billed charges",""
"PLATE RADIUS 2.4X55MM 7 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095977","CDM","C1713","HCPCS","0278","RC","","","","both","","","4238.87","2543.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","492.98","3603.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 2.4X55MM 7 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095977","CDM","C1713","HCPCS","0278","RC","","","","both","","","4238.87","2543.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","492.98","3603.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 2.4X55MM 7 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095977","CDM","C1713","HCPCS","0278","RC","","","","both","","","4238.87","2543.32","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2411.92","56.9","","812.12","238.65","1587.46","163","492.98","3603.04","percent of total billed charges",""
"PLATE RADIUS 2.4X55MM 7 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095977","CDM","C1713","HCPCS","0278","RC","","","","both","","","4238.87","2543.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","492.98","11.63","","112.68","112.68","146.99","38","492.98","3603.04","percent of total billed charges",""
"PLATE RADIUS 2.4X55MM 7 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095977","CDM","C1713","HCPCS","0278","RC","","","","both","","","4238.87","2543.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3280.89","77.4","","303.98","303.98","5854.79","1 through 10","492.98","3603.04","percent of total billed charges",""
"PLATE RADIUS 2.4X55MM 7 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4238.87","2543.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","492.98","11.63","","112.68","112.68","146.99","38","492.98","3280.89","percent of total billed charges",""
"PLATE RADIUS 2.4X55MM 7 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4238.87","2543.32","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2661.16","62.78","","780.86","208.94","10480.28","15","492.98","3280.89","percent of total billed charges",""
"PLATE RADIUS 2.4X55MM 7 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4238.87","2543.32","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1853.23","43.72","","179.76","179.76","179.76","1 through 10","492.98","3280.89","percent of total billed charges",""
"PLATE RADIUS 2.4X55MM 7 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4238.87","2543.32","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3082.51","72.72","","2355.45","298.99","3965.19","155","492.98","3280.89","percent of total billed charges",""
"PLATE RADIUS 2.4X55MM 7 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4238.87","2543.32","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3082.51","72.72","","3643.09","3643.09","3643.09","1 through 10","492.98","3280.89","percent of total billed charges",""
"PLATE RADIUS 2.4X55MM 7 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4238.87","2543.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2255.93","53.22","","554.28","554.28","554.28","16","492.98","3280.89","percent of total billed charges",""
"PLATE RADIUS 2.4X55MM 7 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4238.87","2543.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2666.25","62.9","","619.64","173.09","2370.64","150","492.98","3280.89","percent of total billed charges",""
"PLATE RADIUS 2.4X55MM 7 HOLE HEAD 3 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4238.87","2543.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3280.89","77.4","","303.98","303.98","5854.79","1 through 10","492.98","3280.89","percent of total billed charges",""
"PLATE RADIUS 2.4X77MM 7 HOLE HEAD 5 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095981","CDM","C1713","HCPCS","0278","RC","","","","both","","","4581.61","2748.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","532.84","3894.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 2.4X77MM 7 HOLE HEAD 5 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095981","CDM","C1713","HCPCS","0278","RC","","","","both","","","4581.61","2748.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","532.84","3894.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 2.4X77MM 7 HOLE HEAD 5 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095981","CDM","C1713","HCPCS","0278","RC","","","","both","","","4581.61","2748.97","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2606.94","56.9","","812.12","238.65","1587.46","163","532.84","3894.37","percent of total billed charges",""
"PLATE RADIUS 2.4X77MM 7 HOLE HEAD 5 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095981","CDM","C1713","HCPCS","0278","RC","","","","both","","","4581.61","2748.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","532.84","11.63","","112.68","112.68","146.99","38","532.84","3894.37","percent of total billed charges",""
"PLATE RADIUS 2.4X77MM 7 HOLE HEAD 5 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095981","CDM","C1713","HCPCS","0278","RC","","","","both","","","4581.61","2748.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3546.17","77.4","","303.98","303.98","5854.79","1 through 10","532.84","3894.37","percent of total billed charges",""
"PLATE RADIUS 2.4X77MM 7 HOLE HEAD 5 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4581.61","2748.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","532.84","11.63","","112.68","112.68","146.99","38","532.84","3546.17","percent of total billed charges",""
"PLATE RADIUS 2.4X77MM 7 HOLE HEAD 5 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4581.61","2748.97","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2876.33","62.78","","780.86","208.94","10480.28","15","532.84","3546.17","percent of total billed charges",""
"PLATE RADIUS 2.4X77MM 7 HOLE HEAD 5 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4581.61","2748.97","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2003.08","43.72","","179.76","179.76","179.76","1 through 10","532.84","3546.17","percent of total billed charges",""
"PLATE RADIUS 2.4X77MM 7 HOLE HEAD 5 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4581.61","2748.97","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3331.75","72.72","","2355.45","298.99","3965.19","155","532.84","3546.17","percent of total billed charges",""
"PLATE RADIUS 2.4X77MM 7 HOLE HEAD 5 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4581.61","2748.97","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3331.75","72.72","","3643.09","3643.09","3643.09","1 through 10","532.84","3546.17","percent of total billed charges",""
"PLATE RADIUS 2.4X77MM 7 HOLE HEAD 5 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4581.61","2748.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2438.33","53.22","","554.28","554.28","554.28","16","532.84","3546.17","percent of total billed charges",""
"PLATE RADIUS 2.4X77MM 7 HOLE HEAD 5 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4581.61","2748.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2881.83","62.9","","619.64","173.09","2370.64","150","532.84","3546.17","percent of total billed charges",""
"PLATE RADIUS 2.4X77MM 7 HOLE HEAD 5 SHAFT VOLAR VA LCP TITANIUM COMPRESSION DISTAL RIGHT","SUP-ITM-10095981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4581.61","2748.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3546.17","77.4","","303.98","303.98","5854.79","1 through 10","532.84","3546.17","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","both","","","7523.81","4514.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","875.02","6395.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","both","","","7523.81","4514.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","875.02","6395.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","both","","","7523.81","4514.29","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4281.05","56.9","","812.12","238.65","1587.46","163","875.02","6395.24","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","both","","","7523.81","4514.29","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","875.02","11.63","","112.68","112.68","146.99","38","875.02","6395.24","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","both","","","7523.81","4514.29","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5823.43","77.4","","303.98","303.98","5854.79","1 through 10","875.02","6395.24","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7523.81","4514.29","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","875.02","11.63","","112.68","112.68","146.99","38","875.02","5823.43","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7523.81","4514.29","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4723.45","62.78","","780.86","208.94","10480.28","15","875.02","5823.43","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7523.81","4514.29","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3289.41","43.72","","179.76","179.76","179.76","1 through 10","875.02","5823.43","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7523.81","4514.29","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5471.31","72.72","","2355.45","298.99","3965.19","155","875.02","5823.43","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7523.81","4514.29","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5471.31","72.72","","3643.09","3643.09","3643.09","1 through 10","875.02","5823.43","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7523.81","4514.29","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4004.17","53.22","","554.28","554.28","554.28","16","875.02","5823.43","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7523.81","4514.29","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4732.48","62.9","","619.64","173.09","2370.64","150","875.02","5823.43","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7523.81","4514.29","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5823.43","77.4","","303.98","303.98","5854.79","1 through 10","875.02","5823.43","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","both","","","6060.46","3636.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","704.83","5151.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","both","","","6060.46","3636.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","704.83","5151.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","both","","","6060.46","3636.28","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3448.40","56.9","","812.12","238.65","1587.46","163","704.83","5151.39","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","both","","","6060.46","3636.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","704.83","11.63","","112.68","112.68","146.99","38","704.83","5151.39","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","both","","","6060.46","3636.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4690.80","77.4","","303.98","303.98","5854.79","1 through 10","704.83","5151.39","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6060.46","3636.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","704.83","11.63","","112.68","112.68","146.99","38","704.83","4690.8","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6060.46","3636.28","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3804.76","62.78","","780.86","208.94","10480.28","15","704.83","4690.8","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6060.46","3636.28","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2649.63","43.72","","179.76","179.76","179.76","1 through 10","704.83","4690.8","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6060.46","3636.28","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4407.17","72.72","","2355.45","298.99","3965.19","155","704.83","4690.8","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6060.46","3636.28","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4407.17","72.72","","3643.09","3643.09","3643.09","1 through 10","704.83","4690.8","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6060.46","3636.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3225.38","53.22","","554.28","554.28","554.28","16","704.83","4690.8","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6060.46","3636.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3812.03","62.9","","619.64","173.09","2370.64","150","704.83","4690.8","percent of total billed charges",""
"PLATE RADIUS 95MM 5 HOLE SHAFT LCP SS DIA META VOLAR EXTRA ACTICULAR LEFT DISTAL","SUP-ITM-10022652","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6060.46","3636.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4690.80","77.4","","303.98","303.98","5854.79","1 through 10","704.83","4690.8","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124990","CDM","C1713","HCPCS","0278","RC","","","","both","","","9276.30","5565.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1078.83","7884.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE TIBIA 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124990","CDM","C1713","HCPCS","0278","RC","","","","both","","","9276.30","5565.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1078.83","7884.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE TIBIA 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124990","CDM","C1713","HCPCS","0278","RC","","","","both","","","9276.30","5565.78","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5278.21","56.9","","812.12","238.65","1587.46","163","1078.83","7884.86","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124990","CDM","C1713","HCPCS","0278","RC","","","","both","","","9276.30","5565.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1078.83","11.63","","112.68","112.68","146.99","38","1078.83","7884.86","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124990","CDM","C1713","HCPCS","0278","RC","","","","both","","","9276.30","5565.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7179.86","77.4","","303.98","303.98","5854.79","1 through 10","1078.83","7884.86","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9276.30","5565.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1078.83","11.63","","112.68","112.68","146.99","38","1078.83","7179.86","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9276.30","5565.78","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5823.66","62.78","","780.86","208.94","10480.28","15","1078.83","7179.86","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9276.30","5565.78","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4055.60","43.72","","179.76","179.76","179.76","1 through 10","1078.83","7179.86","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9276.30","5565.78","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6745.73","72.72","","2355.45","298.99","3965.19","155","1078.83","7179.86","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9276.30","5565.78","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6745.73","72.72","","3643.09","3643.09","3643.09","1 through 10","1078.83","7179.86","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9276.30","5565.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4936.85","53.22","","554.28","554.28","554.28","16","1078.83","7179.86","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9276.30","5565.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5834.79","62.9","","619.64","173.09","2370.64","150","1078.83","7179.86","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9276.30","5565.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7179.86","77.4","","303.98","303.98","5854.79","1 through 10","1078.83","7179.86","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5MM 8 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124935","CDM","C1713","HCPCS","0278","RC","","","","both","","","7059.42","4235.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","821.01","6000.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE TIBIA 2.7/3.5MM 8 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124935","CDM","C1713","HCPCS","0278","RC","","","","both","","","7059.42","4235.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","821.01","6000.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE TIBIA 2.7/3.5MM 8 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124935","CDM","C1713","HCPCS","0278","RC","","","","both","","","7059.42","4235.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4016.81","56.9","","812.12","238.65","1587.46","163","821.01","6000.51","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5MM 8 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124935","CDM","C1713","HCPCS","0278","RC","","","","both","","","7059.42","4235.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","821.01","11.63","","112.68","112.68","146.99","38","821.01","6000.51","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5MM 8 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124935","CDM","C1713","HCPCS","0278","RC","","","","both","","","7059.42","4235.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5463.99","77.4","","303.98","303.98","5854.79","1 through 10","821.01","6000.51","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5MM 8 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7059.42","4235.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","821.01","11.63","","112.68","112.68","146.99","38","821.01","5463.99","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5MM 8 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7059.42","4235.65","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4431.90","62.78","","780.86","208.94","10480.28","15","821.01","5463.99","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5MM 8 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7059.42","4235.65","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3086.38","43.72","","179.76","179.76","179.76","1 through 10","821.01","5463.99","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5MM 8 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7059.42","4235.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5133.61","72.72","","2355.45","298.99","3965.19","155","821.01","5463.99","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5MM 8 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7059.42","4235.65","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5133.61","72.72","","3643.09","3643.09","3643.09","1 through 10","821.01","5463.99","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5MM 8 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7059.42","4235.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3757.02","53.22","","554.28","554.28","554.28","16","821.01","5463.99","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5MM 8 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7059.42","4235.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4440.38","62.9","","619.64","173.09","2370.64","150","821.01","5463.99","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5MM 8 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7059.42","4235.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5463.99","77.4","","303.98","303.98","5854.79","1 through 10","821.01","5463.99","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","both","","","6417.08","3850.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","746.31","5454.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","both","","","6417.08","3850.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","746.31","5454.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","both","","","6417.08","3850.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3651.32","56.9","","812.12","238.65","1587.46","163","746.31","5454.52","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","both","","","6417.08","3850.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","746.31","11.63","","112.68","112.68","146.99","38","746.31","5454.52","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","both","","","6417.08","3850.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4966.82","77.4","","303.98","303.98","5854.79","1 through 10","746.31","5454.52","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6417.08","3850.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","746.31","11.63","","112.68","112.68","146.99","38","746.31","4966.82","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6417.08","3850.25","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4028.64","62.78","","780.86","208.94","10480.28","15","746.31","4966.82","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6417.08","3850.25","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2805.55","43.72","","179.76","179.76","179.76","1 through 10","746.31","4966.82","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6417.08","3850.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4666.50","72.72","","2355.45","298.99","3965.19","155","746.31","4966.82","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6417.08","3850.25","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4666.50","72.72","","3643.09","3643.09","3643.09","1 through 10","746.31","4966.82","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6417.08","3850.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3415.17","53.22","","554.28","554.28","554.28","16","746.31","4966.82","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6417.08","3850.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4036.34","62.9","","619.64","173.09","2370.64","150","746.31","4966.82","percent of total billed charges",""
"PLATE TIBIA 2.7/3.5X172MM 8 HOLE VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6417.08","3850.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4966.82","77.4","","303.98","303.98","5854.79","1 through 10","746.31","4966.82","percent of total billed charges",""
"PLATE TIBIA 3.5X117MM LG 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125104","CDM","C1713","HCPCS","0278","RC","","","","both","","","6779.96","4067.98","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","788.51","5762.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE TIBIA 3.5X117MM LG 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125104","CDM","C1713","HCPCS","0278","RC","","","","both","","","6779.96","4067.98","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","788.51","5762.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE TIBIA 3.5X117MM LG 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125104","CDM","C1713","HCPCS","0278","RC","","","","both","","","6779.96","4067.98","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3857.80","56.9","","812.12","238.65","1587.46","163","788.51","5762.97","percent of total billed charges",""
"PLATE TIBIA 3.5X117MM LG 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125104","CDM","C1713","HCPCS","0278","RC","","","","both","","","6779.96","4067.98","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","788.51","11.63","","112.68","112.68","146.99","38","788.51","5762.97","percent of total billed charges",""
"PLATE TIBIA 3.5X117MM LG 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125104","CDM","C1713","HCPCS","0278","RC","","","","both","","","6779.96","4067.98","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5247.69","77.4","","303.98","303.98","5854.79","1 through 10","788.51","5762.97","percent of total billed charges",""
"PLATE TIBIA 3.5X117MM LG 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6779.96","4067.98","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","788.51","11.63","","112.68","112.68","146.99","38","788.51","5247.69","percent of total billed charges",""
"PLATE TIBIA 3.5X117MM LG 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6779.96","4067.98","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4256.46","62.78","","780.86","208.94","10480.28","15","788.51","5247.69","percent of total billed charges",""
"PLATE TIBIA 3.5X117MM LG 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6779.96","4067.98","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2964.20","43.72","","179.76","179.76","179.76","1 through 10","788.51","5247.69","percent of total billed charges",""
"PLATE TIBIA 3.5X117MM LG 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6779.96","4067.98","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4930.39","72.72","","2355.45","298.99","3965.19","155","788.51","5247.69","percent of total billed charges",""
"PLATE TIBIA 3.5X117MM LG 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6779.96","4067.98","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4930.39","72.72","","3643.09","3643.09","3643.09","1 through 10","788.51","5247.69","percent of total billed charges",""
"PLATE TIBIA 3.5X117MM LG 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6779.96","4067.98","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3608.29","53.22","","554.28","554.28","554.28","16","788.51","5247.69","percent of total billed charges",""
"PLATE TIBIA 3.5X117MM LG 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6779.96","4067.98","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4264.59","62.9","","619.64","173.09","2370.64","150","788.51","5247.69","percent of total billed charges",""
"PLATE TIBIA 3.5X117MM LG 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6779.96","4067.98","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5247.69","77.4","","303.98","303.98","5854.79","1 through 10","788.51","5247.69","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","both","","","5654.42","3392.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","657.61","4806.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","both","","","5654.42","3392.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","657.61","4806.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","both","","","5654.42","3392.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3217.36","56.9","","812.12","238.65","1587.46","163","657.61","4806.26","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","both","","","5654.42","3392.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","657.61","11.63","","112.68","112.68","146.99","38","657.61","4806.26","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","both","","","5654.42","3392.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4376.52","77.4","","303.98","303.98","5854.79","1 through 10","657.61","4806.26","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5654.42","3392.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","657.61","11.63","","112.68","112.68","146.99","38","657.61","4376.52","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5654.42","3392.65","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3549.84","62.78","","780.86","208.94","10480.28","15","657.61","4376.52","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5654.42","3392.65","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2472.11","43.72","","179.76","179.76","179.76","1 through 10","657.61","4376.52","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5654.42","3392.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4111.89","72.72","","2355.45","298.99","3965.19","155","657.61","4376.52","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5654.42","3392.65","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4111.89","72.72","","3643.09","3643.09","3643.09","1 through 10","657.61","4376.52","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5654.42","3392.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3009.28","53.22","","554.28","554.28","554.28","16","657.61","4376.52","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5654.42","3392.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3556.63","62.9","","619.64","173.09","2370.64","150","657.61","4376.52","percent of total billed charges",""
"PLATE TIBIA 3.5X145MM 8 HOLE BONE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5654.42","3392.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4376.52","77.4","","303.98","303.98","5854.79","1 through 10","657.61","4376.52","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","both","","","7262.49","4357.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","844.63","6173.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","both","","","7262.49","4357.49","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4132.36","56.9","","2911.53","1863.86","5209.05","65","844.63","6173.12","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","both","","","7262.49","4357.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","844.63","11.63","","400.94","400.94","400.94","1 through 10","844.63","6173.12","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","both","","","7262.49","4357.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5621.17","77.4","","5214.50","5214.50","16415.28","1 through 10","844.63","6173.12","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7262.49","4357.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","844.63","11.63","","400.94","400.94","400.94","1 through 10","844.63","5621.17","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7262.49","4357.49","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3175.16","43.72","","1543.33","1543.33","1671.61","1 through 10","844.63","5621.17","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7262.49","4357.49","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5281.28","72.72","","3700.21","2382.07","6427.18","53","844.63","5621.17","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7262.49","4357.49","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5281.28","72.72","","12685.80","12685.80","12685.80","1 through 10","844.63","5621.17","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7262.49","4357.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4568.11","62.9","","3408.87","2784.05","9859.40","46","844.63","5621.17","percent of total billed charges",""
"PLATE TIBIA 3.5X147MM 8 HOLE SM LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125094","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7262.49","4357.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5621.17","77.4","","5214.50","5214.50","16415.28","1 through 10","844.63","5621.17","percent of total billed charges",""
"PLATE TIBIA 3.5X171MM 10 H LEG LCP SS MEDIAL PROXIMALIMAL RIGHT","SUP-ITM-10030074","CDM","C1713","HCPCS","0278","RC","","","","both","","","7249.20","4349.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","843.08","6161.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE TIBIA 3.5X171MM 10 H LEG LCP SS MEDIAL PROXIMALIMAL RIGHT","SUP-ITM-10030074","CDM","C1713","HCPCS","0278","RC","","","","both","","","7249.20","4349.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","843.08","6161.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE TIBIA 3.5X171MM 10 H LEG LCP SS MEDIAL PROXIMALIMAL RIGHT","SUP-ITM-10030074","CDM","C1713","HCPCS","0278","RC","","","","both","","","7249.20","4349.52","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4124.79","56.9","","812.12","238.65","1587.46","163","843.08","6161.82","percent of total billed charges",""
"PLATE TIBIA 3.5X171MM 10 H LEG LCP SS MEDIAL PROXIMALIMAL RIGHT","SUP-ITM-10030074","CDM","C1713","HCPCS","0278","RC","","","","both","","","7249.20","4349.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","843.08","11.63","","112.68","112.68","146.99","38","843.08","6161.82","percent of total billed charges",""
"PLATE TIBIA 3.5X171MM 10 H LEG LCP SS MEDIAL PROXIMALIMAL RIGHT","SUP-ITM-10030074","CDM","C1713","HCPCS","0278","RC","","","","both","","","7249.20","4349.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5610.88","77.4","","303.98","303.98","5854.79","1 through 10","843.08","6161.82","percent of total billed charges",""
"PLATE TIBIA 3.5X171MM 10 H LEG LCP SS MEDIAL PROXIMALIMAL RIGHT","SUP-ITM-10030074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7249.20","4349.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","843.08","11.63","","112.68","112.68","146.99","38","843.08","5610.88","percent of total billed charges",""
"PLATE TIBIA 3.5X171MM 10 H LEG LCP SS MEDIAL PROXIMALIMAL RIGHT","SUP-ITM-10030074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7249.20","4349.52","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4551.05","62.78","","780.86","208.94","10480.28","15","843.08","5610.88","percent of total billed charges",""
"PLATE TIBIA 3.5X171MM 10 H LEG LCP SS MEDIAL PROXIMALIMAL RIGHT","SUP-ITM-10030074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7249.20","4349.52","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3169.35","43.72","","179.76","179.76","179.76","1 through 10","843.08","5610.88","percent of total billed charges",""
"PLATE TIBIA 3.5X171MM 10 H LEG LCP SS MEDIAL PROXIMALIMAL RIGHT","SUP-ITM-10030074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7249.20","4349.52","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5271.62","72.72","","2355.45","298.99","3965.19","155","843.08","5610.88","percent of total billed charges",""
"PLATE TIBIA 3.5X171MM 10 H LEG LCP SS MEDIAL PROXIMALIMAL RIGHT","SUP-ITM-10030074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7249.20","4349.52","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5271.62","72.72","","3643.09","3643.09","3643.09","1 through 10","843.08","5610.88","percent of total billed charges",""
"PLATE TIBIA 3.5X171MM 10 H LEG LCP SS MEDIAL PROXIMALIMAL RIGHT","SUP-ITM-10030074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7249.20","4349.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3858.02","53.22","","554.28","554.28","554.28","16","843.08","5610.88","percent of total billed charges",""
"PLATE TIBIA 3.5X171MM 10 H LEG LCP SS MEDIAL PROXIMALIMAL RIGHT","SUP-ITM-10030074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7249.20","4349.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4559.75","62.9","","619.64","173.09","2370.64","150","843.08","5610.88","percent of total billed charges",""
"PLATE TIBIA 3.5X171MM 10 H LEG LCP SS MEDIAL PROXIMALIMAL RIGHT","SUP-ITM-10030074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7249.20","4349.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5610.88","77.4","","303.98","303.98","5854.79","1 through 10","843.08","5610.88","percent of total billed charges",""
"PLATE TIBIA 3.5X207MM SM 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125099","CDM","C1776","HCPCS","0278","RC","","","","both","","","8990.59","5394.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1045.61","7642","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE TIBIA 3.5X207MM SM 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125099","CDM","C1776","HCPCS","0278","RC","","","","both","","","8990.59","5394.35","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5115.65","56.9","","2911.53","1863.86","5209.05","65","1045.61","7642","percent of total billed charges",""
"PLATE TIBIA 3.5X207MM SM 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125099","CDM","C1776","HCPCS","0278","RC","","","","both","","","8990.59","5394.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1045.61","11.63","","400.94","400.94","400.94","1 through 10","1045.61","7642","percent of total billed charges",""
"PLATE TIBIA 3.5X207MM SM 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125099","CDM","C1776","HCPCS","0278","RC","","","","both","","","8990.59","5394.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6958.72","77.4","","5214.50","5214.50","16415.28","1 through 10","1045.61","7642","percent of total billed charges",""
"PLATE TIBIA 3.5X207MM SM 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125099","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8990.59","5394.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1045.61","11.63","","400.94","400.94","400.94","1 through 10","1045.61","6958.72","percent of total billed charges",""
"PLATE TIBIA 3.5X207MM SM 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125099","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8990.59","5394.35","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3930.69","43.72","","1543.33","1543.33","1671.61","1 through 10","1045.61","6958.72","percent of total billed charges",""
"PLATE TIBIA 3.5X207MM SM 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125099","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8990.59","5394.35","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6537.96","72.72","","3700.21","2382.07","6427.18","53","1045.61","6958.72","percent of total billed charges",""
"PLATE TIBIA 3.5X207MM SM 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125099","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8990.59","5394.35","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6537.96","72.72","","12685.80","12685.80","12685.80","1 through 10","1045.61","6958.72","percent of total billed charges",""
"PLATE TIBIA 3.5X207MM SM 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125099","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8990.59","5394.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5655.08","62.9","","3408.87","2784.05","9859.40","46","1045.61","6958.72","percent of total billed charges",""
"PLATE TIBIA 3.5X207MM SM 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125099","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8990.59","5394.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6958.72","77.4","","5214.50","5214.50","16415.28","1 through 10","1045.61","6958.72","percent of total billed charges",""
"PLATE TIBIA 3.5X87MM 4 HOLE LG L LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10120335","CDM","C1776","HCPCS","0278","RC","","","","both","","","6538.04","3922.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","760.37","5557.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE TIBIA 3.5X87MM 4 HOLE LG L LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10120335","CDM","C1776","HCPCS","0278","RC","","","","both","","","6538.04","3922.82","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3720.14","56.9","","2911.53","1863.86","5209.05","65","760.37","5557.33","percent of total billed charges",""
"PLATE TIBIA 3.5X87MM 4 HOLE LG L LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10120335","CDM","C1776","HCPCS","0278","RC","","","","both","","","6538.04","3922.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","760.37","11.63","","400.94","400.94","400.94","1 through 10","760.37","5557.33","percent of total billed charges",""
"PLATE TIBIA 3.5X87MM 4 HOLE LG L LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10120335","CDM","C1776","HCPCS","0278","RC","","","","both","","","6538.04","3922.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5060.44","77.4","","5214.50","5214.50","16415.28","1 through 10","760.37","5557.33","percent of total billed charges",""
"PLATE TIBIA 3.5X87MM 4 HOLE LG L LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10120335","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6538.04","3922.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","760.37","11.63","","400.94","400.94","400.94","1 through 10","760.37","5060.44","percent of total billed charges",""
"PLATE TIBIA 3.5X87MM 4 HOLE LG L LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10120335","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6538.04","3922.82","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2858.43","43.72","","1543.33","1543.33","1671.61","1 through 10","760.37","5060.44","percent of total billed charges",""
"PLATE TIBIA 3.5X87MM 4 HOLE LG L LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10120335","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6538.04","3922.82","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4754.46","72.72","","3700.21","2382.07","6427.18","53","760.37","5060.44","percent of total billed charges",""
"PLATE TIBIA 3.5X87MM 4 HOLE LG L LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10120335","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6538.04","3922.82","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4754.46","72.72","","12685.80","12685.80","12685.80","1 through 10","760.37","5060.44","percent of total billed charges",""
"PLATE TIBIA 3.5X87MM 4 HOLE LG L LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10120335","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6538.04","3922.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4112.43","62.9","","3408.87","2784.05","9859.40","46","760.37","5060.44","percent of total billed charges",""
"PLATE TIBIA 3.5X87MM 4 HOLE LG L LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10120335","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6538.04","3922.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5060.44","77.4","","5214.50","5214.50","16415.28","1 through 10","760.37","5060.44","percent of total billed charges",""
"PLATE TIBIAL 3.5X147MM LG 8 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125106","CDM","C1776","HCPCS","0278","RC","","","","both","","","7847.74","4708.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","912.69","6670.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE TIBIAL 3.5X147MM LG 8 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125106","CDM","C1776","HCPCS","0278","RC","","","","both","","","7847.74","4708.64","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4465.36","56.9","","2911.53","1863.86","5209.05","65","912.69","6670.58","percent of total billed charges",""
"PLATE TIBIAL 3.5X147MM LG 8 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125106","CDM","C1776","HCPCS","0278","RC","","","","both","","","7847.74","4708.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","912.69","11.63","","400.94","400.94","400.94","1 through 10","912.69","6670.58","percent of total billed charges",""
"PLATE TIBIAL 3.5X147MM LG 8 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125106","CDM","C1776","HCPCS","0278","RC","","","","both","","","7847.74","4708.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6074.15","77.4","","5214.50","5214.50","16415.28","1 through 10","912.69","6670.58","percent of total billed charges",""
"PLATE TIBIAL 3.5X147MM LG 8 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125106","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7847.74","4708.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","912.69","11.63","","400.94","400.94","400.94","1 through 10","912.69","6074.15","percent of total billed charges",""
"PLATE TIBIAL 3.5X147MM LG 8 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125106","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7847.74","4708.64","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3431.03","43.72","","1543.33","1543.33","1671.61","1 through 10","912.69","6074.15","percent of total billed charges",""
"PLATE TIBIAL 3.5X147MM LG 8 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125106","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7847.74","4708.64","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5706.88","72.72","","3700.21","2382.07","6427.18","53","912.69","6074.15","percent of total billed charges",""
"PLATE TIBIAL 3.5X147MM LG 8 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125106","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7847.74","4708.64","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5706.88","72.72","","12685.80","12685.80","12685.80","1 through 10","912.69","6074.15","percent of total billed charges",""
"PLATE TIBIAL 3.5X147MM LG 8 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125106","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7847.74","4708.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4936.23","62.9","","3408.87","2784.05","9859.40","46","912.69","6074.15","percent of total billed charges",""
"PLATE TIBIAL 3.5X147MM LG 8 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125106","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7847.74","4708.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6074.15","77.4","","5214.50","5214.50","16415.28","1 through 10","912.69","6074.15","percent of total billed charges",""
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125110","CDM","C1713","HCPCS","0278","RC","","","","both","","","9007.27","5404.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1047.55","7656.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125110","CDM","C1713","HCPCS","0278","RC","","","","both","","","9007.27","5404.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1047.55","7656.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125110","CDM","C1713","HCPCS","0278","RC","","","","both","","","9007.27","5404.36","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5125.14","56.9","","812.12","238.65","1587.46","163","1047.55","7656.18","percent of total billed charges",""
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125110","CDM","C1713","HCPCS","0278","RC","","","","both","","","9007.27","5404.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1047.55","11.63","","112.68","112.68","146.99","38","1047.55","7656.18","percent of total billed charges",""
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125110","CDM","C1713","HCPCS","0278","RC","","","","both","","","9007.27","5404.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6971.63","77.4","","303.98","303.98","5854.79","1 through 10","1047.55","7656.18","percent of total billed charges",""
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9007.27","5404.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1047.55","11.63","","112.68","112.68","146.99","38","1047.55","6971.63","percent of total billed charges",""
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9007.27","5404.36","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5654.76","62.78","","780.86","208.94","10480.28","15","1047.55","6971.63","percent of total billed charges",""
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9007.27","5404.36","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3937.98","43.72","","179.76","179.76","179.76","1 through 10","1047.55","6971.63","percent of total billed charges",""
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9007.27","5404.36","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6550.09","72.72","","2355.45","298.99","3965.19","155","1047.55","6971.63","percent of total billed charges",""
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9007.27","5404.36","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6550.09","72.72","","3643.09","3643.09","3643.09","1 through 10","1047.55","6971.63","percent of total billed charges",""
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9007.27","5404.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4793.67","53.22","","554.28","554.28","554.28","16","1047.55","6971.63","percent of total billed charges",""
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9007.27","5404.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5665.57","62.9","","619.64","173.09","2370.64","150","1047.55","6971.63","percent of total billed charges",""
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9007.27","5404.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6971.63","77.4","","303.98","303.98","5854.79","1 through 10","1047.55","6971.63","percent of total billed charges",""
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT STERILE","SUP-ITM-10125090","CDM","C1713","HCPCS","0278","RC","","","","both","","","9910.30","5946.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1152.57","8423.76","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT STERILE","SUP-ITM-10125090","CDM","C1713","HCPCS","0278","RC","","","","both","","","9910.30","5946.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1152.57","8423.76","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT STERILE","SUP-ITM-10125090","CDM","C1713","HCPCS","0278","RC","","","","both","","","9910.30","5946.18","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5638.96","56.9","","812.12","238.65","1587.46","163","1152.57","8423.76","percent of total billed charges",""
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT STERILE","SUP-ITM-10125090","CDM","C1713","HCPCS","0278","RC","","","","both","","","9910.30","5946.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1152.57","11.63","","112.68","112.68","146.99","38","1152.57","8423.76","percent of total billed charges",""
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT STERILE","SUP-ITM-10125090","CDM","C1713","HCPCS","0278","RC","","","","both","","","9910.30","5946.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7670.57","77.4","","303.98","303.98","5854.79","1 through 10","1152.57","8423.76","percent of total billed charges",""
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT STERILE","SUP-ITM-10125090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9910.30","5946.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1152.57","11.63","","112.68","112.68","146.99","38","1152.57","7670.57","percent of total billed charges",""
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT STERILE","SUP-ITM-10125090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9910.30","5946.18","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6221.69","62.78","","780.86","208.94","10480.28","15","1152.57","7670.57","percent of total billed charges",""
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT STERILE","SUP-ITM-10125090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9910.30","5946.18","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4332.78","43.72","","179.76","179.76","179.76","1 through 10","1152.57","7670.57","percent of total billed charges",""
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT STERILE","SUP-ITM-10125090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9910.30","5946.18","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7206.77","72.72","","2355.45","298.99","3965.19","155","1152.57","7670.57","percent of total billed charges",""
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT STERILE","SUP-ITM-10125090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9910.30","5946.18","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7206.77","72.72","","3643.09","3643.09","3643.09","1 through 10","1152.57","7670.57","percent of total billed charges",""
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT STERILE","SUP-ITM-10125090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9910.30","5946.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","5274.26","53.22","","554.28","554.28","554.28","16","1152.57","7670.57","percent of total billed charges",""
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT STERILE","SUP-ITM-10125090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9910.30","5946.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6233.58","62.9","","619.64","173.09","2370.64","150","1152.57","7670.57","percent of total billed charges",""
"PLATE TIBIAL 3.5X207MM LG 12 HOLE LCP SS VARIABLE ANGLE BEND IMAL LEFT STERILE","SUP-ITM-10125090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9910.30","5946.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7670.57","77.4","","303.98","303.98","5854.79","1 through 10","1152.57","7670.57","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","both","","","6314.41","3788.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","734.37","5367.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","both","","","6314.41","3788.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","734.37","5367.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","both","","","6314.41","3788.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3592.90","56.9","","812.12","238.65","1587.46","163","734.37","5367.25","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","both","","","6314.41","3788.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","734.37","11.63","","112.68","112.68","146.99","38","734.37","5367.25","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","both","","","6314.41","3788.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4887.35","77.4","","303.98","303.98","5854.79","1 through 10","734.37","5367.25","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6314.41","3788.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","734.37","11.63","","112.68","112.68","146.99","38","734.37","4887.35","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6314.41","3788.65","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3964.19","62.78","","780.86","208.94","10480.28","15","734.37","4887.35","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6314.41","3788.65","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2760.66","43.72","","179.76","179.76","179.76","1 through 10","734.37","4887.35","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6314.41","3788.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4591.84","72.72","","2355.45","298.99","3965.19","155","734.37","4887.35","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6314.41","3788.65","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4591.84","72.72","","3643.09","3643.09","3643.09","1 through 10","734.37","4887.35","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6314.41","3788.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3360.53","53.22","","554.28","554.28","554.28","16","734.37","4887.35","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6314.41","3788.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3971.76","62.9","","619.64","173.09","2370.64","150","734.37","4887.35","percent of total billed charges",""
"PLATE TIBIAL 3.5X87MM SM 4 HOLE LCP SS VARIABLE ANGLE BEND PROXIMAL LEFT","SUP-ITM-10113989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6314.41","3788.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4887.35","77.4","","303.98","303.98","5854.79","1 through 10","734.37","4887.35","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","both","","","6174.43","3704.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","718.09","5248.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","both","","","6174.43","3704.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","718.09","5248.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","both","","","6174.43","3704.66","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3513.25","56.9","","812.12","238.65","1587.46","163","718.09","5248.27","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","both","","","6174.43","3704.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","718.09","11.63","","112.68","112.68","146.99","38","718.09","5248.27","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","both","","","6174.43","3704.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4779.01","77.4","","303.98","303.98","5854.79","1 through 10","718.09","5248.27","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6174.43","3704.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","718.09","11.63","","112.68","112.68","146.99","38","718.09","4779.01","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6174.43","3704.66","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3876.31","62.78","","780.86","208.94","10480.28","15","718.09","4779.01","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6174.43","3704.66","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2699.46","43.72","","179.76","179.76","179.76","1 through 10","718.09","4779.01","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6174.43","3704.66","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4490.05","72.72","","2355.45","298.99","3965.19","155","718.09","4779.01","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6174.43","3704.66","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4490.05","72.72","","3643.09","3643.09","3643.09","1 through 10","718.09","4779.01","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6174.43","3704.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3286.03","53.22","","554.28","554.28","554.28","16","718.09","4779.01","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6174.43","3704.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3883.72","62.9","","619.64","173.09","2370.64","150","718.09","4779.01","percent of total billed charges",""
"PLATE ULNA 2.7-3.5X211MM 12 HOLE ELBOW VA LCP SS RIGHT EXTRA ARTICULAR PROXIMAL","SUP-ITM-10114062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6174.43","3704.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4779.01","77.4","","303.98","303.98","5854.79","1 through 10","718.09","4779.01","percent of total billed charges",""
"Platelet Aggregation Ea Agent","PX-30001114","CDM","85576","CPT","0305","RC","","","","outpatient","","","116.00","69.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","84.36","72.72","","81.45","81.45","81.45","1 through 10","12.16","89.78","percent of total billed charges",""
"Platelets, Pheresis, Pathogen-Reduced, Each Unit","PX-39000069","CDM","P9073","HCPCS","0390","RC","","","","both","","","3150.00","1890.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1688.48","","Case rate ($1,688.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1647.32","1647.32","1647.32","1 through 10","575.53","3921.23","other","OPPS APC"
"Platelets, Pheresis, Pathogen-Reduced, Each Unit","PX-39000069","CDM","P9073","HCPCS","0390","RC","","","","both","","","3150.00","1890.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1792.35","56.9","","1729.76","1729.76","1729.76","1 through 10","575.53","3921.23","percent of total billed charges",""
"Platelets, Pheresis, Pathogen-Reduced, Each Unit","PX-39000069","CDM","P9073","HCPCS","0390","RC","","","","both","","","3150.00","1890.00","MEDICARE [2001]","HB WDH MEDICARE","587.28","","APC Price ($587.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","587.28","587.28","1174.56","42","575.53","3921.23","other","OPPS APC"
"Platelets, Pheresis, Pathogen-Reduced, Each Unit","PX-39000069","CDM","P9073","HCPCS","0390","RC","","","","both","","","3150.00","1890.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","587.28","","APC Price ($587.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","575.54","575.54","575.54","1 through 10","575.53","3921.23","other","OPPS APC"
"Platelets, Pheresis, Pathogen-Reduced, Each Unit","PX-39000069","CDM","P9073","HCPCS","0390","RC","","","","outpatient","","","3150.00","1890.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2290.68","72.72","","2210.69","2210.69","2210.69","1 through 10","1377.18","2438.1","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","469.00","281.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","327.36","69.8","","316.19","316.19","316.19","1 through 10","266.86","2079.19","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","469.00","281.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2079.19","","Case rate ($2,079.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1491.00","453.00","1491.00","1 through 10","266.86","2079.19","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","469.00","281.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","895.30","","Case rate ($895.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","873.47","856.04","873.47","1 through 10","266.86","2079.19","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","469.00","281.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","318.83","","APC Price ($325.34). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","318.87","318.87","318.87","1 through 10","266.86","2079.19","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","469.00","281.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1680.59","","Case rate ($1,680.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1491.00","453.00","1491.00","1 through 10","266.86","2079.19","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","469.00","281.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","266.86","56.9","","257.76","257.76","257.76","14","266.86","2079.19","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","469.00","281.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","335.10","","APC Price ($325.34). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","329.44","329.44","333.56","1 through 10","266.86","2079.19","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","469.00","281.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","325.34","","APC Price ($325.34). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","325.38","319.85","325.38","1 through 10","266.86","2079.19","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","469.00","281.40","MEDICARE [2001]","HB WDH MEDICARE","325.34","","APC Price ($325.34). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","325.38","325.38","325.38","1 through 10","266.86","2079.19","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","469.00","281.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","325.34","","APC Price ($325.34). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","320.18","305.82","325.38","1 through 10","266.86","2079.19","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","outpatient","","","469.00","281.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","67.63","14.42","","65.32","55.99","65.32","1 through 10","54.54","363.01","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","outpatient","","","469.00","281.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","54.54","11.63","","55.45","53.51","62.38","16","54.54","363.01","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","outpatient","","","469.00","281.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","341.06","72.72","","329.42","329.42","329.42","1 through 10","54.54","363.01","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","outpatient","","","469.00","281.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","295.00","62.9","","285.39","285.39","285.39","31","54.54","363.01","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","outpatient","","","469.00","281.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","363.01","77.4","","351.08","329.42","351.08","1 through 10","54.54","363.01","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","outpatient","","","469.00","281.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","54.54","11.63","","53.51","53.51","53.51","1 through 10","54.54","363.01","percent of total billed charges",""
"Pleural Effusion With Cc","187","MS-DRG","","","","","","","","inpatient","","","20201.37","12120.82","MEDICARE [2001]","HB WDH MEDICARE","7964.44","","Case rate ($7,964.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,385.35, add-ons for qualifying new technology services are included. If operating cost exceeds $11,303.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,354.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,970.08 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,940.48 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $549.49. The transfer capital threshold is the transfer adjustment factor * $549.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","969.94","969.94","969.94","1 through 10","3975","37585.9","other","Inpatient DRG"
"Pleural Effusion With McC","186","MS-DRG","","","","","","","","inpatient","","","50165.31","30099.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","12047.40","","Case rate ($12,293.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,380.81, add-ons for qualifying new technology services are included. If operating cost exceeds $15,298.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,670.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,982.58 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,935.94 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.81. The transfer capital threshold is the transfer adjustment factor * $865.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","12119.42","12119.42","12119.42","1 through 10","3975","59223.16","other","Inpatient DRG"
"Pleural Effusion With McC","186","MS-DRG","","","","","","","","inpatient","","","50165.31","30099.19","MARTIN'S POINT [160007]","HB WDH MEDICARE","12293.27","","Case rate ($12,293.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,380.81, add-ons for qualifying new technology services are included. If operating cost exceeds $15,298.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,670.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,982.58 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,935.94 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.81. The transfer capital threshold is the transfer adjustment factor * $865.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8437.49","8437.49","8437.49","1 through 10","3975","59223.16","other","Inpatient DRG"
"Pleural Effusion With McC","186","MS-DRG","","","","","","","","inpatient","","","50165.31","30099.19","MEDICARE [2001]","HB WDH MEDICARE","12293.27","","Case rate ($12,293.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,380.81, add-ons for qualifying new technology services are included. If operating cost exceeds $15,298.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,670.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,982.58 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,935.94 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $865.81. The transfer capital threshold is the transfer adjustment factor * $865.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12366.76","12366.76","12397.82","1 through 10","3975","59223.16","other","Inpatient DRG"
"Pleural Effusion With McC","186","MS-DRG","","","","","","","","inpatient","","","50165.31","30099.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","31933.67","","Fee schedule rate ($31,933.67). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","32374.20","32374.20","32374.20","1 through 10","3975","59223.16","case rate",""
"PLIAFX PRIME 1.0CC FREEZE DRIED","SUP-ITM-10243414","CDM","C1889","HCPCS","0278","RC","","","","both","","","1119.01","671.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","130.14","951.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLIAFX PRIME 1.0CC FREEZE DRIED","SUP-ITM-10243414","CDM","C1889","HCPCS","0278","RC","","","","both","","","1119.01","671.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","130.14","951.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLIAFX PRIME 1.0CC FREEZE DRIED","SUP-ITM-10243414","CDM","C1889","HCPCS","0278","RC","","","","both","","","1119.01","671.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","636.72","56.9","","0.63","0.63","0.63","1 through 10","130.14","951.16","percent of total billed charges",""
"PLIAFX PRIME 1.0CC FREEZE DRIED","SUP-ITM-10243414","CDM","C1889","HCPCS","0278","RC","","","","both","","","1119.01","671.41","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","161.36","14.42","","317.14","317.14","317.14","1 through 10","130.14","951.16","percent of total billed charges",""
"PLIAFX PRIME 1.0CC FREEZE DRIED","SUP-ITM-10243414","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1119.01","671.41","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","161.36","14.42","","317.14","317.14","317.14","1 through 10","130.14","866.11","percent of total billed charges",""
"PLIAFX PRIME 1.0CC FREEZE DRIED","SUP-ITM-10243414","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1119.01","671.41","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","702.51","62.78","","1125.09","1125.09","1125.09","1 through 10","130.14","866.11","percent of total billed charges",""
"PLIAFX PRIME 1.0CC FREEZE DRIED","SUP-ITM-10243414","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1119.01","671.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","813.74","72.72","","4732.50","1617.43","14180.40","1 through 10","130.14","866.11","percent of total billed charges",""
"PLIAFX PRIME 1.0CC FREEZE DRIED","SUP-ITM-10243414","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1119.01","671.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","703.86","62.9","","3896.20","3341.38","3896.20","1 through 10","130.14","866.11","percent of total billed charges",""
"PLIAFX PRIME 10.0CC FREEZE DRIED","SUP-ITM-10243411","CDM","C1889","HCPCS","0278","RC","","","","both","","","6308.14","3784.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","733.64","5361.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLIAFX PRIME 10.0CC FREEZE DRIED","SUP-ITM-10243411","CDM","C1889","HCPCS","0278","RC","","","","both","","","6308.14","3784.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","733.64","5361.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLIAFX PRIME 10.0CC FREEZE DRIED","SUP-ITM-10243411","CDM","C1889","HCPCS","0278","RC","","","","both","","","6308.14","3784.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3589.33","56.9","","0.63","0.63","0.63","1 through 10","733.64","5361.92","percent of total billed charges",""
"PLIAFX PRIME 10.0CC FREEZE DRIED","SUP-ITM-10243411","CDM","C1889","HCPCS","0278","RC","","","","both","","","6308.14","3784.88","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","909.63","14.42","","317.14","317.14","317.14","1 through 10","733.64","5361.92","percent of total billed charges",""
"PLIAFX PRIME 10.0CC FREEZE DRIED","SUP-ITM-10243411","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6308.14","3784.88","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","909.63","14.42","","317.14","317.14","317.14","1 through 10","733.64","4882.5","percent of total billed charges",""
"PLIAFX PRIME 10.0CC FREEZE DRIED","SUP-ITM-10243411","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6308.14","3784.88","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3960.25","62.78","","1125.09","1125.09","1125.09","1 through 10","733.64","4882.5","percent of total billed charges",""
"PLIAFX PRIME 10.0CC FREEZE DRIED","SUP-ITM-10243411","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6308.14","3784.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4587.28","72.72","","4732.50","1617.43","14180.40","1 through 10","733.64","4882.5","percent of total billed charges",""
"PLIAFX PRIME 10.0CC FREEZE DRIED","SUP-ITM-10243411","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6308.14","3784.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3967.82","62.9","","3896.20","3341.38","3896.20","1 through 10","733.64","4882.5","percent of total billed charges",""
"PLIAFX PRIME 2.5CC FREEZE DRIED","SUP-ITM-10243413","CDM","C1889","HCPCS","0278","RC","","","","both","","","2565.89","1539.53","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","298.41","2181.01","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLIAFX PRIME 2.5CC FREEZE DRIED","SUP-ITM-10243413","CDM","C1889","HCPCS","0278","RC","","","","both","","","2565.89","1539.53","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","298.41","2181.01","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLIAFX PRIME 2.5CC FREEZE DRIED","SUP-ITM-10243413","CDM","C1889","HCPCS","0278","RC","","","","both","","","2565.89","1539.53","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1459.99","56.9","","0.63","0.63","0.63","1 through 10","298.41","2181.01","percent of total billed charges",""
"PLIAFX PRIME 2.5CC FREEZE DRIED","SUP-ITM-10243413","CDM","C1889","HCPCS","0278","RC","","","","both","","","2565.89","1539.53","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","370.00","14.42","","317.14","317.14","317.14","1 through 10","298.41","2181.01","percent of total billed charges",""
"PLIAFX PRIME 2.5CC FREEZE DRIED","SUP-ITM-10243413","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2565.89","1539.53","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","370.00","14.42","","317.14","317.14","317.14","1 through 10","298.41","1986","percent of total billed charges",""
"PLIAFX PRIME 2.5CC FREEZE DRIED","SUP-ITM-10243413","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2565.89","1539.53","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1610.87","62.78","","1125.09","1125.09","1125.09","1 through 10","298.41","1986","percent of total billed charges",""
"PLIAFX PRIME 2.5CC FREEZE DRIED","SUP-ITM-10243413","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2565.89","1539.53","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1865.92","72.72","","4732.50","1617.43","14180.40","1 through 10","298.41","1986","percent of total billed charges",""
"PLIAFX PRIME 2.5CC FREEZE DRIED","SUP-ITM-10243413","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2565.89","1539.53","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1613.94","62.9","","3896.20","3341.38","3896.20","1 through 10","298.41","1986","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","both","","","4271.21","2562.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","496.74","3630.53","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","both","","","4271.21","2562.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","496.74","3630.53","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","both","","","4271.21","2562.73","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2430.32","56.9","","0.63","0.63","0.63","1 through 10","496.74","3630.53","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","both","","","4271.21","2562.73","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","615.91","14.42","","317.14","317.14","317.14","1 through 10","496.74","3630.53","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4271.21","2562.73","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","615.91","14.42","","317.14","317.14","317.14","1 through 10","496.74","3305.92","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4271.21","2562.73","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2681.47","62.78","","1125.09","1125.09","1125.09","1 through 10","496.74","3305.92","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4271.21","2562.73","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3106.02","72.72","","4732.50","1617.43","14180.40","1 through 10","496.74","3305.92","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4271.21","2562.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2686.59","62.9","","3896.20","3341.38","3896.20","1 through 10","496.74","3305.92","percent of total billed charges",""
"PLUG FISTULA 0.7X5.1CM BIODESIGN(CONICAL) STERILE LF","SUP-ITM-10118290","CDM","C1763","HCPCS","0278","RC","","","","both","","","6028.55","3617.13","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3430.24","56.9","","1156.60","963.29","1156.60","1 through 10","701.12","5124.27","percent of total billed charges",""
"PLUG FISTULA 0.7X5.1CM BIODESIGN(CONICAL) STERILE LF","SUP-ITM-10118290","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","6028.55","3617.13","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4383.96","72.72","","8111.92","3502.08","8111.92","1 through 10","701.12","4666.1","percent of total billed charges",""
"PLUG FISTULA 0.7X5.1CM BIODESIGN(CONICAL) STERILE LF","SUP-ITM-10118290","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","6028.55","3617.13","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3791.96","62.9","","1066.56","1066.56","1066.56","1 through 10","701.12","4666.1","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","6564.50","3938.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","763.45","5579.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","6564.50","3938.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3735.20","56.9","","2911.53","1863.86","5209.05","65","763.45","5579.83","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","6564.50","3938.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","763.45","11.63","","400.94","400.94","400.94","1 through 10","763.45","5579.83","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","6564.50","3938.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5080.92","77.4","","5214.50","5214.50","16415.28","1 through 10","763.45","5579.83","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6564.50","3938.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","763.45","11.63","","400.94","400.94","400.94","1 through 10","763.45","5080.92","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6564.50","3938.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2870.00","43.72","","1543.33","1543.33","1671.61","1 through 10","763.45","5080.92","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6564.50","3938.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4773.70","72.72","","3700.21","2382.07","6427.18","53","763.45","5080.92","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6564.50","3938.70","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4773.70","72.72","","12685.80","12685.80","12685.80","1 through 10","763.45","5080.92","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6564.50","3938.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4129.07","62.9","","3408.87","2784.05","9859.40","46","763.45","5080.92","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6564.50","3938.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5080.92","77.4","","5214.50","5214.50","16415.28","1 through 10","763.45","5080.92","percent of total billed charges",""
"Pneumothorax With Cc","200","MS-DRG","","","","","","","","inpatient","","","42112.50","25267.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","33270.62","","Fee schedule rate ($33,270.62). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","12081.04","12081.04","12081.04","1 through 10","3975","41773.51","case rate",""
"Pneumothorax With Cc","200","MS-DRG","","","","","","","","inpatient","","","42112.50","25267.50","MEDICARE [2001]","HB WDH MEDICARE","8802.22","","Case rate ($8,802.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,158.62, add-ons for qualifying new technology services are included. If operating cost exceeds $12,076.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,415.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,746.65 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,713.75 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $610.71. The transfer capital threshold is the transfer adjustment factor * $610.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8823.26","8801.49","8823.26","1 through 10","3975","41773.51","other","Inpatient DRG"
"Pneumothorax With Cc","200","MS-DRG","","","","","","","","inpatient","","","42112.50","25267.50","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8802.22","","Case rate ($8,802.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,158.62, add-ons for qualifying new technology services are included. If operating cost exceeds $12,076.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,415.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,746.65 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,713.75 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $610.71. The transfer capital threshold is the transfer adjustment factor * $610.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8801.49","8664.96","8823.26","1 through 10","3975","41773.51","other","Inpatient DRG"
"Pneumothorax With McC","199","MS-DRG","","","","","","","","inpatient","","","45036.17","27021.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","53390.98","","Fee schedule rate ($53,390.98). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","13998.42","13998.42","13998.42","1 through 10","3975","67035.98","case rate",""
"Pneumothorax With McC","199","MS-DRG","","","","","","","","inpatient","","","45036.17","27021.70","MARTIN'S POINT [160007]","HB WDH MEDICARE","13856.33","","Case rate ($13,856.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,823.50, add-ons for qualifying new technology services are included. If operating cost exceeds $16,741.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,785.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,431.42 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,378.63 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $980.03. The transfer capital threshold is the transfer adjustment factor * $980.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13553.67","13553.67","13553.67","1 through 10","3975","67035.98","other","Inpatient DRG"
"Pneumothorax With McC","199","MS-DRG","","","","","","","","inpatient","","","45036.17","27021.70","MEDICARE [2001]","HB WDH MEDICARE","13856.33","","Case rate ($13,856.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,823.50, add-ons for qualifying new technology services are included. If operating cost exceeds $16,741.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,785.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,431.42 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,378.63 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $980.03. The transfer capital threshold is the transfer adjustment factor * $980.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13799.66","11318.06","13799.66","1 through 10","3975","67035.98","other","Inpatient DRG"
"Pneumothorax With McC","199","MS-DRG","","","","","","","","inpatient","","","45036.17","27021.70","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","13856.33","","Case rate ($13,856.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,823.50, add-ons for qualifying new technology services are included. If operating cost exceeds $16,741.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,785.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,431.42 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,378.63 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $980.03. The transfer capital threshold is the transfer adjustment factor * $980.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13764.96","13764.96","13764.96","1 through 10","3975","67035.98","other","Inpatient DRG"
"Pneumothorax Without Cc/McC","201","MS-DRG","","","","","","","","inpatient","","","18021.48","10812.89","MARTIN'S POINT [160007]","HB WDH MEDICARE","5881.37","","Case rate ($5,881.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,462.70, add-ons for qualifying new technology services are included. If operating cost exceeds $9,380.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,202.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,039.23 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,017.83 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $397.27. The transfer capital threshold is the transfer adjustment factor * $397.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5500.85","5500.85","5500.85","1 through 10","3975","27173.87","other","Inpatient DRG"
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","148.15","88.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","17.23","125.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","148.15","88.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","17.23","125.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","148.15","88.89","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","84.30","56.9","","812.12","238.65","1587.46","163","17.23","125.93","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","148.15","88.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","17.23","11.63","","112.68","112.68","146.99","38","17.23","125.93","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","148.15","88.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","114.67","77.4","","303.98","303.98","5854.79","1 through 10","17.23","125.93","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","148.15","88.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","17.23","11.63","","112.68","112.68","146.99","38","17.23","114.67","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","148.15","88.89","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","93.01","62.78","","780.86","208.94","10480.28","15","17.23","114.67","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","148.15","88.89","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","64.77","43.72","","179.76","179.76","179.76","1 through 10","17.23","114.67","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","148.15","88.89","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","107.73","72.72","","2355.45","298.99","3965.19","155","17.23","114.67","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","148.15","88.89","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","107.73","72.72","","3643.09","3643.09","3643.09","1 through 10","17.23","114.67","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","148.15","88.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","78.85","53.22","","554.28","554.28","554.28","16","17.23","114.67","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","148.15","88.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","93.19","62.9","","619.64","173.09","2370.64","150","17.23","114.67","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","148.15","88.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","114.67","77.4","","303.98","303.98","5854.79","1 through 10","17.23","114.67","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.68","104.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","20.32","148.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.68","104.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","20.32","148.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.68","104.81","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","99.39","56.9","","812.12","238.65","1587.46","163","20.32","148.48","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.68","104.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.32","11.63","","112.68","112.68","146.99","38","20.32","148.48","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.68","104.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","135.20","77.4","","303.98","303.98","5854.79","1 through 10","20.32","148.48","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","174.68","104.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.32","11.63","","112.68","112.68","146.99","38","20.32","135.2","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","174.68","104.81","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","109.66","62.78","","780.86","208.94","10480.28","15","20.32","135.2","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","174.68","104.81","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","76.37","43.72","","179.76","179.76","179.76","1 through 10","20.32","135.2","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","174.68","104.81","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","127.03","72.72","","2355.45","298.99","3965.19","155","20.32","135.2","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","174.68","104.81","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","127.03","72.72","","3643.09","3643.09","3643.09","1 through 10","20.32","135.2","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","174.68","104.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","92.96","53.22","","554.28","554.28","554.28","16","20.32","135.2","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","174.68","104.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","109.87","62.9","","619.64","173.09","2370.64","150","20.32","135.2","percent of total billed charges",""
"POINT SPADE 2.0MM 230 WIRE BONE KIRSCHNER FIXATION SS THREADED NONCOLOR","SUP-ITM-10038567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","174.68","104.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","135.20","77.4","","303.98","303.98","5854.79","1 through 10","20.32","135.2","percent of total billed charges",""
"Poisoning And Toxic Effects Of Drugs With McC","917","MS-DRG","","","","","","","","inpatient","","","37493.69","22496.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","23467.78","","Fee schedule rate ($23,467.78). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","23936.22","23936.22","23936.22","1 through 10","3975","59599.36","case rate",""
"Poisoning And Toxic Effects Of Drugs With McC","917","MS-DRG","","","","","","","","inpatient","","","37493.69","22496.21","MEDICARE [2001]","HB WDH MEDICARE","12368.53","","Case rate ($12,368.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,450.27, add-ons for qualifying new technology services are included. If operating cost exceeds $15,368.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,676.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,052.35 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,005.41 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $871.31. The transfer capital threshold is the transfer adjustment factor * $871.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6956.40","0.05","12849.48","1 through 10","3975","59599.36","other","Inpatient DRG"
"Poisoning And Toxic Effects Of Drugs With McC","917","MS-DRG","","","","","","","","inpatient","","","37493.69","22496.21","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","12368.53","","Case rate ($12,368.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,450.27, add-ons for qualifying new technology services are included. If operating cost exceeds $15,368.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,676.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,052.35 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,005.41 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $871.31. The transfer capital threshold is the transfer adjustment factor * $871.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12626.70","12626.70","12626.70","1 through 10","3975","59599.36","other","Inpatient DRG"
"Poisoning And Toxic Effects Of Drugs Without McC","918","MS-DRG","","","","","","","","inpatient","","","29651.53","17790.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","32569.89","","Fee schedule rate ($32,569.89). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","14751.04","14751.04","14751.04","1 through 10","3975","32569.89","case rate",""
"Poisoning And Toxic Effects Of Drugs Without McC","918","MS-DRG","","","","","","","","inpatient","","","29651.53","17790.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","25940.37","","Fee schedule rate ($25,940.37). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","21437.96","21437.96","26119.67","1 through 10","3975","32569.89","case rate",""
"Poisoning And Toxic Effects Of Drugs Without McC","918","MS-DRG","","","","","","","","inpatient","","","29651.53","17790.92","MEDICARE [2001]","HB WDH MEDICARE","6960.91","","Case rate ($6,960.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,459.11, add-ons for qualifying new technology services are included. If operating cost exceeds $10,377.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,281.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,039.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,014.24 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $476.16. The transfer capital threshold is the transfer adjustment factor * $476.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","640.62","640.62","640.62","1 through 10","3975","32569.89","other","Inpatient DRG"
"Poisoning And Toxic Effects Of Drugs Without McC","918","MS-DRG","","","","","","","","inpatient","","","29651.53","17790.92","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6960.91","","Case rate ($6,960.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,459.11, add-ons for qualifying new technology services are included. If operating cost exceeds $10,377.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,281.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,039.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,014.24 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $476.16. The transfer capital threshold is the transfer adjustment factor * $476.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7136.98","7136.98","7136.98","1 through 10","3975","32569.89","other","Inpatient DRG"
"Polysom <6 Yrs Sleep Stage 4/> Addl","PX-92000123","CDM","95782","CPT","0920","RC","","","","outpatient","","","12444.00","7466.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1794.42","14.42","","1731.55","1731.55","1731.55","1 through 10","1447.24","9631.66","percent of total billed charges",""
"Polysom <6 Yrs Sleep Stage 4/> Addl","PX-92000123","CDM","95782","CPT","0920","RC","","","","outpatient","","","12444.00","7466.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","9049.28","72.72","","8732.22","8732.22","8732.22","1 through 10","1447.24","9631.66","percent of total billed charges",""
"Polysom <6 Yrs Sleep Stage 4/> Addl","PX-92000123","CDM","95782","CPT","0929","RC","","","","both","","","12444.00","7466.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","6793.11","","Case rate ($6,793.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6627.44","6627.44","6627.44","1 through 10","2925.1","6793.11","other","OPPS APC"
"Polysom <6 Yrs Sleep Stage 4/> Addl","PX-92000123","CDM","95782","CPT","0929","RC","","","","both","","","12444.00","7466.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","2925.10","","Case rate ($2,925.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2853.79","2853.79","2853.79","1 through 10","2925.1","6793.11","other","OPPS APC"
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","both","","","1098.69","659.21","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","625.15","56.9","","766.70","625.15","1875.45","1 through 10","127.78","933.89","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","both","","","1098.69","659.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","127.78","11.63","","185.54","151.29","286.33","1 through 10","127.78","933.89","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","both","","","1098.69","659.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","850.39","77.4","","1611.50","1044.27","1611.50","1 through 10","127.78","933.89","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1098.69","659.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","127.78","11.63","","185.54","151.29","286.33","1 through 10","127.78","850.39","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1098.69","659.21","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","689.76","62.78","","845.93","845.93","845.93","1 through 10","127.78","850.39","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1098.69","659.21","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","798.97","72.72","","979.87","798.97","1685.81","1 through 10","127.78","850.39","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1098.69","659.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","691.08","62.9","","1460.47","692.17","1460.47","1 through 10","127.78","850.39","percent of total billed charges",""
"PORT DIGNITY 8FR INFUSION MID SIZE ATTACHABLE SILICONE FILLED SUTURE HOLE","SUP-ITM-10130365","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1098.69","659.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","850.39","77.4","","1611.50","1044.27","1611.50","1 through 10","127.78","850.39","percent of total billed charges",""
"PORT IMPLANT 6.6FR DIGNITY LOW PROFILE CT ATTACHABLE OPEN SUTURE HOLE","SUP-ITM-10237354","CDM","C1788","HCPCS","0278","RC","","","","both","","","1115.20","669.12","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","634.55","56.9","","766.70","625.15","1875.45","1 through 10","129.7","947.92","percent of total billed charges",""
"PORT IMPLANT 6.6FR DIGNITY LOW PROFILE CT ATTACHABLE OPEN SUTURE HOLE","SUP-ITM-10237354","CDM","C1788","HCPCS","0278","RC","","","","both","","","1115.20","669.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","129.70","11.63","","185.54","151.29","286.33","1 through 10","129.7","947.92","percent of total billed charges",""
"PORT IMPLANT 6.6FR DIGNITY LOW PROFILE CT ATTACHABLE OPEN SUTURE HOLE","SUP-ITM-10237354","CDM","C1788","HCPCS","0278","RC","","","","both","","","1115.20","669.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","863.16","77.4","","1611.50","1044.27","1611.50","1 through 10","129.7","947.92","percent of total billed charges",""
"PORT IMPLANT 6.6FR DIGNITY LOW PROFILE CT ATTACHABLE OPEN SUTURE HOLE","SUP-ITM-10237354","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1115.20","669.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","129.70","11.63","","185.54","151.29","286.33","1 through 10","129.7","863.16","percent of total billed charges",""
"PORT IMPLANT 6.6FR DIGNITY LOW PROFILE CT ATTACHABLE OPEN SUTURE HOLE","SUP-ITM-10237354","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1115.20","669.12","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","700.12","62.78","","845.93","845.93","845.93","1 through 10","129.7","863.16","percent of total billed charges",""
"PORT IMPLANT 6.6FR DIGNITY LOW PROFILE CT ATTACHABLE OPEN SUTURE HOLE","SUP-ITM-10237354","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1115.20","669.12","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","810.97","72.72","","979.87","798.97","1685.81","1 through 10","129.7","863.16","percent of total billed charges",""
"PORT IMPLANT 6.6FR DIGNITY LOW PROFILE CT ATTACHABLE OPEN SUTURE HOLE","SUP-ITM-10237354","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1115.20","669.12","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","701.46","62.9","","1460.47","692.17","1460.47","1 through 10","129.7","863.16","percent of total billed charges",""
"PORT IMPLANT 6.6FR DIGNITY LOW PROFILE CT ATTACHABLE OPEN SUTURE HOLE","SUP-ITM-10237354","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1115.20","669.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","863.16","77.4","","1611.50","1044.27","1611.50","1 through 10","129.7","863.16","percent of total billed charges",""
"PORT INFUSION 9.6FR MIDSIZE DIGNITY CT PLASTIC SHAPED ATTACHABLE SILICONE CATHETER","SUP-ITM-10286293","CDM","C1788","HCPCS","0278","RC","","","","both","","","1243.80","746.28","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","707.72","56.9","","766.70","625.15","1875.45","1 through 10","144.65","1057.23","percent of total billed charges",""
"PORT INFUSION 9.6FR MIDSIZE DIGNITY CT PLASTIC SHAPED ATTACHABLE SILICONE CATHETER","SUP-ITM-10286293","CDM","C1788","HCPCS","0278","RC","","","","both","","","1243.80","746.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","144.65","11.63","","185.54","151.29","286.33","1 through 10","144.65","1057.23","percent of total billed charges",""
"PORT INFUSION 9.6FR MIDSIZE DIGNITY CT PLASTIC SHAPED ATTACHABLE SILICONE CATHETER","SUP-ITM-10286293","CDM","C1788","HCPCS","0278","RC","","","","both","","","1243.80","746.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","962.70","77.4","","1611.50","1044.27","1611.50","1 through 10","144.65","1057.23","percent of total billed charges",""
"PORT INFUSION 9.6FR MIDSIZE DIGNITY CT PLASTIC SHAPED ATTACHABLE SILICONE CATHETER","SUP-ITM-10286293","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1243.80","746.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","144.65","11.63","","185.54","151.29","286.33","1 through 10","144.65","962.7","percent of total billed charges",""
"PORT INFUSION 9.6FR MIDSIZE DIGNITY CT PLASTIC SHAPED ATTACHABLE SILICONE CATHETER","SUP-ITM-10286293","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1243.80","746.28","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","780.86","62.78","","845.93","845.93","845.93","1 through 10","144.65","962.7","percent of total billed charges",""
"PORT INFUSION 9.6FR MIDSIZE DIGNITY CT PLASTIC SHAPED ATTACHABLE SILICONE CATHETER","SUP-ITM-10286293","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1243.80","746.28","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","904.49","72.72","","979.87","798.97","1685.81","1 through 10","144.65","962.7","percent of total billed charges",""
"PORT INFUSION 9.6FR MIDSIZE DIGNITY CT PLASTIC SHAPED ATTACHABLE SILICONE CATHETER","SUP-ITM-10286293","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1243.80","746.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","782.35","62.9","","1460.47","692.17","1460.47","1 through 10","144.65","962.7","percent of total billed charges",""
"PORT INFUSION 9.6FR MIDSIZE DIGNITY CT PLASTIC SHAPED ATTACHABLE SILICONE CATHETER","SUP-ITM-10286293","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1243.80","746.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","962.70","77.4","","1611.50","1044.27","1611.50","1 through 10","144.65","962.7","percent of total billed charges",""
"Port Plan Special","PX-33000017","CDM","77321","CPT","0333","RC","","","","both","","","2180.00","1308.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2444.27","","Case rate ($2,444.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1953.34","1953.34","1953.34","1 through 10","358.98","2444.27","other","OPPS APC"
"Port Plan Special","PX-33000017","CDM","77321","CPT","0333","RC","","","","both","","","2180.00","1308.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","374.81","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","650.25","374.85","650.25","1 through 10","358.98","2444.27","other","OPPS APC"
"Port Plan Special","PX-33000017","CDM","77321","CPT","0333","RC","","","","both","","","2180.00","1308.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","393.93","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","387.68","387.68","387.68","1 through 10","358.98","2444.27","other","OPPS APC"
"Port Plan Special","PX-33000017","CDM","77321","CPT","0333","RC","","","","both","","","2180.00","1308.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","382.50","376.38","382.50","1 through 10","358.98","2444.27","other","OPPS APC"
"Port Plan Special","PX-33000017","CDM","77321","CPT","0333","RC","","","","both","","","2180.00","1308.00","MEDICARE [2001]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","382.50","360.01","382.50","1 through 10","358.98","2444.27","other","OPPS APC"
"Port Plan Special","PX-33000017","CDM","77321","CPT","0333","RC","","","","both","","","2180.00","1308.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","382.50","376.38","382.50","1 through 10","358.98","2444.27","other","OPPS APC"
"Port Plan Special","PX-33000017","CDM","77321","CPT","0333","RC","","","","both","","","2180.00","1308.00","WELLPOINT [1015]","HB WDH ANTHEM PPO","1975.68","","Case rate ($1,975.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1927.49","1927.49","1927.49","1 through 10","358.98","2444.27","other","OPPS APC"
"Port Plan Special","PX-33000017","CDM","77321","CPT","0333","RC","","","","both","","","2180.00","1308.00","WELLSENSE NH [1050]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","395.20","395.20","395.20","1 through 10","358.98","2444.27","other","OPPS APC"
"Port Plan Special","PX-33000017","CDM","77321","CPT","0333","RC","","","","outpatient","","","2180.00","1308.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","314.36","14.42","","303.40","303.40","303.40","1 through 10","253.53","1687.32","percent of total billed charges",""
"Port Plan Special","PX-33000017","CDM","77321","CPT","0333","RC","","","","outpatient","","","2180.00","1308.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1368.60","62.78","","1320.89","1320.89","1320.89","1 through 10","253.53","1687.32","percent of total billed charges",""
"Port Plan Special","PX-33000017","CDM","77321","CPT","0333","RC","","","","outpatient","","","2180.00","1308.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1585.30","72.72","","1530.03","1530.03","1530.03","1 through 10","253.53","1687.32","percent of total billed charges",""
"Port Plan Special","PX-33000017","CDM","77321","CPT","0333","RC","","","","outpatient","","","2180.00","1308.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1371.22","62.9","","1325.52","1325.52","1325.52","1 through 10","253.53","1687.32","percent of total billed charges",""
"Port Plan Special","PX-33000017","CDM","77321","CPT","0333","RC","","","","outpatient","","","2180.00","1308.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","253.53","11.63","","248.51","248.51","248.51","1 through 10","253.53","1687.32","percent of total billed charges",""
"PORT POWERPORT 6FR LOW PLASTIC CLEARVIEW","SUP-ITM-10159340","CDM","C1788","HCPCS","0278","RC","","","","both","","","2256.12","1353.67","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1283.73","56.9","","766.70","625.15","1875.45","1 through 10","262.39","1917.7","percent of total billed charges",""
"PORT POWERPORT 6FR LOW PLASTIC CLEARVIEW","SUP-ITM-10159340","CDM","C1788","HCPCS","0278","RC","","","","both","","","2256.12","1353.67","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","262.39","11.63","","185.54","151.29","286.33","1 through 10","262.39","1917.7","percent of total billed charges",""
"PORT POWERPORT 6FR LOW PLASTIC CLEARVIEW","SUP-ITM-10159340","CDM","C1788","HCPCS","0278","RC","","","","both","","","2256.12","1353.67","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1746.24","77.4","","1611.50","1044.27","1611.50","1 through 10","262.39","1917.7","percent of total billed charges",""
"PORT POWERPORT 6FR LOW PLASTIC CLEARVIEW","SUP-ITM-10159340","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","2256.12","1353.67","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","262.39","11.63","","185.54","151.29","286.33","1 through 10","262.39","1746.24","percent of total billed charges",""
"PORT POWERPORT 6FR LOW PLASTIC CLEARVIEW","SUP-ITM-10159340","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","2256.12","1353.67","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1416.39","62.78","","845.93","845.93","845.93","1 through 10","262.39","1746.24","percent of total billed charges",""
"PORT POWERPORT 6FR LOW PLASTIC CLEARVIEW","SUP-ITM-10159340","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","2256.12","1353.67","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1640.65","72.72","","979.87","798.97","1685.81","1 through 10","262.39","1746.24","percent of total billed charges",""
"PORT POWERPORT 6FR LOW PLASTIC CLEARVIEW","SUP-ITM-10159340","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","2256.12","1353.67","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1419.10","62.9","","1460.47","692.17","1460.47","1 through 10","262.39","1746.24","percent of total billed charges",""
"PORT POWERPORT 6FR LOW PLASTIC CLEARVIEW","SUP-ITM-10159340","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","2256.12","1353.67","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1746.24","77.4","","1611.50","1044.27","1611.50","1 through 10","262.39","1746.24","percent of total billed charges",""
"PORT POWERPORT 9.5FR IMPLANTABLE INFUSION DUAL LUMEN CATHETER POLYURETHANE","SUP-ITM-10115542","CDM","C1788","HCPCS","0278","RC","","","","both","","","3316.80","1990.08","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1887.26","56.9","","766.70","625.15","1875.45","1 through 10","385.74","2819.28","percent of total billed charges",""
"PORT POWERPORT 9.5FR IMPLANTABLE INFUSION DUAL LUMEN CATHETER POLYURETHANE","SUP-ITM-10115542","CDM","C1788","HCPCS","0278","RC","","","","both","","","3316.80","1990.08","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","385.74","11.63","","185.54","151.29","286.33","1 through 10","385.74","2819.28","percent of total billed charges",""
"PORT POWERPORT 9.5FR IMPLANTABLE INFUSION DUAL LUMEN CATHETER POLYURETHANE","SUP-ITM-10115542","CDM","C1788","HCPCS","0278","RC","","","","both","","","3316.80","1990.08","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2567.20","77.4","","1611.50","1044.27","1611.50","1 through 10","385.74","2819.28","percent of total billed charges",""
"PORT POWERPORT 9.5FR IMPLANTABLE INFUSION DUAL LUMEN CATHETER POLYURETHANE","SUP-ITM-10115542","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","3316.80","1990.08","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","385.74","11.63","","185.54","151.29","286.33","1 through 10","385.74","2567.2","percent of total billed charges",""
"PORT POWERPORT 9.5FR IMPLANTABLE INFUSION DUAL LUMEN CATHETER POLYURETHANE","SUP-ITM-10115542","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","3316.80","1990.08","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2082.29","62.78","","845.93","845.93","845.93","1 through 10","385.74","2567.2","percent of total billed charges",""
"PORT POWERPORT 9.5FR IMPLANTABLE INFUSION DUAL LUMEN CATHETER POLYURETHANE","SUP-ITM-10115542","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","3316.80","1990.08","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2411.98","72.72","","979.87","798.97","1685.81","1 through 10","385.74","2567.2","percent of total billed charges",""
"PORT POWERPORT 9.5FR IMPLANTABLE INFUSION DUAL LUMEN CATHETER POLYURETHANE","SUP-ITM-10115542","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","3316.80","1990.08","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2086.27","62.9","","1460.47","692.17","1460.47","1 through 10","385.74","2567.2","percent of total billed charges",""
"PORT POWERPORT 9.5FR IMPLANTABLE INFUSION DUAL LUMEN CATHETER POLYURETHANE","SUP-ITM-10115542","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","3316.80","1990.08","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2567.20","77.4","","1611.50","1044.27","1611.50","1 through 10","385.74","2567.2","percent of total billed charges",""
"PORT VAS-CATH 8FR 45CM INFUSION POWER VACCESS CATHETER CENTRAL VENOUS VACCESS CT","SUP-ITM-10092391","CDM","C1788","HCPCS","0278","RC","","","","both","","","1278.35","767.01","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","727.38","56.9","","766.70","625.15","1875.45","1 through 10","148.67","1086.6","percent of total billed charges",""
"PORT VAS-CATH 8FR 45CM INFUSION POWER VACCESS CATHETER CENTRAL VENOUS VACCESS CT","SUP-ITM-10092391","CDM","C1788","HCPCS","0278","RC","","","","both","","","1278.35","767.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","148.67","11.63","","185.54","151.29","286.33","1 through 10","148.67","1086.6","percent of total billed charges",""
"PORT VAS-CATH 8FR 45CM INFUSION POWER VACCESS CATHETER CENTRAL VENOUS VACCESS CT","SUP-ITM-10092391","CDM","C1788","HCPCS","0278","RC","","","","both","","","1278.35","767.01","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","989.44","77.4","","1611.50","1044.27","1611.50","1 through 10","148.67","1086.6","percent of total billed charges",""
"PORT VAS-CATH 8FR 45CM INFUSION POWER VACCESS CATHETER CENTRAL VENOUS VACCESS CT","SUP-ITM-10092391","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1278.35","767.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","148.67","11.63","","185.54","151.29","286.33","1 through 10","148.67","989.44","percent of total billed charges",""
"PORT VAS-CATH 8FR 45CM INFUSION POWER VACCESS CATHETER CENTRAL VENOUS VACCESS CT","SUP-ITM-10092391","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1278.35","767.01","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","802.55","62.78","","845.93","845.93","845.93","1 through 10","148.67","989.44","percent of total billed charges",""
"PORT VAS-CATH 8FR 45CM INFUSION POWER VACCESS CATHETER CENTRAL VENOUS VACCESS CT","SUP-ITM-10092391","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1278.35","767.01","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","929.62","72.72","","979.87","798.97","1685.81","1 through 10","148.67","989.44","percent of total billed charges",""
"PORT VAS-CATH 8FR 45CM INFUSION POWER VACCESS CATHETER CENTRAL VENOUS VACCESS CT","SUP-ITM-10092391","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1278.35","767.01","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","804.08","62.9","","1460.47","692.17","1460.47","1 through 10","148.67","989.44","percent of total billed charges",""
"PORT VAS-CATH 8FR 45CM INFUSION POWER VACCESS CATHETER CENTRAL VENOUS VACCESS CT","SUP-ITM-10092391","CDM","C1788","HCPCS","0278","RC","","","","outpatient","","","1278.35","767.01","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","989.44","77.4","","1611.50","1044.27","1611.50","1 through 10","148.67","989.44","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.70","343.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","66.61","486.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.70","343.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","66.61","486.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.70","343.62","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","325.87","56.9","","812.12","238.65","1587.46","163","66.61","486.8","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.70","343.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","66.61","11.63","","112.68","112.68","146.99","38","66.61","486.8","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.70","343.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","443.27","77.4","","303.98","303.98","5854.79","1 through 10","66.61","486.8","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.70","343.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","66.61","11.63","","112.68","112.68","146.99","38","66.61","443.27","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.70","343.62","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","359.54","62.78","","780.86","208.94","10480.28","15","66.61","443.27","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.70","343.62","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","250.38","43.72","","179.76","179.76","179.76","1 through 10","66.61","443.27","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.70","343.62","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","416.47","72.72","","2355.45","298.99","3965.19","155","66.61","443.27","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.70","343.62","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","416.47","72.72","","3643.09","3643.09","3643.09","1 through 10","66.61","443.27","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.70","343.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","304.79","53.22","","554.28","554.28","554.28","16","66.61","443.27","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.70","343.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","360.23","62.9","","619.64","173.09","2370.64","150","66.61","443.27","percent of total billed charges",""
"POST 11MM 30DEG EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER","SUP-ITM-10021893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.70","343.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","443.27","77.4","","303.98","303.98","5854.79","1 through 10","66.61","443.27","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.70","343.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","66.61","486.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.70","343.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","66.61","486.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.70","343.62","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","325.87","56.9","","812.12","238.65","1587.46","163","66.61","486.8","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.70","343.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","66.61","11.63","","112.68","112.68","146.99","38","66.61","486.8","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","both","","","572.70","343.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","443.27","77.4","","303.98","303.98","5854.79","1 through 10","66.61","486.8","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.70","343.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","66.61","11.63","","112.68","112.68","146.99","38","66.61","443.27","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.70","343.62","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","359.54","62.78","","780.86","208.94","10480.28","15","66.61","443.27","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.70","343.62","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","250.38","43.72","","179.76","179.76","179.76","1 through 10","66.61","443.27","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.70","343.62","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","416.47","72.72","","2355.45","298.99","3965.19","155","66.61","443.27","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.70","343.62","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","416.47","72.72","","3643.09","3643.09","3643.09","1 through 10","66.61","443.27","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.70","343.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","304.79","53.22","","554.28","554.28","554.28","16","66.61","443.27","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.70","343.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","360.23","62.9","","619.64","173.09","2370.64","150","66.61","443.27","percent of total billed charges",""
"POST 11MM EXTERNAL FIXATION SS MR CONDITIONAL OUTRIGGER STRAIGHT","SUP-ITM-10021892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","572.70","343.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","443.27","77.4","","303.98","303.98","5854.79","1 through 10","66.61","443.27","percent of total billed charges",""
"POST PRESS-FIT SHORT 7MM PERFORM REVERSED THREADED AEQUALIS","SUP-ITM-10267866","CDM","C1776","HCPCS","0278","RC","","","","both","","","1796.60","1077.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","208.94","1527.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"POST PRESS-FIT SHORT 7MM PERFORM REVERSED THREADED AEQUALIS","SUP-ITM-10267866","CDM","C1776","HCPCS","0278","RC","","","","both","","","1796.60","1077.96","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1022.27","56.9","","2911.53","1863.86","5209.05","65","208.94","1527.11","percent of total billed charges",""
"POST PRESS-FIT SHORT 7MM PERFORM REVERSED THREADED AEQUALIS","SUP-ITM-10267866","CDM","C1776","HCPCS","0278","RC","","","","both","","","1796.60","1077.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","208.94","11.63","","400.94","400.94","400.94","1 through 10","208.94","1527.11","percent of total billed charges",""
"POST PRESS-FIT SHORT 7MM PERFORM REVERSED THREADED AEQUALIS","SUP-ITM-10267866","CDM","C1776","HCPCS","0278","RC","","","","both","","","1796.60","1077.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1390.57","77.4","","5214.50","5214.50","16415.28","1 through 10","208.94","1527.11","percent of total billed charges",""
"POST PRESS-FIT SHORT 7MM PERFORM REVERSED THREADED AEQUALIS","SUP-ITM-10267866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1796.60","1077.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","208.94","11.63","","400.94","400.94","400.94","1 through 10","208.94","1390.57","percent of total billed charges",""
"POST PRESS-FIT SHORT 7MM PERFORM REVERSED THREADED AEQUALIS","SUP-ITM-10267866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1796.60","1077.96","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","785.47","43.72","","1543.33","1543.33","1671.61","1 through 10","208.94","1390.57","percent of total billed charges",""
"POST PRESS-FIT SHORT 7MM PERFORM REVERSED THREADED AEQUALIS","SUP-ITM-10267866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1796.60","1077.96","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1306.49","72.72","","3700.21","2382.07","6427.18","53","208.94","1390.57","percent of total billed charges",""
"POST PRESS-FIT SHORT 7MM PERFORM REVERSED THREADED AEQUALIS","SUP-ITM-10267866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1796.60","1077.96","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1306.49","72.72","","12685.80","12685.80","12685.80","1 through 10","208.94","1390.57","percent of total billed charges",""
"POST PRESS-FIT SHORT 7MM PERFORM REVERSED THREADED AEQUALIS","SUP-ITM-10267866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1796.60","1077.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1130.06","62.9","","3408.87","2784.05","9859.40","46","208.94","1390.57","percent of total billed charges",""
"POST PRESS-FIT SHORT 7MM PERFORM REVERSED THREADED AEQUALIS","SUP-ITM-10267866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1796.60","1077.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1390.57","77.4","","5214.50","5214.50","16415.28","1 through 10","208.94","1390.57","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","2252.66","1351.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","261.98","1914.76","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","2252.66","1351.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1281.76","56.9","","2911.53","1863.86","5209.05","65","261.98","1914.76","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","2252.66","1351.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","261.98","11.63","","400.94","400.94","400.94","1 through 10","261.98","1914.76","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","2252.66","1351.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1743.56","77.4","","5214.50","5214.50","16415.28","1 through 10","261.98","1914.76","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2252.66","1351.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","261.98","11.63","","400.94","400.94","400.94","1 through 10","261.98","1743.56","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2252.66","1351.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","984.86","43.72","","1543.33","1543.33","1671.61","1 through 10","261.98","1743.56","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2252.66","1351.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1638.13","72.72","","3700.21","2382.07","6427.18","53","261.98","1743.56","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2252.66","1351.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1638.13","72.72","","12685.80","12685.80","12685.80","1 through 10","261.98","1743.56","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2252.66","1351.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1416.92","62.9","","3408.87","2784.05","9859.40","46","261.98","1743.56","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2252.66","1351.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1743.56","77.4","","5214.50","5214.50","16415.28","1 through 10","261.98","1743.56","percent of total billed charges",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","both","","","6483.79","3890.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","754.06","5511.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","both","","","6483.79","3890.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","754.06","5511.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","both","","","6483.79","3890.27","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3689.28","56.9","","812.12","238.65","1587.46","163","754.06","5511.22","percent of total billed charges",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","both","","","6483.79","3890.27","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","754.06","11.63","","112.68","112.68","146.99","38","754.06","5511.22","percent of total billed charges",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","both","","","6483.79","3890.27","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5018.45","77.4","","303.98","303.98","5854.79","1 through 10","754.06","5511.22","percent of total billed charges",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6483.79","3890.27","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","754.06","11.63","","112.68","112.68","146.99","38","754.06","5018.45","percent of total billed charges",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6483.79","3890.27","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4070.52","62.78","","780.86","208.94","10480.28","15","754.06","5018.45","percent of total billed charges",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6483.79","3890.27","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2834.71","43.72","","179.76","179.76","179.76","1 through 10","754.06","5018.45","percent of total billed charges",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6483.79","3890.27","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4715.01","72.72","","2355.45","298.99","3965.19","155","754.06","5018.45","percent of total billed charges",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6483.79","3890.27","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4715.01","72.72","","3643.09","3643.09","3643.09","1 through 10","754.06","5018.45","percent of total billed charges",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6483.79","3890.27","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3450.67","53.22","","554.28","554.28","554.28","16","754.06","5018.45","percent of total billed charges",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6483.79","3890.27","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4078.30","62.9","","619.64","173.09","2370.64","150","754.06","5018.45","percent of total billed charges",""
"POSTERIOR PLATE 3.5MMX79 2 HOLE TIBIAL LCP SS PROXIMALIMAL MEDIAL","SUP-ITM-10074535","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6483.79","3890.27","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5018.45","77.4","","303.98","303.98","5854.79","1 through 10","754.06","5018.45","percent of total billed charges",""
"Postoperative And Post-Traumatic Infections With McC","862","MS-DRG","","","","","","","","inpatient","","","43957.76","26374.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","27287.80","","Fee schedule rate ($27,287.80). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","26841.21","26841.21","26841.21","1 through 10","3975","69300.78","case rate",""
"Postoperative And Post-Traumatic Infections With McC","862","MS-DRG","","","","","","","","inpatient","","","43957.76","26374.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","14023.23","","Case rate ($14,309.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,241.70, add-ons for qualifying new technology services are included. If operating cost exceeds $17,159.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,818.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $12,851.42 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,796.84 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,013.14. The transfer capital threshold is the transfer adjustment factor * $1,013.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14067.85","14067.85","14067.85","1 through 10","3975","69300.78","other","Inpatient DRG"
"Postoperative And Post-Traumatic Infections With McC","862","MS-DRG","","","","","","","","inpatient","","","43957.76","26374.66","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","14738.70","","Case rate ($14,309.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,241.70, add-ons for qualifying new technology services are included. If operating cost exceeds $17,159.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,818.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $12,851.42 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,796.84 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,013.14. The transfer capital threshold is the transfer adjustment factor * $1,013.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","39477.80","39477.80","39477.80","1 through 10","3975","69300.78","other","Inpatient DRG"
"Postoperative And Post-Traumatic Infections With McC","862","MS-DRG","","","","","","","","inpatient","","","43957.76","26374.66","MEDICARE [2001]","HB WDH MEDICARE","14309.42","","Case rate ($14,309.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,241.70, add-ons for qualifying new technology services are included. If operating cost exceeds $17,159.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,818.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $12,851.42 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,796.84 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,013.14. The transfer capital threshold is the transfer adjustment factor * $1,013.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14354.95","14318.80","14354.95","1 through 10","3975","69300.78","other","Inpatient DRG"
"Postoperative And Post-Traumatic Infections With McC","862","MS-DRG","","","","","","","","inpatient","","","43957.76","26374.66","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","14309.42","","Case rate ($14,309.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,241.70, add-ons for qualifying new technology services are included. If operating cost exceeds $17,159.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,818.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $12,851.42 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,796.84 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,013.14. The transfer capital threshold is the transfer adjustment factor * $1,013.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13840.48","13840.48","13840.48","1 through 10","3975","69300.78","other","Inpatient DRG"
"Postoperative And Post-Traumatic Infections Without McC","863","MS-DRG","","","","","","","","inpatient","","","29021.12","17412.67","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","14931.46","","Fee schedule rate ($14,931.46). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","21051.93","21051.93","21051.93","1 through 10","3975","37920.3","case rate",""
"Postoperative And Post-Traumatic Infections Without McC","863","MS-DRG","","","","","","","","inpatient","","","29021.12","17412.67","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","7870.70","","Case rate ($8,031.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,447.10, add-ons for qualifying new technology services are included. If operating cost exceeds $11,365.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,359.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,032.09 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,002.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $554.38. The transfer capital threshold is the transfer adjustment factor * $554.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7829.81","7829.81","7829.81","1 through 10","3975","37920.3","other","Inpatient DRG"
"Postoperative And Post-Traumatic Infections Without McC","863","MS-DRG","","","","","","","","inpatient","","","29021.12","17412.67","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","30201.72","","Fee schedule rate ($30,201.72). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","4580.39","4580.39","4580.39","1 through 10","3975","37920.3","case rate",""
"Postoperative And Post-Traumatic Infections Without McC","863","MS-DRG","","","","","","","","inpatient","","","29021.12","17412.67","MEDICARE [2001]","HB WDH MEDICARE","8031.33","","Case rate ($8,031.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,447.10, add-ons for qualifying new technology services are included. If operating cost exceeds $11,365.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,359.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,032.09 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,002.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $554.38. The transfer capital threshold is the transfer adjustment factor * $554.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7119.67","7119.67","8009.25","1 through 10","3975","37920.3","other","Inpatient DRG"
"Postoperative And Post-Traumatic Infections Without McC","863","MS-DRG","","","","","","","","inpatient","","","29021.12","17412.67","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8031.33","","Case rate ($8,031.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,447.10, add-ons for qualifying new technology services are included. If operating cost exceeds $11,365.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,359.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $7,032.09 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,002.23 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $554.38. The transfer capital threshold is the transfer adjustment factor * $554.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14102.06","14102.06","14102.06","1 through 10","3975","37920.3","other","Inpatient DRG"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","","","","inpatient","","","55847.03","33508.22","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","16390.98","","Case rate ($16,725.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,471.70, add-ons for qualifying new technology services are included. If operating cost exceeds $19,389.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,994.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $15,090.92 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,026.83 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,189.70. The transfer capital threshold is the transfer adjustment factor * $1,189.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","15393.06","15393.06","15393.06","1 through 10","3975","81377.21","other","Inpatient DRG"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","","","","inpatient","","","55847.03","33508.22","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","16725.49","","Case rate ($16,725.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,471.70, add-ons for qualifying new technology services are included. If operating cost exceeds $19,389.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,994.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $15,090.92 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,026.83 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,189.70. The transfer capital threshold is the transfer adjustment factor * $1,189.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","21466.49","21466.49","21466.49","1 through 10","3975","81377.21","other","Inpatient DRG"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC","856","MS-DRG","","","","","","","","inpatient","","","87358.30","52414.98","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","34325.55","","Case rate ($35,026.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $32,362.93, add-ons for qualifying new technology services are included. If operating cost exceeds $36,281.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,332.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $32,054.20 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $31,918.07 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,527.00. The transfer capital threshold is the transfer adjustment factor * $2,527.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","33926.02","33926.02","33926.02","1 through 10","3975","172851.05","other","Inpatient DRG"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC","856","MS-DRG","","","","","","","","inpatient","","","87358.30","52414.98","MEDICARE [2001]","HB WDH MEDICARE","35026.07","","Case rate ($35,026.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $32,362.93, add-ons for qualifying new technology services are included. If operating cost exceeds $36,281.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,332.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $32,054.20 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $31,918.07 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,527.00. The transfer capital threshold is the transfer adjustment factor * $2,527.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","34576.04","34487.34","34576.04","1 through 10","3975","172851.05","other","Inpatient DRG"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC","856","MS-DRG","","","","","","","","inpatient","","","87358.30","52414.98","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","35026.07","","Case rate ($35,026.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $32,362.93, add-ons for qualifying new technology services are included. If operating cost exceeds $36,281.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,332.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $32,054.20 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $31,918.07 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,527.00. The transfer capital threshold is the transfer adjustment factor * $2,527.00. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15004.06","15004.06","19238.10","1 through 10","3975","172851.05","other","Inpatient DRG"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/McC","858","MS-DRG","","","","","","","","inpatient","","","41657.72","24994.63","MEDICARE [2001]","HB WDH MEDICARE","11034.31","","Case rate ($11,034.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,218.80, add-ons for qualifying new technology services are included. If operating cost exceeds $14,136.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,578.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,815.62 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,773.93 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.82. The transfer capital threshold is the transfer adjustment factor * $773.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10191.82","10191.82","10191.82","1 through 10","3975","52930.34","other","Inpatient DRG"
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","","","","inpatient","","","5667.78","3400.67","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","9796.20","","Fee schedule rate ($9,796.20). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","10415.62","10415.62","10415.62","1 through 10","3975","24878.67","case rate",""
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","","","","inpatient","","","5667.78","3400.67","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","19814.68","","Fee schedule rate ($19,814.68). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","7849.79","7849.79","7849.79","1 through 10","3975","24878.67","case rate",""
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","","","","inpatient","","","5667.78","3400.67","MARTIN'S POINT [160007]","HB WDH MEDICARE","5422.17","","Case rate ($5,422.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,038.87, add-ons for qualifying new technology services are included. If operating cost exceeds $8,957.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,168.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,613.60 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,594.01 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $363.71. The transfer capital threshold is the transfer adjustment factor * $363.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","4664.14","4664.14","4664.14","1 through 10","3975","24878.67","other","Inpatient DRG"
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","","","","inpatient","","","5667.78","3400.67","TRICARE [160005]","HB WDH MEDICARE","5422.17","","Case rate ($5,422.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,038.87, add-ons for qualifying new technology services are included. If operating cost exceeds $8,957.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,168.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,613.60 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,594.01 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $363.71. The transfer capital threshold is the transfer adjustment factor * $363.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","3817.24","3817.24","3817.24","1 through 10","3975","24878.67","other","Inpatient DRG"
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","","","","inpatient","","","5667.78","3400.67","WELLSENSE NH [1050]","HB WDH MEDICARE","5422.17","","Case rate ($5,422.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,038.87, add-ons for qualifying new technology services are included. If operating cost exceeds $8,957.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,168.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $4,613.60 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,594.01 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $363.71. The transfer capital threshold is the transfer adjustment factor * $363.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5740.52","5740.52","5740.52","1 through 10","3975","24878.67","other","Inpatient DRG"
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","both","","","66.00","39.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","46.07","69.8","","44.67","5.24","44.67","1 through 10","3.09","56.1","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","outpatient","","","66.00","39.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","41.43","62.78","","40.18","40.18","40.18","1 through 10","4.28","51.08","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","outpatient","","","66.00","39.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","48.00","72.72","","46.54","46.54","46.54","1 through 10","4.28","51.08","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","outpatient","","","66.00","39.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","48.00","72.72","","46.54","46.54","46.54","1 through 10","4.28","51.08","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","outpatient","","","66.00","39.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","35.13","53.22","","31.60","31.60","31.60","1 through 10","4.28","51.08","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","outpatient","","","66.00","39.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","41.51","62.9","","40.32","40.32","40.32","1 through 10","4.28","51.08","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","outpatient","","","66.00","39.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","51.08","77.4","","49.60","49.60","49.60","17","4.28","51.08","percent of total billed charges",""
"Potassium Urine","PX-30000629","CDM","84133","CPT","0301","RC","","","","both","","","61.00","36.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","42.58","69.8","","41.18","41.18","41.18","1 through 10","3.07","51.85","percent of total billed charges",""
"Potassium Urine","PX-30000629","CDM","84133","CPT","0301","RC","","","","outpatient","","","61.00","36.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","44.36","72.72","","42.90","42.90","42.90","1 through 10","4.01","47.21","percent of total billed charges",""
"Potassium Urine","PX-30000629","CDM","84133","CPT","0301","RC","","","","outpatient","","","61.00","36.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","38.37","62.9","","37.17","37.17","37.17","1 through 10","4.01","47.21","percent of total billed charges",""
"Potassium Urine","PX-30000629","CDM","84133","CPT","0301","RC","","","","outpatient","","","61.00","36.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","47.21","77.4","","45.73","45.73","45.73","1 through 10","4.01","47.21","percent of total billed charges",""
"Prealbumin","PX-30000630","CDM","84134","CPT","0301","RC","","","","both","","","207.00","124.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","144.49","69.8","","139.60","139.60","139.60","1 through 10","9.48","175.95","percent of total billed charges",""
"Prealbumin","PX-30000630","CDM","84134","CPT","0301","RC","","","","outpatient","","","207.00","124.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","150.53","72.72","","145.44","145.44","145.44","18","13.59","160.22","percent of total billed charges",""
"Prealbumin","PX-30000630","CDM","84134","CPT","0301","RC","","","","outpatient","","","207.00","124.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","110.17","53.22","","106.62","106.62","106.62","1 through 10","13.59","160.22","percent of total billed charges",""
"Prealbumin","PX-30000630","CDM","84134","CPT","0301","RC","","","","outpatient","","","207.00","124.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","130.20","62.9","","126.00","126.00","126.00","1 through 10","13.59","160.22","percent of total billed charges",""
"Precerebral Occlusion Without Infarction Without McC","068","MS-DRG","","","","","","","","inpatient","","","42342.02","25405.21","MEDICARE [2001]","HB WDH MEDICARE","7016.41","","Case rate ($7,016.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,510.33, add-ons for qualifying new technology services are included. If operating cost exceeds $10,428.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,285.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,091.33 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,065.46 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $480.21. The transfer capital threshold is the transfer adjustment factor * $480.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","0.05","1 through 10","3975","32847.29","other","Inpatient DRG"
"Pregnenolone","PX-30000633","CDM","84140","CPT","0301","RC","","","","both","","","238.00","142.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","166.12","69.8","","160.54","160.54","160.54","1 through 10","13.44","202.3","percent of total billed charges",""
"Pregnenolone","PX-30000633","CDM","84140","CPT","0301","RC","","","","outpatient","","","238.00","142.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","149.42","62.78","","100.56","100.56","100.56","1 through 10","24.79","184.21","percent of total billed charges",""
"Prematurity With Major Problems","791","MS-DRG","","","","","","","","inpatient","","","34385.01","20631.01","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","154242.41","","Fee schedule rate ($154,242.41). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","140288.60","140288.60","140288.60","1 through 10","629.84","154242.41","case rate",""
"Prematurity With Major Problems","791","MS-DRG","","","","","","","","inpatient","","","34385.01","20631.01","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","60734.33","","Fee schedule rate ($60,734.33). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","59266.13","59266.13","62113.57","1 through 10","629.84","154242.41","case rate",""
"Prematurity With Major Problems","791","MS-DRG","","","","","","","","inpatient","","","34385.01","20631.01","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","30677.09","","Case rate ($31,303.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $28,926.73, add-ons for qualifying new technology services are included. If operating cost exceeds $32,844.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,059.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 13.3. The base transfer operating payment is the transfer adjustment factor * $28,603.33 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $28,481.86 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,254.95. The transfer capital threshold is the transfer adjustment factor * $2,254.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","31079.00","31079.00","31079.00","1 through 10","629.84","154242.41","other","Inpatient DRG"
"Prematurity With Major Problems","791","MS-DRG","","","","","","","","inpatient","","","34385.01","20631.01","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","122846.77","","Fee schedule rate ($122,846.77). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","23774.87","15365.59","87240.52","1 through 10","629.84","154242.41","case rate",""
"Prematurity With Major Problems","791","MS-DRG","","","","","","","","inpatient","","","34385.01","20631.01","TRICARE [160005]","HB WDH MEDICARE","31303.15","","Case rate ($31,303.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $28,926.73, add-ons for qualifying new technology services are included. If operating cost exceeds $32,844.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,059.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 13.3. The base transfer operating payment is the transfer adjustment factor * $28,603.33 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $28,481.86 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,254.95. The transfer capital threshold is the transfer adjustment factor * $2,254.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","2176.51","2176.51","2176.51","1 through 10","629.84","154242.41","other","Inpatient DRG"
"Prematurity Without Major Problems","792","MS-DRG","","","","","","","","inpatient","","","18016.81","10810.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","93069.84","","Fee schedule rate ($93,069.84). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","68700.49","44540.30","90818.38","1 through 10","548.85","93069.84","case rate",""
"Prematurity Without Major Problems","792","MS-DRG","","","","","","","","inpatient","","","18016.81","10810.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","36647.09","","Fee schedule rate ($36,647.09). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","35760.54","2916.66","35760.54","1 through 10","548.85","93069.84","case rate",""
"Prematurity Without Major Problems","792","MS-DRG","","","","","","","","inpatient","","","18016.81","10810.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","18683.46","","Case rate ($19,064.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $17,630.82, add-ons for qualifying new technology services are included. If operating cost exceeds $21,549.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,165.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $17,259.25 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,185.95 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,360.64. The transfer capital threshold is the transfer adjustment factor * $1,360.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","18977.30","18929.14","71103.66","1 through 10","548.85","93069.84","other","Inpatient DRG"
"Prematurity Without Major Problems","792","MS-DRG","","","","","","","","inpatient","","","18016.81","10810.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","74125.72","","Fee schedule rate ($74,125.72). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","5899.51","5899.51","72332.53","1 through 10","548.85","93069.84","case rate",""
"Prematurity Without Major Problems","792","MS-DRG","","","","","","","","inpatient","","","18016.81","10810.09","TRICARE [160005]","HB WDH MEDICARE","19064.75","","Case rate ($19,064.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $17,630.82, add-ons for qualifying new technology services are included. If operating cost exceeds $21,549.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,165.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.6. The base transfer operating payment is the transfer adjustment factor * $17,259.25 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,185.95 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,360.64. The transfer capital threshold is the transfer adjustment factor * $1,360.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8129.89","8129.89","8129.89","1 through 10","548.85","93069.84","other","Inpatient DRG"
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0300","RC","","","","inpatient","","","826.00","495.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","634.86","76.86","","503.37","503.37","503.37","1 through 10","546.81","634.86","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","both","","","826.00","495.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","576.55","69.8","","557.70","502.57","557.70","21","40.39","702.1","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","both","","","826.00","495.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","576.55","69.8","","557.70","557.70","557.70","1 through 10","40.39","702.1","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","outpatient","","","826.00","495.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","518.56","62.78","","501.61","501.61","501.61","1 through 10","51.55","639.32","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","outpatient","","","826.00","495.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","361.13","43.72","","349.32","349.32","698.64","1 through 10","51.55","639.32","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","outpatient","","","826.00","495.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","600.67","72.72","","581.03","581.03","581.03","35","51.55","639.32","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","outpatient","","","826.00","495.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","600.67","72.72","","581.03","581.03","581.03","1 through 10","51.55","639.32","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","outpatient","","","826.00","495.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","439.60","53.22","","425.95","47.55","425.95","1 through 10","51.55","639.32","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","outpatient","","","826.00","495.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","519.55","62.9","","503.37","503.37","1510.11","61","51.55","639.32","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","outpatient","","","826.00","495.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","639.32","77.4","","619.23","619.23","619.23","22","51.55","639.32","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","outpatient","","","826.00","495.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","600.67","72.72","","581.03","581.03","581.03","1 through 10","51.55","639.32","percent of total billed charges",""
"Prgrmg Dev Eval Implantable Subq Lead Dfb System","PX-48000421","CDM","93260","CPT","0480","RC","","","","both","","","303.00","181.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","201.25","","Case rate ($201.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","196.34","196.34","196.34","1 through 10","38.18","257.55","other","OPPS APC"
"Prgrmg Dev Eval Implantable Subq Lead Dfb System","PX-48000421","CDM","93260","CPT","0480","RC","","","","both","","","303.00","181.80","MEDICARE [2001]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.96","38.96","38.96","1 through 10","38.18","257.55","other","OPPS APC"
"Prgrmg Dev Eval Implantable Subq Lead Dfb System","PX-48000421","CDM","93260","CPT","0480","RC","","","","both","","","303.00","181.80","WELLSENSE NH [1050]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","40.09","40.09","40.09","1 through 10","38.18","257.55","other","OPPS APC"
"Prgrmg Dev Eval Implantable Subq Lead Dfb System","PX-48000421","CDM","93260","CPT","0480","RC","","","","outpatient","","","303.00","181.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","35.24","11.63","","34.49","34.49","34.49","1 through 10","35.24","234.52","percent of total billed charges",""
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","both","","","251.00","150.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","248.99","","Case rate ($248.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","242.00","242.00","242.00","1 through 10","38.18","248.99","other","OPPS APC"
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","both","","","251.00","150.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","107.21","","Case rate ($107.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.60","102.85","104.60","1 through 10","38.18","248.99","other","OPPS APC"
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","both","","","251.00","150.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","38.18","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","38.18","38.18","38.41","26","38.18","248.99","other","OPPS APC"
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","both","","","251.00","150.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","201.25","","Case rate ($201.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","196.34","196.34","196.34","1 through 10","38.18","248.99","other","OPPS APC"
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","both","","","251.00","150.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","40.13","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","40.13","40.13","40.13","11","38.18","248.99","other","OPPS APC"
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","both","","","251.00","150.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.30","38.22","38.96","15","38.18","248.99","other","OPPS APC"
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","both","","","251.00","150.60","MEDICARE [2001]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.96","38.96","38.96","62","38.18","248.99","other","OPPS APC"
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","both","","","251.00","150.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.69","38.19","38.96","35","38.18","248.99","other","OPPS APC"
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","outpatient","","","251.00","150.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","29.19","11.63","","29.62","28.58","33.32","1 through 10","29.19","194.27","percent of total billed charges",""
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","outpatient","","","251.00","150.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","182.53","72.72","","175.98","175.98","175.98","1 through 10","29.19","194.27","percent of total billed charges",""
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","outpatient","","","251.00","150.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","157.88","62.9","","152.46","152.46","152.46","1 through 10","29.19","194.27","percent of total billed charges",""
"Prgrmg Eval Implantable in Person Multi Lead Dfb","PX-48000010","CDM","93284","CPT","0480","RC","","","","outpatient","","","251.00","150.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","29.19","11.63","","28.58","28.58","28.58","1 through 10","29.19","194.27","percent of total billed charges",""
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","both","","","217.00","130.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","248.99","","Case rate ($248.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","209.00","209.00","209.00","1 through 10","38.18","248.99","other","OPPS APC"
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","both","","","217.00","130.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","107.21","","Case rate ($107.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.60","104.60","104.60","1 through 10","38.18","248.99","other","OPPS APC"
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","both","","","217.00","130.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","38.18","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","38.34","38.18","38.41","1 through 10","38.18","248.99","other","OPPS APC"
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","both","","","217.00","130.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","123.47","56.9","","118.92","118.92","118.92","1 through 10","38.18","248.99","percent of total billed charges",""
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","both","","","217.00","130.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","40.13","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","40.13","40.13","40.13","1 through 10","38.18","248.99","other","OPPS APC"
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","both","","","217.00","130.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.30","38.30","38.96","11","38.18","248.99","other","OPPS APC"
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","both","","","217.00","130.20","MEDICARE [2001]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.96","36.74","38.96","45","38.18","248.99","other","OPPS APC"
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","both","","","217.00","130.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.69","36.01","38.96","18","38.18","248.99","other","OPPS APC"
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","outpatient","","","217.00","130.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","25.24","11.63","","53.78","53.78","53.78","1 through 10","25.24","167.96","percent of total billed charges",""
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","outpatient","","","217.00","130.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","157.80","72.72","","151.98","151.98","151.98","1 through 10","25.24","167.96","percent of total billed charges",""
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","outpatient","","","217.00","130.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","136.49","62.9","","131.67","131.67","131.67","1 through 10","25.24","167.96","percent of total billed charges",""
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","outpatient","","","217.00","130.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","167.96","77.4","","161.98","161.98","161.98","1 through 10","25.24","167.96","percent of total billed charges",""
"Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb","PX-48000008","CDM","93282","CPT","0480","RC","","","","outpatient","","","217.00","130.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","25.24","11.63","","24.68","24.68","24.68","1 through 10","25.24","167.96","percent of total billed charges",""
"PROBE BREAST BIOPSY GAMMA TRUNODE BX/10EA","SUP-ITM-10282919","CDM","A4648","HCPCS","0278","RC","","","","both","","","2142.10","1285.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","2142.10","2142.10","2142.10","1 through 10","249.13","1820.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PROBE BREAST BIOPSY GAMMA TRUNODE BX/10EA","SUP-ITM-10282919","CDM","A4648","HCPCS","0278","RC","","","","both","","","2142.10","1285.26","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1218.85","56.9","","2142.10","1218.85","3656.55","13","249.13","1820.79","percent of total billed charges",""
"PROBE BREAST BIOPSY GAMMA TRUNODE BX/10EA","SUP-ITM-10282919","CDM","A4648","HCPCS","0278","RC","","","","both","","","2142.10","1285.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","249.13","11.63","","682.96","135.41","682.96","1 through 10","249.13","1820.79","percent of total billed charges",""
"PROBE BREAST BIOPSY GAMMA TRUNODE BX/10EA","SUP-ITM-10282919","CDM","A4648","HCPCS","0278","RC","","","","both","","","2142.10","1285.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1657.99","77.4","","294.54","294.54","294.54","1 through 10","249.13","1820.79","percent of total billed charges",""
"PROBE BREAST BIOPSY GAMMA TRUNODE BX/10EA","SUP-ITM-10282919","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","2142.10","1285.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","249.13","11.63","","682.96","135.41","682.96","1 through 10","249.13","1657.99","percent of total billed charges",""
"PROBE BREAST BIOPSY GAMMA TRUNODE BX/10EA","SUP-ITM-10282919","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","2142.10","1285.26","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1344.81","62.78","","4034.43","4034.43","4034.43","1 through 10","249.13","1657.99","percent of total billed charges",""
"PROBE BREAST BIOPSY GAMMA TRUNODE BX/10EA","SUP-ITM-10282919","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","2142.10","1285.26","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","936.53","43.72","","2809.59","2809.59","2809.59","1 through 10","249.13","1657.99","percent of total billed charges",""
"PROBE BREAST BIOPSY GAMMA TRUNODE BX/10EA","SUP-ITM-10282919","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","2142.10","1285.26","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1557.74","72.72","","1784.84","1266.30","4673.22","15","249.13","1657.99","percent of total billed charges",""
"PROBE BREAST BIOPSY GAMMA TRUNODE BX/10EA","SUP-ITM-10282919","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","2142.10","1285.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1347.38","62.9","","1499.38","337.82","4048.56","1 through 10","249.13","1657.99","percent of total billed charges",""
"PROBE BREAST BIOPSY GAMMA TRUNODE BX/10EA","SUP-ITM-10282919","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","2142.10","1285.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1657.99","77.4","","294.54","294.54","294.54","1 through 10","249.13","1657.99","percent of total billed charges",""
"PROBE BREAST BIOPSY GAMMA TRUNODE BX/10EA","SUP-ITM-10282919","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","2142.10","1285.26","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","1557.74","72.72","","1565.72","1565.72","1565.72","1 through 10","249.13","1657.99","percent of total billed charges",""
"PROBE ENDOSCOPY 2.3MM 220CM FIAPC FILTER INTEGRATED ARGON PLASMA COAGULATION FLEXIBLE MUST BE ORDERED IN MULTIPLES OF 10","SUP-ITM-10321771","CDM","C1886","HCPCS","0272","RC","","","","both","","","1699.86","1019.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","17905.28","17905.28","17905.28","1 through 10","197.69","1444.88","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PROBE ENDOSCOPY 2.3MM 220CM FIAPC FILTER INTEGRATED ARGON PLASMA COAGULATION FLEXIBLE MUST BE ORDERED IN MULTIPLES OF 10","SUP-ITM-10321771","CDM","C1886","HCPCS","0272","RC","","","","both","","","1699.86","1019.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","5539.33","5539.33","5539.33","1 through 10","197.69","1444.88","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PROBE ENDOSCOPY 2.3MM 220CM FIAPC FILTER INTEGRATED ARGON PLASMA COAGULATION FLEXIBLE MUST BE ORDERED IN MULTIPLES OF 10","SUP-ITM-10321771","CDM","C1886","HCPCS","0272","RC","","","","both","","","1699.86","1019.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","197.69","11.63","","1314.65","1314.65","1314.65","1 through 10","197.69","1444.88","percent of total billed charges",""
"PROBE ENDOSCOPY 2.3MM 220CM FIAPC FILTER INTEGRATED ARGON PLASMA COAGULATION FLEXIBLE MUST BE ORDERED IN MULTIPLES OF 10","SUP-ITM-10321771","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","1699.86","1019.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","197.69","11.63","","1314.65","1314.65","1314.65","1 through 10","197.69","1315.69","percent of total billed charges",""
"PROBE ENDOSCOPY 2.3MM 220CM FIAPC FILTER INTEGRATED ARGON PLASMA COAGULATION FLEXIBLE MUST BE ORDERED IN MULTIPLES OF 10","SUP-ITM-10321771","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","1699.86","1019.92","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1236.14","72.72","","16561.06","16561.06","16561.06","1 through 10","197.69","1315.69","percent of total billed charges",""
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","both","","","17856.80","10714.08","AETNA [1001]","HB WDH AETNA COMMERCIAL","12464.05","69.8","","1552.48","1552.48","1552.48","1 through 10","2076.75","15178.28","percent of total billed charges",""
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","both","","","17856.80","10714.08","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","2076.75","15178.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","both","","","17856.80","10714.08","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","2076.75","15178.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","both","","","17856.80","10714.08","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","10160.52","56.9","","0.63","0.63","0.63","1 through 10","2076.75","15178.28","percent of total billed charges",""
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","both","","","17856.80","10714.08","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2574.95","14.42","","317.14","317.14","317.14","1 through 10","2076.75","15178.28","percent of total billed charges",""
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","17856.80","10714.08","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2574.95","14.42","","317.14","317.14","317.14","1 through 10","2076.75","13821.16","percent of total billed charges",""
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","17856.80","10714.08","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","11210.50","62.78","","1125.09","1125.09","1125.09","1 through 10","2076.75","13821.16","percent of total billed charges",""
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","17856.80","10714.08","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","12985.46","72.72","","4732.50","1617.43","14180.40","1 through 10","2076.75","13821.16","percent of total billed charges",""
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","17856.80","10714.08","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","11231.93","62.9","","3896.20","3341.38","3896.20","1 through 10","2076.75","13821.16","percent of total billed charges",""
"PROBE RADIOFREQUENCY 16-22GA 10CM ACCURIAN STAINLESS PK/4EA","SUP-ITM-10320567","CDM","C1889","HCPCS","0272","RC","","","","both","","","621.90","373.14","AETNA [1001]","HB WDH AETNA COMMERCIAL","434.09","69.8","","1552.48","1552.48","1552.48","1 through 10","72.33","528.62","percent of total billed charges",""
"PROBE RADIOFREQUENCY 16-22GA 10CM ACCURIAN STAINLESS PK/4EA","SUP-ITM-10320567","CDM","C1889","HCPCS","0272","RC","","","","both","","","621.90","373.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","72.33","528.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PROBE RADIOFREQUENCY 16-22GA 10CM ACCURIAN STAINLESS PK/4EA","SUP-ITM-10320567","CDM","C1889","HCPCS","0272","RC","","","","both","","","621.90","373.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","72.33","528.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PROBE RADIOFREQUENCY 16-22GA 10CM ACCURIAN STAINLESS PK/4EA","SUP-ITM-10320567","CDM","C1889","HCPCS","0272","RC","","","","both","","","621.90","373.14","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","353.86","56.9","","0.63","0.63","0.63","1 through 10","72.33","528.62","percent of total billed charges",""
"PROBE RADIOFREQUENCY 16-22GA 10CM ACCURIAN STAINLESS PK/4EA","SUP-ITM-10320567","CDM","C1889","HCPCS","0272","RC","","","","both","","","621.90","373.14","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","89.68","14.42","","317.14","317.14","317.14","1 through 10","72.33","528.62","percent of total billed charges",""
"PROBE RADIOFREQUENCY 16-22GA 10CM ACCURIAN STAINLESS PK/4EA","SUP-ITM-10320567","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","621.90","373.14","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","89.68","14.42","","317.14","317.14","317.14","1 through 10","72.33","481.35","percent of total billed charges",""
"PROBE RADIOFREQUENCY 16-22GA 10CM ACCURIAN STAINLESS PK/4EA","SUP-ITM-10320567","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","621.90","373.14","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","390.43","62.78","","1125.09","1125.09","1125.09","1 through 10","72.33","481.35","percent of total billed charges",""
"PROBE RADIOFREQUENCY 16-22GA 10CM ACCURIAN STAINLESS PK/4EA","SUP-ITM-10320567","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","621.90","373.14","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","452.25","72.72","","4732.50","1617.43","14180.40","1 through 10","72.33","481.35","percent of total billed charges",""
"PROBE RADIOFREQUENCY 16-22GA 10CM ACCURIAN STAINLESS PK/4EA","SUP-ITM-10320567","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","621.90","373.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","391.18","62.9","","3896.20","3341.38","3896.20","1 through 10","72.33","481.35","percent of total billed charges",""
"Procalcitonin (Pct)","PX-30000636","CDM","84145","CPT","0300","RC","","","","inpatient","","","343.00","205.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","263.63","76.86","","209.16","209.16","209.16","1 through 10","227.07","263.63","percent of total billed charges",""
"Procalcitonin (Pct)","PX-30000636","CDM","84145","CPT","0301","RC","","","","both","","","343.00","205.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","239.41","69.8","","214.98","60.01","214.98","1 through 10","17.69","291.55","percent of total billed charges",""
"Procalcitonin (Pct)","PX-30000636","CDM","84145","CPT","0301","RC","","","","outpatient","","","343.00","205.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","215.34","62.78","","208.43","208.43","208.43","1 through 10","18.06","265.48","percent of total billed charges",""
"Procalcitonin (Pct)","PX-30000636","CDM","84145","CPT","0301","RC","","","","outpatient","","","343.00","205.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","249.43","72.72","","241.43","241.43","241.43","1 through 10","18.06","265.48","percent of total billed charges",""
"Procalcitonin (Pct)","PX-30000636","CDM","84145","CPT","0301","RC","","","","outpatient","","","343.00","205.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","215.75","62.9","","209.16","209.16","627.48","1 through 10","18.06","265.48","percent of total billed charges",""
"Procalcitonin (Pct)","PX-30000636","CDM","84145","CPT","0301","RC","","","","outpatient","","","343.00","205.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","265.48","77.4","","257.30","257.30","257.30","1 through 10","18.06","265.48","percent of total billed charges",""
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","239.00","143.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","248.99","","Case rate ($248.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","231.00","231.00","231.00","1 through 10","38.18","248.99","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","239.00","143.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","107.21","","Case rate ($107.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.60","104.60","104.60","1 through 10","38.18","248.99","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","239.00","143.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","38.18","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","38.18","36.74","38.41","49","38.18","248.99","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","239.00","143.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","201.25","","Case rate ($201.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","193.06","94.14","196.34","1 through 10","38.18","248.99","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","239.00","143.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","135.99","56.9","","131.44","131.44","131.44","17","38.18","248.99","percent of total billed charges",""
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","239.00","143.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","40.13","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","40.13","40.13","40.13","25","38.18","248.99","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","239.00","143.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.30","38.22","38.96","76","38.18","248.99","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","239.00","143.40","MEDICARE [2001]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.96","38.96","38.96","209","38.18","248.99","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","239.00","143.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.69","38.19","38.96","118","38.18","248.99","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","both","","","239.00","143.40","WELLSENSE NH [1050]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","40.09","40.09","40.91","1 through 10","38.18","248.99","other","OPPS APC"
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","outpatient","","","239.00","143.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","27.80","11.63","","31.81","27.29","58.35","1 through 10","27.8","184.99","percent of total billed charges",""
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","outpatient","","","239.00","143.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","173.80","72.72","","167.98","167.98","167.98","1 through 10","27.8","184.99","percent of total billed charges",""
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","outpatient","","","239.00","143.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","150.33","62.9","","145.53","139.99","145.53","1 through 10","27.8","184.99","percent of total billed charges",""
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","outpatient","","","239.00","143.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","184.99","77.4","","179.03","179.03","179.03","1 through 10","27.8","184.99","percent of total billed charges",""
"Prog Dev Eval Dual Lead Pcmkr","PX-48000006","CDM","93280","CPT","0480","RC","","","","outpatient","","","239.00","143.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","27.80","11.63","","27.29","27.29","27.29","1 through 10","27.8","184.99","percent of total billed charges",""
"Prog Dev Eval Multi Lead Pcmkr","PX-48000007","CDM","93281","CPT","0480","RC","","","","both","","","236.00","141.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","38.18","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","38.18","38.18","38.18","1 through 10","38.18","248.99","other","OPPS APC"
"Prog Dev Eval Multi Lead Pcmkr","PX-48000007","CDM","93281","CPT","0480","RC","","","","both","","","236.00","141.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","134.28","56.9","","129.73","129.73","129.73","1 through 10","38.18","248.99","percent of total billed charges",""
"Prog Dev Eval Multi Lead Pcmkr","PX-48000007","CDM","93281","CPT","0480","RC","","","","both","","","236.00","141.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.96","38.22","38.96","1 through 10","38.18","248.99","other","OPPS APC"
"Prog Dev Eval Multi Lead Pcmkr","PX-48000007","CDM","93281","CPT","0480","RC","","","","both","","","236.00","141.60","MEDICARE [2001]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.96","36.74","38.96","20","38.18","248.99","other","OPPS APC"
"Prog Dev Eval Multi Lead Pcmkr","PX-48000007","CDM","93281","CPT","0480","RC","","","","both","","","236.00","141.60","TRICARE [160005]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.96","38.96","38.96","1 through 10","38.18","248.99","other","OPPS APC"
"Prog Dev Eval Multi Lead Pcmkr","PX-48000007","CDM","93281","CPT","0480","RC","","","","both","","","236.00","141.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.96","38.19","38.96","1 through 10","38.18","248.99","other","OPPS APC"
"Prog Dev Eval Multi Lead Pcmkr","PX-48000007","CDM","93281","CPT","0480","RC","","","","both","","","236.00","141.60","WELLSENSE NH [1050]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","40.09","40.09","40.09","1 through 10","38.18","248.99","other","OPPS APC"
"Prog Dev Eval Single Lead Pcmkr","PX-48000005","CDM","93279","CPT","0480","RC","","","","both","","","202.00","121.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","248.99","","Case rate ($248.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","195.00","195.00","195.00","1 through 10","38.18","248.99","other","OPPS APC"
"Prog Dev Eval Single Lead Pcmkr","PX-48000005","CDM","93279","CPT","0480","RC","","","","both","","","202.00","121.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","38.18","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","38.18","38.18","38.18","1 through 10","38.18","248.99","other","OPPS APC"
"Prog Dev Eval Single Lead Pcmkr","PX-48000005","CDM","93279","CPT","0480","RC","","","","both","","","202.00","121.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","40.13","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","40.13","40.13","40.13","1 through 10","38.18","248.99","other","OPPS APC"
"Prog Dev Eval Single Lead Pcmkr","PX-48000005","CDM","93279","CPT","0480","RC","","","","both","","","202.00","121.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.96","38.30","38.96","13","38.18","248.99","other","OPPS APC"
"Prog Dev Eval Single Lead Pcmkr","PX-48000005","CDM","93279","CPT","0480","RC","","","","both","","","202.00","121.20","MEDICARE [2001]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.96","36.74","38.96","37","38.18","248.99","other","OPPS APC"
"Prog Dev Eval Single Lead Pcmkr","PX-48000005","CDM","93279","CPT","0480","RC","","","","both","","","202.00","121.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.69","36.74","38.96","16","38.18","248.99","other","OPPS APC"
"Prog Dev Eval Single Lead Pcmkr","PX-48000005","CDM","93279","CPT","0480","RC","","","","both","","","202.00","121.20","WELLSENSE NH [1050]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","40.09","40.09","40.09","1 through 10","38.18","248.99","other","OPPS APC"
"Prog Dev Eval Single Lead Pcmkr","PX-48000005","CDM","93279","CPT","0480","RC","","","","outpatient","","","202.00","121.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","146.89","72.72","","141.80","141.80","141.80","1 through 10","23.49","156.35","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","both","","","297.00","178.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","207.31","69.8","","200.33","180.52","200.33","21","13.56","252.45","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","both","","","297.00","178.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","252.45","85","","196.68","196.68","196.68","1 through 10","13.56","252.45","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","outpatient","","","297.00","178.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","186.46","62.78","","180.18","180.18","180.18","1 through 10","19.44","229.88","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","outpatient","","","297.00","178.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","129.85","43.72","","125.48","125.48","125.48","1 through 10","19.44","229.88","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","outpatient","","","297.00","178.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","215.98","72.72","","208.71","208.71","208.71","21","19.44","229.88","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","outpatient","","","297.00","178.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","158.06","53.22","","153.00","153.00","153.00","1 through 10","19.44","229.88","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","outpatient","","","297.00","178.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","186.81","62.9","","180.81","180.81","180.81","47","19.44","229.88","percent of total billed charges",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","outpatient","","","297.00","178.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","229.88","77.4","","222.43","222.43","222.43","18","19.44","229.88","percent of total billed charges",""
"PROGRAMMER DEVICE PATIENT SMART INTERSTIM II MODULATION","SUP-ITM-10295477","CDM","C1787","HCPCS","0270","RC","","","","both","","","9079.20","5447.52","AETNA [1001]","HB WDH AETNA COMMERCIAL","6337.28","69.8","","1412.58","1412.58","1412.58","1 through 10","1055.91","7717.32","percent of total billed charges",""
"PROGRAMMER DEVICE PATIENT SMART INTERSTIM II MODULATION","SUP-ITM-10295477","CDM","C1787","HCPCS","0270","RC","","","","both","","","9079.20","5447.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","18158.40","2245.75","18158.40","1 through 10","1055.91","7717.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PROGRAMMER DEVICE PATIENT SMART INTERSTIM II MODULATION","SUP-ITM-10295477","CDM","C1787","HCPCS","0270","RC","","","","both","","","9079.20","5447.52","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5166.06","56.9","","15498.18","15498.18","15498.18","1 through 10","1055.91","7717.32","percent of total billed charges",""
"PROGRAMMER DEVICE PATIENT SMART INTERSTIM II MODULATION","SUP-ITM-10295477","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","9079.20","5447.52","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","6602.39","72.72","","4236.03","4236.03","4236.03","1 through 10","1055.91","7027.3","percent of total billed charges",""
"PROGRAMMER NEUROSTIMULATOR 2.8X5.6 9.4CM MYSTIM PATIENT HAND HELD","SUP-ITM-10104824","CDM","C1787","HCPCS","0270","RC","","","","both","","","6184.45","3710.67","AETNA [1001]","HB WDH AETNA COMMERCIAL","4316.75","69.8","","1412.58","1412.58","1412.58","1 through 10","719.25","5256.78","percent of total billed charges",""
"PROGRAMMER NEUROSTIMULATOR 2.8X5.6 9.4CM MYSTIM PATIENT HAND HELD","SUP-ITM-10104824","CDM","C1787","HCPCS","0270","RC","","","","both","","","6184.45","3710.67","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","18158.40","2245.75","18158.40","1 through 10","719.25","5256.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PROGRAMMER NEUROSTIMULATOR 2.8X5.6 9.4CM MYSTIM PATIENT HAND HELD","SUP-ITM-10104824","CDM","C1787","HCPCS","0270","RC","","","","both","","","6184.45","3710.67","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3518.95","56.9","","15498.18","15498.18","15498.18","1 through 10","719.25","5256.78","percent of total billed charges",""
"PROGRAMMER NEUROSTIMULATOR 2.8X5.6 9.4CM MYSTIM PATIENT HAND HELD","SUP-ITM-10104824","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","6184.45","3710.67","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","4497.33","72.72","","4236.03","4236.03","4236.03","1 through 10","719.25","4786.76","percent of total billed charges",""
"Proinsulin","PX-30000658","CDM","84206","CPT","0301","RC","","","","outpatient","","","116.00","69.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","72.96","62.9","","70.56","70.56","70.56","1 through 10","21.36","89.78","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","both","","","275.00","165.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","191.95","69.8","","185.67","167.31","185.67","45","12.6","233.75","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","both","","","275.00","165.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","191.95","69.8","","185.67","185.67","185.67","1 through 10","12.6","233.75","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","both","","","275.00","165.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","233.75","85","","172.66","17.44","226.10","1 through 10","12.6","233.75","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","outpatient","","","275.00","165.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","172.65","62.78","","166.99","166.99","166.99","1 through 10","18.06","212.85","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","outpatient","","","275.00","165.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","120.23","43.72","","116.30","116.30","116.30","1 through 10","18.06","212.85","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","outpatient","","","275.00","165.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","199.98","72.72","","193.44","193.44","193.44","60","18.06","212.85","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","outpatient","","","275.00","165.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","199.98","72.72","","193.44","193.44","193.44","1 through 10","18.06","212.85","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","outpatient","","","275.00","165.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","146.36","53.22","","141.80","141.80","141.80","1 through 10","18.06","212.85","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","outpatient","","","275.00","165.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","172.98","62.9","","167.58","167.58","502.74","103","18.06","212.85","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","outpatient","","","275.00","165.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","212.85","77.4","","206.15","206.15","206.15","41","18.06","212.85","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","outpatient","","","275.00","165.00","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","199.98","72.72","","193.44","193.44","193.44","1 through 10","18.06","212.85","percent of total billed charges",""
"Prostaglandin","PX-30000639","CDM","84150","CPT","0301","RC","","","","outpatient","","","480.00","288.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","371.52","77.4","","359.60","359.60","359.60","1 through 10","29.93","371.52","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","both","","","261.00","156.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","182.18","69.8","","175.90","158.51","175.90","165","12.55","221.85","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","both","","","261.00","156.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","182.18","69.8","","175.90","175.90","175.90","1 through 10","12.55","221.85","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","both","","","261.00","156.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","221.85","85","","93.46","24.15","214.20","1 through 10","12.55","221.85","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","outpatient","","","261.00","156.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","30.35","11.63","","17.92","17.92","17.92","29","13.66","202.01","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","outpatient","","","261.00","156.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","163.86","62.78","","158.21","132.54","158.21","1 through 10","13.66","202.01","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","outpatient","","","261.00","156.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","114.11","43.72","","110.17","110.17","110.17","1 through 10","13.66","202.01","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","outpatient","","","261.00","156.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","189.80","72.72","","183.25","183.25","183.25","294","13.66","202.01","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","outpatient","","","261.00","156.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","189.80","72.72","","183.25","183.25","183.25","1 through 10","13.66","202.01","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","outpatient","","","261.00","156.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","202.01","77.4","","195.30","195.30","195.30","94","13.66","202.01","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","outpatient","","","261.00","156.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","189.80","72.72","","183.25","154.09","183.25","1 through 10","13.66","202.01","percent of total billed charges",""
"Prostatectomy With Cc","666","MS-DRG","","","","","","","","inpatient","","","72284.90","43370.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","52943.05","","Fee schedule rate ($52,943.05). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","48639.99","48639.99","48639.99","1 through 10","3975","66473.57","case rate",""
"Prostatectomy With Cc","666","MS-DRG","","","","","","","","inpatient","","","72284.90","43370.94","MARTIN'S POINT [160007]","HB WDH MEDICARE","13743.80","","Case rate ($13,743.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,719.64, add-ons for qualifying new technology services are included. If operating cost exceeds $16,637.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,776.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,327.13 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,274.78 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.81. The transfer capital threshold is the transfer adjustment factor * $971.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12654.59","12654.59","12654.59","1 through 10","3975","66473.57","other","Inpatient DRG"
"Prostatectomy With McC","665","MS-DRG","","","","","","","","inpatient","","","71434.57","42860.74","MARTIN'S POINT [160007]","HB WDH MEDICARE","24173.59","","Case rate ($24,173.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $22,346.22, add-ons for qualifying new technology services are included. If operating cost exceeds $26,264.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,538.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $21,994.76 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $21,901.35 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,733.96. The transfer capital threshold is the transfer adjustment factor * $1,733.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25907.32","25907.32","25907.32","1 through 10","3975","118605.91","other","Inpatient DRG"
"Prostatectomy Without Cc/McC","667","MS-DRG","","","","","","","","inpatient","","","29104.31","17462.59","MEDICARE [2001]","HB WDH MEDICARE","8854.68","","Case rate ($8,854.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,207.04, add-ons for qualifying new technology services are included. If operating cost exceeds $12,125.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,419.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $7,795.27 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,762.17 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $614.54. The transfer capital threshold is the transfer adjustment factor * $614.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8220.32","8220.32","8220.32","1 through 10","3975","42035.71","other","Inpatient DRG"
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","both","","","99.00","59.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","69.10","69.8","","67.01","60.38","67.01","1 through 10","11.95","94.81","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","outpatient","","","99.00","59.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","43.28","43.72","","41.97","41.97","41.97","1 through 10","13.05","76.63","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","outpatient","","","99.00","59.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","71.99","72.72","","69.81","69.81","253.06","15","13.05","76.63","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","outpatient","","","99.00","59.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","71.99","72.72","","69.81","69.81","69.81","1 through 10","13.05","76.63","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","outpatient","","","99.00","59.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","52.69","53.22","","51.18","51.18","51.18","1 through 10","13.05","76.63","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","outpatient","","","99.00","59.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","62.27","62.9","","60.48","60.48","60.48","15","13.05","76.63","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","outpatient","","","99.00","59.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","76.63","77.4","","74.40","74.39","74.40","1 through 10","13.05","76.63","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","both","","","261.00","156.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","182.18","69.8","","175.90","175.90","175.90","39","11.95","221.85","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","both","","","261.00","156.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","221.85","85","","252.00","252.00","252.00","1 through 10","11.95","221.85","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","outpatient","","","261.00","156.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","163.86","62.78","","158.21","158.21","158.21","1 through 10","13.53","202.01","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","outpatient","","","261.00","156.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","114.11","43.72","","110.17","110.17","110.17","1 through 10","13.53","202.01","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","outpatient","","","261.00","156.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","189.80","72.72","","183.25","183.25","183.25","82","13.53","202.01","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","outpatient","","","261.00","156.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","189.80","72.72","","183.25","183.25","183.25","1 through 10","13.53","202.01","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","outpatient","","","261.00","156.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","138.90","53.22","","134.34","134.34","134.34","31","13.53","202.01","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","outpatient","","","261.00","156.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","164.17","62.9","","158.76","158.76","158.76","319","13.53","202.01","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","outpatient","","","261.00","156.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","202.01","77.4","","195.30","195.30","195.30","42","13.53","202.01","percent of total billed charges",""
"PROSTHESIS EAR .8X1.4X1.09X1.14MM DORNHOFFER TITANIUM SHOE FOOT PATE OSSICULAR","SUP-ITM-10082921","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","1028.48","617.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","646.91","62.9","","2038.65","2038.65","2038.65","1 through 10","547.36","796.04","percent of total billed charges",""
"PROSTHESIS EAR 3X1.X7MM PORP AUSTIN MODIFIED OFF CENTERED HEAD","SUP-ITM-10216807","CDM","C1713","HCPCS","0278","RC","","","","both","","","1456.01","873.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","169.33","1237.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PROSTHESIS EAR 3X1.X7MM PORP AUSTIN MODIFIED OFF CENTERED HEAD","SUP-ITM-10216807","CDM","C1713","HCPCS","0278","RC","","","","both","","","1456.01","873.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","169.33","1237.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PROSTHESIS EAR 3X1.X7MM PORP AUSTIN MODIFIED OFF CENTERED HEAD","SUP-ITM-10216807","CDM","C1713","HCPCS","0278","RC","","","","both","","","1456.01","873.61","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","828.47","56.9","","812.12","238.65","1587.46","163","169.33","1237.61","percent of total billed charges",""
"PROSTHESIS EAR 3X1.X7MM PORP AUSTIN MODIFIED OFF CENTERED HEAD","SUP-ITM-10216807","CDM","C1713","HCPCS","0278","RC","","","","both","","","1456.01","873.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","169.33","11.63","","112.68","112.68","146.99","38","169.33","1237.61","percent of total billed charges",""
"PROSTHESIS EAR 3X1.X7MM PORP AUSTIN MODIFIED OFF CENTERED HEAD","SUP-ITM-10216807","CDM","C1713","HCPCS","0278","RC","","","","both","","","1456.01","873.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1126.95","77.4","","303.98","303.98","5854.79","1 through 10","169.33","1237.61","percent of total billed charges",""
"PROSTHESIS EAR 3X1.X7MM PORP AUSTIN MODIFIED OFF CENTERED HEAD","SUP-ITM-10216807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1456.01","873.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","169.33","11.63","","112.68","112.68","146.99","38","169.33","1126.95","percent of total billed charges",""
"PROSTHESIS EAR 3X1.X7MM PORP AUSTIN MODIFIED OFF CENTERED HEAD","SUP-ITM-10216807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1456.01","873.61","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","914.08","62.78","","780.86","208.94","10480.28","15","169.33","1126.95","percent of total billed charges",""
"PROSTHESIS EAR 3X1.X7MM PORP AUSTIN MODIFIED OFF CENTERED HEAD","SUP-ITM-10216807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1456.01","873.61","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","636.57","43.72","","179.76","179.76","179.76","1 through 10","169.33","1126.95","percent of total billed charges",""
"PROSTHESIS EAR 3X1.X7MM PORP AUSTIN MODIFIED OFF CENTERED HEAD","SUP-ITM-10216807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1456.01","873.61","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1058.81","72.72","","2355.45","298.99","3965.19","155","169.33","1126.95","percent of total billed charges",""
"PROSTHESIS EAR 3X1.X7MM PORP AUSTIN MODIFIED OFF CENTERED HEAD","SUP-ITM-10216807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1456.01","873.61","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1058.81","72.72","","3643.09","3643.09","3643.09","1 through 10","169.33","1126.95","percent of total billed charges",""
"PROSTHESIS EAR 3X1.X7MM PORP AUSTIN MODIFIED OFF CENTERED HEAD","SUP-ITM-10216807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1456.01","873.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","774.89","53.22","","554.28","554.28","554.28","16","169.33","1126.95","percent of total billed charges",""
"PROSTHESIS EAR 3X1.X7MM PORP AUSTIN MODIFIED OFF CENTERED HEAD","SUP-ITM-10216807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1456.01","873.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","915.83","62.9","","619.64","173.09","2370.64","150","169.33","1126.95","percent of total billed charges",""
"PROSTHESIS EAR 3X1.X7MM PORP AUSTIN MODIFIED OFF CENTERED HEAD","SUP-ITM-10216807","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1456.01","873.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1126.95","77.4","","303.98","303.98","5854.79","1 through 10","169.33","1126.95","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 4 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004998","CDM","C1776","HCPCS","0278","RC","","","","both","","","5997.88","3598.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","697.55","5098.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PROSTHESIS JOINT SIZE 4 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004998","CDM","C1776","HCPCS","0278","RC","","","","both","","","5997.88","3598.73","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3412.79","56.9","","2911.53","1863.86","5209.05","65","697.55","5098.2","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 4 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004998","CDM","C1776","HCPCS","0278","RC","","","","both","","","5997.88","3598.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","697.55","11.63","","400.94","400.94","400.94","1 through 10","697.55","5098.2","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 4 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004998","CDM","C1776","HCPCS","0278","RC","","","","both","","","5997.88","3598.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4642.36","77.4","","5214.50","5214.50","16415.28","1 through 10","697.55","5098.2","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 4 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004998","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5997.88","3598.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","697.55","11.63","","400.94","400.94","400.94","1 through 10","697.55","4642.36","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 4 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004998","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5997.88","3598.73","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2622.27","43.72","","1543.33","1543.33","1671.61","1 through 10","697.55","4642.36","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 4 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004998","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5997.88","3598.73","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4361.66","72.72","","3700.21","2382.07","6427.18","53","697.55","4642.36","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 4 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004998","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5997.88","3598.73","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4361.66","72.72","","12685.80","12685.80","12685.80","1 through 10","697.55","4642.36","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 4 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004998","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5997.88","3598.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3772.67","62.9","","3408.87","2784.05","9859.40","46","697.55","4642.36","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 4 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004998","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5997.88","3598.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4642.36","77.4","","5214.50","5214.50","16415.28","1 through 10","697.55","4642.36","percent of total billed charges",""
"PROSTHESIS OSSICULAR ADJUSTABLE CENTERED ALTO CONCISE PARTIAL TOTAL TITANIUM 3.0 X 0.8MM","SUP-ITM-10232018","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","2829.65","1697.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1779.85","62.9","","2038.65","2038.65","2038.65","1 through 10","1505.94","2190.15","percent of total billed charges",""
"PROSTHESIS OSSICULAR CROWN KRAUS K HELIX TI CUP 1.45MM COIL 2.75MM","SUP-ITM-10124303","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","3435.86","2061.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2161.16","62.9","","2038.65","2038.65","2038.65","1 through 10","1828.56","2659.36","percent of total billed charges",""
"PROTECTOR GRAFT 20X2.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124163","CDM","C1763","HCPCS","0278","RC","","","","both","","","9889.15","5933.49","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5626.93","56.9","","1156.60","963.29","1156.60","1 through 10","1150.11","8405.78","percent of total billed charges",""
"PROTECTOR GRAFT 20X2.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124163","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","9889.15","5933.49","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7191.39","72.72","","8111.92","3502.08","8111.92","1 through 10","1150.11","7654.2","percent of total billed charges",""
"PROTECTOR GRAFT 20X2.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124163","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","9889.15","5933.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6220.28","62.9","","1066.56","1066.56","1066.56","1 through 10","1150.11","7654.2","percent of total billed charges",""
"PROTECTOR GRAFT 40X5.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124168","CDM","C1763","HCPCS","0278","RC","","","","both","","","10782.76","6469.66","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6135.39","56.9","","1156.60","963.29","1156.60","1 through 10","1254.03","9165.35","percent of total billed charges",""
"PROTECTOR GRAFT 40X5.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124168","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","10782.76","6469.66","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7841.22","72.72","","8111.92","3502.08","8111.92","1 through 10","1254.03","8345.86","percent of total billed charges",""
"PROTECTOR GRAFT 40X5.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124168","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","10782.76","6469.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6782.36","62.9","","1066.56","1066.56","1066.56","1 through 10","1254.03","8345.86","percent of total billed charges",""
"PROTECTOR GRAFT 40X7.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124169","CDM","C1763","HCPCS","0278","RC","","","","both","","","11061.52","6636.91","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6294.00","56.9","","1156.60","963.29","1156.60","1 through 10","1286.45","9402.29","percent of total billed charges",""
"PROTECTOR GRAFT 40X7.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124169","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","11061.52","6636.91","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8043.94","72.72","","8111.92","3502.08","8111.92","1 through 10","1286.45","8561.62","percent of total billed charges",""
"PROTECTOR GRAFT 40X7.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124169","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","11061.52","6636.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6957.70","62.9","","1066.56","1066.56","1066.56","1 through 10","1286.45","8561.62","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.86","190.72","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","36.97","270.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.86","190.72","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","36.97","270.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.86","190.72","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","180.86","56.9","","812.12","238.65","1587.46","163","36.97","270.18","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.86","190.72","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","36.97","11.63","","112.68","112.68","146.99","38","36.97","270.18","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.86","190.72","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","246.02","77.4","","303.98","303.98","5854.79","1 through 10","36.97","270.18","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.86","190.72","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","36.97","11.63","","112.68","112.68","146.99","38","36.97","246.02","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.86","190.72","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","199.55","62.78","","780.86","208.94","10480.28","15","36.97","246.02","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.86","190.72","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","138.97","43.72","","179.76","179.76","179.76","1 through 10","36.97","246.02","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.86","190.72","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","231.15","72.72","","2355.45","298.99","3965.19","155","36.97","246.02","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.86","190.72","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","231.15","72.72","","3643.09","3643.09","3643.09","1 through 10","36.97","246.02","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.86","190.72","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","169.17","53.22","","554.28","554.28","554.28","16","36.97","246.02","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.86","190.72","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","199.93","62.9","","619.64","173.09","2370.64","150","36.97","246.02","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.86","190.72","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","246.02","77.4","","303.98","303.98","5854.79","1 through 10","36.97","246.02","percent of total billed charges",""
"Protein C Activity","PX-30001074","CDM","85303","CPT","0305","RC","","","","both","","","74.00","44.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","51.65","69.8","","50.26","50.26","50.26","1 through 10","9","70.73","percent of total billed charges",""
"Protein C Activity","PX-30001074","CDM","85303","CPT","0305","RC","","","","outpatient","","","74.00","44.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","32.35","43.72","","31.48","31.48","31.48","1 through 10","11.88","57.28","percent of total billed charges",""
"Protein C Activity","PX-30001074","CDM","85303","CPT","0305","RC","","","","outpatient","","","74.00","44.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","53.81","72.72","","52.36","52.36","104.72","1 through 10","11.88","57.28","percent of total billed charges",""
"Protein C Activity","PX-30001074","CDM","85303","CPT","0305","RC","","","","outpatient","","","74.00","44.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","53.81","72.72","","52.36","52.36","52.36","1 through 10","11.88","57.28","percent of total billed charges",""
"Protein C Activity","PX-30001074","CDM","85303","CPT","0305","RC","","","","outpatient","","","74.00","44.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","46.55","62.9","","45.36","45.36","45.36","1 through 10","11.88","57.28","percent of total billed charges",""
"Protein C Activity","PX-30001074","CDM","85303","CPT","0305","RC","","","","outpatient","","","74.00","44.40","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","53.81","72.72","","52.36","52.36","52.36","1 through 10","11.88","57.28","percent of total billed charges",""
"Protein C Activity","PX-30001074","CDM","85303","CPT","0305","RC","","","","outpatient","","","74.00","44.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","57.28","77.4","","55.80","55.80","55.80","1 through 10","11.88","57.28","percent of total billed charges",""
"Protein C Antigen","PX-30001073","CDM","85302","CPT","0305","RC","","","","outpatient","","","65.00","39.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","47.27","72.72","","45.81","45.81","45.81","1 through 10","11.2","50.31","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","59.00","35.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","41.18","69.8","","39.79","39.79","39.79","48","6.98","55.69","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","outpatient","","","59.00","35.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","25.79","43.72","","24.92","24.92","24.92","1 through 10","11.91","45.67","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","outpatient","","","59.00","35.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","42.90","72.72","","41.45","41.45","80.26","37","11.91","45.67","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","outpatient","","","59.00","35.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","42.90","72.72","","41.45","41.45","41.45","1 through 10","11.91","45.67","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","outpatient","","","59.00","35.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","31.40","53.22","","91.17","30.39","91.17","1 through 10","11.91","45.67","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","outpatient","","","59.00","35.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","37.11","62.9","","35.91","35.91","107.73","37","11.91","45.67","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","outpatient","","","59.00","35.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","45.67","77.4","","44.18","44.17","44.18","40","11.91","45.67","percent of total billed charges",""
"Protein S Free","PX-30001076","CDM","85306","CPT","0305","RC","","","","both","","","86.00","51.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","60.03","69.8","","57.93","57.93","57.93","1 through 10","9.96","79.77","percent of total billed charges",""
"Protein S Free","PX-30001076","CDM","85306","CPT","0305","RC","","","","outpatient","","","86.00","51.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","37.60","43.72","","36.29","36.29","36.29","1 through 10","13.31","66.56","percent of total billed charges",""
"Protein S Free","PX-30001076","CDM","85306","CPT","0305","RC","","","","outpatient","","","86.00","51.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","62.54","72.72","","60.36","60.36","120.72","1 through 10","13.31","66.56","percent of total billed charges",""
"Protein S Free","PX-30001076","CDM","85306","CPT","0305","RC","","","","outpatient","","","86.00","51.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","62.54","72.72","","60.36","60.36","60.36","1 through 10","13.31","66.56","percent of total billed charges",""
"Protein S Free","PX-30001076","CDM","85306","CPT","0305","RC","","","","outpatient","","","86.00","51.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","54.09","62.9","","52.29","52.29","52.29","1 through 10","13.31","66.56","percent of total billed charges",""
"Protein S Free","PX-30001076","CDM","85306","CPT","0305","RC","","","","outpatient","","","86.00","51.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","66.56","77.4","","64.33","64.32","64.33","1 through 10","13.31","66.56","percent of total billed charges",""
"Protein Total Other Source","PX-30000646","CDM","84157","CPT","0300","RC","","","","inpatient","","","52.00","31.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","39.97","76.86","","31.50","31.50","31.50","1 through 10","34.42","39.97","percent of total billed charges",""
"Protein Total Other Source","PX-30000646","CDM","84157","CPT","0301","RC","","","","both","","","52.00","31.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","36.30","69.8","","34.90","34.90","34.90","1 through 10","2.6","44.2","percent of total billed charges",""
"Protein Total Other Source","PX-30000646","CDM","84157","CPT","0301","RC","","","","outpatient","","","52.00","31.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","37.81","72.72","","36.36","36.36","36.36","1 through 10","4.34","40.25","percent of total billed charges",""
"Protein Total Other Source","PX-30000646","CDM","84157","CPT","0301","RC","","","","outpatient","","","52.00","31.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","37.81","72.72","","36.36","36.36","36.36","1 through 10","4.34","40.25","percent of total billed charges",""
"Protein Total Other Source","PX-30000646","CDM","84157","CPT","0301","RC","","","","outpatient","","","52.00","31.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","32.71","62.9","","94.50","31.50","121.08","18","4.34","40.25","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0300","RC","","","","inpatient","","","52.00","31.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","39.97","76.86","","30.27","30.27","30.27","1 through 10","34.42","39.97","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","52.00","31.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","36.30","69.8","","34.90","31.45","34.90","79","2.39","44.2","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","outpatient","","","52.00","31.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","32.65","62.78","","31.39","31.39","31.39","1 through 10","3.35","40.25","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","outpatient","","","52.00","31.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","22.73","43.72","","21.86","21.86","21.86","1 through 10","3.35","40.25","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","outpatient","","","52.00","31.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","37.81","72.72","","36.36","36.36","36.36","112","3.35","40.25","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","outpatient","","","52.00","31.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","27.67","53.22","","26.66","26.66","26.66","1 through 10","3.35","40.25","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","outpatient","","","52.00","31.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","32.71","62.9","","31.50","31.50","94.50","116","3.35","40.25","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","outpatient","","","52.00","31.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","40.25","77.4","","38.75","38.75","38.75","41","3.35","40.25","percent of total billed charges",""
"Protein Total Xcpt Refra Serum Plas","PX-30000643","CDM","84155","CPT","0301","RC","","","","outpatient","","","52.00","31.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","32.71","62.9","","31.50","31.50","31.50","1 through 10","3.35","40.25","percent of total billed charges",""
"Protein Total Xcpt Refra Serum Plas","PX-30000643","CDM","84155","CPT","0301","RC","","","","outpatient","","","52.00","31.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","40.25","77.4","","38.75","38.75","38.75","1 through 10","3.35","40.25","percent of total billed charges",""
"Protein Western Blot Band ID","PX-30000654","CDM","84182","CPT","0301","RC","","","","both","","","335.00","201.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","233.83","69.8","","226.15","226.15","226.15","1 through 10","18.99","284.75","percent of total billed charges",""
"Protein Western Blot Band ID","PX-30000654","CDM","84182","CPT","0301","RC","","","","outpatient","","","335.00","201.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","210.72","62.9","","204.12","204.12","204.12","1 through 10","16.77","259.29","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0300","RC","","","","inpatient","","","59.00","35.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","45.35","76.86","","35.91","35.91","35.91","1 through 10","39.06","45.35","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","59.00","35.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","41.18","69.8","","39.79","39.79","39.79","96","2.79","50.15","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","59.00","35.40","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","41.18","69.8","","39.79","39.79","39.79","1 through 10","2.79","50.15","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","outpatient","","","59.00","35.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","37.04","62.78","","35.78","35.78","35.78","1 through 10","3.65","45.67","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","outpatient","","","59.00","35.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","25.79","43.72","","24.92","24.92","24.92","14","3.65","45.67","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","outpatient","","","59.00","35.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","42.90","72.72","","41.45","41.45","41.45","157","3.65","45.67","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","outpatient","","","59.00","35.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","42.90","72.72","","41.45","41.45","41.45","1 through 10","3.65","45.67","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","outpatient","","","59.00","35.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","31.40","53.22","","30.39","30.39","56.78","1 through 10","3.65","45.67","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","outpatient","","","59.00","35.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","37.11","62.9","","35.91","35.91","143.64","366","3.65","45.67","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","outpatient","","","59.00","35.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","45.67","77.4","","44.18","44.16","44.18","96","3.65","45.67","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","outpatient","","","59.00","35.40","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","42.90","72.72","","41.45","41.45","41.45","1 through 10","3.65","45.67","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30000984","CDM","86753","CPT","0302","RC","","","","both","","","67.00","40.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","46.77","69.8","","45.37","45.37","115.87","11","8.05","63.21","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30000984","CDM","86753","CPT","0302","RC","","","","outpatient","","","67.00","40.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","48.72","72.72","","47.27","47.27","94.54","1 through 10","8.68","51.86","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30000984","CDM","86753","CPT","0302","RC","","","","outpatient","","","67.00","40.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","42.14","62.9","","78.19","40.95","122.85","40","8.68","51.86","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30000984","CDM","86753","CPT","0302","RC","","","","outpatient","","","67.00","40.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","51.86","77.4","","100.75","100.75","100.75","1 through 10","8.68","51.86","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30000984","CDM","86753","CPT","0302","RC","","","","outpatient","","","67.00","40.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","48.72","72.72","","47.27","47.27","47.27","1 through 10","8.68","51.86","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","both","","","7838.00","4702.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1041.67","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1063.05","1041.79","1063.05","1 through 10","1041.67","6662.3","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","both","","","7838.00","4702.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","5490.80","","Case rate ($5,490.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5356.85","2853.79","5356.85","11","1041.67","6662.3","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","both","","","7838.00","4702.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4459.82","56.9","","4303.35","4303.35","4303.35","25","1041.67","6662.3","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","both","","","7838.00","4702.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","1094.82","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1082.27","1074.84","1085.84","1 through 10","1041.67","6662.3","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","both","","","7838.00","4702.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","1062.93","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1044.98","1044.98","1063.05","20","1041.67","6662.3","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","both","","","7838.00","4702.80","MEDICARE [2001]","HB WDH MEDICARE","1062.93","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1063.05","1063.05","1063.05","83","1041.67","6662.3","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","both","","","7838.00","4702.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","6662.30","85","","4909.14","4909.14","4909.14","1 through 10","1041.67","6662.3","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","both","","","7838.00","4702.80","TRICARE [160005]","HB WDH MEDICARE","1062.93","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1063.05","1063.05","1063.05","17","1041.67","6662.3","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","both","","","7838.00","4702.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1062.93","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1043.92","1042.29","1063.05","34","1041.67","6662.3","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","both","","","7838.00","4702.80","WELLPOINT [1015]","HB WDH ANTHEM PPO","5490.80","","Case rate ($5,490.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5356.85","5356.85","5356.85","1 through 10","1041.67","6662.3","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","both","","","7838.00","4702.80","WELLSENSE NH [1050]","HB WDH MEDICARE","1062.93","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1093.88","1093.88","1093.88","1 through 10","1041.67","6662.3","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","outpatient","","","7838.00","4702.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1130.24","14.42","","1090.58","934.79","1090.58","11","911.56","6066.61","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","outpatient","","","7838.00","4702.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","911.56","11.63","","1041.43","893.32","1910.06","12","911.56","6066.61","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","outpatient","","","7838.00","4702.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3426.77","43.72","","3306.54","3306.54","3306.54","1 through 10","911.56","6066.61","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","outpatient","","","7838.00","4702.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5699.79","72.72","","5499.81","5499.81","5499.81","13","911.56","6066.61","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","outpatient","","","7838.00","4702.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4930.10","62.9","","4764.69","4764.69","19058.76","13","911.56","6066.61","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","outpatient","","","7838.00","4702.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6066.61","77.4","","5861.33","5629.88","5861.33","1 through 10","911.56","6066.61","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","outpatient","","","7838.00","4702.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","5699.79","72.72","","5499.81","5499.81","5499.81","1 through 10","911.56","6066.61","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","outpatient","","","7838.00","4702.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","911.56","11.63","","893.32","893.32","1700.88","1 through 10","911.56","6066.61","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0929","RC","","","","both","","","7838.00","4702.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","6793.11","","Case rate ($6,793.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6627.44","6621.98","6627.44","16","2925.1","6793.11","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0929","RC","","","","both","","","7838.00","4702.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","2925.10","","Case rate ($2,925.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2853.79","2851.44","2853.79","23","2925.1","6793.11","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","both","","","7838.00","4702.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1041.67","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1063.05","1041.79","1063.05","1 through 10","1041.67","6662.3","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","both","","","7838.00","4702.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","5490.80","","Case rate ($5,490.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5356.85","2853.79","5356.85","11","1041.67","6662.3","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","both","","","7838.00","4702.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4459.82","56.9","","4303.35","4303.35","4303.35","25","1041.67","6662.3","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","both","","","7838.00","4702.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","1094.82","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1082.27","1074.84","1085.84","1 through 10","1041.67","6662.3","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","both","","","7838.00","4702.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","1062.93","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1044.98","1044.98","1063.05","20","1041.67","6662.3","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","both","","","7838.00","4702.80","MEDICARE [2001]","HB WDH MEDICARE","1062.93","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1063.05","1063.05","1063.05","83","1041.67","6662.3","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","both","","","7838.00","4702.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","6662.30","85","","4909.14","4909.14","4909.14","1 through 10","1041.67","6662.3","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","both","","","7838.00","4702.80","TRICARE [160005]","HB WDH MEDICARE","1062.93","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1063.05","1063.05","1063.05","17","1041.67","6662.3","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","both","","","7838.00","4702.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1062.93","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1043.92","1042.29","1063.05","34","1041.67","6662.3","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","both","","","7838.00","4702.80","WELLPOINT [1015]","HB WDH ANTHEM PPO","5490.80","","Case rate ($5,490.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5356.85","5356.85","5356.85","1 through 10","1041.67","6662.3","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","both","","","7838.00","4702.80","WELLSENSE NH [1050]","HB WDH MEDICARE","1062.93","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1093.88","1093.88","1093.88","1 through 10","1041.67","6662.3","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","outpatient","","","7838.00","4702.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1130.24","14.42","","1090.58","934.79","1090.58","11","911.56","6066.61","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","outpatient","","","7838.00","4702.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","911.56","11.63","","1041.43","893.32","1910.06","12","911.56","6066.61","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","outpatient","","","7838.00","4702.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3426.77","43.72","","3306.54","3306.54","3306.54","1 through 10","911.56","6066.61","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","outpatient","","","7838.00","4702.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5699.79","72.72","","5499.81","5499.81","5499.81","13","911.56","6066.61","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","outpatient","","","7838.00","4702.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4930.10","62.9","","4764.69","4764.69","19058.76","13","911.56","6066.61","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","outpatient","","","7838.00","4702.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6066.61","77.4","","5861.33","5629.88","5861.33","1 through 10","911.56","6066.61","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","outpatient","","","7838.00","4702.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","5699.79","72.72","","5499.81","5499.81","5499.81","1 through 10","911.56","6066.61","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","outpatient","","","7838.00","4702.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","911.56","11.63","","893.32","893.32","1700.88","1 through 10","911.56","6066.61","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0929","RC","","","","both","","","7838.00","4702.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","6793.11","","Case rate ($6,793.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6627.44","6621.98","6627.44","16","2925.1","6793.11","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0929","RC","","","","both","","","7838.00","4702.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","2925.10","","Case rate ($2,925.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2853.79","2851.44","2853.79","23","2925.1","6793.11","other","OPPS APC"
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","both","","","8237.00","4942.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","5749.43","69.8","","5547.70","5547.70","5547.70","1 through 10","1041.67","7001.45","percent of total billed charges",""
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","both","","","8237.00","4942.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1041.67","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1049.69","1041.79","1063.05","24","1041.67","7001.45","other","OPPS APC"
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","both","","","8237.00","4942.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","5490.80","","Case rate ($5,490.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5356.85","2853.79","5356.85","1 through 10","1041.67","7001.45","other","OPPS APC"
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","both","","","8237.00","4942.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4686.85","56.9","","4522.41","4522.41","4522.41","15","1041.67","7001.45","percent of total billed charges",""
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","both","","","8237.00","4942.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","1094.82","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1077.42","1074.84","1077.42","1 through 10","1041.67","7001.45","other","OPPS APC"
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","both","","","8237.00","4942.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","1062.93","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1044.98","1001.39","1063.05","20","1041.67","7001.45","other","OPPS APC"
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","both","","","8237.00","4942.20","MEDICARE [2001]","HB WDH MEDICARE","1062.93","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1063.05","1063.05","1063.05","104","1041.67","7001.45","other","OPPS APC"
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","both","","","8237.00","4942.20","TRICARE [160005]","HB WDH MEDICARE","1062.93","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1063.05","1063.05","1063.05","1 through 10","1041.67","7001.45","other","OPPS APC"
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","both","","","8237.00","4942.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1062.93","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1042.79","999.34","1050.16","28","1041.67","7001.45","other","OPPS APC"
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","both","","","8237.00","4942.20","WELLSENSE NH [1050]","HB WDH MEDICARE","1062.93","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1116.20","1116.20","1116.20","1 through 10","1041.67","7001.45","other","OPPS APC"
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","outpatient","","","8237.00","4942.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1187.78","14.42","","1146.10","982.37","1146.10","1 through 10","957.96","6375.44","percent of total billed charges",""
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","outpatient","","","8237.00","4942.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","957.96","11.63","","1094.44","938.79","1094.44","1 through 10","957.96","6375.44","percent of total billed charges",""
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","outpatient","","","8237.00","4942.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5171.19","62.78","","4989.75","4989.75","4989.75","1 through 10","957.96","6375.44","percent of total billed charges",""
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","outpatient","","","8237.00","4942.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3601.22","43.72","","3474.87","3474.87","3474.87","1 through 10","957.96","6375.44","percent of total billed charges",""
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","outpatient","","","8237.00","4942.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5989.95","72.72","","5779.79","5779.79","5779.79","15","957.96","6375.44","percent of total billed charges",""
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","outpatient","","","8237.00","4942.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5181.07","62.9","","5007.24","5007.24","5007.24","1 through 10","957.96","6375.44","percent of total billed charges",""
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","outpatient","","","8237.00","4942.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6375.44","77.4","","6159.70","5779.79","6159.70","1 through 10","957.96","6375.44","percent of total billed charges",""
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","outpatient","","","8237.00","4942.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","5989.95","72.72","","5779.79","5779.79","5779.79","1 through 10","957.96","6375.44","percent of total billed charges",""
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","outpatient","","","8237.00","4942.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","957.96","11.63","","938.79","938.79","1676.32","1 through 10","957.96","6375.44","percent of total billed charges",""
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0929","RC","","","","both","","","8237.00","4942.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","6793.11","","Case rate ($6,793.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6627.44","6621.98","6627.44","22","2925.1","6793.11","other","OPPS APC"
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0929","RC","","","","both","","","8237.00","4942.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","2925.10","","Case rate ($2,925.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2853.79","2853.79","2853.79","19","2925.1","6793.11","other","OPPS APC"
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd|REDUCED SERVICES","PX-74000015","CDM","95811","CPT","0740","RC","","","52","both","","","8237.00","4942.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1041.67","","APC Price ($1,062.93). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","531.53","531.53","531.53","1 through 10","1041.67","1094.82","other","OPPS APC"
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd|REDUCED SERVICES","PX-74000015","CDM","95811","CPT","0740","RC","","","52","both","","","8237.00","4942.20","MEDICARE [2001]","HB WDH MEDICARE","1062.93","","APC Price ($1,062.93). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","531.53","531.53","531.53","1 through 10","1041.67","1094.82","other","OPPS APC"
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","both","","","8237.00","4942.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","5749.43","69.8","","5547.70","5547.70","5547.70","1 through 10","1041.67","7001.45","percent of total billed charges",""
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","both","","","8237.00","4942.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1041.67","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1049.69","1041.79","1063.05","24","1041.67","7001.45","other","OPPS APC"
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","both","","","8237.00","4942.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","5490.80","","Case rate ($5,490.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5356.85","2853.79","5356.85","1 through 10","1041.67","7001.45","other","OPPS APC"
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","both","","","8237.00","4942.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4686.85","56.9","","4522.41","4522.41","4522.41","15","1041.67","7001.45","percent of total billed charges",""
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","both","","","8237.00","4942.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","1094.82","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1077.42","1074.84","1077.42","1 through 10","1041.67","7001.45","other","OPPS APC"
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","both","","","8237.00","4942.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","1062.93","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1044.98","1001.39","1063.05","20","1041.67","7001.45","other","OPPS APC"
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","both","","","8237.00","4942.20","MEDICARE [2001]","HB WDH MEDICARE","1062.93","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1063.05","1063.05","1063.05","104","1041.67","7001.45","other","OPPS APC"
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","both","","","8237.00","4942.20","TRICARE [160005]","HB WDH MEDICARE","1062.93","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1063.05","1063.05","1063.05","1 through 10","1041.67","7001.45","other","OPPS APC"
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","both","","","8237.00","4942.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1062.93","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1042.79","999.34","1050.16","28","1041.67","7001.45","other","OPPS APC"
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","both","","","8237.00","4942.20","WELLSENSE NH [1050]","HB WDH MEDICARE","1062.93","","APC Price ($1,062.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1116.20","1116.20","1116.20","1 through 10","1041.67","7001.45","other","OPPS APC"
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","outpatient","","","8237.00","4942.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1187.78","14.42","","1146.10","982.37","1146.10","1 through 10","957.96","6375.44","percent of total billed charges",""
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","outpatient","","","8237.00","4942.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","957.96","11.63","","1094.44","938.79","1094.44","1 through 10","957.96","6375.44","percent of total billed charges",""
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","outpatient","","","8237.00","4942.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5171.19","62.78","","4989.75","4989.75","4989.75","1 through 10","957.96","6375.44","percent of total billed charges",""
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","outpatient","","","8237.00","4942.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3601.22","43.72","","3474.87","3474.87","3474.87","1 through 10","957.96","6375.44","percent of total billed charges",""
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","outpatient","","","8237.00","4942.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5989.95","72.72","","5779.79","5779.79","5779.79","15","957.96","6375.44","percent of total billed charges",""
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","outpatient","","","8237.00","4942.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5181.07","62.9","","5007.24","5007.24","5007.24","1 through 10","957.96","6375.44","percent of total billed charges",""
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","outpatient","","","8237.00","4942.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6375.44","77.4","","6159.70","5779.79","6159.70","1 through 10","957.96","6375.44","percent of total billed charges",""
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","outpatient","","","8237.00","4942.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","5989.95","72.72","","5779.79","5779.79","5779.79","1 through 10","957.96","6375.44","percent of total billed charges",""
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","outpatient","","","8237.00","4942.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","957.96","11.63","","938.79","938.79","1676.32","1 through 10","957.96","6375.44","percent of total billed charges",""
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0929","RC","","","","both","","","8237.00","4942.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","6793.11","","Case rate ($6,793.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6627.44","6621.98","6627.44","22","2925.1","6793.11","other","OPPS APC"
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0929","RC","","","","both","","","8237.00","4942.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","2925.10","","Case rate ($2,925.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2853.79","2853.79","2853.79","19","2925.1","6793.11","other","OPPS APC"
"Psg 6/> Yrs 4+ Parameters W/ Cpap|REDUCED SERVICES","PX-74000014","CDM","95811","CPT","0740","RC","","","52","both","","","8237.00","4942.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1041.67","","APC Price ($1,062.93). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","531.53","531.53","531.53","1 through 10","1041.67","1094.82","other","OPPS APC"
"Psg 6/> Yrs 4+ Parameters W/ Cpap|REDUCED SERVICES","PX-74000014","CDM","95811","CPT","0740","RC","","","52","both","","","8237.00","4942.20","MEDICARE [2001]","HB WDH MEDICARE","1062.93","","APC Price ($1,062.93). Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","531.53","531.53","531.53","1 through 10","1041.67","1094.82","other","OPPS APC"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","41966.95","25180.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","10842.68","","Case rate ($11,063.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,246.17, add-ons for qualifying new technology services are included. If operating cost exceeds $14,164.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,581.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $9,843.10 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,801.30 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $775.98. The transfer capital threshold is the transfer adjustment factor * $775.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11108.72","11108.72","11108.72","1 through 10","3975","53078.54","other","Inpatient DRG"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","41966.95","25180.17","MARTIN'S POINT [160007]","HB WDH MEDICARE","11063.96","","Case rate ($11,063.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,246.17, add-ons for qualifying new technology services are included. If operating cost exceeds $14,164.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,581.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $9,843.10 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,801.30 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $775.98. The transfer capital threshold is the transfer adjustment factor * $775.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5948.32","5948.32","5948.32","1 through 10","3975","53078.54","other","Inpatient DRG"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","41966.95","25180.17","MEDICARE [2001]","HB WDH MEDICARE","11063.96","","Case rate ($11,063.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,246.17, add-ons for qualifying new technology services are included. If operating cost exceeds $14,164.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,581.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $9,843.10 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,801.30 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $775.98. The transfer capital threshold is the transfer adjustment factor * $775.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11108.72","11108.72","11109.45","1 through 10","3975","53078.54","other","Inpatient DRG"
"Pt Aquatic Therapy/Exercise 15 Min","PX-42000025","CDM","97113","CPT","0421","RC","","","","both","","","235.00","141.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","158.45","155.42","272.03","111","37.11","199.75","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Pt Aquatic Therapy/Exercise 15 Min","PX-42000025","CDM","97113","CPT","0421","RC","","","","both","","","235.00","141.00","TRICARE [160005]","HB WDH MEDICARE","37.11","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($37.11). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($26.41). Each line will be capped at the line billed amount.","37.22","37.22","111.84","1 through 10","37.11","199.75","fee schedule",""
"Pt Aquatic Therapy/Exercise 15 Min","PX-42000025","CDM","97113","CPT","0421","RC","","","","both","","","235.00","141.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","37.11","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($37.11). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($26.41). Each line will be capped at the line billed amount.","29.61","26.05","29.87","660","37.11","199.75","fee schedule",""
"Pt Aquatic Therapy/Exercise 15 Min","PX-42000025","CDM","97113","CPT","0421","RC","","","","outpatient","","","235.00","141.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","170.89","72.72","","495.22","330.15","495.22","1 through 10","27.33","181.89","percent of total billed charges",""
"Pt Aquatic Therapy/Exercise 15 Min","PX-42000025","CDM","97113","CPT","0421","RC","","","","outpatient","","","235.00","141.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","147.82","62.9","","143.01","143.01","143.01","94","27.33","181.89","percent of total billed charges",""
"Pt Aquatic Therapy/Exercise 15 Min","PX-42000025","CDM","97113","CPT","0421","RC","","","","outpatient","","","235.00","141.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","27.33","11.63","","26.81","26.81","26.81","81","27.33","181.89","percent of total billed charges",""
"Pt Debride/Rem Dev Tiss <20 Sq Cm","PX-42000039","CDM","97597","CPT","0421","RC","","","","both","","","768.00","460.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","536.06","69.8","","517.22","517.22","517.22","13","34.05","652.8","percent of total billed charges",""
"Pt Debride/Rem Dev Tiss <20 Sq Cm","PX-42000039","CDM","97597","CPT","0421","RC","","","","outpatient","","","768.00","460.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","110.75","14.42","","106.85","91.59","106.85","24","89.32","594.43","percent of total billed charges",""
"Pt Debride/Rem Dev Tiss <20 Sq Cm","PX-42000039","CDM","97597","CPT","0421","RC","","","","outpatient","","","768.00","460.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","89.32","11.63","","102.04","87.53","187.14","49","89.32","594.43","percent of total billed charges",""
"Pt Debride/Rem Dev Tiss <20 Sq Cm","PX-42000039","CDM","97597","CPT","0421","RC","","","","outpatient","","","768.00","460.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","482.15","62.78","","465.20","465.20","465.20","1 through 10","89.32","594.43","percent of total billed charges",""
"Pt Debride/Rem Dev Tiss <20 Sq Cm","PX-42000039","CDM","97597","CPT","0421","RC","","","","outpatient","","","768.00","460.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","558.49","72.72","","538.86","538.86","555.48","34","89.32","594.43","percent of total billed charges",""
"Pt Debride/Rem Dev Tiss <20 Sq Cm","PX-42000039","CDM","97597","CPT","0421","RC","","","","outpatient","","","768.00","460.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","483.07","62.9","","466.83","466.83","466.83","53","89.32","594.43","percent of total billed charges",""
"Pt Debride/Rem Dev Tiss <20 Sq Cm","PX-42000039","CDM","97597","CPT","0421","RC","","","","outpatient","","","768.00","460.80","PHCS MULTIPLAN [1022]","HB WDH AMERIHEALTH CARITAS","110.75","14.42","","106.85","106.85","106.85","1 through 10","89.32","594.43","percent of total billed charges",""
"Pt Debride/Rem Dev Tiss <20 Sq Cm","PX-42000039","CDM","97597","CPT","0421","RC","","","","outpatient","","","768.00","460.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","594.43","77.4","","538.86","503.72","739.84","1 through 10","89.32","594.43","percent of total billed charges",""
"Pt Debride/Rem Dev Tiss <20 Sq Cm","PX-42000039","CDM","97597","CPT","0421","RC","","","","outpatient","","","768.00","460.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","89.32","11.63","","87.53","87.53","437.65","35","89.32","594.43","percent of total billed charges",""
"Pt E-Stim Unattended Other","PX-42000053","CDM","G0283","HCPCS","0421","RC","","","","both","","","85.00","51.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","12.43","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($12.43). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($9.25). Each line will be capped at the line billed amount.","9.15","9.11","9.29","17","5","157.54","fee schedule",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","182.00","109.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","194.66","110.70","216.02","3550","29.13","157.54","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","182.00","109.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","114.19","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($32.11). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($23.78). Each line will be capped at the line billed amount. Final payment is multiplied by 355.62%.","84.78","76.47","88.94","19","29.13","157.54","fee schedule",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","182.00","109.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","114.24","114.24","368.54","59","29.13","157.54","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","182.00","109.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","154.70","85","","100.00","33.76","368.54","26","29.13","157.54","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","182.00","109.20","TRICARE [160005]","HB WDH MEDICARE","29.13","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($29.13). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($21.94). Each line will be capped at the line billed amount.","29.23","29.23","87.69","969","29.13","157.54","fee schedule",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","182.00","109.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","29.13","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($29.13). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($21.94). Each line will be capped at the line billed amount.","24.12","21.76","25.60","7502","29.13","157.54","fee schedule",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","outpatient","","","182.00","109.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","132.35","72.72","","383.96","255.97","383.96","176","21.17","140.87","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","outpatient","","","182.00","109.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","132.35","72.72","","255.97","255.97","383.96","1 through 10","21.17","140.87","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","outpatient","","","182.00","109.20","INTERNATIONAL COMMERCIAL [140001]","HB WDH UNITED HMO / PPO / INDEM","140.87","77.4","","409.20","136.40","409.20","18","21.17","140.87","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","outpatient","","","182.00","109.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","96.86","53.22","","93.83","93.83","93.83","39","21.17","140.87","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","outpatient","","","182.00","109.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","114.48","62.9","","110.88","110.88","110.88","5182","21.17","140.87","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","outpatient","","","182.00","109.20","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","132.35","72.72","","136.40","136.40","136.40","1 through 10","21.17","140.87","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","outpatient","","","182.00","109.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","140.87","77.4","","127.99","127.99","136.40","49","21.17","140.87","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","outpatient","","","182.00","109.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","21.17","11.63","","20.79","20.79","20.79","809","21.17","140.87","percent of total billed charges",""
"Pt Gait Training 15 Min","PX-42000026","CDM","97116","CPT","0421","RC","","","","both","","","181.00","108.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","92.64","92.64","122.15","30","29.13","157.54","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Pt Gait Training 15 Min","PX-42000026","CDM","97116","CPT","0421","RC","","","","both","","","181.00","108.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","114.19","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($32.11). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($23.78). Each line will be capped at the line billed amount. Final payment is multiplied by 355.62%.","76.47","76.47","76.47","1 through 10","29.13","157.54","fee schedule",""
"Pt Gait Training 15 Min","PX-42000026","CDM","97116","CPT","0421","RC","","","","both","","","181.00","108.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","186.00","186.00","186.00","1 through 10","29.13","157.54","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Pt Gait Training 15 Min","PX-42000026","CDM","97116","CPT","0421","RC","","","","both","","","181.00","108.60","TRICARE [160005]","HB WDH MEDICARE","29.13","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($29.13). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($21.94). Each line will be capped at the line billed amount.","29.23","29.23","29.23","1 through 10","29.13","157.54","fee schedule",""
"Pt Gait Training 15 Min","PX-42000026","CDM","97116","CPT","0421","RC","","","","both","","","181.00","108.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","29.13","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($29.13). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($21.94). Each line will be capped at the line billed amount.","21.60","21.51","22.04","80","29.13","157.54","fee schedule",""
"Pt Gait Training 15 Min","PX-42000026","CDM","97116","CPT","0421","RC","","","","outpatient","","","181.00","108.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","131.62","72.72","","254.52","254.52","254.52","1 through 10","21.05","140.09","percent of total billed charges",""
"Pt Gait Training 15 Min","PX-42000026","CDM","97116","CPT","0421","RC","","","","outpatient","","","181.00","108.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","113.85","62.9","","110.25","110.25","330.75","40","21.05","140.09","percent of total billed charges",""
"Pt Gait Training 15 Min","PX-42000026","CDM","97116","CPT","0421","RC","","","","outpatient","","","181.00","108.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","21.05","11.63","","103.37","20.68","103.37","27","21.05","140.09","percent of total billed charges",""
"Pt Home Instruction/Program 15min","PX-42000034","CDM","97535","CPT","0421","RC","","","","both","","","145.00","87.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","97.72","71.56","169.28","15","32.47","157.54","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Pt Home Instruction/Program 15min","PX-42000034","CDM","97535","CPT","0421","RC","","","","both","","","145.00","87.00","TRICARE [160005]","HB WDH MEDICARE","32.47","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($32.47). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($23.61). Each line will be capped at the line billed amount.","32.57","32.57","32.57","1 through 10","32.47","157.54","fee schedule",""
"Pt Home Instruction/Program 15min","PX-42000034","CDM","97535","CPT","0421","RC","","","","both","","","145.00","87.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","32.47","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($32.47). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($23.61). Each line will be capped at the line billed amount.","23.34","23.14","32.05","38","32.47","157.54","fee schedule",""
"Pt Home Instruction/Program 15min","PX-42000034","CDM","97535","CPT","0421","RC","","","","outpatient","","","145.00","87.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","105.44","72.72","","203.62","101.81","203.62","1 through 10","16.86","112.23","percent of total billed charges",""
"Pt Home Instruction/Program 15min","PX-42000034","CDM","97535","CPT","0421","RC","","","","outpatient","","","145.00","87.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","91.21","62.9","","88.20","88.20","88.20","29","16.86","112.23","percent of total billed charges",""
"Pt Home Instruction/Program 15min","PX-42000034","CDM","97535","CPT","0421","RC","","","","outpatient","","","145.00","87.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16.86","11.63","","16.54","16.53","82.65","21","16.86","112.23","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","both","","","168.00","100.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","86.16","77.64","180.53","1238","27.48","157.54","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","both","","","168.00","100.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","107.65","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($30.27). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($22.53). Each line will be capped at the line billed amount. Final payment is multiplied by 355.62%.","72.48","72.48","72.48","1 through 10","27.48","157.54","fee schedule",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","both","","","168.00","100.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","105.15","105.15","105.15","24","27.48","157.54","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","both","","","168.00","100.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","142.80","85","","38.85","31.44","333.63","11","27.48","157.54","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","both","","","168.00","100.80","TRICARE [160005]","HB WDH MEDICARE","27.48","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($27.48). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($20.79). Each line will be capped at the line billed amount.","27.58","27.34","55.16","390","27.48","157.54","fee schedule",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","both","","","168.00","100.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","27.48","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($27.48). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($20.79). Each line will be capped at the line billed amount.","20.48","18.16","22.75","2463","27.48","157.54","fee schedule",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","outpatient","","","168.00","100.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","122.17","72.72","","353.42","235.61","353.42","65","19.54","130.03","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","outpatient","","","168.00","100.80","INTERNATIONAL COMMERCIAL [140001]","HB WDH UNITED HMO / PPO / INDEM","130.03","77.4","","125.55","125.55","125.55","1 through 10","19.54","130.03","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","outpatient","","","168.00","100.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","89.41","53.22","","86.36","86.36","86.36","23","19.54","130.03","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","outpatient","","","168.00","100.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","105.67","62.9","","102.06","102.06","102.06","2475","19.54","130.03","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","outpatient","","","168.00","100.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","130.03","77.4","","117.81","117.81","117.81","1 through 10","19.54","130.03","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","outpatient","","","168.00","100.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","19.54","11.63","","19.14","19.14","19.14","267","19.54","130.03","percent of total billed charges",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","both","","","209.00","125.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","222.67","127.06","247.82","115","32.4","177.65","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","both","","","209.00","125.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","127.06","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($35.73). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($26.43). Each line will be capped at the line billed amount. Final payment is multiplied by 355.62%.","98.90","98.90","112.83","1 through 10","32.4","177.65","fee schedule",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","both","","","209.00","125.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","177.65","85","","281.99","171.70","281.99","1 through 10","32.4","177.65","percent of total billed charges",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","both","","","209.00","125.40","TRICARE [160005]","HB WDH MEDICARE","32.40","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($32.40). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($24.38). Each line will be capped at the line billed amount.","32.51","32.51","65.02","12","32.4","177.65","fee schedule",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","both","","","209.00","125.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","32.40","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($32.40). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($24.38). Each line will be capped at the line billed amount.","27.86","26.15","31.87","1004","32.4","177.65","fee schedule",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","outpatient","","","209.00","125.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","151.98","72.72","","440.68","293.79","440.68","15","24.31","161.77","percent of total billed charges",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","outpatient","","","209.00","125.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","111.23","53.22","","107.69","107.69","107.69","1 through 10","24.31","161.77","percent of total billed charges",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","outpatient","","","209.00","125.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","131.46","62.9","","127.26","127.26","127.26","318","24.31","161.77","percent of total billed charges",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","outpatient","","","209.00","125.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","24.31","11.63","","23.86","23.86","23.86","61","24.31","161.77","percent of total billed charges",""
"Pt Orthotic Mngmnt/Fit/Tran 15 Min","PX-42000046","CDM","97760","CPT","0421","RC","","","","both","","","288.00","172.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","194.04","194.04","194.04","1 through 10","46.79","244.8","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Pt Orthotic Mngmnt/Fit/Tran 15 Min","PX-42000046","CDM","97760","CPT","0421","RC","","","","both","","","288.00","172.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","46.79","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($46.79). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($31.57). Each line will be capped at the line billed amount.","32.26","31.15","45.86","22","46.79","244.8","fee schedule",""
"Pt Orthotic Mngmnt/Fit/Tran 15 Min","PX-42000046","CDM","97760","CPT","0421","RC","","","","outpatient","","","288.00","172.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","181.15","62.9","","175.14","175.14","175.14","27","33.49","222.91","percent of total billed charges",""
"Pt Orthotic Mngmnt/Fit/Tran 15 Min","PX-42000046","CDM","97760","CPT","0421","RC","","","","outpatient","","","288.00","172.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","222.91","77.4","","215.45","215.45","215.45","1 through 10","33.49","222.91","percent of total billed charges",""
"Pt Orthotic Mngmnt/Fit/Tran 15 Min","PX-42000046","CDM","97760","CPT","0421","RC","","","","outpatient","","","288.00","172.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","33.49","11.63","","32.83","32.83","32.83","1 through 10","33.49","222.91","percent of total billed charges",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","both","","","240.00","144.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","248.75","115.02","276.96","418","35.16","204","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","both","","","240.00","144.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","139.15","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($39.13). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($27.12). Each line will be capped at the line billed amount. Final payment is multiplied by 355.62%.","122.33","122.33","122.33","1 through 10","35.16","204","fee schedule",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","both","","","240.00","144.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","161.94","124.00","161.94","1 through 10","35.16","204","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","both","","","240.00","144.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","204.00","85","","161.94","35.75","369.98","1 through 10","35.16","204","percent of total billed charges",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","both","","","240.00","144.00","TRICARE [160005]","HB WDH MEDICARE","35.16","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($35.16). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($24.79). Each line will be capped at the line billed amount.","35.26","35.26","70.52","89","35.16","204","fee schedule",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","both","","","240.00","144.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","35.16","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($35.16). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($24.79). Each line will be capped at the line billed amount.","27.98","24.89","34.56","1257","35.16","204","fee schedule",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","outpatient","","","240.00","144.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","34.61","14.42","","32.48","32.48","32.48","1 through 10","27.91","185.76","percent of total billed charges",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","outpatient","","","240.00","144.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","174.53","72.72","","506.13","168.71","506.13","25","27.91","185.76","percent of total billed charges",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","outpatient","","","240.00","144.00","INTERNATIONAL COMMERCIAL [140001]","HB WDH UNITED HMO / PPO / INDEM","185.76","77.4","","232.00","179.80","359.60","1 through 10","27.91","185.76","percent of total billed charges",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","outpatient","","","240.00","144.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","127.73","53.22","","123.68","123.68","123.68","1 through 10","27.91","185.76","percent of total billed charges",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","outpatient","","","240.00","144.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","150.96","62.9","","146.16","146.16","146.16","740","27.91","185.76","percent of total billed charges",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","outpatient","","","240.00","144.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","27.91","11.63","","27.40","27.40","27.41","126","27.91","185.76","percent of total billed charges",""
"Pt Traction Mechanical","PX-42000009","CDM","97012","CPT","0421","RC","","","","outpatient","","","88.00","52.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","55.35","62.9","","53.55","53.55","53.55","1 through 10","10.23","68.11","percent of total billed charges",""
"Pt Ultrasound 15 Min","PX-42000020","CDM","97035","CPT","0421","RC","","","","both","","","82.00","49.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","41.68","37.56","55.14","37","14.06","157.54","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Pt Ultrasound 15 Min","PX-42000020","CDM","97035","CPT","0421","RC","","","","both","","","82.00","49.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","69.70","85","","18.94","12.17","18.94","1 through 10","14.06","157.54","percent of total billed charges",""
"Pt Ultrasound 15 Min","PX-42000020","CDM","97035","CPT","0421","RC","","","","both","","","82.00","49.20","TRICARE [160005]","HB WDH MEDICARE","14.06","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($14.06). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($10.55). Each line will be capped at the line billed amount.","14.11","14.11","14.11","1 through 10","14.06","157.54","fee schedule",""
"Pt Ultrasound 15 Min","PX-42000020","CDM","97035","CPT","0421","RC","","","","both","","","82.00","49.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","14.06","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($14.06). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($10.55). Each line will be capped at the line billed amount.","10.59","10.41","10.73","47","14.06","157.54","fee schedule",""
"Pt Ultrasound 15 Min","PX-42000020","CDM","97035","CPT","0421","RC","","","","outpatient","","","82.00","49.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","51.58","62.9","","49.77","49.77","49.77","34","9.54","63.47","percent of total billed charges",""
"Pt Ultrasound 15 Min","PX-42000020","CDM","97035","CPT","0421","RC","","","","outpatient","","","82.00","49.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","9.54","11.63","","9.33","9.33","9.33","1 through 10","9.54","63.47","percent of total billed charges",""
"Pt Vasopneumatic Treatment","PX-42000011","CDM","97016","CPT","0421","RC","","","","both","","","76.00","45.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","35.08","35.08","38.92","1 through 10","11.76","157.54","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Pt Vasopneumatic Treatment","PX-42000011","CDM","97016","CPT","0421","RC","","","","both","","","76.00","45.60","TRICARE [160005]","HB WDH MEDICARE","11.76","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($11.76). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($8.92). Each line will be capped at the line billed amount.","11.79","11.79","11.79","1 through 10","11.76","157.54","fee schedule",""
"Pt Vasopneumatic Treatment","PX-42000011","CDM","97016","CPT","0421","RC","","","","both","","","76.00","45.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","11.76","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($11.76). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($8.92). Each line will be capped at the line billed amount.","8.79","8.79","8.82","33","11.76","157.54","fee schedule",""
"Pt Vasopneumatic Treatment","PX-42000011","CDM","97016","CPT","0421","RC","","","","outpatient","","","76.00","45.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","47.80","62.9","","45.99","45.99","45.99","27","8.84","58.82","percent of total billed charges",""
"Pt Vasopneumatic Treatment","PX-42000011","CDM","97016","CPT","0421","RC","","","","outpatient","","","76.00","45.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","8.84","11.63","","8.62","8.62","8.62","1 through 10","8.84","58.82","percent of total billed charges",""
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","27658.67","16595.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","10033.64","","Case rate ($9,836.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,113.62, add-ons for qualifying new technology services are included. If operating cost exceeds $13,031.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,491.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $8,705.73 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,668.76 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $686.32. The transfer capital threshold is the transfer adjustment factor * $686.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","9781.66","9781.66","9781.66","1 through 10","3975","46945.32","other","Inpatient DRG"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","27658.67","16595.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","18485.14","","Fee schedule rate ($18,485.14). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","18063.47","18063.47","18063.47","1 through 10","3975","46945.32","case rate",""
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","27658.67","16595.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","9640.16","","Case rate ($9,836.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,113.62, add-ons for qualifying new technology services are included. If operating cost exceeds $13,031.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,491.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $8,705.73 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,668.76 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $686.32. The transfer capital threshold is the transfer adjustment factor * $686.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9626.46","9626.46","9626.46","1 through 10","3975","46945.32","other","Inpatient DRG"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","27658.67","16595.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","37389.73","","Fee schedule rate ($37,389.73). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","36536.83","36536.83","36536.83","1 through 10","3975","46945.32","case rate",""
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","27658.67","16595.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","10132.01","","Case rate ($9,836.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,113.62, add-ons for qualifying new technology services are included. If operating cost exceeds $13,031.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,491.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $8,705.73 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,668.76 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $686.32. The transfer capital threshold is the transfer adjustment factor * $686.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","29974.46","29974.46","29974.46","1 through 10","3975","46945.32","other","Inpatient DRG"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","27658.67","16595.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","9836.90","","Case rate ($9,836.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,113.62, add-ons for qualifying new technology services are included. If operating cost exceeds $13,031.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,491.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $8,705.73 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,668.76 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $686.32. The transfer capital threshold is the transfer adjustment factor * $686.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9601.03","9586.49","9662.36","1 through 10","3975","46945.32","other","Inpatient DRG"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","27658.67","16595.20","MEDICARE [2001]","HB WDH MEDICARE","9836.90","","Case rate ($9,836.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,113.62, add-ons for qualifying new technology services are included. If operating cost exceeds $13,031.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,491.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $8,705.73 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,668.76 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $686.32. The transfer capital threshold is the transfer adjustment factor * $686.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9805.98","9781.66","9805.98","31","3975","46945.32","other","Inpatient DRG"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","27658.67","16595.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","9836.90","","Case rate ($9,836.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,113.62, add-ons for qualifying new technology services are included. If operating cost exceeds $13,031.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,491.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $8,705.73 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,668.76 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $686.32. The transfer capital threshold is the transfer adjustment factor * $686.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9781.66","9622.03","9806.63","1 through 10","3975","46945.32","other","Inpatient DRG"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","27658.67","16595.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","25313.35","","Fee schedule rate ($25,313.35). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","24615.60","24615.60","24615.60","1 through 10","3975","46945.32","case rate",""
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","27658.67","16595.20","WELLSENSE NH [1050]","HB WDH MEDICARE","9836.90","","Case rate ($9,836.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,113.62, add-ons for qualifying new technology services are included. If operating cost exceeds $13,031.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,491.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $8,705.73 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,668.76 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $686.32. The transfer capital threshold is the transfer adjustment factor * $686.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10134.75","10134.75","10134.75","1 through 10","3975","46945.32","other","Inpatient DRG"
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","34597.15","20758.29","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","11105.34","","Case rate ($10,887.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,083.38, add-ons for qualifying new technology services are included. If operating cost exceeds $14,001.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,568.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,679.61 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,638.50 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.09. The transfer capital threshold is the transfer adjustment factor * $763.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","6606.65","6606.65","6606.65","1 through 10","3975","52196.94","other","Inpatient DRG"
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","34597.15","20758.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","20553.01","","Fee schedule rate ($20,553.01). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","20569.94","20569.94","20569.94","1 through 10","3975","52196.94","case rate",""
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","34597.15","20758.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","10669.84","","Case rate ($10,887.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,083.38, add-ons for qualifying new technology services are included. If operating cost exceeds $14,001.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,568.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,679.61 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,638.50 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.09. The transfer capital threshold is the transfer adjustment factor * $763.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10855.70","10855.70","10855.70","1 through 10","3975","52196.94","other","Inpatient DRG"
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","34597.15","20758.29","MARTIN'S POINT [160007]","HB WDH MEDICARE","10887.59","","Case rate ($10,887.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,083.38, add-ons for qualifying new technology services are included. If operating cost exceeds $14,001.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,568.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,679.61 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,638.50 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.09. The transfer capital threshold is the transfer adjustment factor * $763.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10885.70","10885.70","10885.70","1 through 10","3975","52196.94","other","Inpatient DRG"
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","34597.15","20758.29","MEDICARE [2001]","HB WDH MEDICARE","10887.59","","Case rate ($10,887.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,083.38, add-ons for qualifying new technology services are included. If operating cost exceeds $14,001.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,568.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,679.61 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,638.50 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.09. The transfer capital threshold is the transfer adjustment factor * $763.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11077.24","0.05","11104.94","19","3975","52196.94","other","Inpatient DRG"
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","34597.15","20758.29","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","10887.59","","Case rate ($10,887.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,083.38, add-ons for qualifying new technology services are included. If operating cost exceeds $14,001.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,568.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,679.61 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,638.50 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $763.09. The transfer capital threshold is the transfer adjustment factor * $763.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10941.31","10895.20","11104.94","1 through 10","3975","52196.94","other","Inpatient DRG"
"Pulmonary Embolism Without McC","176","MS-DRG","","","","","","","","inpatient","","","30497.47","18298.48","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","12045.12","","Fee schedule rate ($12,045.12). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","11890.01","11890.01","11890.01","1 through 10","3975","30590.08","case rate",""
"Pulmonary Embolism Without McC","176","MS-DRG","","","","","","","","inpatient","","","30497.47","18298.48","MEDICARE [2001]","HB WDH MEDICARE","6564.83","","Case rate ($6,564.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,093.53, add-ons for qualifying new technology services are included. If operating cost exceeds $10,011.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,252.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,672.75 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,648.66 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.21. The transfer capital threshold is the transfer adjustment factor * $447.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6590.64","0.05","6606.65","1 through 10","3975","30590.08","other","Inpatient DRG"
"Pulmonary Embolism Without McC","176","MS-DRG","","","","","","","","inpatient","","","30497.47","18298.48","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6564.83","","Case rate ($6,564.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,093.53, add-ons for qualifying new technology services are included. If operating cost exceeds $10,011.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,252.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,672.75 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,648.66 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.21. The transfer capital threshold is the transfer adjustment factor * $447.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6606.65","6606.65","6606.65","1 through 10","3975","30590.08","other","Inpatient DRG"
"Pulmonary Stress Test Cplx","PX-46000037","CDM","94621","CPT","0460","RC","","","","both","","","1064.00","638.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","605.42","56.9","","584.36","584.36","584.36","1 through 10","318.83","2079.19","percent of total billed charges",""
"Pulmonary Stress Test Cplx","PX-46000037","CDM","94621","CPT","0460","RC","","","","both","","","1064.00","638.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","318.88","318.88","318.88","1 through 10","318.83","2079.19","other","OPPS APC"
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","593.00","355.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","860.68","","Case rate ($860.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","572.00","572.00","572.00","1 through 10","131.98","860.68","other","OPPS APC"
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","593.00","355.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","370.61","","Case rate ($370.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","361.57","361.57","361.57","1 through 10","131.98","860.68","other","OPPS APC"
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","593.00","355.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","131.98","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","132.53","132.00","132.53","12","131.98","860.68","other","OPPS APC"
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","593.00","355.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","695.68","","Case rate ($695.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","572.00","361.57","572.00","1 through 10","131.98","860.68","other","OPPS APC"
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","593.00","355.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","337.42","56.9","","325.47","325.47","675.76","1 through 10","131.98","860.68","percent of total billed charges",""
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","593.00","355.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","138.71","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","135.96","135.96","136.96","1 through 10","131.98","860.68","other","OPPS APC"
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","593.00","355.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","134.69","132.40","134.69","12","131.98","860.68","other","OPPS APC"
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","593.00","355.80","MEDICARE [2001]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","134.69","124.46","134.69","50","131.98","860.68","other","OPPS APC"
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","593.00","355.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","132.50","122.98","134.69","25","131.98","860.68","other","OPPS APC"
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","593.00","355.80","WELLSENSE NH [1050]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","138.59","138.59","138.59","1 through 10","131.98","860.68","other","OPPS APC"
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","outpatient","","","593.00","355.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","85.51","14.42","","82.48","70.70","82.48","1 through 10","68.97","458.98","percent of total billed charges",""
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","outpatient","","","593.00","355.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","68.97","11.63","","78.76","70.01","144.46","1 through 10","68.97","458.98","percent of total billed charges",""
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","outpatient","","","593.00","355.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","431.23","72.72","","415.96","415.96","415.96","1 through 10","68.97","458.98","percent of total billed charges",""
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","outpatient","","","593.00","355.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","373.00","62.9","","360.36","360.36","360.36","1 through 10","68.97","458.98","percent of total billed charges",""
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","outpatient","","","593.00","355.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","458.98","77.4","","443.30","443.30","443.30","1 through 10","68.97","458.98","percent of total billed charges",""
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","outpatient","","","593.00","355.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","68.97","11.63","","67.56","67.56","67.56","1 through 10","68.97","458.98","percent of total billed charges",""
"Pulse Ox Overnight","PX-46000050","CDM","94762","CPT","0460","RC","","","","both","","","285.00","171.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1044.65","","Case rate ($1,044.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","275.00","275.00","275.00","1 through 10","160.19","1044.65","other","OPPS APC"
"Pulse Ox Overnight","PX-46000050","CDM","94762","CPT","0460","RC","","","","both","","","285.00","171.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","449.83","","Case rate ($449.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","275.00","275.00","438.86","1 through 10","160.19","1044.65","other","OPPS APC"
"Pulse Ox Overnight","PX-46000050","CDM","94762","CPT","0460","RC","","","","both","","","285.00","171.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","160.19","","APC Price ($163.46). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","160.86","160.21","163.48","1 through 10","160.19","1044.65","other","OPPS APC"
"Pulse Ox Overnight","PX-46000050","CDM","94762","CPT","0460","RC","","","","both","","","285.00","171.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","844.38","","Case rate ($844.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","275.00","275.00","275.00","1 through 10","160.19","1044.65","other","OPPS APC"
"Pulse Ox Overnight","PX-46000050","CDM","94762","CPT","0460","RC","","","","both","","","285.00","171.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","168.37","","APC Price ($163.46). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","166.01","165.01","166.01","1 through 10","160.19","1044.65","other","OPPS APC"
"Pulse Ox Overnight","PX-46000050","CDM","94762","CPT","0460","RC","","","","both","","","285.00","171.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","163.46","","APC Price ($163.46). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","160.70","149.61","160.70","1 through 10","160.19","1044.65","other","OPPS APC"
"Pulse Ox Overnight","PX-46000050","CDM","94762","CPT","0460","RC","","","","both","","","285.00","171.00","MEDICARE [2001]","HB WDH MEDICARE","163.46","","APC Price ($163.46). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","163.48","152.20","163.48","19","160.19","1044.65","other","OPPS APC"
"Pulse Ox Overnight","PX-46000050","CDM","94762","CPT","0460","RC","","","","both","","","285.00","171.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","163.46","","APC Price ($163.46). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","160.87","150.16","163.48","23","160.19","1044.65","other","OPPS APC"
"Pulse Ox Overnight","PX-46000050","CDM","94762","CPT","0460","RC","","","","both","","","285.00","171.00","WELLSENSE NH [1050]","HB WDH MEDICARE","163.46","","APC Price ($163.46). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","168.22","168.22","168.22","1 through 10","160.19","1044.65","other","OPPS APC"
"Pulse Ox Overnight","PX-46000050","CDM","94762","CPT","0460","RC","","","","outpatient","","","285.00","171.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","33.15","11.63","","37.87","32.49","37.87","1 through 10","33.15","220.59","percent of total billed charges",""
"Pulse Ox Overnight","PX-46000050","CDM","94762","CPT","0460","RC","","","","outpatient","","","285.00","171.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","179.27","62.9","","173.25","173.25","173.25","1 through 10","33.15","220.59","percent of total billed charges",""
"Pulse Ox Overnight","PX-46000050","CDM","94762","CPT","0460","RC","","","","outpatient","","","285.00","171.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","220.59","77.4","","213.13","213.13","213.13","1 through 10","33.15","220.59","percent of total billed charges",""
"Pump Refill & Main Spin/ Brain Req","PX-94000002","CDM","95991","CPT","0940","RC","","","","both","","","2019.00","1211.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","302.23","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","303.50","283.96","303.50","1 through 10","302.23","1971.01","other","OPPS APC"
"Pump Refill & Main Spin/ Brain Req","PX-94000002","CDM","95991","CPT","0940","RC","","","","both","","","2019.00","1211.40","MEDICARE [2001]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","925.32","308.44","925.32","11","302.23","1971.01","other","OPPS APC"
"Pump Refill & Main Spin/ Brain Req","PX-94000002","CDM","95991","CPT","0940","RC","","","","both","","","2019.00","1211.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","308.40","","APC Price ($308.40). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","308.44","308.44","308.44","1 through 10","302.23","1971.01","other","OPPS APC"
"Pump Refill & Main Spin/ Brain Req","PX-94000002","CDM","95991","CPT","0940","RC","","","","outpatient","","","2019.00","1211.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","234.81","11.63","","258.05","221.35","258.05","1 through 10","234.81","1562.71","percent of total billed charges",""
"Pump Refill & Main Spin/ Brain Req","PX-94000002","CDM","95991","CPT","0940","RC","","","","outpatient","","","2019.00","1211.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","234.81","11.63","","221.35","221.35","221.35","1 through 10","234.81","1562.71","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","542.00","325.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","425.76","","APC Price ($417.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","417.46","417.46","417.46","1 through 10","308.4","2667.66","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","542.00","325.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1148.69","","Case rate ($1,148.69). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1019.08","1019.08","1019.08","1 through 10","308.4","2667.66","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","542.00","325.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","409.06","","APC Price ($417.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","411.11","411.11","411.11","1 through 10","308.4","2667.66","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","542.00","325.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","308.40","56.9","","297.58","297.58","297.58","1 through 10","308.4","2667.66","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","542.00","325.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","417.41","","APC Price ($417.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","410.01","388.51","410.01","1 through 10","308.4","2667.66","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","542.00","325.20","MEDICARE [2001]","HB WDH MEDICARE","417.41","","APC Price ($417.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.46","388.51","1252.38","21","308.4","2667.66","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","542.00","325.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","417.41","","APC Price ($417.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","388.51","388.51","409.12","1 through 10","308.4","2667.66","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","542.00","325.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","380.33","380.33","380.33","1 through 10","288.45","419.51","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Punct Arterial","PX-76001115","CDM","36600","CPT","0761","RC","","","","both","","","295.00","177.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","131.98","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","134.69","133.00","134.69","1 through 10","131.98","860.68","other","OPPS APC"
"Punct Arterial","PX-76001115","CDM","36600","CPT","0761","RC","","","","both","","","295.00","177.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","167.86","56.9","","162.17","162.17","162.17","1 through 10","131.98","860.68","percent of total billed charges",""
"Punct Arterial","PX-76001115","CDM","36600","CPT","0761","RC","","","","both","","","295.00","177.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","134.69","134.69","134.69","1 through 10","131.98","860.68","other","OPPS APC"
"Punct Arterial","PX-76001115","CDM","36600","CPT","0761","RC","","","","both","","","295.00","177.00","MEDICARE [2001]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","134.69","134.69","134.69","1 through 10","131.98","860.68","other","OPPS APC"
"Punct Asp/Inj Shunt Tubing/Reserv","PX-76001419","CDM","61070","CPT","0761","RC","","","","both","","","4737.00","2842.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","709.05","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","710.13","710.13","710.13","1 through 10","709.05","4623.96","other","OPPS APC"
"PUSHER PANCREATIC 3FR STENT RX","SUP-ITM-10147616","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","347.02","208.21","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","252.35","72.72","","324.46","324.46","324.46","1 through 10","40.36","268.59","percent of total billed charges",""
"PUSHER STENT 4 TO 5FR ADVANIX PANCREATIC CATHETER","SUP-ITM-10147619","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","347.02","208.21","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","252.35","72.72","","324.46","324.46","324.46","1 through 10","40.36","268.59","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","both","","","1014.94","608.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","118.04","862.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","both","","","1014.94","608.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","118.04","862.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","both","","","1014.94","608.96","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","577.50","56.9","","0.63","0.63","0.63","1 through 10","118.04","862.7","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","both","","","1014.94","608.96","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","146.35","14.42","","317.14","317.14","317.14","1 through 10","118.04","862.7","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1014.94","608.96","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","146.35","14.42","","317.14","317.14","317.14","1 through 10","118.04","785.56","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1014.94","608.96","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","637.18","62.78","","1125.09","1125.09","1125.09","1 through 10","118.04","785.56","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1014.94","608.96","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","738.06","72.72","","4732.50","1617.43","14180.40","1 through 10","118.04","785.56","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1014.94","608.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","638.40","62.9","","3896.20","3341.38","3896.20","1 through 10","118.04","785.56","percent of total billed charges",""
"PUTTY BONE 1CC GRAFTON DBF MATRIX SPINE","SUP-ITM-10158946","CDM","C1889","HCPCS","0278","RC","","","","both","","","1792.11","1075.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","208.42","1523.29","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PUTTY BONE 1CC GRAFTON DBF MATRIX SPINE","SUP-ITM-10158946","CDM","C1889","HCPCS","0278","RC","","","","both","","","1792.11","1075.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","208.42","1523.29","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PUTTY BONE 1CC GRAFTON DBF MATRIX SPINE","SUP-ITM-10158946","CDM","C1889","HCPCS","0278","RC","","","","both","","","1792.11","1075.27","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1019.71","56.9","","0.63","0.63","0.63","1 through 10","208.42","1523.29","percent of total billed charges",""
"PUTTY BONE 1CC GRAFTON DBF MATRIX SPINE","SUP-ITM-10158946","CDM","C1889","HCPCS","0278","RC","","","","both","","","1792.11","1075.27","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","258.42","14.42","","317.14","317.14","317.14","1 through 10","208.42","1523.29","percent of total billed charges",""
"PUTTY BONE 1CC GRAFTON DBF MATRIX SPINE","SUP-ITM-10158946","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1792.11","1075.27","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","258.42","14.42","","317.14","317.14","317.14","1 through 10","208.42","1387.09","percent of total billed charges",""
"PUTTY BONE 1CC GRAFTON DBF MATRIX SPINE","SUP-ITM-10158946","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1792.11","1075.27","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1125.09","62.78","","1125.09","1125.09","1125.09","1 through 10","208.42","1387.09","percent of total billed charges",""
"PUTTY BONE 1CC GRAFTON DBF MATRIX SPINE","SUP-ITM-10158946","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1792.11","1075.27","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1303.22","72.72","","4732.50","1617.43","14180.40","1 through 10","208.42","1387.09","percent of total billed charges",""
"PUTTY BONE 1CC GRAFTON DBF MATRIX SPINE","SUP-ITM-10158946","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1792.11","1075.27","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1127.24","62.9","","3896.20","3341.38","3896.20","1 through 10","208.42","1387.09","percent of total billed charges",""
"PUTTY BONE 3CC GRAFTON DBF MATRIX SPINE","SUP-ITM-10158947","CDM","C1889","HCPCS","0278","RC","","","","both","","","3341.68","2005.01","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","388.64","2840.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PUTTY BONE 3CC GRAFTON DBF MATRIX SPINE","SUP-ITM-10158947","CDM","C1889","HCPCS","0278","RC","","","","both","","","3341.68","2005.01","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","388.64","2840.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PUTTY BONE 3CC GRAFTON DBF MATRIX SPINE","SUP-ITM-10158947","CDM","C1889","HCPCS","0278","RC","","","","both","","","3341.68","2005.01","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1901.42","56.9","","0.63","0.63","0.63","1 through 10","388.64","2840.43","percent of total billed charges",""
"PUTTY BONE 3CC GRAFTON DBF MATRIX SPINE","SUP-ITM-10158947","CDM","C1889","HCPCS","0278","RC","","","","both","","","3341.68","2005.01","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","481.87","14.42","","317.14","317.14","317.14","1 through 10","388.64","2840.43","percent of total billed charges",""
"PUTTY BONE 3CC GRAFTON DBF MATRIX SPINE","SUP-ITM-10158947","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3341.68","2005.01","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","481.87","14.42","","317.14","317.14","317.14","1 through 10","388.64","2586.46","percent of total billed charges",""
"PUTTY BONE 3CC GRAFTON DBF MATRIX SPINE","SUP-ITM-10158947","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3341.68","2005.01","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2097.91","62.78","","1125.09","1125.09","1125.09","1 through 10","388.64","2586.46","percent of total billed charges",""
"PUTTY BONE 3CC GRAFTON DBF MATRIX SPINE","SUP-ITM-10158947","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3341.68","2005.01","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2430.07","72.72","","4732.50","1617.43","14180.40","1 through 10","388.64","2586.46","percent of total billed charges",""
"PUTTY BONE 3CC GRAFTON DBF MATRIX SPINE","SUP-ITM-10158947","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3341.68","2005.01","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2101.92","62.9","","3896.20","3341.38","3896.20","1 through 10","388.64","2586.46","percent of total billed charges",""
"PUTTY BONE 3CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058775","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.06","1029.04","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","199.46","1457.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PUTTY BONE 3CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058775","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.06","1029.04","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","199.46","1457.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PUTTY BONE 3CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058775","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.06","1029.04","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","975.87","56.9","","812.12","238.65","1587.46","163","199.46","1457.8","percent of total billed charges",""
"PUTTY BONE 3CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058775","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.06","1029.04","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","199.46","11.63","","112.68","112.68","146.99","38","199.46","1457.8","percent of total billed charges",""
"PUTTY BONE 3CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058775","CDM","C1713","HCPCS","0278","RC","","","","both","","","1715.06","1029.04","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1327.46","77.4","","303.98","303.98","5854.79","1 through 10","199.46","1457.8","percent of total billed charges",""
"PUTTY BONE 3CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058775","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.06","1029.04","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","199.46","11.63","","112.68","112.68","146.99","38","199.46","1327.46","percent of total billed charges",""
"PUTTY BONE 3CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058775","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.06","1029.04","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1076.71","62.78","","780.86","208.94","10480.28","15","199.46","1327.46","percent of total billed charges",""
"PUTTY BONE 3CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058775","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.06","1029.04","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","749.82","43.72","","179.76","179.76","179.76","1 through 10","199.46","1327.46","percent of total billed charges",""
"PUTTY BONE 3CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058775","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.06","1029.04","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1247.19","72.72","","2355.45","298.99","3965.19","155","199.46","1327.46","percent of total billed charges",""
"PUTTY BONE 3CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058775","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.06","1029.04","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1247.19","72.72","","3643.09","3643.09","3643.09","1 through 10","199.46","1327.46","percent of total billed charges",""
"PUTTY BONE 3CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058775","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.06","1029.04","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","912.75","53.22","","554.28","554.28","554.28","16","199.46","1327.46","percent of total billed charges",""
"PUTTY BONE 3CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058775","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.06","1029.04","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1078.77","62.9","","619.64","173.09","2370.64","150","199.46","1327.46","percent of total billed charges",""
"PUTTY BONE 3CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058775","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1715.06","1029.04","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1327.46","77.4","","303.98","303.98","5854.79","1 through 10","199.46","1327.46","percent of total billed charges",""
"PUTTY BONE 6CC GRAFTON SPINE","SUP-ITM-10158948","CDM","C1889","HCPCS","0278","RC","","","","both","","","5838.95","3503.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","679.07","4963.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PUTTY BONE 6CC GRAFTON SPINE","SUP-ITM-10158948","CDM","C1889","HCPCS","0278","RC","","","","both","","","5838.95","3503.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","679.07","4963.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PUTTY BONE 6CC GRAFTON SPINE","SUP-ITM-10158948","CDM","C1889","HCPCS","0278","RC","","","","both","","","5838.95","3503.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3322.36","56.9","","0.63","0.63","0.63","1 through 10","679.07","4963.11","percent of total billed charges",""
"PUTTY BONE 6CC GRAFTON SPINE","SUP-ITM-10158948","CDM","C1889","HCPCS","0278","RC","","","","both","","","5838.95","3503.37","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","841.98","14.42","","317.14","317.14","317.14","1 through 10","679.07","4963.11","percent of total billed charges",""
"PUTTY BONE 6CC GRAFTON SPINE","SUP-ITM-10158948","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5838.95","3503.37","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","841.98","14.42","","317.14","317.14","317.14","1 through 10","679.07","4519.35","percent of total billed charges",""
"PUTTY BONE 6CC GRAFTON SPINE","SUP-ITM-10158948","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5838.95","3503.37","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3665.69","62.78","","1125.09","1125.09","1125.09","1 through 10","679.07","4519.35","percent of total billed charges",""
"PUTTY BONE 6CC GRAFTON SPINE","SUP-ITM-10158948","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5838.95","3503.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4246.08","72.72","","4732.50","1617.43","14180.40","1 through 10","679.07","4519.35","percent of total billed charges",""
"PUTTY BONE 6CC GRAFTON SPINE","SUP-ITM-10158948","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5838.95","3503.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3672.70","62.9","","3896.20","3341.38","3896.20","1 through 10","679.07","4519.35","percent of total billed charges",""
"PUTTY BONE 9CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058776","CDM","C1713","HCPCS","0278","RC","","","","both","","","4933.74","2960.24","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","573.79","4193.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PUTTY BONE 9CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058776","CDM","C1713","HCPCS","0278","RC","","","","both","","","4933.74","2960.24","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","573.79","4193.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PUTTY BONE 9CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058776","CDM","C1713","HCPCS","0278","RC","","","","both","","","4933.74","2960.24","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2807.30","56.9","","812.12","238.65","1587.46","163","573.79","4193.68","percent of total billed charges",""
"PUTTY BONE 9CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058776","CDM","C1713","HCPCS","0278","RC","","","","both","","","4933.74","2960.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","573.79","11.63","","112.68","112.68","146.99","38","573.79","4193.68","percent of total billed charges",""
"PUTTY BONE 9CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058776","CDM","C1713","HCPCS","0278","RC","","","","both","","","4933.74","2960.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3818.71","77.4","","303.98","303.98","5854.79","1 through 10","573.79","4193.68","percent of total billed charges",""
"PUTTY BONE 9CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4933.74","2960.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","573.79","11.63","","112.68","112.68","146.99","38","573.79","3818.71","percent of total billed charges",""
"PUTTY BONE 9CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4933.74","2960.24","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3097.40","62.78","","780.86","208.94","10480.28","15","573.79","3818.71","percent of total billed charges",""
"PUTTY BONE 9CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4933.74","2960.24","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2157.03","43.72","","179.76","179.76","179.76","1 through 10","573.79","3818.71","percent of total billed charges",""
"PUTTY BONE 9CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4933.74","2960.24","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3587.82","72.72","","2355.45","298.99","3965.19","155","573.79","3818.71","percent of total billed charges",""
"PUTTY BONE 9CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4933.74","2960.24","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3587.82","72.72","","3643.09","3643.09","3643.09","1 through 10","573.79","3818.71","percent of total billed charges",""
"PUTTY BONE 9CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4933.74","2960.24","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2625.74","53.22","","554.28","554.28","554.28","16","573.79","3818.71","percent of total billed charges",""
"PUTTY BONE 9CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4933.74","2960.24","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3103.32","62.9","","619.64","173.09","2370.64","150","573.79","3818.71","percent of total billed charges",""
"PUTTY BONE 9CC RESORBABLE CERAMIC GRANULE MASTERGRAFT","SUP-ITM-10058776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4933.74","2960.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3818.71","77.4","","303.98","303.98","5854.79","1 through 10","573.79","3818.71","percent of total billed charges",""
"PUTTY MATRIX 0.5CC GRAFT BONE ALLOGRAFT DEMINERALIZED SYRINGE FREEZE DRIED","SUP-ITM-10048893","CDM","C1713","HCPCS","0278","RC","","","","both","","","567.73","340.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","66.03","482.57","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PUTTY MATRIX 0.5CC GRAFT BONE ALLOGRAFT DEMINERALIZED SYRINGE FREEZE DRIED","SUP-ITM-10048893","CDM","C1713","HCPCS","0278","RC","","","","both","","","567.73","340.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","66.03","482.57","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"PUTTY MATRIX 0.5CC GRAFT BONE ALLOGRAFT DEMINERALIZED SYRINGE FREEZE DRIED","SUP-ITM-10048893","CDM","C1713","HCPCS","0278","RC","","","","both","","","567.73","340.64","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","323.04","56.9","","812.12","238.65","1587.46","163","66.03","482.57","percent of total billed charges",""
"PUTTY MATRIX 0.5CC GRAFT BONE ALLOGRAFT DEMINERALIZED SYRINGE FREEZE DRIED","SUP-ITM-10048893","CDM","C1713","HCPCS","0278","RC","","","","both","","","567.73","340.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","66.03","11.63","","112.68","112.68","146.99","38","66.03","482.57","percent of total billed charges",""
"PUTTY MATRIX 0.5CC GRAFT BONE ALLOGRAFT DEMINERALIZED SYRINGE FREEZE DRIED","SUP-ITM-10048893","CDM","C1713","HCPCS","0278","RC","","","","both","","","567.73","340.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","439.42","77.4","","303.98","303.98","5854.79","1 through 10","66.03","482.57","percent of total billed charges",""
"PUTTY MATRIX 0.5CC GRAFT BONE ALLOGRAFT DEMINERALIZED SYRINGE FREEZE DRIED","SUP-ITM-10048893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","567.73","340.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","66.03","11.63","","112.68","112.68","146.99","38","66.03","439.42","percent of total billed charges",""
"PUTTY MATRIX 0.5CC GRAFT BONE ALLOGRAFT DEMINERALIZED SYRINGE FREEZE DRIED","SUP-ITM-10048893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","567.73","340.64","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","356.42","62.78","","780.86","208.94","10480.28","15","66.03","439.42","percent of total billed charges",""
"PUTTY MATRIX 0.5CC GRAFT BONE ALLOGRAFT DEMINERALIZED SYRINGE FREEZE DRIED","SUP-ITM-10048893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","567.73","340.64","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","248.21","43.72","","179.76","179.76","179.76","1 through 10","66.03","439.42","percent of total billed charges",""
"PUTTY MATRIX 0.5CC GRAFT BONE ALLOGRAFT DEMINERALIZED SYRINGE FREEZE DRIED","SUP-ITM-10048893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","567.73","340.64","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","412.85","72.72","","2355.45","298.99","3965.19","155","66.03","439.42","percent of total billed charges",""
"PUTTY MATRIX 0.5CC GRAFT BONE ALLOGRAFT DEMINERALIZED SYRINGE FREEZE DRIED","SUP-ITM-10048893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","567.73","340.64","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","412.85","72.72","","3643.09","3643.09","3643.09","1 through 10","66.03","439.42","percent of total billed charges",""
"PUTTY MATRIX 0.5CC GRAFT BONE ALLOGRAFT DEMINERALIZED SYRINGE FREEZE DRIED","SUP-ITM-10048893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","567.73","340.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","302.15","53.22","","554.28","554.28","554.28","16","66.03","439.42","percent of total billed charges",""
"PUTTY MATRIX 0.5CC GRAFT BONE ALLOGRAFT DEMINERALIZED SYRINGE FREEZE DRIED","SUP-ITM-10048893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","567.73","340.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","357.10","62.9","","619.64","173.09","2370.64","150","66.03","439.42","percent of total billed charges",""
"PUTTY MATRIX 0.5CC GRAFT BONE ALLOGRAFT DEMINERALIZED SYRINGE FREEZE DRIED","SUP-ITM-10048893","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","567.73","340.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","439.42","77.4","","303.98","303.98","5854.79","1 through 10","66.03","439.42","percent of total billed charges",""
"Pvb Thoracic Single Injection Site W/Img Gid","PX-76002194","CDM","64461","CPT","0761","RC","","","","both","","","3742.00","2245.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","665.83","665.83","665.83","1 through 10","539.6","4623.96","other","OPPS APC"
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","both","","","605.82","363.49","AETNA [1001]","HB WDH AETNA COMMERCIAL","390.33","64.43","","390.75","363.43","422.86","11","293.59","1462.21","percent of total billed charges",""
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","both","","","605.82","363.49","MARTIN'S POINT [160007]","HB WDH MEDICARE","313.68","","APC Price ($313.68).","311.32","311.32","311.32","1 through 10","293.59","1462.21","other","OPPS APC"
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","both","","","605.82","363.49","TRICARE [160005]","HB WDH MEDICARE","313.68","","APC Price ($313.68).","312.03","312.03","312.03","1 through 10","293.59","1462.21","other","OPPS APC"
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","both","","","605.82","363.49","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","313.68","","APC Price ($313.68).","312.03","312.03","321.23","1 through 10","293.59","1462.21","other","OPPS APC"
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","outpatient","","","605.82","363.49","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","87.36","14.42","","87.36","87.36","87.36","1 through 10","70.46","912.74","percent of total billed charges",""
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","outpatient","","","605.82","363.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","70.46","11.63","","83.42","83.42","83.42","1 through 10","70.46","912.74","percent of total billed charges",""
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","outpatient","","","605.82","363.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","468.90","77.4","","469.51","469.51","469.51","1 through 10","70.46","912.74","percent of total billed charges",""
"Rabies Vaccine Intramuscular","PX-63601004","CDM","90675","CPT","0636","RC","","","","outpatient","","","605.82","363.49","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","70.46","11.63","","501.15","71.55","1501.05","1 through 10","70.46","912.74","percent of total billed charges",""
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","3506.00","2103.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","2447.19","69.8","","2361.33","2361.33","2361.33","1 through 10","251.54","3862.47","percent of total billed charges",""
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","3506.00","2103.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","3862.47","","Case rate ($3,862.47). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3383.00","3276.77","3768.27","12","251.54","3862.47","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","3506.00","2103.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1663.17","","Case rate ($1,663.17). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1622.63","1460.38","5005.63","1 through 10","251.54","3862.47","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","3506.00","2103.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","592.28","","APC Price ($604.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","594.76","592.34","1027.53","25","251.54","3862.47","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","3506.00","2103.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","3122.00","","Case rate ($3,122.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3045.83","2712.18","6163.67","1 through 10","251.54","3862.47","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","3506.00","2103.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","622.49","","APC Price ($604.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","612.60","610.11","614.94","14","251.54","3862.47","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","3506.00","2103.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","604.36","","APC Price ($604.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","594.76","592.34","594.76","18","251.54","3862.47","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","3506.00","2103.60","MEDICARE [2001]","HB WDH MEDICARE","604.36","","APC Price ($604.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","604.43","573.56","604.43","102","251.54","3862.47","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","3506.00","2103.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","604.36","","APC Price ($604.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","594.76","592.35","604.43","33","251.54","3862.47","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","3506.00","2103.60","WELLPOINT [1015]","HB WDH ANTHEM PPO","3122.00","","Case rate ($3,122.00). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3045.83","3013.53","3045.83","1 through 10","251.54","3862.47","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","both","","","3506.00","2103.60","WELLSENSE NH [1050]","HB WDH MEDICARE","604.36","","APC Price ($604.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","624.50","624.50","624.50","1 through 10","251.54","3862.47","other","OPPS APC"
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","outpatient","","","3506.00","2103.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","505.57","14.42","","418.14","418.14","487.83","11","407.75","2713.64","percent of total billed charges",""
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","outpatient","","","3506.00","2103.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","407.75","11.63","","465.84","399.59","854.39","1 through 10","407.75","2713.64","percent of total billed charges",""
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","outpatient","","","3506.00","2103.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2549.56","72.72","","2460.12","2460.12","5678.71","1 through 10","407.75","2713.64","percent of total billed charges",""
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","outpatient","","","3506.00","2103.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2205.27","62.9","","2131.29","2131.29","8525.16","1 through 10","407.75","2713.64","percent of total billed charges",""
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","outpatient","","","3506.00","2103.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2713.64","77.4","","2621.83","2621.83","2621.83","1 through 10","407.75","2713.64","percent of total billed charges",""
"Rad Therapy Special","PX-33000054","CDM","77470","CPT","0333","RC","","","","outpatient","","","3506.00","2103.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","407.75","11.63","","947.75","399.59","967.09","1 through 10","407.75","2713.64","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","1373.00","823.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","692.73","692.73","1 through 10","108.88","1167.05","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","1373.00","823.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","299.84","298.29","299.84","1 through 10","108.88","1167.05","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","1373.00","823.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","111.11","111.11","111.11","1 through 10","108.88","1167.05","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","1373.00","823.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","562.84","298.29","562.84","1 through 10","108.88","1167.05","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","1373.00","823.80","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","1167.05","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","1373.00","823.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.39","108.89","111.11","1 through 10","108.88","1167.05","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","outpatient","","","1373.00","823.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","197.99","14.42","","191.07","191.07","191.07","1 through 10","159.68","1062.7","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","outpatient","","","1373.00","823.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","159.68","11.63","","182.45","156.51","182.45","1 through 10","159.68","1062.7","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","outpatient","","","1373.00","823.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","861.97","62.78","","579.29","579.29","579.29","1 through 10","159.68","1062.7","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","outpatient","","","1373.00","823.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","998.45","72.72","","963.54","963.54","963.54","1 through 10","159.68","1062.7","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","outpatient","","","1373.00","823.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","863.62","62.9","","834.75","834.75","834.75","1 through 10","159.68","1062.7","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","outpatient","","","1373.00","823.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1062.70","77.4","","1026.88","1026.88","1026.88","1 through 10","159.68","1062.7","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","outpatient","","","1373.00","823.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","159.68","11.63","","156.51","156.51","156.51","1 through 10","159.68","1062.7","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 6/> Vw","PX-32000421","CDM","72084","CPT","0320","RC","","","","outpatient","","","2650.00","1590.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1666.85","62.9","","1610.91","1610.91","1610.91","1 through 10","308.2","2051.1","percent of total billed charges",""
"Radex Hip Unilateral With Pelvis 2-3 Views","PX-32000423","CDM","73502","CPT","0320","RC","","","","both","","","893.00","535.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","623.31","69.8","","601.68","601.68","601.68","1 through 10","90.15","759.05","percent of total billed charges",""
"Radex Hip Unilateral With Pelvis 2-3 Views","PX-32000423","CDM","73502","CPT","0320","RC","","","","both","","","893.00","535.80","MEDICARE [2001]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","92.00","92.00","92.00","1 through 10","90.15","759.05","other","OPPS APC"
"Radex Hip Unilateral With Pelvis 2-3 Views","PX-32000423","CDM","73502","CPT","0320","RC","","","","both","","","893.00","535.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.53","90.16","90.66","39","90.15","759.05","other","OPPS APC"
"Radex Hip Unilateral With Pelvis 2-3 Views","PX-32000423","CDM","73502","CPT","0320","RC","","","","outpatient","","","893.00","535.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","649.39","72.72","","626.85","626.85","626.85","1 through 10","103.86","691.18","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis 3-4 Views","PX-32000426","CDM","73522","CPT","0320","RC","","","","both","","","982.00","589.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","834.7","other","OPPS APC"
"Radex Hips Bilateral With Pelvis 3-4 Views","PX-32000426","CDM","73522","CPT","0320","RC","","","","both","","","982.00","589.20","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","107.12","107.12","111.11","1 through 10","108.88","834.7","other","OPPS APC"
"Radex Hips Bilateral With Pelvis 3-4 Views","PX-32000426","CDM","73522","CPT","0320","RC","","","","both","","","982.00","589.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.39","109.39","109.39","1 through 10","108.88","834.7","other","OPPS APC"
"Radex Hips Bilateral With Pelvis 3-4 Views","PX-32000426","CDM","73522","CPT","0320","RC","","","","outpatient","","","982.00","589.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","141.60","14.42","","136.70","136.70","136.70","1 through 10","114.21","760.07","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis 3-4 Views","PX-32000426","CDM","73522","CPT","0320","RC","","","","outpatient","","","982.00","589.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","114.21","11.63","","111.98","111.98","111.98","1 through 10","114.21","760.07","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis 3-4 Views","PX-32000426","CDM","73522","CPT","0320","RC","","","","outpatient","","","982.00","589.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","114.21","11.63","","111.98","111.98","111.98","1 through 10","114.21","760.07","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","1192.00","715.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","692.73","692.73","1 through 10","108.88","1013.2","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","1192.00","715.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","299.84","12","108.88","1013.2","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","1192.00","715.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","111.11","108.89","111.11","11","108.88","1013.2","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","1192.00","715.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","298.29","559.93","1 through 10","108.88","1013.2","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","1192.00","715.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","114.44","112.15","114.44","1 through 10","108.88","1013.2","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","1192.00","715.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.22","109.22","111.11","12","108.88","1013.2","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","1192.00","715.20","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","27","108.88","1013.2","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","1192.00","715.20","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","1013.2","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","1192.00","715.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.39","108.89","111.11","15","108.88","1013.2","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","1192.00","715.20","WELLSENSE NH [1050]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","115.94","115.94","115.94","1 through 10","108.88","1013.2","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","outpatient","","","1192.00","715.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","171.89","14.42","","142.14","142.14","142.14","1 through 10","138.63","922.61","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","outpatient","","","1192.00","715.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","138.63","11.63","","290.43","135.83","290.43","1 through 10","138.63","922.61","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","outpatient","","","1192.00","715.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","866.82","72.72","","836.28","836.28","836.28","1 through 10","138.63","922.61","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","outpatient","","","1192.00","715.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","749.77","62.9","","724.50","724.50","724.50","1 through 10","138.63","922.61","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","outpatient","","","1192.00","715.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","922.61","77.4","","891.25","891.25","891.25","1 through 10","138.63","922.61","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","outpatient","","","1192.00","715.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","138.63","11.63","","135.83","135.83","135.83","1 through 10","138.63","922.61","percent of total billed charges",""
"Radex Spine Thoracolumbar Junction Min 2 Views","PX-32000063","CDM","72080","CPT","0320","RC","","","","both","","","632.00","379.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.44","90.44","90.44","1 through 10","90.15","587.88","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2721.00","1632.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","1899.26","69.8","","1832.95","1651.75","1832.95","141","269.26","2312.85","percent of total billed charges",""
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2721.00","1632.60","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","280.25","","APC Price ($274.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","274.78","274.78","274.78","71","269.26","2312.85","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2721.00","1632.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1755.89","","Case rate ($1,755.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1713.07","1702.15","1713.07","228","269.26","2312.85","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2721.00","1632.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","756.09","","Case rate ($756.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","737.65","732.95","737.65","175","269.26","2312.85","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2721.00","1632.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","269.26","","APC Price ($274.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","270.38","269.28","467.13","327","269.26","2312.85","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2721.00","1632.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1419.27","","Case rate ($1,419.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1246.18","732.95","1384.65","174","269.26","2312.85","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2721.00","1632.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","282.99","","APC Price ($274.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","278.49","277.36","278.49","149","269.26","2312.85","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2721.00","1632.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","274.75","","APC Price ($274.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","270.38","269.28","274.78","433","269.26","2312.85","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2721.00","1632.60","MEDICARE [2001]","HB WDH MEDICARE","274.75","","APC Price ($274.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","274.78","274.78","274.78","1119","269.26","2312.85","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2721.00","1632.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","2312.85","85","","2825.54","2825.54","3675.86","13","269.26","2312.85","percent of total billed charges",""
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2721.00","1632.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","274.75","","APC Price ($274.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","270.39","257.82","274.78","305","269.26","2312.85","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2721.00","1632.60","WELLPOINT [1015]","HB WDH ANTHEM PPO","1419.27","","Case rate ($1,419.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1384.65","1384.65","1384.65","20","269.26","2312.85","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","both","","","2721.00","1632.60","WELLSENSE NH [1050]","HB WDH MEDICARE","274.75","","APC Price ($274.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.35","283.90","284.35","23","269.26","2312.85","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","outpatient","","","2721.00","1632.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","392.37","14.42","","378.67","378.67","378.67","58","316.45","2106.05","percent of total billed charges",""
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","outpatient","","","2721.00","1632.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","316.45","11.63","","361.60","310.17","361.60","66","316.45","2106.05","percent of total billed charges",""
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","outpatient","","","2721.00","1632.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1708.24","62.78","","1648.60","1648.60","1648.60","20","316.45","2106.05","percent of total billed charges",""
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","outpatient","","","2721.00","1632.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1978.71","72.72","","1909.63","1728.43","3165.50","204","316.45","2106.05","percent of total billed charges",""
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","outpatient","","","2721.00","1632.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1711.51","62.9","","1654.38","1654.38","1654.38","123","316.45","2106.05","percent of total billed charges",""
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","outpatient","","","2721.00","1632.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2106.05","77.4","","1909.63","1909.63","1909.63","25","316.45","2106.05","percent of total billed charges",""
"Radiation Treatment Delivery 1 Mev >= Complex","PX-33000113","CDM","77412","CPT","0333","RC","","","","outpatient","","","2721.00","1632.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","316.45","11.63","","430.86","310.17","1292.58","58","316.45","2106.05","percent of total billed charges",""
"Radiation Treatment Delivery 1 Mev >= Simple","PX-33000111","CDM","77402","CPT","0333","RC","","","","both","","","1830.00","1098.00","MEDICARE [2001]","HB WDH MEDICARE","114.40","","APC Price ($114.40). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","228.82","228.82","228.82","1 through 10","112.11","1555.5","other","OPPS APC"
"Radiation Treatment Delivery 1 Mev >= Simple","PX-33000111","CDM","77402","CPT","0333","RC","","","","outpatient","","","1830.00","1098.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","263.89","14.42","","218.28","218.28","218.28","1 through 10","212.83","1416.42","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","541.00","324.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","377.62","69.8","","94.35","94.35","94.35","1 through 10","90.15","587.88","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","541.00","324.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","587.88","","Case rate ($587.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","522.00","522.00","522.00","31","90.15","587.88","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","541.00","324.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","253.14","","Case rate ($253.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","246.97","246.97","247.82","57","90.15","587.88","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","541.00","324.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","90.15","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","92.00","90.16","92.00","46","90.15","587.88","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","541.00","324.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","475.18","","Case rate ($475.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","463.58","246.97","465.18","36","90.15","587.88","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","541.00","324.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","94.75","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","94.76","94.56","94.76","1 through 10","90.15","587.88","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","541.00","324.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.44","90.25","92.00","64","90.15","587.88","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","541.00","324.60","MEDICARE [2001]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","92.00","88.54","92.00","151","90.15","587.88","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","541.00","324.60","TRICARE [160005]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","92.00","92.00","92.00","1 through 10","90.15","587.88","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","541.00","324.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.66","90.16","92.00","76","90.15","587.88","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","541.00","324.60","WELLSENSE NH [1050]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","94.67","94.67","96.60","1 through 10","90.15","587.88","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","outpatient","","","541.00","324.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","78.01","14.42","","75.27","64.52","75.27","21","62.92","418.73","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","outpatient","","","541.00","324.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","62.92","11.63","","123.32","61.66","184.98","89","62.92","418.73","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","outpatient","","","541.00","324.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","339.64","62.78","","327.71","327.71","327.71","1 through 10","62.92","418.73","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","outpatient","","","541.00","324.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","236.53","43.72","","228.22","228.22","228.22","1 through 10","62.92","418.73","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","outpatient","","","541.00","324.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","393.42","72.72","","379.60","379.60","379.60","48","62.92","418.73","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","outpatient","","","541.00","324.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","287.92","53.22","","556.56","278.28","556.56","1 through 10","62.92","418.73","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","outpatient","","","541.00","324.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","340.29","62.9","","328.86","328.86","328.86","46","62.92","418.73","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","outpatient","","","541.00","324.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","418.73","77.4","","404.55","404.55","404.55","15","62.92","418.73","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","outpatient","","","541.00","324.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","393.42","72.72","","379.60","379.60","379.60","1 through 10","62.92","418.73","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","outpatient","","","541.00","324.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","62.92","11.63","","61.66","61.66","145.76","40","62.92","418.73","percent of total billed charges",""
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","652.00","391.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","298.29","1 through 10","108.88","710.05","other","OPPS APC"
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","652.00","391.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","109.89","108.89","603.00","1 through 10","108.88","710.05","other","OPPS APC"
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","652.00","391.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","158.86","158.86","559.93","1 through 10","108.88","710.05","other","OPPS APC"
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","652.00","391.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","113.95","113.95","113.95","1 through 10","108.88","710.05","other","OPPS APC"
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","652.00","391.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","109.22","111.11","1 through 10","108.88","710.05","other","OPPS APC"
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","652.00","391.20","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","710.05","other","OPPS APC"
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","652.00","391.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.34","108.89","111.11","1 through 10","108.88","710.05","other","OPPS APC"
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","652.00","391.20","WELLSENSE NH [1050]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","114.34","114.34","116.67","1 through 10","108.88","710.05","other","OPPS APC"
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","outpatient","","","652.00","391.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","94.02","14.42","","90.70","90.70","90.70","1 through 10","75.83","504.65","percent of total billed charges",""
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","outpatient","","","652.00","391.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","75.83","11.63","","158.86","76.99","158.86","1 through 10","75.83","504.65","percent of total billed charges",""
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","outpatient","","","652.00","391.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","474.13","72.72","","457.41","457.41","457.41","1 through 10","75.83","504.65","percent of total billed charges",""
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","outpatient","","","652.00","391.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","410.11","62.9","","1521.00","396.27","1521.00","1 through 10","75.83","504.65","percent of total billed charges",""
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","outpatient","","","652.00","391.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","504.65","77.4","","487.48","487.48","487.48","1 through 10","75.83","504.65","percent of total billed charges",""
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","outpatient","","","652.00","391.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","75.83","11.63","","74.30","74.30","74.30","1 through 10","75.83","504.65","percent of total billed charges",""
"Radiologic Exam Abdomen 3+ Views","PX-32000438","CDM","74021","CPT","0320","RC","","","","both","","","742.00","445.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.39","109.39","109.39","1 through 10","108.88","710.05","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","581.00","348.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","405.54","69.8","","391.58","101.39","391.58","18","90.15","587.88","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","581.00","348.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","587.88","","Case rate ($587.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","561.00","561.00","561.00","105","90.15","587.88","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","581.00","348.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","253.14","","Case rate ($253.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","246.97","246.97","247.82","206","90.15","587.88","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","581.00","348.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","90.15","","APC Price ($91.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","90.34","88.54","92.00","405","90.15","587.88","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","581.00","348.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","475.18","","Case rate ($475.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","463.58","246.97","465.18","101","90.15","587.88","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","581.00","348.60","CHAMPVA [160001]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","561.00","90.04","561.00","1 through 10","90.15","587.88","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","581.00","348.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","405.54","69.8","","391.58","364.15","391.58","1 through 10","90.15","587.88","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","581.00","348.60","HARVARD PILGRIM [120001]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","87.07","87.07","87.07","1 through 10","90.15","587.88","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","581.00","348.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","94.75","","APC Price ($91.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","94.76","92.86","94.76","106","90.15","587.88","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","581.00","348.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.44","88.54","92.00","375","90.15","587.88","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","581.00","348.60","MEDICARE [2001]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","92.00","92.00","92.00","824","90.15","587.88","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","581.00","348.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","493.85","85","","391.58","86.88","538.00","12","90.15","587.88","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","581.00","348.60","TRICARE [160005]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","92.00","92.00","92.00","40","90.15","587.88","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","581.00","348.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.66","87.13","92.00","513","90.15","587.88","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","581.00","348.60","WELLPOINT [1015]","HB WDH ANTHEM PPO","475.18","","Case rate ($475.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","465.18","463.58","465.18","1 through 10","90.15","587.88","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","581.00","348.60","WELLSENSE NH [1050]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","96.27","96.27","96.60","48","90.15","587.88","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","inpatient","","","581.00","348.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","446.56","76.86","","353.43","339.26","353.43","1 through 10","384.62","446.56","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","581.00","348.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","83.78","14.42","","80.90","69.34","80.90","123","67.57","449.69","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","581.00","348.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","67.57","11.63","","77.25","66.26","141.68","432","67.57","449.69","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","581.00","348.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","364.75","62.78","","352.20","352.20","352.20","13","67.57","449.69","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","581.00","348.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","254.01","43.72","","245.27","245.27","735.81","13","67.57","449.69","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","581.00","348.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","422.50","72.72","","407.96","407.96","407.96","274","67.57","449.69","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","581.00","348.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","422.50","72.72","","407.96","407.96","815.92","11","67.57","449.69","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","581.00","348.60","INTERNATIONAL COMMERCIAL [140001]","HB WDH UNITED HMO / PPO / INDEM","449.69","77.4","","434.78","434.78","434.78","1 through 10","67.57","449.69","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","581.00","348.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","309.21","53.22","","299.07","299.07","299.07","1 through 10","67.57","449.69","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","581.00","348.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","365.45","62.9","","353.43","353.43","353.43","342","67.57","449.69","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","581.00","348.60","PHCS MULTIPLAN [1022]","HB WDH AMERIHEALTH CARITAS","83.78","14.42","","80.90","80.90","80.90","1 through 10","67.57","449.69","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","581.00","348.60","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","422.50","72.72","","407.96","407.96","407.96","1 through 10","67.57","449.69","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","581.00","348.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","449.69","77.4","","434.78","434.78","434.78","117","67.57","449.69","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","581.00","348.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","422.50","72.72","","407.96","407.96","407.96","1 through 10","67.57","449.69","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","581.00","348.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","67.57","11.63","","66.26","66.26","331.30","123","67.57","449.69","percent of total billed charges",""
"Radiologic Exam Chest 3 Views","PX-32000441","CDM","71047","CPT","0324","RC","","","","both","","","721.00","432.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.66","90.66","90.66","1 through 10","43.17","612.85","other","OPPS APC"
"Radiologic Exam Chest 3 Views","PX-32000441","CDM","71047","CPT","0324","RC","","","","both","","","721.00","432.60","WELLSENSE NH [1050]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","96.27","96.27","96.27","1 through 10","43.17","612.85","other","OPPS APC"
"Radiologic Exam Chest 3 Views","PX-32000441","CDM","71047","CPT","0324","RC","","","","outpatient","","","721.00","432.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","83.85","11.63","","82.21","82.21","82.21","1 through 10","83.85","558.05","percent of total billed charges",""
"Radiologic Exam Chest 4+ Views","PX-32000442","CDM","71048","CPT","0324","RC","","","","both","","","751.00","450.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","298.29","1 through 10","108.88","710.05","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","441.00","264.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","587.88","","Case rate ($587.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","573.54","426.00","575.52","1 through 10","84.82","587.88","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","441.00","264.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","253.14","","Case rate ($253.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","246.97","246.97","247.82","13","84.82","587.88","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","441.00","264.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","90.15","","APC Price ($91.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","90.16","86.77","150.52","1 through 10","84.82","587.88","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","441.00","264.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","475.18","","Case rate ($475.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","463.58","426.00","465.18","12","84.82","587.88","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","441.00","264.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","94.75","","APC Price ($91.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","92.86","89.38","94.76","1 through 10","84.82","587.88","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","441.00","264.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","92.00","86.77","92.00","16","84.82","587.88","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","441.00","264.60","MEDICARE [2001]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","92.00","92.00","265.62","39","84.82","587.88","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","441.00","264.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.35","90.16","92.00","17","84.82","587.88","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","441.00","264.60","WELLSENSE NH [1050]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","192.54","192.54","192.54","1 through 10","84.82","587.88","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","inpatient","","","441.00","264.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","338.95","76.86","","515.84","268.38","515.84","1 through 10","291.94","338.95","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","outpatient","","","441.00","264.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","63.59","14.42","","61.43","52.65","61.43","24","51.29","341.33","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","outpatient","","","441.00","264.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","51.29","11.63","","58.66","50.32","150.96","80","51.29","341.33","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","outpatient","","","441.00","264.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","276.86","62.78","","267.44","267.44","267.44","1 through 10","51.29","341.33","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","outpatient","","","441.00","264.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","192.81","43.72","","558.74","186.25","558.74","11","51.29","341.33","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","outpatient","","","441.00","264.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","320.70","72.72","","619.58","309.79","1239.15","39","51.29","341.33","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","outpatient","","","441.00","264.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","234.70","53.22","","227.10","227.10","227.10","1 through 10","51.29","341.33","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","outpatient","","","441.00","264.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","277.39","62.9","","268.38","268.38","1031.68","39","51.29","341.33","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","outpatient","","","441.00","264.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","341.33","77.4","","330.15","330.15","330.15","12","51.29","341.33","percent of total billed charges",""
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","outpatient","","","441.00","264.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","51.29","11.63","","50.32","50.32","150.96","32","51.29","341.33","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","2068.00","1240.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","1443.46","69.8","","1393.21","1255.48","1393.21","1 through 10","182.27","1757.8","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","2068.00","1240.80","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","189.71","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","186.01","186.01","186.01","1 through 10","182.27","1757.8","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","2068.00","1240.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1188.62","","Case rate ($1,188.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1159.63","1159.63","1163.69","12","182.27","1757.8","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","2068.00","1240.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","511.82","","Case rate ($511.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","499.34","499.34","499.34","11","182.27","1757.8","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","2068.00","1240.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","182.27","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.29","182.29","186.01","13","182.27","1757.8","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","2068.00","1240.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","960.75","","Case rate ($960.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","937.31","499.34","940.60","13","182.27","1757.8","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","2068.00","1240.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1176.69","56.9","","1135.72","1135.72","1135.72","15","182.27","1757.8","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","2068.00","1240.80","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","1176.69","56.9","","1135.72","1135.72","1135.72","1 through 10","182.27","1757.8","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","2068.00","1240.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","191.57","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","190.36","190.36","190.36","1 through 10","182.27","1757.8","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","2068.00","1240.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","183.03","182.85","186.01","1 through 10","182.27","1757.8","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","2068.00","1240.80","MEDICARE [2001]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","186.01","186.01","90","182.27","1757.8","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","2068.00","1240.80","TRICARE [160005]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","186.01","186.01","1 through 10","182.27","1757.8","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","2068.00","1240.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.79","182.29","186.01","34","182.27","1757.8","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","2068.00","1240.80","WELLPOINT [1015]","HB WDH ANTHEM PPO","960.75","","Case rate ($960.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","940.60","940.60","940.60","1 through 10","182.27","1757.8","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","2068.00","1240.80","WELLSENSE NH [1050]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","191.40","191.40","195.31","1 through 10","182.27","1757.8","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","outpatient","","","2068.00","1240.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","298.21","14.42","","287.82","246.71","287.82","1 through 10","240.51","1600.63","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","outpatient","","","2068.00","1240.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","240.51","11.63","","504.09","274.85","504.09","11","240.51","1600.63","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","outpatient","","","2068.00","1240.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1298.29","62.78","","1253.09","1253.09","1253.09","1 through 10","240.51","1600.63","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","outpatient","","","2068.00","1240.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","904.13","43.72","","872.65","872.65","872.65","1 through 10","240.51","1600.63","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","outpatient","","","2068.00","1240.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1503.85","72.72","","1451.49","1451.49","1451.49","1 through 10","240.51","1600.63","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","outpatient","","","2068.00","1240.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1300.77","62.9","","1257.48","1257.48","1257.48","1 through 10","240.51","1600.63","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","outpatient","","","2068.00","1240.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1600.63","77.4","","1546.90","1451.49","1546.90","1 through 10","240.51","1600.63","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","outpatient","","","2068.00","1240.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","240.51","11.63","","235.76","235.76","297.62","1 through 10","240.51","1600.63","percent of total billed charges",""
"Radiologic Examination Femur Minimum 2 Views","PX-32000429","CDM","73552","CPT","0320","RC","","","","both","","","682.00","409.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","476.04","69.8","","459.28","459.28","459.28","1 through 10","90.15","587.88","percent of total billed charges",""
"Radiologic Examination Femur Minimum 2 Views","PX-32000429","CDM","73552","CPT","0320","RC","","","","both","","","682.00","409.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.66","87.07","90.66","1 through 10","90.15","587.88","other","OPPS APC"
"Radiologic Small Intestine Follow-Through Study","PX-32000448","CDM","74248","CPT","0320","RC","","","","both","","","703.00","421.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","400.01","56.9","","385.78","385.78","385.78","1 through 10","400.01","597.55","percent of total billed charges",""
"Radiologic Small Intestine Follow-Through Study","PX-32000448","CDM","74248","CPT","0320","RC","","","","outpatient","","","703.00","421.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","511.22","72.72","","493.04","493.04","493.04","1 through 10","81.76","544.12","percent of total billed charges",""
"Radiologic Small Intestine Follow-Through Study","PX-32000448","CDM","74248","CPT","0320","RC","","","","outpatient","","","703.00","421.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","442.19","62.9","","427.14","427.14","427.14","1 through 10","81.76","544.12","percent of total billed charges",""
"Radiologic Small Intestine Follow-Through Study","PX-32000448","CDM","74248","CPT","0320","RC","","","","outpatient","","","703.00","421.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","544.12","77.4","","525.45","525.45","525.45","1 through 10","81.76","544.12","percent of total billed charges",""
"Radiologic Small Intestine Follow-Through Study","PX-32000448","CDM","74248","CPT","0320","RC","","","","outpatient","","","703.00","421.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","81.76","11.63","","80.08","80.08","80.08","1 through 10","81.76","544.12","percent of total billed charges",""
"RADIUS HEAD 10X2.0MM STEM RADIAL UNIV TAPERED POROUS COATED PRESS FIT OFFSET COBALT TITANIUM ANATOMIC","SUP-ITM-10045173","CDM","C1776","HCPCS","0278","RC","","","","both","","","10728.20","6436.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1247.69","9118.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS HEAD 10X2.0MM STEM RADIAL UNIV TAPERED POROUS COATED PRESS FIT OFFSET COBALT TITANIUM ANATOMIC","SUP-ITM-10045173","CDM","C1776","HCPCS","0278","RC","","","","both","","","10728.20","6436.92","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6104.35","56.9","","2911.53","1863.86","5209.05","65","1247.69","9118.97","percent of total billed charges",""
"RADIUS HEAD 10X2.0MM STEM RADIAL UNIV TAPERED POROUS COATED PRESS FIT OFFSET COBALT TITANIUM ANATOMIC","SUP-ITM-10045173","CDM","C1776","HCPCS","0278","RC","","","","both","","","10728.20","6436.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1247.69","11.63","","400.94","400.94","400.94","1 through 10","1247.69","9118.97","percent of total billed charges",""
"RADIUS HEAD 10X2.0MM STEM RADIAL UNIV TAPERED POROUS COATED PRESS FIT OFFSET COBALT TITANIUM ANATOMIC","SUP-ITM-10045173","CDM","C1776","HCPCS","0278","RC","","","","both","","","10728.20","6436.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8303.63","77.4","","5214.50","5214.50","16415.28","1 through 10","1247.69","9118.97","percent of total billed charges",""
"RADIUS HEAD 10X2.0MM STEM RADIAL UNIV TAPERED POROUS COATED PRESS FIT OFFSET COBALT TITANIUM ANATOMIC","SUP-ITM-10045173","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10728.20","6436.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1247.69","11.63","","400.94","400.94","400.94","1 through 10","1247.69","8303.63","percent of total billed charges",""
"RADIUS HEAD 10X2.0MM STEM RADIAL UNIV TAPERED POROUS COATED PRESS FIT OFFSET COBALT TITANIUM ANATOMIC","SUP-ITM-10045173","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10728.20","6436.92","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4690.37","43.72","","1543.33","1543.33","1671.61","1 through 10","1247.69","8303.63","percent of total billed charges",""
"RADIUS HEAD 10X2.0MM STEM RADIAL UNIV TAPERED POROUS COATED PRESS FIT OFFSET COBALT TITANIUM ANATOMIC","SUP-ITM-10045173","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10728.20","6436.92","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7801.55","72.72","","3700.21","2382.07","6427.18","53","1247.69","8303.63","percent of total billed charges",""
"RADIUS HEAD 10X2.0MM STEM RADIAL UNIV TAPERED POROUS COATED PRESS FIT OFFSET COBALT TITANIUM ANATOMIC","SUP-ITM-10045173","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10728.20","6436.92","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7801.55","72.72","","12685.80","12685.80","12685.80","1 through 10","1247.69","8303.63","percent of total billed charges",""
"RADIUS HEAD 10X2.0MM STEM RADIAL UNIV TAPERED POROUS COATED PRESS FIT OFFSET COBALT TITANIUM ANATOMIC","SUP-ITM-10045173","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10728.20","6436.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6748.04","62.9","","3408.87","2784.05","9859.40","46","1247.69","8303.63","percent of total billed charges",""
"RADIUS HEAD 10X2.0MM STEM RADIAL UNIV TAPERED POROUS COATED PRESS FIT OFFSET COBALT TITANIUM ANATOMIC","SUP-ITM-10045173","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10728.20","6436.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8303.63","77.4","","5214.50","5214.50","16415.28","1 through 10","1247.69","8303.63","percent of total billed charges",""
"RADIUS HEAD 24MM 4DEG RADIAL LT CURVED POLISHED FINISH PRESS FIT OFFSET COBALT TITANIUM ANATOMIC","SUP-ITM-10045146","CDM","C1776","HCPCS","0278","RC","","","","both","","","14531.88","8719.13","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1690.06","12352.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS HEAD 24MM 4DEG RADIAL LT CURVED POLISHED FINISH PRESS FIT OFFSET COBALT TITANIUM ANATOMIC","SUP-ITM-10045146","CDM","C1776","HCPCS","0278","RC","","","","both","","","14531.88","8719.13","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","8268.64","56.9","","2911.53","1863.86","5209.05","65","1690.06","12352.1","percent of total billed charges",""
"RADIUS HEAD 24MM 4DEG RADIAL LT CURVED POLISHED FINISH PRESS FIT OFFSET COBALT TITANIUM ANATOMIC","SUP-ITM-10045146","CDM","C1776","HCPCS","0278","RC","","","","both","","","14531.88","8719.13","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1690.06","11.63","","400.94","400.94","400.94","1 through 10","1690.06","12352.1","percent of total billed charges",""
"RADIUS HEAD 24MM 4DEG RADIAL LT CURVED POLISHED FINISH PRESS FIT OFFSET COBALT TITANIUM ANATOMIC","SUP-ITM-10045146","CDM","C1776","HCPCS","0278","RC","","","","both","","","14531.88","8719.13","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","11247.68","77.4","","5214.50","5214.50","16415.28","1 through 10","1690.06","12352.1","percent of total billed charges",""
"RADIUS HEAD 24MM 4DEG RADIAL LT CURVED POLISHED FINISH PRESS FIT OFFSET COBALT TITANIUM ANATOMIC","SUP-ITM-10045146","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14531.88","8719.13","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1690.06","11.63","","400.94","400.94","400.94","1 through 10","1690.06","11247.68","percent of total billed charges",""
"RADIUS HEAD 24MM 4DEG RADIAL LT CURVED POLISHED FINISH PRESS FIT OFFSET COBALT TITANIUM ANATOMIC","SUP-ITM-10045146","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14531.88","8719.13","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","6353.34","43.72","","1543.33","1543.33","1671.61","1 through 10","1690.06","11247.68","percent of total billed charges",""
"RADIUS HEAD 24MM 4DEG RADIAL LT CURVED POLISHED FINISH PRESS FIT OFFSET COBALT TITANIUM ANATOMIC","SUP-ITM-10045146","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14531.88","8719.13","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10567.58","72.72","","3700.21","2382.07","6427.18","53","1690.06","11247.68","percent of total billed charges",""
"RADIUS HEAD 24MM 4DEG RADIAL LT CURVED POLISHED FINISH PRESS FIT OFFSET COBALT TITANIUM ANATOMIC","SUP-ITM-10045146","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14531.88","8719.13","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","10567.58","72.72","","12685.80","12685.80","12685.80","1 through 10","1690.06","11247.68","percent of total billed charges",""
"RADIUS HEAD 24MM 4DEG RADIAL LT CURVED POLISHED FINISH PRESS FIT OFFSET COBALT TITANIUM ANATOMIC","SUP-ITM-10045146","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14531.88","8719.13","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","9140.55","62.9","","3408.87","2784.05","9859.40","46","1690.06","11247.68","percent of total billed charges",""
"RADIUS HEAD 24MM 4DEG RADIAL LT CURVED POLISHED FINISH PRESS FIT OFFSET COBALT TITANIUM ANATOMIC","SUP-ITM-10045146","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","14531.88","8719.13","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","11247.68","77.4","","5214.50","5214.50","16415.28","1 through 10","1690.06","11247.68","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","both","","","7040.89","4224.53","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","818.86","5984.76","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","both","","","7040.89","4224.53","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","818.86","5984.76","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","both","","","7040.89","4224.53","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4006.27","56.9","","812.12","238.65","1587.46","163","818.86","5984.76","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","both","","","7040.89","4224.53","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","818.86","11.63","","112.68","112.68","146.99","38","818.86","5984.76","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","both","","","7040.89","4224.53","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5449.65","77.4","","303.98","303.98","5854.79","1 through 10","818.86","5984.76","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7040.89","4224.53","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","818.86","11.63","","112.68","112.68","146.99","38","818.86","5449.65","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7040.89","4224.53","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4420.27","62.78","","780.86","208.94","10480.28","15","818.86","5449.65","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7040.89","4224.53","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3078.28","43.72","","179.76","179.76","179.76","1 through 10","818.86","5449.65","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7040.89","4224.53","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5120.14","72.72","","2355.45","298.99","3965.19","155","818.86","5449.65","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7040.89","4224.53","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5120.14","72.72","","3643.09","3643.09","3643.09","1 through 10","818.86","5449.65","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7040.89","4224.53","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3747.16","53.22","","554.28","554.28","554.28","16","818.86","5449.65","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7040.89","4224.53","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4428.72","62.9","","619.64","173.09","2370.64","150","818.86","5449.65","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7040.89","4224.53","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5449.65","77.4","","303.98","303.98","5854.79","1 through 10","818.86","5449.65","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","4798.79","2879.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","558.1","4078.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","4798.79","2879.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","558.1","4078.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","4798.79","2879.27","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2730.51","56.9","","812.12","238.65","1587.46","163","558.1","4078.97","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","4798.79","2879.27","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","558.10","11.63","","112.68","112.68","146.99","38","558.1","4078.97","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","4798.79","2879.27","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3714.26","77.4","","303.98","303.98","5854.79","1 through 10","558.1","4078.97","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4798.79","2879.27","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","558.10","11.63","","112.68","112.68","146.99","38","558.1","3714.26","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4798.79","2879.27","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3012.68","62.78","","780.86","208.94","10480.28","15","558.1","3714.26","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4798.79","2879.27","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2098.03","43.72","","179.76","179.76","179.76","1 through 10","558.1","3714.26","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4798.79","2879.27","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3489.68","72.72","","2355.45","298.99","3965.19","155","558.1","3714.26","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4798.79","2879.27","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3489.68","72.72","","3643.09","3643.09","3643.09","1 through 10","558.1","3714.26","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4798.79","2879.27","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2553.92","53.22","","554.28","554.28","554.28","16","558.1","3714.26","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4798.79","2879.27","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3018.44","62.9","","619.64","173.09","2370.64","150","558.1","3714.26","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4798.79","2879.27","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3714.26","77.4","","303.98","303.98","5854.79","1 through 10","558.1","3714.26","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","both","","","3433.65","2060.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","399.33","2918.6","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","both","","","3433.65","2060.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","399.33","2918.6","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","both","","","3433.65","2060.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1953.75","56.9","","812.12","238.65","1587.46","163","399.33","2918.6","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","both","","","3433.65","2060.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","399.33","11.63","","112.68","112.68","146.99","38","399.33","2918.6","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","both","","","3433.65","2060.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2657.65","77.4","","303.98","303.98","5854.79","1 through 10","399.33","2918.6","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3433.65","2060.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","399.33","11.63","","112.68","112.68","146.99","38","399.33","2657.65","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3433.65","2060.19","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2155.65","62.78","","780.86","208.94","10480.28","15","399.33","2657.65","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3433.65","2060.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1501.19","43.72","","179.76","179.76","179.76","1 through 10","399.33","2657.65","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3433.65","2060.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2496.95","72.72","","2355.45","298.99","3965.19","155","399.33","2657.65","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3433.65","2060.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2496.95","72.72","","3643.09","3643.09","3643.09","1 through 10","399.33","2657.65","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3433.65","2060.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1827.39","53.22","","554.28","554.28","554.28","16","399.33","2657.65","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3433.65","2060.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2159.77","62.9","","619.64","173.09","2370.64","150","399.33","2657.65","percent of total billed charges",""
"RADIUS PLATE 2.4X46MM 5 HOLE SHAFT VA LCP DORSAL DISTAL RADIAL COLUMN","SUP-ITM-10090909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3433.65","2060.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2657.65","77.4","","303.98","303.98","5854.79","1 through 10","399.33","2657.65","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","both","","","4097.35","2458.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","476.52","3482.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","both","","","4097.35","2458.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","476.52","3482.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","both","","","4097.35","2458.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2331.39","56.9","","812.12","238.65","1587.46","163","476.52","3482.75","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","both","","","4097.35","2458.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","476.52","11.63","","112.68","112.68","146.99","38","476.52","3482.75","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","both","","","4097.35","2458.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3171.35","77.4","","303.98","303.98","5854.79","1 through 10","476.52","3482.75","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4097.35","2458.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","476.52","11.63","","112.68","112.68","146.99","38","476.52","3171.35","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4097.35","2458.41","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2572.32","62.78","","780.86","208.94","10480.28","15","476.52","3171.35","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4097.35","2458.41","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1791.36","43.72","","179.76","179.76","179.76","1 through 10","476.52","3171.35","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4097.35","2458.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2979.59","72.72","","2355.45","298.99","3965.19","155","476.52","3171.35","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4097.35","2458.41","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2979.59","72.72","","3643.09","3643.09","3643.09","1 through 10","476.52","3171.35","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4097.35","2458.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2180.61","53.22","","554.28","554.28","554.28","16","476.52","3171.35","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4097.35","2458.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2577.23","62.9","","619.64","173.09","2370.64","150","476.52","3171.35","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4097.35","2458.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3171.35","77.4","","303.98","303.98","5854.79","1 through 10","476.52","3171.35","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","4989.09","2993.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","580.23","4240.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","4989.09","2993.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","580.23","4240.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","4989.09","2993.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2838.79","56.9","","812.12","238.65","1587.46","163","580.23","4240.73","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","4989.09","2993.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","580.23","11.63","","112.68","112.68","146.99","38","580.23","4240.73","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","4989.09","2993.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3861.56","77.4","","303.98","303.98","5854.79","1 through 10","580.23","4240.73","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4989.09","2993.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","580.23","11.63","","112.68","112.68","146.99","38","580.23","3861.56","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4989.09","2993.45","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3132.15","62.78","","780.86","208.94","10480.28","15","580.23","3861.56","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4989.09","2993.45","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2181.23","43.72","","179.76","179.76","179.76","1 through 10","580.23","3861.56","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4989.09","2993.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3628.07","72.72","","2355.45","298.99","3965.19","155","580.23","3861.56","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4989.09","2993.45","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3628.07","72.72","","3643.09","3643.09","3643.09","1 through 10","580.23","3861.56","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4989.09","2993.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2655.19","53.22","","554.28","554.28","554.28","16","580.23","3861.56","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4989.09","2993.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3138.14","62.9","","619.64","173.09","2370.64","150","580.23","3861.56","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4989.09","2993.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3861.56","77.4","","303.98","303.98","5854.79","1 through 10","580.23","3861.56","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.69","2498.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","484.24","3539.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.69","2498.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","484.24","3539.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.69","2498.21","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2369.14","56.9","","812.12","238.65","1587.46","163","484.24","3539.14","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.69","2498.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","484.24","11.63","","112.68","112.68","146.99","38","484.24","3539.14","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","both","","","4163.69","2498.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3222.70","77.4","","303.98","303.98","5854.79","1 through 10","484.24","3539.14","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.69","2498.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","484.24","11.63","","112.68","112.68","146.99","38","484.24","3222.7","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.69","2498.21","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2613.96","62.78","","780.86","208.94","10480.28","15","484.24","3222.7","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.69","2498.21","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1820.37","43.72","","179.76","179.76","179.76","1 through 10","484.24","3222.7","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.69","2498.21","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3027.84","72.72","","2355.45","298.99","3965.19","155","484.24","3222.7","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.69","2498.21","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3027.84","72.72","","3643.09","3643.09","3643.09","1 through 10","484.24","3222.7","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.69","2498.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2215.92","53.22","","554.28","554.28","554.28","16","484.24","3222.7","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.69","2498.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2618.96","62.9","","619.64","173.09","2370.64","150","484.24","3222.7","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL RIGHT","SUP-ITM-10080028","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4163.69","2498.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3222.70","77.4","","303.98","303.98","5854.79","1 through 10","484.24","3222.7","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","both","","","3679.09","2207.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","427.88","3127.23","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","both","","","3679.09","2207.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","427.88","3127.23","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","both","","","3679.09","2207.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2093.40","56.9","","812.12","238.65","1587.46","163","427.88","3127.23","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","both","","","3679.09","2207.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","427.88","11.63","","112.68","112.68","146.99","38","427.88","3127.23","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","both","","","3679.09","2207.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2847.62","77.4","","303.98","303.98","5854.79","1 through 10","427.88","3127.23","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3679.09","2207.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","427.88","11.63","","112.68","112.68","146.99","38","427.88","2847.62","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3679.09","2207.45","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2309.73","62.78","","780.86","208.94","10480.28","15","427.88","2847.62","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3679.09","2207.45","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1608.50","43.72","","179.76","179.76","179.76","1 through 10","427.88","2847.62","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3679.09","2207.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2675.43","72.72","","2355.45","298.99","3965.19","155","427.88","2847.62","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3679.09","2207.45","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2675.43","72.72","","3643.09","3643.09","3643.09","1 through 10","427.88","2847.62","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3679.09","2207.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1958.01","53.22","","554.28","554.28","554.28","16","427.88","2847.62","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3679.09","2207.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2314.15","62.9","","619.64","173.09","2370.64","150","427.88","2847.62","percent of total billed charges",""
"RADIUS PLATE 2X51MM 5 HOLE SHAFT 90DEG ARM VA LCP SS L SHAPE DORSAL PLUS","SUP-ITM-10095130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3679.09","2207.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2847.62","77.4","","303.98","303.98","5854.79","1 through 10","427.88","2847.62","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","both","","","6709.61","4025.77","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","780.33","5703.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","both","","","6709.61","4025.77","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3817.77","56.9","","2911.53","1863.86","5209.05","65","780.33","5703.17","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","both","","","6709.61","4025.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","780.33","11.63","","400.94","400.94","400.94","1 through 10","780.33","5703.17","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","both","","","6709.61","4025.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5193.24","77.4","","5214.50","5214.50","16415.28","1 through 10","780.33","5703.17","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6709.61","4025.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","780.33","11.63","","400.94","400.94","400.94","1 through 10","780.33","5193.24","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6709.61","4025.77","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2933.44","43.72","","1543.33","1543.33","1671.61","1 through 10","780.33","5193.24","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6709.61","4025.77","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4879.23","72.72","","3700.21","2382.07","6427.18","53","780.33","5193.24","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6709.61","4025.77","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4879.23","72.72","","12685.80","12685.80","12685.80","1 through 10","780.33","5193.24","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6709.61","4025.77","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4220.34","62.9","","3408.87","2784.05","9859.40","46","780.33","5193.24","percent of total billed charges",""
"RADIUS PLATE 3 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM LT NARROW","SUP-ITM-10130522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6709.61","4025.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5193.24","77.4","","5214.50","5214.50","16415.28","1 through 10","780.33","5193.24","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","6799.44","4079.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","790.77","5779.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","6799.44","4079.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","790.77","5779.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","6799.44","4079.66","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3868.88","56.9","","812.12","238.65","1587.46","163","790.77","5779.52","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","6799.44","4079.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","790.77","11.63","","112.68","112.68","146.99","38","790.77","5779.52","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","6799.44","4079.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5262.77","77.4","","303.98","303.98","5854.79","1 through 10","790.77","5779.52","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6799.44","4079.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","790.77","11.63","","112.68","112.68","146.99","38","790.77","5262.77","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6799.44","4079.66","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4268.69","62.78","","780.86","208.94","10480.28","15","790.77","5262.77","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6799.44","4079.66","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2972.72","43.72","","179.76","179.76","179.76","1 through 10","790.77","5262.77","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6799.44","4079.66","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4944.55","72.72","","2355.45","298.99","3965.19","155","790.77","5262.77","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6799.44","4079.66","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4944.55","72.72","","3643.09","3643.09","3643.09","1 through 10","790.77","5262.77","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6799.44","4079.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3618.66","53.22","","554.28","554.28","554.28","16","790.77","5262.77","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6799.44","4079.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4276.85","62.9","","619.64","173.09","2370.64","150","790.77","5262.77","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6799.44","4079.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5262.77","77.4","","303.98","303.98","5854.79","1 through 10","790.77","5262.77","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3768.58","2261.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","438.29","3203.29","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3768.58","2261.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","438.29","3203.29","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3768.58","2261.15","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2144.32","56.9","","812.12","238.65","1587.46","163","438.29","3203.29","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3768.58","2261.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","438.29","11.63","","112.68","112.68","146.99","38","438.29","3203.29","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3768.58","2261.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2916.88","77.4","","303.98","303.98","5854.79","1 through 10","438.29","3203.29","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3768.58","2261.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","438.29","11.63","","112.68","112.68","146.99","38","438.29","2916.88","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3768.58","2261.15","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2365.91","62.78","","780.86","208.94","10480.28","15","438.29","2916.88","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3768.58","2261.15","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1647.62","43.72","","179.76","179.76","179.76","1 through 10","438.29","2916.88","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3768.58","2261.15","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2740.51","72.72","","2355.45","298.99","3965.19","155","438.29","2916.88","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3768.58","2261.15","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2740.51","72.72","","3643.09","3643.09","3643.09","1 through 10","438.29","2916.88","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3768.58","2261.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2005.64","53.22","","554.28","554.28","554.28","16","438.29","2916.88","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3768.58","2261.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2370.44","62.9","","619.64","173.09","2370.64","150","438.29","2916.88","percent of total billed charges",""
"RADIUS PLATE 41MM 2 HOLE HEAD 3 SHAFT 90DEG VA LCP SS INTERMEDIATE COLUMN DORSEL","SUP-ITM-10094080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3768.58","2261.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2916.88","77.4","","303.98","303.98","5854.79","1 through 10","438.29","2916.88","percent of total billed charges",""
"RADIUS PLATE 53MM SHORT 10 HOLE VARIAX TITANIUM LOCKING STANDARD","SUP-ITM-10028299","CDM","C1713","HCPCS","0278","RC","","","","both","","","5950.51","3570.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","692.04","5057.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 53MM SHORT 10 HOLE VARIAX TITANIUM LOCKING STANDARD","SUP-ITM-10028299","CDM","C1713","HCPCS","0278","RC","","","","both","","","5950.51","3570.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","692.04","5057.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 53MM SHORT 10 HOLE VARIAX TITANIUM LOCKING STANDARD","SUP-ITM-10028299","CDM","C1713","HCPCS","0278","RC","","","","both","","","5950.51","3570.31","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3385.84","56.9","","812.12","238.65","1587.46","163","692.04","5057.93","percent of total billed charges",""
"RADIUS PLATE 53MM SHORT 10 HOLE VARIAX TITANIUM LOCKING STANDARD","SUP-ITM-10028299","CDM","C1713","HCPCS","0278","RC","","","","both","","","5950.51","3570.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","692.04","11.63","","112.68","112.68","146.99","38","692.04","5057.93","percent of total billed charges",""
"RADIUS PLATE 53MM SHORT 10 HOLE VARIAX TITANIUM LOCKING STANDARD","SUP-ITM-10028299","CDM","C1713","HCPCS","0278","RC","","","","both","","","5950.51","3570.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4605.69","77.4","","303.98","303.98","5854.79","1 through 10","692.04","5057.93","percent of total billed charges",""
"RADIUS PLATE 53MM SHORT 10 HOLE VARIAX TITANIUM LOCKING STANDARD","SUP-ITM-10028299","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5950.51","3570.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","692.04","11.63","","112.68","112.68","146.99","38","692.04","4605.69","percent of total billed charges",""
"RADIUS PLATE 53MM SHORT 10 HOLE VARIAX TITANIUM LOCKING STANDARD","SUP-ITM-10028299","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5950.51","3570.31","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3735.73","62.78","","780.86","208.94","10480.28","15","692.04","4605.69","percent of total billed charges",""
"RADIUS PLATE 53MM SHORT 10 HOLE VARIAX TITANIUM LOCKING STANDARD","SUP-ITM-10028299","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5950.51","3570.31","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2601.56","43.72","","179.76","179.76","179.76","1 through 10","692.04","4605.69","percent of total billed charges",""
"RADIUS PLATE 53MM SHORT 10 HOLE VARIAX TITANIUM LOCKING STANDARD","SUP-ITM-10028299","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5950.51","3570.31","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4327.21","72.72","","2355.45","298.99","3965.19","155","692.04","4605.69","percent of total billed charges",""
"RADIUS PLATE 53MM SHORT 10 HOLE VARIAX TITANIUM LOCKING STANDARD","SUP-ITM-10028299","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5950.51","3570.31","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4327.21","72.72","","3643.09","3643.09","3643.09","1 through 10","692.04","4605.69","percent of total billed charges",""
"RADIUS PLATE 53MM SHORT 10 HOLE VARIAX TITANIUM LOCKING STANDARD","SUP-ITM-10028299","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5950.51","3570.31","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3166.86","53.22","","554.28","554.28","554.28","16","692.04","4605.69","percent of total billed charges",""
"RADIUS PLATE 53MM SHORT 10 HOLE VARIAX TITANIUM LOCKING STANDARD","SUP-ITM-10028299","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5950.51","3570.31","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3742.87","62.9","","619.64","173.09","2370.64","150","692.04","4605.69","percent of total billed charges",""
"RADIUS PLATE 53MM SHORT 10 HOLE VARIAX TITANIUM LOCKING STANDARD","SUP-ITM-10028299","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5950.51","3570.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4605.69","77.4","","303.98","303.98","5854.79","1 through 10","692.04","4605.69","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","both","","","5244.35","3146.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","609.92","4457.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","both","","","5244.35","3146.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","609.92","4457.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","both","","","5244.35","3146.61","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2984.04","56.9","","812.12","238.65","1587.46","163","609.92","4457.7","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","both","","","5244.35","3146.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","609.92","11.63","","112.68","112.68","146.99","38","609.92","4457.7","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","both","","","5244.35","3146.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4059.13","77.4","","303.98","303.98","5854.79","1 through 10","609.92","4457.7","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5244.35","3146.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","609.92","11.63","","112.68","112.68","146.99","38","609.92","4059.13","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5244.35","3146.61","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3292.40","62.78","","780.86","208.94","10480.28","15","609.92","4059.13","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5244.35","3146.61","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2292.83","43.72","","179.76","179.76","179.76","1 through 10","609.92","4059.13","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5244.35","3146.61","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3813.69","72.72","","2355.45","298.99","3965.19","155","609.92","4059.13","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5244.35","3146.61","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3813.69","72.72","","3643.09","3643.09","3643.09","1 through 10","609.92","4059.13","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5244.35","3146.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2791.04","53.22","","554.28","554.28","554.28","16","609.92","4059.13","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5244.35","3146.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3298.70","62.9","","619.64","173.09","2370.64","150","609.92","4059.13","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5244.35","3146.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4059.13","77.4","","303.98","303.98","5854.79","1 through 10","609.92","4059.13","percent of total billed charges",""
"RADIUS PLATE 60MMX1.5CM XLONG VARIAX NARROW","SUP-ITM-10143627","CDM","C1713","HCPCS","0278","RC","","","","both","","","6365.92","3819.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","740.36","5411.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 60MMX1.5CM XLONG VARIAX NARROW","SUP-ITM-10143627","CDM","C1713","HCPCS","0278","RC","","","","both","","","6365.92","3819.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","740.36","5411.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RADIUS PLATE 60MMX1.5CM XLONG VARIAX NARROW","SUP-ITM-10143627","CDM","C1713","HCPCS","0278","RC","","","","both","","","6365.92","3819.55","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3622.21","56.9","","812.12","238.65","1587.46","163","740.36","5411.03","percent of total billed charges",""
"RADIUS PLATE 60MMX1.5CM XLONG VARIAX NARROW","SUP-ITM-10143627","CDM","C1713","HCPCS","0278","RC","","","","both","","","6365.92","3819.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","740.36","11.63","","112.68","112.68","146.99","38","740.36","5411.03","percent of total billed charges",""
"RADIUS PLATE 60MMX1.5CM XLONG VARIAX NARROW","SUP-ITM-10143627","CDM","C1713","HCPCS","0278","RC","","","","both","","","6365.92","3819.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4927.22","77.4","","303.98","303.98","5854.79","1 through 10","740.36","5411.03","percent of total billed charges",""
"RADIUS PLATE 60MMX1.5CM XLONG VARIAX NARROW","SUP-ITM-10143627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6365.92","3819.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","740.36","11.63","","112.68","112.68","146.99","38","740.36","4927.22","percent of total billed charges",""
"RADIUS PLATE 60MMX1.5CM XLONG VARIAX NARROW","SUP-ITM-10143627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6365.92","3819.55","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3996.52","62.78","","780.86","208.94","10480.28","15","740.36","4927.22","percent of total billed charges",""
"RADIUS PLATE 60MMX1.5CM XLONG VARIAX NARROW","SUP-ITM-10143627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6365.92","3819.55","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2783.18","43.72","","179.76","179.76","179.76","1 through 10","740.36","4927.22","percent of total billed charges",""
"RADIUS PLATE 60MMX1.5CM XLONG VARIAX NARROW","SUP-ITM-10143627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6365.92","3819.55","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4629.30","72.72","","2355.45","298.99","3965.19","155","740.36","4927.22","percent of total billed charges",""
"RADIUS PLATE 60MMX1.5CM XLONG VARIAX NARROW","SUP-ITM-10143627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6365.92","3819.55","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4629.30","72.72","","3643.09","3643.09","3643.09","1 through 10","740.36","4927.22","percent of total billed charges",""
"RADIUS PLATE 60MMX1.5CM XLONG VARIAX NARROW","SUP-ITM-10143627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6365.92","3819.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3387.94","53.22","","554.28","554.28","554.28","16","740.36","4927.22","percent of total billed charges",""
"RADIUS PLATE 60MMX1.5CM XLONG VARIAX NARROW","SUP-ITM-10143627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6365.92","3819.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4004.16","62.9","","619.64","173.09","2370.64","150","740.36","4927.22","percent of total billed charges",""
"RADIUS PLATE 60MMX1.5CM XLONG VARIAX NARROW","SUP-ITM-10143627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6365.92","3819.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4927.22","77.4","","303.98","303.98","5854.79","1 through 10","740.36","4927.22","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","both","","","71.00","42.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","49.56","69.8","","48.16","5.95","48.16","156","3.39","60.35","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","outpatient","","","71.00","42.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","31.04","43.72","","452.50","452.50","452.50","1 through 10","4.86","54.95","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","outpatient","","","71.00","42.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","51.63","72.72","","50.18","50.18","150.54","97","4.86","54.95","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","outpatient","","","71.00","42.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","37.79","53.22","","36.78","36.78","36.78","29","4.86","54.95","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","outpatient","","","71.00","42.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","44.66","62.9","","43.47","43.47","43.47","235","4.86","54.95","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","outpatient","","","71.00","42.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","54.95","77.4","","53.48","49.60","53.48","109","4.86","54.95","percent of total billed charges",""
"RBC Antibody Elution","PX-30000068","CDM","86860","CPT","0302","RC","","","","both","","","377.00","226.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","924.85","","Case rate ($924.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28.46","28.46","28.46","1 through 10","139.98","1144.2","other","OPPS APC"
"RBC Antibody Elution","PX-30000068","CDM","86860","CPT","0302","RC","","","","outpatient","","","377.00","226.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","237.13","62.9","","229.95","229.95","229.95","1 through 10","11.27","291.8","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","377.00","226.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","263.15","69.8","","254.77","229.59","254.77","1 through 10","191.15","2401.82","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","377.00","226.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1034.22","","Case rate ($1,034.22). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.86","38.86","38.86","1 through 10","191.15","2401.82","other","OPPS APC"
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","377.00","226.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","368.30","","APC Price ($375.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","32.91","24.47","32.91","12","191.15","2401.82","other","OPPS APC"
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","377.00","226.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1941.37","","Case rate ($1,941.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.86","18.29","38.86","16","191.15","2401.82","other","OPPS APC"
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","377.00","226.20","MEDICARE [2001]","HB WDH MEDICARE","375.82","","APC Price ($375.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","375.86","375.86","375.86","1 through 10","191.15","2401.82","other","OPPS APC"
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","377.00","226.20","TRICARE [160005]","HB WDH MEDICARE","375.82","","APC Price ($375.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","375.86","375.86","375.86","1 through 10","191.15","2401.82","other","OPPS APC"
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","377.00","226.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","375.82","","APC Price ($375.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","375.86","343.23","375.86","44","191.15","2401.82","other","OPPS APC"
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","outpatient","","","377.00","226.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","274.15","72.72","","265.43","265.43","1327.14","1 through 10","26.89","291.8","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","outpatient","","","377.00","226.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","237.13","62.9","","229.95","229.95","229.95","1 through 10","26.89","291.8","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","outpatient","","","377.00","226.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","291.80","77.4","","282.88","282.88","282.88","1 through 10","26.89","291.8","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0300","RC","","","","inpatient","","","131.00","78.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","100.69","76.86","","80.01","80.01","80.01","1 through 10","86.72","100.69","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","131.00","78.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","91.44","69.8","","88.65","79.88","88.65","102","40.65","356.75","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","131.00","78.60","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","56.94","","APC Price ($55.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","52.80","52.80","52.80","1 through 10","40.65","356.75","other","OPPS APC"
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","131.00","78.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","356.75","","Case rate ($356.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6.35","6.35","6.35","117","40.65","356.75","other","OPPS APC"
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","131.00","78.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","153.62","","Case rate ($153.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6.35","6.35","6.35","242","40.65","356.75","other","OPPS APC"
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","131.00","78.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","54.71","","APC Price ($55.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","9.77","9.57","13.29","96","40.65","356.75","other","OPPS APC"
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","131.00","78.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","288.36","","Case rate ($288.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6.35","6.35","6.35","264","40.65","356.75","other","OPPS APC"
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","131.00","78.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","91.44","69.8","","88.65","88.65","88.65","1 through 10","40.65","356.75","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","131.00","78.60","MEDICARE [2001]","HB WDH MEDICARE","55.82","","APC Price ($55.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","55.83","55.83","55.83","1 through 10","40.65","356.75","other","OPPS APC"
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","131.00","78.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","111.35","85","","88.65","88.65","88.65","1 through 10","40.65","356.75","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","131.00","78.60","TRICARE [160005]","HB WDH MEDICARE","55.82","","APC Price ($55.82). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","134.69","13.69","134.69","1 through 10","40.65","356.75","other","OPPS APC"
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","131.00","78.60","WELLPOINT [1015]","HB WDH ANTHEM PPO","288.36","","Case rate ($288.36). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","63.50","63.50","63.50","1 through 10","40.65","356.75","other","OPPS APC"
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","outpatient","","","131.00","78.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","82.24","62.78","","79.73","79.73","239.19","1 through 10","11.27","101.39","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","outpatient","","","131.00","78.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","57.27","43.72","","55.52","55.52","111.04","13","11.27","101.39","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","outpatient","","","131.00","78.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","95.26","72.72","","92.35","92.35","92.35","128","11.27","101.39","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","outpatient","","","131.00","78.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","95.26","72.72","","92.35","92.35","92.35","1 through 10","11.27","101.39","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","outpatient","","","131.00","78.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","69.72","53.22","","67.70","67.70","67.70","1 through 10","11.27","101.39","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","outpatient","","","131.00","78.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","82.40","62.9","","80.01","80.01","80.01","149","11.27","101.39","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","outpatient","","","131.00","78.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","101.39","77.4","","98.43","98.43","98.43","71","11.27","101.39","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","outpatient","","","131.00","78.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","95.26","72.72","","92.35","92.35","92.35","1 through 10","11.27","101.39","percent of total billed charges",""
"RBC Pretreatment Chemical","PX-30000098","CDM","86970","CPT","0300","RC","","","","both","","","434.00","260.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","60.82","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2536.32","22.32","2536.32","13","60.82","396.58","other","OPPS APC"
"RBC Pretreatment Chemical","PX-30000098","CDM","86970","CPT","0300","RC","","","","outpatient","","","434.00","260.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","315.60","72.72","","609.39","609.39","609.39","1 through 10","189.74","335.92","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.80","331.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","64.29","469.88","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.80","331.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","64.29","469.88","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.80","331.68","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","314.54","56.9","","812.12","238.65","1587.46","163","64.29","469.88","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.80","331.68","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","64.29","11.63","","112.68","112.68","146.99","38","64.29","469.88","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.80","331.68","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","427.87","77.4","","303.98","303.98","5854.79","1 through 10","64.29","469.88","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","552.80","331.68","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","64.29","11.63","","112.68","112.68","146.99","38","64.29","427.87","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","552.80","331.68","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","347.05","62.78","","780.86","208.94","10480.28","15","64.29","427.87","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","552.80","331.68","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","241.68","43.72","","179.76","179.76","179.76","1 through 10","64.29","427.87","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","552.80","331.68","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","402.00","72.72","","2355.45","298.99","3965.19","155","64.29","427.87","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","552.80","331.68","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","402.00","72.72","","3643.09","3643.09","3643.09","1 through 10","64.29","427.87","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","552.80","331.68","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","294.20","53.22","","554.28","554.28","554.28","16","64.29","427.87","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","552.80","331.68","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","347.71","62.9","","619.64","173.09","2370.64","150","64.29","427.87","percent of total billed charges",""
"REAMER CANN PILOT REMOVABLE FOR AEQUALIS REVERSED II NON IMPLANTED 02","SUP-ITM-10094727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","552.80","331.68","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","427.87","77.4","","303.98","303.98","5854.79","1 through 10","64.29","427.87","percent of total billed charges",""
"Red Blood Cell Disorders With McC","811","MS-DRG","","","","","","","","inpatient","","","42435.44","25461.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","10898.54","","Case rate ($11,120.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,298.79, add-ons for qualifying new technology services are included. If operating cost exceeds $14,216.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,585.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,895.95 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,853.92 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $780.15. The transfer capital threshold is the transfer adjustment factor * $780.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10866.51","10866.51","10866.51","1 through 10","3975","53363.54","other","Inpatient DRG"
"Red Blood Cell Disorders With McC","811","MS-DRG","","","","","","","","inpatient","","","42435.44","25461.26","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","11454.59","","Case rate ($11,120.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,298.79, add-ons for qualifying new technology services are included. If operating cost exceeds $14,216.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,585.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,895.95 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,853.92 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $780.15. The transfer capital threshold is the transfer adjustment factor * $780.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","10640.52","10640.52","10647.02","1 through 10","3975","53363.54","other","Inpatient DRG"
"Red Blood Cell Disorders With McC","811","MS-DRG","","","","","","","","inpatient","","","42435.44","25461.26","MARTIN'S POINT [160007]","HB WDH MEDICARE","11120.96","","Case rate ($11,120.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,298.79, add-ons for qualifying new technology services are included. If operating cost exceeds $14,216.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,585.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,895.95 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,853.92 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $780.15. The transfer capital threshold is the transfer adjustment factor * $780.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13206.29","13206.29","13206.29","1 through 10","3975","53363.54","other","Inpatient DRG"
"Red Blood Cell Disorders With McC","811","MS-DRG","","","","","","","","inpatient","","","42435.44","25461.26","MEDICARE [2001]","HB WDH MEDICARE","11120.96","","Case rate ($11,120.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,298.79, add-ons for qualifying new technology services are included. If operating cost exceeds $14,216.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,585.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,895.95 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,853.92 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $780.15. The transfer capital threshold is the transfer adjustment factor * $780.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11060.62","11060.62","11089.02","19","3975","53363.54","other","Inpatient DRG"
"Red Blood Cell Disorders With McC","811","MS-DRG","","","","","","","","inpatient","","","42435.44","25461.26","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","11120.96","","Case rate ($11,120.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,298.79, add-ons for qualifying new technology services are included. If operating cost exceeds $14,216.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,585.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,895.95 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,853.92 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $780.15. The transfer capital threshold is the transfer adjustment factor * $780.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10906.02","10839.41","11088.28","1 through 10","3975","53363.54","other","Inpatient DRG"
"Red Blood Cell Disorders Without McC","812","MS-DRG","","","","","","","","inpatient","","","29493.76","17696.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","27789.58","","Fee schedule rate ($27,789.58). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","13472.42","13472.42","13472.42","1 through 10","3975","34891.69","case rate",""
"Red Blood Cell Disorders Without McC","812","MS-DRG","","","","","","","","inpatient","","","29493.76","17696.26","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","7648.19","","Case rate ($7,425.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,887.85, add-ons for qualifying new technology services are included. If operating cost exceeds $10,806.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,315.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,470.46 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,442.98 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.10. The transfer capital threshold is the transfer adjustment factor * $510.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","25315.88","25315.88","25315.88","1 through 10","3975","34891.69","other","Inpatient DRG"
"Red Blood Cell Disorders Without McC","812","MS-DRG","","","","","","","","inpatient","","","29493.76","17696.26","MEDICARE [2001]","HB WDH MEDICARE","7425.43","","Case rate ($7,425.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,887.85, add-ons for qualifying new technology services are included. If operating cost exceeds $10,806.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,315.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,470.46 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,442.98 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.10. The transfer capital threshold is the transfer adjustment factor * $510.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7408.58","0.05","7426.73","1 through 10","3975","34891.69","other","Inpatient DRG"
"Red Blood Cell Disorders Without McC","812","MS-DRG","","","","","","","","inpatient","","","29493.76","17696.26","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7425.43","","Case rate ($7,425.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,887.85, add-ons for qualifying new technology services are included. If operating cost exceeds $10,806.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,315.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,470.46 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,442.98 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.10. The transfer capital threshold is the transfer adjustment factor * $510.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7426.73","7283.51","7427.21","1 through 10","3975","34891.69","other","Inpatient DRG"
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","both","","","1169.00","701.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1215.23","","Case rate ($1,215.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1185.59","1128.00","1185.60","17","178.36","1215.23","other","OPPS APC"
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","both","","","1169.00","701.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","523.28","","Case rate ($523.28). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","510.52","510.52","510.52","11","178.36","1215.23","other","OPPS APC"
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","both","","","1169.00","701.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","178.36","","APC Price ($182). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.00","178.36","182.00","26","178.36","1215.23","other","OPPS APC"
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","both","","","1169.00","701.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","982.26","","Case rate ($982.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","958.30","510.52","971.54","1 through 10","178.36","1215.23","other","OPPS APC"
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","both","","","1169.00","701.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","665.16","56.9","","641.83","641.83","641.83","17","178.36","1215.23","percent of total billed charges",""
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","both","","","1169.00","701.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","187.46","","APC Price ($182). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","183.71","182.52","185.71","15","178.36","1215.23","other","OPPS APC"
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","both","","","1169.00","701.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","182.00","","APC Price ($182). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","178.36","178.36","182.00","26","178.36","1215.23","other","OPPS APC"
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","both","","","1169.00","701.40","MEDICARE [2001]","HB WDH MEDICARE","182.00","","APC Price ($182). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.00","182.00","182.00","155","178.36","1215.23","other","OPPS APC"
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","both","","","1169.00","701.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","182.00","","APC Price ($182). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.00","177.93","182.00","108","178.36","1215.23","other","OPPS APC"
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","outpatient","","","1169.00","701.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","168.57","14.42","","162.66","139.42","162.66","15","135.95","904.81","percent of total billed charges",""
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","outpatient","","","1169.00","701.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","135.95","11.63","","155.33","133.23","399.69","28","135.95","904.81","percent of total billed charges",""
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","outpatient","","","1169.00","701.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","511.09","43.72","","493.16","493.16","986.32","1 through 10","135.95","904.81","percent of total billed charges",""
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","outpatient","","","1169.00","701.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","850.10","72.72","","820.28","820.28","820.28","1 through 10","135.95","904.81","percent of total billed charges",""
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","outpatient","","","1169.00","701.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","735.30","62.9","","710.64","710.64","710.64","1 through 10","135.95","904.81","percent of total billed charges",""
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","outpatient","","","1169.00","701.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","904.81","77.4","","874.20","874.20","874.20","1 through 10","135.95","904.81","percent of total billed charges",""
"Red Cells L/R Ea","PX-39000004","CDM","P9016","HCPCS","0390","RC","","","","outpatient","","","1169.00","701.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","135.95","11.63","","133.23","133.23","399.69","11","135.95","904.81","percent of total billed charges",""
"Rem Interrog Icpms <30 D Phys/Qhp","PX-48000523","CDM","93297","CPT","0480","RC","","","","both","","","336.00","201.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","40.13","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","40.13","39.49","40.13","1 through 10","38.18","285.6","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","721.00","432.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","503.26","69.8","","485.81","485.81","485.81","20","38.18","612.85","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","721.00","432.60","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","39.74","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","38.96","38.96","38.96","27","38.18","612.85","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","721.00","432.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","248.99","","Case rate ($248.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","242.92","238.85","242.92","55","38.18","612.85","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","721.00","432.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","107.21","","Case rate ($107.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.60","102.85","104.60","105","38.18","612.85","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","721.00","432.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","38.18","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","38.41","36.74","38.96","76","38.18","612.85","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","721.00","432.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","201.25","","Case rate ($201.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","196.34","193.06","196.34","17","38.18","612.85","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","721.00","432.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","410.25","56.9","","396.02","396.02","396.02","39","38.18","612.85","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","721.00","432.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","40.13","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","40.13","39.49","40.13","24","38.18","612.85","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","721.00","432.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.18","36.74","38.96","119","38.18","612.85","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","721.00","432.60","MEDICARE [2001]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.96","38.96","38.96","450","38.18","612.85","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","721.00","432.60","TRICARE [160005]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.96","38.96","38.96","1 through 10","38.18","612.85","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","721.00","432.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","38.69","36.74","38.96","113","38.18","612.85","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","both","","","721.00","432.60","WELLSENSE NH [1050]","HB WDH MEDICARE","38.96","","APC Price ($38.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","40.09","40.09","40.09","1 through 10","38.18","612.85","other","OPPS APC"
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","outpatient","","","721.00","432.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","103.97","14.42","","100.36","86.03","100.36","1 through 10","83.85","558.05","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","outpatient","","","721.00","432.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","83.85","11.63","","95.84","82.21","175.77","18","83.85","558.05","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","outpatient","","","721.00","432.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","524.31","72.72","","506.13","506.13","506.13","1 through 10","83.85","558.05","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","outpatient","","","721.00","432.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","453.51","62.9","","438.48","438.48","438.48","27","83.85","558.05","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","outpatient","","","721.00","432.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","558.05","77.4","","539.40","539.40","539.40","1 through 10","83.85","558.05","percent of total billed charges",""
"Rem Interrog Scrms <30 D Phys/Qhp","PX-48000524","CDM","93298","CPT","0480","RC","","","","outpatient","","","721.00","432.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","83.85","11.63","","82.21","82.21","82.21","1 through 10","83.85","558.05","percent of total billed charges",""
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","6546.00","3927.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","4466.30","","Case rate ($4,466.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4357.42","4357.42","4357.42","1 through 10","1590.51","10372.29","other","OPPS APC"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","6546.00","3927.60","MEDICARE [2001]","HB WDH MEDICARE","1622.97","","APC Price ($1,622.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1623.16","1623.16","1623.16","1 through 10","1590.51","10372.29","other","OPPS APC"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","6546.00","3927.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1622.97","","APC Price ($1,622.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1623.16","1623.16","1623.16","1 through 10","1590.51","10372.29","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","4724.00","2834.40","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","658.85","","APC Price ($645.93). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","646.01","646.01","646.01","1 through 10","633.01","4128.13","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","4724.00","2834.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","4128.13","","Case rate ($4,128.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4027.45","3978.77","4027.45","1 through 10","633.01","4128.13","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","4724.00","2834.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1777.57","","Case rate ($1,777.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1734.23","1734.23","1734.23","1 through 10","633.01","4128.13","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","4724.00","2834.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","633.01","","APC Price ($645.93). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","646.01","646.01","646.01","1 through 10","633.01","4128.13","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","4724.00","2834.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2687.96","56.9","","2594.07","2594.07","2594.07","1 through 10","633.01","4128.13","percent of total billed charges",""
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","4724.00","2834.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","665.31","","APC Price ($645.93). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","663.08","652.08","663.08","1 through 10","633.01","4128.13","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","4724.00","2834.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","645.93","","APC Price ($645.93). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","633.09","633.09","633.09","1 through 10","633.01","4128.13","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","4724.00","2834.40","MEDICARE [2001]","HB WDH MEDICARE","645.93","","APC Price ($645.93). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","646.01","612.09","646.01","13","633.01","4128.13","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","4724.00","2834.40","TRICARE [160005]","HB WDH MEDICARE","645.93","","APC Price ($645.93). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","646.01","646.01","646.01","1 through 10","633.01","4128.13","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","4724.00","2834.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","645.93","","APC Price ($645.93). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","646.01","636.09","646.01","1 through 10","633.01","4128.13","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","outpatient","","","4724.00","2834.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","549.40","11.63","","627.77","627.77","627.77","1 through 10","549.4","3656.38","percent of total billed charges",""
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","outpatient","","","4724.00","2834.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","1993.19","1993.19","1993.19","1 through 10","549.4","3656.38","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Rem Tun Intraperitoneal Cath","PX-75000292","CDM","49422","CPT","0361","RC","","","","both","","","2719.00","1631.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","9049.37","","Case rate ($9,049.37). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8693.07","8693.07","8693.07","1 through 10","1547.11","21015.78","other","OPPS APC"
"Rem Tun Intraperitoneal Cath","PX-75000292","CDM","49422","CPT","0361","RC","","","","both","","","2719.00","1631.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1547.11","56.9","","5115.60","5115.60","5115.60","1 through 10","1547.11","21015.78","percent of total billed charges",""
"Rem Tun Intraperitoneal Cath","PX-75000292","CDM","49422","CPT","0361","RC","","","","both","","","2719.00","1631.40","MEDICARE [2001]","HB WDH MEDICARE","3288.38","","APC Price ($3,288.38). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6211.42","3105.71","6211.42","1 through 10","1547.11","21015.78","other","OPPS APC"
"REMOTE SLEEP BLUETOOTH PATIENT HANDHELD INSPIRE IPG COMPATIBLE","SUP-ITM-10306192","CDM","C1787","HCPCS","0270","RC","","","","both","","","6790.00","4074.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","4739.42","69.8","","1412.58","1412.58","1412.58","1 through 10","789.68","5771.5","percent of total billed charges",""
"REMOTE SLEEP BLUETOOTH PATIENT HANDHELD INSPIRE IPG COMPATIBLE","SUP-ITM-10306192","CDM","C1787","HCPCS","0270","RC","","","","both","","","6790.00","4074.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","18158.40","2245.75","18158.40","1 through 10","789.68","5771.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"REMOTE SLEEP BLUETOOTH PATIENT HANDHELD INSPIRE IPG COMPATIBLE","SUP-ITM-10306192","CDM","C1787","HCPCS","0270","RC","","","","both","","","6790.00","4074.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3863.51","56.9","","15498.18","15498.18","15498.18","1 through 10","789.68","5771.5","percent of total billed charges",""
"REMOTE SLEEP BLUETOOTH PATIENT HANDHELD INSPIRE IPG COMPATIBLE","SUP-ITM-10306192","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","6790.00","4074.00","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","4937.69","72.72","","4236.03","4236.03","4236.03","1 through 10","789.68","5255.46","percent of total billed charges",""
"Removal Impacted Cerumen Irrigation/Lvg Unilat","PX-76002197","CDM","69209","CPT","0761","RC","","","","both","","","138.00","82.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","96.32","69.8","","101.56","67.71","101.56","11","15.02","396.58","percent of total billed charges",""
"Removal Impacted Cerumen Irrigation/Lvg Unilat","PX-76002197","CDM","69209","CPT","0761","RC","","","","both","","","138.00","82.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","78.52","56.9","","97.00","94.59","97.00","17","15.02","396.58","percent of total billed charges",""
"Removal Impacted Cerumen Irrigation/Lvg Unilat","PX-76002197","CDM","69209","CPT","0761","RC","","","","outpatient","","","138.00","82.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","86.80","62.9","","183.33","61.11","183.33","12","16.05","106.81","percent of total billed charges",""
"Removal Impacted Cerumen Irrigation/Lvg Unilat","PX-76002197","CDM","69209","CPT","0761","RC","","","","outpatient","","","138.00","82.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","106.81","77.4","","75.18","75.18","150.35","1 through 10","16.05","106.81","percent of total billed charges",""
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","both","","","4135.00","2481.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","735.08","","APC Price ($735.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","727.97","727.47","728.37","1 through 10","720.38","4697.85","other","OPPS APC"
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","both","","","4135.00","2481.00","MEDICARE [2001]","HB WDH MEDICARE","735.08","","APC Price ($735.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","735.17","685.52","735.17","1 through 10","720.38","4697.85","other","OPPS APC"
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","both","","","4135.00","2481.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","735.08","","APC Price ($735.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","735.17","728.37","735.17","1 through 10","720.38","4697.85","other","OPPS APC"
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","outpatient","","","4135.00","2481.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3200.49","77.4","","3092.25","3092.25","3092.25","1 through 10","2200.65","3200.49","percent of total billed charges",""
"Remove Cerumen Impacted Unilate","PX-76001668","CDM","69210","CPT","0761","RC","","","","both","","","344.00","206.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","195.74","56.9","","445.63","445.63","445.63","1 through 10","34.99","396.58","percent of total billed charges",""
"Remove Cerumen Impacted Unilate","PX-76001668","CDM","69210","CPT","0761","RC","","","","outpatient","","","344.00","206.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","49.60","14.42","","56.11","56.11","56.11","1 through 10","40.01","266.26","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","both","","","1809.00","1085.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","1262.68","69.8","","5655.02","5655.02","5655.02","1 through 10","311.45","2031.08","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","both","","","1809.00","1085.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","311.45","","APC Price ($317.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","312.57","312.57","312.57","1 through 10","311.45","2031.08","other","OPPS APC"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","both","","","1809.00","1085.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1641.70","","Case rate ($1,641.70). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4544.33","4544.33","4544.33","1 through 10","311.45","2031.08","other","OPPS APC"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","both","","","1809.00","1085.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1029.32","56.9","","2595.92","2595.92","2595.92","1 through 10","311.45","2031.08","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","both","","","1809.00","1085.40","TRICARE [160005]","HB WDH MEDICARE","317.81","","APC Price ($317.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","317.84","317.84","317.84","1 through 10","311.45","2031.08","other","OPPS APC"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","1809.00","1085.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","260.86","14.42","","864.29","864.29","864.29","1 through 10","210.39","1400.17","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","1809.00","1085.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","210.39","11.63","","1338.72","308.28","1338.72","1 through 10","210.39","1400.17","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","1809.00","1085.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","42356.85","2747.36","42356.85","1 through 10","210.39","1400.17","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","1809.00","1085.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","2673.91","2673.91","2673.91","1 through 10","210.39","1400.17","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","1809.00","1085.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1137.86","62.9","","3046.26","1586.76","4639.95","1 through 10","210.39","1400.17","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","1809.00","1085.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1400.17","77.4","","5621.08","5621.08","5621.08","1 through 10","210.39","1400.17","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","1809.00","1085.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","210.39","11.63","","1701.23","718.50","1802.49","1 through 10","210.39","1400.17","percent of total billed charges",""
"Remove FB Conjuctival Superficial","PX-76001601","CDM","65205","CPT","0761","RC","","","","outpatient","","","370.00","222.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","232.73","62.9","","153.72","153.72","153.72","1 through 10","43.03","286.38","percent of total billed charges",""
"Remove FB Corneal W/O Slit Lamp","PX-76001603","CDM","65220","CPT","0761","RC","","","","both","","","430.00","258.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","244.67","56.9","","246.99","246.99","246.99","1 through 10","43.49","2664.39","percent of total billed charges",""
"Remove FB Corneal W/Slit Lamp","PX-76001604","CDM","65222","CPT","0761","RC","","","","both","","","535.00","321.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","131.98","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.46","124.46","124.46","1 through 10","131.98","860.68","other","OPPS APC"
"Remove FB Muscle/Tendon Smp","PX-76000283","CDM","20520","CPT","0761","RC","","","","both","","","8687.00","5212.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4942.90","56.9","","6276.64","6276.64","6276.64","1 through 10","4942.9","7383.95","percent of total billed charges",""
"Remove FB Nasal","PX-76000747","CDM","30300","CPT","0761","RC","","","","outpatient","","","1145.00","687.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","720.21","62.9","","473.13","473.13","473.13","1 through 10","133.16","886.23","percent of total billed charges",""
"Remove Suture Cerclage Under Anes","PX-72000038","CDM","59871","CPT","0361","RC","","","","outpatient","","","3411.00","2046.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","396.70","11.63","","1372.23","453.31","1372.23","1 through 10","396.7","2640.11","percent of total billed charges",""
"Remove Tag Skin <15","PX-76000033","CDM","11200","CPT","0761","RC","","","","both","","","715.00","429.00","MEDICARE [2001]","HB WDH MEDICARE","207.59","","APC Price ($207.59). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.62","207.62","207.62","1 through 10","77.54","1326.74","other","OPPS APC"
"Remove Tag Skin <15","PX-76000033","CDM","11200","CPT","0761","RC","","","","outpatient","","","715.00","429.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","83.15","11.63","","1955.75","1955.75","1955.75","1 through 10","83.15","553.41","percent of total billed charges",""
"Remove/Rplc Perm Pm Gen Dual Sys","PX-48000063","CDM","33228","CPT","0361","RC","","","","both","","","48720.00","29232.00","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","11152.43","","APC Price ($10,933.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","10935.01","10935.01","10935.01","1 through 10","10715.08","69876.83","other","OPPS APC"
"Remove/Rplc Perm Pm Gen Dual Sys","PX-48000063","CDM","33228","CPT","0361","RC","","","","both","","","48720.00","29232.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","10715.08","","APC Price ($10,933.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","10716.31","10716.31","10716.31","1 through 10","10715.08","69876.83","other","OPPS APC"
"Remove/Rplc Perm Pm Gen Dual Sys","PX-48000063","CDM","33228","CPT","0361","RC","","","","both","","","48720.00","29232.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","11261.77","","APC Price ($10,933.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","10509.10","10509.10","10509.10","1 through 10","10715.08","69876.83","other","OPPS APC"
"Remove/Rplc Perm Pm Gen Dual Sys","PX-48000063","CDM","33228","CPT","0361","RC","","","","both","","","48720.00","29232.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","10933.76","","APC Price ($10,933.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","10724.21","10723.81","19534.03","1 through 10","10715.08","69876.83","other","OPPS APC"
"Remove/Rplc Perm Pm Gen Dual Sys","PX-48000063","CDM","33228","CPT","0361","RC","","","","both","","","48720.00","29232.00","MEDICARE [2001]","HB WDH MEDICARE","10933.76","","APC Price ($10,933.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","10935.01","10935.01","32805.03","16","10715.08","69876.83","other","OPPS APC"
"Remove/Rplc Perm Pm Gen Dual Sys","PX-48000063","CDM","33228","CPT","0361","RC","","","","both","","","48720.00","29232.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","10933.76","","APC Price ($10,933.76). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","10760.05","10725.31","10935.01","1 through 10","10715.08","69876.83","other","OPPS APC"
"Remove/Rplc Perm Pm Gen Dual Sys","PX-48000063","CDM","33228","CPT","0361","RC","","","","outpatient","","","48720.00","29232.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","5666.14","11.63","","5552.99","5552.99","5552.99","1 through 10","5666.14","37709.28","percent of total billed charges",""
"Remove/Rplc Perm Pm Gen Mlt Sys","PX-48000064","CDM","33229","CPT","0361","RC","","","","both","","","89870.00","53922.00","MEDICARE [2001]","HB WDH MEDICARE","19924.79","","APC Price ($19,924.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","59781.21","19927.07","59781.21","1 through 10","19526.29","127337.85","other","OPPS APC"
"Remove/Rplc Perm Pm Gen Sgl Sys","PX-48000062","CDM","33227","CPT","0361","RC","","","","both","","","33588.00","20152.80","MEDICARE [2001]","HB WDH MEDICARE","8646.41","","APC Price ($8,646.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8647.41","8647.41","8647.41","1 through 10","8473.48","55258.59","other","OPPS APC"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","26688.53","16013.12","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","7245.14","","Case rate ($7,103.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,590.33, add-ons for qualifying new technology services are included. If operating cost exceeds $10,508.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,291.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,171.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,145.46 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.55. The transfer capital threshold is the transfer adjustment factor * $486.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","7169.50","7169.50","7169.50","1 through 10","3975","33280.49","other","Inpatient DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","26688.53","16013.12","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","6961.02","","Case rate ($7,103.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,590.33, add-ons for qualifying new technology services are included. If operating cost exceeds $10,508.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,291.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,171.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,145.46 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.55. The transfer capital threshold is the transfer adjustment factor * $486.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7059.63","7026.56","7169.50","1 through 10","3975","33280.49","other","Inpatient DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","26688.53","16013.12","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","26506.33","","Fee schedule rate ($26,506.33). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","17539.80","17539.80","17539.80","1 through 10","3975","33280.49","case rate",""
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","26688.53","16013.12","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","7316.17","","Case rate ($7,103.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,590.33, add-ons for qualifying new technology services are included. If operating cost exceeds $10,508.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,291.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,171.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,145.46 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.55. The transfer capital threshold is the transfer adjustment factor * $486.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","6743.93","6743.93","6743.93","1 through 10","3975","33280.49","other","Inpatient DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","26688.53","16013.12","MARTIN'S POINT [160007]","HB WDH MEDICARE","7103.08","","Case rate ($7,103.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,590.33, add-ons for qualifying new technology services are included. If operating cost exceeds $10,508.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,291.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,171.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,145.46 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.55. The transfer capital threshold is the transfer adjustment factor * $486.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7041.91","7041.91","7041.91","1 through 10","3975","33280.49","other","Inpatient DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","26688.53","16013.12","MEDICARE [2001]","HB WDH MEDICARE","7103.08","","Case rate ($7,103.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,590.33, add-ons for qualifying new technology services are included. If operating cost exceeds $10,508.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,291.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,171.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,145.46 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.55. The transfer capital threshold is the transfer adjustment factor * $486.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7152.02","0.05","7169.50","42","3975","33280.49","other","Inpatient DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","26688.53","16013.12","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7103.08","","Case rate ($7,103.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,590.33, add-ons for qualifying new technology services are included. If operating cost exceeds $10,508.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,291.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,171.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,145.46 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.55. The transfer capital threshold is the transfer adjustment factor * $486.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7056.91","7026.11","7169.50","1 through 10","3975","33280.49","other","Inpatient DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","26688.53","16013.12","WELLSENSE NH [1050]","HB WDH MEDICARE","7103.08","","Case rate ($7,103.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,590.33, add-ons for qualifying new technology services are included. If operating cost exceeds $10,508.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,291.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $6,171.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,145.46 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $486.55. The transfer capital threshold is the transfer adjustment factor * $486.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7026.11","7026.11","7026.11","1 through 10","3975","33280.49","other","Inpatient DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","39634.47","23780.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","56278.15","","Fee schedule rate ($56,278.15). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","41473.97","41473.97","41473.97","1 through 10","3975","56278.15","case rate",""
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","39634.47","23780.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","11470.01","","Case rate ($11,704.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,837, add-ons for qualifying new technology services are included. If operating cost exceeds $14,755.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,627.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,436.45 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,392.12 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $822.76. The transfer capital threshold is the transfer adjustment factor * $822.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11541.92","10558.68","11587.61","1 through 10","3975","56278.15","other","Inpatient DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","39634.47","23780.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","44822.88","","Fee schedule rate ($44,822.88). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","29549.58","29549.58","29549.58","1 through 10","3975","56278.15","case rate",""
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","39634.47","23780.68","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","12055.21","","Case rate ($11,704.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,837, add-ons for qualifying new technology services are included. If operating cost exceeds $14,755.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,627.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,436.45 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,392.12 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $822.76. The transfer capital threshold is the transfer adjustment factor * $822.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7464.28","7464.28","7464.28","1 through 10","3975","56278.15","other","Inpatient DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","39634.47","23780.68","MARTIN'S POINT [160007]","HB WDH MEDICARE","11704.09","","Case rate ($11,704.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,837, add-ons for qualifying new technology services are included. If operating cost exceeds $14,755.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,627.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,436.45 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,392.12 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $822.76. The transfer capital threshold is the transfer adjustment factor * $822.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13575.96","13575.96","13575.96","1 through 10","3975","56278.15","other","Inpatient DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","39634.47","23780.68","MEDICARE [2001]","HB WDH MEDICARE","11704.09","","Case rate ($11,704.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,837, add-ons for qualifying new technology services are included. If operating cost exceeds $14,755.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,627.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,436.45 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,392.12 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $822.76. The transfer capital threshold is the transfer adjustment factor * $822.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10747.32","0.05","11806.99","40","3975","56278.15","other","Inpatient DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","39634.47","23780.68","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","11704.09","","Case rate ($11,704.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,837, add-ons for qualifying new technology services are included. If operating cost exceeds $14,755.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,627.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,436.45 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,392.12 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $822.76. The transfer capital threshold is the transfer adjustment factor * $822.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11594.86","2943.93","11806.99","1 through 10","3975","56278.15","other","Inpatient DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","39634.47","23780.68","WELLSENSE NH [1050]","HB WDH MEDICARE","11704.09","","Case rate ($11,704.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,837, add-ons for qualifying new technology services are included. If operating cost exceeds $14,755.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,627.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $10,436.45 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,392.12 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $822.76. The transfer capital threshold is the transfer adjustment factor * $822.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12186.39","12186.39","12186.39","1 through 10","3975","56278.15","other","Inpatient DRG"
"Renal Failure Without Cc/McC","684","MS-DRG","","","","","","","","inpatient","","","18112.67","10867.60","MEDICARE [2001]","HB WDH MEDICARE","5008.62","","Case rate ($5,008.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $4,657.16, add-ons for qualifying new technology services are included. If operating cost exceeds $8,575.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,138.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,230.25 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,212.28 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $333.49. The transfer capital threshold is the transfer adjustment factor * $333.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","0.05","1 through 10","3975","22811.46","other","Inpatient DRG"
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","both","","","123.00","73.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","85.85","69.8","","83.06","74.85","83.06","16","5.64","104.55","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","outpatient","","","123.00","73.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","89.45","72.72","","86.54","86.54","181.80","30","8.09","95.2","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","outpatient","","","123.00","73.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","65.46","53.22","","63.44","63.44","63.44","1 through 10","8.09","95.2","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","outpatient","","","123.00","73.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","77.37","62.9","","74.97","74.97","143.78","27","8.09","95.2","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","outpatient","","","123.00","73.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","95.20","77.4","","92.23","92.23","92.23","15","8.09","95.2","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","outpatient","","","123.00","73.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","89.45","72.72","","86.54","86.54","86.54","1 through 10","8.09","95.2","percent of total billed charges",""
"Renin","PX-30000667","CDM","84244","CPT","0301","RC","","","","both","","","119.00","71.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","83.06","69.8","","72.34","72.34","80.27","1 through 10","14.29","112.86","percent of total billed charges",""
"Renin","PX-30000667","CDM","84244","CPT","0301","RC","","","","outpatient","","","119.00","71.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","86.54","72.72","","83.63","83.63","160.54","1 through 10","20.5","92.11","percent of total billed charges",""
"Renin","PX-30000667","CDM","84244","CPT","0301","RC","","","","outpatient","","","119.00","71.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","63.33","53.22","","61.31","61.31","61.31","1 through 10","20.5","92.11","percent of total billed charges",""
"Renin","PX-30000667","CDM","84244","CPT","0301","RC","","","","outpatient","","","119.00","71.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","74.85","62.9","","72.45","72.45","72.45","1 through 10","20.5","92.11","percent of total billed charges",""
"Renin","PX-30000667","CDM","84244","CPT","0301","RC","","","","outpatient","","","119.00","71.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","92.11","77.4","","89.13","89.13","89.13","1 through 10","20.5","92.11","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","5873.50","3524.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","683.09","4992.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","5873.50","3524.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","683.09","4992.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","5873.50","3524.10","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3342.02","56.9","","812.12","238.65","1587.46","163","683.09","4992.48","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","5873.50","3524.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","683.09","11.63","","112.68","112.68","146.99","38","683.09","4992.48","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","5873.50","3524.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4546.09","77.4","","303.98","303.98","5854.79","1 through 10","683.09","4992.48","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5873.50","3524.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","683.09","11.63","","112.68","112.68","146.99","38","683.09","4546.09","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5873.50","3524.10","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3687.38","62.78","","780.86","208.94","10480.28","15","683.09","4546.09","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5873.50","3524.10","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2567.89","43.72","","179.76","179.76","179.76","1 through 10","683.09","4546.09","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5873.50","3524.10","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4271.21","72.72","","2355.45","298.99","3965.19","155","683.09","4546.09","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5873.50","3524.10","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4271.21","72.72","","3643.09","3643.09","3643.09","1 through 10","683.09","4546.09","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5873.50","3524.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3125.88","53.22","","554.28","554.28","554.28","16","683.09","4546.09","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5873.50","3524.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3694.43","62.9","","619.64","173.09","2370.64","150","683.09","4546.09","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5873.50","3524.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4546.09","77.4","","303.98","303.98","5854.79","1 through 10","683.09","4546.09","percent of total billed charges",""
"Repair Complex 2.6-7.5 Cm - 13132","PX-76000147","CDM","13132","CPT","0761","RC","","","","outpatient","","","3051.00","1830.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","354.83","11.63","","1255.22","1255.22","1255.22","1 through 10","354.83","2361.47","percent of total billed charges",""
"Repl Cath Cv Tnl W/O Port","PX-76001099","CDM","36581","CPT","0361","RC","","","","both","","","12150.00","7290.00","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","3354.15","","APC Price ($3,288.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","3288.76","3288.76","3288.76","1 through 10","3222.61","21015.78","other","OPPS APC"
"Repl Cath Cv Tnl W/O Port","PX-76001099","CDM","36581","CPT","0361","RC","","","","both","","","12150.00","7290.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","3222.61","","APC Price ($3,288.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3288.76","3288.76","3288.76","1 through 10","3222.61","21015.78","other","OPPS APC"
"Repl Cath Cv Tnl W/O Port","PX-76001099","CDM","36581","CPT","0361","RC","","","","both","","","12150.00","7290.00","MEDICARE [2001]","HB WDH MEDICARE","3288.38","","APC Price ($3,288.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3288.76","3288.76","3288.76","1 through 10","3222.61","21015.78","other","OPPS APC"
"Repl Cath Cv Tnl W/O Port","PX-76001099","CDM","36581","CPT","0361","RC","","","","outpatient","","","12150.00","7290.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","5125.73","5125.73","5125.73","1 through 10","1413.05","9404.1","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Replace Picc W/O Imaging","PX-76002574","CDM","37799","CPT","0761","RC","","","","both","","","5677.00","3406.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3230.21","56.9","","6379.42","6379.42","6379.42","1 through 10","633.01","4825.45","percent of total billed charges",""
"Replace Picc W/O Imaging","PX-76002574","CDM","37799","CPT","0761","RC","","","","both","","","5677.00","3406.20","MEDICARE [2001]","HB WDH MEDICARE","645.93","","APC Price ($645.93). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1292.02","646.01","1292.02","1 through 10","633.01","4825.45","other","OPPS APC"
"Reposition Cv Cath W/Fluoro","PX-76001113","CDM","36597","CPT","0361","RC","","","","both","","","4408.00","2644.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","4466.30","","Case rate ($4,466.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8611.42","8611.42","8611.42","1 through 10","1590.51","10372.29","other","OPPS APC"
"Resp Function Group","PX-41000006","CDM","G0239","HCPCS","0410","RC","","","","both","","","76.00","45.60","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","41.83","","APC Price ($41.01). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","41.01","39.07","41.01","43","10.96","262.09","other","OPPS APC"
"Resp Function Group","PX-41000006","CDM","G0239","HCPCS","0410","RC","","","","both","","","76.00","45.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","112.85","","Case rate ($112.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.38","73.00","110.10","1 through 10","10.96","262.09","other","OPPS APC"
"Resp Function Group","PX-41000006","CDM","G0239","HCPCS","0410","RC","","","","both","","","76.00","45.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","43.24","56.9","","73.00","73.00","73.00","12","10.96","262.09","percent of total billed charges",""
"Resp Function Group","PX-41000006","CDM","G0239","HCPCS","0410","RC","","","","both","","","76.00","45.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","42.24","","APC Price ($41.01). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","41.70","41.70","41.70","1 through 10","10.96","262.09","other","OPPS APC"
"Resp Function Group","PX-41000006","CDM","G0239","HCPCS","0410","RC","","","","both","","","76.00","45.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","41.01","","APC Price ($41.01). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","40.19","38.29","40.19","32","10.96","262.09","other","OPPS APC"
"Resp Function Group","PX-41000006","CDM","G0239","HCPCS","0410","RC","","","","both","","","76.00","45.60","MEDICARE [2001]","HB WDH MEDICARE","41.01","","APC Price ($41.01). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","41.01","41.01","41.01","93","10.96","262.09","other","OPPS APC"
"Resp Function Group","PX-41000006","CDM","G0239","HCPCS","0410","RC","","","","both","","","76.00","45.60","TRICARE [160005]","HB WDH MEDICARE","41.01","","APC Price ($41.01). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","41.01","41.01","41.01","1 through 10","10.96","262.09","other","OPPS APC"
"Resp Function Group","PX-41000006","CDM","G0239","HCPCS","0410","RC","","","","both","","","76.00","45.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","41.01","","APC Price ($41.01). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","40.49","38.59","40.49","58","10.96","262.09","other","OPPS APC"
"Resp Function Group","PX-41000006","CDM","G0239","HCPCS","0410","RC","","","","both","","","76.00","45.60","WELLSENSE NH [1050]","HB WDH MEDICARE","41.01","","APC Price ($41.01). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","42.80","42.80","42.80","1 through 10","10.96","262.09","other","OPPS APC"
"Resp Function Group","PX-41000006","CDM","G0239","HCPCS","0410","RC","","","","outpatient","","","76.00","45.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","8.84","11.63","","8.62","8.62","8.62","20","8.84","8.84","percent of total billed charges",""
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","","","","inpatient","","","26138.31","15682.99","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","8022.15","","Case rate ($7,864.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,293.43, add-ons for qualifying new technology services are included. If operating cost exceeds $11,211.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,347.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,877.77 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,848.56 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.21. The transfer capital threshold is the transfer adjustment factor * $542.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","6267.73","6267.73","6267.73","1 through 10","3975","37088.1","other","Inpatient DRG"
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","","","","inpatient","","","26138.31","15682.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","29538.91","","Fee schedule rate ($29,538.91). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","23663.67","23663.67","23663.67","1 through 10","3975","37088.1","case rate",""
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","","","","inpatient","","","26138.31","15682.99","MARTIN'S POINT [160007]","HB WDH MEDICARE","7864.85","","Case rate ($7,864.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,293.43, add-ons for qualifying new technology services are included. If operating cost exceeds $11,211.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,347.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,877.77 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,848.56 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.21. The transfer capital threshold is the transfer adjustment factor * $542.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8898.93","8898.93","8898.93","1 through 10","3975","37088.1","other","Inpatient DRG"
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","","","","inpatient","","","26138.31","15682.99","MEDICARE [2001]","HB WDH MEDICARE","7864.85","","Case rate ($7,864.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,293.43, add-ons for qualifying new technology services are included. If operating cost exceeds $11,211.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,347.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,877.77 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,848.56 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.21. The transfer capital threshold is the transfer adjustment factor * $542.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7481.15","0.05","7930.72","31","3975","37088.1","other","Inpatient DRG"
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","","","","inpatient","","","26138.31","15682.99","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7864.85","","Case rate ($7,864.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,293.43, add-ons for qualifying new technology services are included. If operating cost exceeds $11,211.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,347.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,877.77 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,848.56 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.21. The transfer capital threshold is the transfer adjustment factor * $542.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7788.61","732.62","7950.23","1 through 10","3975","37088.1","other","Inpatient DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","40917.70","24550.62","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","12571.70","","Case rate ($12,325.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,410.28, add-ons for qualifying new technology services are included. If operating cost exceeds $15,328.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,673.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,012.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,965.41 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $868.15. The transfer capital threshold is the transfer adjustment factor * $868.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","12642.18","12642.18","12642.18","1 through 10","3975","59382.76","other","Inpatient DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","40917.70","24550.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","59382.76","","Fee schedule rate ($59,382.76). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","44060.88","44060.88","44060.88","1 through 10","3975","59382.76","case rate",""
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","40917.70","24550.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","12078.70","","Case rate ($12,325.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,410.28, add-ons for qualifying new technology services are included. If operating cost exceeds $15,328.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,673.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,012.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,965.41 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $868.15. The transfer capital threshold is the transfer adjustment factor * $868.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10891.21","6184.94","12422.86","1 through 10","3975","59382.76","other","Inpatient DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","40917.70","24550.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","47295.55","","Fee schedule rate ($47,295.55). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","45707.30","45707.30","45707.30","1 through 10","3975","59382.76","case rate",""
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","40917.70","24550.62","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","12694.96","","Case rate ($12,325.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,410.28, add-ons for qualifying new technology services are included. If operating cost exceeds $15,328.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,673.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,012.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,965.41 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $868.15. The transfer capital threshold is the transfer adjustment factor * $868.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","12225.75","12225.75","37191.48","1 through 10","3975","59382.76","other","Inpatient DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","40917.70","24550.62","MARTIN'S POINT [160007]","HB WDH MEDICARE","12325.20","","Case rate ($12,325.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,410.28, add-ons for qualifying new technology services are included. If operating cost exceeds $15,328.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,673.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,012.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,965.41 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $868.15. The transfer capital threshold is the transfer adjustment factor * $868.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12465.48","12420.48","13127.90","1 through 10","3975","59382.76","other","Inpatient DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","40917.70","24550.62","MEDICARE [2001]","HB WDH MEDICARE","12325.20","","Case rate ($12,325.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,410.28, add-ons for qualifying new technology services are included. If operating cost exceeds $15,328.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,673.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,012.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,965.41 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $868.15. The transfer capital threshold is the transfer adjustment factor * $868.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12642.18","0.05","12673.96","144","3975","59382.76","other","Inpatient DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","40917.70","24550.62","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","12325.20","","Case rate ($12,325.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,410.28, add-ons for qualifying new technology services are included. If operating cost exceeds $15,328.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,673.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $11,012.18 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,965.41 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $868.15. The transfer capital threshold is the transfer adjustment factor * $868.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12428.39","7795.81","12673.96","30","3975","59382.76","other","Inpatient DRG"
"Respiratory Infections And Inflammations Without Cc/McC","179","MS-DRG","","","","","","","","inpatient","","","25792.41","15475.45","MEDICARE [2001]","HB WDH MEDICARE","6184.70","","Case rate ($6,184.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,742.67, add-ons for qualifying new technology services are included. If operating cost exceeds $9,660.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,224.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,320.40 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,297.81 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $419.44. The transfer capital threshold is the transfer adjustment factor * $419.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6252.60","6252.60","6252.60","1 through 10","3975","28690.08","other","Inpatient DRG"
"Respiratory Motion Management Simulation","PX-33000097","CDM","77293","CPT","0333","RC","","","","both","","","5964.00","3578.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","5520.00","5520.00","5520.00","1 through 10","2970.64","5069.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Respiratory Motion Management Simulation","PX-33000097","CDM","77293","CPT","0333","RC","","","","outpatient","","","5964.00","3578.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","860.01","14.42","","829.87","829.87","829.87","1 through 10","693.61","4616.14","percent of total billed charges",""
"Respiratory Motion Management Simulation","PX-33000097","CDM","77293","CPT","0333","RC","","","","outpatient","","","5964.00","3578.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","693.61","11.63","","1453.44","679.76","1453.44","1 through 10","693.61","4616.14","percent of total billed charges",""
"Respiratory Motion Management Simulation","PX-33000097","CDM","77293","CPT","0333","RC","","","","outpatient","","","5964.00","3578.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","693.61","11.63","","679.76","679.76","679.76","1 through 10","693.61","4616.14","percent of total billed charges",""
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","","","","inpatient","","","30005.42","18003.25","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","8844.69","","Case rate ($8,587.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,960.04, add-ons for qualifying new technology services are included. If operating cost exceeds $11,878.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,400.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,547.22 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,515.17 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $594.99. The transfer capital threshold is the transfer adjustment factor * $594.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","8429.82","8429.82","8429.82","1 through 10","3975","40698.11","other","Inpatient DRG"
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","","","","inpatient","","","30005.42","18003.25","MEDICARE [2001]","HB WDH MEDICARE","8587.08","","Case rate ($8,587.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,960.04, add-ons for qualifying new technology services are included. If operating cost exceeds $11,878.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,400.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,547.22 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,515.17 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $594.99. The transfer capital threshold is the transfer adjustment factor * $594.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8844.45","8844.45","8844.45","1 through 10","3975","40698.11","other","Inpatient DRG"
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","","","","inpatient","","","30005.42","18003.25","WELLPOINT [1015]","HB WDH ANTHEM PPO","32414.11","","Fee schedule rate ($32,414.11). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","6000.00","6000.00","6000.00","1 through 10","3975","40698.11","case rate",""
"Respiratory Neoplasms With McC","180","MS-DRG","","","","","","","","inpatient","","","49068.03","29440.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","53448.48","","Fee schedule rate ($53,448.48). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","29885.50","29885.50","29885.50","1 through 10","3975","67108.18","case rate",""
"Respiratory Neoplasms With McC","180","MS-DRG","","","","","","","","inpatient","","","49068.03","29440.82","MEDICARE [2001]","HB WDH MEDICARE","13870.77","","Case rate ($13,870.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,836.83, add-ons for qualifying new technology services are included. If operating cost exceeds $16,755.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,786.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,444.81 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,391.96 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $981.09. The transfer capital threshold is the transfer adjustment factor * $981.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13632.90","8708.83","13667.27","1 through 10","3975","67108.18","other","Inpatient DRG"
"Respiratory Neoplasms With McC","180","MS-DRG","","","","","","","","inpatient","","","49068.03","29440.82","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","13870.77","","Case rate ($13,870.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,836.83, add-ons for qualifying new technology services are included. If operating cost exceeds $16,755.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,786.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $12,444.81 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,391.96 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $981.09. The transfer capital threshold is the transfer adjustment factor * $981.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13393.93","8529.42","13434.32","1 through 10","3975","67108.18","other","Inpatient DRG"
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","","","","inpatient","","","27048.65","16229.19","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","6714.72","","Case rate ($6,583.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,110.36, add-ons for qualifying new technology services are included. If operating cost exceeds $10,028.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,253.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,689.66 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,665.50 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.55. The transfer capital threshold is the transfer adjustment factor * $448.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","6564.23","6564.23","6564.23","1 through 10","3975","30681.28","other","Inpatient DRG"
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","","","","inpatient","","","27048.65","16229.19","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","6780.55","","Case rate ($6,583.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,110.36, add-ons for qualifying new technology services are included. If operating cost exceeds $10,028.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,253.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,689.66 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,665.50 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.55. The transfer capital threshold is the transfer adjustment factor * $448.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","14744.91","14744.91","14744.91","1 through 10","3975","30681.28","other","Inpatient DRG"
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","","","","inpatient","","","27048.65","16229.19","MEDICARE [2001]","HB WDH MEDICARE","6583.06","","Case rate ($6,583.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,110.36, add-ons for qualifying new technology services are included. If operating cost exceeds $10,028.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,253.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,689.66 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,665.50 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.55. The transfer capital threshold is the transfer adjustment factor * $448.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6580.18","6564.23","6580.18","1 through 10","3975","30681.28","other","Inpatient DRG"
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","","","","inpatient","","","27048.65","16229.19","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6583.06","","Case rate ($6,583.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,110.36, add-ons for qualifying new technology services are included. If operating cost exceeds $10,028.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,253.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,689.66 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,665.50 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $448.55. The transfer capital threshold is the transfer adjustment factor * $448.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","26837.53","26837.53","26837.53","1 through 10","3975","30681.28","other","Inpatient DRG"
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","","","","inpatient","","","64114.11","38468.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","20914.85","","Case rate ($21,341.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $19,732.40, add-ons for qualifying new technology services are included. If operating cost exceeds $23,650.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,332.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $19,369.79 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $19,287.53 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,527.02. The transfer capital threshold is the transfer adjustment factor * $1,527.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20333.35","20333.35","20333.35","1 through 10","3975","104450.87","other","Inpatient DRG"
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","","","","inpatient","","","64114.11","38468.47","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","21981.93","","Case rate ($21,341.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $19,732.40, add-ons for qualifying new technology services are included. If operating cost exceeds $23,650.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,332.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $19,369.79 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $19,287.53 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,527.02. The transfer capital threshold is the transfer adjustment factor * $1,527.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","20341.55","20341.55","20341.55","1 through 10","3975","104450.87","other","Inpatient DRG"
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","","","","inpatient","","","64114.11","38468.47","MARTIN'S POINT [160007]","HB WDH MEDICARE","21341.68","","Case rate ($21,341.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $19,732.40, add-ons for qualifying new technology services are included. If operating cost exceeds $23,650.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,332.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $19,369.79 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $19,287.53 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,527.02. The transfer capital threshold is the transfer adjustment factor * $1,527.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20340.85","20340.85","20340.85","1 through 10","3975","104450.87","other","Inpatient DRG"
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","","","","inpatient","","","64114.11","38468.47","MEDICARE [2001]","HB WDH MEDICARE","21341.68","","Case rate ($21,341.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $19,732.40, add-ons for qualifying new technology services are included. If operating cost exceeds $23,650.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,332.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $19,369.79 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $19,287.53 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,527.02. The transfer capital threshold is the transfer adjustment factor * $1,527.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20748.32","20695.56","20748.32","1 through 10","3975","104450.87","other","Inpatient DRG"
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","","","","inpatient","","","64114.11","38468.47","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","21341.68","","Case rate ($21,341.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $19,732.40, add-ons for qualifying new technology services are included. If operating cost exceeds $23,650.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,332.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $19,369.79 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $19,287.53 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,527.02. The transfer capital threshold is the transfer adjustment factor * $1,527.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20374.66","20374.66","20374.66","1 through 10","3975","104450.87","other","Inpatient DRG"
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","","","","inpatient","","","212229.11","127337.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","48376.98","","Case rate ($49,364.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $45,596.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,515.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $51,379.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $45,344.63 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $45,152.06 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,574.76. The transfer capital threshold is the transfer adjustment factor * $3,574.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","49243.45","49243.45","49243.45","1 through 10","4637","244519.24","other","Inpatient DRG"
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","","","","inpatient","","","212229.11","127337.47","MARTIN'S POINT [160007]","HB WDH MEDICARE","49364.27","","Case rate ($49,364.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $45,596.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,515.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $51,379.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $45,344.63 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $45,152.06 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,574.76. The transfer capital threshold is the transfer adjustment factor * $3,574.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","73561.49","73561.49","73561.49","1 through 10","4637","244519.24","other","Inpatient DRG"
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","","","","inpatient","","","212229.11","127337.47","MEDICARE [2001]","HB WDH MEDICARE","49364.27","","Case rate ($49,364.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $45,596.93, add-ons for qualifying new technology services are included. If operating cost exceeds $49,515.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $51,379.78, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $45,344.63 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $45,152.06 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,574.76. The transfer capital threshold is the transfer adjustment factor * $3,574.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","49373.97","49373.97","49373.97","1 through 10","4637","244519.24","other","Inpatient DRG"
"Resporatory Muscle Force","PX-46000058","CDM","94799","CPT","0460","RC","","","","both","","","276.00","165.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1044.65","","Case rate ($1,044.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","266.00","266.00","266.00","1 through 10","157.04","1044.65","other","OPPS APC"
"Resporatory Muscle Force","PX-46000058","CDM","94799","CPT","0460","RC","","","","both","","","276.00","165.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","160.19","","APC Price ($163.46). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","149.76","149.76","149.76","1 through 10","157.04","1044.65","other","OPPS APC"
"RESTRICTOR BONE 25MM CEMENT FEMORAL BUCK HIP 16B BX/3EA","SUP-ITM-10001951","CDM","C1776","HCPCS","0278","RC","","","","both","","","345.50","207.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","40.18","293.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RESTRICTOR BONE 25MM CEMENT FEMORAL BUCK HIP 16B BX/3EA","SUP-ITM-10001951","CDM","C1776","HCPCS","0278","RC","","","","both","","","345.50","207.30","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","196.59","56.9","","2911.53","1863.86","5209.05","65","40.18","293.68","percent of total billed charges",""
"RESTRICTOR BONE 25MM CEMENT FEMORAL BUCK HIP 16B BX/3EA","SUP-ITM-10001951","CDM","C1776","HCPCS","0278","RC","","","","both","","","345.50","207.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.18","11.63","","400.94","400.94","400.94","1 through 10","40.18","293.68","percent of total billed charges",""
"RESTRICTOR BONE 25MM CEMENT FEMORAL BUCK HIP 16B BX/3EA","SUP-ITM-10001951","CDM","C1776","HCPCS","0278","RC","","","","both","","","345.50","207.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","267.42","77.4","","5214.50","5214.50","16415.28","1 through 10","40.18","293.68","percent of total billed charges",""
"RESTRICTOR BONE 25MM CEMENT FEMORAL BUCK HIP 16B BX/3EA","SUP-ITM-10001951","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.18","11.63","","400.94","400.94","400.94","1 through 10","40.18","267.42","percent of total billed charges",""
"RESTRICTOR BONE 25MM CEMENT FEMORAL BUCK HIP 16B BX/3EA","SUP-ITM-10001951","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","151.05","43.72","","1543.33","1543.33","1671.61","1 through 10","40.18","267.42","percent of total billed charges",""
"RESTRICTOR BONE 25MM CEMENT FEMORAL BUCK HIP 16B BX/3EA","SUP-ITM-10001951","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","251.25","72.72","","3700.21","2382.07","6427.18","53","40.18","267.42","percent of total billed charges",""
"RESTRICTOR BONE 25MM CEMENT FEMORAL BUCK HIP 16B BX/3EA","SUP-ITM-10001951","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","251.25","72.72","","12685.80","12685.80","12685.80","1 through 10","40.18","267.42","percent of total billed charges",""
"RESTRICTOR BONE 25MM CEMENT FEMORAL BUCK HIP 16B BX/3EA","SUP-ITM-10001951","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","217.32","62.9","","3408.87","2784.05","9859.40","46","40.18","267.42","percent of total billed charges",""
"RESTRICTOR BONE 25MM CEMENT FEMORAL BUCK HIP 16B BX/3EA","SUP-ITM-10001951","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","267.42","77.4","","5214.50","5214.50","16415.28","1 through 10","40.18","267.42","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","587.35","352.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","68.31","499.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","587.35","352.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","334.20","56.9","","2911.53","1863.86","5209.05","65","68.31","499.25","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","587.35","352.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","68.31","11.63","","400.94","400.94","400.94","1 through 10","68.31","499.25","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","587.35","352.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","454.61","77.4","","5214.50","5214.50","16415.28","1 through 10","68.31","499.25","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","587.35","352.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","68.31","11.63","","400.94","400.94","400.94","1 through 10","68.31","454.61","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","587.35","352.41","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","256.79","43.72","","1543.33","1543.33","1671.61","1 through 10","68.31","454.61","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","587.35","352.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","427.12","72.72","","3700.21","2382.07","6427.18","53","68.31","454.61","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","587.35","352.41","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","427.12","72.72","","12685.80","12685.80","12685.80","1 through 10","68.31","454.61","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","587.35","352.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","369.44","62.9","","3408.87","2784.05","9859.40","46","68.31","454.61","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","587.35","352.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","454.61","77.4","","5214.50","5214.50","16415.28","1 through 10","68.31","454.61","percent of total billed charges",""
"Reticulated Platelet Assay","PX-30001047","CDM","85055","CPT","0305","RC","","","","both","","","437.00","262.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","305.03","69.8","","295.25","295.25","295.25","1 through 10","23.23","371.45","percent of total billed charges",""
"Reticulated Platelet Assay","PX-30001047","CDM","85055","CPT","0305","RC","","","","outpatient","","","437.00","262.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","191.06","43.72","","184.94","184.94","184.94","12","191.06","338.24","percent of total billed charges",""
"Reticulated Platelet Assay","PX-30001047","CDM","85055","CPT","0305","RC","","","","outpatient","","","437.00","262.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","317.79","72.72","","307.61","307.61","375.07","40","191.06","338.24","percent of total billed charges",""
"Reticulated Platelet Assay","PX-30001047","CDM","85055","CPT","0305","RC","","","","outpatient","","","437.00","262.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","232.57","53.22","","225.50","225.50","225.50","1 through 10","191.06","338.24","percent of total billed charges",""
"Reticulated Platelet Assay","PX-30001047","CDM","85055","CPT","0305","RC","","","","outpatient","","","437.00","262.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","274.87","62.9","","266.49","266.49","799.47","1 through 10","191.06","338.24","percent of total billed charges",""
"Reticulated Platelet Assay","PX-30001047","CDM","85055","CPT","0305","RC","","","","outpatient","","","437.00","262.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","338.24","77.4","","327.83","327.82","327.83","1 through 10","191.06","338.24","percent of total billed charges",""
"Reticulated Platelet Assay","PX-30001047","CDM","85055","CPT","0305","RC","","","","outpatient","","","437.00","262.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","317.79","72.72","","307.61","307.61","307.61","1 through 10","191.06","338.24","percent of total billed charges",""
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","","","","inpatient","","","39964.73","23978.84","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","8316.80","","Case rate ($8,153.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,560.07, add-ons for qualifying new technology services are included. If operating cost exceeds $11,478.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,368.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,145.55 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,115.20 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.32. The transfer capital threshold is the transfer adjustment factor * $563.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","8132.33","8132.33","8132.33","1 through 10","3975","38532.1","other","Inpatient DRG"
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","","","","inpatient","","","39964.73","23978.84","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","30688.99","","Fee schedule rate ($30,688.99). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","30002.48","30002.48","30002.48","1 through 10","3975","38532.1","case rate",""
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","","","","inpatient","","","39964.73","23978.84","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8153.73","","Case rate ($8,153.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,560.07, add-ons for qualifying new technology services are included. If operating cost exceeds $11,478.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,368.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,145.55 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,115.20 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $563.32. The transfer capital threshold is the transfer adjustment factor * $563.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8131.80","8131.80","8131.80","1 through 10","3975","38532.1","other","Inpatient DRG"
"Reticuloendothelial And Immunity Disorders With McC","814","MS-DRG","","","","","","","","inpatient","","","34610.95","20766.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","80814.81","","Fee schedule rate ($80,814.81). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","47770.55","47770.55","47770.55","1 through 10","3975","80814.81","case rate",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","594.26","356.56","AETNA [1001]","HB WDH AETNA COMMERCIAL","414.79","69.8","","94.15","94.15","427.63","1 through 10","69.11","505.12","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","594.26","356.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","69.11","505.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","594.26","356.56","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","338.13","56.9","","401.89","65.85","401.89","1 through 10","69.11","505.12","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","594.26","356.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","69.11","11.63","","49.19","10.57","114.40","19","69.11","505.12","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","594.26","356.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","459.96","77.4","","200.75","81.67","643.86","11","69.11","505.12","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","594.26","356.56","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","69.11","505.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","594.26","356.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","69.11","11.63","","49.19","10.57","114.40","19","69.11","459.96","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","594.26","356.56","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","373.08","62.78","","93.27","93.27","93.27","1 through 10","69.11","459.96","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","594.26","356.56","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","259.81","43.72","","363.22","363.22","363.22","1 through 10","69.11","459.96","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","594.26","356.56","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","432.15","72.72","","271.85","111.24","551.69","14","69.11","459.96","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","594.26","356.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","373.79","62.9","","706.53","93.60","938.00","53","69.11","459.96","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","594.26","356.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","459.96","77.4","","200.75","81.67","643.86","11","69.11","459.96","percent of total billed charges",""
"Revasc Fem/Pop Artery Unilateral","PX-76001152","CDM","37224","CPT","0361","RC","","","","both","","","35102.00","21061.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","5956.72","","APC Price ($5,956.72). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5467.44","5467.44","5467.44","1 through 10","5837.59","38068.95","other","OPPS APC"
"Revasc Iliac Artery Unilateral","PX-76001148","CDM","37220","CPT","0361","RC","","","","both","","","31752.00","19051.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","5956.72","","APC Price ($5,956.72). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11659.94","11659.94","11659.94","1 through 10","5837.59","38068.95","other","OPPS APC"
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","","","","inpatient","","","88110.24","52866.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","106733.54","","Fee schedule rate ($106,733.54). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","122391.32","122391.32","122391.32","1 through 10","25185.67","134011.15","case rate",""
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","","","","inpatient","","","88110.24","52866.14","MARTIN'S POINT [160007]","HB WDH MEDICARE","27255.61","","Case rate ($27,255.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $25,190.89, add-ons for qualifying new technology services are included. If operating cost exceeds $29,109.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,764.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $24,851.57 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $24,746.03 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,959.18. The transfer capital threshold is the transfer adjustment factor * $1,959.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","37153.32","37153.32","37153.32","1 through 10","25185.67","134011.15","other","Inpatient DRG"
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","","","","inpatient","","","88110.24","52866.14","MEDICARE [2001]","HB WDH MEDICARE","27255.61","","Case rate ($27,255.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $25,190.89, add-ons for qualifying new technology services are included. If operating cost exceeds $29,109.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,764.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $24,851.57 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $24,746.03 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,959.18. The transfer capital threshold is the transfer adjustment factor * $1,959.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","26357.18","17720.58","26357.18","1 through 10","25185.67","134011.15","other","Inpatient DRG"
"Revision Of Hip Or Knee Replacement With McC","466","MS-DRG","","","","","","","","inpatient","","","108516.89","65110.13","MEDICARE [2001]","HB WDH MEDICARE","40018.59","","Case rate ($40,018.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $36,970.98, add-ons for qualifying new technology services are included. If operating cost exceeds $40,889.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,696.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $36,681.89 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $36,526.11 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,891.83. The transfer capital threshold is the transfer adjustment factor * $2,891.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","38886.41","38443.13","38986.57","1 through 10","37175.04","197805.72","other","Inpatient DRG"
"Revision Of Hip Or Knee Replacement Without Cc/McC","468","MS-DRG","","","","","","","","inpatient","","","81557.62","48934.57","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","21763.09","","Case rate ($21,336.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $19,727.48, add-ons for qualifying new technology services are included. If operating cost exceeds $23,645.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,331.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $19,364.86 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $19,282.62 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,526.63. The transfer capital threshold is the transfer adjustment factor * $1,526.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 102%.","20239.07","20239.07","20239.07","1 through 10","19625.2","104424.27","other","Inpatient DRG"
"Revision Of Hip Or Knee Replacement Without Cc/McC","468","MS-DRG","","","","","","","","inpatient","","","81557.62","48934.57","MARTIN'S POINT [160007]","HB WDH MEDICARE","21336.36","","Case rate ($21,336.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $19,727.48, add-ons for qualifying new technology services are included. If operating cost exceeds $23,645.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,331.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $19,364.86 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $19,282.62 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,526.63. The transfer capital threshold is the transfer adjustment factor * $1,526.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","25733.72","25733.72","25733.72","1 through 10","19625.2","104424.27","other","Inpatient DRG"
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","both","","","80.00","48.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","55.84","69.8","","53.75","48.43","53.75","31","3.69","68","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","outpatient","","","80.00","48.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","50.22","62.78","","48.34","48.34","48.34","1 through 10","5.29","61.92","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","outpatient","","","80.00","48.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","34.98","43.72","","67.32","33.66","67.32","1 through 10","5.29","61.92","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","outpatient","","","80.00","48.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","58.18","72.72","","55.99","55.99","55.99","50","5.29","61.92","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","outpatient","","","80.00","48.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","58.18","72.72","","55.99","55.99","55.99","1 through 10","5.29","61.92","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","outpatient","","","80.00","48.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","42.58","53.22","","41.05","41.05","41.05","1 through 10","5.29","61.92","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","outpatient","","","80.00","48.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","50.32","62.9","","48.51","48.51","145.53","69","5.29","61.92","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","outpatient","","","80.00","48.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","61.92","77.4","","59.68","59.68","59.68","31","5.29","61.92","percent of total billed charges",""
"Rickettsia Antibody","PX-30000988","CDM","86757","CPT","0302","RC","","","","both","","","103.00","61.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","71.89","69.8","","22.06","22.06","22.06","1 through 10","12.58","99.33","percent of total billed charges",""
"Rickettsia Antibody","PX-30000988","CDM","86757","CPT","0302","RC","","","","outpatient","","","103.00","61.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","74.90","72.72","","72.72","72.72","72.72","1 through 10","23.19","79.72","percent of total billed charges",""
"Rickettsia Antibody","PX-30000988","CDM","86757","CPT","0302","RC","","","","outpatient","","","103.00","61.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","64.79","62.9","","121.08","63.00","189.00","14","23.19","79.72","percent of total billed charges",""
"Rickettsia Antibody","PX-30000988","CDM","86757","CPT","0302","RC","","","","outpatient","","","103.00","61.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","79.72","77.4","","77.50","77.50","77.50","1 through 10","23.19","79.72","percent of total billed charges",""
"Right Heart Artery/Graft Angio","PX-48000122","CDM","93457","CPT","0481","RC","","","","both","","","18722.00","11233.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","3461.19","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3398.55","3398.55","3398.55","1 through 10","3293.17","21475.95","other","OPPS APC"
"Right Heart Artery/Graft Angio","PX-48000122","CDM","93457","CPT","0481","RC","","","","both","","","18722.00","11233.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3321.32","3301.25","3360.76","1 through 10","3293.17","21475.95","other","OPPS APC"
"Rmvl Impltbl Dfb Plse Gen W/Repl Plse Gen 1 Lead","PX-48000075","CDM","33262","CPT","0361","RC","","","","both","","","97413.00","58447.80","MEDICARE [2001]","HB WDH MEDICARE","23450.88","","APC Price ($23,450.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70360.74","22966.66","70360.74","1 through 10","22981.86","149872.86","other","OPPS APC"
"Rmvl Impltbl Dfb Plse Gen W/Rplcmt Plse Gen 2 Ld","PX-48000076","CDM","33263","CPT","0361","RC","","","","both","","","98100.00","58860.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","23450.88","","APC Price ($23,450.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","23453.58","22993.51","23453.58","1 through 10","22981.86","149872.86","other","OPPS APC"
"Rmvl Impltbl Dfb Plse Gen W/Rplcmt Plse Gen 2 Ld","PX-48000076","CDM","33263","CPT","0361","RC","","","","outpatient","","","98100.00","58860.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","75929.40","77.4","","73364.60","73364.60","73364.60","1 through 10","11409.03","75929.4","percent of total billed charges",""
"Rmvl Ndwellg Tun Pleural Cath W/Cuf","PX-76000828","CDM","32552","CPT","0761","RC","","","","both","","","8516.00","5109.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","633.01","","APC Price ($645.93). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","633.09","633.09","633.09","1 through 10","633.01","7238.6","other","OPPS APC"
"Rmvl Ndwellg Tun Pleural Cath W/Cuf","PX-76000828","CDM","32552","CPT","0761","RC","","","","both","","","8516.00","5109.60","MEDICARE [2001]","HB WDH MEDICARE","645.93","","APC Price ($645.93). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","646.01","646.01","646.01","1 through 10","633.01","7238.6","other","OPPS APC"
"Rmvl Ndwellg Tun Pleural Cath W/Cuf","PX-76000828","CDM","32552","CPT","0761","RC","","","","outpatient","","","8516.00","5109.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","990.41","11.63","","1012.95","1012.95","1012.95","1 through 10","990.41","6591.38","percent of total billed charges",""
"ROD 5.5X45MM SPINAL CD HORIZON SOLERA TITANIUM CURVE","SUP-ITM-10111302","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.50","621.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","120.54","881.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ROD 5.5X45MM SPINAL CD HORIZON SOLERA TITANIUM CURVE","SUP-ITM-10111302","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.50","621.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","120.54","881.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ROD 5.5X45MM SPINAL CD HORIZON SOLERA TITANIUM CURVE","SUP-ITM-10111302","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.50","621.90","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","589.77","56.9","","0.63","0.63","0.63","1 through 10","120.54","881.03","percent of total billed charges",""
"ROD 5.5X45MM SPINAL CD HORIZON SOLERA TITANIUM CURVE","SUP-ITM-10111302","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.50","621.90","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","149.46","14.42","","317.14","317.14","317.14","1 through 10","120.54","881.03","percent of total billed charges",""
"ROD 5.5X45MM SPINAL CD HORIZON SOLERA TITANIUM CURVE","SUP-ITM-10111302","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","149.46","14.42","","317.14","317.14","317.14","1 through 10","120.54","802.25","percent of total billed charges",""
"ROD 5.5X45MM SPINAL CD HORIZON SOLERA TITANIUM CURVE","SUP-ITM-10111302","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","650.71","62.78","","1125.09","1125.09","1125.09","1 through 10","120.54","802.25","percent of total billed charges",""
"ROD 5.5X45MM SPINAL CD HORIZON SOLERA TITANIUM CURVE","SUP-ITM-10111302","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","753.74","72.72","","4732.50","1617.43","14180.40","1 through 10","120.54","802.25","percent of total billed charges",""
"ROD 5.5X45MM SPINAL CD HORIZON SOLERA TITANIUM CURVE","SUP-ITM-10111302","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","651.96","62.9","","3896.20","3341.38","3896.20","1 through 10","120.54","802.25","percent of total billed charges",""
"ROD 8X250MM EXTERNAL FIXATION HOFFMANN II CARBON CONNECTING","SUP-ITM-10138501","CDM","C1889","HCPCS","0278","RC","","","","both","","","3432.61","2059.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","399.21","2917.72","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ROD 8X250MM EXTERNAL FIXATION HOFFMANN II CARBON CONNECTING","SUP-ITM-10138501","CDM","C1889","HCPCS","0278","RC","","","","both","","","3432.61","2059.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","399.21","2917.72","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ROD 8X250MM EXTERNAL FIXATION HOFFMANN II CARBON CONNECTING","SUP-ITM-10138501","CDM","C1889","HCPCS","0278","RC","","","","both","","","3432.61","2059.57","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1953.16","56.9","","0.63","0.63","0.63","1 through 10","399.21","2917.72","percent of total billed charges",""
"ROD 8X250MM EXTERNAL FIXATION HOFFMANN II CARBON CONNECTING","SUP-ITM-10138501","CDM","C1889","HCPCS","0278","RC","","","","both","","","3432.61","2059.57","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","494.98","14.42","","317.14","317.14","317.14","1 through 10","399.21","2917.72","percent of total billed charges",""
"ROD 8X250MM EXTERNAL FIXATION HOFFMANN II CARBON CONNECTING","SUP-ITM-10138501","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3432.61","2059.57","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","494.98","14.42","","317.14","317.14","317.14","1 through 10","399.21","2656.84","percent of total billed charges",""
"ROD 8X250MM EXTERNAL FIXATION HOFFMANN II CARBON CONNECTING","SUP-ITM-10138501","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3432.61","2059.57","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2154.99","62.78","","1125.09","1125.09","1125.09","1 through 10","399.21","2656.84","percent of total billed charges",""
"ROD 8X250MM EXTERNAL FIXATION HOFFMANN II CARBON CONNECTING","SUP-ITM-10138501","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3432.61","2059.57","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2496.19","72.72","","4732.50","1617.43","14180.40","1 through 10","399.21","2656.84","percent of total billed charges",""
"ROD 8X250MM EXTERNAL FIXATION HOFFMANN II CARBON CONNECTING","SUP-ITM-10138501","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3432.61","2059.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2159.11","62.9","","3896.20","3341.38","3896.20","1 through 10","399.21","2656.84","percent of total billed charges",""
"ROD 8X5MM COUPLING EXTERNAL FIXATION HOFFMAN II MRI COMPACT TO","SUP-ITM-10138500","CDM","C1889","HCPCS","0278","RC","","","","both","","","5977.43","3586.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","695.18","5080.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ROD 8X5MM COUPLING EXTERNAL FIXATION HOFFMAN II MRI COMPACT TO","SUP-ITM-10138500","CDM","C1889","HCPCS","0278","RC","","","","both","","","5977.43","3586.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","695.18","5080.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ROD 8X5MM COUPLING EXTERNAL FIXATION HOFFMAN II MRI COMPACT TO","SUP-ITM-10138500","CDM","C1889","HCPCS","0278","RC","","","","both","","","5977.43","3586.46","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3401.16","56.9","","0.63","0.63","0.63","1 through 10","695.18","5080.82","percent of total billed charges",""
"ROD 8X5MM COUPLING EXTERNAL FIXATION HOFFMAN II MRI COMPACT TO","SUP-ITM-10138500","CDM","C1889","HCPCS","0278","RC","","","","both","","","5977.43","3586.46","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","861.95","14.42","","317.14","317.14","317.14","1 through 10","695.18","5080.82","percent of total billed charges",""
"ROD 8X5MM COUPLING EXTERNAL FIXATION HOFFMAN II MRI COMPACT TO","SUP-ITM-10138500","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5977.43","3586.46","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","861.95","14.42","","317.14","317.14","317.14","1 through 10","695.18","4626.53","percent of total billed charges",""
"ROD 8X5MM COUPLING EXTERNAL FIXATION HOFFMAN II MRI COMPACT TO","SUP-ITM-10138500","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5977.43","3586.46","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3752.63","62.78","","1125.09","1125.09","1125.09","1 through 10","695.18","4626.53","percent of total billed charges",""
"ROD 8X5MM COUPLING EXTERNAL FIXATION HOFFMAN II MRI COMPACT TO","SUP-ITM-10138500","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5977.43","3586.46","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4346.79","72.72","","4732.50","1617.43","14180.40","1 through 10","695.18","4626.53","percent of total billed charges",""
"ROD 8X5MM COUPLING EXTERNAL FIXATION HOFFMAN II MRI COMPACT TO","SUP-ITM-10138500","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5977.43","3586.46","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3759.80","62.9","","3896.20","3341.38","3896.20","1 through 10","695.18","4626.53","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","both","","","1121.08","672.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","130.38","952.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","both","","","1121.08","672.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","130.38","952.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","both","","","1121.08","672.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","637.89","56.9","","0.63","0.63","0.63","1 through 10","130.38","952.92","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","both","","","1121.08","672.65","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","161.66","14.42","","317.14","317.14","317.14","1 through 10","130.38","952.92","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1121.08","672.65","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","161.66","14.42","","317.14","317.14","317.14","1 through 10","130.38","867.72","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1121.08","672.65","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","703.81","62.78","","1125.09","1125.09","1125.09","1 through 10","130.38","867.72","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1121.08","672.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","815.25","72.72","","4732.50","1617.43","14180.40","1 through 10","130.38","867.72","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1121.08","672.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","705.16","62.9","","3896.20","3341.38","3896.20","1 through 10","130.38","867.72","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","both","","","1229.43","737.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","142.98","1045.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","both","","","1229.43","737.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","142.98","1045.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","both","","","1229.43","737.66","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","699.55","56.9","","0.63","0.63","0.63","1 through 10","142.98","1045.02","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","both","","","1229.43","737.66","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","177.28","14.42","","317.14","317.14","317.14","1 through 10","142.98","1045.02","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1229.43","737.66","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","177.28","14.42","","317.14","317.14","317.14","1 through 10","142.98","951.58","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1229.43","737.66","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","771.84","62.78","","1125.09","1125.09","1125.09","1 through 10","142.98","951.58","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1229.43","737.66","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","894.04","72.72","","4732.50","1617.43","14180.40","1 through 10","142.98","951.58","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1229.43","737.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","773.31","62.9","","3896.20","3341.38","3896.20","1 through 10","142.98","951.58","percent of total billed charges",""
"ROD BONE 11X450MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004242","CDM","C1889","HCPCS","0278","RC","","","","both","","","1229.43","737.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","142.98","1045.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ROD BONE 11X450MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004242","CDM","C1889","HCPCS","0278","RC","","","","both","","","1229.43","737.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","142.98","1045.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ROD BONE 11X450MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004242","CDM","C1889","HCPCS","0278","RC","","","","both","","","1229.43","737.66","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","699.55","56.9","","0.63","0.63","0.63","1 through 10","142.98","1045.02","percent of total billed charges",""
"ROD BONE 11X450MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004242","CDM","C1889","HCPCS","0278","RC","","","","both","","","1229.43","737.66","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","177.28","14.42","","317.14","317.14","317.14","1 through 10","142.98","1045.02","percent of total billed charges",""
"ROD BONE 11X450MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004242","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1229.43","737.66","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","177.28","14.42","","317.14","317.14","317.14","1 through 10","142.98","951.58","percent of total billed charges",""
"ROD BONE 11X450MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004242","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1229.43","737.66","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","771.84","62.78","","1125.09","1125.09","1125.09","1 through 10","142.98","951.58","percent of total billed charges",""
"ROD BONE 11X450MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004242","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1229.43","737.66","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","894.04","72.72","","4732.50","1617.43","14180.40","1 through 10","142.98","951.58","percent of total billed charges",""
"ROD BONE 11X450MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004242","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1229.43","737.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","773.31","62.9","","3896.20","3341.38","3896.20","1 through 10","142.98","951.58","percent of total billed charges",""
"ROD STANDARD 3.2MM X 240MM","SUP-ITM-10260188","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.50","621.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","120.54","881.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ROD STANDARD 3.2MM X 240MM","SUP-ITM-10260188","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.50","621.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","120.54","881.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ROD STANDARD 3.2MM X 240MM","SUP-ITM-10260188","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.50","621.90","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","589.77","56.9","","812.12","238.65","1587.46","163","120.54","881.03","percent of total billed charges",""
"ROD STANDARD 3.2MM X 240MM","SUP-ITM-10260188","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.50","621.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","120.54","11.63","","112.68","112.68","146.99","38","120.54","881.03","percent of total billed charges",""
"ROD STANDARD 3.2MM X 240MM","SUP-ITM-10260188","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.50","621.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","802.25","77.4","","303.98","303.98","5854.79","1 through 10","120.54","881.03","percent of total billed charges",""
"ROD STANDARD 3.2MM X 240MM","SUP-ITM-10260188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","120.54","11.63","","112.68","112.68","146.99","38","120.54","802.25","percent of total billed charges",""
"ROD STANDARD 3.2MM X 240MM","SUP-ITM-10260188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","650.71","62.78","","780.86","208.94","10480.28","15","120.54","802.25","percent of total billed charges",""
"ROD STANDARD 3.2MM X 240MM","SUP-ITM-10260188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","453.16","43.72","","179.76","179.76","179.76","1 through 10","120.54","802.25","percent of total billed charges",""
"ROD STANDARD 3.2MM X 240MM","SUP-ITM-10260188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","753.74","72.72","","2355.45","298.99","3965.19","155","120.54","802.25","percent of total billed charges",""
"ROD STANDARD 3.2MM X 240MM","SUP-ITM-10260188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","753.74","72.72","","3643.09","3643.09","3643.09","1 through 10","120.54","802.25","percent of total billed charges",""
"ROD STANDARD 3.2MM X 240MM","SUP-ITM-10260188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","551.63","53.22","","554.28","554.28","554.28","16","120.54","802.25","percent of total billed charges",""
"ROD STANDARD 3.2MM X 240MM","SUP-ITM-10260188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","651.96","62.9","","619.64","173.09","2370.64","150","120.54","802.25","percent of total billed charges",""
"ROD STANDARD 3.2MM X 240MM","SUP-ITM-10260188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","802.25","77.4","","303.98","303.98","5854.79","1 through 10","120.54","802.25","percent of total billed charges",""
"Roux-en-Y Excluded Stomach to Duodenum Stent Insert With Eus","PX-75000491","CDM","43999","CPT","0750","RC","","","","both","","","32290.00","19374.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","979.53","","APC Price ($979.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","979.64","979.64","979.64","1 through 10","959.93","27446.5","other","OPPS APC"
"Rp Loclzj Tum Spect 1 Area/Acquisj 1 Day Img","PX-34000117","CDM","78803","CPT","0341","RC","","","","both","","","3075.00","1845.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","8716.66","","Case rate ($8,716.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3498.99","3498.99","3498.99","1 through 10","1336.64","8716.66","other","OPPS APC"
"Rp Loclzj Tum Spect 1 Area/Acquisj 1 Day Img","PX-34000117","CDM","78803","CPT","0341","RC","","","","both","","","3075.00","1845.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","3753.38","","Case rate ($3,753.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3661.88","3498.99","3661.88","1 through 10","1336.64","8716.66","other","OPPS APC"
"Rp Loclzj Tum Spect 1 Area/Acquisj 1 Day Img","PX-34000117","CDM","78803","CPT","0341","RC","","","","both","","","3075.00","1845.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1336.64","","APC Price ($1,363.91). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1336.79","1336.79","1364.07","1 through 10","1336.64","8716.66","other","OPPS APC"
"Rp Loclzj Tum Spect 1 Area/Acquisj 1 Day Img","PX-34000117","CDM","78803","CPT","0341","RC","","","","both","","","3075.00","1845.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","7045.59","","Case rate ($7,045.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2967.00","2967.00","2967.00","1 through 10","1336.64","8716.66","other","OPPS APC"
"Rp Loclzj Tum Spect 1 Area/Acquisj 1 Day Img","PX-34000117","CDM","78803","CPT","0341","RC","","","","both","","","3075.00","1845.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","1404.83","","APC Price ($1,363.91). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1389.11","1378.01","1389.11","1 through 10","1336.64","8716.66","other","OPPS APC"
"Rp Loclzj Tum Spect 1 Area/Acquisj 1 Day Img","PX-34000117","CDM","78803","CPT","0341","RC","","","","both","","","3075.00","1845.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","1363.91","","APC Price ($1,363.91). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1342.24","1342.24","1364.07","1 through 10","1336.64","8716.66","other","OPPS APC"
"Rp Loclzj Tum Spect 1 Area/Acquisj 1 Day Img","PX-34000117","CDM","78803","CPT","0341","RC","","","","both","","","3075.00","1845.00","MEDICARE [2001]","HB WDH MEDICARE","1363.91","","APC Price ($1,363.91). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1364.07","1364.07","1383.53","27","1336.64","8716.66","other","OPPS APC"
"Rp Loclzj Tum Spect 1 Area/Acquisj 1 Day Img","PX-34000117","CDM","78803","CPT","0341","RC","","","","both","","","3075.00","1845.00","TRICARE [160005]","HB WDH MEDICARE","1363.91","","APC Price ($1,363.91). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1364.07","1364.07","1364.07","1 through 10","1336.64","8716.66","other","OPPS APC"
"Rp Loclzj Tum Spect 1 Area/Acquisj 1 Day Img","PX-34000117","CDM","78803","CPT","0341","RC","","","","both","","","3075.00","1845.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1363.91","","APC Price ($1,363.91). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1339.79","1336.79","1358.86","1 through 10","1336.64","8716.66","other","OPPS APC"
"Rp Loclzj Tum Spect 1 Area/Acquisj 1 Day Img","PX-34000117","CDM","78803","CPT","0341","RC","","","","both","","","3075.00","1845.00","WELLSENSE NH [1050]","HB WDH MEDICARE","1363.91","","APC Price ($1,363.91). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1405.22","1405.22","1405.22","1 through 10","1336.64","8716.66","other","OPPS APC"
"Rp Loclzj Tum Spect 1 Area/Acquisj 1 Day Img","PX-34000117","CDM","78803","CPT","0341","RC","","","","outpatient","","","3075.00","1845.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2236.14","72.72","","2157.60","2157.60","2157.60","1 through 10","357.62","2380.05","percent of total billed charges",""
"Rp Loclzj Tum Spect 1 Area/Acquisj 1 Day Img","PX-34000117","CDM","78803","CPT","0341","RC","","","","outpatient","","","3075.00","1845.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1934.18","62.9","","1869.21","1869.21","1869.21","1 through 10","357.62","2380.05","percent of total billed charges",""
"Rpr Lac Cplx Forehd/Hnd/Ft Add 5cm","PX-76000148","CDM","13133","CPT","0761","RC","","","","outpatient","","","1272.00","763.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","147.93","11.63","","1255.22","1255.22","1255.22","1 through 10","147.93","984.53","percent of total billed charges",""
"Rpr Lac Cplx Scalp/Arm/Leg 2-7.5cm","PX-76000144","CDM","13121","CPT","0761","RC","","","","both","","","2592.00","1555.20","MEDICARE [2001]","HB WDH MEDICARE","639.53","","APC Price ($639.53). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","319.80","319.80","319.80","1 through 10","626.74","4087.16","other","OPPS APC"
"Rpr Lac Intermd Face/Ear/Lip5.1-7.5","PX-76000135","CDM","12053","CPT","0761","RC","","","","outpatient","","","2267.00","1360.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1754.66","77.4","","1695.70","1695.70","1695.70","1 through 10","263.65","1754.66","percent of total billed charges",""
"Rpr Lac Intermd Hnd/Ft/Gen <2.5cm","PX-76000127","CDM","12041","CPT","0761","RC","","","","outpatient","","","1557.00","934.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","1763.47","1763.47","1763.47","1 through 10","181.08","1205.12","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Rpr Lac Intermd Hnd/Ft/Gen <2.5cm","PX-76000127","CDM","12041","CPT","0761","RC","","","","outpatient","","","1557.00","934.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","979.35","62.9","","643.23","643.23","643.23","1 through 10","181.08","1205.12","percent of total billed charges",""
"Rpr Lac Intermd Hnd/Ft/Gen 2.6-7.5","PX-76000128","CDM","12042","CPT","0761","RC","","","","both","","","2085.00","1251.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","429.94","","APC Price ($417.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","255.37","255.37","255.37","1 through 10","409.06","2667.66","other","OPPS APC"
"Rpr Lac Intermd Hnd/Ft/Gen 2.6-7.5","PX-76000128","CDM","12042","CPT","0761","RC","","","","outpatient","","","2085.00","1251.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","300.66","14.42","","1546.98","1546.98","1546.98","1 through 10","242.49","1613.79","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","both","","","1599.00","959.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2667.66","","Case rate ($2,667.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1301.30","1301.30","1301.30","1 through 10","160.38","2667.66","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","both","","","1599.00","959.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","909.83","56.9","","398.18","366.64","398.18","1 through 10","160.38","2667.66","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","both","","","1599.00","959.40","MEDICARE [2001]","HB WDH MEDICARE","417.41","","APC Price ($417.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.73","208.73","208.73","1 through 10","160.38","2667.66","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","both","","","1599.00","959.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","417.41","","APC Price ($417.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.73","208.73","208.73","1 through 10","160.38","2667.66","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil 12.6-20.","PX-76000124","CDM","12035","CPT","0761","RC","","","","both","","","2621.00","1572.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","417.41","","APC Price ($417.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","409.12","409.12","409.12","1 through 10","409.06","2667.66","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","both","","","2027.00","1216.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","425.76","","APC Price ($417.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","417.46","417.46","417.46","1 through 10","200.94","2667.66","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","both","","","2027.00","1216.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","429.94","","APC Price ($417.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","422.48","422.48","422.48","1 through 10","200.94","2667.66","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","both","","","2027.00","1216.20","MEDICARE [2001]","HB WDH MEDICARE","417.41","","APC Price ($417.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.73","208.73","208.73","1 through 10","200.94","2667.66","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil 20.1-30.","PX-76000125","CDM","12036","CPT","0761","RC","","","","both","","","2621.00","1572.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1491.35","56.9","","4190.68","4190.68","4190.68","1 through 10","626.74","4087.16","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil 7.6-12.5","PX-76000123","CDM","12034","CPT","0761","RC","","","","both","","","2159.00","1295.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","417.41","","APC Price ($417.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","204.56","204.56","204.56","1 through 10","216.89","2667.66","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil 7.6-12.5","PX-76000123","CDM","12034","CPT","0761","RC","","","","outpatient","","","2159.00","1295.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","251.09","11.63","","856.70","856.70","856.70","1 through 10","251.09","1671.07","percent of total billed charges",""
"Rpr Lac Smp Face/Ear/Lip <2.5cm","PX-76000112","CDM","12011","CPT","0761","RC","","","","both","","","564.00","338.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","320.92","56.9","","270.85","245.75","276.65","1 through 10","59.24","1326.74","percent of total billed charges",""
"Rpr Lac Smp Face/Ear/Lip <2.5cm","PX-76000112","CDM","12011","CPT","0761","RC","","","","outpatient","","","564.00","338.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","81.33","14.42","","78.44","53.35","78.44","1 through 10","65.59","436.54","percent of total billed charges",""
"Rpr Lac Smp Face/Ear/Lip <2.5cm","PX-76000112","CDM","12011","CPT","0761","RC","","","","outpatient","","","564.00","338.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","65.59","11.63","","50.95","50.95","50.95","1 through 10","65.59","436.54","percent of total billed charges",""
"Rpr Lac Smp Face/Ear/Lip <2.5cm","PX-76000112","CDM","12011","CPT","0761","RC","","","","outpatient","","","564.00","338.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","354.76","62.9","","233.10","233.10","233.10","1 through 10","65.59","436.54","percent of total billed charges",""
"Rpr Lac Smp Face/Ear/Lip <2.5cm","PX-76000112","CDM","12011","CPT","0761","RC","","","","outpatient","","","564.00","338.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","436.54","77.4","","421.60","421.60","421.60","1 through 10","65.59","436.54","percent of total billed charges",""
"Rpr Lac Smp Face/Ear/Lip <2.5cm","PX-76000112","CDM","12011","CPT","0761","RC","","","","outpatient","","","564.00","338.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","65.59","11.63","","43.71","43.71","43.71","1 through 10","65.59","436.54","percent of total billed charges",""
"Rpr Lac Smp Face/Ear/Lip 2.6-5.0cm","PX-76000113","CDM","12013","CPT","0761","RC","","","","outpatient","","","595.00","357.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","69.20","11.63","","46.19","46.19","46.19","1 through 10","69.2","460.53","percent of total billed charges",""
"Rpr Lac Smp Face/Ear/Lip 7.6-12.5cm","PX-76000115","CDM","12015","CPT","0761","RC","","","","outpatient","","","965.00","579.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","139.15","14.42","","115.07","115.07","115.07","1 through 10","112.23","746.91","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen <2.5cm","PX-76000106","CDM","12001","CPT","0761","RC","","","","both","","","458.00","274.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","319.68","69.8","","209.40","209.40","209.40","12","47.3","1326.74","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen <2.5cm","PX-76000106","CDM","12001","CPT","0761","RC","","","","both","","","458.00","274.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","260.60","56.9","","246.16","177.75","425.00","35","47.3","1326.74","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen <2.5cm","PX-76000106","CDM","12001","CPT","0761","RC","","","","both","","","458.00","274.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","389.30","85","","249.14","249.14","249.14","1 through 10","47.3","1326.74","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen <2.5cm","PX-76000106","CDM","12001","CPT","0761","RC","","","","outpatient","","","458.00","274.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","66.04","14.42","","43.26","37.08","43.26","1 through 10","53.27","354.49","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen <2.5cm","PX-76000106","CDM","12001","CPT","0761","RC","","","","outpatient","","","458.00","274.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","53.27","11.63","","41.31","36.72","75.76","14","53.27","354.49","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen <2.5cm","PX-76000106","CDM","12001","CPT","0761","RC","","","","outpatient","","","458.00","274.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","321.42","321.42","321.42","1 through 10","53.27","354.49","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Rpr Lac Smp Sclp/Hnd/Gen <2.5cm","PX-76000106","CDM","12001","CPT","0761","RC","","","","outpatient","","","458.00","274.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","243.75","53.22","","159.93","159.93","159.93","1 through 10","53.27","354.49","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen <2.5cm","PX-76000106","CDM","12001","CPT","0761","RC","","","","outpatient","","","458.00","274.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","288.08","62.9","","567.00","189.00","945.00","35","53.27","354.49","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen <2.5cm","PX-76000106","CDM","12001","CPT","0761","RC","","","","outpatient","","","458.00","274.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","354.49","77.4","","232.50","232.50","232.50","1 through 10","53.27","354.49","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen <2.5cm","PX-76000106","CDM","12001","CPT","0761","RC","","","","outpatient","","","458.00","274.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","53.27","11.63","","35.43","35.43","590.00","12","53.27","354.49","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen 2.6-7.5cm","PX-76000107","CDM","12002","CPT","0761","RC","","","","both","","","602.00","361.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","420.20","69.8","","275.01","275.01","275.01","1 through 10","62.87","1326.74","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen 2.6-7.5cm","PX-76000107","CDM","12002","CPT","0761","RC","","","","both","","","602.00","361.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","342.54","56.9","","254.09","217.40","275.58","1 through 10","62.87","1326.74","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen 2.6-7.5cm","PX-76000107","CDM","12002","CPT","0761","RC","","","","outpatient","","","602.00","361.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","86.81","14.42","","56.81","48.70","56.81","1 through 10","70.01","465.95","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen 2.6-7.5cm","PX-76000107","CDM","12002","CPT","0761","RC","","","","outpatient","","","602.00","361.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","70.01","11.63","","54.25","54.25","54.25","1 through 10","70.01","465.95","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen 2.6-7.5cm","PX-76000107","CDM","12002","CPT","0761","RC","","","","outpatient","","","602.00","361.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","378.66","62.9","","248.22","248.22","366.03","1 through 10","70.01","465.95","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen 2.6-7.5cm","PX-76000107","CDM","12002","CPT","0761","RC","","","","outpatient","","","602.00","361.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","465.95","77.4","","305.35","305.35","305.35","1 through 10","70.01","465.95","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen 20.1-30.0","PX-76000110","CDM","12006","CPT","0761","RC","","","","outpatient","","","1115.00","669.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","131.46","11.79","","1255.22","1255.22","1255.22","1 through 10","131.46","863.01","percent of total billed charges",""
"Rpr Lac Smp Sclp/Hnd/Gen 7.6-12.5cm","PX-76000108","CDM","12004","CPT","0761","RC","","","","outpatient","","","751.00","450.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","581.27","77.4","","382.08","382.08","382.08","1 through 10","87.34","581.27","percent of total billed charges",""
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","both","","","16857.00","10114.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","11766.19","69.8","","11354.37","10231.94","11354.37","1 through 10","3293.17","21475.95","percent of total billed charges",""
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","both","","","16857.00","10114.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","21475.95","","Case rate ($21,475.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","19152.99","19152.99","19152.99","1 through 10","3293.17","21475.95","other","OPPS APC"
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","both","","","16857.00","10114.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","3293.17","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3313.71","3174.96","3360.76","1 through 10","3293.17","21475.95","other","OPPS APC"
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","both","","","16857.00","10114.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","17358.81","","Case rate ($17,358.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","16935.33","16935.33","16935.33","1 through 10","3293.17","21475.95","other","OPPS APC"
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","both","","","16857.00","10114.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","9591.63","56.9","","9255.92","9255.92","9255.92","1 through 10","3293.17","21475.95","percent of total billed charges",""
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","both","","","16857.00","10114.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","3461.19","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3403.35","3403.35","3403.35","1 through 10","3293.17","21475.95","other","OPPS APC"
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","both","","","16857.00","10114.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3300.04","3300.04","3300.04","1 through 10","3293.17","21475.95","other","OPPS APC"
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","both","","","16857.00","10114.20","MEDICARE [2001]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3360.76","3174.96","10082.28","16","3293.17","21475.95","other","OPPS APC"
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","both","","","16857.00","10114.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","14328.45","85","","1490.19","1490.19","1490.19","1 through 10","3293.17","21475.95","percent of total billed charges",""
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","both","","","16857.00","10114.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3306.99","3302.45","3306.99","1 through 10","3293.17","21475.95","other","OPPS APC"
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","both","","","16857.00","10114.20","WELLSENSE NH [1050]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","35341.54","35341.54","35341.54","1 through 10","3293.17","21475.95","other","OPPS APC"
"Rt Hrt Coronary Artery Angio S&I","PX-48000121","CDM","93456","CPT","0481","RC","","","","outpatient","","","16857.00","10114.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1960.47","11.63","","1921.39","1921.39","1921.39","1 through 10","1960.47","13047.32","percent of total billed charges",""
"Rt&Lt Hrt Art/Vent Angio Bypass","PX-48000126","CDM","93461","CPT","0481","RC","","","","both","","","19562.00","11737.20","MEDICARE [2001]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3360.76","3360.76","3360.76","1 through 10","3293.17","21475.95","other","OPPS APC"
"Rt&Lt Hrt Art/Vent Angio Bypass","PX-48000126","CDM","93461","CPT","0481","RC","","","","both","","","19562.00","11737.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6229.43","3306.99","6229.43","1 through 10","3293.17","21475.95","other","OPPS APC"
"Rt&Lt Hrt Art/Ventricle Angio","PX-48000125","CDM","93460","CPT","0481","RC","","","","both","","","18359.00","11015.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","21475.95","","Case rate ($21,475.95). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","20638.25","20638.25","20638.25","1 through 10","3293.17","21475.95","other","OPPS APC"
"Rt&Lt Hrt Art/Ventricle Angio","PX-48000125","CDM","93460","CPT","0481","RC","","","","both","","","18359.00","11015.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","9247.52","","Case rate ($9,247.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","15992.82","15992.82","15992.82","1 through 10","3293.17","21475.95","other","OPPS APC"
"Rt&Lt Hrt Art/Ventricle Angio","PX-48000125","CDM","93460","CPT","0481","RC","","","","both","","","18359.00","11015.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","3293.17","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3293.54","3293.54","3293.54","1 through 10","3293.17","21475.95","other","OPPS APC"
"Rt&Lt Hrt Art/Ventricle Angio","PX-48000125","CDM","93460","CPT","0481","RC","","","","both","","","18359.00","11015.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","17358.81","","Case rate ($17,358.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","16935.33","16935.33","16935.33","1 through 10","3293.17","21475.95","other","OPPS APC"
"Rt&Lt Hrt Art/Ventricle Angio","PX-48000125","CDM","93460","CPT","0481","RC","","","","both","","","18359.00","11015.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","10446.27","56.9","","10080.40","10080.40","10080.40","1 through 10","3293.17","21475.95","percent of total billed charges",""
"Rt&Lt Hrt Art/Ventricle Angio","PX-48000125","CDM","93460","CPT","0481","RC","","","","both","","","18359.00","11015.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","3461.19","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","6024.40","3399.26","6024.40","1 through 10","3293.17","21475.95","other","OPPS APC"
"Rt&Lt Hrt Art/Ventricle Angio","PX-48000125","CDM","93460","CPT","0481","RC","","","","both","","","18359.00","11015.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3301.44","3116.46","3301.44","1 through 10","3293.17","21475.95","other","OPPS APC"
"Rt&Lt Hrt Art/Ventricle Angio","PX-48000125","CDM","93460","CPT","0481","RC","","","","both","","","18359.00","11015.40","MEDICARE [2001]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3360.76","3174.96","5569.02","13","3293.17","21475.95","other","OPPS APC"
"Rt&Lt Hrt Art/Ventricle Angio","PX-48000125","CDM","93460","CPT","0481","RC","","","","both","","","18359.00","11015.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3360.76","3301.45","5838.26","1 through 10","3293.17","21475.95","other","OPPS APC"
"Rt&Lt Hrt Art/Ventricle Angio","PX-48000125","CDM","93460","CPT","0481","RC","","","","both","","","18359.00","11015.40","WELLSENSE NH [1050]","HB WDH MEDICARE","3360.38","","APC Price ($3,360.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3458.22","3458.22","3458.22","1 through 10","3293.17","21475.95","other","OPPS APC"
"Rt&Lt Hrt Art/Ventricle Angio","PX-48000125","CDM","93460","CPT","0481","RC","","","","outpatient","","","18359.00","11015.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2647.37","14.42","","2554.65","2554.65","2554.65","1 through 10","2135.15","14209.87","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","both","","","205.00","123.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","143.09","69.8","","138.20","124.54","138.20","73","9.35","174.25","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","both","","","205.00","123.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","143.09","69.8","","138.20","138.20","138.20","1 through 10","9.35","174.25","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","both","","","205.00","123.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","174.25","85","","138.20","138.20","138.20","1 through 10","9.35","174.25","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","outpatient","","","205.00","123.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","128.70","62.78","","124.30","124.30","124.30","1 through 10","13.41","158.67","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","outpatient","","","205.00","123.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","89.63","43.72","","86.57","86.57","86.57","1 through 10","13.41","158.67","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","outpatient","","","205.00","123.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","149.08","72.72","","143.99","143.99","143.99","95","13.41","158.67","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","outpatient","","","205.00","123.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","109.10","53.22","","105.55","105.55","105.55","1 through 10","13.41","158.67","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","outpatient","","","205.00","123.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","128.95","62.9","","124.74","124.74","124.74","115","13.41","158.67","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","outpatient","","","205.00","123.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","158.67","77.4","","153.45","153.45","153.45","62","13.41","158.67","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","both","","","182.00","109.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","127.04","69.8","","122.85","110.70","122.85","22","8.37","154.7","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","outpatient","","","182.00","109.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","79.57","43.72","","76.95","76.95","76.95","1 through 10","12.01","140.87","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","outpatient","","","182.00","109.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","132.35","72.72","","127.99","127.99","127.99","34","12.01","140.87","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","outpatient","","","182.00","109.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","96.86","53.22","","93.83","93.83","93.83","1 through 10","12.01","140.87","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","outpatient","","","182.00","109.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","114.48","62.9","","110.88","110.88","176.00","43","12.01","140.87","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","outpatient","","","182.00","109.20","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","132.35","72.72","","136.40","136.40","136.40","1 through 10","12.01","140.87","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","outpatient","","","182.00","109.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","140.87","77.4","","136.40","136.40","136.40","13","12.01","140.87","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","both","","","52.00","31.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","36.30","69.8","","34.90","31.45","34.90","1 through 10","6.23","49.65","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","outpatient","","","52.00","31.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","22.73","43.72","","21.86","21.86","21.86","1 through 10","8.9","40.25","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","outpatient","","","52.00","31.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","37.81","72.72","","36.36","36.36","36.36","1 through 10","8.9","40.25","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","outpatient","","","52.00","31.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","37.81","72.72","","36.36","36.36","36.36","1 through 10","8.9","40.25","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","outpatient","","","52.00","31.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","32.71","62.9","","31.50","31.50","31.50","11","8.9","40.25","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","outpatient","","","52.00","31.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","40.25","77.4","","38.75","38.75","38.75","1 through 10","8.9","40.25","percent of total billed charges",""
"Sc Infus Thpy/Proph/Dx Intl Up to 1","PX-26000007","CDM","96369","CPT","0260","RC","","","","both","","","1288.00","772.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","226.72","","APC Price ($220.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","223.12","223.12","223.12","1 through 10","215.72","1406.76","other","OPPS APC"
"SCAPULA PLATE 6 HOLE BONE ACROMION LOCKING RIGHT","SUP-ITM-10045070","CDM","C1713","HCPCS","0278","RC","","","","both","","","7692.10","4615.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","894.59","6538.29","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCAPULA PLATE 6 HOLE BONE ACROMION LOCKING RIGHT","SUP-ITM-10045070","CDM","C1713","HCPCS","0278","RC","","","","both","","","7692.10","4615.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","894.59","6538.29","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCAPULA PLATE 6 HOLE BONE ACROMION LOCKING RIGHT","SUP-ITM-10045070","CDM","C1713","HCPCS","0278","RC","","","","both","","","7692.10","4615.26","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4376.80","56.9","","812.12","238.65","1587.46","163","894.59","6538.29","percent of total billed charges",""
"SCAPULA PLATE 6 HOLE BONE ACROMION LOCKING RIGHT","SUP-ITM-10045070","CDM","C1713","HCPCS","0278","RC","","","","both","","","7692.10","4615.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","894.59","11.63","","112.68","112.68","146.99","38","894.59","6538.29","percent of total billed charges",""
"SCAPULA PLATE 6 HOLE BONE ACROMION LOCKING RIGHT","SUP-ITM-10045070","CDM","C1713","HCPCS","0278","RC","","","","both","","","7692.10","4615.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5953.69","77.4","","303.98","303.98","5854.79","1 through 10","894.59","6538.29","percent of total billed charges",""
"SCAPULA PLATE 6 HOLE BONE ACROMION LOCKING RIGHT","SUP-ITM-10045070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7692.10","4615.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","894.59","11.63","","112.68","112.68","146.99","38","894.59","5953.69","percent of total billed charges",""
"SCAPULA PLATE 6 HOLE BONE ACROMION LOCKING RIGHT","SUP-ITM-10045070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7692.10","4615.26","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4829.10","62.78","","780.86","208.94","10480.28","15","894.59","5953.69","percent of total billed charges",""
"SCAPULA PLATE 6 HOLE BONE ACROMION LOCKING RIGHT","SUP-ITM-10045070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7692.10","4615.26","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3362.99","43.72","","179.76","179.76","179.76","1 through 10","894.59","5953.69","percent of total billed charges",""
"SCAPULA PLATE 6 HOLE BONE ACROMION LOCKING RIGHT","SUP-ITM-10045070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7692.10","4615.26","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5593.70","72.72","","2355.45","298.99","3965.19","155","894.59","5953.69","percent of total billed charges",""
"SCAPULA PLATE 6 HOLE BONE ACROMION LOCKING RIGHT","SUP-ITM-10045070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7692.10","4615.26","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5593.70","72.72","","3643.09","3643.09","3643.09","1 through 10","894.59","5953.69","percent of total billed charges",""
"SCAPULA PLATE 6 HOLE BONE ACROMION LOCKING RIGHT","SUP-ITM-10045070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7692.10","4615.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4093.74","53.22","","554.28","554.28","554.28","16","894.59","5953.69","percent of total billed charges",""
"SCAPULA PLATE 6 HOLE BONE ACROMION LOCKING RIGHT","SUP-ITM-10045070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7692.10","4615.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4838.33","62.9","","619.64","173.09","2370.64","150","894.59","5953.69","percent of total billed charges",""
"SCAPULA PLATE 6 HOLE BONE ACROMION LOCKING RIGHT","SUP-ITM-10045070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7692.10","4615.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5953.69","77.4","","303.98","303.98","5854.79","1 through 10","894.59","5953.69","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","284.00","170.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","198.23","69.8","","191.25","191.25","191.25","31","24.08","241.4","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","284.00","170.40","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","198.23","69.8","","191.25","191.25","191.25","1 through 10","24.08","241.4","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","284.00","170.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","241.40","85","","74.03","40.73","232.90","1 through 10","24.08","241.4","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","outpatient","","","284.00","170.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","151.14","53.22","","146.07","146.07","146.07","16","151.14","219.82","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","outpatient","","","284.00","170.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","178.64","62.9","","172.62","172.62","172.62","600","151.14","219.82","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","outpatient","","","284.00","170.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","219.82","77.4","","212.35","212.35","212.35","232","151.14","219.82","percent of total billed charges",""
"SCREW BONE 1.2X3MM SELF-TAPPING CROSS-PIN","SUP-ITM-10042208","CDM","C1713","HCPCS","0278","RC","","","","both","","","432.65","259.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","50.32","367.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.2X3MM SELF-TAPPING CROSS-PIN","SUP-ITM-10042208","CDM","C1713","HCPCS","0278","RC","","","","both","","","432.65","259.59","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","50.32","367.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.2X3MM SELF-TAPPING CROSS-PIN","SUP-ITM-10042208","CDM","C1713","HCPCS","0278","RC","","","","both","","","432.65","259.59","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","246.18","56.9","","812.12","238.65","1587.46","163","50.32","367.75","percent of total billed charges",""
"SCREW BONE 1.2X3MM SELF-TAPPING CROSS-PIN","SUP-ITM-10042208","CDM","C1713","HCPCS","0278","RC","","","","both","","","432.65","259.59","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","50.32","11.63","","112.68","112.68","146.99","38","50.32","367.75","percent of total billed charges",""
"SCREW BONE 1.2X3MM SELF-TAPPING CROSS-PIN","SUP-ITM-10042208","CDM","C1713","HCPCS","0278","RC","","","","both","","","432.65","259.59","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","334.87","77.4","","303.98","303.98","5854.79","1 through 10","50.32","367.75","percent of total billed charges",""
"SCREW BONE 1.2X3MM SELF-TAPPING CROSS-PIN","SUP-ITM-10042208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","432.65","259.59","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","50.32","11.63","","112.68","112.68","146.99","38","50.32","334.87","percent of total billed charges",""
"SCREW BONE 1.2X3MM SELF-TAPPING CROSS-PIN","SUP-ITM-10042208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","432.65","259.59","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","271.62","62.78","","780.86","208.94","10480.28","15","50.32","334.87","percent of total billed charges",""
"SCREW BONE 1.2X3MM SELF-TAPPING CROSS-PIN","SUP-ITM-10042208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","432.65","259.59","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","189.15","43.72","","179.76","179.76","179.76","1 through 10","50.32","334.87","percent of total billed charges",""
"SCREW BONE 1.2X3MM SELF-TAPPING CROSS-PIN","SUP-ITM-10042208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","432.65","259.59","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","314.62","72.72","","2355.45","298.99","3965.19","155","50.32","334.87","percent of total billed charges",""
"SCREW BONE 1.2X3MM SELF-TAPPING CROSS-PIN","SUP-ITM-10042208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","432.65","259.59","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","314.62","72.72","","3643.09","3643.09","3643.09","1 through 10","50.32","334.87","percent of total billed charges",""
"SCREW BONE 1.2X3MM SELF-TAPPING CROSS-PIN","SUP-ITM-10042208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","432.65","259.59","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","230.26","53.22","","554.28","554.28","554.28","16","50.32","334.87","percent of total billed charges",""
"SCREW BONE 1.2X3MM SELF-TAPPING CROSS-PIN","SUP-ITM-10042208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","432.65","259.59","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","272.14","62.9","","619.64","173.09","2370.64","150","50.32","334.87","percent of total billed charges",""
"SCREW BONE 1.2X3MM SELF-TAPPING CROSS-PIN","SUP-ITM-10042208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","432.65","259.59","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","334.87","77.4","","303.98","303.98","5854.79","1 through 10","50.32","334.87","percent of total billed charges",""
"SCREW BONE 1.2X4MM CROSS PIN TITANIUM SELF DRILLING GOLD","SUP-ITM-10042216","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.65","378.39","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","73.34","536.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.2X4MM CROSS PIN TITANIUM SELF DRILLING GOLD","SUP-ITM-10042216","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.65","378.39","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","73.34","536.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.2X4MM CROSS PIN TITANIUM SELF DRILLING GOLD","SUP-ITM-10042216","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.65","378.39","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","358.84","56.9","","812.12","238.65","1587.46","163","73.34","536.05","percent of total billed charges",""
"SCREW BONE 1.2X4MM CROSS PIN TITANIUM SELF DRILLING GOLD","SUP-ITM-10042216","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.65","378.39","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","73.34","11.63","","112.68","112.68","146.99","38","73.34","536.05","percent of total billed charges",""
"SCREW BONE 1.2X4MM CROSS PIN TITANIUM SELF DRILLING GOLD","SUP-ITM-10042216","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.65","378.39","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","488.12","77.4","","303.98","303.98","5854.79","1 through 10","73.34","536.05","percent of total billed charges",""
"SCREW BONE 1.2X4MM CROSS PIN TITANIUM SELF DRILLING GOLD","SUP-ITM-10042216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.65","378.39","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","73.34","11.63","","112.68","112.68","146.99","38","73.34","488.12","percent of total billed charges",""
"SCREW BONE 1.2X4MM CROSS PIN TITANIUM SELF DRILLING GOLD","SUP-ITM-10042216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.65","378.39","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","395.92","62.78","","780.86","208.94","10480.28","15","73.34","488.12","percent of total billed charges",""
"SCREW BONE 1.2X4MM CROSS PIN TITANIUM SELF DRILLING GOLD","SUP-ITM-10042216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.65","378.39","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","275.72","43.72","","179.76","179.76","179.76","1 through 10","73.34","488.12","percent of total billed charges",""
"SCREW BONE 1.2X4MM CROSS PIN TITANIUM SELF DRILLING GOLD","SUP-ITM-10042216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.65","378.39","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","458.61","72.72","","2355.45","298.99","3965.19","155","73.34","488.12","percent of total billed charges",""
"SCREW BONE 1.2X4MM CROSS PIN TITANIUM SELF DRILLING GOLD","SUP-ITM-10042216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.65","378.39","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","458.61","72.72","","3643.09","3643.09","3643.09","1 through 10","73.34","488.12","percent of total billed charges",""
"SCREW BONE 1.2X4MM CROSS PIN TITANIUM SELF DRILLING GOLD","SUP-ITM-10042216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.65","378.39","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","335.63","53.22","","554.28","554.28","554.28","16","73.34","488.12","percent of total billed charges",""
"SCREW BONE 1.2X4MM CROSS PIN TITANIUM SELF DRILLING GOLD","SUP-ITM-10042216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.65","378.39","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","396.68","62.9","","619.64","173.09","2370.64","150","73.34","488.12","percent of total billed charges",""
"SCREW BONE 1.2X4MM CROSS PIN TITANIUM SELF DRILLING GOLD","SUP-ITM-10042216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.65","378.39","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","488.12","77.4","","303.98","303.98","5854.79","1 through 10","73.34","488.12","percent of total billed charges",""
"SCREW BONE 1.2X8MM CRANIAL EMERGENCY TITANIUM SELF TAPPING TEAL PK/5EA","SUP-ITM-10002360","CDM","C1713","HCPCS","0278","RC","","","","both","","","384.25","230.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","44.69","326.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.2X8MM CRANIAL EMERGENCY TITANIUM SELF TAPPING TEAL PK/5EA","SUP-ITM-10002360","CDM","C1713","HCPCS","0278","RC","","","","both","","","384.25","230.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","44.69","326.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.2X8MM CRANIAL EMERGENCY TITANIUM SELF TAPPING TEAL PK/5EA","SUP-ITM-10002360","CDM","C1713","HCPCS","0278","RC","","","","both","","","384.25","230.55","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","218.64","56.9","","812.12","238.65","1587.46","163","44.69","326.61","percent of total billed charges",""
"SCREW BONE 1.2X8MM CRANIAL EMERGENCY TITANIUM SELF TAPPING TEAL PK/5EA","SUP-ITM-10002360","CDM","C1713","HCPCS","0278","RC","","","","both","","","384.25","230.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","44.69","11.63","","112.68","112.68","146.99","38","44.69","326.61","percent of total billed charges",""
"SCREW BONE 1.2X8MM CRANIAL EMERGENCY TITANIUM SELF TAPPING TEAL PK/5EA","SUP-ITM-10002360","CDM","C1713","HCPCS","0278","RC","","","","both","","","384.25","230.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","297.41","77.4","","303.98","303.98","5854.79","1 through 10","44.69","326.61","percent of total billed charges",""
"SCREW BONE 1.2X8MM CRANIAL EMERGENCY TITANIUM SELF TAPPING TEAL PK/5EA","SUP-ITM-10002360","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","384.25","230.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","44.69","11.63","","112.68","112.68","146.99","38","44.69","297.41","percent of total billed charges",""
"SCREW BONE 1.2X8MM CRANIAL EMERGENCY TITANIUM SELF TAPPING TEAL PK/5EA","SUP-ITM-10002360","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","384.25","230.55","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","241.23","62.78","","780.86","208.94","10480.28","15","44.69","297.41","percent of total billed charges",""
"SCREW BONE 1.2X8MM CRANIAL EMERGENCY TITANIUM SELF TAPPING TEAL PK/5EA","SUP-ITM-10002360","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","384.25","230.55","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","167.99","43.72","","179.76","179.76","179.76","1 through 10","44.69","297.41","percent of total billed charges",""
"SCREW BONE 1.2X8MM CRANIAL EMERGENCY TITANIUM SELF TAPPING TEAL PK/5EA","SUP-ITM-10002360","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","384.25","230.55","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","279.43","72.72","","2355.45","298.99","3965.19","155","44.69","297.41","percent of total billed charges",""
"SCREW BONE 1.2X8MM CRANIAL EMERGENCY TITANIUM SELF TAPPING TEAL PK/5EA","SUP-ITM-10002360","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","384.25","230.55","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","279.43","72.72","","3643.09","3643.09","3643.09","1 through 10","44.69","297.41","percent of total billed charges",""
"SCREW BONE 1.2X8MM CRANIAL EMERGENCY TITANIUM SELF TAPPING TEAL PK/5EA","SUP-ITM-10002360","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","384.25","230.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","204.50","53.22","","554.28","554.28","554.28","16","44.69","297.41","percent of total billed charges",""
"SCREW BONE 1.2X8MM CRANIAL EMERGENCY TITANIUM SELF TAPPING TEAL PK/5EA","SUP-ITM-10002360","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","384.25","230.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","241.69","62.9","","619.64","173.09","2370.64","150","44.69","297.41","percent of total billed charges",""
"SCREW BONE 1.2X8MM CRANIAL EMERGENCY TITANIUM SELF TAPPING TEAL PK/5EA","SUP-ITM-10002360","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","384.25","230.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","297.41","77.4","","303.98","303.98","5854.79","1 through 10","44.69","297.41","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.84","209.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","40.69","297.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.84","209.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","40.69","297.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.84","209.90","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","199.06","56.9","","812.12","238.65","1587.46","163","40.69","297.36","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.84","209.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.69","11.63","","112.68","112.68","146.99","38","40.69","297.36","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.84","209.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","270.78","77.4","","303.98","303.98","5854.79","1 through 10","40.69","297.36","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","349.84","209.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.69","11.63","","112.68","112.68","146.99","38","40.69","270.78","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","349.84","209.90","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","219.63","62.78","","780.86","208.94","10480.28","15","40.69","270.78","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","349.84","209.90","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","152.95","43.72","","179.76","179.76","179.76","1 through 10","40.69","270.78","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","349.84","209.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","254.40","72.72","","2355.45","298.99","3965.19","155","40.69","270.78","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","349.84","209.90","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","254.40","72.72","","3643.09","3643.09","3643.09","1 through 10","40.69","270.78","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","349.84","209.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","186.18","53.22","","554.28","554.28","554.28","16","40.69","270.78","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","349.84","209.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","220.05","62.9","","619.64","173.09","2370.64","150","40.69","270.78","percent of total billed charges",""
"SCREW BONE 1.3X4MM CRANIAL CORTEX TI SELF TAPPING FLUTED TIP CRUCIFORM STARDRIVE RECESS GOLD PK/5EA","SUP-ITM-10002379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","349.84","209.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","270.78","77.4","","303.98","303.98","5854.79","1 through 10","40.69","270.78","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX TI CRUCIFORM RECESS SELF TAPPING GOLD PK/5EA","SUP-ITM-10275532","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.84","209.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","40.69","297.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.3X6MM CORTEX TI CRUCIFORM RECESS SELF TAPPING GOLD PK/5EA","SUP-ITM-10275532","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.84","209.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","40.69","297.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.3X6MM CORTEX TI CRUCIFORM RECESS SELF TAPPING GOLD PK/5EA","SUP-ITM-10275532","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.84","209.90","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","199.06","56.9","","812.12","238.65","1587.46","163","40.69","297.36","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX TI CRUCIFORM RECESS SELF TAPPING GOLD PK/5EA","SUP-ITM-10275532","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.84","209.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.69","11.63","","112.68","112.68","146.99","38","40.69","297.36","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX TI CRUCIFORM RECESS SELF TAPPING GOLD PK/5EA","SUP-ITM-10275532","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.84","209.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","270.78","77.4","","303.98","303.98","5854.79","1 through 10","40.69","297.36","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX TI CRUCIFORM RECESS SELF TAPPING GOLD PK/5EA","SUP-ITM-10275532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","349.84","209.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.69","11.63","","112.68","112.68","146.99","38","40.69","270.78","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX TI CRUCIFORM RECESS SELF TAPPING GOLD PK/5EA","SUP-ITM-10275532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","349.84","209.90","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","219.63","62.78","","780.86","208.94","10480.28","15","40.69","270.78","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX TI CRUCIFORM RECESS SELF TAPPING GOLD PK/5EA","SUP-ITM-10275532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","349.84","209.90","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","152.95","43.72","","179.76","179.76","179.76","1 through 10","40.69","270.78","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX TI CRUCIFORM RECESS SELF TAPPING GOLD PK/5EA","SUP-ITM-10275532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","349.84","209.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","254.40","72.72","","2355.45","298.99","3965.19","155","40.69","270.78","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX TI CRUCIFORM RECESS SELF TAPPING GOLD PK/5EA","SUP-ITM-10275532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","349.84","209.90","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","254.40","72.72","","3643.09","3643.09","3643.09","1 through 10","40.69","270.78","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX TI CRUCIFORM RECESS SELF TAPPING GOLD PK/5EA","SUP-ITM-10275532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","349.84","209.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","186.18","53.22","","554.28","554.28","554.28","16","40.69","270.78","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX TI CRUCIFORM RECESS SELF TAPPING GOLD PK/5EA","SUP-ITM-10275532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","349.84","209.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","220.05","62.9","","619.64","173.09","2370.64","150","40.69","270.78","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX TI CRUCIFORM RECESS SELF TAPPING GOLD PK/5EA","SUP-ITM-10275532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","349.84","209.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","270.78","77.4","","303.98","303.98","5854.79","1 through 10","40.69","270.78","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","508.78","305.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","59.17","432.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","508.78","305.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","59.17","432.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","508.78","305.27","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","289.50","56.9","","812.12","238.65","1587.46","163","59.17","432.46","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","508.78","305.27","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","59.17","11.63","","112.68","112.68","146.99","38","59.17","432.46","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","508.78","305.27","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","393.80","77.4","","303.98","303.98","5854.79","1 through 10","59.17","432.46","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","508.78","305.27","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","59.17","11.63","","112.68","112.68","146.99","38","59.17","393.8","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","508.78","305.27","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","319.41","62.78","","780.86","208.94","10480.28","15","59.17","393.8","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","508.78","305.27","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","222.44","43.72","","179.76","179.76","179.76","1 through 10","59.17","393.8","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","508.78","305.27","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","369.98","72.72","","2355.45","298.99","3965.19","155","59.17","393.8","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","508.78","305.27","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","369.98","72.72","","3643.09","3643.09","3643.09","1 through 10","59.17","393.8","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","508.78","305.27","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","270.77","53.22","","554.28","554.28","554.28","16","59.17","393.8","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","508.78","305.27","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","320.02","62.9","","619.64","173.09","2370.64","150","59.17","393.8","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","508.78","305.27","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","393.80","77.4","","303.98","303.98","5854.79","1 through 10","59.17","393.8","percent of total billed charges",""
"SCREW BONE 1.4X3MM SELF-TAPPING EMERGENCY CROSS-PIN","SUP-ITM-10042217","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.94","279.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","54.19","396.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.4X3MM SELF-TAPPING EMERGENCY CROSS-PIN","SUP-ITM-10042217","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.94","279.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","54.19","396.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.4X3MM SELF-TAPPING EMERGENCY CROSS-PIN","SUP-ITM-10042217","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.94","279.56","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","265.12","56.9","","812.12","238.65","1587.46","163","54.19","396.05","percent of total billed charges",""
"SCREW BONE 1.4X3MM SELF-TAPPING EMERGENCY CROSS-PIN","SUP-ITM-10042217","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.94","279.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","54.19","11.63","","112.68","112.68","146.99","38","54.19","396.05","percent of total billed charges",""
"SCREW BONE 1.4X3MM SELF-TAPPING EMERGENCY CROSS-PIN","SUP-ITM-10042217","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.94","279.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","360.64","77.4","","303.98","303.98","5854.79","1 through 10","54.19","396.05","percent of total billed charges",""
"SCREW BONE 1.4X3MM SELF-TAPPING EMERGENCY CROSS-PIN","SUP-ITM-10042217","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.94","279.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","54.19","11.63","","112.68","112.68","146.99","38","54.19","360.64","percent of total billed charges",""
"SCREW BONE 1.4X3MM SELF-TAPPING EMERGENCY CROSS-PIN","SUP-ITM-10042217","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.94","279.56","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","292.52","62.78","","780.86","208.94","10480.28","15","54.19","360.64","percent of total billed charges",""
"SCREW BONE 1.4X3MM SELF-TAPPING EMERGENCY CROSS-PIN","SUP-ITM-10042217","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.94","279.56","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","203.71","43.72","","179.76","179.76","179.76","1 through 10","54.19","360.64","percent of total billed charges",""
"SCREW BONE 1.4X3MM SELF-TAPPING EMERGENCY CROSS-PIN","SUP-ITM-10042217","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.94","279.56","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","338.83","72.72","","2355.45","298.99","3965.19","155","54.19","360.64","percent of total billed charges",""
"SCREW BONE 1.4X3MM SELF-TAPPING EMERGENCY CROSS-PIN","SUP-ITM-10042217","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.94","279.56","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","338.83","72.72","","3643.09","3643.09","3643.09","1 through 10","54.19","360.64","percent of total billed charges",""
"SCREW BONE 1.4X3MM SELF-TAPPING EMERGENCY CROSS-PIN","SUP-ITM-10042217","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.94","279.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","247.97","53.22","","554.28","554.28","554.28","16","54.19","360.64","percent of total billed charges",""
"SCREW BONE 1.4X3MM SELF-TAPPING EMERGENCY CROSS-PIN","SUP-ITM-10042217","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.94","279.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","293.08","62.9","","619.64","173.09","2370.64","150","54.19","360.64","percent of total billed charges",""
"SCREW BONE 1.4X3MM SELF-TAPPING EMERGENCY CROSS-PIN","SUP-ITM-10042217","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.94","279.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","360.64","77.4","","303.98","303.98","5854.79","1 through 10","54.19","360.64","percent of total billed charges",""
"SCREW BONE 1.5X10MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10073010","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.46","174.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","33.9","247.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.5X10MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10073010","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.46","174.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","33.9","247.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.5X10MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10073010","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.46","174.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","165.84","56.9","","812.12","238.65","1587.46","163","33.9","247.74","percent of total billed charges",""
"SCREW BONE 1.5X10MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10073010","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.46","174.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","33.90","11.63","","112.68","112.68","146.99","38","33.9","247.74","percent of total billed charges",""
"SCREW BONE 1.5X10MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10073010","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.46","174.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","225.59","77.4","","303.98","303.98","5854.79","1 through 10","33.9","247.74","percent of total billed charges",""
"SCREW BONE 1.5X10MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10073010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.46","174.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","33.90","11.63","","112.68","112.68","146.99","38","33.9","225.59","percent of total billed charges",""
"SCREW BONE 1.5X10MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10073010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.46","174.88","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","182.98","62.78","","780.86","208.94","10480.28","15","33.9","225.59","percent of total billed charges",""
"SCREW BONE 1.5X10MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10073010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.46","174.88","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","127.43","43.72","","179.76","179.76","179.76","1 through 10","33.9","225.59","percent of total billed charges",""
"SCREW BONE 1.5X10MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10073010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.46","174.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","211.95","72.72","","2355.45","298.99","3965.19","155","33.9","225.59","percent of total billed charges",""
"SCREW BONE 1.5X10MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10073010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.46","174.88","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","211.95","72.72","","3643.09","3643.09","3643.09","1 through 10","33.9","225.59","percent of total billed charges",""
"SCREW BONE 1.5X10MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10073010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.46","174.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","155.12","53.22","","554.28","554.28","554.28","16","33.9","225.59","percent of total billed charges",""
"SCREW BONE 1.5X10MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10073010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.46","174.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","183.33","62.9","","619.64","173.09","2370.64","150","33.9","225.59","percent of total billed charges",""
"SCREW BONE 1.5X10MM CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10073010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.46","174.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","225.59","77.4","","303.98","303.98","5854.79","1 through 10","33.9","225.59","percent of total billed charges",""
"SCREW BONE 1.5X15MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164633","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.52","392.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","76.12","556.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.5X15MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164633","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.52","392.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","76.12","556.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.5X15MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164633","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.52","392.71","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","372.42","56.9","","812.12","238.65","1587.46","163","76.12","556.34","percent of total billed charges",""
"SCREW BONE 1.5X15MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164633","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.52","392.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","76.12","11.63","","112.68","112.68","146.99","38","76.12","556.34","percent of total billed charges",""
"SCREW BONE 1.5X15MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164633","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.52","392.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","506.60","77.4","","303.98","303.98","5854.79","1 through 10","76.12","556.34","percent of total billed charges",""
"SCREW BONE 1.5X15MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.52","392.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","76.12","11.63","","112.68","112.68","146.99","38","76.12","506.6","percent of total billed charges",""
"SCREW BONE 1.5X15MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.52","392.71","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","410.91","62.78","","780.86","208.94","10480.28","15","76.12","506.6","percent of total billed charges",""
"SCREW BONE 1.5X15MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.52","392.71","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","286.16","43.72","","179.76","179.76","179.76","1 through 10","76.12","506.6","percent of total billed charges",""
"SCREW BONE 1.5X15MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.52","392.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","475.97","72.72","","2355.45","298.99","3965.19","155","76.12","506.6","percent of total billed charges",""
"SCREW BONE 1.5X15MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.52","392.71","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","475.97","72.72","","3643.09","3643.09","3643.09","1 through 10","76.12","506.6","percent of total billed charges",""
"SCREW BONE 1.5X15MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.52","392.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","348.34","53.22","","554.28","554.28","554.28","16","76.12","506.6","percent of total billed charges",""
"SCREW BONE 1.5X15MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.52","392.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","411.69","62.9","","619.64","173.09","2370.64","150","76.12","506.6","percent of total billed charges",""
"SCREW BONE 1.5X15MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.52","392.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","506.60","77.4","","303.98","303.98","5854.79","1 through 10","76.12","506.6","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131092","CDM","C1713","HCPCS","0278","RC","","","","both","","","395.74","237.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","46.02","336.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.5X4MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131092","CDM","C1713","HCPCS","0278","RC","","","","both","","","395.74","237.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","46.02","336.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.5X4MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131092","CDM","C1713","HCPCS","0278","RC","","","","both","","","395.74","237.44","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","225.18","56.9","","812.12","238.65","1587.46","163","46.02","336.38","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131092","CDM","C1713","HCPCS","0278","RC","","","","both","","","395.74","237.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","46.02","11.63","","112.68","112.68","146.99","38","46.02","336.38","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131092","CDM","C1713","HCPCS","0278","RC","","","","both","","","395.74","237.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","306.30","77.4","","303.98","303.98","5854.79","1 through 10","46.02","336.38","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","395.74","237.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","46.02","11.63","","112.68","112.68","146.99","38","46.02","306.3","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","395.74","237.44","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","248.45","62.78","","780.86","208.94","10480.28","15","46.02","306.3","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","395.74","237.44","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","173.02","43.72","","179.76","179.76","179.76","1 through 10","46.02","306.3","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","395.74","237.44","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","287.78","72.72","","2355.45","298.99","3965.19","155","46.02","306.3","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","395.74","237.44","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","287.78","72.72","","3643.09","3643.09","3643.09","1 through 10","46.02","306.3","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","395.74","237.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","210.61","53.22","","554.28","554.28","554.28","16","46.02","306.3","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","395.74","237.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","248.92","62.9","","619.64","173.09","2370.64","150","46.02","306.3","percent of total billed charges",""
"SCREW BONE 1.5X4MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","395.74","237.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","306.30","77.4","","303.98","303.98","5854.79","1 through 10","46.02","306.3","percent of total billed charges",""
"SCREW BONE 1.5X9MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10082517","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.25","182.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","35.38","258.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.5X9MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10082517","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.25","182.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","35.38","258.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.5X9MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10082517","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.25","182.55","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","173.12","56.9","","812.12","238.65","1587.46","163","35.38","258.61","percent of total billed charges",""
"SCREW BONE 1.5X9MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10082517","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.25","182.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","35.38","11.63","","112.68","112.68","146.99","38","35.38","258.61","percent of total billed charges",""
"SCREW BONE 1.5X9MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10082517","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.25","182.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","235.49","77.4","","303.98","303.98","5854.79","1 through 10","35.38","258.61","percent of total billed charges",""
"SCREW BONE 1.5X9MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10082517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.25","182.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","35.38","11.63","","112.68","112.68","146.99","38","35.38","235.49","percent of total billed charges",""
"SCREW BONE 1.5X9MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10082517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.25","182.55","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","191.01","62.78","","780.86","208.94","10480.28","15","35.38","235.49","percent of total billed charges",""
"SCREW BONE 1.5X9MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10082517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.25","182.55","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","133.02","43.72","","179.76","179.76","179.76","1 through 10","35.38","235.49","percent of total billed charges",""
"SCREW BONE 1.5X9MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10082517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.25","182.55","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","221.25","72.72","","2355.45","298.99","3965.19","155","35.38","235.49","percent of total billed charges",""
"SCREW BONE 1.5X9MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10082517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.25","182.55","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","221.25","72.72","","3643.09","3643.09","3643.09","1 through 10","35.38","235.49","percent of total billed charges",""
"SCREW BONE 1.5X9MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10082517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.25","182.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","161.92","53.22","","554.28","554.28","554.28","16","35.38","235.49","percent of total billed charges",""
"SCREW BONE 1.5X9MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10082517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.25","182.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","191.37","62.9","","619.64","173.09","2370.64","150","35.38","235.49","percent of total billed charges",""
"SCREW BONE 1.5X9MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10082517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.25","182.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","235.49","77.4","","303.98","303.98","5854.79","1 through 10","35.38","235.49","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.22","141.13","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","27.36","199.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.22","141.13","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","27.36","199.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.22","141.13","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","133.84","56.9","","812.12","238.65","1587.46","163","27.36","199.94","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.22","141.13","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","27.36","11.63","","112.68","112.68","146.99","38","27.36","199.94","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.22","141.13","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","182.06","77.4","","303.98","303.98","5854.79","1 through 10","27.36","199.94","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.22","141.13","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","27.36","11.63","","112.68","112.68","146.99","38","27.36","182.06","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.22","141.13","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","147.67","62.78","","780.86","208.94","10480.28","15","27.36","182.06","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.22","141.13","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","102.84","43.72","","179.76","179.76","179.76","1 through 10","27.36","182.06","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.22","141.13","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","171.05","72.72","","2355.45","298.99","3965.19","155","27.36","182.06","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.22","141.13","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","171.05","72.72","","3643.09","3643.09","3643.09","1 through 10","27.36","182.06","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.22","141.13","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","125.18","53.22","","554.28","554.28","554.28","16","27.36","182.06","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.22","141.13","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","147.95","62.9","","619.64","173.09","2370.64","150","27.36","182.06","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.22","141.13","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","182.06","77.4","","303.98","303.98","5854.79","1 through 10","27.36","182.06","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","both","","","1242.83","745.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","144.54","1056.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","both","","","1242.83","745.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","144.54","1056.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","both","","","1242.83","745.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","707.17","56.9","","812.12","238.65","1587.46","163","144.54","1056.41","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","both","","","1242.83","745.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","144.54","11.63","","112.68","112.68","146.99","38","144.54","1056.41","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","both","","","1242.83","745.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","961.95","77.4","","303.98","303.98","5854.79","1 through 10","144.54","1056.41","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.83","745.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","144.54","11.63","","112.68","112.68","146.99","38","144.54","961.95","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.83","745.70","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","780.25","62.78","","780.86","208.94","10480.28","15","144.54","961.95","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.83","745.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","543.37","43.72","","179.76","179.76","179.76","1 through 10","144.54","961.95","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.83","745.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","903.79","72.72","","2355.45","298.99","3965.19","155","144.54","961.95","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.83","745.70","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","903.79","72.72","","3643.09","3643.09","3643.09","1 through 10","144.54","961.95","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.83","745.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","661.43","53.22","","554.28","554.28","554.28","16","144.54","961.95","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.83","745.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","781.74","62.9","","619.64","173.09","2370.64","150","144.54","961.95","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.83","745.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","961.95","77.4","","303.98","303.98","5854.79","1 through 10","144.54","961.95","percent of total billed charges",""
"SCREW BONE 1.7X3MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042219","CDM","C1713","HCPCS","0278","RC","","","","both","","","351.09","210.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","40.83","298.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.7X3MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042219","CDM","C1713","HCPCS","0278","RC","","","","both","","","351.09","210.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","40.83","298.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.7X3MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042219","CDM","C1713","HCPCS","0278","RC","","","","both","","","351.09","210.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","199.77","56.9","","812.12","238.65","1587.46","163","40.83","298.43","percent of total billed charges",""
"SCREW BONE 1.7X3MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042219","CDM","C1713","HCPCS","0278","RC","","","","both","","","351.09","210.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.83","11.63","","112.68","112.68","146.99","38","40.83","298.43","percent of total billed charges",""
"SCREW BONE 1.7X3MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042219","CDM","C1713","HCPCS","0278","RC","","","","both","","","351.09","210.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","271.74","77.4","","303.98","303.98","5854.79","1 through 10","40.83","298.43","percent of total billed charges",""
"SCREW BONE 1.7X3MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","351.09","210.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.83","11.63","","112.68","112.68","146.99","38","40.83","271.74","percent of total billed charges",""
"SCREW BONE 1.7X3MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","351.09","210.65","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","220.41","62.78","","780.86","208.94","10480.28","15","40.83","271.74","percent of total billed charges",""
"SCREW BONE 1.7X3MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","351.09","210.65","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","153.50","43.72","","179.76","179.76","179.76","1 through 10","40.83","271.74","percent of total billed charges",""
"SCREW BONE 1.7X3MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","351.09","210.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","255.31","72.72","","2355.45","298.99","3965.19","155","40.83","271.74","percent of total billed charges",""
"SCREW BONE 1.7X3MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","351.09","210.65","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","255.31","72.72","","3643.09","3643.09","3643.09","1 through 10","40.83","271.74","percent of total billed charges",""
"SCREW BONE 1.7X3MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","351.09","210.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","186.85","53.22","","554.28","554.28","554.28","16","40.83","271.74","percent of total billed charges",""
"SCREW BONE 1.7X3MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","351.09","210.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","220.84","62.9","","619.64","173.09","2370.64","150","40.83","271.74","percent of total billed charges",""
"SCREW BONE 1.7X3MM LEIBINGER UNIVERSAL 2 TITANIUM SELF TAPPING CROSS PIN","SUP-ITM-10042219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","351.09","210.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","271.74","77.4","","303.98","303.98","5854.79","1 through 10","40.83","271.74","percent of total billed charges",""
"SCREW BONE 1.7X6MM TITANIUM LOCKING SELF TAPPING FULL THREAD CROSS PIN","SUP-ITM-10143462","CDM","C1713","HCPCS","0278","RC","","","","both","","","1242.83","745.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","144.54","1056.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.7X6MM TITANIUM LOCKING SELF TAPPING FULL THREAD CROSS PIN","SUP-ITM-10143462","CDM","C1713","HCPCS","0278","RC","","","","both","","","1242.83","745.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","144.54","1056.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.7X6MM TITANIUM LOCKING SELF TAPPING FULL THREAD CROSS PIN","SUP-ITM-10143462","CDM","C1713","HCPCS","0278","RC","","","","both","","","1242.83","745.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","707.17","56.9","","812.12","238.65","1587.46","163","144.54","1056.41","percent of total billed charges",""
"SCREW BONE 1.7X6MM TITANIUM LOCKING SELF TAPPING FULL THREAD CROSS PIN","SUP-ITM-10143462","CDM","C1713","HCPCS","0278","RC","","","","both","","","1242.83","745.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","144.54","11.63","","112.68","112.68","146.99","38","144.54","1056.41","percent of total billed charges",""
"SCREW BONE 1.7X6MM TITANIUM LOCKING SELF TAPPING FULL THREAD CROSS PIN","SUP-ITM-10143462","CDM","C1713","HCPCS","0278","RC","","","","both","","","1242.83","745.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","961.95","77.4","","303.98","303.98","5854.79","1 through 10","144.54","1056.41","percent of total billed charges",""
"SCREW BONE 1.7X6MM TITANIUM LOCKING SELF TAPPING FULL THREAD CROSS PIN","SUP-ITM-10143462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.83","745.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","144.54","11.63","","112.68","112.68","146.99","38","144.54","961.95","percent of total billed charges",""
"SCREW BONE 1.7X6MM TITANIUM LOCKING SELF TAPPING FULL THREAD CROSS PIN","SUP-ITM-10143462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.83","745.70","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","780.25","62.78","","780.86","208.94","10480.28","15","144.54","961.95","percent of total billed charges",""
"SCREW BONE 1.7X6MM TITANIUM LOCKING SELF TAPPING FULL THREAD CROSS PIN","SUP-ITM-10143462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.83","745.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","543.37","43.72","","179.76","179.76","179.76","1 through 10","144.54","961.95","percent of total billed charges",""
"SCREW BONE 1.7X6MM TITANIUM LOCKING SELF TAPPING FULL THREAD CROSS PIN","SUP-ITM-10143462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.83","745.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","903.79","72.72","","2355.45","298.99","3965.19","155","144.54","961.95","percent of total billed charges",""
"SCREW BONE 1.7X6MM TITANIUM LOCKING SELF TAPPING FULL THREAD CROSS PIN","SUP-ITM-10143462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.83","745.70","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","903.79","72.72","","3643.09","3643.09","3643.09","1 through 10","144.54","961.95","percent of total billed charges",""
"SCREW BONE 1.7X6MM TITANIUM LOCKING SELF TAPPING FULL THREAD CROSS PIN","SUP-ITM-10143462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.83","745.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","661.43","53.22","","554.28","554.28","554.28","16","144.54","961.95","percent of total billed charges",""
"SCREW BONE 1.7X6MM TITANIUM LOCKING SELF TAPPING FULL THREAD CROSS PIN","SUP-ITM-10143462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.83","745.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","781.74","62.9","","619.64","173.09","2370.64","150","144.54","961.95","percent of total billed charges",""
"SCREW BONE 1.7X6MM TITANIUM LOCKING SELF TAPPING FULL THREAD CROSS PIN","SUP-ITM-10143462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.83","745.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","961.95","77.4","","303.98","303.98","5854.79","1 through 10","144.54","961.95","percent of total billed charges",""
"SCREW BONE 1.7X7MM TI PROFYLE SELF TAPPING","SUP-ITM-10143877","CDM","C1713","HCPCS","0278","RC","","","","both","","","1028.28","616.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","119.59","874.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.7X7MM TI PROFYLE SELF TAPPING","SUP-ITM-10143877","CDM","C1713","HCPCS","0278","RC","","","","both","","","1028.28","616.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","119.59","874.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.7X7MM TI PROFYLE SELF TAPPING","SUP-ITM-10143877","CDM","C1713","HCPCS","0278","RC","","","","both","","","1028.28","616.97","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","585.09","56.9","","812.12","238.65","1587.46","163","119.59","874.04","percent of total billed charges",""
"SCREW BONE 1.7X7MM TI PROFYLE SELF TAPPING","SUP-ITM-10143877","CDM","C1713","HCPCS","0278","RC","","","","both","","","1028.28","616.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","119.59","11.63","","112.68","112.68","146.99","38","119.59","874.04","percent of total billed charges",""
"SCREW BONE 1.7X7MM TI PROFYLE SELF TAPPING","SUP-ITM-10143877","CDM","C1713","HCPCS","0278","RC","","","","both","","","1028.28","616.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","795.89","77.4","","303.98","303.98","5854.79","1 through 10","119.59","874.04","percent of total billed charges",""
"SCREW BONE 1.7X7MM TI PROFYLE SELF TAPPING","SUP-ITM-10143877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","119.59","11.63","","112.68","112.68","146.99","38","119.59","795.89","percent of total billed charges",""
"SCREW BONE 1.7X7MM TI PROFYLE SELF TAPPING","SUP-ITM-10143877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","645.55","62.78","","780.86","208.94","10480.28","15","119.59","795.89","percent of total billed charges",""
"SCREW BONE 1.7X7MM TI PROFYLE SELF TAPPING","SUP-ITM-10143877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","449.56","43.72","","179.76","179.76","179.76","1 through 10","119.59","795.89","percent of total billed charges",""
"SCREW BONE 1.7X7MM TI PROFYLE SELF TAPPING","SUP-ITM-10143877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","747.77","72.72","","2355.45","298.99","3965.19","155","119.59","795.89","percent of total billed charges",""
"SCREW BONE 1.7X7MM TI PROFYLE SELF TAPPING","SUP-ITM-10143877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","747.77","72.72","","3643.09","3643.09","3643.09","1 through 10","119.59","795.89","percent of total billed charges",""
"SCREW BONE 1.7X7MM TI PROFYLE SELF TAPPING","SUP-ITM-10143877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","547.25","53.22","","554.28","554.28","554.28","16","119.59","795.89","percent of total billed charges",""
"SCREW BONE 1.7X7MM TI PROFYLE SELF TAPPING","SUP-ITM-10143877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","646.79","62.9","","619.64","173.09","2370.64","150","119.59","795.89","percent of total billed charges",""
"SCREW BONE 1.7X7MM TI PROFYLE SELF TAPPING","SUP-ITM-10143877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","795.89","77.4","","303.98","303.98","5854.79","1 through 10","119.59","795.89","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","both","","","647.88","388.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","75.35","550.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","both","","","647.88","388.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","75.35","550.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","both","","","647.88","388.73","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","368.64","56.9","","812.12","238.65","1587.46","163","75.35","550.7","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","both","","","647.88","388.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","75.35","11.63","","112.68","112.68","146.99","38","75.35","550.7","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","both","","","647.88","388.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","501.46","77.4","","303.98","303.98","5854.79","1 through 10","75.35","550.7","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","75.35","11.63","","112.68","112.68","146.99","38","75.35","501.46","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","406.74","62.78","","780.86","208.94","10480.28","15","75.35","501.46","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","283.25","43.72","","179.76","179.76","179.76","1 through 10","75.35","501.46","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","471.14","72.72","","2355.45","298.99","3965.19","155","75.35","501.46","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","471.14","72.72","","3643.09","3643.09","3643.09","1 through 10","75.35","501.46","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","344.80","53.22","","554.28","554.28","554.28","16","75.35","501.46","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","407.52","62.9","","619.64","173.09","2370.64","150","75.35","501.46","percent of total billed charges",""
"SCREW BONE 1.8X18MM PIN BUTTRESS SS LOCKING VARIABLE ANGLE T8 STARDRIVE RECESS","SUP-ITM-10092343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","647.88","388.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","501.46","77.4","","303.98","303.98","5854.79","1 through 10","75.35","501.46","percent of total billed charges",""
"SCREW BONE 1.8X6MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131098","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.93","233.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","45.35","331.44","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.8X6MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131098","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.93","233.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","45.35","331.44","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 1.8X6MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131098","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.93","233.96","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","221.87","56.9","","812.12","238.65","1587.46","163","45.35","331.44","percent of total billed charges",""
"SCREW BONE 1.8X6MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131098","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.93","233.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","45.35","11.63","","112.68","112.68","146.99","38","45.35","331.44","percent of total billed charges",""
"SCREW BONE 1.8X6MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131098","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.93","233.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","301.81","77.4","","303.98","303.98","5854.79","1 through 10","45.35","331.44","percent of total billed charges",""
"SCREW BONE 1.8X6MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.93","233.96","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","45.35","11.63","","112.68","112.68","146.99","38","45.35","301.81","percent of total billed charges",""
"SCREW BONE 1.8X6MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.93","233.96","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","244.80","62.78","","780.86","208.94","10480.28","15","45.35","301.81","percent of total billed charges",""
"SCREW BONE 1.8X6MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.93","233.96","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","170.48","43.72","","179.76","179.76","179.76","1 through 10","45.35","301.81","percent of total billed charges",""
"SCREW BONE 1.8X6MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.93","233.96","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","283.56","72.72","","2355.45","298.99","3965.19","155","45.35","301.81","percent of total billed charges",""
"SCREW BONE 1.8X6MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.93","233.96","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","283.56","72.72","","3643.09","3643.09","3643.09","1 through 10","45.35","301.81","percent of total billed charges",""
"SCREW BONE 1.8X6MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.93","233.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","207.52","53.22","","554.28","554.28","554.28","16","45.35","301.81","percent of total billed charges",""
"SCREW BONE 1.8X6MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.93","233.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","245.27","62.9","","619.64","173.09","2370.64","150","45.35","301.81","percent of total billed charges",""
"SCREW BONE 1.8X6MM EMERGENCY MATRIXMIDFACE TI SELF TAPPING LIGHT BLUE","SUP-ITM-10131098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.93","233.96","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","301.81","77.4","","303.98","303.98","5854.79","1 through 10","45.35","301.81","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","5910.88","3546.53","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","687.44","5024.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","5910.88","3546.53","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","687.44","5024.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","5910.88","3546.53","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3363.29","56.9","","812.12","238.65","1587.46","163","687.44","5024.25","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","5910.88","3546.53","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","687.44","11.63","","112.68","112.68","146.99","38","687.44","5024.25","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","5910.88","3546.53","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4575.02","77.4","","303.98","303.98","5854.79","1 through 10","687.44","5024.25","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5910.88","3546.53","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","687.44","11.63","","112.68","112.68","146.99","38","687.44","4575.02","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5910.88","3546.53","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3710.85","62.78","","780.86","208.94","10480.28","15","687.44","4575.02","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5910.88","3546.53","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2584.24","43.72","","179.76","179.76","179.76","1 through 10","687.44","4575.02","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5910.88","3546.53","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4298.39","72.72","","2355.45","298.99","3965.19","155","687.44","4575.02","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5910.88","3546.53","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4298.39","72.72","","3643.09","3643.09","3643.09","1 through 10","687.44","4575.02","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5910.88","3546.53","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3145.77","53.22","","554.28","554.28","554.28","16","687.44","4575.02","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5910.88","3546.53","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3717.94","62.9","","619.64","173.09","2370.64","150","687.44","4575.02","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5910.88","3546.53","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4575.02","77.4","","303.98","303.98","5854.79","1 through 10","687.44","4575.02","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","3336.49","2001.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","388.03","2836.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","3336.49","2001.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","388.03","2836.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","3336.49","2001.89","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1898.46","56.9","","812.12","238.65","1587.46","163","388.03","2836.02","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","3336.49","2001.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","388.03","11.63","","112.68","112.68","146.99","38","388.03","2836.02","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","3336.49","2001.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2582.44","77.4","","303.98","303.98","5854.79","1 through 10","388.03","2836.02","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3336.49","2001.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","388.03","11.63","","112.68","112.68","146.99","38","388.03","2582.44","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3336.49","2001.89","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2094.65","62.78","","780.86","208.94","10480.28","15","388.03","2582.44","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3336.49","2001.89","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1458.71","43.72","","179.76","179.76","179.76","1 through 10","388.03","2582.44","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3336.49","2001.89","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2426.30","72.72","","2355.45","298.99","3965.19","155","388.03","2582.44","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3336.49","2001.89","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2426.30","72.72","","3643.09","3643.09","3643.09","1 through 10","388.03","2582.44","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3336.49","2001.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1775.68","53.22","","554.28","554.28","554.28","16","388.03","2582.44","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3336.49","2001.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2098.65","62.9","","619.64","173.09","2370.64","150","388.03","2582.44","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3336.49","2001.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2582.44","77.4","","303.98","303.98","5854.79","1 through 10","388.03","2582.44","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","both","","","3336.49","2001.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","388.03","2836.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","both","","","3336.49","2001.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","388.03","2836.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","both","","","3336.49","2001.89","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1898.46","56.9","","812.12","238.65","1587.46","163","388.03","2836.02","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","both","","","3336.49","2001.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","388.03","11.63","","112.68","112.68","146.99","38","388.03","2836.02","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","both","","","3336.49","2001.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2582.44","77.4","","303.98","303.98","5854.79","1 through 10","388.03","2836.02","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3336.49","2001.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","388.03","11.63","","112.68","112.68","146.99","38","388.03","2582.44","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3336.49","2001.89","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2094.65","62.78","","780.86","208.94","10480.28","15","388.03","2582.44","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3336.49","2001.89","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1458.71","43.72","","179.76","179.76","179.76","1 through 10","388.03","2582.44","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3336.49","2001.89","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2426.30","72.72","","2355.45","298.99","3965.19","155","388.03","2582.44","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3336.49","2001.89","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2426.30","72.72","","3643.09","3643.09","3643.09","1 through 10","388.03","2582.44","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3336.49","2001.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1775.68","53.22","","554.28","554.28","554.28","16","388.03","2582.44","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3336.49","2001.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2098.65","62.9","","619.64","173.09","2370.64","150","388.03","2582.44","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3336.49","2001.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2582.44","77.4","","303.98","303.98","5854.79","1 through 10","388.03","2582.44","percent of total billed charges",""
"SCREW BONE 10MM 4X24 CANNULATED SS PARTIAL THREAD","SUP-ITM-10018570","CDM","C1713","HCPCS","0278","RC","","","","both","","","2936.75","1762.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","341.54","2496.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 10MM 4X24 CANNULATED SS PARTIAL THREAD","SUP-ITM-10018570","CDM","C1713","HCPCS","0278","RC","","","","both","","","2936.75","1762.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","341.54","2496.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 10MM 4X24 CANNULATED SS PARTIAL THREAD","SUP-ITM-10018570","CDM","C1713","HCPCS","0278","RC","","","","both","","","2936.75","1762.05","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1671.01","56.9","","812.12","238.65","1587.46","163","341.54","2496.24","percent of total billed charges",""
"SCREW BONE 10MM 4X24 CANNULATED SS PARTIAL THREAD","SUP-ITM-10018570","CDM","C1713","HCPCS","0278","RC","","","","both","","","2936.75","1762.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","341.54","11.63","","112.68","112.68","146.99","38","341.54","2496.24","percent of total billed charges",""
"SCREW BONE 10MM 4X24 CANNULATED SS PARTIAL THREAD","SUP-ITM-10018570","CDM","C1713","HCPCS","0278","RC","","","","both","","","2936.75","1762.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2273.04","77.4","","303.98","303.98","5854.79","1 through 10","341.54","2496.24","percent of total billed charges",""
"SCREW BONE 10MM 4X24 CANNULATED SS PARTIAL THREAD","SUP-ITM-10018570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","341.54","11.63","","112.68","112.68","146.99","38","341.54","2273.04","percent of total billed charges",""
"SCREW BONE 10MM 4X24 CANNULATED SS PARTIAL THREAD","SUP-ITM-10018570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1843.69","62.78","","780.86","208.94","10480.28","15","341.54","2273.04","percent of total billed charges",""
"SCREW BONE 10MM 4X24 CANNULATED SS PARTIAL THREAD","SUP-ITM-10018570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1283.95","43.72","","179.76","179.76","179.76","1 through 10","341.54","2273.04","percent of total billed charges",""
"SCREW BONE 10MM 4X24 CANNULATED SS PARTIAL THREAD","SUP-ITM-10018570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2135.60","72.72","","2355.45","298.99","3965.19","155","341.54","2273.04","percent of total billed charges",""
"SCREW BONE 10MM 4X24 CANNULATED SS PARTIAL THREAD","SUP-ITM-10018570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2135.60","72.72","","3643.09","3643.09","3643.09","1 through 10","341.54","2273.04","percent of total billed charges",""
"SCREW BONE 10MM 4X24 CANNULATED SS PARTIAL THREAD","SUP-ITM-10018570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1562.94","53.22","","554.28","554.28","554.28","16","341.54","2273.04","percent of total billed charges",""
"SCREW BONE 10MM 4X24 CANNULATED SS PARTIAL THREAD","SUP-ITM-10018570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1847.22","62.9","","619.64","173.09","2370.64","150","341.54","2273.04","percent of total billed charges",""
"SCREW BONE 10MM 4X24 CANNULATED SS PARTIAL THREAD","SUP-ITM-10018570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2273.04","77.4","","303.98","303.98","5854.79","1 through 10","341.54","2273.04","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE COMPOSITCP PLDLA 60% BETA TRICALCIUM RESORBABLE ANTERIOR ROUND HEAD","SUP-ITM-10216283","CDM","C1713","HCPCS","0278","RC","","","","both","","","2647.64","1588.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","307.92","2250.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 10X25MM INTERFERENCE COMPOSITCP PLDLA 60% BETA TRICALCIUM RESORBABLE ANTERIOR ROUND HEAD","SUP-ITM-10216283","CDM","C1713","HCPCS","0278","RC","","","","both","","","2647.64","1588.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","307.92","2250.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 10X25MM INTERFERENCE COMPOSITCP PLDLA 60% BETA TRICALCIUM RESORBABLE ANTERIOR ROUND HEAD","SUP-ITM-10216283","CDM","C1713","HCPCS","0278","RC","","","","both","","","2647.64","1588.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1506.51","56.9","","812.12","238.65","1587.46","163","307.92","2250.49","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE COMPOSITCP PLDLA 60% BETA TRICALCIUM RESORBABLE ANTERIOR ROUND HEAD","SUP-ITM-10216283","CDM","C1713","HCPCS","0278","RC","","","","both","","","2647.64","1588.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","307.92","11.63","","112.68","112.68","146.99","38","307.92","2250.49","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE COMPOSITCP PLDLA 60% BETA TRICALCIUM RESORBABLE ANTERIOR ROUND HEAD","SUP-ITM-10216283","CDM","C1713","HCPCS","0278","RC","","","","both","","","2647.64","1588.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2049.27","77.4","","303.98","303.98","5854.79","1 through 10","307.92","2250.49","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE COMPOSITCP PLDLA 60% BETA TRICALCIUM RESORBABLE ANTERIOR ROUND HEAD","SUP-ITM-10216283","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2647.64","1588.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","307.92","11.63","","112.68","112.68","146.99","38","307.92","2049.27","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE COMPOSITCP PLDLA 60% BETA TRICALCIUM RESORBABLE ANTERIOR ROUND HEAD","SUP-ITM-10216283","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2647.64","1588.58","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1662.19","62.78","","780.86","208.94","10480.28","15","307.92","2049.27","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE COMPOSITCP PLDLA 60% BETA TRICALCIUM RESORBABLE ANTERIOR ROUND HEAD","SUP-ITM-10216283","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2647.64","1588.58","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1157.55","43.72","","179.76","179.76","179.76","1 through 10","307.92","2049.27","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE COMPOSITCP PLDLA 60% BETA TRICALCIUM RESORBABLE ANTERIOR ROUND HEAD","SUP-ITM-10216283","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2647.64","1588.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1925.36","72.72","","2355.45","298.99","3965.19","155","307.92","2049.27","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE COMPOSITCP PLDLA 60% BETA TRICALCIUM RESORBABLE ANTERIOR ROUND HEAD","SUP-ITM-10216283","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2647.64","1588.58","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1925.36","72.72","","3643.09","3643.09","3643.09","1 through 10","307.92","2049.27","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE COMPOSITCP PLDLA 60% BETA TRICALCIUM RESORBABLE ANTERIOR ROUND HEAD","SUP-ITM-10216283","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2647.64","1588.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1409.07","53.22","","554.28","554.28","554.28","16","307.92","2049.27","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE COMPOSITCP PLDLA 60% BETA TRICALCIUM RESORBABLE ANTERIOR ROUND HEAD","SUP-ITM-10216283","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2647.64","1588.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1665.37","62.9","","619.64","173.09","2370.64","150","307.92","2049.27","percent of total billed charges",""
"SCREW BONE 10X25MM INTERFERENCE COMPOSITCP PLDLA 60% BETA TRICALCIUM RESORBABLE ANTERIOR ROUND HEAD","SUP-ITM-10216283","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2647.64","1588.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2049.27","77.4","","303.98","303.98","5854.79","1 through 10","307.92","2049.27","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","718.64","431.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","83.58","610.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","718.64","431.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","83.58","610.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","718.64","431.18","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","408.91","56.9","","812.12","238.65","1587.46","163","83.58","610.84","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","718.64","431.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","83.58","11.63","","112.68","112.68","146.99","38","83.58","610.84","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","718.64","431.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","556.23","77.4","","303.98","303.98","5854.79","1 through 10","83.58","610.84","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","83.58","11.63","","112.68","112.68","146.99","38","83.58","556.23","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","451.16","62.78","","780.86","208.94","10480.28","15","83.58","556.23","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","314.19","43.72","","179.76","179.76","179.76","1 through 10","83.58","556.23","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","522.60","72.72","","2355.45","298.99","3965.19","155","83.58","556.23","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","522.60","72.72","","3643.09","3643.09","3643.09","1 through 10","83.58","556.23","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","382.46","53.22","","554.28","554.28","554.28","16","83.58","556.23","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","452.02","62.9","","619.64","173.09","2370.64","150","83.58","556.23","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","556.23","77.4","","303.98","303.98","5854.79","1 through 10","83.58","556.23","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","both","","","739.37","443.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","85.99","628.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","both","","","739.37","443.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","85.99","628.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","both","","","739.37","443.62","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","420.70","56.9","","812.12","238.65","1587.46","163","85.99","628.46","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","both","","","739.37","443.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","85.99","11.63","","112.68","112.68","146.99","38","85.99","628.46","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","both","","","739.37","443.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","572.27","77.4","","303.98","303.98","5854.79","1 through 10","85.99","628.46","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","739.37","443.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","85.99","11.63","","112.68","112.68","146.99","38","85.99","572.27","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","739.37","443.62","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","464.18","62.78","","780.86","208.94","10480.28","15","85.99","572.27","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","739.37","443.62","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","323.25","43.72","","179.76","179.76","179.76","1 through 10","85.99","572.27","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","739.37","443.62","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","537.67","72.72","","2355.45","298.99","3965.19","155","85.99","572.27","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","739.37","443.62","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","537.67","72.72","","3643.09","3643.09","3643.09","1 through 10","85.99","572.27","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","739.37","443.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","393.49","53.22","","554.28","554.28","554.28","16","85.99","572.27","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","739.37","443.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","465.06","62.9","","619.64","173.09","2370.64","150","85.99","572.27","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","739.37","443.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","572.27","77.4","","303.98","303.98","5854.79","1 through 10","85.99","572.27","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","2176.65","1305.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","253.14","1850.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","2176.65","1305.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","253.14","1850.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","2176.65","1305.99","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1238.51","56.9","","812.12","238.65","1587.46","163","253.14","1850.15","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","2176.65","1305.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","253.14","11.63","","112.68","112.68","146.99","38","253.14","1850.15","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","2176.65","1305.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1684.73","77.4","","303.98","303.98","5854.79","1 through 10","253.14","1850.15","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2176.65","1305.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","253.14","11.63","","112.68","112.68","146.99","38","253.14","1684.73","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2176.65","1305.99","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1366.50","62.78","","780.86","208.94","10480.28","15","253.14","1684.73","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2176.65","1305.99","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","951.63","43.72","","179.76","179.76","179.76","1 through 10","253.14","1684.73","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2176.65","1305.99","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1582.86","72.72","","2355.45","298.99","3965.19","155","253.14","1684.73","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2176.65","1305.99","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1582.86","72.72","","3643.09","3643.09","3643.09","1 through 10","253.14","1684.73","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2176.65","1305.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1158.41","53.22","","554.28","554.28","554.28","16","253.14","1684.73","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2176.65","1305.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1369.11","62.9","","619.64","173.09","2370.64","150","253.14","1684.73","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2176.65","1305.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1684.73","77.4","","303.98","303.98","5854.79","1 through 10","253.14","1684.73","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1554.75","932.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","180.82","1321.54","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1554.75","932.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","180.82","1321.54","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1554.75","932.85","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","884.65","56.9","","812.12","238.65","1587.46","163","180.82","1321.54","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1554.75","932.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","180.82","11.63","","112.68","112.68","146.99","38","180.82","1321.54","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","both","","","1554.75","932.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1203.38","77.4","","303.98","303.98","5854.79","1 through 10","180.82","1321.54","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1554.75","932.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","180.82","11.63","","112.68","112.68","146.99","38","180.82","1203.38","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1554.75","932.85","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","976.07","62.78","","780.86","208.94","10480.28","15","180.82","1203.38","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1554.75","932.85","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","679.74","43.72","","179.76","179.76","179.76","1 through 10","180.82","1203.38","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1554.75","932.85","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1130.61","72.72","","2355.45","298.99","3965.19","155","180.82","1203.38","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1554.75","932.85","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1130.61","72.72","","3643.09","3643.09","3643.09","1 through 10","180.82","1203.38","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1554.75","932.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","827.44","53.22","","554.28","554.28","554.28","16","180.82","1203.38","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1554.75","932.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","977.94","62.9","","619.64","173.09","2370.64","150","180.82","1203.38","percent of total billed charges",""
"SCREW BONE 11X28MM BIOSTEON INTERFERENCE","SUP-ITM-10091968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1554.75","932.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1203.38","77.4","","303.98","303.98","5854.79","1 through 10","180.82","1203.38","percent of total billed charges",""
"SCREW BONE 12.7X110MM LAG 22MM THREAD DHS DCS ONE STEP SS","SUP-ITM-10007170","CDM","C1713","HCPCS","0278","RC","","","","both","","","1774.35","1064.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","206.36","1508.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 12.7X110MM LAG 22MM THREAD DHS DCS ONE STEP SS","SUP-ITM-10007170","CDM","C1713","HCPCS","0278","RC","","","","both","","","1774.35","1064.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","206.36","1508.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 12.7X110MM LAG 22MM THREAD DHS DCS ONE STEP SS","SUP-ITM-10007170","CDM","C1713","HCPCS","0278","RC","","","","both","","","1774.35","1064.61","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1009.61","56.9","","812.12","238.65","1587.46","163","206.36","1508.2","percent of total billed charges",""
"SCREW BONE 12.7X110MM LAG 22MM THREAD DHS DCS ONE STEP SS","SUP-ITM-10007170","CDM","C1713","HCPCS","0278","RC","","","","both","","","1774.35","1064.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","206.36","11.63","","112.68","112.68","146.99","38","206.36","1508.2","percent of total billed charges",""
"SCREW BONE 12.7X110MM LAG 22MM THREAD DHS DCS ONE STEP SS","SUP-ITM-10007170","CDM","C1713","HCPCS","0278","RC","","","","both","","","1774.35","1064.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1373.35","77.4","","303.98","303.98","5854.79","1 through 10","206.36","1508.2","percent of total billed charges",""
"SCREW BONE 12.7X110MM LAG 22MM THREAD DHS DCS ONE STEP SS","SUP-ITM-10007170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","206.36","11.63","","112.68","112.68","146.99","38","206.36","1373.35","percent of total billed charges",""
"SCREW BONE 12.7X110MM LAG 22MM THREAD DHS DCS ONE STEP SS","SUP-ITM-10007170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1113.94","62.78","","780.86","208.94","10480.28","15","206.36","1373.35","percent of total billed charges",""
"SCREW BONE 12.7X110MM LAG 22MM THREAD DHS DCS ONE STEP SS","SUP-ITM-10007170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","775.75","43.72","","179.76","179.76","179.76","1 through 10","206.36","1373.35","percent of total billed charges",""
"SCREW BONE 12.7X110MM LAG 22MM THREAD DHS DCS ONE STEP SS","SUP-ITM-10007170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1290.31","72.72","","2355.45","298.99","3965.19","155","206.36","1373.35","percent of total billed charges",""
"SCREW BONE 12.7X110MM LAG 22MM THREAD DHS DCS ONE STEP SS","SUP-ITM-10007170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1290.31","72.72","","3643.09","3643.09","3643.09","1 through 10","206.36","1373.35","percent of total billed charges",""
"SCREW BONE 12.7X110MM LAG 22MM THREAD DHS DCS ONE STEP SS","SUP-ITM-10007170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","944.31","53.22","","554.28","554.28","554.28","16","206.36","1373.35","percent of total billed charges",""
"SCREW BONE 12.7X110MM LAG 22MM THREAD DHS DCS ONE STEP SS","SUP-ITM-10007170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1116.07","62.9","","619.64","173.09","2370.64","150","206.36","1373.35","percent of total billed charges",""
"SCREW BONE 12.7X110MM LAG 22MM THREAD DHS DCS ONE STEP SS","SUP-ITM-10007170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1373.35","77.4","","303.98","303.98","5854.79","1 through 10","206.36","1373.35","percent of total billed charges",""
"SCREW BONE 12.7X22X85MM LAG STAINLESS STEEL DHS DCS ONE STEP THREAD","SUP-ITM-10038181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2027.46","1216.48","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","235.79","1723.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 12.7X22X85MM LAG STAINLESS STEEL DHS DCS ONE STEP THREAD","SUP-ITM-10038181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2027.46","1216.48","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","235.79","1723.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 12.7X22X85MM LAG STAINLESS STEEL DHS DCS ONE STEP THREAD","SUP-ITM-10038181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2027.46","1216.48","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1153.62","56.9","","812.12","238.65","1587.46","163","235.79","1723.34","percent of total billed charges",""
"SCREW BONE 12.7X22X85MM LAG STAINLESS STEEL DHS DCS ONE STEP THREAD","SUP-ITM-10038181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2027.46","1216.48","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","235.79","11.63","","112.68","112.68","146.99","38","235.79","1723.34","percent of total billed charges",""
"SCREW BONE 12.7X22X85MM LAG STAINLESS STEEL DHS DCS ONE STEP THREAD","SUP-ITM-10038181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2027.46","1216.48","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1569.25","77.4","","303.98","303.98","5854.79","1 through 10","235.79","1723.34","percent of total billed charges",""
"SCREW BONE 12.7X22X85MM LAG STAINLESS STEEL DHS DCS ONE STEP THREAD","SUP-ITM-10038181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2027.46","1216.48","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","235.79","11.63","","112.68","112.68","146.99","38","235.79","1569.25","percent of total billed charges",""
"SCREW BONE 12.7X22X85MM LAG STAINLESS STEEL DHS DCS ONE STEP THREAD","SUP-ITM-10038181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2027.46","1216.48","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1272.84","62.78","","780.86","208.94","10480.28","15","235.79","1569.25","percent of total billed charges",""
"SCREW BONE 12.7X22X85MM LAG STAINLESS STEEL DHS DCS ONE STEP THREAD","SUP-ITM-10038181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2027.46","1216.48","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","886.41","43.72","","179.76","179.76","179.76","1 through 10","235.79","1569.25","percent of total billed charges",""
"SCREW BONE 12.7X22X85MM LAG STAINLESS STEEL DHS DCS ONE STEP THREAD","SUP-ITM-10038181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2027.46","1216.48","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1474.37","72.72","","2355.45","298.99","3965.19","155","235.79","1569.25","percent of total billed charges",""
"SCREW BONE 12.7X22X85MM LAG STAINLESS STEEL DHS DCS ONE STEP THREAD","SUP-ITM-10038181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2027.46","1216.48","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1474.37","72.72","","3643.09","3643.09","3643.09","1 through 10","235.79","1569.25","percent of total billed charges",""
"SCREW BONE 12.7X22X85MM LAG STAINLESS STEEL DHS DCS ONE STEP THREAD","SUP-ITM-10038181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2027.46","1216.48","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1079.01","53.22","","554.28","554.28","554.28","16","235.79","1569.25","percent of total billed charges",""
"SCREW BONE 12.7X22X85MM LAG STAINLESS STEEL DHS DCS ONE STEP THREAD","SUP-ITM-10038181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2027.46","1216.48","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1275.27","62.9","","619.64","173.09","2370.64","150","235.79","1569.25","percent of total billed charges",""
"SCREW BONE 12.7X22X85MM LAG STAINLESS STEEL DHS DCS ONE STEP THREAD","SUP-ITM-10038181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2027.46","1216.48","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1569.25","77.4","","303.98","303.98","5854.79","1 through 10","235.79","1569.25","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","both","","","230.10","138.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","26.76","195.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","both","","","230.10","138.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","26.76","195.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","both","","","230.10","138.06","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","130.93","56.9","","812.12","238.65","1587.46","163","26.76","195.59","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","both","","","230.10","138.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","26.76","11.63","","112.68","112.68","146.99","38","26.76","195.59","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","both","","","230.10","138.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","178.10","77.4","","303.98","303.98","5854.79","1 through 10","26.76","195.59","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","230.10","138.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","26.76","11.63","","112.68","112.68","146.99","38","26.76","178.1","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","230.10","138.06","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","144.46","62.78","","780.86","208.94","10480.28","15","26.76","178.1","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","230.10","138.06","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","100.60","43.72","","179.76","179.76","179.76","1 through 10","26.76","178.1","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","230.10","138.06","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","167.33","72.72","","2355.45","298.99","3965.19","155","26.76","178.1","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","230.10","138.06","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","167.33","72.72","","3643.09","3643.09","3643.09","1 through 10","26.76","178.1","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","230.10","138.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","122.46","53.22","","554.28","554.28","554.28","16","26.76","178.1","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","230.10","138.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","144.73","62.9","","619.64","173.09","2370.64","150","26.76","178.1","percent of total billed charges",""
"SCREW BONE 12.7X36MM LAG DHS/DCS ONE STEP SS CANNULATED THREAD","SUP-ITM-10015778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","230.10","138.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","178.10","77.4","","303.98","303.98","5854.79","1 through 10","26.76","178.1","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1774.35","1064.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","206.36","1508.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1774.35","1064.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","206.36","1508.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1774.35","1064.61","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1009.61","56.9","","812.12","238.65","1587.46","163","206.36","1508.2","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1774.35","1064.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","206.36","11.63","","112.68","112.68","146.99","38","206.36","1508.2","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1774.35","1064.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1373.35","77.4","","303.98","303.98","5854.79","1 through 10","206.36","1508.2","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","206.36","11.63","","112.68","112.68","146.99","38","206.36","1373.35","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1113.94","62.78","","780.86","208.94","10480.28","15","206.36","1373.35","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","775.75","43.72","","179.76","179.76","179.76","1 through 10","206.36","1373.35","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1290.31","72.72","","2355.45","298.99","3965.19","155","206.36","1373.35","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1290.31","72.72","","3643.09","3643.09","3643.09","1 through 10","206.36","1373.35","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","944.31","53.22","","554.28","554.28","554.28","16","206.36","1373.35","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1116.07","62.9","","619.64","173.09","2370.64","150","206.36","1373.35","percent of total billed charges",""
"SCREW BONE 12.7X90MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10007168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1774.35","1064.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1373.35","77.4","","303.98","303.98","5854.79","1 through 10","206.36","1373.35","percent of total billed charges",""
"SCREW BONE 12X3.5MM CORTEX PERI LOC SS SELF TAPPING LOW PROFILE HEX HEAD","SUP-ITM-10064530","CDM","C1713","HCPCS","0278","RC","","","","both","","","379.36","227.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","44.12","322.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 12X3.5MM CORTEX PERI LOC SS SELF TAPPING LOW PROFILE HEX HEAD","SUP-ITM-10064530","CDM","C1713","HCPCS","0278","RC","","","","both","","","379.36","227.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","44.12","322.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 12X3.5MM CORTEX PERI LOC SS SELF TAPPING LOW PROFILE HEX HEAD","SUP-ITM-10064530","CDM","C1713","HCPCS","0278","RC","","","","both","","","379.36","227.62","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","215.86","56.9","","812.12","238.65","1587.46","163","44.12","322.46","percent of total billed charges",""
"SCREW BONE 12X3.5MM CORTEX PERI LOC SS SELF TAPPING LOW PROFILE HEX HEAD","SUP-ITM-10064530","CDM","C1713","HCPCS","0278","RC","","","","both","","","379.36","227.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","44.12","11.63","","112.68","112.68","146.99","38","44.12","322.46","percent of total billed charges",""
"SCREW BONE 12X3.5MM CORTEX PERI LOC SS SELF TAPPING LOW PROFILE HEX HEAD","SUP-ITM-10064530","CDM","C1713","HCPCS","0278","RC","","","","both","","","379.36","227.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","293.62","77.4","","303.98","303.98","5854.79","1 through 10","44.12","322.46","percent of total billed charges",""
"SCREW BONE 12X3.5MM CORTEX PERI LOC SS SELF TAPPING LOW PROFILE HEX HEAD","SUP-ITM-10064530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","379.36","227.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","44.12","11.63","","112.68","112.68","146.99","38","44.12","293.62","percent of total billed charges",""
"SCREW BONE 12X3.5MM CORTEX PERI LOC SS SELF TAPPING LOW PROFILE HEX HEAD","SUP-ITM-10064530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","379.36","227.62","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","238.16","62.78","","780.86","208.94","10480.28","15","44.12","293.62","percent of total billed charges",""
"SCREW BONE 12X3.5MM CORTEX PERI LOC SS SELF TAPPING LOW PROFILE HEX HEAD","SUP-ITM-10064530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","379.36","227.62","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","165.86","43.72","","179.76","179.76","179.76","1 through 10","44.12","293.62","percent of total billed charges",""
"SCREW BONE 12X3.5MM CORTEX PERI LOC SS SELF TAPPING LOW PROFILE HEX HEAD","SUP-ITM-10064530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","379.36","227.62","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","275.87","72.72","","2355.45","298.99","3965.19","155","44.12","293.62","percent of total billed charges",""
"SCREW BONE 12X3.5MM CORTEX PERI LOC SS SELF TAPPING LOW PROFILE HEX HEAD","SUP-ITM-10064530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","379.36","227.62","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","275.87","72.72","","3643.09","3643.09","3643.09","1 through 10","44.12","293.62","percent of total billed charges",""
"SCREW BONE 12X3.5MM CORTEX PERI LOC SS SELF TAPPING LOW PROFILE HEX HEAD","SUP-ITM-10064530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","379.36","227.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","201.90","53.22","","554.28","554.28","554.28","16","44.12","293.62","percent of total billed charges",""
"SCREW BONE 12X3.5MM CORTEX PERI LOC SS SELF TAPPING LOW PROFILE HEX HEAD","SUP-ITM-10064530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","379.36","227.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","238.62","62.9","","619.64","173.09","2370.64","150","44.12","293.62","percent of total billed charges",""
"SCREW BONE 12X3.5MM CORTEX PERI LOC SS SELF TAPPING LOW PROFILE HEX HEAD","SUP-ITM-10064530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","379.36","227.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","293.62","77.4","","303.98","303.98","5854.79","1 through 10","44.12","293.62","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","718.64","431.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","83.58","610.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","718.64","431.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","83.58","610.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","718.64","431.18","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","408.91","56.9","","812.12","238.65","1587.46","163","83.58","610.84","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","718.64","431.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","83.58","11.63","","112.68","112.68","146.99","38","83.58","610.84","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","718.64","431.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","556.23","77.4","","303.98","303.98","5854.79","1 through 10","83.58","610.84","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","83.58","11.63","","112.68","112.68","146.99","38","83.58","556.23","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","451.16","62.78","","780.86","208.94","10480.28","15","83.58","556.23","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","314.19","43.72","","179.76","179.76","179.76","1 through 10","83.58","556.23","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","522.60","72.72","","2355.45","298.99","3965.19","155","83.58","556.23","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","522.60","72.72","","3643.09","3643.09","3643.09","1 through 10","83.58","556.23","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","382.46","53.22","","554.28","554.28","554.28","16","83.58","556.23","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","452.02","62.9","","619.64","173.09","2370.64","150","83.58","556.23","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","718.64","431.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","556.23","77.4","","303.98","303.98","5854.79","1 through 10","83.58","556.23","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.61","294.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","57.06","417.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.61","294.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","57.06","417.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.61","294.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","279.16","56.9","","812.12","238.65","1587.46","163","57.06","417.02","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.61","294.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","57.06","11.63","","112.68","112.68","146.99","38","57.06","417.02","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.61","294.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","379.73","77.4","","303.98","303.98","5854.79","1 through 10","57.06","417.02","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.61","294.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","57.06","11.63","","112.68","112.68","146.99","38","57.06","379.73","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.61","294.37","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","308.00","62.78","","780.86","208.94","10480.28","15","57.06","379.73","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.61","294.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","214.49","43.72","","179.76","179.76","179.76","1 through 10","57.06","379.73","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.61","294.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","356.77","72.72","","2355.45","298.99","3965.19","155","57.06","379.73","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.61","294.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","356.77","72.72","","3643.09","3643.09","3643.09","1 through 10","57.06","379.73","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.61","294.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","261.10","53.22","","554.28","554.28","554.28","16","57.06","379.73","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.61","294.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","308.59","62.9","","619.64","173.09","2370.64","150","57.06","379.73","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.61","294.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","379.73","77.4","","303.98","303.98","5854.79","1 through 10","57.06","379.73","percent of total billed charges",""
"SCREW BONE 12X4MM SPINE CERVICAL ATLANTIS TI SELF TAPPING VARIABLE ANGLE","SUP-ITM-10058991","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.00","414.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","80.36","587.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 12X4MM SPINE CERVICAL ATLANTIS TI SELF TAPPING VARIABLE ANGLE","SUP-ITM-10058991","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.00","414.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","80.36","587.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 12X4MM SPINE CERVICAL ATLANTIS TI SELF TAPPING VARIABLE ANGLE","SUP-ITM-10058991","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.00","414.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","393.18","56.9","","812.12","238.65","1587.46","163","80.36","587.35","percent of total billed charges",""
"SCREW BONE 12X4MM SPINE CERVICAL ATLANTIS TI SELF TAPPING VARIABLE ANGLE","SUP-ITM-10058991","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.00","414.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","80.36","11.63","","112.68","112.68","146.99","38","80.36","587.35","percent of total billed charges",""
"SCREW BONE 12X4MM SPINE CERVICAL ATLANTIS TI SELF TAPPING VARIABLE ANGLE","SUP-ITM-10058991","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.00","414.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","534.83","77.4","","303.98","303.98","5854.79","1 through 10","80.36","587.35","percent of total billed charges",""
"SCREW BONE 12X4MM SPINE CERVICAL ATLANTIS TI SELF TAPPING VARIABLE ANGLE","SUP-ITM-10058991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","80.36","11.63","","112.68","112.68","146.99","38","80.36","534.83","percent of total billed charges",""
"SCREW BONE 12X4MM SPINE CERVICAL ATLANTIS TI SELF TAPPING VARIABLE ANGLE","SUP-ITM-10058991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","433.81","62.78","","780.86","208.94","10480.28","15","80.36","534.83","percent of total billed charges",""
"SCREW BONE 12X4MM SPINE CERVICAL ATLANTIS TI SELF TAPPING VARIABLE ANGLE","SUP-ITM-10058991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","302.11","43.72","","179.76","179.76","179.76","1 through 10","80.36","534.83","percent of total billed charges",""
"SCREW BONE 12X4MM SPINE CERVICAL ATLANTIS TI SELF TAPPING VARIABLE ANGLE","SUP-ITM-10058991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","502.50","72.72","","2355.45","298.99","3965.19","155","80.36","534.83","percent of total billed charges",""
"SCREW BONE 12X4MM SPINE CERVICAL ATLANTIS TI SELF TAPPING VARIABLE ANGLE","SUP-ITM-10058991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","502.50","72.72","","3643.09","3643.09","3643.09","1 through 10","80.36","534.83","percent of total billed charges",""
"SCREW BONE 12X4MM SPINE CERVICAL ATLANTIS TI SELF TAPPING VARIABLE ANGLE","SUP-ITM-10058991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","367.75","53.22","","554.28","554.28","554.28","16","80.36","534.83","percent of total billed charges",""
"SCREW BONE 12X4MM SPINE CERVICAL ATLANTIS TI SELF TAPPING VARIABLE ANGLE","SUP-ITM-10058991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","434.64","62.9","","619.64","173.09","2370.64","150","80.36","534.83","percent of total billed charges",""
"SCREW BONE 12X4MM SPINE CERVICAL ATLANTIS TI SELF TAPPING VARIABLE ANGLE","SUP-ITM-10058991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","534.83","77.4","","303.98","303.98","5854.79","1 through 10","80.36","534.83","percent of total billed charges",""
"SCREW BONE 130MM FEMORAL PROXIMAL TITANIUM TFN-ADVANCE","SUP-ITM-10164412","CDM","C1713","HCPCS","0278","RC","","","","both","","","3034.80","1820.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","352.95","2579.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 130MM FEMORAL PROXIMAL TITANIUM TFN-ADVANCE","SUP-ITM-10164412","CDM","C1713","HCPCS","0278","RC","","","","both","","","3034.80","1820.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","352.95","2579.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 130MM FEMORAL PROXIMAL TITANIUM TFN-ADVANCE","SUP-ITM-10164412","CDM","C1713","HCPCS","0278","RC","","","","both","","","3034.80","1820.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1726.80","56.9","","812.12","238.65","1587.46","163","352.95","2579.58","percent of total billed charges",""
"SCREW BONE 130MM FEMORAL PROXIMAL TITANIUM TFN-ADVANCE","SUP-ITM-10164412","CDM","C1713","HCPCS","0278","RC","","","","both","","","3034.80","1820.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","352.95","11.63","","112.68","112.68","146.99","38","352.95","2579.58","percent of total billed charges",""
"SCREW BONE 130MM FEMORAL PROXIMAL TITANIUM TFN-ADVANCE","SUP-ITM-10164412","CDM","C1713","HCPCS","0278","RC","","","","both","","","3034.80","1820.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2348.94","77.4","","303.98","303.98","5854.79","1 through 10","352.95","2579.58","percent of total billed charges",""
"SCREW BONE 130MM FEMORAL PROXIMAL TITANIUM TFN-ADVANCE","SUP-ITM-10164412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3034.80","1820.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","352.95","11.63","","112.68","112.68","146.99","38","352.95","2348.94","percent of total billed charges",""
"SCREW BONE 130MM FEMORAL PROXIMAL TITANIUM TFN-ADVANCE","SUP-ITM-10164412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3034.80","1820.88","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1905.25","62.78","","780.86","208.94","10480.28","15","352.95","2348.94","percent of total billed charges",""
"SCREW BONE 130MM FEMORAL PROXIMAL TITANIUM TFN-ADVANCE","SUP-ITM-10164412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3034.80","1820.88","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1326.81","43.72","","179.76","179.76","179.76","1 through 10","352.95","2348.94","percent of total billed charges",""
"SCREW BONE 130MM FEMORAL PROXIMAL TITANIUM TFN-ADVANCE","SUP-ITM-10164412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3034.80","1820.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2206.91","72.72","","2355.45","298.99","3965.19","155","352.95","2348.94","percent of total billed charges",""
"SCREW BONE 130MM FEMORAL PROXIMAL TITANIUM TFN-ADVANCE","SUP-ITM-10164412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3034.80","1820.88","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2206.91","72.72","","3643.09","3643.09","3643.09","1 through 10","352.95","2348.94","percent of total billed charges",""
"SCREW BONE 130MM FEMORAL PROXIMAL TITANIUM TFN-ADVANCE","SUP-ITM-10164412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3034.80","1820.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1615.12","53.22","","554.28","554.28","554.28","16","352.95","2348.94","percent of total billed charges",""
"SCREW BONE 130MM FEMORAL PROXIMAL TITANIUM TFN-ADVANCE","SUP-ITM-10164412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3034.80","1820.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1908.89","62.9","","619.64","173.09","2370.64","150","352.95","2348.94","percent of total billed charges",""
"SCREW BONE 130MM FEMORAL PROXIMAL TITANIUM TFN-ADVANCE","SUP-ITM-10164412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3034.80","1820.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2348.94","77.4","","303.98","303.98","5854.79","1 through 10","352.95","2348.94","percent of total billed charges",""
"SCREW BONE 14X2.7MM VARIAX TITANIUM LOCKING FULL THREAD T7 DRIVE","SUP-ITM-10086653","CDM","C1713","HCPCS","0278","RC","","","","both","","","1302.05","781.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","151.43","1106.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 14X2.7MM VARIAX TITANIUM LOCKING FULL THREAD T7 DRIVE","SUP-ITM-10086653","CDM","C1713","HCPCS","0278","RC","","","","both","","","1302.05","781.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","151.43","1106.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 14X2.7MM VARIAX TITANIUM LOCKING FULL THREAD T7 DRIVE","SUP-ITM-10086653","CDM","C1713","HCPCS","0278","RC","","","","both","","","1302.05","781.23","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","740.87","56.9","","812.12","238.65","1587.46","163","151.43","1106.74","percent of total billed charges",""
"SCREW BONE 14X2.7MM VARIAX TITANIUM LOCKING FULL THREAD T7 DRIVE","SUP-ITM-10086653","CDM","C1713","HCPCS","0278","RC","","","","both","","","1302.05","781.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","151.43","11.63","","112.68","112.68","146.99","38","151.43","1106.74","percent of total billed charges",""
"SCREW BONE 14X2.7MM VARIAX TITANIUM LOCKING FULL THREAD T7 DRIVE","SUP-ITM-10086653","CDM","C1713","HCPCS","0278","RC","","","","both","","","1302.05","781.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1007.79","77.4","","303.98","303.98","5854.79","1 through 10","151.43","1106.74","percent of total billed charges",""
"SCREW BONE 14X2.7MM VARIAX TITANIUM LOCKING FULL THREAD T7 DRIVE","SUP-ITM-10086653","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","151.43","11.63","","112.68","112.68","146.99","38","151.43","1007.79","percent of total billed charges",""
"SCREW BONE 14X2.7MM VARIAX TITANIUM LOCKING FULL THREAD T7 DRIVE","SUP-ITM-10086653","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","817.43","62.78","","780.86","208.94","10480.28","15","151.43","1007.79","percent of total billed charges",""
"SCREW BONE 14X2.7MM VARIAX TITANIUM LOCKING FULL THREAD T7 DRIVE","SUP-ITM-10086653","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","569.26","43.72","","179.76","179.76","179.76","1 through 10","151.43","1007.79","percent of total billed charges",""
"SCREW BONE 14X2.7MM VARIAX TITANIUM LOCKING FULL THREAD T7 DRIVE","SUP-ITM-10086653","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","946.85","72.72","","2355.45","298.99","3965.19","155","151.43","1007.79","percent of total billed charges",""
"SCREW BONE 14X2.7MM VARIAX TITANIUM LOCKING FULL THREAD T7 DRIVE","SUP-ITM-10086653","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","946.85","72.72","","3643.09","3643.09","3643.09","1 through 10","151.43","1007.79","percent of total billed charges",""
"SCREW BONE 14X2.7MM VARIAX TITANIUM LOCKING FULL THREAD T7 DRIVE","SUP-ITM-10086653","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","692.95","53.22","","554.28","554.28","554.28","16","151.43","1007.79","percent of total billed charges",""
"SCREW BONE 14X2.7MM VARIAX TITANIUM LOCKING FULL THREAD T7 DRIVE","SUP-ITM-10086653","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","818.99","62.9","","619.64","173.09","2370.64","150","151.43","1007.79","percent of total billed charges",""
"SCREW BONE 14X2.7MM VARIAX TITANIUM LOCKING FULL THREAD T7 DRIVE","SUP-ITM-10086653","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1007.79","77.4","","303.98","303.98","5854.79","1 through 10","151.43","1007.79","percent of total billed charges",""
"SCREW BONE 14X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025232","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","401.82","2936.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 14X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025232","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","401.82","2936.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 14X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025232","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1965.90","56.9","","812.12","238.65","1587.46","163","401.82","2936.75","percent of total billed charges",""
"SCREW BONE 14X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025232","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","401.82","11.63","","112.68","112.68","146.99","38","401.82","2936.75","percent of total billed charges",""
"SCREW BONE 14X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025232","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2674.17","77.4","","303.98","303.98","5854.79","1 through 10","401.82","2936.75","percent of total billed charges",""
"SCREW BONE 14X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","401.82","11.63","","112.68","112.68","146.99","38","401.82","2674.17","percent of total billed charges",""
"SCREW BONE 14X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2169.05","62.78","","780.86","208.94","10480.28","15","401.82","2674.17","percent of total billed charges",""
"SCREW BONE 14X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1510.53","43.72","","179.76","179.76","179.76","1 through 10","401.82","2674.17","percent of total billed charges",""
"SCREW BONE 14X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2512.48","72.72","","2355.45","298.99","3965.19","155","401.82","2674.17","percent of total billed charges",""
"SCREW BONE 14X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2512.48","72.72","","3643.09","3643.09","3643.09","1 through 10","401.82","2674.17","percent of total billed charges",""
"SCREW BONE 14X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1838.75","53.22","","554.28","554.28","554.28","16","401.82","2674.17","percent of total billed charges",""
"SCREW BONE 14X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2173.20","62.9","","619.64","173.09","2370.64","150","401.82","2674.17","percent of total billed charges",""
"SCREW BONE 14X3.5MM SPINE PEDICLE VERTEX MAX TI MULTIAXIAL SELF TAPPING GREEN","SUP-ITM-10025232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2674.17","77.4","","303.98","303.98","5854.79","1 through 10","401.82","2674.17","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","2383.95","1430.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","277.25","2026.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","2383.95","1430.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","277.25","2026.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","2383.95","1430.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1356.47","56.9","","812.12","238.65","1587.46","163","277.25","2026.36","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","2383.95","1430.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","277.25","11.63","","112.68","112.68","146.99","38","277.25","2026.36","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","2383.95","1430.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1845.18","77.4","","303.98","303.98","5854.79","1 through 10","277.25","2026.36","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2383.95","1430.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","277.25","11.63","","112.68","112.68","146.99","38","277.25","1845.18","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2383.95","1430.37","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1496.64","62.78","","780.86","208.94","10480.28","15","277.25","1845.18","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2383.95","1430.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1042.26","43.72","","179.76","179.76","179.76","1 through 10","277.25","1845.18","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2383.95","1430.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1733.61","72.72","","2355.45","298.99","3965.19","155","277.25","1845.18","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2383.95","1430.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1733.61","72.72","","3643.09","3643.09","3643.09","1 through 10","277.25","1845.18","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2383.95","1430.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1268.74","53.22","","554.28","554.28","554.28","16","277.25","1845.18","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2383.95","1430.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1499.50","62.9","","619.64","173.09","2370.64","150","277.25","1845.18","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2383.95","1430.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1845.18","77.4","","303.98","303.98","5854.79","1 through 10","277.25","1845.18","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.58","157.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","30.54","223.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.58","157.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","30.54","223.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.58","157.55","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","149.41","56.9","","812.12","238.65","1587.46","163","30.54","223.19","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.58","157.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","30.54","11.63","","112.68","112.68","146.99","38","30.54","223.19","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.58","157.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","203.24","77.4","","303.98","303.98","5854.79","1 through 10","30.54","223.19","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","30.54","11.63","","112.68","112.68","146.99","38","30.54","203.24","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","164.85","62.78","","780.86","208.94","10480.28","15","30.54","203.24","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","114.80","43.72","","179.76","179.76","179.76","1 through 10","30.54","203.24","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","190.95","72.72","","2355.45","298.99","3965.19","155","30.54","203.24","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","190.95","72.72","","3643.09","3643.09","3643.09","1 through 10","30.54","203.24","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","139.75","53.22","","554.28","554.28","554.28","16","30.54","203.24","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","165.16","62.9","","619.64","173.09","2370.64","150","30.54","203.24","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","203.24","77.4","","303.98","303.98","5854.79","1 through 10","30.54","203.24","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076876","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.85","145.11","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","28.13","205.57","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 16.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076876","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.85","145.11","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","28.13","205.57","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 16.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076876","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.85","145.11","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","137.61","56.9","","812.12","238.65","1587.46","163","28.13","205.57","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076876","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.85","145.11","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","28.13","11.63","","112.68","112.68","146.99","38","28.13","205.57","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076876","CDM","C1713","HCPCS","0278","RC","","","","both","","","241.85","145.11","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","187.19","77.4","","303.98","303.98","5854.79","1 through 10","28.13","205.57","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","241.85","145.11","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","28.13","11.63","","112.68","112.68","146.99","38","28.13","187.19","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","241.85","145.11","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","151.83","62.78","","780.86","208.94","10480.28","15","28.13","187.19","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","241.85","145.11","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","105.74","43.72","","179.76","179.76","179.76","1 through 10","28.13","187.19","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","241.85","145.11","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","175.87","72.72","","2355.45","298.99","3965.19","155","28.13","187.19","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","241.85","145.11","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","175.87","72.72","","3643.09","3643.09","3643.09","1 through 10","28.13","187.19","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","241.85","145.11","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","128.71","53.22","","554.28","554.28","554.28","16","28.13","187.19","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","241.85","145.11","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","152.12","62.9","","619.64","173.09","2370.64","150","28.13","187.19","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","241.85","145.11","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","187.19","77.4","","303.98","303.98","5854.79","1 through 10","28.13","187.19","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.26","356.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","69.11","505.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.26","356.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","69.11","505.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.26","356.56","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","338.13","56.9","","812.12","238.65","1587.46","163","69.11","505.12","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.26","356.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","69.11","11.63","","112.68","112.68","146.99","38","69.11","505.12","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.26","356.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","459.96","77.4","","303.98","303.98","5854.79","1 through 10","69.11","505.12","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","594.26","356.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","69.11","11.63","","112.68","112.68","146.99","38","69.11","459.96","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","594.26","356.56","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","373.08","62.78","","780.86","208.94","10480.28","15","69.11","459.96","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","594.26","356.56","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","259.81","43.72","","179.76","179.76","179.76","1 through 10","69.11","459.96","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","594.26","356.56","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","432.15","72.72","","2355.45","298.99","3965.19","155","69.11","459.96","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","594.26","356.56","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","432.15","72.72","","3643.09","3643.09","3643.09","1 through 10","69.11","459.96","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","594.26","356.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","316.27","53.22","","554.28","554.28","554.28","16","69.11","459.96","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","594.26","356.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","373.79","62.9","","619.64","173.09","2370.64","150","69.11","459.96","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","594.26","356.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","459.96","77.4","","303.98","303.98","5854.79","1 through 10","69.11","459.96","percent of total billed charges",""
"SCREW BONE 16X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076910","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.65","476.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","92.42","675.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 16X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076910","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.65","476.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","92.42","675.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 16X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076910","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.65","476.79","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","452.16","56.9","","812.12","238.65","1587.46","163","92.42","675.45","percent of total billed charges",""
"SCREW BONE 16X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076910","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.65","476.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","92.42","11.63","","112.68","112.68","146.99","38","92.42","675.45","percent of total billed charges",""
"SCREW BONE 16X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076910","CDM","C1713","HCPCS","0278","RC","","","","both","","","794.65","476.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","615.06","77.4","","303.98","303.98","5854.79","1 through 10","92.42","675.45","percent of total billed charges",""
"SCREW BONE 16X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","92.42","11.63","","112.68","112.68","146.99","38","92.42","615.06","percent of total billed charges",""
"SCREW BONE 16X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","498.88","62.78","","780.86","208.94","10480.28","15","92.42","615.06","percent of total billed charges",""
"SCREW BONE 16X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","347.42","43.72","","179.76","179.76","179.76","1 through 10","92.42","615.06","percent of total billed charges",""
"SCREW BONE 16X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","577.87","72.72","","2355.45","298.99","3965.19","155","92.42","615.06","percent of total billed charges",""
"SCREW BONE 16X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","577.87","72.72","","3643.09","3643.09","3643.09","1 through 10","92.42","615.06","percent of total billed charges",""
"SCREW BONE 16X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","422.91","53.22","","554.28","554.28","554.28","16","92.42","615.06","percent of total billed charges",""
"SCREW BONE 16X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","499.83","62.9","","619.64","173.09","2370.64","150","92.42","615.06","percent of total billed charges",""
"SCREW BONE 16X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","794.65","476.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","615.06","77.4","","303.98","303.98","5854.79","1 through 10","92.42","615.06","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.90","787.74","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","152.69","1115.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.90","787.74","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","152.69","1115.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.90","787.74","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","747.04","56.9","","812.12","238.65","1587.46","163","152.69","1115.97","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.90","787.74","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","152.69","11.63","","112.68","112.68","146.99","38","152.69","1115.97","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.90","787.74","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1016.18","77.4","","303.98","303.98","5854.79","1 through 10","152.69","1115.97","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.90","787.74","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","152.69","11.63","","112.68","112.68","146.99","38","152.69","1016.18","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.90","787.74","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","824.24","62.78","","780.86","208.94","10480.28","15","152.69","1016.18","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.90","787.74","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","574.00","43.72","","179.76","179.76","179.76","1 through 10","152.69","1016.18","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.90","787.74","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","954.74","72.72","","2355.45","298.99","3965.19","155","152.69","1016.18","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.90","787.74","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","954.74","72.72","","3643.09","3643.09","3643.09","1 through 10","152.69","1016.18","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.90","787.74","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","698.73","53.22","","554.28","554.28","554.28","16","152.69","1016.18","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.90","787.74","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","825.81","62.9","","619.64","173.09","2370.64","150","152.69","1016.18","percent of total billed charges",""
"SCREW BONE 16X2.7MM ORTHOLOC 3DI FUSION TITANIUM LOCKING HEAD","SUP-ITM-10124485","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.90","787.74","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1016.18","77.4","","303.98","303.98","5854.79","1 through 10","152.69","1016.18","percent of total billed charges",""
"SCREW BONE 16X4MM SPINE CERVICAL ATLANTIS TI SELF TAPPING VARIABLE ANGLE","SUP-ITM-10058995","CDM","C1889","HCPCS","0278","RC","","","","both","","","691.00","414.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","80.36","587.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 16X4MM SPINE CERVICAL ATLANTIS TI SELF TAPPING VARIABLE ANGLE","SUP-ITM-10058995","CDM","C1889","HCPCS","0278","RC","","","","both","","","691.00","414.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","80.36","587.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 16X4MM SPINE CERVICAL ATLANTIS TI SELF TAPPING VARIABLE ANGLE","SUP-ITM-10058995","CDM","C1889","HCPCS","0278","RC","","","","both","","","691.00","414.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","393.18","56.9","","0.63","0.63","0.63","1 through 10","80.36","587.35","percent of total billed charges",""
"SCREW BONE 16X4MM SPINE CERVICAL ATLANTIS TI SELF TAPPING VARIABLE ANGLE","SUP-ITM-10058995","CDM","C1889","HCPCS","0278","RC","","","","both","","","691.00","414.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","99.64","14.42","","317.14","317.14","317.14","1 through 10","80.36","587.35","percent of total billed charges",""
"SCREW BONE 16X4MM SPINE CERVICAL ATLANTIS TI SELF TAPPING VARIABLE ANGLE","SUP-ITM-10058995","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","99.64","14.42","","317.14","317.14","317.14","1 through 10","80.36","534.83","percent of total billed charges",""
"SCREW BONE 16X4MM SPINE CERVICAL ATLANTIS TI SELF TAPPING VARIABLE ANGLE","SUP-ITM-10058995","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","433.81","62.78","","1125.09","1125.09","1125.09","1 through 10","80.36","534.83","percent of total billed charges",""
"SCREW BONE 16X4MM SPINE CERVICAL ATLANTIS TI SELF TAPPING VARIABLE ANGLE","SUP-ITM-10058995","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","502.50","72.72","","4732.50","1617.43","14180.40","1 through 10","80.36","534.83","percent of total billed charges",""
"SCREW BONE 16X4MM SPINE CERVICAL ATLANTIS TI SELF TAPPING VARIABLE ANGLE","SUP-ITM-10058995","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","434.64","62.9","","3896.20","3341.38","3896.20","1 through 10","80.36","534.83","percent of total billed charges",""
"SCREW BONE 18MM COMPRESSION ACUTRAK 2 MINI TI CANNULATED FULL THREAD HEADLESS","SUP-ITM-10140094","CDM","C1713","HCPCS","0278","RC","","","","both","","","3496.46","2097.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","406.64","2971.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 18MM COMPRESSION ACUTRAK 2 MINI TI CANNULATED FULL THREAD HEADLESS","SUP-ITM-10140094","CDM","C1713","HCPCS","0278","RC","","","","both","","","3496.46","2097.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","406.64","2971.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 18MM COMPRESSION ACUTRAK 2 MINI TI CANNULATED FULL THREAD HEADLESS","SUP-ITM-10140094","CDM","C1713","HCPCS","0278","RC","","","","both","","","3496.46","2097.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1989.49","56.9","","812.12","238.65","1587.46","163","406.64","2971.99","percent of total billed charges",""
"SCREW BONE 18MM COMPRESSION ACUTRAK 2 MINI TI CANNULATED FULL THREAD HEADLESS","SUP-ITM-10140094","CDM","C1713","HCPCS","0278","RC","","","","both","","","3496.46","2097.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","406.64","11.63","","112.68","112.68","146.99","38","406.64","2971.99","percent of total billed charges",""
"SCREW BONE 18MM COMPRESSION ACUTRAK 2 MINI TI CANNULATED FULL THREAD HEADLESS","SUP-ITM-10140094","CDM","C1713","HCPCS","0278","RC","","","","both","","","3496.46","2097.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2706.26","77.4","","303.98","303.98","5854.79","1 through 10","406.64","2971.99","percent of total billed charges",""
"SCREW BONE 18MM COMPRESSION ACUTRAK 2 MINI TI CANNULATED FULL THREAD HEADLESS","SUP-ITM-10140094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3496.46","2097.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","406.64","11.63","","112.68","112.68","146.99","38","406.64","2706.26","percent of total billed charges",""
"SCREW BONE 18MM COMPRESSION ACUTRAK 2 MINI TI CANNULATED FULL THREAD HEADLESS","SUP-ITM-10140094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3496.46","2097.88","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2195.08","62.78","","780.86","208.94","10480.28","15","406.64","2706.26","percent of total billed charges",""
"SCREW BONE 18MM COMPRESSION ACUTRAK 2 MINI TI CANNULATED FULL THREAD HEADLESS","SUP-ITM-10140094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3496.46","2097.88","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1528.65","43.72","","179.76","179.76","179.76","1 through 10","406.64","2706.26","percent of total billed charges",""
"SCREW BONE 18MM COMPRESSION ACUTRAK 2 MINI TI CANNULATED FULL THREAD HEADLESS","SUP-ITM-10140094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3496.46","2097.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2542.63","72.72","","2355.45","298.99","3965.19","155","406.64","2706.26","percent of total billed charges",""
"SCREW BONE 18MM COMPRESSION ACUTRAK 2 MINI TI CANNULATED FULL THREAD HEADLESS","SUP-ITM-10140094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3496.46","2097.88","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2542.63","72.72","","3643.09","3643.09","3643.09","1 through 10","406.64","2706.26","percent of total billed charges",""
"SCREW BONE 18MM COMPRESSION ACUTRAK 2 MINI TI CANNULATED FULL THREAD HEADLESS","SUP-ITM-10140094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3496.46","2097.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1860.82","53.22","","554.28","554.28","554.28","16","406.64","2706.26","percent of total billed charges",""
"SCREW BONE 18MM COMPRESSION ACUTRAK 2 MINI TI CANNULATED FULL THREAD HEADLESS","SUP-ITM-10140094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3496.46","2097.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2199.27","62.9","","619.64","173.09","2370.64","150","406.64","2706.26","percent of total billed charges",""
"SCREW BONE 18MM COMPRESSION ACUTRAK 2 MINI TI CANNULATED FULL THREAD HEADLESS","SUP-ITM-10140094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3496.46","2097.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2706.26","77.4","","303.98","303.98","5854.79","1 through 10","406.64","2706.26","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","863.75","518.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","100.45","734.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","863.75","518.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","100.45","734.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","863.75","518.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","491.47","56.9","","812.12","238.65","1587.46","163","100.45","734.19","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","863.75","518.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","100.45","11.63","","112.68","112.68","146.99","38","100.45","734.19","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","863.75","518.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","668.54","77.4","","303.98","303.98","5854.79","1 through 10","100.45","734.19","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","863.75","518.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","100.45","11.63","","112.68","112.68","146.99","38","100.45","668.54","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","863.75","518.25","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","542.26","62.78","","780.86","208.94","10480.28","15","100.45","668.54","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","863.75","518.25","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","377.63","43.72","","179.76","179.76","179.76","1 through 10","100.45","668.54","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","863.75","518.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","628.12","72.72","","2355.45","298.99","3965.19","155","100.45","668.54","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","863.75","518.25","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","628.12","72.72","","3643.09","3643.09","3643.09","1 through 10","100.45","668.54","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","863.75","518.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","459.69","53.22","","554.28","554.28","554.28","16","100.45","668.54","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","863.75","518.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","543.30","62.9","","619.64","173.09","2370.64","150","100.45","668.54","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","863.75","518.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","668.54","77.4","","303.98","303.98","5854.79","1 through 10","100.45","668.54","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","1302.05","781.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","151.43","1106.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","1302.05","781.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","151.43","1106.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","1302.05","781.23","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","740.87","56.9","","812.12","238.65","1587.46","163","151.43","1106.74","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","1302.05","781.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","151.43","11.63","","112.68","112.68","146.99","38","151.43","1106.74","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","1302.05","781.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1007.79","77.4","","303.98","303.98","5854.79","1 through 10","151.43","1106.74","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","151.43","11.63","","112.68","112.68","146.99","38","151.43","1007.79","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","817.43","62.78","","780.86","208.94","10480.28","15","151.43","1007.79","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","569.26","43.72","","179.76","179.76","179.76","1 through 10","151.43","1007.79","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","946.85","72.72","","2355.45","298.99","3965.19","155","151.43","1007.79","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","946.85","72.72","","3643.09","3643.09","3643.09","1 through 10","151.43","1007.79","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","692.95","53.22","","554.28","554.28","554.28","16","151.43","1007.79","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","818.99","62.9","","619.64","173.09","2370.64","150","151.43","1007.79","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1302.05","781.23","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1007.79","77.4","","303.98","303.98","5854.79","1 through 10","151.43","1007.79","percent of total billed charges",""
"SCREW BONE 2.3X14MM VARIAX TITANIUM LOCKING T7 DRIVE 53-23214E","SUP-ITM-10097960","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.52","585.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","113.57","830.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.3X14MM VARIAX TITANIUM LOCKING T7 DRIVE 53-23214E","SUP-ITM-10097960","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.52","585.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","113.57","830.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.3X14MM VARIAX TITANIUM LOCKING T7 DRIVE 53-23214E","SUP-ITM-10097960","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.52","585.91","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","555.64","56.9","","812.12","238.65","1587.46","163","113.57","830.04","percent of total billed charges",""
"SCREW BONE 2.3X14MM VARIAX TITANIUM LOCKING T7 DRIVE 53-23214E","SUP-ITM-10097960","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.52","585.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","113.57","11.63","","112.68","112.68","146.99","38","113.57","830.04","percent of total billed charges",""
"SCREW BONE 2.3X14MM VARIAX TITANIUM LOCKING T7 DRIVE 53-23214E","SUP-ITM-10097960","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.52","585.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","755.83","77.4","","303.98","303.98","5854.79","1 through 10","113.57","830.04","percent of total billed charges",""
"SCREW BONE 2.3X14MM VARIAX TITANIUM LOCKING T7 DRIVE 53-23214E","SUP-ITM-10097960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","976.52","585.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","113.57","11.63","","112.68","112.68","146.99","38","113.57","755.83","percent of total billed charges",""
"SCREW BONE 2.3X14MM VARIAX TITANIUM LOCKING T7 DRIVE 53-23214E","SUP-ITM-10097960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","976.52","585.91","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","613.06","62.78","","780.86","208.94","10480.28","15","113.57","755.83","percent of total billed charges",""
"SCREW BONE 2.3X14MM VARIAX TITANIUM LOCKING T7 DRIVE 53-23214E","SUP-ITM-10097960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","976.52","585.91","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","426.93","43.72","","179.76","179.76","179.76","1 through 10","113.57","755.83","percent of total billed charges",""
"SCREW BONE 2.3X14MM VARIAX TITANIUM LOCKING T7 DRIVE 53-23214E","SUP-ITM-10097960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","976.52","585.91","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","710.13","72.72","","2355.45","298.99","3965.19","155","113.57","755.83","percent of total billed charges",""
"SCREW BONE 2.3X14MM VARIAX TITANIUM LOCKING T7 DRIVE 53-23214E","SUP-ITM-10097960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","976.52","585.91","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","710.13","72.72","","3643.09","3643.09","3643.09","1 through 10","113.57","755.83","percent of total billed charges",""
"SCREW BONE 2.3X14MM VARIAX TITANIUM LOCKING T7 DRIVE 53-23214E","SUP-ITM-10097960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","976.52","585.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","519.70","53.22","","554.28","554.28","554.28","16","113.57","755.83","percent of total billed charges",""
"SCREW BONE 2.3X14MM VARIAX TITANIUM LOCKING T7 DRIVE 53-23214E","SUP-ITM-10097960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","976.52","585.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","614.23","62.9","","619.64","173.09","2370.64","150","113.57","755.83","percent of total billed charges",""
"SCREW BONE 2.3X14MM VARIAX TITANIUM LOCKING T7 DRIVE 53-23214E","SUP-ITM-10097960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","976.52","585.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","755.83","77.4","","303.98","303.98","5854.79","1 through 10","113.57","755.83","percent of total billed charges",""
"SCREW BONE 2.3X6MM LOCKING SELF TAPPING CROSS PIN","SUP-ITM-10143481","CDM","C1713","HCPCS","0278","RC","","","","both","","","1250.23","750.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","145.4","1062.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.3X6MM LOCKING SELF TAPPING CROSS PIN","SUP-ITM-10143481","CDM","C1713","HCPCS","0278","RC","","","","both","","","1250.23","750.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","145.4","1062.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.3X6MM LOCKING SELF TAPPING CROSS PIN","SUP-ITM-10143481","CDM","C1713","HCPCS","0278","RC","","","","both","","","1250.23","750.14","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","711.38","56.9","","812.12","238.65","1587.46","163","145.4","1062.7","percent of total billed charges",""
"SCREW BONE 2.3X6MM LOCKING SELF TAPPING CROSS PIN","SUP-ITM-10143481","CDM","C1713","HCPCS","0278","RC","","","","both","","","1250.23","750.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","145.40","11.63","","112.68","112.68","146.99","38","145.4","1062.7","percent of total billed charges",""
"SCREW BONE 2.3X6MM LOCKING SELF TAPPING CROSS PIN","SUP-ITM-10143481","CDM","C1713","HCPCS","0278","RC","","","","both","","","1250.23","750.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","967.68","77.4","","303.98","303.98","5854.79","1 through 10","145.4","1062.7","percent of total billed charges",""
"SCREW BONE 2.3X6MM LOCKING SELF TAPPING CROSS PIN","SUP-ITM-10143481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1250.23","750.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","145.40","11.63","","112.68","112.68","146.99","38","145.4","967.68","percent of total billed charges",""
"SCREW BONE 2.3X6MM LOCKING SELF TAPPING CROSS PIN","SUP-ITM-10143481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1250.23","750.14","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","784.89","62.78","","780.86","208.94","10480.28","15","145.4","967.68","percent of total billed charges",""
"SCREW BONE 2.3X6MM LOCKING SELF TAPPING CROSS PIN","SUP-ITM-10143481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1250.23","750.14","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","546.60","43.72","","179.76","179.76","179.76","1 through 10","145.4","967.68","percent of total billed charges",""
"SCREW BONE 2.3X6MM LOCKING SELF TAPPING CROSS PIN","SUP-ITM-10143481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1250.23","750.14","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","909.17","72.72","","2355.45","298.99","3965.19","155","145.4","967.68","percent of total billed charges",""
"SCREW BONE 2.3X6MM LOCKING SELF TAPPING CROSS PIN","SUP-ITM-10143481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1250.23","750.14","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","909.17","72.72","","3643.09","3643.09","3643.09","1 through 10","145.4","967.68","percent of total billed charges",""
"SCREW BONE 2.3X6MM LOCKING SELF TAPPING CROSS PIN","SUP-ITM-10143481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1250.23","750.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","665.37","53.22","","554.28","554.28","554.28","16","145.4","967.68","percent of total billed charges",""
"SCREW BONE 2.3X6MM LOCKING SELF TAPPING CROSS PIN","SUP-ITM-10143481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1250.23","750.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","786.39","62.9","","619.64","173.09","2370.64","150","145.4","967.68","percent of total billed charges",""
"SCREW BONE 2.3X6MM LOCKING SELF TAPPING CROSS PIN","SUP-ITM-10143481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1250.23","750.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","967.68","77.4","","303.98","303.98","5854.79","1 through 10","145.4","967.68","percent of total billed charges",""
"SCREW BONE 2.3X6MM SELF TAPPING CROSS-PIN","SUP-ITM-10042252","CDM","C1713","HCPCS","0278","RC","","","","both","","","428.62","257.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","49.85","364.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.3X6MM SELF TAPPING CROSS-PIN","SUP-ITM-10042252","CDM","C1713","HCPCS","0278","RC","","","","both","","","428.62","257.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","49.85","364.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.3X6MM SELF TAPPING CROSS-PIN","SUP-ITM-10042252","CDM","C1713","HCPCS","0278","RC","","","","both","","","428.62","257.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","243.88","56.9","","812.12","238.65","1587.46","163","49.85","364.33","percent of total billed charges",""
"SCREW BONE 2.3X6MM SELF TAPPING CROSS-PIN","SUP-ITM-10042252","CDM","C1713","HCPCS","0278","RC","","","","both","","","428.62","257.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","49.85","11.63","","112.68","112.68","146.99","38","49.85","364.33","percent of total billed charges",""
"SCREW BONE 2.3X6MM SELF TAPPING CROSS-PIN","SUP-ITM-10042252","CDM","C1713","HCPCS","0278","RC","","","","both","","","428.62","257.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","331.75","77.4","","303.98","303.98","5854.79","1 through 10","49.85","364.33","percent of total billed charges",""
"SCREW BONE 2.3X6MM SELF TAPPING CROSS-PIN","SUP-ITM-10042252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","428.62","257.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","49.85","11.63","","112.68","112.68","146.99","38","49.85","331.75","percent of total billed charges",""
"SCREW BONE 2.3X6MM SELF TAPPING CROSS-PIN","SUP-ITM-10042252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","428.62","257.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","269.09","62.78","","780.86","208.94","10480.28","15","49.85","331.75","percent of total billed charges",""
"SCREW BONE 2.3X6MM SELF TAPPING CROSS-PIN","SUP-ITM-10042252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","428.62","257.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","187.39","43.72","","179.76","179.76","179.76","1 through 10","49.85","331.75","percent of total billed charges",""
"SCREW BONE 2.3X6MM SELF TAPPING CROSS-PIN","SUP-ITM-10042252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","428.62","257.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","311.69","72.72","","2355.45","298.99","3965.19","155","49.85","331.75","percent of total billed charges",""
"SCREW BONE 2.3X6MM SELF TAPPING CROSS-PIN","SUP-ITM-10042252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","428.62","257.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","311.69","72.72","","3643.09","3643.09","3643.09","1 through 10","49.85","331.75","percent of total billed charges",""
"SCREW BONE 2.3X6MM SELF TAPPING CROSS-PIN","SUP-ITM-10042252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","428.62","257.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","228.11","53.22","","554.28","554.28","554.28","16","49.85","331.75","percent of total billed charges",""
"SCREW BONE 2.3X6MM SELF TAPPING CROSS-PIN","SUP-ITM-10042252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","428.62","257.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","269.60","62.9","","619.64","173.09","2370.64","150","49.85","331.75","percent of total billed charges",""
"SCREW BONE 2.3X6MM SELF TAPPING CROSS-PIN","SUP-ITM-10042252","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","428.62","257.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","331.75","77.4","","303.98","303.98","5854.79","1 through 10","49.85","331.75","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","both","","","1028.28","616.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","119.59","874.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","both","","","1028.28","616.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","119.59","874.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","both","","","1028.28","616.97","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","585.09","56.9","","812.12","238.65","1587.46","163","119.59","874.04","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","both","","","1028.28","616.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","119.59","11.63","","112.68","112.68","146.99","38","119.59","874.04","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","both","","","1028.28","616.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","795.89","77.4","","303.98","303.98","5854.79","1 through 10","119.59","874.04","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","119.59","11.63","","112.68","112.68","146.99","38","119.59","795.89","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","645.55","62.78","","780.86","208.94","10480.28","15","119.59","795.89","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","449.56","43.72","","179.76","179.76","179.76","1 through 10","119.59","795.89","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","747.77","72.72","","2355.45","298.99","3965.19","155","119.59","795.89","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","747.77","72.72","","3643.09","3643.09","3643.09","1 through 10","119.59","795.89","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","547.25","53.22","","554.28","554.28","554.28","16","119.59","795.89","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","646.79","62.9","","619.64","173.09","2370.64","150","119.59","795.89","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1028.28","616.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","795.89","77.4","","303.98","303.98","5854.79","1 through 10","119.59","795.89","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","both","","","882.27","529.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","102.61","749.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","both","","","882.27","529.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","102.61","749.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","both","","","882.27","529.36","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","502.01","56.9","","812.12","238.65","1587.46","163","102.61","749.93","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","both","","","882.27","529.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","102.61","11.63","","112.68","112.68","146.99","38","102.61","749.93","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","both","","","882.27","529.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","682.88","77.4","","303.98","303.98","5854.79","1 through 10","102.61","749.93","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","882.27","529.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","102.61","11.63","","112.68","112.68","146.99","38","102.61","682.88","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","882.27","529.36","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","553.89","62.78","","780.86","208.94","10480.28","15","102.61","682.88","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","882.27","529.36","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","385.73","43.72","","179.76","179.76","179.76","1 through 10","102.61","682.88","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","882.27","529.36","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","641.59","72.72","","2355.45","298.99","3965.19","155","102.61","682.88","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","882.27","529.36","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","641.59","72.72","","3643.09","3643.09","3643.09","1 through 10","102.61","682.88","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","882.27","529.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","469.54","53.22","","554.28","554.28","554.28","16","102.61","682.88","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","882.27","529.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","554.95","62.9","","619.64","173.09","2370.64","150","102.61","682.88","percent of total billed charges",""
"SCREW BONE 2.4X10MM CANNULATED SS LONG THREAD","SUP-ITM-10019111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","882.27","529.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","682.88","77.4","","303.98","303.98","5854.79","1 through 10","102.61","682.88","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.36","185.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","35.98","262.96","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.36","185.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","35.98","262.96","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.36","185.62","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","176.03","56.9","","812.12","238.65","1587.46","163","35.98","262.96","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.36","185.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","35.98","11.63","","112.68","112.68","146.99","38","35.98","262.96","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.36","185.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","239.44","77.4","","303.98","303.98","5854.79","1 through 10","35.98","262.96","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.36","185.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","35.98","11.63","","112.68","112.68","146.99","38","35.98","239.44","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.36","185.62","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","194.22","62.78","","780.86","208.94","10480.28","15","35.98","239.44","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.36","185.62","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","135.25","43.72","","179.76","179.76","179.76","1 through 10","35.98","239.44","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.36","185.62","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","224.97","72.72","","2355.45","298.99","3965.19","155","35.98","239.44","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.36","185.62","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","224.97","72.72","","3643.09","3643.09","3643.09","1 through 10","35.98","239.44","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.36","185.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","164.64","53.22","","554.28","554.28","554.28","16","35.98","239.44","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.36","185.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","194.59","62.9","","619.64","173.09","2370.64","150","35.98","239.44","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.36","185.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","239.44","77.4","","303.98","303.98","5854.79","1 through 10","35.98","239.44","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","751.67","451.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","87.42","638.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","751.67","451.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","87.42","638.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","751.67","451.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","427.70","56.9","","812.12","238.65","1587.46","163","87.42","638.92","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","751.67","451.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","87.42","11.63","","112.68","112.68","146.99","38","87.42","638.92","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","751.67","451.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","581.79","77.4","","303.98","303.98","5854.79","1 through 10","87.42","638.92","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","751.67","451.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","87.42","11.63","","112.68","112.68","146.99","38","87.42","581.79","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","751.67","451.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","471.90","62.78","","780.86","208.94","10480.28","15","87.42","581.79","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","751.67","451.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","328.63","43.72","","179.76","179.76","179.76","1 through 10","87.42","581.79","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","751.67","451.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","546.61","72.72","","2355.45","298.99","3965.19","155","87.42","581.79","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","751.67","451.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","546.61","72.72","","3643.09","3643.09","3643.09","1 through 10","87.42","581.79","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","751.67","451.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","400.04","53.22","","554.28","554.28","554.28","16","87.42","581.79","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","751.67","451.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","472.80","62.9","","619.64","173.09","2370.64","150","87.42","581.79","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","751.67","451.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","581.79","77.4","","303.98","303.98","5854.79","1 through 10","87.42","581.79","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.32","279.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","54.12","395.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.32","279.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","54.12","395.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.32","279.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","264.77","56.9","","812.12","238.65","1587.46","163","54.12","395.52","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.32","279.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","54.12","11.63","","112.68","112.68","146.99","38","54.12","395.52","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.32","279.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","360.16","77.4","","303.98","303.98","5854.79","1 through 10","54.12","395.52","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.32","279.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","54.12","11.63","","112.68","112.68","146.99","38","54.12","360.16","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.32","279.19","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","292.13","62.78","","780.86","208.94","10480.28","15","54.12","360.16","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.32","279.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","203.44","43.72","","179.76","179.76","179.76","1 through 10","54.12","360.16","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.32","279.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","338.38","72.72","","2355.45","298.99","3965.19","155","54.12","360.16","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.32","279.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","338.38","72.72","","3643.09","3643.09","3643.09","1 through 10","54.12","360.16","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.32","279.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","247.64","53.22","","554.28","554.28","554.28","16","54.12","360.16","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.32","279.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","292.69","62.9","","619.64","173.09","2370.64","150","54.12","360.16","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.32","279.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","360.16","77.4","","303.98","303.98","5854.79","1 through 10","54.12","360.16","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","both","","","690.31","414.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","80.28","586.76","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","both","","","690.31","414.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","80.28","586.76","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","both","","","690.31","414.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","392.79","56.9","","812.12","238.65","1587.46","163","80.28","586.76","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","both","","","690.31","414.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","80.28","11.63","","112.68","112.68","146.99","38","80.28","586.76","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","both","","","690.31","414.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","534.30","77.4","","303.98","303.98","5854.79","1 through 10","80.28","586.76","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","690.31","414.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","80.28","11.63","","112.68","112.68","146.99","38","80.28","534.3","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","690.31","414.19","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","433.38","62.78","","780.86","208.94","10480.28","15","80.28","534.3","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","690.31","414.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","301.80","43.72","","179.76","179.76","179.76","1 through 10","80.28","534.3","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","690.31","414.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","501.99","72.72","","2355.45","298.99","3965.19","155","80.28","534.3","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","690.31","414.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","501.99","72.72","","3643.09","3643.09","3643.09","1 through 10","80.28","534.3","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","690.31","414.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","367.38","53.22","","554.28","554.28","554.28","16","80.28","534.3","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","690.31","414.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","434.20","62.9","","619.64","173.09","2370.64","150","80.28","534.3","percent of total billed charges",""
"SCREW BONE 2.4X12MM LOCKING SELF TAPPING STARDRIVE RECESS TI","SUP-ITM-10012497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","690.31","414.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","534.30","77.4","","303.98","303.98","5854.79","1 through 10","80.28","534.3","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.04","204.02","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","39.55","289.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.04","204.02","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","39.55","289.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.04","204.02","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","193.48","56.9","","812.12","238.65","1587.46","163","39.55","289.03","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.04","204.02","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","39.55","11.63","","112.68","112.68","146.99","38","39.55","289.03","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.04","204.02","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","263.19","77.4","","303.98","303.98","5854.79","1 through 10","39.55","289.03","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.04","204.02","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","39.55","11.63","","112.68","112.68","146.99","38","39.55","263.19","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.04","204.02","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","213.48","62.78","","780.86","208.94","10480.28","15","39.55","263.19","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.04","204.02","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","148.67","43.72","","179.76","179.76","179.76","1 through 10","39.55","263.19","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.04","204.02","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","247.28","72.72","","2355.45","298.99","3965.19","155","39.55","263.19","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.04","204.02","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","247.28","72.72","","3643.09","3643.09","3643.09","1 through 10","39.55","263.19","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.04","204.02","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","180.97","53.22","","554.28","554.28","554.28","16","39.55","263.19","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.04","204.02","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","213.89","62.9","","619.64","173.09","2370.64","150","39.55","263.19","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.04","204.02","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","263.19","77.4","","303.98","303.98","5854.79","1 through 10","39.55","263.19","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.39","375.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","72.85","532.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.39","375.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","72.85","532.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.39","375.83","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","356.42","56.9","","812.12","238.65","1587.46","163","72.85","532.43","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.39","375.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","72.85","11.63","","112.68","112.68","146.99","38","72.85","532.43","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.39","375.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","484.83","77.4","","303.98","303.98","5854.79","1 through 10","72.85","532.43","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.39","375.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","72.85","11.63","","112.68","112.68","146.99","38","72.85","484.83","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.39","375.83","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","393.25","62.78","","780.86","208.94","10480.28","15","72.85","484.83","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.39","375.83","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","273.86","43.72","","179.76","179.76","179.76","1 through 10","72.85","484.83","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.39","375.83","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","455.51","72.72","","2355.45","298.99","3965.19","155","72.85","484.83","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.39","375.83","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","455.51","72.72","","3643.09","3643.09","3643.09","1 through 10","72.85","484.83","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.39","375.83","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","333.36","53.22","","554.28","554.28","554.28","16","72.85","484.83","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.39","375.83","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","394.00","62.9","","619.64","173.09","2370.64","150","72.85","484.83","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.39","375.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","484.83","77.4","","303.98","303.98","5854.79","1 through 10","72.85","484.83","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","both","","","1065.31","639.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","123.9","905.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","both","","","1065.31","639.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","123.9","905.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","both","","","1065.31","639.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","606.16","56.9","","812.12","238.65","1587.46","163","123.9","905.51","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","both","","","1065.31","639.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","123.90","11.63","","112.68","112.68","146.99","38","123.9","905.51","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","both","","","1065.31","639.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","824.55","77.4","","303.98","303.98","5854.79","1 through 10","123.9","905.51","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1065.31","639.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","123.90","11.63","","112.68","112.68","146.99","38","123.9","824.55","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1065.31","639.19","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","668.80","62.78","","780.86","208.94","10480.28","15","123.9","824.55","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1065.31","639.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","465.75","43.72","","179.76","179.76","179.76","1 through 10","123.9","824.55","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1065.31","639.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","774.69","72.72","","2355.45","298.99","3965.19","155","123.9","824.55","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1065.31","639.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","774.69","72.72","","3643.09","3643.09","3643.09","1 through 10","123.9","824.55","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1065.31","639.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","566.96","53.22","","554.28","554.28","554.28","16","123.9","824.55","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1065.31","639.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","670.08","62.9","","619.64","173.09","2370.64","150","123.9","824.55","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10186877","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1065.31","639.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","824.55","77.4","","303.98","303.98","5854.79","1 through 10","123.9","824.55","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.39","375.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","72.85","532.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.39","375.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","72.85","532.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.39","375.83","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","356.42","56.9","","812.12","238.65","1587.46","163","72.85","532.43","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.39","375.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","72.85","11.63","","112.68","112.68","146.99","38","72.85","532.43","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.39","375.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","484.83","77.4","","303.98","303.98","5854.79","1 through 10","72.85","532.43","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.39","375.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","72.85","11.63","","112.68","112.68","146.99","38","72.85","484.83","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.39","375.83","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","393.25","62.78","","780.86","208.94","10480.28","15","72.85","484.83","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.39","375.83","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","273.86","43.72","","179.76","179.76","179.76","1 through 10","72.85","484.83","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.39","375.83","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","455.51","72.72","","2355.45","298.99","3965.19","155","72.85","484.83","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.39","375.83","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","455.51","72.72","","3643.09","3643.09","3643.09","1 through 10","72.85","484.83","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.39","375.83","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","333.36","53.22","","554.28","554.28","554.28","16","72.85","484.83","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.39","375.83","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","394.00","62.9","","619.64","173.09","2370.64","150","72.85","484.83","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.39","375.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","484.83","77.4","","303.98","303.98","5854.79","1 through 10","72.85","484.83","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.36","185.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","35.98","262.96","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.36","185.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","35.98","262.96","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.36","185.62","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","176.03","56.9","","812.12","238.65","1587.46","163","35.98","262.96","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.36","185.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","35.98","11.63","","112.68","112.68","146.99","38","35.98","262.96","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","309.36","185.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","239.44","77.4","","303.98","303.98","5854.79","1 through 10","35.98","262.96","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.36","185.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","35.98","11.63","","112.68","112.68","146.99","38","35.98","239.44","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.36","185.62","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","194.22","62.78","","780.86","208.94","10480.28","15","35.98","239.44","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.36","185.62","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","135.25","43.72","","179.76","179.76","179.76","1 through 10","35.98","239.44","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.36","185.62","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","224.97","72.72","","2355.45","298.99","3965.19","155","35.98","239.44","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.36","185.62","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","224.97","72.72","","3643.09","3643.09","3643.09","1 through 10","35.98","239.44","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.36","185.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","164.64","53.22","","554.28","554.28","554.28","16","35.98","239.44","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.36","185.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","194.59","62.9","","619.64","173.09","2370.64","150","35.98","239.44","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","309.36","185.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","239.44","77.4","","303.98","303.98","5854.79","1 through 10","35.98","239.44","percent of total billed charges",""
"SCREW BONE 2.4X8MM STARDRIVE TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 RECESS","SUP-ITM-10096188","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.93","498.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","96.64","706.29","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.4X8MM STARDRIVE TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 RECESS","SUP-ITM-10096188","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.93","498.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","96.64","706.29","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.4X8MM STARDRIVE TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 RECESS","SUP-ITM-10096188","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.93","498.56","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","472.80","56.9","","812.12","238.65","1587.46","163","96.64","706.29","percent of total billed charges",""
"SCREW BONE 2.4X8MM STARDRIVE TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 RECESS","SUP-ITM-10096188","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.93","498.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","96.64","11.63","","112.68","112.68","146.99","38","96.64","706.29","percent of total billed charges",""
"SCREW BONE 2.4X8MM STARDRIVE TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 RECESS","SUP-ITM-10096188","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.93","498.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","643.14","77.4","","303.98","303.98","5854.79","1 through 10","96.64","706.29","percent of total billed charges",""
"SCREW BONE 2.4X8MM STARDRIVE TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 RECESS","SUP-ITM-10096188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","830.93","498.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","96.64","11.63","","112.68","112.68","146.99","38","96.64","643.14","percent of total billed charges",""
"SCREW BONE 2.4X8MM STARDRIVE TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 RECESS","SUP-ITM-10096188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","830.93","498.56","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","521.66","62.78","","780.86","208.94","10480.28","15","96.64","643.14","percent of total billed charges",""
"SCREW BONE 2.4X8MM STARDRIVE TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 RECESS","SUP-ITM-10096188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","830.93","498.56","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","363.28","43.72","","179.76","179.76","179.76","1 through 10","96.64","643.14","percent of total billed charges",""
"SCREW BONE 2.4X8MM STARDRIVE TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 RECESS","SUP-ITM-10096188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","830.93","498.56","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","604.25","72.72","","2355.45","298.99","3965.19","155","96.64","643.14","percent of total billed charges",""
"SCREW BONE 2.4X8MM STARDRIVE TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 RECESS","SUP-ITM-10096188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","830.93","498.56","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","604.25","72.72","","3643.09","3643.09","3643.09","1 through 10","96.64","643.14","percent of total billed charges",""
"SCREW BONE 2.4X8MM STARDRIVE TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 RECESS","SUP-ITM-10096188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","830.93","498.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","442.22","53.22","","554.28","554.28","554.28","16","96.64","643.14","percent of total billed charges",""
"SCREW BONE 2.4X8MM STARDRIVE TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 RECESS","SUP-ITM-10096188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","830.93","498.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","522.65","62.9","","619.64","173.09","2370.64","150","96.64","643.14","percent of total billed charges",""
"SCREW BONE 2.4X8MM STARDRIVE TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 RECESS","SUP-ITM-10096188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","830.93","498.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","643.14","77.4","","303.98","303.98","5854.79","1 through 10","96.64","643.14","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.44","444.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","86.23","630.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.44","444.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","86.23","630.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.44","444.86","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","421.88","56.9","","812.12","238.65","1587.46","163","86.23","630.22","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.44","444.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","86.23","11.63","","112.68","112.68","146.99","38","86.23","630.22","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","both","","","741.44","444.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","573.87","77.4","","303.98","303.98","5854.79","1 through 10","86.23","630.22","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","741.44","444.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","86.23","11.63","","112.68","112.68","146.99","38","86.23","573.87","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","741.44","444.86","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","465.48","62.78","","780.86","208.94","10480.28","15","86.23","573.87","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","741.44","444.86","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","324.16","43.72","","179.76","179.76","179.76","1 through 10","86.23","573.87","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","741.44","444.86","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","539.18","72.72","","2355.45","298.99","3965.19","155","86.23","573.87","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","741.44","444.86","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","539.18","72.72","","3643.09","3643.09","3643.09","1 through 10","86.23","573.87","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","741.44","444.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","394.59","53.22","","554.28","554.28","554.28","16","86.23","573.87","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","741.44","444.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","466.37","62.9","","619.64","173.09","2370.64","150","86.23","573.87","percent of total billed charges",""
"SCREW BONE 2.5X65MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL SELF DRILLING 18MM THREAD","SUP-ITM-10038627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","741.44","444.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","573.87","77.4","","303.98","303.98","5854.79","1 through 10","86.23","573.87","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1501.75","901.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","174.65","1276.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1501.75","901.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","174.65","1276.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1501.75","901.05","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","854.50","56.9","","812.12","238.65","1587.46","163","174.65","1276.49","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1501.75","901.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","174.65","11.63","","112.68","112.68","146.99","38","174.65","1276.49","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1501.75","901.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1162.35","77.4","","303.98","303.98","5854.79","1 through 10","174.65","1276.49","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1501.75","901.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","174.65","11.63","","112.68","112.68","146.99","38","174.65","1162.35","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1501.75","901.05","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","942.80","62.78","","780.86","208.94","10480.28","15","174.65","1162.35","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1501.75","901.05","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","656.57","43.72","","179.76","179.76","179.76","1 through 10","174.65","1162.35","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1501.75","901.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1092.07","72.72","","2355.45","298.99","3965.19","155","174.65","1162.35","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1501.75","901.05","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1092.07","72.72","","3643.09","3643.09","3643.09","1 through 10","174.65","1162.35","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1501.75","901.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","799.23","53.22","","554.28","554.28","554.28","16","174.65","1162.35","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1501.75","901.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","944.60","62.9","","619.64","173.09","2370.64","150","174.65","1162.35","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1501.75","901.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1162.35","77.4","","303.98","303.98","5854.79","1 through 10","174.65","1162.35","percent of total billed charges",""
"SCREW BONE 2.7MM 12 COMPRESSION DARCO SNAP OFF TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD","SUP-ITM-10133459","CDM","C1713","HCPCS","0278","RC","","","","both","","","1229.98","737.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","143.05","1045.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7MM 12 COMPRESSION DARCO SNAP OFF TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD","SUP-ITM-10133459","CDM","C1713","HCPCS","0278","RC","","","","both","","","1229.98","737.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","143.05","1045.48","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7MM 12 COMPRESSION DARCO SNAP OFF TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD","SUP-ITM-10133459","CDM","C1713","HCPCS","0278","RC","","","","both","","","1229.98","737.99","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","699.86","56.9","","812.12","238.65","1587.46","163","143.05","1045.48","percent of total billed charges",""
"SCREW BONE 2.7MM 12 COMPRESSION DARCO SNAP OFF TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD","SUP-ITM-10133459","CDM","C1713","HCPCS","0278","RC","","","","both","","","1229.98","737.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","143.05","11.63","","112.68","112.68","146.99","38","143.05","1045.48","percent of total billed charges",""
"SCREW BONE 2.7MM 12 COMPRESSION DARCO SNAP OFF TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD","SUP-ITM-10133459","CDM","C1713","HCPCS","0278","RC","","","","both","","","1229.98","737.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","952.00","77.4","","303.98","303.98","5854.79","1 through 10","143.05","1045.48","percent of total billed charges",""
"SCREW BONE 2.7MM 12 COMPRESSION DARCO SNAP OFF TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD","SUP-ITM-10133459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1229.98","737.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","143.05","11.63","","112.68","112.68","146.99","38","143.05","952","percent of total billed charges",""
"SCREW BONE 2.7MM 12 COMPRESSION DARCO SNAP OFF TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD","SUP-ITM-10133459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1229.98","737.99","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","772.18","62.78","","780.86","208.94","10480.28","15","143.05","952","percent of total billed charges",""
"SCREW BONE 2.7MM 12 COMPRESSION DARCO SNAP OFF TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD","SUP-ITM-10133459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1229.98","737.99","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","537.75","43.72","","179.76","179.76","179.76","1 through 10","143.05","952","percent of total billed charges",""
"SCREW BONE 2.7MM 12 COMPRESSION DARCO SNAP OFF TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD","SUP-ITM-10133459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1229.98","737.99","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","894.44","72.72","","2355.45","298.99","3965.19","155","143.05","952","percent of total billed charges",""
"SCREW BONE 2.7MM 12 COMPRESSION DARCO SNAP OFF TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD","SUP-ITM-10133459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1229.98","737.99","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","894.44","72.72","","3643.09","3643.09","3643.09","1 through 10","143.05","952","percent of total billed charges",""
"SCREW BONE 2.7MM 12 COMPRESSION DARCO SNAP OFF TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD","SUP-ITM-10133459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1229.98","737.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","654.60","53.22","","554.28","554.28","554.28","16","143.05","952","percent of total billed charges",""
"SCREW BONE 2.7MM 12 COMPRESSION DARCO SNAP OFF TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD","SUP-ITM-10133459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1229.98","737.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","773.66","62.9","","619.64","173.09","2370.64","150","143.05","952","percent of total billed charges",""
"SCREW BONE 2.7MM 12 COMPRESSION DARCO SNAP OFF TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD","SUP-ITM-10133459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1229.98","737.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","952.00","77.4","","303.98","303.98","5854.79","1 through 10","143.05","952","percent of total billed charges",""
"SCREW BONE 2.7MM LOCKING LAPIPLASTY FASTPITCH HIGH PITCH","SUP-ITM-10297855","CDM","C1713","HCPCS","0278","RC","","","","both","","","4318.75","2591.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","502.27","3670.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7MM LOCKING LAPIPLASTY FASTPITCH HIGH PITCH","SUP-ITM-10297855","CDM","C1713","HCPCS","0278","RC","","","","both","","","4318.75","2591.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","502.27","3670.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7MM LOCKING LAPIPLASTY FASTPITCH HIGH PITCH","SUP-ITM-10297855","CDM","C1713","HCPCS","0278","RC","","","","both","","","4318.75","2591.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2457.37","56.9","","812.12","238.65","1587.46","163","502.27","3670.94","percent of total billed charges",""
"SCREW BONE 2.7MM LOCKING LAPIPLASTY FASTPITCH HIGH PITCH","SUP-ITM-10297855","CDM","C1713","HCPCS","0278","RC","","","","both","","","4318.75","2591.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","502.27","11.63","","112.68","112.68","146.99","38","502.27","3670.94","percent of total billed charges",""
"SCREW BONE 2.7MM LOCKING LAPIPLASTY FASTPITCH HIGH PITCH","SUP-ITM-10297855","CDM","C1713","HCPCS","0278","RC","","","","both","","","4318.75","2591.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3342.71","77.4","","303.98","303.98","5854.79","1 through 10","502.27","3670.94","percent of total billed charges",""
"SCREW BONE 2.7MM LOCKING LAPIPLASTY FASTPITCH HIGH PITCH","SUP-ITM-10297855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4318.75","2591.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","502.27","11.63","","112.68","112.68","146.99","38","502.27","3342.71","percent of total billed charges",""
"SCREW BONE 2.7MM LOCKING LAPIPLASTY FASTPITCH HIGH PITCH","SUP-ITM-10297855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4318.75","2591.25","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2711.31","62.78","","780.86","208.94","10480.28","15","502.27","3342.71","percent of total billed charges",""
"SCREW BONE 2.7MM LOCKING LAPIPLASTY FASTPITCH HIGH PITCH","SUP-ITM-10297855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4318.75","2591.25","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1888.16","43.72","","179.76","179.76","179.76","1 through 10","502.27","3342.71","percent of total billed charges",""
"SCREW BONE 2.7MM LOCKING LAPIPLASTY FASTPITCH HIGH PITCH","SUP-ITM-10297855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4318.75","2591.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3140.60","72.72","","2355.45","298.99","3965.19","155","502.27","3342.71","percent of total billed charges",""
"SCREW BONE 2.7MM LOCKING LAPIPLASTY FASTPITCH HIGH PITCH","SUP-ITM-10297855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4318.75","2591.25","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3140.60","72.72","","3643.09","3643.09","3643.09","1 through 10","502.27","3342.71","percent of total billed charges",""
"SCREW BONE 2.7MM LOCKING LAPIPLASTY FASTPITCH HIGH PITCH","SUP-ITM-10297855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4318.75","2591.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2298.44","53.22","","554.28","554.28","554.28","16","502.27","3342.71","percent of total billed charges",""
"SCREW BONE 2.7MM LOCKING LAPIPLASTY FASTPITCH HIGH PITCH","SUP-ITM-10297855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4318.75","2591.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2716.49","62.9","","619.64","173.09","2370.64","150","502.27","3342.71","percent of total billed charges",""
"SCREW BONE 2.7MM LOCKING LAPIPLASTY FASTPITCH HIGH PITCH","SUP-ITM-10297855","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4318.75","2591.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3342.71","77.4","","303.98","303.98","5854.79","1 through 10","502.27","3342.71","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.54","420.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","81.47","595.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.54","420.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","81.47","595.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.54","420.32","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","398.61","56.9","","812.12","238.65","1587.46","163","81.47","595.46","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.54","420.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","81.47","11.63","","112.68","112.68","146.99","38","81.47","595.46","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.54","420.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","542.22","77.4","","303.98","303.98","5854.79","1 through 10","81.47","595.46","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.54","420.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","81.47","11.63","","112.68","112.68","146.99","38","81.47","542.22","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.54","420.32","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","439.80","62.78","","780.86","208.94","10480.28","15","81.47","542.22","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.54","420.32","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","306.28","43.72","","179.76","179.76","179.76","1 through 10","81.47","542.22","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.54","420.32","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","509.43","72.72","","2355.45","298.99","3965.19","155","81.47","542.22","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.54","420.32","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","509.43","72.72","","3643.09","3643.09","3643.09","1 through 10","81.47","542.22","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.54","420.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","372.83","53.22","","554.28","554.28","554.28","16","81.47","542.22","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.54","420.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","440.64","62.9","","619.64","173.09","2370.64","150","81.47","542.22","percent of total billed charges",""
"SCREW BONE 2.7X11MM STARDRIVE SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 RECESS","SUP-ITM-10095276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.54","420.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","542.22","77.4","","303.98","303.98","5854.79","1 through 10","81.47","542.22","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","242.89","145.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","28.25","206.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","242.89","145.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","28.25","206.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","242.89","145.73","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","138.20","56.9","","812.12","238.65","1587.46","163","28.25","206.46","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","242.89","145.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","28.25","11.63","","112.68","112.68","146.99","38","28.25","206.46","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","242.89","145.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","188.00","77.4","","303.98","303.98","5854.79","1 through 10","28.25","206.46","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","242.89","145.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","28.25","11.63","","112.68","112.68","146.99","38","28.25","188","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","242.89","145.73","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","152.49","62.78","","780.86","208.94","10480.28","15","28.25","188","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","242.89","145.73","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","106.19","43.72","","179.76","179.76","179.76","1 through 10","28.25","188","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","242.89","145.73","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","176.63","72.72","","2355.45","298.99","3965.19","155","28.25","188","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","242.89","145.73","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","176.63","72.72","","3643.09","3643.09","3643.09","1 through 10","28.25","188","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","242.89","145.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","129.27","53.22","","554.28","554.28","554.28","16","28.25","188","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","242.89","145.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","152.78","62.9","","619.64","173.09","2370.64","150","28.25","188","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","242.89","145.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","188.00","77.4","","303.98","303.98","5854.79","1 through 10","28.25","188","percent of total billed charges",""
"SCREW BONE 2.7X12MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171315","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.28","661.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","128.2","936.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X12MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171315","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.28","661.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","128.2","936.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X12MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171315","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.28","661.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","627.20","56.9","","812.12","238.65","1587.46","163","128.2","936.94","percent of total billed charges",""
"SCREW BONE 2.7X12MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171315","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.28","661.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","128.20","11.63","","112.68","112.68","146.99","38","128.2","936.94","percent of total billed charges",""
"SCREW BONE 2.7X12MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171315","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.28","661.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","853.16","77.4","","303.98","303.98","5854.79","1 through 10","128.2","936.94","percent of total billed charges",""
"SCREW BONE 2.7X12MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","128.20","11.63","","112.68","112.68","146.99","38","128.2","853.16","percent of total billed charges",""
"SCREW BONE 2.7X12MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","692.01","62.78","","780.86","208.94","10480.28","15","128.2","853.16","percent of total billed charges",""
"SCREW BONE 2.7X12MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","481.92","43.72","","179.76","179.76","179.76","1 through 10","128.2","853.16","percent of total billed charges",""
"SCREW BONE 2.7X12MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","801.58","72.72","","2355.45","298.99","3965.19","155","128.2","853.16","percent of total billed charges",""
"SCREW BONE 2.7X12MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","801.58","72.72","","3643.09","3643.09","3643.09","1 through 10","128.2","853.16","percent of total billed charges",""
"SCREW BONE 2.7X12MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","586.63","53.22","","554.28","554.28","554.28","16","128.2","853.16","percent of total billed charges",""
"SCREW BONE 2.7X12MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","693.33","62.9","","619.64","173.09","2370.64","150","128.2","853.16","percent of total billed charges",""
"SCREW BONE 2.7X12MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","853.16","77.4","","303.98","303.98","5854.79","1 through 10","128.2","853.16","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","224.99","134.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","26.17","191.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","224.99","134.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","26.17","191.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","224.99","134.99","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","128.02","56.9","","812.12","238.65","1587.46","163","26.17","191.24","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","224.99","134.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","26.17","11.63","","112.68","112.68","146.99","38","26.17","191.24","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","224.99","134.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","174.14","77.4","","303.98","303.98","5854.79","1 through 10","26.17","191.24","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","224.99","134.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","26.17","11.63","","112.68","112.68","146.99","38","26.17","174.14","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","224.99","134.99","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","141.25","62.78","","780.86","208.94","10480.28","15","26.17","174.14","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","224.99","134.99","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","98.37","43.72","","179.76","179.76","179.76","1 through 10","26.17","174.14","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","224.99","134.99","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","163.61","72.72","","2355.45","298.99","3965.19","155","26.17","174.14","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","224.99","134.99","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","163.61","72.72","","3643.09","3643.09","3643.09","1 through 10","26.17","174.14","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","224.99","134.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","119.74","53.22","","554.28","554.28","554.28","16","26.17","174.14","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","224.99","134.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","141.52","62.9","","619.64","173.09","2370.64","150","26.17","174.14","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","224.99","134.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","174.14","77.4","","303.98","303.98","5854.79","1 through 10","26.17","174.14","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","919.03","551.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","106.88","781.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","919.03","551.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","106.88","781.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","919.03","551.42","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","522.93","56.9","","812.12","238.65","1587.46","163","106.88","781.18","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","919.03","551.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","106.88","11.63","","112.68","112.68","146.99","38","106.88","781.18","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","919.03","551.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","711.33","77.4","","303.98","303.98","5854.79","1 through 10","106.88","781.18","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","919.03","551.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","106.88","11.63","","112.68","112.68","146.99","38","106.88","711.33","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","919.03","551.42","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","576.97","62.78","","780.86","208.94","10480.28","15","106.88","711.33","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","919.03","551.42","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","401.80","43.72","","179.76","179.76","179.76","1 through 10","106.88","711.33","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","919.03","551.42","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","668.32","72.72","","2355.45","298.99","3965.19","155","106.88","711.33","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","919.03","551.42","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","668.32","72.72","","3643.09","3643.09","3643.09","1 through 10","106.88","711.33","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","919.03","551.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","489.11","53.22","","554.28","554.28","554.28","16","106.88","711.33","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","919.03","551.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","578.07","62.9","","619.64","173.09","2370.64","150","106.88","711.33","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","919.03","551.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","711.33","77.4","","303.98","303.98","5854.79","1 through 10","106.88","711.33","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.00","148.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","28.84","210.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.00","148.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","28.84","210.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.00","148.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","141.11","56.9","","812.12","238.65","1587.46","163","28.84","210.8","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.00","148.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","28.84","11.63","","112.68","112.68","146.99","38","28.84","210.8","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","both","","","248.00","148.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","191.95","77.4","","303.98","303.98","5854.79","1 through 10","28.84","210.8","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.00","148.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","28.84","11.63","","112.68","112.68","146.99","38","28.84","191.95","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.00","148.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","155.69","62.78","","780.86","208.94","10480.28","15","28.84","191.95","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.00","148.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","108.43","43.72","","179.76","179.76","179.76","1 through 10","28.84","191.95","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.00","148.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","180.35","72.72","","2355.45","298.99","3965.19","155","28.84","191.95","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.00","148.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","180.35","72.72","","3643.09","3643.09","3643.09","1 through 10","28.84","191.95","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.00","148.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","131.99","53.22","","554.28","554.28","554.28","16","28.84","191.95","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.00","148.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","155.99","62.9","","619.64","173.09","2370.64","150","28.84","191.95","percent of total billed charges",""
"SCREW BONE 2.7X16MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10024292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","248.00","148.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","191.95","77.4","","303.98","303.98","5854.79","1 through 10","28.84","191.95","percent of total billed charges",""
"SCREW BONE 2.7X16MM ORTHOLOC 3DI CORTICAL TITANIUM NONLOCKING LOW PROFILE","SUP-ITM-10124566","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.99","368.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","71.52","522.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X16MM ORTHOLOC 3DI CORTICAL TITANIUM NONLOCKING LOW PROFILE","SUP-ITM-10124566","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.99","368.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","71.52","522.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X16MM ORTHOLOC 3DI CORTICAL TITANIUM NONLOCKING LOW PROFILE","SUP-ITM-10124566","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.99","368.99","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","349.93","56.9","","812.12","238.65","1587.46","163","71.52","522.74","percent of total billed charges",""
"SCREW BONE 2.7X16MM ORTHOLOC 3DI CORTICAL TITANIUM NONLOCKING LOW PROFILE","SUP-ITM-10124566","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.99","368.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.52","11.63","","112.68","112.68","146.99","38","71.52","522.74","percent of total billed charges",""
"SCREW BONE 2.7X16MM ORTHOLOC 3DI CORTICAL TITANIUM NONLOCKING LOW PROFILE","SUP-ITM-10124566","CDM","C1713","HCPCS","0278","RC","","","","both","","","614.99","368.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","476.00","77.4","","303.98","303.98","5854.79","1 through 10","71.52","522.74","percent of total billed charges",""
"SCREW BONE 2.7X16MM ORTHOLOC 3DI CORTICAL TITANIUM NONLOCKING LOW PROFILE","SUP-ITM-10124566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.99","368.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.52","11.63","","112.68","112.68","146.99","38","71.52","476","percent of total billed charges",""
"SCREW BONE 2.7X16MM ORTHOLOC 3DI CORTICAL TITANIUM NONLOCKING LOW PROFILE","SUP-ITM-10124566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.99","368.99","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","386.09","62.78","","780.86","208.94","10480.28","15","71.52","476","percent of total billed charges",""
"SCREW BONE 2.7X16MM ORTHOLOC 3DI CORTICAL TITANIUM NONLOCKING LOW PROFILE","SUP-ITM-10124566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.99","368.99","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","268.87","43.72","","179.76","179.76","179.76","1 through 10","71.52","476","percent of total billed charges",""
"SCREW BONE 2.7X16MM ORTHOLOC 3DI CORTICAL TITANIUM NONLOCKING LOW PROFILE","SUP-ITM-10124566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.99","368.99","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","447.22","72.72","","2355.45","298.99","3965.19","155","71.52","476","percent of total billed charges",""
"SCREW BONE 2.7X16MM ORTHOLOC 3DI CORTICAL TITANIUM NONLOCKING LOW PROFILE","SUP-ITM-10124566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.99","368.99","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","447.22","72.72","","3643.09","3643.09","3643.09","1 through 10","71.52","476","percent of total billed charges",""
"SCREW BONE 2.7X16MM ORTHOLOC 3DI CORTICAL TITANIUM NONLOCKING LOW PROFILE","SUP-ITM-10124566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.99","368.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","327.30","53.22","","554.28","554.28","554.28","16","71.52","476","percent of total billed charges",""
"SCREW BONE 2.7X16MM ORTHOLOC 3DI CORTICAL TITANIUM NONLOCKING LOW PROFILE","SUP-ITM-10124566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.99","368.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","386.83","62.9","","619.64","173.09","2370.64","150","71.52","476","percent of total billed charges",""
"SCREW BONE 2.7X16MM ORTHOLOC 3DI CORTICAL TITANIUM NONLOCKING LOW PROFILE","SUP-ITM-10124566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","614.99","368.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","476.00","77.4","","303.98","303.98","5854.79","1 through 10","71.52","476","percent of total billed charges",""
"SCREW BONE 2.7X16MM PARTIAL THREAD","SUP-ITM-10143599","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.01","759.01","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","147.12","1075.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X16MM PARTIAL THREAD","SUP-ITM-10143599","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.01","759.01","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","147.12","1075.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X16MM PARTIAL THREAD","SUP-ITM-10143599","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.01","759.01","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","719.79","56.9","","812.12","238.65","1587.46","163","147.12","1075.26","percent of total billed charges",""
"SCREW BONE 2.7X16MM PARTIAL THREAD","SUP-ITM-10143599","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.01","759.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","147.12","11.63","","112.68","112.68","146.99","38","147.12","1075.26","percent of total billed charges",""
"SCREW BONE 2.7X16MM PARTIAL THREAD","SUP-ITM-10143599","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.01","759.01","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","979.12","77.4","","303.98","303.98","5854.79","1 through 10","147.12","1075.26","percent of total billed charges",""
"SCREW BONE 2.7X16MM PARTIAL THREAD","SUP-ITM-10143599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1265.01","759.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","147.12","11.63","","112.68","112.68","146.99","38","147.12","979.12","percent of total billed charges",""
"SCREW BONE 2.7X16MM PARTIAL THREAD","SUP-ITM-10143599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1265.01","759.01","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","794.17","62.78","","780.86","208.94","10480.28","15","147.12","979.12","percent of total billed charges",""
"SCREW BONE 2.7X16MM PARTIAL THREAD","SUP-ITM-10143599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1265.01","759.01","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","553.06","43.72","","179.76","179.76","179.76","1 through 10","147.12","979.12","percent of total billed charges",""
"SCREW BONE 2.7X16MM PARTIAL THREAD","SUP-ITM-10143599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1265.01","759.01","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","919.92","72.72","","2355.45","298.99","3965.19","155","147.12","979.12","percent of total billed charges",""
"SCREW BONE 2.7X16MM PARTIAL THREAD","SUP-ITM-10143599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1265.01","759.01","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","919.92","72.72","","3643.09","3643.09","3643.09","1 through 10","147.12","979.12","percent of total billed charges",""
"SCREW BONE 2.7X16MM PARTIAL THREAD","SUP-ITM-10143599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1265.01","759.01","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","673.24","53.22","","554.28","554.28","554.28","16","147.12","979.12","percent of total billed charges",""
"SCREW BONE 2.7X16MM PARTIAL THREAD","SUP-ITM-10143599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1265.01","759.01","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","795.69","62.9","","619.64","173.09","2370.64","150","147.12","979.12","percent of total billed charges",""
"SCREW BONE 2.7X16MM PARTIAL THREAD","SUP-ITM-10143599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1265.01","759.01","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","979.12","77.4","","303.98","303.98","5854.79","1 through 10","147.12","979.12","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.54","420.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","81.47","595.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.54","420.32","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","81.47","595.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.54","420.32","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","398.61","56.9","","812.12","238.65","1587.46","163","81.47","595.46","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.54","420.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","81.47","11.63","","112.68","112.68","146.99","38","81.47","595.46","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","700.54","420.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","542.22","77.4","","303.98","303.98","5854.79","1 through 10","81.47","595.46","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.54","420.32","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","81.47","11.63","","112.68","112.68","146.99","38","81.47","542.22","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.54","420.32","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","439.80","62.78","","780.86","208.94","10480.28","15","81.47","542.22","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.54","420.32","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","306.28","43.72","","179.76","179.76","179.76","1 through 10","81.47","542.22","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.54","420.32","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","509.43","72.72","","2355.45","298.99","3965.19","155","81.47","542.22","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.54","420.32","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","509.43","72.72","","3643.09","3643.09","3643.09","1 through 10","81.47","542.22","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.54","420.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","372.83","53.22","","554.28","554.28","554.28","16","81.47","542.22","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.54","420.32","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","440.64","62.9","","619.64","173.09","2370.64","150","81.47","542.22","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","700.54","420.32","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","542.22","77.4","","303.98","303.98","5854.79","1 through 10","81.47","542.22","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186821","CDM","C1713","HCPCS","0278","RC","","","","both","","","2034.44","1220.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","236.61","1729.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X16MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186821","CDM","C1713","HCPCS","0278","RC","","","","both","","","2034.44","1220.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","236.61","1729.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X16MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186821","CDM","C1713","HCPCS","0278","RC","","","","both","","","2034.44","1220.66","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1157.60","56.9","","812.12","238.65","1587.46","163","236.61","1729.27","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186821","CDM","C1713","HCPCS","0278","RC","","","","both","","","2034.44","1220.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","236.61","11.63","","112.68","112.68","146.99","38","236.61","1729.27","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186821","CDM","C1713","HCPCS","0278","RC","","","","both","","","2034.44","1220.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1574.66","77.4","","303.98","303.98","5854.79","1 through 10","236.61","1729.27","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2034.44","1220.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","236.61","11.63","","112.68","112.68","146.99","38","236.61","1574.66","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2034.44","1220.66","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1277.22","62.78","","780.86","208.94","10480.28","15","236.61","1574.66","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2034.44","1220.66","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","889.46","43.72","","179.76","179.76","179.76","1 through 10","236.61","1574.66","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2034.44","1220.66","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1479.44","72.72","","2355.45","298.99","3965.19","155","236.61","1574.66","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2034.44","1220.66","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1479.44","72.72","","3643.09","3643.09","3643.09","1 through 10","236.61","1574.66","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2034.44","1220.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1082.73","53.22","","554.28","554.28","554.28","16","236.61","1574.66","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2034.44","1220.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1279.66","62.9","","619.64","173.09","2370.64","150","236.61","1574.66","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10186821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2034.44","1220.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1574.66","77.4","","303.98","303.98","5854.79","1 through 10","236.61","1574.66","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.28","661.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","128.2","936.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.28","661.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","128.2","936.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.28","661.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","627.20","56.9","","812.12","238.65","1587.46","163","128.2","936.94","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.28","661.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","128.20","11.63","","112.68","112.68","146.99","38","128.2","936.94","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.28","661.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","853.16","77.4","","303.98","303.98","5854.79","1 through 10","128.2","936.94","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","128.20","11.63","","112.68","112.68","146.99","38","128.2","853.16","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","692.01","62.78","","780.86","208.94","10480.28","15","128.2","853.16","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","481.92","43.72","","179.76","179.76","179.76","1 through 10","128.2","853.16","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","801.58","72.72","","2355.45","298.99","3965.19","155","128.2","853.16","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","801.58","72.72","","3643.09","3643.09","3643.09","1 through 10","128.2","853.16","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","586.63","53.22","","554.28","554.28","554.28","16","128.2","853.16","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","693.33","62.9","","619.64","173.09","2370.64","150","128.2","853.16","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","853.16","77.4","","303.98","303.98","5854.79","1 through 10","128.2","853.16","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","both","","","1819.89","1091.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","211.65","1546.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","both","","","1819.89","1091.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","211.65","1546.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","both","","","1819.89","1091.93","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1035.52","56.9","","812.12","238.65","1587.46","163","211.65","1546.91","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","both","","","1819.89","1091.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","211.65","11.63","","112.68","112.68","146.99","38","211.65","1546.91","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","both","","","1819.89","1091.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1408.59","77.4","","303.98","303.98","5854.79","1 through 10","211.65","1546.91","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1819.89","1091.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","211.65","11.63","","112.68","112.68","146.99","38","211.65","1408.59","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1819.89","1091.93","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1142.53","62.78","","780.86","208.94","10480.28","15","211.65","1408.59","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1819.89","1091.93","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","795.66","43.72","","179.76","179.76","179.76","1 through 10","211.65","1408.59","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1819.89","1091.93","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1323.42","72.72","","2355.45","298.99","3965.19","155","211.65","1408.59","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1819.89","1091.93","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1323.42","72.72","","3643.09","3643.09","3643.09","1 through 10","211.65","1408.59","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1819.89","1091.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","968.55","53.22","","554.28","554.28","554.28","16","211.65","1408.59","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1819.89","1091.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1144.71","62.9","","619.64","173.09","2370.64","150","211.65","1408.59","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1819.89","1091.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1408.59","77.4","","303.98","303.98","5854.79","1 through 10","211.65","1408.59","percent of total billed charges",""
"SCREW BONE 2.7X18MM LOCKING ST","SUP-ITM-10317506","CDM","C1713","HCPCS","0278","RC","","","","both","","","984.68","590.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","114.52","836.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X18MM LOCKING ST","SUP-ITM-10317506","CDM","C1713","HCPCS","0278","RC","","","","both","","","984.68","590.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","114.52","836.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X18MM LOCKING ST","SUP-ITM-10317506","CDM","C1713","HCPCS","0278","RC","","","","both","","","984.68","590.81","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","560.28","56.9","","812.12","238.65","1587.46","163","114.52","836.98","percent of total billed charges",""
"SCREW BONE 2.7X18MM LOCKING ST","SUP-ITM-10317506","CDM","C1713","HCPCS","0278","RC","","","","both","","","984.68","590.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","114.52","11.63","","112.68","112.68","146.99","38","114.52","836.98","percent of total billed charges",""
"SCREW BONE 2.7X18MM LOCKING ST","SUP-ITM-10317506","CDM","C1713","HCPCS","0278","RC","","","","both","","","984.68","590.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","762.14","77.4","","303.98","303.98","5854.79","1 through 10","114.52","836.98","percent of total billed charges",""
"SCREW BONE 2.7X18MM LOCKING ST","SUP-ITM-10317506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","984.68","590.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","114.52","11.63","","112.68","112.68","146.99","38","114.52","762.14","percent of total billed charges",""
"SCREW BONE 2.7X18MM LOCKING ST","SUP-ITM-10317506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","984.68","590.81","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","618.18","62.78","","780.86","208.94","10480.28","15","114.52","762.14","percent of total billed charges",""
"SCREW BONE 2.7X18MM LOCKING ST","SUP-ITM-10317506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","984.68","590.81","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","430.50","43.72","","179.76","179.76","179.76","1 through 10","114.52","762.14","percent of total billed charges",""
"SCREW BONE 2.7X18MM LOCKING ST","SUP-ITM-10317506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","984.68","590.81","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","716.06","72.72","","2355.45","298.99","3965.19","155","114.52","762.14","percent of total billed charges",""
"SCREW BONE 2.7X18MM LOCKING ST","SUP-ITM-10317506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","984.68","590.81","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","716.06","72.72","","3643.09","3643.09","3643.09","1 through 10","114.52","762.14","percent of total billed charges",""
"SCREW BONE 2.7X18MM LOCKING ST","SUP-ITM-10317506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","984.68","590.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","524.05","53.22","","554.28","554.28","554.28","16","114.52","762.14","percent of total billed charges",""
"SCREW BONE 2.7X18MM LOCKING ST","SUP-ITM-10317506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","984.68","590.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","619.36","62.9","","619.64","173.09","2370.64","150","114.52","762.14","percent of total billed charges",""
"SCREW BONE 2.7X18MM LOCKING ST","SUP-ITM-10317506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","984.68","590.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","762.14","77.4","","303.98","303.98","5854.79","1 through 10","114.52","762.14","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","1819.89","1091.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","211.65","1546.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","1819.89","1091.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","211.65","1546.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","1819.89","1091.93","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1035.52","56.9","","812.12","238.65","1587.46","163","211.65","1546.91","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","1819.89","1091.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","211.65","11.63","","112.68","112.68","146.99","38","211.65","1546.91","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","1819.89","1091.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1408.59","77.4","","303.98","303.98","5854.79","1 through 10","211.65","1546.91","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1819.89","1091.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","211.65","11.63","","112.68","112.68","146.99","38","211.65","1408.59","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1819.89","1091.93","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1142.53","62.78","","780.86","208.94","10480.28","15","211.65","1408.59","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1819.89","1091.93","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","795.66","43.72","","179.76","179.76","179.76","1 through 10","211.65","1408.59","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1819.89","1091.93","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1323.42","72.72","","2355.45","298.99","3965.19","155","211.65","1408.59","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1819.89","1091.93","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1323.42","72.72","","3643.09","3643.09","3643.09","1 through 10","211.65","1408.59","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1819.89","1091.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","968.55","53.22","","554.28","554.28","554.28","16","211.65","1408.59","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1819.89","1091.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1144.71","62.9","","619.64","173.09","2370.64","150","211.65","1408.59","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1819.89","1091.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1408.59","77.4","","303.98","303.98","5854.79","1 through 10","211.65","1408.59","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656418","SUP-ITM-10168026","CDM","C1713","HCPCS","0278","RC","","","","both","","","1065.31","639.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","123.9","905.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656418","SUP-ITM-10168026","CDM","C1713","HCPCS","0278","RC","","","","both","","","1065.31","639.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","123.9","905.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656418","SUP-ITM-10168026","CDM","C1713","HCPCS","0278","RC","","","","both","","","1065.31","639.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","606.16","56.9","","812.12","238.65","1587.46","163","123.9","905.51","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656418","SUP-ITM-10168026","CDM","C1713","HCPCS","0278","RC","","","","both","","","1065.31","639.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","123.90","11.63","","112.68","112.68","146.99","38","123.9","905.51","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656418","SUP-ITM-10168026","CDM","C1713","HCPCS","0278","RC","","","","both","","","1065.31","639.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","824.55","77.4","","303.98","303.98","5854.79","1 through 10","123.9","905.51","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656418","SUP-ITM-10168026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1065.31","639.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","123.90","11.63","","112.68","112.68","146.99","38","123.9","824.55","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656418","SUP-ITM-10168026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1065.31","639.19","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","668.80","62.78","","780.86","208.94","10480.28","15","123.9","824.55","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656418","SUP-ITM-10168026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1065.31","639.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","465.75","43.72","","179.76","179.76","179.76","1 through 10","123.9","824.55","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656418","SUP-ITM-10168026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1065.31","639.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","774.69","72.72","","2355.45","298.99","3965.19","155","123.9","824.55","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656418","SUP-ITM-10168026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1065.31","639.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","774.69","72.72","","3643.09","3643.09","3643.09","1 through 10","123.9","824.55","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656418","SUP-ITM-10168026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1065.31","639.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","566.96","53.22","","554.28","554.28","554.28","16","123.9","824.55","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656418","SUP-ITM-10168026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1065.31","639.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","670.08","62.9","","619.64","173.09","2370.64","150","123.9","824.55","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656418","SUP-ITM-10168026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1065.31","639.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","824.55","77.4","","303.98","303.98","5854.79","1 through 10","123.9","824.55","percent of total billed charges",""
"SCREW BONE 2.7X20MM TC 100 SS CORTEX SELF TAPPING FULL THREAD HEX HEAD","SUP-ITM-10063276","CDM","C1713","HCPCS","0278","RC","","","","both","","","505.81","303.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","58.83","429.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X20MM TC 100 SS CORTEX SELF TAPPING FULL THREAD HEX HEAD","SUP-ITM-10063276","CDM","C1713","HCPCS","0278","RC","","","","both","","","505.81","303.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","58.83","429.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X20MM TC 100 SS CORTEX SELF TAPPING FULL THREAD HEX HEAD","SUP-ITM-10063276","CDM","C1713","HCPCS","0278","RC","","","","both","","","505.81","303.49","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","287.81","56.9","","812.12","238.65","1587.46","163","58.83","429.94","percent of total billed charges",""
"SCREW BONE 2.7X20MM TC 100 SS CORTEX SELF TAPPING FULL THREAD HEX HEAD","SUP-ITM-10063276","CDM","C1713","HCPCS","0278","RC","","","","both","","","505.81","303.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","58.83","11.63","","112.68","112.68","146.99","38","58.83","429.94","percent of total billed charges",""
"SCREW BONE 2.7X20MM TC 100 SS CORTEX SELF TAPPING FULL THREAD HEX HEAD","SUP-ITM-10063276","CDM","C1713","HCPCS","0278","RC","","","","both","","","505.81","303.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","391.50","77.4","","303.98","303.98","5854.79","1 through 10","58.83","429.94","percent of total billed charges",""
"SCREW BONE 2.7X20MM TC 100 SS CORTEX SELF TAPPING FULL THREAD HEX HEAD","SUP-ITM-10063276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","505.81","303.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","58.83","11.63","","112.68","112.68","146.99","38","58.83","391.5","percent of total billed charges",""
"SCREW BONE 2.7X20MM TC 100 SS CORTEX SELF TAPPING FULL THREAD HEX HEAD","SUP-ITM-10063276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","505.81","303.49","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","317.55","62.78","","780.86","208.94","10480.28","15","58.83","391.5","percent of total billed charges",""
"SCREW BONE 2.7X20MM TC 100 SS CORTEX SELF TAPPING FULL THREAD HEX HEAD","SUP-ITM-10063276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","505.81","303.49","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","221.14","43.72","","179.76","179.76","179.76","1 through 10","58.83","391.5","percent of total billed charges",""
"SCREW BONE 2.7X20MM TC 100 SS CORTEX SELF TAPPING FULL THREAD HEX HEAD","SUP-ITM-10063276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","505.81","303.49","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","367.83","72.72","","2355.45","298.99","3965.19","155","58.83","391.5","percent of total billed charges",""
"SCREW BONE 2.7X20MM TC 100 SS CORTEX SELF TAPPING FULL THREAD HEX HEAD","SUP-ITM-10063276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","505.81","303.49","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","367.83","72.72","","3643.09","3643.09","3643.09","1 through 10","58.83","391.5","percent of total billed charges",""
"SCREW BONE 2.7X20MM TC 100 SS CORTEX SELF TAPPING FULL THREAD HEX HEAD","SUP-ITM-10063276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","505.81","303.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","269.19","53.22","","554.28","554.28","554.28","16","58.83","391.5","percent of total billed charges",""
"SCREW BONE 2.7X20MM TC 100 SS CORTEX SELF TAPPING FULL THREAD HEX HEAD","SUP-ITM-10063276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","505.81","303.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","318.15","62.9","","619.64","173.09","2370.64","150","58.83","391.5","percent of total billed charges",""
"SCREW BONE 2.7X20MM TC 100 SS CORTEX SELF TAPPING FULL THREAD HEX HEAD","SUP-ITM-10063276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","505.81","303.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","391.50","77.4","","303.98","303.98","5854.79","1 through 10","58.83","391.5","percent of total billed charges",""
"SCREW BONE 2.7X22MM RAYHACK TITANIUM LOCKING","SUP-ITM-10056842","CDM","C1713","HCPCS","0278","RC","","","","both","","","919.03","551.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","106.88","781.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X22MM RAYHACK TITANIUM LOCKING","SUP-ITM-10056842","CDM","C1713","HCPCS","0278","RC","","","","both","","","919.03","551.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","106.88","781.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X22MM RAYHACK TITANIUM LOCKING","SUP-ITM-10056842","CDM","C1713","HCPCS","0278","RC","","","","both","","","919.03","551.42","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","522.93","56.9","","812.12","238.65","1587.46","163","106.88","781.18","percent of total billed charges",""
"SCREW BONE 2.7X22MM RAYHACK TITANIUM LOCKING","SUP-ITM-10056842","CDM","C1713","HCPCS","0278","RC","","","","both","","","919.03","551.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","106.88","11.63","","112.68","112.68","146.99","38","106.88","781.18","percent of total billed charges",""
"SCREW BONE 2.7X22MM RAYHACK TITANIUM LOCKING","SUP-ITM-10056842","CDM","C1713","HCPCS","0278","RC","","","","both","","","919.03","551.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","711.33","77.4","","303.98","303.98","5854.79","1 through 10","106.88","781.18","percent of total billed charges",""
"SCREW BONE 2.7X22MM RAYHACK TITANIUM LOCKING","SUP-ITM-10056842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","919.03","551.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","106.88","11.63","","112.68","112.68","146.99","38","106.88","711.33","percent of total billed charges",""
"SCREW BONE 2.7X22MM RAYHACK TITANIUM LOCKING","SUP-ITM-10056842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","919.03","551.42","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","576.97","62.78","","780.86","208.94","10480.28","15","106.88","711.33","percent of total billed charges",""
"SCREW BONE 2.7X22MM RAYHACK TITANIUM LOCKING","SUP-ITM-10056842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","919.03","551.42","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","401.80","43.72","","179.76","179.76","179.76","1 through 10","106.88","711.33","percent of total billed charges",""
"SCREW BONE 2.7X22MM RAYHACK TITANIUM LOCKING","SUP-ITM-10056842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","919.03","551.42","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","668.32","72.72","","2355.45","298.99","3965.19","155","106.88","711.33","percent of total billed charges",""
"SCREW BONE 2.7X22MM RAYHACK TITANIUM LOCKING","SUP-ITM-10056842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","919.03","551.42","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","668.32","72.72","","3643.09","3643.09","3643.09","1 through 10","106.88","711.33","percent of total billed charges",""
"SCREW BONE 2.7X22MM RAYHACK TITANIUM LOCKING","SUP-ITM-10056842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","919.03","551.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","489.11","53.22","","554.28","554.28","554.28","16","106.88","711.33","percent of total billed charges",""
"SCREW BONE 2.7X22MM RAYHACK TITANIUM LOCKING","SUP-ITM-10056842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","919.03","551.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","578.07","62.9","","619.64","173.09","2370.64","150","106.88","711.33","percent of total billed charges",""
"SCREW BONE 2.7X22MM RAYHACK TITANIUM LOCKING","SUP-ITM-10056842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","919.03","551.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","711.33","77.4","","303.98","303.98","5854.79","1 through 10","106.88","711.33","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","both","","","1167.79","700.67","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","135.81","992.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","both","","","1167.79","700.67","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","135.81","992.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","both","","","1167.79","700.67","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","664.47","56.9","","812.12","238.65","1587.46","163","135.81","992.62","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","both","","","1167.79","700.67","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","135.81","11.63","","112.68","112.68","146.99","38","135.81","992.62","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","both","","","1167.79","700.67","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","903.87","77.4","","303.98","303.98","5854.79","1 through 10","135.81","992.62","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1167.79","700.67","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","135.81","11.63","","112.68","112.68","146.99","38","135.81","903.87","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1167.79","700.67","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","733.14","62.78","","780.86","208.94","10480.28","15","135.81","903.87","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1167.79","700.67","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","510.56","43.72","","179.76","179.76","179.76","1 through 10","135.81","903.87","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1167.79","700.67","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","849.22","72.72","","2355.45","298.99","3965.19","155","135.81","903.87","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1167.79","700.67","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","849.22","72.72","","3643.09","3643.09","3643.09","1 through 10","135.81","903.87","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1167.79","700.67","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","621.50","53.22","","554.28","554.28","554.28","16","135.81","903.87","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1167.79","700.67","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","734.54","62.9","","619.64","173.09","2370.64","150","135.81","903.87","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1167.79","700.67","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","903.87","77.4","","303.98","303.98","5854.79","1 through 10","135.81","903.87","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.93","349.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","67.79","495.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.93","349.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","67.79","495.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.93","349.76","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","331.69","56.9","","812.12","238.65","1587.46","163","67.79","495.49","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.93","349.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","67.79","11.63","","112.68","112.68","146.99","38","67.79","495.49","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.93","349.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","451.19","77.4","","303.98","303.98","5854.79","1 through 10","67.79","495.49","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","582.93","349.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","67.79","11.63","","112.68","112.68","146.99","38","67.79","451.19","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","582.93","349.76","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","365.96","62.78","","780.86","208.94","10480.28","15","67.79","451.19","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","582.93","349.76","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","254.86","43.72","","179.76","179.76","179.76","1 through 10","67.79","451.19","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","582.93","349.76","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","423.91","72.72","","2355.45","298.99","3965.19","155","67.79","451.19","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","582.93","349.76","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","423.91","72.72","","3643.09","3643.09","3643.09","1 through 10","67.79","451.19","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","582.93","349.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","310.24","53.22","","554.28","554.28","554.28","16","67.79","451.19","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","582.93","349.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","366.66","62.9","","619.64","173.09","2370.64","150","67.79","451.19","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","582.93","349.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","451.19","77.4","","303.98","303.98","5854.79","1 through 10","67.79","451.19","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.93","349.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","67.79","495.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.93","349.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","67.79","495.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.93","349.76","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","331.69","56.9","","812.12","238.65","1587.46","163","67.79","495.49","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.93","349.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","67.79","11.63","","112.68","112.68","146.99","38","67.79","495.49","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.93","349.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","451.19","77.4","","303.98","303.98","5854.79","1 through 10","67.79","495.49","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","582.93","349.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","67.79","11.63","","112.68","112.68","146.99","38","67.79","451.19","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","582.93","349.76","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","365.96","62.78","","780.86","208.94","10480.28","15","67.79","451.19","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","582.93","349.76","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","254.86","43.72","","179.76","179.76","179.76","1 through 10","67.79","451.19","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","582.93","349.76","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","423.91","72.72","","2355.45","298.99","3965.19","155","67.79","451.19","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","582.93","349.76","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","423.91","72.72","","3643.09","3643.09","3643.09","1 through 10","67.79","451.19","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","582.93","349.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","310.24","53.22","","554.28","554.28","554.28","16","67.79","451.19","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","582.93","349.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","366.66","62.9","","619.64","173.09","2370.64","150","67.79","451.19","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","582.93","349.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","451.19","77.4","","303.98","303.98","5854.79","1 through 10","67.79","451.19","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.52","243.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","47.28","345.54","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.52","243.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","47.28","345.54","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.52","243.91","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","231.31","56.9","","812.12","238.65","1587.46","163","47.28","345.54","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.52","243.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","47.28","11.63","","112.68","112.68","146.99","38","47.28","345.54","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.52","243.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","314.65","77.4","","303.98","303.98","5854.79","1 through 10","47.28","345.54","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","406.52","243.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","47.28","11.63","","112.68","112.68","146.99","38","47.28","314.65","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","406.52","243.91","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","255.21","62.78","","780.86","208.94","10480.28","15","47.28","314.65","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","406.52","243.91","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","177.73","43.72","","179.76","179.76","179.76","1 through 10","47.28","314.65","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","406.52","243.91","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","295.62","72.72","","2355.45","298.99","3965.19","155","47.28","314.65","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","406.52","243.91","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","295.62","72.72","","3643.09","3643.09","3643.09","1 through 10","47.28","314.65","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","406.52","243.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","216.35","53.22","","554.28","554.28","554.28","16","47.28","314.65","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","406.52","243.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","255.70","62.9","","619.64","173.09","2370.64","150","47.28","314.65","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","406.52","243.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","314.65","77.4","","303.98","303.98","5854.79","1 through 10","47.28","314.65","percent of total billed charges",""
"SCREW BONE 2.7X40MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10064607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1145.33","687.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","133.2","973.53","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X40MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10064607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1145.33","687.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","133.2","973.53","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X40MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10064607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1145.33","687.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","651.69","56.9","","812.12","238.65","1587.46","163","133.2","973.53","percent of total billed charges",""
"SCREW BONE 2.7X40MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10064607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1145.33","687.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","133.20","11.63","","112.68","112.68","146.99","38","133.2","973.53","percent of total billed charges",""
"SCREW BONE 2.7X40MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10064607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1145.33","687.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","886.49","77.4","","303.98","303.98","5854.79","1 through 10","133.2","973.53","percent of total billed charges",""
"SCREW BONE 2.7X40MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10064607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1145.33","687.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","133.20","11.63","","112.68","112.68","146.99","38","133.2","886.49","percent of total billed charges",""
"SCREW BONE 2.7X40MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10064607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1145.33","687.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","719.04","62.78","","780.86","208.94","10480.28","15","133.2","886.49","percent of total billed charges",""
"SCREW BONE 2.7X40MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10064607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1145.33","687.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","500.74","43.72","","179.76","179.76","179.76","1 through 10","133.2","886.49","percent of total billed charges",""
"SCREW BONE 2.7X40MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10064607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1145.33","687.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","832.88","72.72","","2355.45","298.99","3965.19","155","133.2","886.49","percent of total billed charges",""
"SCREW BONE 2.7X40MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10064607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1145.33","687.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","832.88","72.72","","3643.09","3643.09","3643.09","1 through 10","133.2","886.49","percent of total billed charges",""
"SCREW BONE 2.7X40MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10064607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1145.33","687.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","609.54","53.22","","554.28","554.28","554.28","16","133.2","886.49","percent of total billed charges",""
"SCREW BONE 2.7X40MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10064607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1145.33","687.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","720.41","62.9","","619.64","173.09","2370.64","150","133.2","886.49","percent of total billed charges",""
"SCREW BONE 2.7X40MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10064607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1145.33","687.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","886.49","77.4","","303.98","303.98","5854.79","1 through 10","133.2","886.49","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","242.89","145.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","28.25","206.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","242.89","145.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","28.25","206.46","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","242.89","145.73","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","138.20","56.9","","812.12","238.65","1587.46","163","28.25","206.46","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","242.89","145.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","28.25","11.63","","112.68","112.68","146.99","38","28.25","206.46","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","242.89","145.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","188.00","77.4","","303.98","303.98","5854.79","1 through 10","28.25","206.46","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","242.89","145.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","28.25","11.63","","112.68","112.68","146.99","38","28.25","188","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","242.89","145.73","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","152.49","62.78","","780.86","208.94","10480.28","15","28.25","188","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","242.89","145.73","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","106.19","43.72","","179.76","179.76","179.76","1 through 10","28.25","188","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","242.89","145.73","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","176.63","72.72","","2355.45","298.99","3965.19","155","28.25","188","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","242.89","145.73","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","176.63","72.72","","3643.09","3643.09","3643.09","1 through 10","28.25","188","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","242.89","145.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","129.27","53.22","","554.28","554.28","554.28","16","28.25","188","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","242.89","145.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","152.78","62.9","","619.64","173.09","2370.64","150","28.25","188","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","242.89","145.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","188.00","77.4","","303.98","303.98","5854.79","1 through 10","28.25","188","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","281.24","168.74","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","32.71","239.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","281.24","168.74","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","32.71","239.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","281.24","168.74","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","160.03","56.9","","812.12","238.65","1587.46","163","32.71","239.05","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","281.24","168.74","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","32.71","11.63","","112.68","112.68","146.99","38","32.71","239.05","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","281.24","168.74","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","217.68","77.4","","303.98","303.98","5854.79","1 through 10","32.71","239.05","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","281.24","168.74","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","32.71","11.63","","112.68","112.68","146.99","38","32.71","217.68","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","281.24","168.74","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","176.56","62.78","","780.86","208.94","10480.28","15","32.71","217.68","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","281.24","168.74","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","122.96","43.72","","179.76","179.76","179.76","1 through 10","32.71","217.68","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","281.24","168.74","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","204.52","72.72","","2355.45","298.99","3965.19","155","32.71","217.68","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","281.24","168.74","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","204.52","72.72","","3643.09","3643.09","3643.09","1 through 10","32.71","217.68","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","281.24","168.74","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","149.68","53.22","","554.28","554.28","554.28","16","32.71","217.68","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","281.24","168.74","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","176.90","62.9","","619.64","173.09","2370.64","150","32.71","217.68","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","281.24","168.74","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","217.68","77.4","","303.98","303.98","5854.79","1 through 10","32.71","217.68","percent of total billed charges",""
"SCREW BONE 2.7X60MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10041435","CDM","C1713","HCPCS","0278","RC","","","","both","","","1235.16","741.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","143.65","1049.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X60MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10041435","CDM","C1713","HCPCS","0278","RC","","","","both","","","1235.16","741.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","143.65","1049.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X60MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10041435","CDM","C1713","HCPCS","0278","RC","","","","both","","","1235.16","741.10","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","702.81","56.9","","812.12","238.65","1587.46","163","143.65","1049.89","percent of total billed charges",""
"SCREW BONE 2.7X60MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10041435","CDM","C1713","HCPCS","0278","RC","","","","both","","","1235.16","741.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","143.65","11.63","","112.68","112.68","146.99","38","143.65","1049.89","percent of total billed charges",""
"SCREW BONE 2.7X60MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10041435","CDM","C1713","HCPCS","0278","RC","","","","both","","","1235.16","741.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","956.01","77.4","","303.98","303.98","5854.79","1 through 10","143.65","1049.89","percent of total billed charges",""
"SCREW BONE 2.7X60MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10041435","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1235.16","741.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","143.65","11.63","","112.68","112.68","146.99","38","143.65","956.01","percent of total billed charges",""
"SCREW BONE 2.7X60MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10041435","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1235.16","741.10","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","775.43","62.78","","780.86","208.94","10480.28","15","143.65","956.01","percent of total billed charges",""
"SCREW BONE 2.7X60MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10041435","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1235.16","741.10","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","540.01","43.72","","179.76","179.76","179.76","1 through 10","143.65","956.01","percent of total billed charges",""
"SCREW BONE 2.7X60MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10041435","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1235.16","741.10","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","898.21","72.72","","2355.45","298.99","3965.19","155","143.65","956.01","percent of total billed charges",""
"SCREW BONE 2.7X60MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10041435","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1235.16","741.10","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","898.21","72.72","","3643.09","3643.09","3643.09","1 through 10","143.65","956.01","percent of total billed charges",""
"SCREW BONE 2.7X60MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10041435","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1235.16","741.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","657.35","53.22","","554.28","554.28","554.28","16","143.65","956.01","percent of total billed charges",""
"SCREW BONE 2.7X60MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10041435","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1235.16","741.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","776.92","62.9","","619.64","173.09","2370.64","150","143.65","956.01","percent of total billed charges",""
"SCREW BONE 2.7X60MM CORTEX PERI LOC SS LOCKING SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10041435","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1235.16","741.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","956.01","77.4","","303.98","303.98","5854.79","1 through 10","143.65","956.01","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.94","512.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","99.31","725.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.94","512.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","99.31","725.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.94","512.36","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","485.89","56.9","","812.12","238.65","1587.46","163","99.31","725.85","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.94","512.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","99.31","11.63","","112.68","112.68","146.99","38","99.31","725.85","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.94","512.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","660.95","77.4","","303.98","303.98","5854.79","1 through 10","99.31","725.85","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","853.94","512.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","99.31","11.63","","112.68","112.68","146.99","38","99.31","660.95","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","853.94","512.36","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","536.10","62.78","","780.86","208.94","10480.28","15","99.31","660.95","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","853.94","512.36","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","373.34","43.72","","179.76","179.76","179.76","1 through 10","99.31","660.95","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","853.94","512.36","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","620.99","72.72","","2355.45","298.99","3965.19","155","99.31","660.95","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","853.94","512.36","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","620.99","72.72","","3643.09","3643.09","3643.09","1 through 10","99.31","660.95","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","853.94","512.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","454.47","53.22","","554.28","554.28","554.28","16","99.31","660.95","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","853.94","512.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","537.13","62.9","","619.64","173.09","2370.64","150","99.31","660.95","percent of total billed charges",""
"SCREW BONE 2.7X75MM STARDRIVE METAPHYSEAL SS LCP SELF TAPPING T8 RECESS","SUP-ITM-10125040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","853.94","512.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","660.95","77.4","","303.98","303.98","5854.79","1 through 10","99.31","660.95","percent of total billed charges",""
"SCREW BONE 20X4.75MM SHOULDER FIXATION COMPREHENSIVE REVERSE FIXED ANGLE TITANIUM NONLOCKING THREAD PERIPHERAL HEXAGONAL SOCKET","SUP-ITM-10202401","CDM","C1776","HCPCS","0278","RC","","","","both","","","616.72","370.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","71.72","524.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 20X4.75MM SHOULDER FIXATION COMPREHENSIVE REVERSE FIXED ANGLE TITANIUM NONLOCKING THREAD PERIPHERAL HEXAGONAL SOCKET","SUP-ITM-10202401","CDM","C1776","HCPCS","0278","RC","","","","both","","","616.72","370.03","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","350.91","56.9","","2911.53","1863.86","5209.05","65","71.72","524.21","percent of total billed charges",""
"SCREW BONE 20X4.75MM SHOULDER FIXATION COMPREHENSIVE REVERSE FIXED ANGLE TITANIUM NONLOCKING THREAD PERIPHERAL HEXAGONAL SOCKET","SUP-ITM-10202401","CDM","C1776","HCPCS","0278","RC","","","","both","","","616.72","370.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.72","11.63","","400.94","400.94","400.94","1 through 10","71.72","524.21","percent of total billed charges",""
"SCREW BONE 20X4.75MM SHOULDER FIXATION COMPREHENSIVE REVERSE FIXED ANGLE TITANIUM NONLOCKING THREAD PERIPHERAL HEXAGONAL SOCKET","SUP-ITM-10202401","CDM","C1776","HCPCS","0278","RC","","","","both","","","616.72","370.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","477.34","77.4","","5214.50","5214.50","16415.28","1 through 10","71.72","524.21","percent of total billed charges",""
"SCREW BONE 20X4.75MM SHOULDER FIXATION COMPREHENSIVE REVERSE FIXED ANGLE TITANIUM NONLOCKING THREAD PERIPHERAL HEXAGONAL SOCKET","SUP-ITM-10202401","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.72","11.63","","400.94","400.94","400.94","1 through 10","71.72","477.34","percent of total billed charges",""
"SCREW BONE 20X4.75MM SHOULDER FIXATION COMPREHENSIVE REVERSE FIXED ANGLE TITANIUM NONLOCKING THREAD PERIPHERAL HEXAGONAL SOCKET","SUP-ITM-10202401","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","269.63","43.72","","1543.33","1543.33","1671.61","1 through 10","71.72","477.34","percent of total billed charges",""
"SCREW BONE 20X4.75MM SHOULDER FIXATION COMPREHENSIVE REVERSE FIXED ANGLE TITANIUM NONLOCKING THREAD PERIPHERAL HEXAGONAL SOCKET","SUP-ITM-10202401","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","448.48","72.72","","3700.21","2382.07","6427.18","53","71.72","477.34","percent of total billed charges",""
"SCREW BONE 20X4.75MM SHOULDER FIXATION COMPREHENSIVE REVERSE FIXED ANGLE TITANIUM NONLOCKING THREAD PERIPHERAL HEXAGONAL SOCKET","SUP-ITM-10202401","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","448.48","72.72","","12685.80","12685.80","12685.80","1 through 10","71.72","477.34","percent of total billed charges",""
"SCREW BONE 20X4.75MM SHOULDER FIXATION COMPREHENSIVE REVERSE FIXED ANGLE TITANIUM NONLOCKING THREAD PERIPHERAL HEXAGONAL SOCKET","SUP-ITM-10202401","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","387.92","62.9","","3408.87","2784.05","9859.40","46","71.72","477.34","percent of total billed charges",""
"SCREW BONE 20X4.75MM SHOULDER FIXATION COMPREHENSIVE REVERSE FIXED ANGLE TITANIUM NONLOCKING THREAD PERIPHERAL HEXAGONAL SOCKET","SUP-ITM-10202401","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","477.34","77.4","","5214.50","5214.50","16415.28","1 through 10","71.72","477.34","percent of total billed charges",""
"SCREW BONE 21MM 12.7X80 LAG AMBI SS THREAD STANDARD","SUP-ITM-10016979","CDM","C1713","HCPCS","0278","RC","","","","both","","","5078.85","3047.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","590.67","4317.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 21MM 12.7X80 LAG AMBI SS THREAD STANDARD","SUP-ITM-10016979","CDM","C1713","HCPCS","0278","RC","","","","both","","","5078.85","3047.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","590.67","4317.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 21MM 12.7X80 LAG AMBI SS THREAD STANDARD","SUP-ITM-10016979","CDM","C1713","HCPCS","0278","RC","","","","both","","","5078.85","3047.31","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2889.87","56.9","","812.12","238.65","1587.46","163","590.67","4317.02","percent of total billed charges",""
"SCREW BONE 21MM 12.7X80 LAG AMBI SS THREAD STANDARD","SUP-ITM-10016979","CDM","C1713","HCPCS","0278","RC","","","","both","","","5078.85","3047.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","590.67","11.63","","112.68","112.68","146.99","38","590.67","4317.02","percent of total billed charges",""
"SCREW BONE 21MM 12.7X80 LAG AMBI SS THREAD STANDARD","SUP-ITM-10016979","CDM","C1713","HCPCS","0278","RC","","","","both","","","5078.85","3047.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3931.03","77.4","","303.98","303.98","5854.79","1 through 10","590.67","4317.02","percent of total billed charges",""
"SCREW BONE 21MM 12.7X80 LAG AMBI SS THREAD STANDARD","SUP-ITM-10016979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5078.85","3047.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","590.67","11.63","","112.68","112.68","146.99","38","590.67","3931.03","percent of total billed charges",""
"SCREW BONE 21MM 12.7X80 LAG AMBI SS THREAD STANDARD","SUP-ITM-10016979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5078.85","3047.31","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3188.50","62.78","","780.86","208.94","10480.28","15","590.67","3931.03","percent of total billed charges",""
"SCREW BONE 21MM 12.7X80 LAG AMBI SS THREAD STANDARD","SUP-ITM-10016979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5078.85","3047.31","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2220.47","43.72","","179.76","179.76","179.76","1 through 10","590.67","3931.03","percent of total billed charges",""
"SCREW BONE 21MM 12.7X80 LAG AMBI SS THREAD STANDARD","SUP-ITM-10016979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5078.85","3047.31","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3693.34","72.72","","2355.45","298.99","3965.19","155","590.67","3931.03","percent of total billed charges",""
"SCREW BONE 21MM 12.7X80 LAG AMBI SS THREAD STANDARD","SUP-ITM-10016979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5078.85","3047.31","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3693.34","72.72","","3643.09","3643.09","3643.09","1 through 10","590.67","3931.03","percent of total billed charges",""
"SCREW BONE 21MM 12.7X80 LAG AMBI SS THREAD STANDARD","SUP-ITM-10016979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5078.85","3047.31","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2702.96","53.22","","554.28","554.28","554.28","16","590.67","3931.03","percent of total billed charges",""
"SCREW BONE 21MM 12.7X80 LAG AMBI SS THREAD STANDARD","SUP-ITM-10016979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5078.85","3047.31","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3194.60","62.9","","619.64","173.09","2370.64","150","590.67","3931.03","percent of total billed charges",""
"SCREW BONE 21MM 12.7X80 LAG AMBI SS THREAD STANDARD","SUP-ITM-10016979","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5078.85","3047.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3931.03","77.4","","303.98","303.98","5854.79","1 through 10","590.67","3931.03","percent of total billed charges",""
"SCREW BONE 21MM 12.7X90 LAG HIP STD FOR AMBI SYSTEM CHS CS/1BX/1EA","SUP-ITM-10005615","CDM","C1713","HCPCS","0278","RC","","","","both","","","5078.85","3047.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","590.67","4317.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 21MM 12.7X90 LAG HIP STD FOR AMBI SYSTEM CHS CS/1BX/1EA","SUP-ITM-10005615","CDM","C1713","HCPCS","0278","RC","","","","both","","","5078.85","3047.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","590.67","4317.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 21MM 12.7X90 LAG HIP STD FOR AMBI SYSTEM CHS CS/1BX/1EA","SUP-ITM-10005615","CDM","C1713","HCPCS","0278","RC","","","","both","","","5078.85","3047.31","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2889.87","56.9","","812.12","238.65","1587.46","163","590.67","4317.02","percent of total billed charges",""
"SCREW BONE 21MM 12.7X90 LAG HIP STD FOR AMBI SYSTEM CHS CS/1BX/1EA","SUP-ITM-10005615","CDM","C1713","HCPCS","0278","RC","","","","both","","","5078.85","3047.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","590.67","11.63","","112.68","112.68","146.99","38","590.67","4317.02","percent of total billed charges",""
"SCREW BONE 21MM 12.7X90 LAG HIP STD FOR AMBI SYSTEM CHS CS/1BX/1EA","SUP-ITM-10005615","CDM","C1713","HCPCS","0278","RC","","","","both","","","5078.85","3047.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3931.03","77.4","","303.98","303.98","5854.79","1 through 10","590.67","4317.02","percent of total billed charges",""
"SCREW BONE 21MM 12.7X90 LAG HIP STD FOR AMBI SYSTEM CHS CS/1BX/1EA","SUP-ITM-10005615","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5078.85","3047.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","590.67","11.63","","112.68","112.68","146.99","38","590.67","3931.03","percent of total billed charges",""
"SCREW BONE 21MM 12.7X90 LAG HIP STD FOR AMBI SYSTEM CHS CS/1BX/1EA","SUP-ITM-10005615","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5078.85","3047.31","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3188.50","62.78","","780.86","208.94","10480.28","15","590.67","3931.03","percent of total billed charges",""
"SCREW BONE 21MM 12.7X90 LAG HIP STD FOR AMBI SYSTEM CHS CS/1BX/1EA","SUP-ITM-10005615","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5078.85","3047.31","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2220.47","43.72","","179.76","179.76","179.76","1 through 10","590.67","3931.03","percent of total billed charges",""
"SCREW BONE 21MM 12.7X90 LAG HIP STD FOR AMBI SYSTEM CHS CS/1BX/1EA","SUP-ITM-10005615","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5078.85","3047.31","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3693.34","72.72","","2355.45","298.99","3965.19","155","590.67","3931.03","percent of total billed charges",""
"SCREW BONE 21MM 12.7X90 LAG HIP STD FOR AMBI SYSTEM CHS CS/1BX/1EA","SUP-ITM-10005615","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5078.85","3047.31","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3693.34","72.72","","3643.09","3643.09","3643.09","1 through 10","590.67","3931.03","percent of total billed charges",""
"SCREW BONE 21MM 12.7X90 LAG HIP STD FOR AMBI SYSTEM CHS CS/1BX/1EA","SUP-ITM-10005615","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5078.85","3047.31","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2702.96","53.22","","554.28","554.28","554.28","16","590.67","3931.03","percent of total billed charges",""
"SCREW BONE 21MM 12.7X90 LAG HIP STD FOR AMBI SYSTEM CHS CS/1BX/1EA","SUP-ITM-10005615","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5078.85","3047.31","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3194.60","62.9","","619.64","173.09","2370.64","150","590.67","3931.03","percent of total billed charges",""
"SCREW BONE 21MM 12.7X90 LAG HIP STD FOR AMBI SYSTEM CHS CS/1BX/1EA","SUP-ITM-10005615","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5078.85","3047.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3931.03","77.4","","303.98","303.98","5854.79","1 through 10","590.67","3931.03","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.37","200.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","38.89","284.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.37","200.62","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","38.89","284.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.37","200.62","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","190.26","56.9","","812.12","238.65","1587.46","163","38.89","284.21","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.37","200.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","38.89","11.63","","112.68","112.68","146.99","38","38.89","284.21","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.37","200.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","258.80","77.4","","303.98","303.98","5854.79","1 through 10","38.89","284.21","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","334.37","200.62","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","38.89","11.63","","112.68","112.68","146.99","38","38.89","258.8","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","334.37","200.62","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","209.92","62.78","","780.86","208.94","10480.28","15","38.89","258.8","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","334.37","200.62","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","146.19","43.72","","179.76","179.76","179.76","1 through 10","38.89","258.8","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","334.37","200.62","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","243.15","72.72","","2355.45","298.99","3965.19","155","38.89","258.8","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","334.37","200.62","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","243.15","72.72","","3643.09","3643.09","3643.09","1 through 10","38.89","258.8","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","334.37","200.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","177.95","53.22","","554.28","554.28","554.28","16","38.89","258.8","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","334.37","200.62","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","210.32","62.9","","619.64","173.09","2370.64","150","38.89","258.8","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","334.37","200.62","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","258.80","77.4","","303.98","303.98","5854.79","1 through 10","38.89","258.8","percent of total billed charges",""
"SCREW BONE 24X2.4MM CORTICAL CORTEX TI LOCKING LOW PROFILE","SUP-ITM-10115986","CDM","C1713","HCPCS","0278","RC","","","","both","","","760.10","456.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","88.4","646.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 24X2.4MM CORTICAL CORTEX TI LOCKING LOW PROFILE","SUP-ITM-10115986","CDM","C1713","HCPCS","0278","RC","","","","both","","","760.10","456.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","88.4","646.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 24X2.4MM CORTICAL CORTEX TI LOCKING LOW PROFILE","SUP-ITM-10115986","CDM","C1713","HCPCS","0278","RC","","","","both","","","760.10","456.06","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","432.50","56.9","","812.12","238.65","1587.46","163","88.4","646.09","percent of total billed charges",""
"SCREW BONE 24X2.4MM CORTICAL CORTEX TI LOCKING LOW PROFILE","SUP-ITM-10115986","CDM","C1713","HCPCS","0278","RC","","","","both","","","760.10","456.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","88.40","11.63","","112.68","112.68","146.99","38","88.4","646.09","percent of total billed charges",""
"SCREW BONE 24X2.4MM CORTICAL CORTEX TI LOCKING LOW PROFILE","SUP-ITM-10115986","CDM","C1713","HCPCS","0278","RC","","","","both","","","760.10","456.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","588.32","77.4","","303.98","303.98","5854.79","1 through 10","88.4","646.09","percent of total billed charges",""
"SCREW BONE 24X2.4MM CORTICAL CORTEX TI LOCKING LOW PROFILE","SUP-ITM-10115986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","760.10","456.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","88.40","11.63","","112.68","112.68","146.99","38","88.4","588.32","percent of total billed charges",""
"SCREW BONE 24X2.4MM CORTICAL CORTEX TI LOCKING LOW PROFILE","SUP-ITM-10115986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","760.10","456.06","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","477.19","62.78","","780.86","208.94","10480.28","15","88.4","588.32","percent of total billed charges",""
"SCREW BONE 24X2.4MM CORTICAL CORTEX TI LOCKING LOW PROFILE","SUP-ITM-10115986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","760.10","456.06","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","332.32","43.72","","179.76","179.76","179.76","1 through 10","88.4","588.32","percent of total billed charges",""
"SCREW BONE 24X2.4MM CORTICAL CORTEX TI LOCKING LOW PROFILE","SUP-ITM-10115986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","760.10","456.06","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","552.74","72.72","","2355.45","298.99","3965.19","155","88.4","588.32","percent of total billed charges",""
"SCREW BONE 24X2.4MM CORTICAL CORTEX TI LOCKING LOW PROFILE","SUP-ITM-10115986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","760.10","456.06","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","552.74","72.72","","3643.09","3643.09","3643.09","1 through 10","88.4","588.32","percent of total billed charges",""
"SCREW BONE 24X2.4MM CORTICAL CORTEX TI LOCKING LOW PROFILE","SUP-ITM-10115986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","760.10","456.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","404.53","53.22","","554.28","554.28","554.28","16","88.4","588.32","percent of total billed charges",""
"SCREW BONE 24X2.4MM CORTICAL CORTEX TI LOCKING LOW PROFILE","SUP-ITM-10115986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","760.10","456.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","478.10","62.9","","619.64","173.09","2370.64","150","88.4","588.32","percent of total billed charges",""
"SCREW BONE 24X2.4MM CORTICAL CORTEX TI LOCKING LOW PROFILE","SUP-ITM-10115986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","760.10","456.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","588.32","77.4","","303.98","303.98","5854.79","1 through 10","88.4","588.32","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","373.14","223.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","43.4","317.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","373.14","223.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","43.4","317.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","373.14","223.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","212.32","56.9","","812.12","238.65","1587.46","163","43.4","317.17","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","373.14","223.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","43.40","11.63","","112.68","112.68","146.99","38","43.4","317.17","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","373.14","223.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","288.81","77.4","","303.98","303.98","5854.79","1 through 10","43.4","317.17","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","373.14","223.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","43.40","11.63","","112.68","112.68","146.99","38","43.4","288.81","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","373.14","223.88","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","234.26","62.78","","780.86","208.94","10480.28","15","43.4","288.81","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","373.14","223.88","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","163.14","43.72","","179.76","179.76","179.76","1 through 10","43.4","288.81","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","373.14","223.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","271.35","72.72","","2355.45","298.99","3965.19","155","43.4","288.81","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","373.14","223.88","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","271.35","72.72","","3643.09","3643.09","3643.09","1 through 10","43.4","288.81","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","373.14","223.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","198.59","53.22","","554.28","554.28","554.28","16","43.4","288.81","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","373.14","223.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","234.71","62.9","","619.64","173.09","2370.64","150","43.4","288.81","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","373.14","223.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","288.81","77.4","","303.98","303.98","5854.79","1 through 10","43.4","288.81","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","both","","","746.56","447.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","86.82","634.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","both","","","746.56","447.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","86.82","634.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","both","","","746.56","447.94","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","424.79","56.9","","812.12","238.65","1587.46","163","86.82","634.58","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","both","","","746.56","447.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","86.82","11.63","","112.68","112.68","146.99","38","86.82","634.58","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","both","","","746.56","447.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","577.84","77.4","","303.98","303.98","5854.79","1 through 10","86.82","634.58","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","746.56","447.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","86.82","11.63","","112.68","112.68","146.99","38","86.82","577.84","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","746.56","447.94","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","468.69","62.78","","780.86","208.94","10480.28","15","86.82","577.84","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","746.56","447.94","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","326.40","43.72","","179.76","179.76","179.76","1 through 10","86.82","577.84","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","746.56","447.94","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","542.90","72.72","","2355.45","298.99","3965.19","155","86.82","577.84","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","746.56","447.94","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","542.90","72.72","","3643.09","3643.09","3643.09","1 through 10","86.82","577.84","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","746.56","447.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","397.32","53.22","","554.28","554.28","554.28","16","86.82","577.84","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","746.56","447.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","469.59","62.9","","619.64","173.09","2370.64","150","86.82","577.84","percent of total billed charges",""
"SCREW BONE 26X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10027427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","746.56","447.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","577.84","77.4","","303.98","303.98","5854.79","1 through 10","86.82","577.84","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.60","248.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","48.22","352.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.60","248.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","48.22","352.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.60","248.76","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","235.91","56.9","","812.12","238.65","1587.46","163","48.22","352.41","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.60","248.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","48.22","11.63","","112.68","112.68","146.99","38","48.22","352.41","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.60","248.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","320.90","77.4","","303.98","303.98","5854.79","1 through 10","48.22","352.41","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","48.22","11.63","","112.68","112.68","146.99","38","48.22","320.9","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","260.29","62.78","","780.86","208.94","10480.28","15","48.22","320.9","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","181.26","43.72","","179.76","179.76","179.76","1 through 10","48.22","320.9","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","301.50","72.72","","2355.45","298.99","3965.19","155","48.22","320.9","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","301.50","72.72","","3643.09","3643.09","3643.09","1 through 10","48.22","320.9","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","220.65","53.22","","554.28","554.28","554.28","16","48.22","320.9","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","260.78","62.9","","619.64","173.09","2370.64","150","48.22","320.9","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","320.90","77.4","","303.98","303.98","5854.79","1 through 10","48.22","320.9","percent of total billed charges",""
"SCREW BONE 26X5MM SPINE CENTERPC SPINAL SYSTEM","SUP-ITM-10019197","CDM","C1713","HCPCS","0278","RC","","","","both","","","621.90","373.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","72.33","528.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 26X5MM SPINE CENTERPC SPINAL SYSTEM","SUP-ITM-10019197","CDM","C1713","HCPCS","0278","RC","","","","both","","","621.90","373.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","72.33","528.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 26X5MM SPINE CENTERPC SPINAL SYSTEM","SUP-ITM-10019197","CDM","C1713","HCPCS","0278","RC","","","","both","","","621.90","373.14","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","353.86","56.9","","812.12","238.65","1587.46","163","72.33","528.62","percent of total billed charges",""
"SCREW BONE 26X5MM SPINE CENTERPC SPINAL SYSTEM","SUP-ITM-10019197","CDM","C1713","HCPCS","0278","RC","","","","both","","","621.90","373.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","72.33","11.63","","112.68","112.68","146.99","38","72.33","528.62","percent of total billed charges",""
"SCREW BONE 26X5MM SPINE CENTERPC SPINAL SYSTEM","SUP-ITM-10019197","CDM","C1713","HCPCS","0278","RC","","","","both","","","621.90","373.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","481.35","77.4","","303.98","303.98","5854.79","1 through 10","72.33","528.62","percent of total billed charges",""
"SCREW BONE 26X5MM SPINE CENTERPC SPINAL SYSTEM","SUP-ITM-10019197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","621.90","373.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","72.33","11.63","","112.68","112.68","146.99","38","72.33","481.35","percent of total billed charges",""
"SCREW BONE 26X5MM SPINE CENTERPC SPINAL SYSTEM","SUP-ITM-10019197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","621.90","373.14","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","390.43","62.78","","780.86","208.94","10480.28","15","72.33","481.35","percent of total billed charges",""
"SCREW BONE 26X5MM SPINE CENTERPC SPINAL SYSTEM","SUP-ITM-10019197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","621.90","373.14","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","271.89","43.72","","179.76","179.76","179.76","1 through 10","72.33","481.35","percent of total billed charges",""
"SCREW BONE 26X5MM SPINE CENTERPC SPINAL SYSTEM","SUP-ITM-10019197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","621.90","373.14","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","452.25","72.72","","2355.45","298.99","3965.19","155","72.33","481.35","percent of total billed charges",""
"SCREW BONE 26X5MM SPINE CENTERPC SPINAL SYSTEM","SUP-ITM-10019197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","621.90","373.14","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","452.25","72.72","","3643.09","3643.09","3643.09","1 through 10","72.33","481.35","percent of total billed charges",""
"SCREW BONE 26X5MM SPINE CENTERPC SPINAL SYSTEM","SUP-ITM-10019197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","621.90","373.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","330.98","53.22","","554.28","554.28","554.28","16","72.33","481.35","percent of total billed charges",""
"SCREW BONE 26X5MM SPINE CENTERPC SPINAL SYSTEM","SUP-ITM-10019197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","621.90","373.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","391.18","62.9","","619.64","173.09","2370.64","150","72.33","481.35","percent of total billed charges",""
"SCREW BONE 26X5MM SPINE CENTERPC SPINAL SYSTEM","SUP-ITM-10019197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","621.90","373.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","481.35","77.4","","303.98","303.98","5854.79","1 through 10","72.33","481.35","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","299.13","179.48","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","34.79","254.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","299.13","179.48","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","34.79","254.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","299.13","179.48","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","170.20","56.9","","812.12","238.65","1587.46","163","34.79","254.26","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","299.13","179.48","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","34.79","11.63","","112.68","112.68","146.99","38","34.79","254.26","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","299.13","179.48","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","231.53","77.4","","303.98","303.98","5854.79","1 through 10","34.79","254.26","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","299.13","179.48","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","34.79","11.63","","112.68","112.68","146.99","38","34.79","231.53","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","299.13","179.48","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","187.79","62.78","","780.86","208.94","10480.28","15","34.79","231.53","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","299.13","179.48","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","130.78","43.72","","179.76","179.76","179.76","1 through 10","34.79","231.53","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","299.13","179.48","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","217.53","72.72","","2355.45","298.99","3965.19","155","34.79","231.53","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","299.13","179.48","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","217.53","72.72","","3643.09","3643.09","3643.09","1 through 10","34.79","231.53","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","299.13","179.48","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","159.20","53.22","","554.28","554.28","554.28","16","34.79","231.53","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","299.13","179.48","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","188.15","62.9","","619.64","173.09","2370.64","150","34.79","231.53","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","299.13","179.48","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","231.53","77.4","","303.98","303.98","5854.79","1 through 10","34.79","231.53","percent of total billed charges",""
"SCREW BONE 2X13MM HAMMERTOE CANNULATED PRO TOE COMPRESSION SS","SUP-ITM-10193896","CDM","C1713","HCPCS","0278","RC","","","","both","","","6253.55","3752.13","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","727.29","5315.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2X13MM HAMMERTOE CANNULATED PRO TOE COMPRESSION SS","SUP-ITM-10193896","CDM","C1713","HCPCS","0278","RC","","","","both","","","6253.55","3752.13","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","727.29","5315.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2X13MM HAMMERTOE CANNULATED PRO TOE COMPRESSION SS","SUP-ITM-10193896","CDM","C1713","HCPCS","0278","RC","","","","both","","","6253.55","3752.13","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3558.27","56.9","","812.12","238.65","1587.46","163","727.29","5315.52","percent of total billed charges",""
"SCREW BONE 2X13MM HAMMERTOE CANNULATED PRO TOE COMPRESSION SS","SUP-ITM-10193896","CDM","C1713","HCPCS","0278","RC","","","","both","","","6253.55","3752.13","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","727.29","11.63","","112.68","112.68","146.99","38","727.29","5315.52","percent of total billed charges",""
"SCREW BONE 2X13MM HAMMERTOE CANNULATED PRO TOE COMPRESSION SS","SUP-ITM-10193896","CDM","C1713","HCPCS","0278","RC","","","","both","","","6253.55","3752.13","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4840.25","77.4","","303.98","303.98","5854.79","1 through 10","727.29","5315.52","percent of total billed charges",""
"SCREW BONE 2X13MM HAMMERTOE CANNULATED PRO TOE COMPRESSION SS","SUP-ITM-10193896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6253.55","3752.13","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","727.29","11.63","","112.68","112.68","146.99","38","727.29","4840.25","percent of total billed charges",""
"SCREW BONE 2X13MM HAMMERTOE CANNULATED PRO TOE COMPRESSION SS","SUP-ITM-10193896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6253.55","3752.13","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3925.98","62.78","","780.86","208.94","10480.28","15","727.29","4840.25","percent of total billed charges",""
"SCREW BONE 2X13MM HAMMERTOE CANNULATED PRO TOE COMPRESSION SS","SUP-ITM-10193896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6253.55","3752.13","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2734.05","43.72","","179.76","179.76","179.76","1 through 10","727.29","4840.25","percent of total billed charges",""
"SCREW BONE 2X13MM HAMMERTOE CANNULATED PRO TOE COMPRESSION SS","SUP-ITM-10193896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6253.55","3752.13","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4547.58","72.72","","2355.45","298.99","3965.19","155","727.29","4840.25","percent of total billed charges",""
"SCREW BONE 2X13MM HAMMERTOE CANNULATED PRO TOE COMPRESSION SS","SUP-ITM-10193896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6253.55","3752.13","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4547.58","72.72","","3643.09","3643.09","3643.09","1 through 10","727.29","4840.25","percent of total billed charges",""
"SCREW BONE 2X13MM HAMMERTOE CANNULATED PRO TOE COMPRESSION SS","SUP-ITM-10193896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6253.55","3752.13","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3328.14","53.22","","554.28","554.28","554.28","16","727.29","4840.25","percent of total billed charges",""
"SCREW BONE 2X13MM HAMMERTOE CANNULATED PRO TOE COMPRESSION SS","SUP-ITM-10193896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6253.55","3752.13","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3933.48","62.9","","619.64","173.09","2370.64","150","727.29","4840.25","percent of total billed charges",""
"SCREW BONE 2X13MM HAMMERTOE CANNULATED PRO TOE COMPRESSION SS","SUP-ITM-10193896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6253.55","3752.13","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4840.25","77.4","","303.98","303.98","5854.79","1 through 10","727.29","4840.25","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","657.07","394.24","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","76.42","558.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","657.07","394.24","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","76.42","558.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","657.07","394.24","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","373.87","56.9","","812.12","238.65","1587.46","163","76.42","558.51","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","657.07","394.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","76.42","11.63","","112.68","112.68","146.99","38","76.42","558.51","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","657.07","394.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","508.57","77.4","","303.98","303.98","5854.79","1 through 10","76.42","558.51","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","657.07","394.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","76.42","11.63","","112.68","112.68","146.99","38","76.42","508.57","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","657.07","394.24","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","412.51","62.78","","780.86","208.94","10480.28","15","76.42","508.57","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","657.07","394.24","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","287.27","43.72","","179.76","179.76","179.76","1 through 10","76.42","508.57","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","657.07","394.24","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","477.82","72.72","","2355.45","298.99","3965.19","155","76.42","508.57","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","657.07","394.24","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","477.82","72.72","","3643.09","3643.09","3643.09","1 through 10","76.42","508.57","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","657.07","394.24","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","349.69","53.22","","554.28","554.28","554.28","16","76.42","508.57","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","657.07","394.24","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","413.30","62.9","","619.64","173.09","2370.64","150","76.42","508.57","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","657.07","394.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","508.57","77.4","","303.98","303.98","5854.79","1 through 10","76.42","508.57","percent of total billed charges",""
"SCREW BONE 2X18MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10275908","CDM","C1713","HCPCS","0278","RC","","","","both","","","2169.05","1301.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","252.26","1843.69","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2X18MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10275908","CDM","C1713","HCPCS","0278","RC","","","","both","","","2169.05","1301.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","252.26","1843.69","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2X18MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10275908","CDM","C1713","HCPCS","0278","RC","","","","both","","","2169.05","1301.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1234.19","56.9","","812.12","238.65","1587.46","163","252.26","1843.69","percent of total billed charges",""
"SCREW BONE 2X18MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10275908","CDM","C1713","HCPCS","0278","RC","","","","both","","","2169.05","1301.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","252.26","11.63","","112.68","112.68","146.99","38","252.26","1843.69","percent of total billed charges",""
"SCREW BONE 2X18MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10275908","CDM","C1713","HCPCS","0278","RC","","","","both","","","2169.05","1301.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1678.84","77.4","","303.98","303.98","5854.79","1 through 10","252.26","1843.69","percent of total billed charges",""
"SCREW BONE 2X18MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10275908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2169.05","1301.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","252.26","11.63","","112.68","112.68","146.99","38","252.26","1678.84","percent of total billed charges",""
"SCREW BONE 2X18MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10275908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2169.05","1301.43","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1361.73","62.78","","780.86","208.94","10480.28","15","252.26","1678.84","percent of total billed charges",""
"SCREW BONE 2X18MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10275908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2169.05","1301.43","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","948.31","43.72","","179.76","179.76","179.76","1 through 10","252.26","1678.84","percent of total billed charges",""
"SCREW BONE 2X18MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10275908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2169.05","1301.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1577.33","72.72","","2355.45","298.99","3965.19","155","252.26","1678.84","percent of total billed charges",""
"SCREW BONE 2X18MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10275908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2169.05","1301.43","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1577.33","72.72","","3643.09","3643.09","3643.09","1 through 10","252.26","1678.84","percent of total billed charges",""
"SCREW BONE 2X18MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10275908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2169.05","1301.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1154.37","53.22","","554.28","554.28","554.28","16","252.26","1678.84","percent of total billed charges",""
"SCREW BONE 2X18MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10275908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2169.05","1301.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1364.33","62.9","","619.64","173.09","2370.64","150","252.26","1678.84","percent of total billed charges",""
"SCREW BONE 2X18MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10275908","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2169.05","1301.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1678.84","77.4","","303.98","303.98","5854.79","1 through 10","252.26","1678.84","percent of total billed charges",""
"SCREW BONE 2X28MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10039725","CDM","C1713","HCPCS","0278","RC","","","","both","","","286.35","171.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","33.3","243.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2X28MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10039725","CDM","C1713","HCPCS","0278","RC","","","","both","","","286.35","171.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","33.3","243.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2X28MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10039725","CDM","C1713","HCPCS","0278","RC","","","","both","","","286.35","171.81","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","162.93","56.9","","812.12","238.65","1587.46","163","33.3","243.4","percent of total billed charges",""
"SCREW BONE 2X28MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10039725","CDM","C1713","HCPCS","0278","RC","","","","both","","","286.35","171.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","33.30","11.63","","112.68","112.68","146.99","38","33.3","243.4","percent of total billed charges",""
"SCREW BONE 2X28MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10039725","CDM","C1713","HCPCS","0278","RC","","","","both","","","286.35","171.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","221.63","77.4","","303.98","303.98","5854.79","1 through 10","33.3","243.4","percent of total billed charges",""
"SCREW BONE 2X28MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10039725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","286.35","171.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","33.30","11.63","","112.68","112.68","146.99","38","33.3","221.63","percent of total billed charges",""
"SCREW BONE 2X28MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10039725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","286.35","171.81","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","179.77","62.78","","780.86","208.94","10480.28","15","33.3","221.63","percent of total billed charges",""
"SCREW BONE 2X28MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10039725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","286.35","171.81","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","125.19","43.72","","179.76","179.76","179.76","1 through 10","33.3","221.63","percent of total billed charges",""
"SCREW BONE 2X28MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10039725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","286.35","171.81","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","208.23","72.72","","2355.45","298.99","3965.19","155","33.3","221.63","percent of total billed charges",""
"SCREW BONE 2X28MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10039725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","286.35","171.81","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","208.23","72.72","","3643.09","3643.09","3643.09","1 through 10","33.3","221.63","percent of total billed charges",""
"SCREW BONE 2X28MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10039725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","286.35","171.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","152.40","53.22","","554.28","554.28","554.28","16","33.3","221.63","percent of total billed charges",""
"SCREW BONE 2X28MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10039725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","286.35","171.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","180.11","62.9","","619.64","173.09","2370.64","150","33.3","221.63","percent of total billed charges",""
"SCREW BONE 2X28MM CORTEX TITANIUM SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10039725","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","286.35","171.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","221.63","77.4","","303.98","303.98","5854.79","1 through 10","33.3","221.63","percent of total billed charges",""
"SCREW BONE 2X38MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10037150","CDM","C1713","HCPCS","0278","RC","","","","both","","","260.78","156.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","30.33","221.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2X38MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10037150","CDM","C1713","HCPCS","0278","RC","","","","both","","","260.78","156.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","30.33","221.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2X38MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10037150","CDM","C1713","HCPCS","0278","RC","","","","both","","","260.78","156.47","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","148.38","56.9","","812.12","238.65","1587.46","163","30.33","221.66","percent of total billed charges",""
"SCREW BONE 2X38MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10037150","CDM","C1713","HCPCS","0278","RC","","","","both","","","260.78","156.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","30.33","11.63","","112.68","112.68","146.99","38","30.33","221.66","percent of total billed charges",""
"SCREW BONE 2X38MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10037150","CDM","C1713","HCPCS","0278","RC","","","","both","","","260.78","156.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","201.84","77.4","","303.98","303.98","5854.79","1 through 10","30.33","221.66","percent of total billed charges",""
"SCREW BONE 2X38MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10037150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","260.78","156.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","30.33","11.63","","112.68","112.68","146.99","38","30.33","201.84","percent of total billed charges",""
"SCREW BONE 2X38MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10037150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","260.78","156.47","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","163.72","62.78","","780.86","208.94","10480.28","15","30.33","201.84","percent of total billed charges",""
"SCREW BONE 2X38MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10037150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","260.78","156.47","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","114.01","43.72","","179.76","179.76","179.76","1 through 10","30.33","201.84","percent of total billed charges",""
"SCREW BONE 2X38MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10037150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","260.78","156.47","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","189.64","72.72","","2355.45","298.99","3965.19","155","30.33","201.84","percent of total billed charges",""
"SCREW BONE 2X38MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10037150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","260.78","156.47","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","189.64","72.72","","3643.09","3643.09","3643.09","1 through 10","30.33","201.84","percent of total billed charges",""
"SCREW BONE 2X38MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10037150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","260.78","156.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","138.79","53.22","","554.28","554.28","554.28","16","30.33","201.84","percent of total billed charges",""
"SCREW BONE 2X38MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10037150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","260.78","156.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","164.03","62.9","","619.64","173.09","2370.64","150","30.33","201.84","percent of total billed charges",""
"SCREW BONE 2X38MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10037150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","260.78","156.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","201.84","77.4","","303.98","303.98","5854.79","1 through 10","30.33","201.84","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1008.65","605.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","117.31","857.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1008.65","605.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","117.31","857.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1008.65","605.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","573.92","56.9","","812.12","238.65","1587.46","163","117.31","857.35","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1008.65","605.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","117.31","11.63","","112.68","112.68","146.99","38","117.31","857.35","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1008.65","605.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","780.70","77.4","","303.98","303.98","5854.79","1 through 10","117.31","857.35","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1008.65","605.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","117.31","11.63","","112.68","112.68","146.99","38","117.31","780.7","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1008.65","605.19","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","633.23","62.78","","780.86","208.94","10480.28","15","117.31","780.7","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1008.65","605.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","440.98","43.72","","179.76","179.76","179.76","1 through 10","117.31","780.7","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1008.65","605.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","733.49","72.72","","2355.45","298.99","3965.19","155","117.31","780.7","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1008.65","605.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","733.49","72.72","","3643.09","3643.09","3643.09","1 through 10","117.31","780.7","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1008.65","605.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","536.80","53.22","","554.28","554.28","554.28","16","117.31","780.7","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1008.65","605.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","634.44","62.9","","619.64","173.09","2370.64","150","117.31","780.7","percent of total billed charges",""
"SCREW BONE 2X6MM SMARTLOCK HYBRID MMF TITANIUM LOCKING SELF DRILLING","SUP-ITM-10118291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1008.65","605.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","780.70","77.4","","303.98","303.98","5854.79","1 through 10","117.31","780.7","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.69","329.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","63.93","467.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.69","329.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","63.93","467.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.69","329.81","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","312.77","56.9","","812.12","238.65","1587.46","163","63.93","467.24","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.69","329.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","63.93","11.63","","112.68","112.68","146.99","38","63.93","467.24","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.69","329.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","425.46","77.4","","303.98","303.98","5854.79","1 through 10","63.93","467.24","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.69","329.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","63.93","11.63","","112.68","112.68","146.99","38","63.93","425.46","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.69","329.81","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","345.10","62.78","","780.86","208.94","10480.28","15","63.93","425.46","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.69","329.81","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","240.32","43.72","","179.76","179.76","179.76","1 through 10","63.93","425.46","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.69","329.81","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","399.73","72.72","","2355.45","298.99","3965.19","155","63.93","425.46","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.69","329.81","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","399.73","72.72","","3643.09","3643.09","3643.09","1 through 10","63.93","425.46","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.69","329.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","292.55","53.22","","554.28","554.28","554.28","16","63.93","425.46","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.69","329.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","345.76","62.9","","619.64","173.09","2370.64","150","63.93","425.46","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.69","329.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","425.46","77.4","","303.98","303.98","5854.79","1 through 10","63.93","425.46","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","230.10","138.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","26.76","195.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","230.10","138.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","26.76","195.59","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","230.10","138.06","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","130.93","56.9","","812.12","238.65","1587.46","163","26.76","195.59","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","230.10","138.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","26.76","11.63","","112.68","112.68","146.99","38","26.76","195.59","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","230.10","138.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","178.10","77.4","","303.98","303.98","5854.79","1 through 10","26.76","195.59","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","230.10","138.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","26.76","11.63","","112.68","112.68","146.99","38","26.76","178.1","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","230.10","138.06","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","144.46","62.78","","780.86","208.94","10480.28","15","26.76","178.1","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","230.10","138.06","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","100.60","43.72","","179.76","179.76","179.76","1 through 10","26.76","178.1","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","230.10","138.06","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","167.33","72.72","","2355.45","298.99","3965.19","155","26.76","178.1","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","230.10","138.06","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","167.33","72.72","","3643.09","3643.09","3643.09","1 through 10","26.76","178.1","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","230.10","138.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","122.46","53.22","","554.28","554.28","554.28","16","26.76","178.1","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","230.10","138.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","144.73","62.9","","619.64","173.09","2370.64","150","26.76","178.1","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","230.10","138.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","178.10","77.4","","303.98","303.98","5854.79","1 through 10","26.76","178.1","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING LOCKING CROSS-PIN","SUP-ITM-10042245","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.74","374.24","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","72.54","530.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2X8MM SELF TAPPING LOCKING CROSS-PIN","SUP-ITM-10042245","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.74","374.24","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","72.54","530.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 2X8MM SELF TAPPING LOCKING CROSS-PIN","SUP-ITM-10042245","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.74","374.24","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","354.91","56.9","","812.12","238.65","1587.46","163","72.54","530.18","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING LOCKING CROSS-PIN","SUP-ITM-10042245","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.74","374.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","72.54","11.63","","112.68","112.68","146.99","38","72.54","530.18","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING LOCKING CROSS-PIN","SUP-ITM-10042245","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.74","374.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","482.77","77.4","","303.98","303.98","5854.79","1 through 10","72.54","530.18","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING LOCKING CROSS-PIN","SUP-ITM-10042245","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","623.74","374.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","72.54","11.63","","112.68","112.68","146.99","38","72.54","482.77","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING LOCKING CROSS-PIN","SUP-ITM-10042245","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","623.74","374.24","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","391.58","62.78","","780.86","208.94","10480.28","15","72.54","482.77","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING LOCKING CROSS-PIN","SUP-ITM-10042245","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","623.74","374.24","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","272.70","43.72","","179.76","179.76","179.76","1 through 10","72.54","482.77","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING LOCKING CROSS-PIN","SUP-ITM-10042245","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","623.74","374.24","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","453.58","72.72","","2355.45","298.99","3965.19","155","72.54","482.77","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING LOCKING CROSS-PIN","SUP-ITM-10042245","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","623.74","374.24","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","453.58","72.72","","3643.09","3643.09","3643.09","1 through 10","72.54","482.77","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING LOCKING CROSS-PIN","SUP-ITM-10042245","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","623.74","374.24","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","331.95","53.22","","554.28","554.28","554.28","16","72.54","482.77","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING LOCKING CROSS-PIN","SUP-ITM-10042245","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","623.74","374.24","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","392.33","62.9","","619.64","173.09","2370.64","150","72.54","482.77","percent of total billed charges",""
"SCREW BONE 2X8MM SELF TAPPING LOCKING CROSS-PIN","SUP-ITM-10042245","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","623.74","374.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","482.77","77.4","","303.98","303.98","5854.79","1 through 10","72.54","482.77","percent of total billed charges",""
"SCREW BONE 3.2X10MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057324","CDM","C1713","HCPCS","0278","RC","","","","both","","","1568.57","941.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","182.42","1333.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.2X10MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057324","CDM","C1713","HCPCS","0278","RC","","","","both","","","1568.57","941.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","182.42","1333.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.2X10MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057324","CDM","C1713","HCPCS","0278","RC","","","","both","","","1568.57","941.14","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","892.52","56.9","","812.12","238.65","1587.46","163","182.42","1333.28","percent of total billed charges",""
"SCREW BONE 3.2X10MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057324","CDM","C1713","HCPCS","0278","RC","","","","both","","","1568.57","941.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","182.42","11.63","","112.68","112.68","146.99","38","182.42","1333.28","percent of total billed charges",""
"SCREW BONE 3.2X10MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057324","CDM","C1713","HCPCS","0278","RC","","","","both","","","1568.57","941.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1214.07","77.4","","303.98","303.98","5854.79","1 through 10","182.42","1333.28","percent of total billed charges",""
"SCREW BONE 3.2X10MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1568.57","941.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","182.42","11.63","","112.68","112.68","146.99","38","182.42","1214.07","percent of total billed charges",""
"SCREW BONE 3.2X10MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1568.57","941.14","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","984.75","62.78","","780.86","208.94","10480.28","15","182.42","1214.07","percent of total billed charges",""
"SCREW BONE 3.2X10MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1568.57","941.14","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","685.78","43.72","","179.76","179.76","179.76","1 through 10","182.42","1214.07","percent of total billed charges",""
"SCREW BONE 3.2X10MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1568.57","941.14","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1140.66","72.72","","2355.45","298.99","3965.19","155","182.42","1214.07","percent of total billed charges",""
"SCREW BONE 3.2X10MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1568.57","941.14","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1140.66","72.72","","3643.09","3643.09","3643.09","1 through 10","182.42","1214.07","percent of total billed charges",""
"SCREW BONE 3.2X10MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1568.57","941.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","834.79","53.22","","554.28","554.28","554.28","16","182.42","1214.07","percent of total billed charges",""
"SCREW BONE 3.2X10MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1568.57","941.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","986.63","62.9","","619.64","173.09","2370.64","150","182.42","1214.07","percent of total billed charges",""
"SCREW BONE 3.2X10MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1568.57","941.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1214.07","77.4","","303.98","303.98","5854.79","1 through 10","182.42","1214.07","percent of total billed charges",""
"SCREW BONE 3.2X12MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057325","CDM","C1713","HCPCS","0278","RC","","","","both","","","1568.57","941.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","182.42","1333.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.2X12MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057325","CDM","C1713","HCPCS","0278","RC","","","","both","","","1568.57","941.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","182.42","1333.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.2X12MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057325","CDM","C1713","HCPCS","0278","RC","","","","both","","","1568.57","941.14","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","892.52","56.9","","812.12","238.65","1587.46","163","182.42","1333.28","percent of total billed charges",""
"SCREW BONE 3.2X12MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057325","CDM","C1713","HCPCS","0278","RC","","","","both","","","1568.57","941.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","182.42","11.63","","112.68","112.68","146.99","38","182.42","1333.28","percent of total billed charges",""
"SCREW BONE 3.2X12MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057325","CDM","C1713","HCPCS","0278","RC","","","","both","","","1568.57","941.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1214.07","77.4","","303.98","303.98","5854.79","1 through 10","182.42","1333.28","percent of total billed charges",""
"SCREW BONE 3.2X12MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1568.57","941.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","182.42","11.63","","112.68","112.68","146.99","38","182.42","1214.07","percent of total billed charges",""
"SCREW BONE 3.2X12MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1568.57","941.14","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","984.75","62.78","","780.86","208.94","10480.28","15","182.42","1214.07","percent of total billed charges",""
"SCREW BONE 3.2X12MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1568.57","941.14","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","685.78","43.72","","179.76","179.76","179.76","1 through 10","182.42","1214.07","percent of total billed charges",""
"SCREW BONE 3.2X12MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1568.57","941.14","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1140.66","72.72","","2355.45","298.99","3965.19","155","182.42","1214.07","percent of total billed charges",""
"SCREW BONE 3.2X12MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1568.57","941.14","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1140.66","72.72","","3643.09","3643.09","3643.09","1 through 10","182.42","1214.07","percent of total billed charges",""
"SCREW BONE 3.2X12MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1568.57","941.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","834.79","53.22","","554.28","554.28","554.28","16","182.42","1214.07","percent of total billed charges",""
"SCREW BONE 3.2X12MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1568.57","941.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","986.63","62.9","","619.64","173.09","2370.64","150","182.42","1214.07","percent of total billed charges",""
"SCREW BONE 3.2X12MM DARCO TITANIUM COMPRESSION HEADLESS","SUP-ITM-10057325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1568.57","941.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1214.07","77.4","","303.98","303.98","5854.79","1 through 10","182.42","1214.07","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.72","370.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","71.72","524.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.72","370.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","71.72","524.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.72","370.03","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","350.91","56.9","","812.12","238.65","1587.46","163","71.72","524.21","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.72","370.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.72","11.63","","112.68","112.68","146.99","38","71.72","524.21","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.72","370.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","477.34","77.4","","303.98","303.98","5854.79","1 through 10","71.72","524.21","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.72","11.63","","112.68","112.68","146.99","38","71.72","477.34","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","387.18","62.78","","780.86","208.94","10480.28","15","71.72","477.34","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","269.63","43.72","","179.76","179.76","179.76","1 through 10","71.72","477.34","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","448.48","72.72","","2355.45","298.99","3965.19","155","71.72","477.34","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","448.48","72.72","","3643.09","3643.09","3643.09","1 through 10","71.72","477.34","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","328.22","53.22","","554.28","554.28","554.28","16","71.72","477.34","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","387.92","62.9","","619.64","173.09","2370.64","150","71.72","477.34","percent of total billed charges",""
"SCREW BONE 3.5MM 20X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10155858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","477.34","77.4","","303.98","303.98","5854.79","1 through 10","71.72","477.34","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.72","370.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","71.72","524.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.72","370.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","71.72","524.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.72","370.03","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","350.91","56.9","","812.12","238.65","1587.46","163","71.72","524.21","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.72","370.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.72","11.63","","112.68","112.68","146.99","38","71.72","524.21","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.72","370.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","477.34","77.4","","303.98","303.98","5854.79","1 through 10","71.72","524.21","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.72","11.63","","112.68","112.68","146.99","38","71.72","477.34","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","387.18","62.78","","780.86","208.94","10480.28","15","71.72","477.34","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","269.63","43.72","","179.76","179.76","179.76","1 through 10","71.72","477.34","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","448.48","72.72","","2355.45","298.99","3965.19","155","71.72","477.34","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","448.48","72.72","","3643.09","3643.09","3643.09","1 through 10","71.72","477.34","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","328.22","53.22","","554.28","554.28","554.28","16","71.72","477.34","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","387.92","62.9","","619.64","173.09","2370.64","150","71.72","477.34","percent of total billed charges",""
"SCREW BONE 3.5MM 30X4.75 TITANIUM LOCKING COMPREHENSIVE REVERSE FIXED HEX DRIVE","SUP-ITM-10134849","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","477.34","77.4","","303.98","303.98","5854.79","1 through 10","71.72","477.34","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","826.99","496.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","96.18","702.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","826.99","496.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","96.18","702.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","826.99","496.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","470.56","56.9","","812.12","238.65","1587.46","163","96.18","702.94","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","826.99","496.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","96.18","11.63","","112.68","112.68","146.99","38","96.18","702.94","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","826.99","496.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","640.09","77.4","","303.98","303.98","5854.79","1 through 10","96.18","702.94","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","96.18","11.63","","112.68","112.68","146.99","38","96.18","640.09","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","519.18","62.78","","780.86","208.94","10480.28","15","96.18","640.09","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","361.56","43.72","","179.76","179.76","179.76","1 through 10","96.18","640.09","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","601.39","72.72","","2355.45","298.99","3965.19","155","96.18","640.09","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","601.39","72.72","","3643.09","3643.09","3643.09","1 through 10","96.18","640.09","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","440.12","53.22","","554.28","554.28","554.28","16","96.18","640.09","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","520.18","62.9","","619.64","173.09","2370.64","150","96.18","640.09","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","640.09","77.4","","303.98","303.98","5854.79","1 through 10","96.18","640.09","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.63","98.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","19.03","139.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.63","98.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","19.03","139.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.63","98.18","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","93.11","56.9","","812.12","238.65","1587.46","163","19.03","139.09","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.63","98.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","19.03","11.63","","112.68","112.68","146.99","38","19.03","139.09","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.63","98.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","126.65","77.4","","303.98","303.98","5854.79","1 through 10","19.03","139.09","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","163.63","98.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","19.03","11.63","","112.68","112.68","146.99","38","19.03","126.65","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","163.63","98.18","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","102.73","62.78","","780.86","208.94","10480.28","15","19.03","126.65","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","163.63","98.18","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","71.54","43.72","","179.76","179.76","179.76","1 through 10","19.03","126.65","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","163.63","98.18","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","118.99","72.72","","2355.45","298.99","3965.19","155","19.03","126.65","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","163.63","98.18","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","118.99","72.72","","3643.09","3643.09","3643.09","1 through 10","19.03","126.65","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","163.63","98.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","87.08","53.22","","554.28","554.28","554.28","16","19.03","126.65","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","163.63","98.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","102.92","62.9","","619.64","173.09","2370.64","150","19.03","126.65","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","163.63","98.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","126.65","77.4","","303.98","303.98","5854.79","1 through 10","19.03","126.65","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.24","478.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","92.84","678.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.24","478.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","92.84","678.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.24","478.94","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","454.20","56.9","","812.12","238.65","1587.46","163","92.84","678.5","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.24","478.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","92.84","11.63","","112.68","112.68","146.99","38","92.84","678.5","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.24","478.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","617.84","77.4","","303.98","303.98","5854.79","1 through 10","92.84","678.5","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.24","478.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","92.84","11.63","","112.68","112.68","146.99","38","92.84","617.84","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.24","478.94","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","501.14","62.78","","780.86","208.94","10480.28","15","92.84","617.84","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.24","478.94","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","348.99","43.72","","179.76","179.76","179.76","1 through 10","92.84","617.84","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.24","478.94","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","580.48","72.72","","2355.45","298.99","3965.19","155","92.84","617.84","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.24","478.94","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","580.48","72.72","","3643.09","3643.09","3643.09","1 through 10","92.84","617.84","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.24","478.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","424.82","53.22","","554.28","554.28","554.28","16","92.84","617.84","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.24","478.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","502.09","62.9","","619.64","173.09","2370.64","150","92.84","617.84","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.24","478.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","617.84","77.4","","303.98","303.98","5854.79","1 through 10","92.84","617.84","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS SELF TAPPING NONLOCKING HEXAGONAL HEAD","SUP-ITM-10064123","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.76","234.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","45.45","332.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X10MM CORTEX SS SELF TAPPING NONLOCKING HEXAGONAL HEAD","SUP-ITM-10064123","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.76","234.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","45.45","332.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X10MM CORTEX SS SELF TAPPING NONLOCKING HEXAGONAL HEAD","SUP-ITM-10064123","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.76","234.46","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","222.34","56.9","","812.12","238.65","1587.46","163","45.45","332.15","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS SELF TAPPING NONLOCKING HEXAGONAL HEAD","SUP-ITM-10064123","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.76","234.46","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","45.45","11.63","","112.68","112.68","146.99","38","45.45","332.15","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS SELF TAPPING NONLOCKING HEXAGONAL HEAD","SUP-ITM-10064123","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.76","234.46","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","302.45","77.4","","303.98","303.98","5854.79","1 through 10","45.45","332.15","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS SELF TAPPING NONLOCKING HEXAGONAL HEAD","SUP-ITM-10064123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","390.76","234.46","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","45.45","11.63","","112.68","112.68","146.99","38","45.45","302.45","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS SELF TAPPING NONLOCKING HEXAGONAL HEAD","SUP-ITM-10064123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","390.76","234.46","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","245.32","62.78","","780.86","208.94","10480.28","15","45.45","302.45","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS SELF TAPPING NONLOCKING HEXAGONAL HEAD","SUP-ITM-10064123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","390.76","234.46","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","170.84","43.72","","179.76","179.76","179.76","1 through 10","45.45","302.45","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS SELF TAPPING NONLOCKING HEXAGONAL HEAD","SUP-ITM-10064123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","390.76","234.46","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","284.16","72.72","","2355.45","298.99","3965.19","155","45.45","302.45","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS SELF TAPPING NONLOCKING HEXAGONAL HEAD","SUP-ITM-10064123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","390.76","234.46","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","284.16","72.72","","3643.09","3643.09","3643.09","1 through 10","45.45","302.45","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS SELF TAPPING NONLOCKING HEXAGONAL HEAD","SUP-ITM-10064123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","390.76","234.46","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","207.96","53.22","","554.28","554.28","554.28","16","45.45","302.45","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS SELF TAPPING NONLOCKING HEXAGONAL HEAD","SUP-ITM-10064123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","390.76","234.46","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","245.79","62.9","","619.64","173.09","2370.64","150","45.45","302.45","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS SELF TAPPING NONLOCKING HEXAGONAL HEAD","SUP-ITM-10064123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","390.76","234.46","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","302.45","77.4","","303.98","303.98","5854.79","1 through 10","45.45","302.45","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037544","CDM","C1713","HCPCS","0278","RC","","","","both","","","166.19","99.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","19.33","141.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X10MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037544","CDM","C1713","HCPCS","0278","RC","","","","both","","","166.19","99.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","19.33","141.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X10MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037544","CDM","C1713","HCPCS","0278","RC","","","","both","","","166.19","99.71","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","94.56","56.9","","812.12","238.65","1587.46","163","19.33","141.26","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037544","CDM","C1713","HCPCS","0278","RC","","","","both","","","166.19","99.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","19.33","11.63","","112.68","112.68","146.99","38","19.33","141.26","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037544","CDM","C1713","HCPCS","0278","RC","","","","both","","","166.19","99.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","128.63","77.4","","303.98","303.98","5854.79","1 through 10","19.33","141.26","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037544","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","166.19","99.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","19.33","11.63","","112.68","112.68","146.99","38","19.33","128.63","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037544","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","166.19","99.71","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","104.33","62.78","","780.86","208.94","10480.28","15","19.33","128.63","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037544","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","166.19","99.71","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","72.66","43.72","","179.76","179.76","179.76","1 through 10","19.33","128.63","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037544","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","166.19","99.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","120.85","72.72","","2355.45","298.99","3965.19","155","19.33","128.63","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037544","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","166.19","99.71","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","120.85","72.72","","3643.09","3643.09","3643.09","1 through 10","19.33","128.63","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037544","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","166.19","99.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","88.45","53.22","","554.28","554.28","554.28","16","19.33","128.63","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037544","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","166.19","99.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","104.53","62.9","","619.64","173.09","2370.64","150","19.33","128.63","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037544","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","166.19","99.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","128.63","77.4","","303.98","303.98","5854.79","1 through 10","19.33","128.63","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX PERI LOC SS LOCKING LOW PROFILE SELF TAPPING","SUP-ITM-10057670","CDM","C1713","HCPCS","0278","RC","","","","both","","","1257.62","754.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","146.26","1068.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X12MM CORTEX PERI LOC SS LOCKING LOW PROFILE SELF TAPPING","SUP-ITM-10057670","CDM","C1713","HCPCS","0278","RC","","","","both","","","1257.62","754.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","146.26","1068.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X12MM CORTEX PERI LOC SS LOCKING LOW PROFILE SELF TAPPING","SUP-ITM-10057670","CDM","C1713","HCPCS","0278","RC","","","","both","","","1257.62","754.57","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","715.59","56.9","","812.12","238.65","1587.46","163","146.26","1068.98","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX PERI LOC SS LOCKING LOW PROFILE SELF TAPPING","SUP-ITM-10057670","CDM","C1713","HCPCS","0278","RC","","","","both","","","1257.62","754.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","146.26","11.63","","112.68","112.68","146.99","38","146.26","1068.98","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX PERI LOC SS LOCKING LOW PROFILE SELF TAPPING","SUP-ITM-10057670","CDM","C1713","HCPCS","0278","RC","","","","both","","","1257.62","754.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","973.40","77.4","","303.98","303.98","5854.79","1 through 10","146.26","1068.98","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX PERI LOC SS LOCKING LOW PROFILE SELF TAPPING","SUP-ITM-10057670","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1257.62","754.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","146.26","11.63","","112.68","112.68","146.99","38","146.26","973.4","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX PERI LOC SS LOCKING LOW PROFILE SELF TAPPING","SUP-ITM-10057670","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1257.62","754.57","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","789.53","62.78","","780.86","208.94","10480.28","15","146.26","973.4","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX PERI LOC SS LOCKING LOW PROFILE SELF TAPPING","SUP-ITM-10057670","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1257.62","754.57","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","549.83","43.72","","179.76","179.76","179.76","1 through 10","146.26","973.4","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX PERI LOC SS LOCKING LOW PROFILE SELF TAPPING","SUP-ITM-10057670","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1257.62","754.57","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","914.54","72.72","","2355.45","298.99","3965.19","155","146.26","973.4","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX PERI LOC SS LOCKING LOW PROFILE SELF TAPPING","SUP-ITM-10057670","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1257.62","754.57","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","914.54","72.72","","3643.09","3643.09","3643.09","1 through 10","146.26","973.4","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX PERI LOC SS LOCKING LOW PROFILE SELF TAPPING","SUP-ITM-10057670","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1257.62","754.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","669.31","53.22","","554.28","554.28","554.28","16","146.26","973.4","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX PERI LOC SS LOCKING LOW PROFILE SELF TAPPING","SUP-ITM-10057670","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1257.62","754.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","791.04","62.9","","619.64","173.09","2370.64","150","146.26","973.4","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX PERI LOC SS LOCKING LOW PROFILE SELF TAPPING","SUP-ITM-10057670","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1257.62","754.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","973.40","77.4","","303.98","303.98","5854.79","1 through 10","146.26","973.4","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","118.92","71.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","13.83","101.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","118.92","71.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","13.83","101.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","118.92","71.35","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","67.67","56.9","","812.12","238.65","1587.46","163","13.83","101.08","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","118.92","71.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","13.83","11.63","","112.68","112.68","146.99","38","13.83","101.08","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","118.92","71.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","92.04","77.4","","303.98","303.98","5854.79","1 through 10","13.83","101.08","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","118.92","71.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","13.83","11.63","","112.68","112.68","146.99","38","13.83","92.04","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","118.92","71.35","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","74.66","62.78","","780.86","208.94","10480.28","15","13.83","92.04","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","118.92","71.35","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","51.99","43.72","","179.76","179.76","179.76","1 through 10","13.83","92.04","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","118.92","71.35","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","86.48","72.72","","2355.45","298.99","3965.19","155","13.83","92.04","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","118.92","71.35","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","86.48","72.72","","3643.09","3643.09","3643.09","1 through 10","13.83","92.04","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","118.92","71.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","63.29","53.22","","554.28","554.28","554.28","16","13.83","92.04","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","118.92","71.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","74.80","62.9","","619.64","173.09","2370.64","150","13.83","92.04","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","118.92","71.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","92.04","77.4","","303.98","303.98","5854.79","1 through 10","13.83","92.04","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","166.19","99.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","19.33","141.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","166.19","99.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","19.33","141.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","166.19","99.71","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","94.56","56.9","","812.12","238.65","1587.46","163","19.33","141.26","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","166.19","99.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","19.33","11.63","","112.68","112.68","146.99","38","19.33","141.26","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","166.19","99.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","128.63","77.4","","303.98","303.98","5854.79","1 through 10","19.33","141.26","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","166.19","99.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","19.33","11.63","","112.68","112.68","146.99","38","19.33","128.63","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","166.19","99.71","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","104.33","62.78","","780.86","208.94","10480.28","15","19.33","128.63","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","166.19","99.71","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","72.66","43.72","","179.76","179.76","179.76","1 through 10","19.33","128.63","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","166.19","99.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","120.85","72.72","","2355.45","298.99","3965.19","155","19.33","128.63","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","166.19","99.71","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","120.85","72.72","","3643.09","3643.09","3643.09","1 through 10","19.33","128.63","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","166.19","99.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","88.45","53.22","","554.28","554.28","554.28","16","19.33","128.63","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","166.19","99.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","104.53","62.9","","619.64","173.09","2370.64","150","19.33","128.63","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","166.19","99.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","128.63","77.4","","303.98","303.98","5854.79","1 through 10","19.33","128.63","percent of total billed charges",""
"SCREW BONE 3.5X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056844","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.79","286.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","55.45","405.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056844","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.79","286.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","55.45","405.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056844","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.79","286.07","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","271.29","56.9","","812.12","238.65","1587.46","163","55.45","405.27","percent of total billed charges",""
"SCREW BONE 3.5X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056844","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.79","286.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","55.45","11.63","","112.68","112.68","146.99","38","55.45","405.27","percent of total billed charges",""
"SCREW BONE 3.5X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056844","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.79","286.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","369.04","77.4","","303.98","303.98","5854.79","1 through 10","55.45","405.27","percent of total billed charges",""
"SCREW BONE 3.5X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.79","286.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","55.45","11.63","","112.68","112.68","146.99","38","55.45","369.04","percent of total billed charges",""
"SCREW BONE 3.5X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.79","286.07","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","299.33","62.78","","780.86","208.94","10480.28","15","55.45","369.04","percent of total billed charges",""
"SCREW BONE 3.5X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.79","286.07","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","208.45","43.72","","179.76","179.76","179.76","1 through 10","55.45","369.04","percent of total billed charges",""
"SCREW BONE 3.5X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.79","286.07","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","346.72","72.72","","2355.45","298.99","3965.19","155","55.45","369.04","percent of total billed charges",""
"SCREW BONE 3.5X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.79","286.07","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","346.72","72.72","","3643.09","3643.09","3643.09","1 through 10","55.45","369.04","percent of total billed charges",""
"SCREW BONE 3.5X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.79","286.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","253.75","53.22","","554.28","554.28","554.28","16","55.45","369.04","percent of total billed charges",""
"SCREW BONE 3.5X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.79","286.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","299.90","62.9","","619.64","173.09","2370.64","150","55.45","369.04","percent of total billed charges",""
"SCREW BONE 3.5X12MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10056844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.79","286.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","369.04","77.4","","303.98","303.98","5854.79","1 through 10","55.45","369.04","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.79","286.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","55.45","405.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.79","286.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","55.45","405.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.79","286.07","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","271.29","56.9","","812.12","238.65","1587.46","163","55.45","405.27","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.79","286.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","55.45","11.63","","112.68","112.68","146.99","38","55.45","405.27","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","476.79","286.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","369.04","77.4","","303.98","303.98","5854.79","1 through 10","55.45","405.27","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.79","286.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","55.45","11.63","","112.68","112.68","146.99","38","55.45","369.04","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.79","286.07","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","299.33","62.78","","780.86","208.94","10480.28","15","55.45","369.04","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.79","286.07","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","208.45","43.72","","179.76","179.76","179.76","1 through 10","55.45","369.04","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.79","286.07","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","346.72","72.72","","2355.45","298.99","3965.19","155","55.45","369.04","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.79","286.07","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","346.72","72.72","","3643.09","3643.09","3643.09","1 through 10","55.45","369.04","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.79","286.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","253.75","53.22","","554.28","554.28","554.28","16","55.45","369.04","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.79","286.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","299.90","62.9","","619.64","173.09","2370.64","150","55.45","369.04","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","476.79","286.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","369.04","77.4","","303.98","303.98","5854.79","1 through 10","55.45","369.04","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","both","","","611.05","366.63","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","71.07","519.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","both","","","611.05","366.63","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","71.07","519.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","both","","","611.05","366.63","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","347.69","56.9","","812.12","238.65","1587.46","163","71.07","519.39","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","both","","","611.05","366.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.07","11.63","","112.68","112.68","146.99","38","71.07","519.39","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","both","","","611.05","366.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","472.95","77.4","","303.98","303.98","5854.79","1 through 10","71.07","519.39","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","611.05","366.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.07","11.63","","112.68","112.68","146.99","38","71.07","472.95","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","611.05","366.63","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","383.62","62.78","","780.86","208.94","10480.28","15","71.07","472.95","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","611.05","366.63","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","267.15","43.72","","179.76","179.76","179.76","1 through 10","71.07","472.95","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","611.05","366.63","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","444.36","72.72","","2355.45","298.99","3965.19","155","71.07","472.95","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","611.05","366.63","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","444.36","72.72","","3643.09","3643.09","3643.09","1 through 10","71.07","472.95","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","611.05","366.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","325.20","53.22","","554.28","554.28","554.28","16","71.07","472.95","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","611.05","366.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","384.35","62.9","","619.64","173.09","2370.64","150","71.07","472.95","percent of total billed charges",""
"SCREW BONE 3.5X150MM PELVIC CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10037189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","611.05","366.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","472.95","77.4","","303.98","303.98","5854.79","1 through 10","71.07","472.95","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","1901.22","1140.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","221.11","1616.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","1901.22","1140.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","221.11","1616.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","1901.22","1140.73","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1081.79","56.9","","812.12","238.65","1587.46","163","221.11","1616.04","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","1901.22","1140.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","221.11","11.63","","112.68","112.68","146.99","38","221.11","1616.04","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","1901.22","1140.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1471.54","77.4","","303.98","303.98","5854.79","1 through 10","221.11","1616.04","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1901.22","1140.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","221.11","11.63","","112.68","112.68","146.99","38","221.11","1471.54","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1901.22","1140.73","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1193.59","62.78","","780.86","208.94","10480.28","15","221.11","1471.54","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1901.22","1140.73","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","831.21","43.72","","179.76","179.76","179.76","1 through 10","221.11","1471.54","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1901.22","1140.73","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1382.57","72.72","","2355.45","298.99","3965.19","155","221.11","1471.54","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1901.22","1140.73","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1382.57","72.72","","3643.09","3643.09","3643.09","1 through 10","221.11","1471.54","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1901.22","1140.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1011.83","53.22","","554.28","554.28","554.28","16","221.11","1471.54","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1901.22","1140.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1195.87","62.9","","619.64","173.09","2370.64","150","221.11","1471.54","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1901.22","1140.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1471.54","77.4","","303.98","303.98","5854.79","1 through 10","221.11","1471.54","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","2034.44","1220.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","236.61","1729.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","2034.44","1220.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","236.61","1729.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","2034.44","1220.66","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1157.60","56.9","","812.12","238.65","1587.46","163","236.61","1729.27","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","2034.44","1220.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","236.61","11.63","","112.68","112.68","146.99","38","236.61","1729.27","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","2034.44","1220.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1574.66","77.4","","303.98","303.98","5854.79","1 through 10","236.61","1729.27","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2034.44","1220.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","236.61","11.63","","112.68","112.68","146.99","38","236.61","1574.66","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2034.44","1220.66","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1277.22","62.78","","780.86","208.94","10480.28","15","236.61","1574.66","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2034.44","1220.66","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","889.46","43.72","","179.76","179.76","179.76","1 through 10","236.61","1574.66","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2034.44","1220.66","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1479.44","72.72","","2355.45","298.99","3965.19","155","236.61","1574.66","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2034.44","1220.66","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1479.44","72.72","","3643.09","3643.09","3643.09","1 through 10","236.61","1574.66","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2034.44","1220.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1082.73","53.22","","554.28","554.28","554.28","16","236.61","1574.66","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2034.44","1220.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1279.66","62.9","","619.64","173.09","2370.64","150","236.61","1574.66","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2034.44","1220.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1574.66","77.4","","303.98","303.98","5854.79","1 through 10","236.61","1574.66","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.28","661.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","128.2","936.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.28","661.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","128.2","936.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.28","661.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","627.20","56.9","","812.12","238.65","1587.46","163","128.2","936.94","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.28","661.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","128.20","11.63","","112.68","112.68","146.99","38","128.2","936.94","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","1102.28","661.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","853.16","77.4","","303.98","303.98","5854.79","1 through 10","128.2","936.94","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","128.20","11.63","","112.68","112.68","146.99","38","128.2","853.16","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","692.01","62.78","","780.86","208.94","10480.28","15","128.2","853.16","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","481.92","43.72","","179.76","179.76","179.76","1 through 10","128.2","853.16","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","801.58","72.72","","2355.45","298.99","3965.19","155","128.2","853.16","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","801.58","72.72","","3643.09","3643.09","3643.09","1 through 10","128.2","853.16","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","586.63","53.22","","554.28","554.28","554.28","16","128.2","853.16","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","693.33","62.9","","619.64","173.09","2370.64","150","128.2","853.16","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1102.28","661.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","853.16","77.4","","303.98","303.98","5854.79","1 through 10","128.2","853.16","percent of total billed charges",""
"SCREW BONE 3.5X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10042378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.20","912.12","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","176.8","1292.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10042378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.20","912.12","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","176.8","1292.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10042378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.20","912.12","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","864.99","56.9","","812.12","238.65","1587.46","163","176.8","1292.17","percent of total billed charges",""
"SCREW BONE 3.5X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10042378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.20","912.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","176.80","11.63","","112.68","112.68","146.99","38","176.8","1292.17","percent of total billed charges",""
"SCREW BONE 3.5X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10042378","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.20","912.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1176.63","77.4","","303.98","303.98","5854.79","1 through 10","176.8","1292.17","percent of total billed charges",""
"SCREW BONE 3.5X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10042378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1520.20","912.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","176.80","11.63","","112.68","112.68","146.99","38","176.8","1176.63","percent of total billed charges",""
"SCREW BONE 3.5X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10042378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1520.20","912.12","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","954.38","62.78","","780.86","208.94","10480.28","15","176.8","1176.63","percent of total billed charges",""
"SCREW BONE 3.5X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10042378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1520.20","912.12","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","664.63","43.72","","179.76","179.76","179.76","1 through 10","176.8","1176.63","percent of total billed charges",""
"SCREW BONE 3.5X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10042378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1520.20","912.12","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1105.49","72.72","","2355.45","298.99","3965.19","155","176.8","1176.63","percent of total billed charges",""
"SCREW BONE 3.5X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10042378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1520.20","912.12","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1105.49","72.72","","3643.09","3643.09","3643.09","1 through 10","176.8","1176.63","percent of total billed charges",""
"SCREW BONE 3.5X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10042378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1520.20","912.12","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","809.05","53.22","","554.28","554.28","554.28","16","176.8","1176.63","percent of total billed charges",""
"SCREW BONE 3.5X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10042378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1520.20","912.12","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","956.21","62.9","","619.64","173.09","2370.64","150","176.8","1176.63","percent of total billed charges",""
"SCREW BONE 3.5X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10042378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1520.20","912.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1176.63","77.4","","303.98","303.98","5854.79","1 through 10","176.8","1176.63","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.41","403.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","78.2","571.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.41","403.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","78.2","571.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.41","403.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","382.60","56.9","","812.12","238.65","1587.46","163","78.2","571.55","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.41","403.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","78.20","11.63","","112.68","112.68","146.99","38","78.2","571.55","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.41","403.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","520.45","77.4","","303.98","303.98","5854.79","1 through 10","78.2","571.55","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.41","403.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","78.20","11.63","","112.68","112.68","146.99","38","78.2","520.45","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.41","403.45","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","422.14","62.78","","780.86","208.94","10480.28","15","78.2","520.45","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.41","403.45","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","293.98","43.72","","179.76","179.76","179.76","1 through 10","78.2","520.45","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.41","403.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","488.98","72.72","","2355.45","298.99","3965.19","155","78.2","520.45","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.41","403.45","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","488.98","72.72","","3643.09","3643.09","3643.09","1 through 10","78.2","520.45","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.41","403.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","357.86","53.22","","554.28","554.28","554.28","16","78.2","520.45","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.41","403.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","422.95","62.9","","619.64","173.09","2370.64","150","78.2","520.45","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.41","403.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","520.45","77.4","","303.98","303.98","5854.79","1 through 10","78.2","520.45","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","2397.49","1438.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","278.83","2037.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","2397.49","1438.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","278.83","2037.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","2397.49","1438.49","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1364.17","56.9","","812.12","238.65","1587.46","163","278.83","2037.87","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","2397.49","1438.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","278.83","11.63","","112.68","112.68","146.99","38","278.83","2037.87","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","2397.49","1438.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1855.66","77.4","","303.98","303.98","5854.79","1 through 10","278.83","2037.87","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2397.49","1438.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","278.83","11.63","","112.68","112.68","146.99","38","278.83","1855.66","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2397.49","1438.49","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1505.14","62.78","","780.86","208.94","10480.28","15","278.83","1855.66","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2397.49","1438.49","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1048.18","43.72","","179.76","179.76","179.76","1 through 10","278.83","1855.66","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2397.49","1438.49","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1743.45","72.72","","2355.45","298.99","3965.19","155","278.83","1855.66","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2397.49","1438.49","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1743.45","72.72","","3643.09","3643.09","3643.09","1 through 10","278.83","1855.66","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2397.49","1438.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1275.94","53.22","","554.28","554.28","554.28","16","278.83","1855.66","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2397.49","1438.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1508.02","62.9","","619.64","173.09","2370.64","150","278.83","1855.66","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2397.49","1438.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1855.66","77.4","","303.98","303.98","5854.79","1 through 10","278.83","1855.66","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.97","107.38","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","20.81","152.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.97","107.38","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","20.81","152.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.97","107.38","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","101.83","56.9","","812.12","238.65","1587.46","163","20.81","152.12","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.97","107.38","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.81","11.63","","112.68","112.68","146.99","38","20.81","152.12","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.97","107.38","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","138.52","77.4","","303.98","303.98","5854.79","1 through 10","20.81","152.12","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.97","107.38","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.81","11.63","","112.68","112.68","146.99","38","20.81","138.52","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.97","107.38","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","112.36","62.78","","780.86","208.94","10480.28","15","20.81","138.52","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.97","107.38","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","78.25","43.72","","179.76","179.76","179.76","1 through 10","20.81","138.52","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.97","107.38","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","130.15","72.72","","2355.45","298.99","3965.19","155","20.81","138.52","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.97","107.38","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","130.15","72.72","","3643.09","3643.09","3643.09","1 through 10","20.81","138.52","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.97","107.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","95.25","53.22","","554.28","554.28","554.28","16","20.81","138.52","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.97","107.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","112.57","62.9","","619.64","173.09","2370.64","150","20.81","138.52","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.97","107.38","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","138.52","77.4","","303.98","303.98","5854.79","1 through 10","20.81","138.52","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1077.96","646.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","125.37","916.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X26MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1077.96","646.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","125.37","916.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X26MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1077.96","646.78","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","613.36","56.9","","812.12","238.65","1587.46","163","125.37","916.27","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1077.96","646.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","125.37","11.63","","112.68","112.68","146.99","38","125.37","916.27","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1077.96","646.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","834.34","77.4","","303.98","303.98","5854.79","1 through 10","125.37","916.27","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1077.96","646.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","125.37","11.63","","112.68","112.68","146.99","38","125.37","834.34","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1077.96","646.78","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","676.74","62.78","","780.86","208.94","10480.28","15","125.37","834.34","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1077.96","646.78","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","471.28","43.72","","179.76","179.76","179.76","1 through 10","125.37","834.34","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1077.96","646.78","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","783.89","72.72","","2355.45","298.99","3965.19","155","125.37","834.34","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1077.96","646.78","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","783.89","72.72","","3643.09","3643.09","3643.09","1 through 10","125.37","834.34","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1077.96","646.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","573.69","53.22","","554.28","554.28","554.28","16","125.37","834.34","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1077.96","646.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","678.04","62.9","","619.64","173.09","2370.64","150","125.37","834.34","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1077.96","646.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","834.34","77.4","","303.98","303.98","5854.79","1 through 10","125.37","834.34","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.72","73.63","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","14.27","104.31","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.72","73.63","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","14.27","104.31","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.72","73.63","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","69.83","56.9","","812.12","238.65","1587.46","163","14.27","104.31","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.72","73.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","14.27","11.63","","112.68","112.68","146.99","38","14.27","104.31","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.72","73.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","94.99","77.4","","303.98","303.98","5854.79","1 through 10","14.27","104.31","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.72","73.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","14.27","11.63","","112.68","112.68","146.99","38","14.27","94.99","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.72","73.63","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","77.04","62.78","","780.86","208.94","10480.28","15","14.27","94.99","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.72","73.63","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","53.65","43.72","","179.76","179.76","179.76","1 through 10","14.27","94.99","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.72","73.63","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","89.24","72.72","","2355.45","298.99","3965.19","155","14.27","94.99","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.72","73.63","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","89.24","72.72","","3643.09","3643.09","3643.09","1 through 10","14.27","94.99","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.72","73.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","65.31","53.22","","554.28","554.28","554.28","16","14.27","94.99","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.72","73.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","77.19","62.9","","619.64","173.09","2370.64","150","14.27","94.99","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.72","73.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","94.99","77.4","","303.98","303.98","5854.79","1 through 10","14.27","94.99","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","826.99","496.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","96.18","702.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","826.99","496.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","96.18","702.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","826.99","496.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","470.56","56.9","","812.12","238.65","1587.46","163","96.18","702.94","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","826.99","496.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","96.18","11.63","","112.68","112.68","146.99","38","96.18","702.94","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","826.99","496.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","640.09","77.4","","303.98","303.98","5854.79","1 through 10","96.18","702.94","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","96.18","11.63","","112.68","112.68","146.99","38","96.18","640.09","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","519.18","62.78","","780.86","208.94","10480.28","15","96.18","640.09","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","361.56","43.72","","179.76","179.76","179.76","1 through 10","96.18","640.09","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","601.39","72.72","","2355.45","298.99","3965.19","155","96.18","640.09","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","601.39","72.72","","3643.09","3643.09","3643.09","1 through 10","96.18","640.09","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","440.12","53.22","","554.28","554.28","554.28","16","96.18","640.09","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","520.18","62.9","","619.64","173.09","2370.64","150","96.18","640.09","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","640.09","77.4","","303.98","303.98","5854.79","1 through 10","96.18","640.09","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.28","541.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","105.05","767.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.28","541.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","105.05","767.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.28","541.97","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","513.97","56.9","","812.12","238.65","1587.46","163","105.05","767.79","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.28","541.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","105.05","11.63","","112.68","112.68","146.99","38","105.05","767.79","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.28","541.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","699.14","77.4","","303.98","303.98","5854.79","1 through 10","105.05","767.79","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.28","541.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","105.05","11.63","","112.68","112.68","146.99","38","105.05","699.14","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.28","541.97","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","567.08","62.78","","780.86","208.94","10480.28","15","105.05","699.14","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.28","541.97","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","394.91","43.72","","179.76","179.76","179.76","1 through 10","105.05","699.14","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.28","541.97","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","656.87","72.72","","2355.45","298.99","3965.19","155","105.05","699.14","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.28","541.97","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","656.87","72.72","","3643.09","3643.09","3643.09","1 through 10","105.05","699.14","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.28","541.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","480.73","53.22","","554.28","554.28","554.28","16","105.05","699.14","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.28","541.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","568.16","62.9","","619.64","173.09","2370.64","150","105.05","699.14","percent of total billed charges",""
"SCREW BONE 3.5X56MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/56","SUP-ITM-10113990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.28","541.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","699.14","77.4","","303.98","303.98","5854.79","1 through 10","105.05","699.14","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","both","","","199.42","119.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","23.19","169.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","both","","","199.42","119.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","23.19","169.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","both","","","199.42","119.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","113.47","56.9","","812.12","238.65","1587.46","163","23.19","169.51","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","both","","","199.42","119.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","23.19","11.63","","112.68","112.68","146.99","38","23.19","169.51","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","both","","","199.42","119.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","154.35","77.4","","303.98","303.98","5854.79","1 through 10","23.19","169.51","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","199.42","119.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","23.19","11.63","","112.68","112.68","146.99","38","23.19","154.35","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","199.42","119.65","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","125.20","62.78","","780.86","208.94","10480.28","15","23.19","154.35","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","199.42","119.65","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","87.19","43.72","","179.76","179.76","179.76","1 through 10","23.19","154.35","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","199.42","119.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","145.02","72.72","","2355.45","298.99","3965.19","155","23.19","154.35","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","199.42","119.65","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","145.02","72.72","","3643.09","3643.09","3643.09","1 through 10","23.19","154.35","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","199.42","119.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","106.13","53.22","","554.28","554.28","554.28","16","23.19","154.35","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","199.42","119.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","125.44","62.9","","619.64","173.09","2370.64","150","23.19","154.35","percent of total billed charges",""
"SCREW BONE 3.5X60MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","199.42","119.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","154.35","77.4","","303.98","303.98","5854.79","1 through 10","23.19","154.35","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","897.33","538.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","104.36","762.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","897.33","538.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","104.36","762.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","897.33","538.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","510.58","56.9","","812.12","238.65","1587.46","163","104.36","762.73","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","897.33","538.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","104.36","11.63","","112.68","112.68","146.99","38","104.36","762.73","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","897.33","538.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","694.53","77.4","","303.98","303.98","5854.79","1 through 10","104.36","762.73","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","897.33","538.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","104.36","11.63","","112.68","112.68","146.99","38","104.36","694.53","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","897.33","538.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","563.34","62.78","","780.86","208.94","10480.28","15","104.36","694.53","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","897.33","538.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","392.31","43.72","","179.76","179.76","179.76","1 through 10","104.36","694.53","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","897.33","538.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","652.54","72.72","","2355.45","298.99","3965.19","155","104.36","694.53","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","897.33","538.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","652.54","72.72","","3643.09","3643.09","3643.09","1 through 10","104.36","694.53","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","897.33","538.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","477.56","53.22","","554.28","554.28","554.28","16","104.36","694.53","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","897.33","538.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","564.42","62.9","","619.64","173.09","2370.64","150","104.36","694.53","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","897.33","538.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","694.53","77.4","","303.98","303.98","5854.79","1 through 10","104.36","694.53","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.41","403.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","78.2","571.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.41","403.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","78.2","571.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.41","403.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","382.60","56.9","","812.12","238.65","1587.46","163","78.2","571.55","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.41","403.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","78.20","11.63","","112.68","112.68","146.99","38","78.2","571.55","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.41","403.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","520.45","77.4","","303.98","303.98","5854.79","1 through 10","78.2","571.55","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.41","403.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","78.20","11.63","","112.68","112.68","146.99","38","78.2","520.45","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.41","403.45","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","422.14","62.78","","780.86","208.94","10480.28","15","78.2","520.45","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.41","403.45","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","293.98","43.72","","179.76","179.76","179.76","1 through 10","78.2","520.45","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.41","403.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","488.98","72.72","","2355.45","298.99","3965.19","155","78.2","520.45","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.41","403.45","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","488.98","72.72","","3643.09","3643.09","3643.09","1 through 10","78.2","520.45","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.41","403.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","357.86","53.22","","554.28","554.28","554.28","16","78.2","520.45","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.41","403.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","422.95","62.9","","619.64","173.09","2370.64","150","78.2","520.45","percent of total billed charges",""
"SCREW BONE 3.5X70MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10013645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.41","403.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","520.45","77.4","","303.98","303.98","5854.79","1 through 10","78.2","520.45","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.87","118.12","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","22.9","167.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.87","118.12","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","22.9","167.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.87","118.12","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","112.02","56.9","","812.12","238.65","1587.46","163","22.9","167.34","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.87","118.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","22.90","11.63","","112.68","112.68","146.99","38","22.9","167.34","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.87","118.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","152.38","77.4","","303.98","303.98","5854.79","1 through 10","22.9","167.34","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.87","118.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","22.90","11.63","","112.68","112.68","146.99","38","22.9","152.38","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.87","118.12","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","123.59","62.78","","780.86","208.94","10480.28","15","22.9","152.38","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.87","118.12","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","86.07","43.72","","179.76","179.76","179.76","1 through 10","22.9","152.38","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.87","118.12","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","143.16","72.72","","2355.45","298.99","3965.19","155","22.9","152.38","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.87","118.12","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","143.16","72.72","","3643.09","3643.09","3643.09","1 through 10","22.9","152.38","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.87","118.12","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","104.77","53.22","","554.28","554.28","554.28","16","22.9","152.38","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.87","118.12","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","123.83","62.9","","619.64","173.09","2370.64","150","22.9","152.38","percent of total billed charges",""
"SCREW BONE 3.5X80MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10002301","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.87","118.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","152.38","77.4","","303.98","303.98","5854.79","1 through 10","22.9","152.38","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.87","118.12","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","22.9","167.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.87","118.12","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","22.9","167.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.87","118.12","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","112.02","56.9","","812.12","238.65","1587.46","163","22.9","167.34","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.87","118.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","22.90","11.63","","112.68","112.68","146.99","38","22.9","167.34","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","both","","","196.87","118.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","152.38","77.4","","303.98","303.98","5854.79","1 through 10","22.9","167.34","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.87","118.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","22.90","11.63","","112.68","112.68","146.99","38","22.9","152.38","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.87","118.12","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","123.59","62.78","","780.86","208.94","10480.28","15","22.9","152.38","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.87","118.12","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","86.07","43.72","","179.76","179.76","179.76","1 through 10","22.9","152.38","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.87","118.12","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","143.16","72.72","","2355.45","298.99","3965.19","155","22.9","152.38","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.87","118.12","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","143.16","72.72","","3643.09","3643.09","3643.09","1 through 10","22.9","152.38","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.87","118.12","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","104.77","53.22","","554.28","554.28","554.28","16","22.9","152.38","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.87","118.12","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","123.83","62.9","","619.64","173.09","2370.64","150","22.9","152.38","percent of total billed charges",""
"SCREW BONE 3.5X90MM CORTEX SS SELF TAPPING HEXAGONAL SOCKET FLAT HEAD STANDARD","SUP-ITM-10004024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","196.87","118.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","152.38","77.4","","303.98","303.98","5854.79","1 through 10","22.9","152.38","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.58","157.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","30.54","223.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.58","157.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","30.54","223.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.58","157.55","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","149.41","56.9","","812.12","238.65","1587.46","163","30.54","223.19","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.58","157.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","30.54","11.63","","112.68","112.68","146.99","38","30.54","223.19","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.58","157.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","203.24","77.4","","303.98","303.98","5854.79","1 through 10","30.54","223.19","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","30.54","11.63","","112.68","112.68","146.99","38","30.54","203.24","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","164.85","62.78","","780.86","208.94","10480.28","15","30.54","203.24","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","114.80","43.72","","179.76","179.76","179.76","1 through 10","30.54","203.24","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","190.95","72.72","","2355.45","298.99","3965.19","155","30.54","203.24","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","190.95","72.72","","3643.09","3643.09","3643.09","1 through 10","30.54","203.24","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","139.75","53.22","","554.28","554.28","554.28","16","30.54","203.24","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","165.16","62.9","","619.64","173.09","2370.64","150","30.54","203.24","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","203.24","77.4","","303.98","303.98","5854.79","1 through 10","30.54","203.24","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","both","","","835.97","501.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","97.22","710.57","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","both","","","835.97","501.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","97.22","710.57","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","both","","","835.97","501.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","475.67","56.9","","812.12","238.65","1587.46","163","97.22","710.57","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","both","","","835.97","501.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","97.22","11.63","","112.68","112.68","146.99","38","97.22","710.57","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","both","","","835.97","501.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","647.04","77.4","","303.98","303.98","5854.79","1 through 10","97.22","710.57","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","835.97","501.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","97.22","11.63","","112.68","112.68","146.99","38","97.22","647.04","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","835.97","501.58","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","524.82","62.78","","780.86","208.94","10480.28","15","97.22","647.04","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","835.97","501.58","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","365.49","43.72","","179.76","179.76","179.76","1 through 10","97.22","647.04","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","835.97","501.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","607.92","72.72","","2355.45","298.99","3965.19","155","97.22","647.04","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","835.97","501.58","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","607.92","72.72","","3643.09","3643.09","3643.09","1 through 10","97.22","647.04","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","835.97","501.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","444.90","53.22","","554.28","554.28","554.28","16","97.22","647.04","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","835.97","501.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","525.83","62.9","","619.64","173.09","2370.64","150","97.22","647.04","percent of total billed charges",""
"SCREW BONE 32.3MM COMPRESSION OMEGA SS PLUS FULL THREAD","SUP-ITM-10034628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","835.97","501.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","647.04","77.4","","303.98","303.98","5854.79","1 through 10","97.22","647.04","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.60","248.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","48.22","352.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.60","248.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","48.22","352.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.60","248.76","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","235.91","56.9","","812.12","238.65","1587.46","163","48.22","352.41","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.60","248.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","48.22","11.63","","112.68","112.68","146.99","38","48.22","352.41","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","414.60","248.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","320.90","77.4","","303.98","303.98","5854.79","1 through 10","48.22","352.41","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","48.22","11.63","","112.68","112.68","146.99","38","48.22","320.9","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","260.29","62.78","","780.86","208.94","10480.28","15","48.22","320.9","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","181.26","43.72","","179.76","179.76","179.76","1 through 10","48.22","320.9","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","301.50","72.72","","2355.45","298.99","3965.19","155","48.22","320.9","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","301.50","72.72","","3643.09","3643.09","3643.09","1 through 10","48.22","320.9","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","220.65","53.22","","554.28","554.28","554.28","16","48.22","320.9","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","260.78","62.9","","619.64","173.09","2370.64","150","48.22","320.9","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","414.60","248.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","320.90","77.4","","303.98","303.98","5854.79","1 through 10","48.22","320.9","percent of total billed charges",""
"SCREW BONE 3MMX18MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10021626","CDM","C1713","HCPCS","0278","RC","","","","both","","","3496.46","2097.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","406.64","2971.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3MMX18MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10021626","CDM","C1713","HCPCS","0278","RC","","","","both","","","3496.46","2097.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","406.64","2971.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3MMX18MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10021626","CDM","C1713","HCPCS","0278","RC","","","","both","","","3496.46","2097.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1989.49","56.9","","812.12","238.65","1587.46","163","406.64","2971.99","percent of total billed charges",""
"SCREW BONE 3MMX18MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10021626","CDM","C1713","HCPCS","0278","RC","","","","both","","","3496.46","2097.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","406.64","11.63","","112.68","112.68","146.99","38","406.64","2971.99","percent of total billed charges",""
"SCREW BONE 3MMX18MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10021626","CDM","C1713","HCPCS","0278","RC","","","","both","","","3496.46","2097.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2706.26","77.4","","303.98","303.98","5854.79","1 through 10","406.64","2971.99","percent of total billed charges",""
"SCREW BONE 3MMX18MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10021626","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3496.46","2097.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","406.64","11.63","","112.68","112.68","146.99","38","406.64","2706.26","percent of total billed charges",""
"SCREW BONE 3MMX18MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10021626","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3496.46","2097.88","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2195.08","62.78","","780.86","208.94","10480.28","15","406.64","2706.26","percent of total billed charges",""
"SCREW BONE 3MMX18MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10021626","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3496.46","2097.88","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1528.65","43.72","","179.76","179.76","179.76","1 through 10","406.64","2706.26","percent of total billed charges",""
"SCREW BONE 3MMX18MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10021626","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3496.46","2097.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2542.63","72.72","","2355.45","298.99","3965.19","155","406.64","2706.26","percent of total billed charges",""
"SCREW BONE 3MMX18MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10021626","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3496.46","2097.88","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2542.63","72.72","","3643.09","3643.09","3643.09","1 through 10","406.64","2706.26","percent of total billed charges",""
"SCREW BONE 3MMX18MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10021626","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3496.46","2097.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1860.82","53.22","","554.28","554.28","554.28","16","406.64","2706.26","percent of total billed charges",""
"SCREW BONE 3MMX18MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10021626","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3496.46","2097.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2199.27","62.9","","619.64","173.09","2370.64","150","406.64","2706.26","percent of total billed charges",""
"SCREW BONE 3MMX18MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10021626","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3496.46","2097.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2706.26","77.4","","303.98","303.98","5854.79","1 through 10","406.64","2706.26","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","897.75","538.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","104.41","763.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","897.75","538.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","104.41","763.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","897.75","538.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","510.82","56.9","","812.12","238.65","1587.46","163","104.41","763.09","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","897.75","538.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","104.41","11.63","","112.68","112.68","146.99","38","104.41","763.09","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","897.75","538.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","694.86","77.4","","303.98","303.98","5854.79","1 through 10","104.41","763.09","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","897.75","538.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","104.41","11.63","","112.68","112.68","146.99","38","104.41","694.86","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","897.75","538.65","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","563.61","62.78","","780.86","208.94","10480.28","15","104.41","694.86","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","897.75","538.65","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","392.50","43.72","","179.76","179.76","179.76","1 through 10","104.41","694.86","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","897.75","538.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","652.84","72.72","","2355.45","298.99","3965.19","155","104.41","694.86","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","897.75","538.65","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","652.84","72.72","","3643.09","3643.09","3643.09","1 through 10","104.41","694.86","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","897.75","538.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","477.78","53.22","","554.28","554.28","554.28","16","104.41","694.86","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","897.75","538.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","564.68","62.9","","619.64","173.09","2370.64","150","104.41","694.86","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","897.75","538.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","694.86","77.4","","303.98","303.98","5854.79","1 through 10","104.41","694.86","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1441.70","865.02","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","167.67","1225.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1441.70","865.02","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","167.67","1225.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1441.70","865.02","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","820.33","56.9","","812.12","238.65","1587.46","163","167.67","1225.45","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1441.70","865.02","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","167.67","11.63","","112.68","112.68","146.99","38","167.67","1225.45","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","1441.70","865.02","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1115.88","77.4","","303.98","303.98","5854.79","1 through 10","167.67","1225.45","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1441.70","865.02","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","167.67","11.63","","112.68","112.68","146.99","38","167.67","1115.88","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1441.70","865.02","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","905.10","62.78","","780.86","208.94","10480.28","15","167.67","1115.88","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1441.70","865.02","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","630.31","43.72","","179.76","179.76","179.76","1 through 10","167.67","1115.88","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1441.70","865.02","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1048.40","72.72","","2355.45","298.99","3965.19","155","167.67","1115.88","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1441.70","865.02","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1048.40","72.72","","3643.09","3643.09","3643.09","1 through 10","167.67","1115.88","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1441.70","865.02","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","767.27","53.22","","554.28","554.28","554.28","16","167.67","1115.88","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1441.70","865.02","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","906.83","62.9","","619.64","173.09","2370.64","150","167.67","1115.88","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1441.70","865.02","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1115.88","77.4","","303.98","303.98","5854.79","1 through 10","167.67","1115.88","percent of total billed charges",""
"SCREW BONE 3X40MM TITANIUM CANNULATED LONG THREAD","SUP-ITM-10039809","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.62","594.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","115.21","842.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3X40MM TITANIUM CANNULATED LONG THREAD","SUP-ITM-10039809","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.62","594.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","115.21","842.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 3X40MM TITANIUM CANNULATED LONG THREAD","SUP-ITM-10039809","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.62","594.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","563.66","56.9","","812.12","238.65","1587.46","163","115.21","842.03","percent of total billed charges",""
"SCREW BONE 3X40MM TITANIUM CANNULATED LONG THREAD","SUP-ITM-10039809","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.62","594.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","115.21","11.63","","112.68","112.68","146.99","38","115.21","842.03","percent of total billed charges",""
"SCREW BONE 3X40MM TITANIUM CANNULATED LONG THREAD","SUP-ITM-10039809","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.62","594.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","766.74","77.4","","303.98","303.98","5854.79","1 through 10","115.21","842.03","percent of total billed charges",""
"SCREW BONE 3X40MM TITANIUM CANNULATED LONG THREAD","SUP-ITM-10039809","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","990.62","594.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","115.21","11.63","","112.68","112.68","146.99","38","115.21","766.74","percent of total billed charges",""
"SCREW BONE 3X40MM TITANIUM CANNULATED LONG THREAD","SUP-ITM-10039809","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","990.62","594.37","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","621.91","62.78","","780.86","208.94","10480.28","15","115.21","766.74","percent of total billed charges",""
"SCREW BONE 3X40MM TITANIUM CANNULATED LONG THREAD","SUP-ITM-10039809","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","990.62","594.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","433.10","43.72","","179.76","179.76","179.76","1 through 10","115.21","766.74","percent of total billed charges",""
"SCREW BONE 3X40MM TITANIUM CANNULATED LONG THREAD","SUP-ITM-10039809","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","990.62","594.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","720.38","72.72","","2355.45","298.99","3965.19","155","115.21","766.74","percent of total billed charges",""
"SCREW BONE 3X40MM TITANIUM CANNULATED LONG THREAD","SUP-ITM-10039809","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","990.62","594.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","720.38","72.72","","3643.09","3643.09","3643.09","1 through 10","115.21","766.74","percent of total billed charges",""
"SCREW BONE 3X40MM TITANIUM CANNULATED LONG THREAD","SUP-ITM-10039809","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","990.62","594.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","527.21","53.22","","554.28","554.28","554.28","16","115.21","766.74","percent of total billed charges",""
"SCREW BONE 3X40MM TITANIUM CANNULATED LONG THREAD","SUP-ITM-10039809","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","990.62","594.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","623.10","62.9","","619.64","173.09","2370.64","150","115.21","766.74","percent of total billed charges",""
"SCREW BONE 3X40MM TITANIUM CANNULATED LONG THREAD","SUP-ITM-10039809","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","990.62","594.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","766.74","77.4","","303.98","303.98","5854.79","1 through 10","115.21","766.74","percent of total billed charges",""
"SCREW BONE 4.0X14MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10041334","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.14","190.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","37","270.42","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.0X14MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10041334","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.14","190.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","37","270.42","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.0X14MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10041334","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.14","190.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","181.02","56.9","","812.12","238.65","1587.46","163","37","270.42","percent of total billed charges",""
"SCREW BONE 4.0X14MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10041334","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.14","190.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","37.00","11.63","","112.68","112.68","146.99","38","37","270.42","percent of total billed charges",""
"SCREW BONE 4.0X14MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10041334","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.14","190.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","246.24","77.4","","303.98","303.98","5854.79","1 through 10","37","270.42","percent of total billed charges",""
"SCREW BONE 4.0X14MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10041334","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.14","190.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","37.00","11.63","","112.68","112.68","146.99","38","37","246.24","percent of total billed charges",""
"SCREW BONE 4.0X14MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10041334","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.14","190.88","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","199.73","62.78","","780.86","208.94","10480.28","15","37","246.24","percent of total billed charges",""
"SCREW BONE 4.0X14MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10041334","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.14","190.88","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","139.09","43.72","","179.76","179.76","179.76","1 through 10","37","246.24","percent of total billed charges",""
"SCREW BONE 4.0X14MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10041334","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.14","190.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","231.35","72.72","","2355.45","298.99","3965.19","155","37","246.24","percent of total billed charges",""
"SCREW BONE 4.0X14MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10041334","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.14","190.88","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","231.35","72.72","","3643.09","3643.09","3643.09","1 through 10","37","246.24","percent of total billed charges",""
"SCREW BONE 4.0X14MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10041334","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.14","190.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","169.31","53.22","","554.28","554.28","554.28","16","37","246.24","percent of total billed charges",""
"SCREW BONE 4.0X14MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10041334","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.14","190.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","200.11","62.9","","619.64","173.09","2370.64","150","37","246.24","percent of total billed charges",""
"SCREW BONE 4.0X14MM CANCELLOUS SS FULL THREAD HEXAGONAL HEAD","SUP-ITM-10041334","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.14","190.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","246.24","77.4","","303.98","303.98","5854.79","1 through 10","37","246.24","percent of total billed charges",""
"SCREW BONE 4.0X24MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033869","CDM","C1713","HCPCS","0278","RC","","","","both","","","2056.62","1233.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","239.18","1748.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.0X24MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033869","CDM","C1713","HCPCS","0278","RC","","","","both","","","2056.62","1233.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","239.18","1748.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.0X24MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033869","CDM","C1713","HCPCS","0278","RC","","","","both","","","2056.62","1233.97","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1170.22","56.9","","812.12","238.65","1587.46","163","239.18","1748.13","percent of total billed charges",""
"SCREW BONE 4.0X24MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033869","CDM","C1713","HCPCS","0278","RC","","","","both","","","2056.62","1233.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","239.18","11.63","","112.68","112.68","146.99","38","239.18","1748.13","percent of total billed charges",""
"SCREW BONE 4.0X24MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033869","CDM","C1713","HCPCS","0278","RC","","","","both","","","2056.62","1233.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1591.82","77.4","","303.98","303.98","5854.79","1 through 10","239.18","1748.13","percent of total billed charges",""
"SCREW BONE 4.0X24MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2056.62","1233.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","239.18","11.63","","112.68","112.68","146.99","38","239.18","1591.82","percent of total billed charges",""
"SCREW BONE 4.0X24MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2056.62","1233.97","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1291.15","62.78","","780.86","208.94","10480.28","15","239.18","1591.82","percent of total billed charges",""
"SCREW BONE 4.0X24MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2056.62","1233.97","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","899.15","43.72","","179.76","179.76","179.76","1 through 10","239.18","1591.82","percent of total billed charges",""
"SCREW BONE 4.0X24MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2056.62","1233.97","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1495.57","72.72","","2355.45","298.99","3965.19","155","239.18","1591.82","percent of total billed charges",""
"SCREW BONE 4.0X24MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2056.62","1233.97","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1495.57","72.72","","3643.09","3643.09","3643.09","1 through 10","239.18","1591.82","percent of total billed charges",""
"SCREW BONE 4.0X24MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2056.62","1233.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1094.53","53.22","","554.28","554.28","554.28","16","239.18","1591.82","percent of total billed charges",""
"SCREW BONE 4.0X24MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2056.62","1233.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1293.61","62.9","","619.64","173.09","2370.64","150","239.18","1591.82","percent of total billed charges",""
"SCREW BONE 4.0X24MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2056.62","1233.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1591.82","77.4","","303.98","303.98","5854.79","1 through 10","239.18","1591.82","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","both","","","2056.62","1233.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","239.18","1748.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","both","","","2056.62","1233.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","239.18","1748.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","both","","","2056.62","1233.97","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1170.22","56.9","","812.12","238.65","1587.46","163","239.18","1748.13","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","both","","","2056.62","1233.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","239.18","11.63","","112.68","112.68","146.99","38","239.18","1748.13","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","both","","","2056.62","1233.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1591.82","77.4","","303.98","303.98","5854.79","1 through 10","239.18","1748.13","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2056.62","1233.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","239.18","11.63","","112.68","112.68","146.99","38","239.18","1591.82","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2056.62","1233.97","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1291.15","62.78","","780.86","208.94","10480.28","15","239.18","1591.82","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2056.62","1233.97","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","899.15","43.72","","179.76","179.76","179.76","1 through 10","239.18","1591.82","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2056.62","1233.97","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1495.57","72.72","","2355.45","298.99","3965.19","155","239.18","1591.82","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2056.62","1233.97","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1495.57","72.72","","3643.09","3643.09","3643.09","1 through 10","239.18","1591.82","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2056.62","1233.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1094.53","53.22","","554.28","554.28","554.28","16","239.18","1591.82","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2056.62","1233.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1293.61","62.9","","619.64","173.09","2370.64","150","239.18","1591.82","percent of total billed charges",""
"SCREW BONE 4.0X28MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2056.62","1233.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1591.82","77.4","","303.98","303.98","5854.79","1 through 10","239.18","1591.82","percent of total billed charges",""
"SCREW BONE 4.0X32MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10033434","CDM","C1713","HCPCS","0278","RC","","","","both","","","2936.75","1762.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","341.54","2496.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.0X32MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10033434","CDM","C1713","HCPCS","0278","RC","","","","both","","","2936.75","1762.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","341.54","2496.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.0X32MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10033434","CDM","C1713","HCPCS","0278","RC","","","","both","","","2936.75","1762.05","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1671.01","56.9","","812.12","238.65","1587.46","163","341.54","2496.24","percent of total billed charges",""
"SCREW BONE 4.0X32MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10033434","CDM","C1713","HCPCS","0278","RC","","","","both","","","2936.75","1762.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","341.54","11.63","","112.68","112.68","146.99","38","341.54","2496.24","percent of total billed charges",""
"SCREW BONE 4.0X32MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10033434","CDM","C1713","HCPCS","0278","RC","","","","both","","","2936.75","1762.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2273.04","77.4","","303.98","303.98","5854.79","1 through 10","341.54","2496.24","percent of total billed charges",""
"SCREW BONE 4.0X32MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10033434","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","341.54","11.63","","112.68","112.68","146.99","38","341.54","2273.04","percent of total billed charges",""
"SCREW BONE 4.0X32MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10033434","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1843.69","62.78","","780.86","208.94","10480.28","15","341.54","2273.04","percent of total billed charges",""
"SCREW BONE 4.0X32MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10033434","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1283.95","43.72","","179.76","179.76","179.76","1 through 10","341.54","2273.04","percent of total billed charges",""
"SCREW BONE 4.0X32MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10033434","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2135.60","72.72","","2355.45","298.99","3965.19","155","341.54","2273.04","percent of total billed charges",""
"SCREW BONE 4.0X32MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10033434","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2135.60","72.72","","3643.09","3643.09","3643.09","1 through 10","341.54","2273.04","percent of total billed charges",""
"SCREW BONE 4.0X32MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10033434","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1562.94","53.22","","554.28","554.28","554.28","16","341.54","2273.04","percent of total billed charges",""
"SCREW BONE 4.0X32MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10033434","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1847.22","62.9","","619.64","173.09","2370.64","150","341.54","2273.04","percent of total billed charges",""
"SCREW BONE 4.0X32MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10033434","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2273.04","77.4","","303.98","303.98","5854.79","1 through 10","341.54","2273.04","percent of total billed charges",""
"SCREW BONE 4.5X18MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE WHITE","SUP-ITM-10170064","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.16","315.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","61.08","446.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X18MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE WHITE","SUP-ITM-10170064","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.16","315.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","61.08","446.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X18MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE WHITE","SUP-ITM-10170064","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.16","315.10","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","298.82","56.9","","812.12","238.65","1587.46","163","61.08","446.39","percent of total billed charges",""
"SCREW BONE 4.5X18MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE WHITE","SUP-ITM-10170064","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.16","315.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","61.08","11.63","","112.68","112.68","146.99","38","61.08","446.39","percent of total billed charges",""
"SCREW BONE 4.5X18MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE WHITE","SUP-ITM-10170064","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.16","315.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","406.47","77.4","","303.98","303.98","5854.79","1 through 10","61.08","446.39","percent of total billed charges",""
"SCREW BONE 4.5X18MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE WHITE","SUP-ITM-10170064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","61.08","11.63","","112.68","112.68","146.99","38","61.08","406.47","percent of total billed charges",""
"SCREW BONE 4.5X18MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE WHITE","SUP-ITM-10170064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","329.70","62.78","","780.86","208.94","10480.28","15","61.08","406.47","percent of total billed charges",""
"SCREW BONE 4.5X18MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE WHITE","SUP-ITM-10170064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","229.60","43.72","","179.76","179.76","179.76","1 through 10","61.08","406.47","percent of total billed charges",""
"SCREW BONE 4.5X18MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE WHITE","SUP-ITM-10170064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","381.90","72.72","","2355.45","298.99","3965.19","155","61.08","406.47","percent of total billed charges",""
"SCREW BONE 4.5X18MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE WHITE","SUP-ITM-10170064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","381.90","72.72","","3643.09","3643.09","3643.09","1 through 10","61.08","406.47","percent of total billed charges",""
"SCREW BONE 4.5X18MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE WHITE","SUP-ITM-10170064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","279.49","53.22","","554.28","554.28","554.28","16","61.08","406.47","percent of total billed charges",""
"SCREW BONE 4.5X18MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE WHITE","SUP-ITM-10170064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","330.33","62.9","","619.64","173.09","2370.64","150","61.08","406.47","percent of total billed charges",""
"SCREW BONE 4.5X18MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE WHITE","SUP-ITM-10170064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","406.47","77.4","","303.98","303.98","5854.79","1 through 10","61.08","406.47","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","888.90","533.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","103.38","755.57","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","888.90","533.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","103.38","755.57","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","888.90","533.34","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","505.78","56.9","","812.12","238.65","1587.46","163","103.38","755.57","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","888.90","533.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","103.38","11.63","","112.68","112.68","146.99","38","103.38","755.57","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","888.90","533.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","688.01","77.4","","303.98","303.98","5854.79","1 through 10","103.38","755.57","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","888.90","533.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","103.38","11.63","","112.68","112.68","146.99","38","103.38","688.01","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","888.90","533.34","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","558.05","62.78","","780.86","208.94","10480.28","15","103.38","688.01","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","888.90","533.34","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","388.63","43.72","","179.76","179.76","179.76","1 through 10","103.38","688.01","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","888.90","533.34","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","646.41","72.72","","2355.45","298.99","3965.19","155","103.38","688.01","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","888.90","533.34","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","646.41","72.72","","3643.09","3643.09","3643.09","1 through 10","103.38","688.01","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","888.90","533.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","473.07","53.22","","554.28","554.28","554.28","16","103.38","688.01","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","888.90","533.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","559.12","62.9","","619.64","173.09","2370.64","150","103.38","688.01","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","888.90","533.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","688.01","77.4","","303.98","303.98","5854.79","1 through 10","103.38","688.01","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","both","","","1558.90","935.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","181.3","1325.07","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","both","","","1558.90","935.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","181.3","1325.07","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","both","","","1558.90","935.34","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","887.01","56.9","","812.12","238.65","1587.46","163","181.3","1325.07","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","both","","","1558.90","935.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","181.30","11.63","","112.68","112.68","146.99","38","181.3","1325.07","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","both","","","1558.90","935.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1206.59","77.4","","303.98","303.98","5854.79","1 through 10","181.3","1325.07","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1558.90","935.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","181.30","11.63","","112.68","112.68","146.99","38","181.3","1206.59","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1558.90","935.34","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","978.68","62.78","","780.86","208.94","10480.28","15","181.3","1206.59","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1558.90","935.34","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","681.55","43.72","","179.76","179.76","179.76","1 through 10","181.3","1206.59","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1558.90","935.34","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1133.63","72.72","","2355.45","298.99","3965.19","155","181.3","1206.59","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1558.90","935.34","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1133.63","72.72","","3643.09","3643.09","3643.09","1 through 10","181.3","1206.59","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1558.90","935.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","829.65","53.22","","554.28","554.28","554.28","16","181.3","1206.59","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1558.90","935.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","980.55","62.9","","619.64","173.09","2370.64","150","181.3","1206.59","percent of total billed charges",""
"SCREW BONE 4.5X20MM COMPRESSION SS SHORT THREAD HEADLESS T15 STARDRIVE RECESS","SUP-ITM-10095296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1558.90","935.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1206.59","77.4","","303.98","303.98","5854.79","1 through 10","181.3","1206.59","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","2123.17","1273.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","246.92","1804.69","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","2123.17","1273.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","246.92","1804.69","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","2123.17","1273.90","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1208.08","56.9","","812.12","238.65","1587.46","163","246.92","1804.69","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","2123.17","1273.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","246.92","11.63","","112.68","112.68","146.99","38","246.92","1804.69","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","2123.17","1273.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1643.33","77.4","","303.98","303.98","5854.79","1 through 10","246.92","1804.69","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2123.17","1273.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","246.92","11.63","","112.68","112.68","146.99","38","246.92","1643.33","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2123.17","1273.90","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1332.93","62.78","","780.86","208.94","10480.28","15","246.92","1643.33","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2123.17","1273.90","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","928.25","43.72","","179.76","179.76","179.76","1 through 10","246.92","1643.33","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2123.17","1273.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1543.97","72.72","","2355.45","298.99","3965.19","155","246.92","1643.33","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2123.17","1273.90","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1543.97","72.72","","3643.09","3643.09","3643.09","1 through 10","246.92","1643.33","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2123.17","1273.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1129.95","53.22","","554.28","554.28","554.28","16","246.92","1643.33","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2123.17","1273.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1335.47","62.9","","619.64","173.09","2370.64","150","246.92","1643.33","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2123.17","1273.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1643.33","77.4","","303.98","303.98","5854.79","1 through 10","246.92","1643.33","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.16","315.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","61.08","446.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.16","315.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","61.08","446.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.16","315.10","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","298.82","56.9","","812.12","238.65","1587.46","163","61.08","446.39","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.16","315.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","61.08","11.63","","112.68","112.68","146.99","38","61.08","446.39","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.16","315.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","406.47","77.4","","303.98","303.98","5854.79","1 through 10","61.08","446.39","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","61.08","11.63","","112.68","112.68","146.99","38","61.08","406.47","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","329.70","62.78","","780.86","208.94","10480.28","15","61.08","406.47","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","229.60","43.72","","179.76","179.76","179.76","1 through 10","61.08","406.47","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","381.90","72.72","","2355.45","298.99","3965.19","155","61.08","406.47","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","381.90","72.72","","3643.09","3643.09","3643.09","1 through 10","61.08","406.47","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","279.49","53.22","","554.28","554.28","554.28","16","61.08","406.47","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","330.33","62.9","","619.64","173.09","2370.64","150","61.08","406.47","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.16","315.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","406.47","77.4","","303.98","303.98","5854.79","1 through 10","61.08","406.47","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","both","","","1347.45","808.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","156.71","1145.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","both","","","1347.45","808.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","156.71","1145.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","both","","","1347.45","808.47","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","766.70","56.9","","812.12","238.65","1587.46","163","156.71","1145.33","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","both","","","1347.45","808.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","156.71","11.63","","112.68","112.68","146.99","38","156.71","1145.33","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","both","","","1347.45","808.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1042.93","77.4","","303.98","303.98","5854.79","1 through 10","156.71","1145.33","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","156.71","11.63","","112.68","112.68","146.99","38","156.71","1042.93","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","845.93","62.78","","780.86","208.94","10480.28","15","156.71","1042.93","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","589.11","43.72","","179.76","179.76","179.76","1 through 10","156.71","1042.93","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","979.87","72.72","","2355.45","298.99","3965.19","155","156.71","1042.93","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","979.87","72.72","","3643.09","3643.09","3643.09","1 through 10","156.71","1042.93","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","717.11","53.22","","554.28","554.28","554.28","16","156.71","1042.93","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","847.55","62.9","","619.64","173.09","2370.64","150","156.71","1042.93","percent of total billed charges",""
"SCREW BONE 4.5X26MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10148123","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1042.93","77.4","","303.98","303.98","5854.79","1 through 10","156.71","1042.93","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER KIT COMPRESSION SS EQUINOXE TORQUE DEFINING REVERSE","SUP-ITM-10170066","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.00","829.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","160.73","1174.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X30MM SHOULDER KIT COMPRESSION SS EQUINOXE TORQUE DEFINING REVERSE","SUP-ITM-10170066","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.00","829.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","160.73","1174.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X30MM SHOULDER KIT COMPRESSION SS EQUINOXE TORQUE DEFINING REVERSE","SUP-ITM-10170066","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.00","829.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","786.36","56.9","","812.12","238.65","1587.46","163","160.73","1174.7","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER KIT COMPRESSION SS EQUINOXE TORQUE DEFINING REVERSE","SUP-ITM-10170066","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.00","829.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","160.73","11.63","","112.68","112.68","146.99","38","160.73","1174.7","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER KIT COMPRESSION SS EQUINOXE TORQUE DEFINING REVERSE","SUP-ITM-10170066","CDM","C1713","HCPCS","0278","RC","","","","both","","","1382.00","829.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1069.67","77.4","","303.98","303.98","5854.79","1 through 10","160.73","1174.7","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER KIT COMPRESSION SS EQUINOXE TORQUE DEFINING REVERSE","SUP-ITM-10170066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.00","829.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","160.73","11.63","","112.68","112.68","146.99","38","160.73","1069.67","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER KIT COMPRESSION SS EQUINOXE TORQUE DEFINING REVERSE","SUP-ITM-10170066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.00","829.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","867.62","62.78","","780.86","208.94","10480.28","15","160.73","1069.67","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER KIT COMPRESSION SS EQUINOXE TORQUE DEFINING REVERSE","SUP-ITM-10170066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.00","829.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","604.21","43.72","","179.76","179.76","179.76","1 through 10","160.73","1069.67","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER KIT COMPRESSION SS EQUINOXE TORQUE DEFINING REVERSE","SUP-ITM-10170066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.00","829.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1004.99","72.72","","2355.45","298.99","3965.19","155","160.73","1069.67","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER KIT COMPRESSION SS EQUINOXE TORQUE DEFINING REVERSE","SUP-ITM-10170066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.00","829.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1004.99","72.72","","3643.09","3643.09","3643.09","1 through 10","160.73","1069.67","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER KIT COMPRESSION SS EQUINOXE TORQUE DEFINING REVERSE","SUP-ITM-10170066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.00","829.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","735.50","53.22","","554.28","554.28","554.28","16","160.73","1069.67","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER KIT COMPRESSION SS EQUINOXE TORQUE DEFINING REVERSE","SUP-ITM-10170066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.00","829.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","869.28","62.9","","619.64","173.09","2370.64","150","160.73","1069.67","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER KIT COMPRESSION SS EQUINOXE TORQUE DEFINING REVERSE","SUP-ITM-10170066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1382.00","829.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1069.67","77.4","","303.98","303.98","5854.79","1 through 10","160.73","1069.67","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","888.90","533.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","103.38","755.57","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","888.90","533.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","103.38","755.57","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","888.90","533.34","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","505.78","56.9","","812.12","238.65","1587.46","163","103.38","755.57","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","888.90","533.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","103.38","11.63","","112.68","112.68","146.99","38","103.38","755.57","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","888.90","533.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","688.01","77.4","","303.98","303.98","5854.79","1 through 10","103.38","755.57","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","888.90","533.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","103.38","11.63","","112.68","112.68","146.99","38","103.38","688.01","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","888.90","533.34","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","558.05","62.78","","780.86","208.94","10480.28","15","103.38","688.01","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","888.90","533.34","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","388.63","43.72","","179.76","179.76","179.76","1 through 10","103.38","688.01","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","888.90","533.34","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","646.41","72.72","","2355.45","298.99","3965.19","155","103.38","688.01","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","888.90","533.34","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","646.41","72.72","","3643.09","3643.09","3643.09","1 through 10","103.38","688.01","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","888.90","533.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","473.07","53.22","","554.28","554.28","554.28","16","103.38","688.01","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","888.90","533.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","559.12","62.9","","619.64","173.09","2370.64","150","103.38","688.01","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","888.90","533.34","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","688.01","77.4","","303.98","303.98","5854.79","1 through 10","103.38","688.01","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10041927","CDM","C1713","HCPCS","0278","RC","","","","both","","","384.68","230.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","44.74","326.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X36MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10041927","CDM","C1713","HCPCS","0278","RC","","","","both","","","384.68","230.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","44.74","326.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X36MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10041927","CDM","C1713","HCPCS","0278","RC","","","","both","","","384.68","230.81","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","218.88","56.9","","812.12","238.65","1587.46","163","44.74","326.98","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10041927","CDM","C1713","HCPCS","0278","RC","","","","both","","","384.68","230.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","44.74","11.63","","112.68","112.68","146.99","38","44.74","326.98","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10041927","CDM","C1713","HCPCS","0278","RC","","","","both","","","384.68","230.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","297.74","77.4","","303.98","303.98","5854.79","1 through 10","44.74","326.98","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10041927","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","384.68","230.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","44.74","11.63","","112.68","112.68","146.99","38","44.74","297.74","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10041927","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","384.68","230.81","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","241.50","62.78","","780.86","208.94","10480.28","15","44.74","297.74","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10041927","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","384.68","230.81","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","168.18","43.72","","179.76","179.76","179.76","1 through 10","44.74","297.74","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10041927","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","384.68","230.81","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","279.74","72.72","","2355.45","298.99","3965.19","155","44.74","297.74","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10041927","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","384.68","230.81","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","279.74","72.72","","3643.09","3643.09","3643.09","1 through 10","44.74","297.74","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10041927","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","384.68","230.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","204.73","53.22","","554.28","554.28","554.28","16","44.74","297.74","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10041927","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","384.68","230.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","241.96","62.9","","619.64","173.09","2370.64","150","44.74","297.74","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL OMEGA 3 SS FULL THREAD","SUP-ITM-10041927","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","384.68","230.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","297.74","77.4","","303.98","303.98","5854.79","1 through 10","44.74","297.74","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","both","","","1347.45","808.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","156.71","1145.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","both","","","1347.45","808.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","156.71","1145.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","both","","","1347.45","808.47","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","766.70","56.9","","812.12","238.65","1587.46","163","156.71","1145.33","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","both","","","1347.45","808.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","156.71","11.63","","112.68","112.68","146.99","38","156.71","1145.33","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","both","","","1347.45","808.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1042.93","77.4","","303.98","303.98","5854.79","1 through 10","156.71","1145.33","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","156.71","11.63","","112.68","112.68","146.99","38","156.71","1042.93","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","845.93","62.78","","780.86","208.94","10480.28","15","156.71","1042.93","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","589.11","43.72","","179.76","179.76","179.76","1 through 10","156.71","1042.93","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","979.87","72.72","","2355.45","298.99","3965.19","155","156.71","1042.93","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","979.87","72.72","","3643.09","3643.09","3643.09","1 through 10","156.71","1042.93","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","717.11","53.22","","554.28","554.28","554.28","16","156.71","1042.93","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","847.55","62.9","","619.64","173.09","2370.64","150","156.71","1042.93","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1347.45","808.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1042.93","77.4","","303.98","303.98","5854.79","1 through 10","156.71","1042.93","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","both","","","913.23","547.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","106.21","776.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","both","","","913.23","547.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","106.21","776.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","both","","","913.23","547.94","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","519.63","56.9","","812.12","238.65","1587.46","163","106.21","776.25","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","both","","","913.23","547.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","106.21","11.63","","112.68","112.68","146.99","38","106.21","776.25","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","both","","","913.23","547.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","706.84","77.4","","303.98","303.98","5854.79","1 through 10","106.21","776.25","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","913.23","547.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","106.21","11.63","","112.68","112.68","146.99","38","106.21","706.84","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","913.23","547.94","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","573.33","62.78","","780.86","208.94","10480.28","15","106.21","706.84","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","913.23","547.94","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","399.26","43.72","","179.76","179.76","179.76","1 through 10","106.21","706.84","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","913.23","547.94","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","664.10","72.72","","2355.45","298.99","3965.19","155","106.21","706.84","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","913.23","547.94","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","664.10","72.72","","3643.09","3643.09","3643.09","1 through 10","106.21","706.84","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","913.23","547.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","486.02","53.22","","554.28","554.28","554.28","16","106.21","706.84","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","913.23","547.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","574.42","62.9","","619.64","173.09","2370.64","150","106.21","706.84","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","913.23","547.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","706.84","77.4","","303.98","303.98","5854.79","1 through 10","106.21","706.84","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040188","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.98","590.39","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","114.44","836.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X38MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040188","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.98","590.39","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","114.44","836.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X38MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040188","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.98","590.39","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","559.88","56.9","","812.12","238.65","1587.46","163","114.44","836.38","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040188","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.98","590.39","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","114.44","11.63","","112.68","112.68","146.99","38","114.44","836.38","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040188","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.98","590.39","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","761.60","77.4","","303.98","303.98","5854.79","1 through 10","114.44","836.38","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","983.98","590.39","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","114.44","11.63","","112.68","112.68","146.99","38","114.44","761.6","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","983.98","590.39","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","617.74","62.78","","780.86","208.94","10480.28","15","114.44","761.6","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","983.98","590.39","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","430.20","43.72","","179.76","179.76","179.76","1 through 10","114.44","761.6","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","983.98","590.39","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","715.55","72.72","","2355.45","298.99","3965.19","155","114.44","761.6","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","983.98","590.39","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","715.55","72.72","","3643.09","3643.09","3643.09","1 through 10","114.44","761.6","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","983.98","590.39","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","523.67","53.22","","554.28","554.28","554.28","16","114.44","761.6","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","983.98","590.39","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","618.92","62.9","","619.64","173.09","2370.64","150","114.44","761.6","percent of total billed charges",""
"SCREW BONE 4.5X38MM CANNULATED TITANIUM PARTIALLY THREADED","SUP-ITM-10040188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","983.98","590.39","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","761.60","77.4","","303.98","303.98","5854.79","1 through 10","114.44","761.6","percent of total billed charges",""
"SCREW BONE 4.5X38MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040239","CDM","C1713","HCPCS","0278","RC","","","","both","","","204.54","122.72","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","23.79","173.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X38MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040239","CDM","C1713","HCPCS","0278","RC","","","","both","","","204.54","122.72","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","23.79","173.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X38MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040239","CDM","C1713","HCPCS","0278","RC","","","","both","","","204.54","122.72","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","116.38","56.9","","812.12","238.65","1587.46","163","23.79","173.86","percent of total billed charges",""
"SCREW BONE 4.5X38MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040239","CDM","C1713","HCPCS","0278","RC","","","","both","","","204.54","122.72","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","23.79","11.63","","112.68","112.68","146.99","38","23.79","173.86","percent of total billed charges",""
"SCREW BONE 4.5X38MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040239","CDM","C1713","HCPCS","0278","RC","","","","both","","","204.54","122.72","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","158.31","77.4","","303.98","303.98","5854.79","1 through 10","23.79","173.86","percent of total billed charges",""
"SCREW BONE 4.5X38MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040239","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","204.54","122.72","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","23.79","11.63","","112.68","112.68","146.99","38","23.79","158.31","percent of total billed charges",""
"SCREW BONE 4.5X38MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040239","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","204.54","122.72","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","128.41","62.78","","780.86","208.94","10480.28","15","23.79","158.31","percent of total billed charges",""
"SCREW BONE 4.5X38MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040239","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","204.54","122.72","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","89.42","43.72","","179.76","179.76","179.76","1 through 10","23.79","158.31","percent of total billed charges",""
"SCREW BONE 4.5X38MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040239","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","204.54","122.72","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","148.74","72.72","","2355.45","298.99","3965.19","155","23.79","158.31","percent of total billed charges",""
"SCREW BONE 4.5X38MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040239","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","204.54","122.72","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","148.74","72.72","","3643.09","3643.09","3643.09","1 through 10","23.79","158.31","percent of total billed charges",""
"SCREW BONE 4.5X38MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040239","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","204.54","122.72","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","108.86","53.22","","554.28","554.28","554.28","16","23.79","158.31","percent of total billed charges",""
"SCREW BONE 4.5X38MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040239","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","204.54","122.72","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","128.66","62.9","","619.64","173.09","2370.64","150","23.79","158.31","percent of total billed charges",""
"SCREW BONE 4.5X38MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040239","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","204.54","122.72","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","158.31","77.4","","303.98","303.98","5854.79","1 through 10","23.79","158.31","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX SS SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10017236","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.35","329.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","63.89","466.95","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X40MM CORTEX SS SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10017236","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.35","329.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","63.89","466.95","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X40MM CORTEX SS SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10017236","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.35","329.61","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","312.58","56.9","","812.12","238.65","1587.46","163","63.89","466.95","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX SS SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10017236","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.35","329.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","63.89","11.63","","112.68","112.68","146.99","38","63.89","466.95","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX SS SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10017236","CDM","C1713","HCPCS","0278","RC","","","","both","","","549.35","329.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","425.20","77.4","","303.98","303.98","5854.79","1 through 10","63.89","466.95","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX SS SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10017236","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.35","329.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","63.89","11.63","","112.68","112.68","146.99","38","63.89","425.2","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX SS SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10017236","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.35","329.61","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","344.88","62.78","","780.86","208.94","10480.28","15","63.89","425.2","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX SS SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10017236","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.35","329.61","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","240.18","43.72","","179.76","179.76","179.76","1 through 10","63.89","425.2","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX SS SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10017236","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.35","329.61","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","399.49","72.72","","2355.45","298.99","3965.19","155","63.89","425.2","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX SS SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10017236","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.35","329.61","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","399.49","72.72","","3643.09","3643.09","3643.09","1 through 10","63.89","425.2","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX SS SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10017236","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.35","329.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","292.36","53.22","","554.28","554.28","554.28","16","63.89","425.2","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX SS SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10017236","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.35","329.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","345.54","62.9","","619.64","173.09","2370.64","150","63.89","425.2","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX SS SELF TAPPING HEXAGONAL HEAD","SUP-ITM-10017236","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","549.35","329.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","425.20","77.4","","303.98","303.98","5854.79","1 through 10","63.89","425.2","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.64","111.98","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","21.71","158.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.64","111.98","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","21.71","158.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.64","111.98","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","106.20","56.9","","812.12","238.65","1587.46","163","21.71","158.64","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.64","111.98","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","21.71","11.63","","112.68","112.68","146.99","38","21.71","158.64","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.64","111.98","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","144.46","77.4","","303.98","303.98","5854.79","1 through 10","21.71","158.64","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.64","111.98","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","21.71","11.63","","112.68","112.68","146.99","38","21.71","144.46","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.64","111.98","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","117.17","62.78","","780.86","208.94","10480.28","15","21.71","144.46","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.64","111.98","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","81.60","43.72","","179.76","179.76","179.76","1 through 10","21.71","144.46","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.64","111.98","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","135.72","72.72","","2355.45","298.99","3965.19","155","21.71","144.46","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.64","111.98","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","135.72","72.72","","3643.09","3643.09","3643.09","1 through 10","21.71","144.46","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.64","111.98","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","99.33","53.22","","554.28","554.28","554.28","16","21.71","144.46","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.64","111.98","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","117.40","62.9","","619.64","173.09","2370.64","150","21.71","144.46","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.64","111.98","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","144.46","77.4","","303.98","303.98","5854.79","1 through 10","21.71","144.46","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM BLUNT TIP SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095894","CDM","C1713","HCPCS","0278","RC","","","","both","","","1278.35","767.01","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","148.67","1086.6","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X46MM TITANIUM BLUNT TIP SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095894","CDM","C1713","HCPCS","0278","RC","","","","both","","","1278.35","767.01","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","148.67","1086.6","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X46MM TITANIUM BLUNT TIP SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095894","CDM","C1713","HCPCS","0278","RC","","","","both","","","1278.35","767.01","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","727.38","56.9","","812.12","238.65","1587.46","163","148.67","1086.6","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM BLUNT TIP SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095894","CDM","C1713","HCPCS","0278","RC","","","","both","","","1278.35","767.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","148.67","11.63","","112.68","112.68","146.99","38","148.67","1086.6","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM BLUNT TIP SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095894","CDM","C1713","HCPCS","0278","RC","","","","both","","","1278.35","767.01","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","989.44","77.4","","303.98","303.98","5854.79","1 through 10","148.67","1086.6","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM BLUNT TIP SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1278.35","767.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","148.67","11.63","","112.68","112.68","146.99","38","148.67","989.44","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM BLUNT TIP SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1278.35","767.01","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","802.55","62.78","","780.86","208.94","10480.28","15","148.67","989.44","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM BLUNT TIP SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1278.35","767.01","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","558.89","43.72","","179.76","179.76","179.76","1 through 10","148.67","989.44","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM BLUNT TIP SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1278.35","767.01","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","929.62","72.72","","2355.45","298.99","3965.19","155","148.67","989.44","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM BLUNT TIP SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1278.35","767.01","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","929.62","72.72","","3643.09","3643.09","3643.09","1 through 10","148.67","989.44","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM BLUNT TIP SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1278.35","767.01","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","680.34","53.22","","554.28","554.28","554.28","16","148.67","989.44","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM BLUNT TIP SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1278.35","767.01","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","804.08","62.9","","619.64","173.09","2370.64","150","148.67","989.44","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM BLUNT TIP SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1278.35","767.01","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","989.44","77.4","","303.98","303.98","5854.79","1 through 10","148.67","989.44","percent of total billed charges",""
"SCREW BONE 4.5X48MM BLUNT TIP TITANIUM SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095895","CDM","C1776","HCPCS","0278","RC","","","","both","","","1278.35","767.01","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","148.67","1086.6","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X48MM BLUNT TIP TITANIUM SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095895","CDM","C1776","HCPCS","0278","RC","","","","both","","","1278.35","767.01","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","727.38","56.9","","2911.53","1863.86","5209.05","65","148.67","1086.6","percent of total billed charges",""
"SCREW BONE 4.5X48MM BLUNT TIP TITANIUM SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095895","CDM","C1776","HCPCS","0278","RC","","","","both","","","1278.35","767.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","148.67","11.63","","400.94","400.94","400.94","1 through 10","148.67","1086.6","percent of total billed charges",""
"SCREW BONE 4.5X48MM BLUNT TIP TITANIUM SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095895","CDM","C1776","HCPCS","0278","RC","","","","both","","","1278.35","767.01","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","989.44","77.4","","5214.50","5214.50","16415.28","1 through 10","148.67","1086.6","percent of total billed charges",""
"SCREW BONE 4.5X48MM BLUNT TIP TITANIUM SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095895","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1278.35","767.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","148.67","11.63","","400.94","400.94","400.94","1 through 10","148.67","989.44","percent of total billed charges",""
"SCREW BONE 4.5X48MM BLUNT TIP TITANIUM SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095895","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1278.35","767.01","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","558.89","43.72","","1543.33","1543.33","1671.61","1 through 10","148.67","989.44","percent of total billed charges",""
"SCREW BONE 4.5X48MM BLUNT TIP TITANIUM SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095895","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1278.35","767.01","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","929.62","72.72","","3700.21","2382.07","6427.18","53","148.67","989.44","percent of total billed charges",""
"SCREW BONE 4.5X48MM BLUNT TIP TITANIUM SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095895","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1278.35","767.01","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","929.62","72.72","","12685.80","12685.80","12685.80","1 through 10","148.67","989.44","percent of total billed charges",""
"SCREW BONE 4.5X48MM BLUNT TIP TITANIUM SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095895","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1278.35","767.01","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","804.08","62.9","","3408.87","2784.05","9859.40","46","148.67","989.44","percent of total billed charges",""
"SCREW BONE 4.5X48MM BLUNT TIP TITANIUM SELF CUTTING FULL THREAD MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095895","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1278.35","767.01","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","989.44","77.4","","5214.50","5214.50","16415.28","1 through 10","148.67","989.44","percent of total billed charges",""
"SCREW BONE 4.5X50MM CHAMFERED","SUP-ITM-10239347","CDM","C1713","HCPCS","0278","RC","","","","both","","","6564.50","3938.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","763.45","5579.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X50MM CHAMFERED","SUP-ITM-10239347","CDM","C1713","HCPCS","0278","RC","","","","both","","","6564.50","3938.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","763.45","5579.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X50MM CHAMFERED","SUP-ITM-10239347","CDM","C1713","HCPCS","0278","RC","","","","both","","","6564.50","3938.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3735.20","56.9","","812.12","238.65","1587.46","163","763.45","5579.83","percent of total billed charges",""
"SCREW BONE 4.5X50MM CHAMFERED","SUP-ITM-10239347","CDM","C1713","HCPCS","0278","RC","","","","both","","","6564.50","3938.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","763.45","11.63","","112.68","112.68","146.99","38","763.45","5579.83","percent of total billed charges",""
"SCREW BONE 4.5X50MM CHAMFERED","SUP-ITM-10239347","CDM","C1713","HCPCS","0278","RC","","","","both","","","6564.50","3938.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5080.92","77.4","","303.98","303.98","5854.79","1 through 10","763.45","5579.83","percent of total billed charges",""
"SCREW BONE 4.5X50MM CHAMFERED","SUP-ITM-10239347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6564.50","3938.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","763.45","11.63","","112.68","112.68","146.99","38","763.45","5080.92","percent of total billed charges",""
"SCREW BONE 4.5X50MM CHAMFERED","SUP-ITM-10239347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6564.50","3938.70","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4121.19","62.78","","780.86","208.94","10480.28","15","763.45","5080.92","percent of total billed charges",""
"SCREW BONE 4.5X50MM CHAMFERED","SUP-ITM-10239347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6564.50","3938.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2870.00","43.72","","179.76","179.76","179.76","1 through 10","763.45","5080.92","percent of total billed charges",""
"SCREW BONE 4.5X50MM CHAMFERED","SUP-ITM-10239347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6564.50","3938.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4773.70","72.72","","2355.45","298.99","3965.19","155","763.45","5080.92","percent of total billed charges",""
"SCREW BONE 4.5X50MM CHAMFERED","SUP-ITM-10239347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6564.50","3938.70","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4773.70","72.72","","3643.09","3643.09","3643.09","1 through 10","763.45","5080.92","percent of total billed charges",""
"SCREW BONE 4.5X50MM CHAMFERED","SUP-ITM-10239347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6564.50","3938.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3493.63","53.22","","554.28","554.28","554.28","16","763.45","5080.92","percent of total billed charges",""
"SCREW BONE 4.5X50MM CHAMFERED","SUP-ITM-10239347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6564.50","3938.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4129.07","62.9","","619.64","173.09","2370.64","150","763.45","5080.92","percent of total billed charges",""
"SCREW BONE 4.5X50MM CHAMFERED","SUP-ITM-10239347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6564.50","3938.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5080.92","77.4","","303.98","303.98","5854.79","1 through 10","763.45","5080.92","percent of total billed charges",""
"SCREW BONE 4.5X50MM METATARSAL FIXED ANGLE TI LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10154455","CDM","C1713","HCPCS","0278","RC","","","","both","","","5493.45","3296.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","638.89","4669.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X50MM METATARSAL FIXED ANGLE TI LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10154455","CDM","C1713","HCPCS","0278","RC","","","","both","","","5493.45","3296.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","638.89","4669.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X50MM METATARSAL FIXED ANGLE TI LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10154455","CDM","C1713","HCPCS","0278","RC","","","","both","","","5493.45","3296.07","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3125.77","56.9","","812.12","238.65","1587.46","163","638.89","4669.43","percent of total billed charges",""
"SCREW BONE 4.5X50MM METATARSAL FIXED ANGLE TI LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10154455","CDM","C1713","HCPCS","0278","RC","","","","both","","","5493.45","3296.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","638.89","11.63","","112.68","112.68","146.99","38","638.89","4669.43","percent of total billed charges",""
"SCREW BONE 4.5X50MM METATARSAL FIXED ANGLE TI LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10154455","CDM","C1713","HCPCS","0278","RC","","","","both","","","5493.45","3296.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4251.93","77.4","","303.98","303.98","5854.79","1 through 10","638.89","4669.43","percent of total billed charges",""
"SCREW BONE 4.5X50MM METATARSAL FIXED ANGLE TI LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10154455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5493.45","3296.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","638.89","11.63","","112.68","112.68","146.99","38","638.89","4251.93","percent of total billed charges",""
"SCREW BONE 4.5X50MM METATARSAL FIXED ANGLE TI LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10154455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5493.45","3296.07","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3448.79","62.78","","780.86","208.94","10480.28","15","638.89","4251.93","percent of total billed charges",""
"SCREW BONE 4.5X50MM METATARSAL FIXED ANGLE TI LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10154455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5493.45","3296.07","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2401.74","43.72","","179.76","179.76","179.76","1 through 10","638.89","4251.93","percent of total billed charges",""
"SCREW BONE 4.5X50MM METATARSAL FIXED ANGLE TI LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10154455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5493.45","3296.07","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3994.84","72.72","","2355.45","298.99","3965.19","155","638.89","4251.93","percent of total billed charges",""
"SCREW BONE 4.5X50MM METATARSAL FIXED ANGLE TI LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10154455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5493.45","3296.07","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3994.84","72.72","","3643.09","3643.09","3643.09","1 through 10","638.89","4251.93","percent of total billed charges",""
"SCREW BONE 4.5X50MM METATARSAL FIXED ANGLE TI LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10154455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5493.45","3296.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2923.61","53.22","","554.28","554.28","554.28","16","638.89","4251.93","percent of total billed charges",""
"SCREW BONE 4.5X50MM METATARSAL FIXED ANGLE TI LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10154455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5493.45","3296.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3455.38","62.9","","619.64","173.09","2370.64","150","638.89","4251.93","percent of total billed charges",""
"SCREW BONE 4.5X50MM METATARSAL FIXED ANGLE TI LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10154455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5493.45","3296.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4251.93","77.4","","303.98","303.98","5854.79","1 through 10","638.89","4251.93","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.25","310.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","60.27","440.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.25","310.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","60.27","440.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.25","310.95","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","294.88","56.9","","812.12","238.65","1587.46","163","60.27","440.51","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.25","310.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","60.27","11.63","","112.68","112.68","146.99","38","60.27","440.51","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.25","310.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","401.13","77.4","","303.98","303.98","5854.79","1 through 10","60.27","440.51","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","60.27","11.63","","112.68","112.68","146.99","38","60.27","401.13","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","325.36","62.78","","780.86","208.94","10480.28","15","60.27","401.13","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","226.58","43.72","","179.76","179.76","179.76","1 through 10","60.27","401.13","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","376.87","72.72","","2355.45","298.99","3965.19","155","60.27","401.13","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","376.87","72.72","","3643.09","3643.09","3643.09","1 through 10","60.27","401.13","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","275.81","53.22","","554.28","554.28","554.28","16","60.27","401.13","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","325.98","62.9","","619.64","173.09","2370.64","150","60.27","401.13","percent of total billed charges",""
"SCREW BONE 4.5X55MM TITANIUM LOW PROFILE LOCKING","SUP-ITM-10153852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","401.13","77.4","","303.98","303.98","5854.79","1 through 10","60.27","401.13","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001682","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.15","207.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","40.14","293.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X60MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001682","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.15","207.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","40.14","293.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X60MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001682","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.15","207.09","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","196.39","56.9","","812.12","238.65","1587.46","163","40.14","293.38","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001682","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.15","207.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.14","11.63","","112.68","112.68","146.99","38","40.14","293.38","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001682","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.15","207.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","267.15","77.4","","303.98","303.98","5854.79","1 through 10","40.14","293.38","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.15","207.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.14","11.63","","112.68","112.68","146.99","38","40.14","267.15","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.15","207.09","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","216.69","62.78","","780.86","208.94","10480.28","15","40.14","267.15","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.15","207.09","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","150.90","43.72","","179.76","179.76","179.76","1 through 10","40.14","267.15","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.15","207.09","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","250.99","72.72","","2355.45","298.99","3965.19","155","40.14","267.15","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.15","207.09","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","250.99","72.72","","3643.09","3643.09","3643.09","1 through 10","40.14","267.15","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.15","207.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","183.69","53.22","","554.28","554.28","554.28","16","40.14","267.15","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.15","207.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","217.10","62.9","","619.64","173.09","2370.64","150","40.14","267.15","percent of total billed charges",""
"SCREW BONE 4.5X60MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.15","207.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","267.15","77.4","","303.98","303.98","5854.79","1 through 10","40.14","267.15","percent of total billed charges",""
"SCREW BONE 4.5X76MM SS CANNULATED SELF DRILLING TAPPING PARTIAL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037492","CDM","C1713","HCPCS","0278","RC","","","","both","","","913.23","547.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","106.21","776.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X76MM SS CANNULATED SELF DRILLING TAPPING PARTIAL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037492","CDM","C1713","HCPCS","0278","RC","","","","both","","","913.23","547.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","106.21","776.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4.5X76MM SS CANNULATED SELF DRILLING TAPPING PARTIAL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037492","CDM","C1713","HCPCS","0278","RC","","","","both","","","913.23","547.94","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","519.63","56.9","","812.12","238.65","1587.46","163","106.21","776.25","percent of total billed charges",""
"SCREW BONE 4.5X76MM SS CANNULATED SELF DRILLING TAPPING PARTIAL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037492","CDM","C1713","HCPCS","0278","RC","","","","both","","","913.23","547.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","106.21","11.63","","112.68","112.68","146.99","38","106.21","776.25","percent of total billed charges",""
"SCREW BONE 4.5X76MM SS CANNULATED SELF DRILLING TAPPING PARTIAL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037492","CDM","C1713","HCPCS","0278","RC","","","","both","","","913.23","547.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","706.84","77.4","","303.98","303.98","5854.79","1 through 10","106.21","776.25","percent of total billed charges",""
"SCREW BONE 4.5X76MM SS CANNULATED SELF DRILLING TAPPING PARTIAL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","913.23","547.94","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","106.21","11.63","","112.68","112.68","146.99","38","106.21","706.84","percent of total billed charges",""
"SCREW BONE 4.5X76MM SS CANNULATED SELF DRILLING TAPPING PARTIAL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","913.23","547.94","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","573.33","62.78","","780.86","208.94","10480.28","15","106.21","706.84","percent of total billed charges",""
"SCREW BONE 4.5X76MM SS CANNULATED SELF DRILLING TAPPING PARTIAL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","913.23","547.94","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","399.26","43.72","","179.76","179.76","179.76","1 through 10","106.21","706.84","percent of total billed charges",""
"SCREW BONE 4.5X76MM SS CANNULATED SELF DRILLING TAPPING PARTIAL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","913.23","547.94","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","664.10","72.72","","2355.45","298.99","3965.19","155","106.21","706.84","percent of total billed charges",""
"SCREW BONE 4.5X76MM SS CANNULATED SELF DRILLING TAPPING PARTIAL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","913.23","547.94","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","664.10","72.72","","3643.09","3643.09","3643.09","1 through 10","106.21","706.84","percent of total billed charges",""
"SCREW BONE 4.5X76MM SS CANNULATED SELF DRILLING TAPPING PARTIAL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","913.23","547.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","486.02","53.22","","554.28","554.28","554.28","16","106.21","706.84","percent of total billed charges",""
"SCREW BONE 4.5X76MM SS CANNULATED SELF DRILLING TAPPING PARTIAL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","913.23","547.94","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","574.42","62.9","","619.64","173.09","2370.64","150","106.21","706.84","percent of total billed charges",""
"SCREW BONE 4.5X76MM SS CANNULATED SELF DRILLING TAPPING PARTIAL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10037492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","913.23","547.94","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","706.84","77.4","","303.98","303.98","5854.79","1 through 10","106.21","706.84","percent of total billed charges",""
"SCREW BONE 40X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076860","CDM","C1713","HCPCS","0278","RC","","","","both","","","1140.15","684.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","132.6","969.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 40X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076860","CDM","C1713","HCPCS","0278","RC","","","","both","","","1140.15","684.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","132.6","969.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 40X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076860","CDM","C1713","HCPCS","0278","RC","","","","both","","","1140.15","684.09","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","648.75","56.9","","812.12","238.65","1587.46","163","132.6","969.13","percent of total billed charges",""
"SCREW BONE 40X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076860","CDM","C1713","HCPCS","0278","RC","","","","both","","","1140.15","684.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","132.60","11.63","","112.68","112.68","146.99","38","132.6","969.13","percent of total billed charges",""
"SCREW BONE 40X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076860","CDM","C1713","HCPCS","0278","RC","","","","both","","","1140.15","684.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","882.48","77.4","","303.98","303.98","5854.79","1 through 10","132.6","969.13","percent of total billed charges",""
"SCREW BONE 40X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1140.15","684.09","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","132.60","11.63","","112.68","112.68","146.99","38","132.6","882.48","percent of total billed charges",""
"SCREW BONE 40X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1140.15","684.09","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","715.79","62.78","","780.86","208.94","10480.28","15","132.6","882.48","percent of total billed charges",""
"SCREW BONE 40X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1140.15","684.09","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","498.47","43.72","","179.76","179.76","179.76","1 through 10","132.6","882.48","percent of total billed charges",""
"SCREW BONE 40X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1140.15","684.09","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","829.12","72.72","","2355.45","298.99","3965.19","155","132.6","882.48","percent of total billed charges",""
"SCREW BONE 40X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1140.15","684.09","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","829.12","72.72","","3643.09","3643.09","3643.09","1 through 10","132.6","882.48","percent of total billed charges",""
"SCREW BONE 40X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1140.15","684.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","606.79","53.22","","554.28","554.28","554.28","16","132.6","882.48","percent of total billed charges",""
"SCREW BONE 40X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1140.15","684.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","717.15","62.9","","619.64","173.09","2370.64","150","132.6","882.48","percent of total billed charges",""
"SCREW BONE 40X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1140.15","684.09","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","882.48","77.4","","303.98","303.98","5854.79","1 through 10","132.6","882.48","percent of total billed charges",""
"SCREW BONE 40X4.5MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10056946","CDM","C1713","HCPCS","0278","RC","","","","both","","","5597.10","3358.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","650.94","4757.54","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 40X4.5MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10056946","CDM","C1713","HCPCS","0278","RC","","","","both","","","5597.10","3358.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","650.94","4757.54","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 40X4.5MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10056946","CDM","C1713","HCPCS","0278","RC","","","","both","","","5597.10","3358.26","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3184.75","56.9","","812.12","238.65","1587.46","163","650.94","4757.54","percent of total billed charges",""
"SCREW BONE 40X4.5MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10056946","CDM","C1713","HCPCS","0278","RC","","","","both","","","5597.10","3358.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","650.94","11.63","","112.68","112.68","146.99","38","650.94","4757.54","percent of total billed charges",""
"SCREW BONE 40X4.5MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10056946","CDM","C1713","HCPCS","0278","RC","","","","both","","","5597.10","3358.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4332.16","77.4","","303.98","303.98","5854.79","1 through 10","650.94","4757.54","percent of total billed charges",""
"SCREW BONE 40X4.5MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10056946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5597.10","3358.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","650.94","11.63","","112.68","112.68","146.99","38","650.94","4332.16","percent of total billed charges",""
"SCREW BONE 40X4.5MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10056946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5597.10","3358.26","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3513.86","62.78","","780.86","208.94","10480.28","15","650.94","4332.16","percent of total billed charges",""
"SCREW BONE 40X4.5MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10056946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5597.10","3358.26","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2447.05","43.72","","179.76","179.76","179.76","1 through 10","650.94","4332.16","percent of total billed charges",""
"SCREW BONE 40X4.5MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10056946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5597.10","3358.26","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4070.21","72.72","","2355.45","298.99","3965.19","155","650.94","4332.16","percent of total billed charges",""
"SCREW BONE 40X4.5MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10056946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5597.10","3358.26","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4070.21","72.72","","3643.09","3643.09","3643.09","1 through 10","650.94","4332.16","percent of total billed charges",""
"SCREW BONE 40X4.5MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10056946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5597.10","3358.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2978.78","53.22","","554.28","554.28","554.28","16","650.94","4332.16","percent of total billed charges",""
"SCREW BONE 40X4.5MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10056946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5597.10","3358.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3520.58","62.9","","619.64","173.09","2370.64","150","650.94","4332.16","percent of total billed charges",""
"SCREW BONE 40X4.5MM FOOT CORTEX SS PARTIAL THREAD LOW PROFILE","SUP-ITM-10056946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5597.10","3358.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4332.16","77.4","","303.98","303.98","5854.79","1 through 10","650.94","4332.16","percent of total billed charges",""
"SCREW BONE 40X5.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10018988","CDM","C1889","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","321.45","2349.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 40X5.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10018988","CDM","C1889","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","321.45","2349.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 40X5.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10018988","CDM","C1889","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1572.72","56.9","","0.63","0.63","0.63","1 through 10","321.45","2349.4","percent of total billed charges",""
"SCREW BONE 40X5.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10018988","CDM","C1889","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","398.57","14.42","","317.14","317.14","317.14","1 through 10","321.45","2349.4","percent of total billed charges",""
"SCREW BONE 40X5.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10018988","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","398.57","14.42","","317.14","317.14","317.14","1 through 10","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 40X5.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10018988","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1735.24","62.78","","1125.09","1125.09","1125.09","1 through 10","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 40X5.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10018988","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2009.98","72.72","","4732.50","1617.43","14180.40","1 through 10","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 40X5.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10018988","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1738.56","62.9","","3896.20","3341.38","3896.20","1 through 10","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.58","157.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","30.54","223.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.58","157.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","30.54","223.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.58","157.55","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","149.41","56.9","","812.12","238.65","1587.46","163","30.54","223.19","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.58","157.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","30.54","11.63","","112.68","112.68","146.99","38","30.54","223.19","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.58","157.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","203.24","77.4","","303.98","303.98","5854.79","1 through 10","30.54","223.19","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","30.54","11.63","","112.68","112.68","146.99","38","30.54","203.24","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","164.85","62.78","","780.86","208.94","10480.28","15","30.54","203.24","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","114.80","43.72","","179.76","179.76","179.76","1 through 10","30.54","203.24","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","190.95","72.72","","2355.45","298.99","3965.19","155","30.54","203.24","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","190.95","72.72","","3643.09","3643.09","3643.09","1 through 10","30.54","203.24","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","139.75","53.22","","554.28","554.28","554.28","16","30.54","203.24","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","165.16","62.9","","619.64","173.09","2370.64","150","30.54","203.24","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","203.24","77.4","","303.98","303.98","5854.79","1 through 10","30.54","203.24","percent of total billed charges",""
"SCREW BONE 45X6.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TITANIUM MULTIAXIAL","SUP-ITM-10013228","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","321.45","2349.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 45X6.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TITANIUM MULTIAXIAL","SUP-ITM-10013228","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","321.45","2349.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 45X6.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TITANIUM MULTIAXIAL","SUP-ITM-10013228","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1572.72","56.9","","812.12","238.65","1587.46","163","321.45","2349.4","percent of total billed charges",""
"SCREW BONE 45X6.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TITANIUM MULTIAXIAL","SUP-ITM-10013228","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.45","11.63","","112.68","112.68","146.99","38","321.45","2349.4","percent of total billed charges",""
"SCREW BONE 45X6.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TITANIUM MULTIAXIAL","SUP-ITM-10013228","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2139.34","77.4","","303.98","303.98","5854.79","1 through 10","321.45","2349.4","percent of total billed charges",""
"SCREW BONE 45X6.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TITANIUM MULTIAXIAL","SUP-ITM-10013228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.45","11.63","","112.68","112.68","146.99","38","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 45X6.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TITANIUM MULTIAXIAL","SUP-ITM-10013228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1735.24","62.78","","780.86","208.94","10480.28","15","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 45X6.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TITANIUM MULTIAXIAL","SUP-ITM-10013228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1208.42","43.72","","179.76","179.76","179.76","1 through 10","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 45X6.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TITANIUM MULTIAXIAL","SUP-ITM-10013228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2009.98","72.72","","2355.45","298.99","3965.19","155","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 45X6.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TITANIUM MULTIAXIAL","SUP-ITM-10013228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2009.98","72.72","","3643.09","3643.09","3643.09","1 through 10","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 45X6.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TITANIUM MULTIAXIAL","SUP-ITM-10013228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1471.00","53.22","","554.28","554.28","554.28","16","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 45X6.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TITANIUM MULTIAXIAL","SUP-ITM-10013228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1738.56","62.9","","619.64","173.09","2370.64","150","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 45X6.5MM SPINE HORIZON LEGACY SPINAL SYSTEM TITANIUM MULTIAXIAL","SUP-ITM-10013228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2139.34","77.4","","303.98","303.98","5854.79","1 through 10","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 4X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL 25MM THREAD DIAMOND POINT","SUP-ITM-10038608","CDM","C1713","HCPCS","0278","RC","","","","both","","","984.33","590.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","114.48","836.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL 25MM THREAD DIAMOND POINT","SUP-ITM-10038608","CDM","C1713","HCPCS","0278","RC","","","","both","","","984.33","590.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","114.48","836.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL 25MM THREAD DIAMOND POINT","SUP-ITM-10038608","CDM","C1713","HCPCS","0278","RC","","","","both","","","984.33","590.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","560.08","56.9","","812.12","238.65","1587.46","163","114.48","836.68","percent of total billed charges",""
"SCREW BONE 4X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL 25MM THREAD DIAMOND POINT","SUP-ITM-10038608","CDM","C1713","HCPCS","0278","RC","","","","both","","","984.33","590.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","114.48","11.63","","112.68","112.68","146.99","38","114.48","836.68","percent of total billed charges",""
"SCREW BONE 4X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL 25MM THREAD DIAMOND POINT","SUP-ITM-10038608","CDM","C1713","HCPCS","0278","RC","","","","both","","","984.33","590.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","761.87","77.4","","303.98","303.98","5854.79","1 through 10","114.48","836.68","percent of total billed charges",""
"SCREW BONE 4X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL 25MM THREAD DIAMOND POINT","SUP-ITM-10038608","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","984.33","590.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","114.48","11.63","","112.68","112.68","146.99","38","114.48","761.87","percent of total billed charges",""
"SCREW BONE 4X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL 25MM THREAD DIAMOND POINT","SUP-ITM-10038608","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","984.33","590.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","617.96","62.78","","780.86","208.94","10480.28","15","114.48","761.87","percent of total billed charges",""
"SCREW BONE 4X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL 25MM THREAD DIAMOND POINT","SUP-ITM-10038608","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","984.33","590.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","430.35","43.72","","179.76","179.76","179.76","1 through 10","114.48","761.87","percent of total billed charges",""
"SCREW BONE 4X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL 25MM THREAD DIAMOND POINT","SUP-ITM-10038608","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","984.33","590.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","715.80","72.72","","2355.45","298.99","3965.19","155","114.48","761.87","percent of total billed charges",""
"SCREW BONE 4X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL 25MM THREAD DIAMOND POINT","SUP-ITM-10038608","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","984.33","590.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","715.80","72.72","","3643.09","3643.09","3643.09","1 through 10","114.48","761.87","percent of total billed charges",""
"SCREW BONE 4X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL 25MM THREAD DIAMOND POINT","SUP-ITM-10038608","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","984.33","590.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","523.86","53.22","","554.28","554.28","554.28","16","114.48","761.87","percent of total billed charges",""
"SCREW BONE 4X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL 25MM THREAD DIAMOND POINT","SUP-ITM-10038608","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","984.33","590.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","619.14","62.9","","619.64","173.09","2370.64","150","114.48","761.87","percent of total billed charges",""
"SCREW BONE 4X100MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL 25MM THREAD DIAMOND POINT","SUP-ITM-10038608","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","984.33","590.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","761.87","77.4","","303.98","303.98","5854.79","1 through 10","114.48","761.87","percent of total billed charges",""
"SCREW BONE 4X14MM CORTEX SS SELF TAPPING","SUP-ITM-10037201","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.75","115.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","22.3","162.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4X14MM CORTEX SS SELF TAPPING","SUP-ITM-10037201","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.75","115.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","22.3","162.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4X14MM CORTEX SS SELF TAPPING","SUP-ITM-10037201","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.75","115.05","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","109.11","56.9","","812.12","238.65","1587.46","163","22.3","162.99","percent of total billed charges",""
"SCREW BONE 4X14MM CORTEX SS SELF TAPPING","SUP-ITM-10037201","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.75","115.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","22.30","11.63","","112.68","112.68","146.99","38","22.3","162.99","percent of total billed charges",""
"SCREW BONE 4X14MM CORTEX SS SELF TAPPING","SUP-ITM-10037201","CDM","C1713","HCPCS","0278","RC","","","","both","","","191.75","115.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","148.41","77.4","","303.98","303.98","5854.79","1 through 10","22.3","162.99","percent of total billed charges",""
"SCREW BONE 4X14MM CORTEX SS SELF TAPPING","SUP-ITM-10037201","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.75","115.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","22.30","11.63","","112.68","112.68","146.99","38","22.3","148.41","percent of total billed charges",""
"SCREW BONE 4X14MM CORTEX SS SELF TAPPING","SUP-ITM-10037201","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.75","115.05","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","120.38","62.78","","780.86","208.94","10480.28","15","22.3","148.41","percent of total billed charges",""
"SCREW BONE 4X14MM CORTEX SS SELF TAPPING","SUP-ITM-10037201","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.75","115.05","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","83.83","43.72","","179.76","179.76","179.76","1 through 10","22.3","148.41","percent of total billed charges",""
"SCREW BONE 4X14MM CORTEX SS SELF TAPPING","SUP-ITM-10037201","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.75","115.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","139.44","72.72","","2355.45","298.99","3965.19","155","22.3","148.41","percent of total billed charges",""
"SCREW BONE 4X14MM CORTEX SS SELF TAPPING","SUP-ITM-10037201","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.75","115.05","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","139.44","72.72","","3643.09","3643.09","3643.09","1 through 10","22.3","148.41","percent of total billed charges",""
"SCREW BONE 4X14MM CORTEX SS SELF TAPPING","SUP-ITM-10037201","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.75","115.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","102.05","53.22","","554.28","554.28","554.28","16","22.3","148.41","percent of total billed charges",""
"SCREW BONE 4X14MM CORTEX SS SELF TAPPING","SUP-ITM-10037201","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.75","115.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","120.61","62.9","","619.64","173.09","2370.64","150","22.3","148.41","percent of total billed charges",""
"SCREW BONE 4X14MM CORTEX SS SELF TAPPING","SUP-ITM-10037201","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","191.75","115.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","148.41","77.4","","303.98","303.98","5854.79","1 through 10","22.3","148.41","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.68","506.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","98.24","717.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.68","506.81","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","98.24","717.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.68","506.81","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","480.62","56.9","","812.12","238.65","1587.46","163","98.24","717.98","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.68","506.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","98.24","11.63","","112.68","112.68","146.99","38","98.24","717.98","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.68","506.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","653.78","77.4","","303.98","303.98","5854.79","1 through 10","98.24","717.98","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","844.68","506.81","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","98.24","11.63","","112.68","112.68","146.99","38","98.24","653.78","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","844.68","506.81","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","530.29","62.78","","780.86","208.94","10480.28","15","98.24","653.78","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","844.68","506.81","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","369.29","43.72","","179.76","179.76","179.76","1 through 10","98.24","653.78","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","844.68","506.81","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","614.25","72.72","","2355.45","298.99","3965.19","155","98.24","653.78","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","844.68","506.81","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","614.25","72.72","","3643.09","3643.09","3643.09","1 through 10","98.24","653.78","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","844.68","506.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","449.54","53.22","","554.28","554.28","554.28","16","98.24","653.78","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","844.68","506.81","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","531.30","62.9","","619.64","173.09","2370.64","150","98.24","653.78","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","844.68","506.81","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","653.78","77.4","","303.98","303.98","5854.79","1 through 10","98.24","653.78","percent of total billed charges",""
"SCREW BONE 4X22MM TI6 TC-SERIES TI CANNULATED LOW PROFILE THREADED","SUP-ITM-10274114","CDM","C1713","HCPCS","0278","RC","","","","both","","","2147.63","1288.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","249.77","1825.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4X22MM TI6 TC-SERIES TI CANNULATED LOW PROFILE THREADED","SUP-ITM-10274114","CDM","C1713","HCPCS","0278","RC","","","","both","","","2147.63","1288.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","249.77","1825.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4X22MM TI6 TC-SERIES TI CANNULATED LOW PROFILE THREADED","SUP-ITM-10274114","CDM","C1713","HCPCS","0278","RC","","","","both","","","2147.63","1288.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1222.00","56.9","","812.12","238.65","1587.46","163","249.77","1825.49","percent of total billed charges",""
"SCREW BONE 4X22MM TI6 TC-SERIES TI CANNULATED LOW PROFILE THREADED","SUP-ITM-10274114","CDM","C1713","HCPCS","0278","RC","","","","both","","","2147.63","1288.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","249.77","11.63","","112.68","112.68","146.99","38","249.77","1825.49","percent of total billed charges",""
"SCREW BONE 4X22MM TI6 TC-SERIES TI CANNULATED LOW PROFILE THREADED","SUP-ITM-10274114","CDM","C1713","HCPCS","0278","RC","","","","both","","","2147.63","1288.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1662.27","77.4","","303.98","303.98","5854.79","1 through 10","249.77","1825.49","percent of total billed charges",""
"SCREW BONE 4X22MM TI6 TC-SERIES TI CANNULATED LOW PROFILE THREADED","SUP-ITM-10274114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2147.63","1288.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","249.77","11.63","","112.68","112.68","146.99","38","249.77","1662.27","percent of total billed charges",""
"SCREW BONE 4X22MM TI6 TC-SERIES TI CANNULATED LOW PROFILE THREADED","SUP-ITM-10274114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2147.63","1288.58","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1348.28","62.78","","780.86","208.94","10480.28","15","249.77","1662.27","percent of total billed charges",""
"SCREW BONE 4X22MM TI6 TC-SERIES TI CANNULATED LOW PROFILE THREADED","SUP-ITM-10274114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2147.63","1288.58","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","938.94","43.72","","179.76","179.76","179.76","1 through 10","249.77","1662.27","percent of total billed charges",""
"SCREW BONE 4X22MM TI6 TC-SERIES TI CANNULATED LOW PROFILE THREADED","SUP-ITM-10274114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2147.63","1288.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1561.76","72.72","","2355.45","298.99","3965.19","155","249.77","1662.27","percent of total billed charges",""
"SCREW BONE 4X22MM TI6 TC-SERIES TI CANNULATED LOW PROFILE THREADED","SUP-ITM-10274114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2147.63","1288.58","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1561.76","72.72","","3643.09","3643.09","3643.09","1 through 10","249.77","1662.27","percent of total billed charges",""
"SCREW BONE 4X22MM TI6 TC-SERIES TI CANNULATED LOW PROFILE THREADED","SUP-ITM-10274114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2147.63","1288.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1142.97","53.22","","554.28","554.28","554.28","16","249.77","1662.27","percent of total billed charges",""
"SCREW BONE 4X22MM TI6 TC-SERIES TI CANNULATED LOW PROFILE THREADED","SUP-ITM-10274114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2147.63","1288.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1350.86","62.9","","619.64","173.09","2370.64","150","249.77","1662.27","percent of total billed charges",""
"SCREW BONE 4X22MM TI6 TC-SERIES TI CANNULATED LOW PROFILE THREADED","SUP-ITM-10274114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2147.63","1288.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1662.27","77.4","","303.98","303.98","5854.79","1 through 10","249.77","1662.27","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","both","","","928.70","557.22","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","108.01","789.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","both","","","928.70","557.22","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","108.01","789.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","both","","","928.70","557.22","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","528.43","56.9","","812.12","238.65","1587.46","163","108.01","789.4","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","both","","","928.70","557.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","108.01","11.63","","112.68","112.68","146.99","38","108.01","789.4","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","both","","","928.70","557.22","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","718.81","77.4","","303.98","303.98","5854.79","1 through 10","108.01","789.4","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","928.70","557.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","108.01","11.63","","112.68","112.68","146.99","38","108.01","718.81","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","928.70","557.22","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","583.04","62.78","","780.86","208.94","10480.28","15","108.01","718.81","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","928.70","557.22","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","406.03","43.72","","179.76","179.76","179.76","1 through 10","108.01","718.81","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","928.70","557.22","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","675.35","72.72","","2355.45","298.99","3965.19","155","108.01","718.81","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","928.70","557.22","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","675.35","72.72","","3643.09","3643.09","3643.09","1 through 10","108.01","718.81","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","928.70","557.22","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","494.25","53.22","","554.28","554.28","554.28","16","108.01","718.81","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","928.70","557.22","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","584.15","62.9","","619.64","173.09","2370.64","150","108.01","718.81","percent of total billed charges",""
"SCREW BONE 4X36MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10006039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","928.70","557.22","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","718.81","77.4","","303.98","303.98","5854.79","1 through 10","108.01","718.81","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.20","113.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","22","160.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.20","113.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","22","160.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.20","113.52","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","107.65","56.9","","812.12","238.65","1587.46","163","22","160.82","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.20","113.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","22.00","11.63","","112.68","112.68","146.99","38","22","160.82","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","189.20","113.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","146.44","77.4","","303.98","303.98","5854.79","1 through 10","22","160.82","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.20","113.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","22.00","11.63","","112.68","112.68","146.99","38","22","146.44","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.20","113.52","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","118.78","62.78","","780.86","208.94","10480.28","15","22","146.44","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.20","113.52","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","82.72","43.72","","179.76","179.76","179.76","1 through 10","22","146.44","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.20","113.52","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","137.59","72.72","","2355.45","298.99","3965.19","155","22","146.44","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.20","113.52","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","137.59","72.72","","3643.09","3643.09","3643.09","1 through 10","22","146.44","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.20","113.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","100.69","53.22","","554.28","554.28","554.28","16","22","146.44","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.20","113.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","119.01","62.9","","619.64","173.09","2370.64","150","22","146.44","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","189.20","113.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","146.44","77.4","","303.98","303.98","5854.79","1 through 10","22","146.44","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS TITANIUM PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001790","CDM","C1713","HCPCS","0278","RC","","","","both","","","214.76","128.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","24.98","182.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4X45MM CANCELLOUS TITANIUM PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001790","CDM","C1713","HCPCS","0278","RC","","","","both","","","214.76","128.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","24.98","182.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4X45MM CANCELLOUS TITANIUM PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001790","CDM","C1713","HCPCS","0278","RC","","","","both","","","214.76","128.86","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","122.20","56.9","","812.12","238.65","1587.46","163","24.98","182.55","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS TITANIUM PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001790","CDM","C1713","HCPCS","0278","RC","","","","both","","","214.76","128.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","24.98","11.63","","112.68","112.68","146.99","38","24.98","182.55","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS TITANIUM PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001790","CDM","C1713","HCPCS","0278","RC","","","","both","","","214.76","128.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","166.22","77.4","","303.98","303.98","5854.79","1 through 10","24.98","182.55","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS TITANIUM PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","214.76","128.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","24.98","11.63","","112.68","112.68","146.99","38","24.98","166.22","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS TITANIUM PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","214.76","128.86","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","134.83","62.78","","780.86","208.94","10480.28","15","24.98","166.22","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS TITANIUM PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","214.76","128.86","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","93.89","43.72","","179.76","179.76","179.76","1 through 10","24.98","166.22","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS TITANIUM PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","214.76","128.86","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","156.17","72.72","","2355.45","298.99","3965.19","155","24.98","166.22","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS TITANIUM PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","214.76","128.86","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","156.17","72.72","","3643.09","3643.09","3643.09","1 through 10","24.98","166.22","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS TITANIUM PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","214.76","128.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","114.30","53.22","","554.28","554.28","554.28","16","24.98","166.22","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS TITANIUM PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","214.76","128.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","135.08","62.9","","619.64","173.09","2370.64","150","24.98","166.22","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS TITANIUM PARTIAL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10001790","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","214.76","128.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","166.22","77.4","","303.98","303.98","5854.79","1 through 10","24.98","166.22","percent of total billed charges",""
"SCREW BONE 4X50MM CANNULATED ASNIS III TI PARTIALLY THREADED","SUP-ITM-10100579","CDM","C1713","HCPCS","0278","RC","","","","both","","","1997.40","1198.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","232.3","1697.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4X50MM CANNULATED ASNIS III TI PARTIALLY THREADED","SUP-ITM-10100579","CDM","C1713","HCPCS","0278","RC","","","","both","","","1997.40","1198.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","232.3","1697.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4X50MM CANNULATED ASNIS III TI PARTIALLY THREADED","SUP-ITM-10100579","CDM","C1713","HCPCS","0278","RC","","","","both","","","1997.40","1198.44","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1136.52","56.9","","812.12","238.65","1587.46","163","232.3","1697.79","percent of total billed charges",""
"SCREW BONE 4X50MM CANNULATED ASNIS III TI PARTIALLY THREADED","SUP-ITM-10100579","CDM","C1713","HCPCS","0278","RC","","","","both","","","1997.40","1198.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","232.30","11.63","","112.68","112.68","146.99","38","232.3","1697.79","percent of total billed charges",""
"SCREW BONE 4X50MM CANNULATED ASNIS III TI PARTIALLY THREADED","SUP-ITM-10100579","CDM","C1713","HCPCS","0278","RC","","","","both","","","1997.40","1198.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1545.99","77.4","","303.98","303.98","5854.79","1 through 10","232.3","1697.79","percent of total billed charges",""
"SCREW BONE 4X50MM CANNULATED ASNIS III TI PARTIALLY THREADED","SUP-ITM-10100579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1997.40","1198.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","232.30","11.63","","112.68","112.68","146.99","38","232.3","1545.99","percent of total billed charges",""
"SCREW BONE 4X50MM CANNULATED ASNIS III TI PARTIALLY THREADED","SUP-ITM-10100579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1997.40","1198.44","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1253.97","62.78","","780.86","208.94","10480.28","15","232.3","1545.99","percent of total billed charges",""
"SCREW BONE 4X50MM CANNULATED ASNIS III TI PARTIALLY THREADED","SUP-ITM-10100579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1997.40","1198.44","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","873.26","43.72","","179.76","179.76","179.76","1 through 10","232.3","1545.99","percent of total billed charges",""
"SCREW BONE 4X50MM CANNULATED ASNIS III TI PARTIALLY THREADED","SUP-ITM-10100579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1997.40","1198.44","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1452.51","72.72","","2355.45","298.99","3965.19","155","232.3","1545.99","percent of total billed charges",""
"SCREW BONE 4X50MM CANNULATED ASNIS III TI PARTIALLY THREADED","SUP-ITM-10100579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1997.40","1198.44","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1452.51","72.72","","3643.09","3643.09","3643.09","1 through 10","232.3","1545.99","percent of total billed charges",""
"SCREW BONE 4X50MM CANNULATED ASNIS III TI PARTIALLY THREADED","SUP-ITM-10100579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1997.40","1198.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1063.02","53.22","","554.28","554.28","554.28","16","232.3","1545.99","percent of total billed charges",""
"SCREW BONE 4X50MM CANNULATED ASNIS III TI PARTIALLY THREADED","SUP-ITM-10100579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1997.40","1198.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1256.36","62.9","","619.64","173.09","2370.64","150","232.3","1545.99","percent of total billed charges",""
"SCREW BONE 4X50MM CANNULATED ASNIS III TI PARTIALLY THREADED","SUP-ITM-10100579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1997.40","1198.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1545.99","77.4","","303.98","303.98","5854.79","1 through 10","232.3","1545.99","percent of total billed charges",""
"SCREW BONE 4X65MM CANCELLOUS SS SELF TAPPING FULLY THREADED","SUP-ITM-10037193","CDM","C1713","HCPCS","0278","RC","","","","both","","","214.76","128.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","24.98","182.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4X65MM CANCELLOUS SS SELF TAPPING FULLY THREADED","SUP-ITM-10037193","CDM","C1713","HCPCS","0278","RC","","","","both","","","214.76","128.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","24.98","182.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 4X65MM CANCELLOUS SS SELF TAPPING FULLY THREADED","SUP-ITM-10037193","CDM","C1713","HCPCS","0278","RC","","","","both","","","214.76","128.86","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","122.20","56.9","","812.12","238.65","1587.46","163","24.98","182.55","percent of total billed charges",""
"SCREW BONE 4X65MM CANCELLOUS SS SELF TAPPING FULLY THREADED","SUP-ITM-10037193","CDM","C1713","HCPCS","0278","RC","","","","both","","","214.76","128.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","24.98","11.63","","112.68","112.68","146.99","38","24.98","182.55","percent of total billed charges",""
"SCREW BONE 4X65MM CANCELLOUS SS SELF TAPPING FULLY THREADED","SUP-ITM-10037193","CDM","C1713","HCPCS","0278","RC","","","","both","","","214.76","128.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","166.22","77.4","","303.98","303.98","5854.79","1 through 10","24.98","182.55","percent of total billed charges",""
"SCREW BONE 4X65MM CANCELLOUS SS SELF TAPPING FULLY THREADED","SUP-ITM-10037193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","214.76","128.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","24.98","11.63","","112.68","112.68","146.99","38","24.98","166.22","percent of total billed charges",""
"SCREW BONE 4X65MM CANCELLOUS SS SELF TAPPING FULLY THREADED","SUP-ITM-10037193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","214.76","128.86","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","134.83","62.78","","780.86","208.94","10480.28","15","24.98","166.22","percent of total billed charges",""
"SCREW BONE 4X65MM CANCELLOUS SS SELF TAPPING FULLY THREADED","SUP-ITM-10037193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","214.76","128.86","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","93.89","43.72","","179.76","179.76","179.76","1 through 10","24.98","166.22","percent of total billed charges",""
"SCREW BONE 4X65MM CANCELLOUS SS SELF TAPPING FULLY THREADED","SUP-ITM-10037193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","214.76","128.86","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","156.17","72.72","","2355.45","298.99","3965.19","155","24.98","166.22","percent of total billed charges",""
"SCREW BONE 4X65MM CANCELLOUS SS SELF TAPPING FULLY THREADED","SUP-ITM-10037193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","214.76","128.86","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","156.17","72.72","","3643.09","3643.09","3643.09","1 through 10","24.98","166.22","percent of total billed charges",""
"SCREW BONE 4X65MM CANCELLOUS SS SELF TAPPING FULLY THREADED","SUP-ITM-10037193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","214.76","128.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","114.30","53.22","","554.28","554.28","554.28","16","24.98","166.22","percent of total billed charges",""
"SCREW BONE 4X65MM CANCELLOUS SS SELF TAPPING FULLY THREADED","SUP-ITM-10037193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","214.76","128.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","135.08","62.9","","619.64","173.09","2370.64","150","24.98","166.22","percent of total billed charges",""
"SCREW BONE 4X65MM CANCELLOUS SS SELF TAPPING FULLY THREADED","SUP-ITM-10037193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","214.76","128.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","166.22","77.4","","303.98","303.98","5854.79","1 through 10","24.98","166.22","percent of total billed charges",""
"SCREW BONE 5.0X3.0MM SPINE PEDICLE CENTERPIECE SELF TAPPING POSTERIOR","SUP-ITM-10022958","CDM","C1889","HCPCS","0278","RC","","","","both","","","621.90","373.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","72.33","528.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5.0X3.0MM SPINE PEDICLE CENTERPIECE SELF TAPPING POSTERIOR","SUP-ITM-10022958","CDM","C1889","HCPCS","0278","RC","","","","both","","","621.90","373.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","72.33","528.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5.0X3.0MM SPINE PEDICLE CENTERPIECE SELF TAPPING POSTERIOR","SUP-ITM-10022958","CDM","C1889","HCPCS","0278","RC","","","","both","","","621.90","373.14","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","353.86","56.9","","0.63","0.63","0.63","1 through 10","72.33","528.62","percent of total billed charges",""
"SCREW BONE 5.0X3.0MM SPINE PEDICLE CENTERPIECE SELF TAPPING POSTERIOR","SUP-ITM-10022958","CDM","C1889","HCPCS","0278","RC","","","","both","","","621.90","373.14","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","89.68","14.42","","317.14","317.14","317.14","1 through 10","72.33","528.62","percent of total billed charges",""
"SCREW BONE 5.0X3.0MM SPINE PEDICLE CENTERPIECE SELF TAPPING POSTERIOR","SUP-ITM-10022958","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","621.90","373.14","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","89.68","14.42","","317.14","317.14","317.14","1 through 10","72.33","481.35","percent of total billed charges",""
"SCREW BONE 5.0X3.0MM SPINE PEDICLE CENTERPIECE SELF TAPPING POSTERIOR","SUP-ITM-10022958","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","621.90","373.14","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","390.43","62.78","","1125.09","1125.09","1125.09","1 through 10","72.33","481.35","percent of total billed charges",""
"SCREW BONE 5.0X3.0MM SPINE PEDICLE CENTERPIECE SELF TAPPING POSTERIOR","SUP-ITM-10022958","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","621.90","373.14","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","452.25","72.72","","4732.50","1617.43","14180.40","1 through 10","72.33","481.35","percent of total billed charges",""
"SCREW BONE 5.0X3.0MM SPINE PEDICLE CENTERPIECE SELF TAPPING POSTERIOR","SUP-ITM-10022958","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","621.90","373.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","391.18","62.9","","3896.20","3341.38","3896.20","1 through 10","72.33","481.35","percent of total billed charges",""
"SCREW BONE 5.0X57.5MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033885","CDM","C1713","HCPCS","0278","RC","","","","both","","","2026.98","1216.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","235.74","1722.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5.0X57.5MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033885","CDM","C1713","HCPCS","0278","RC","","","","both","","","2026.98","1216.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","235.74","1722.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5.0X57.5MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033885","CDM","C1713","HCPCS","0278","RC","","","","both","","","2026.98","1216.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1153.35","56.9","","812.12","238.65","1587.46","163","235.74","1722.93","percent of total billed charges",""
"SCREW BONE 5.0X57.5MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033885","CDM","C1713","HCPCS","0278","RC","","","","both","","","2026.98","1216.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","235.74","11.63","","112.68","112.68","146.99","38","235.74","1722.93","percent of total billed charges",""
"SCREW BONE 5.0X57.5MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033885","CDM","C1713","HCPCS","0278","RC","","","","both","","","2026.98","1216.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1568.88","77.4","","303.98","303.98","5854.79","1 through 10","235.74","1722.93","percent of total billed charges",""
"SCREW BONE 5.0X57.5MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2026.98","1216.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","235.74","11.63","","112.68","112.68","146.99","38","235.74","1568.88","percent of total billed charges",""
"SCREW BONE 5.0X57.5MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2026.98","1216.19","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1272.54","62.78","","780.86","208.94","10480.28","15","235.74","1568.88","percent of total billed charges",""
"SCREW BONE 5.0X57.5MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2026.98","1216.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","886.20","43.72","","179.76","179.76","179.76","1 through 10","235.74","1568.88","percent of total billed charges",""
"SCREW BONE 5.0X57.5MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2026.98","1216.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1474.02","72.72","","2355.45","298.99","3965.19","155","235.74","1568.88","percent of total billed charges",""
"SCREW BONE 5.0X57.5MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2026.98","1216.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1474.02","72.72","","3643.09","3643.09","3643.09","1 through 10","235.74","1568.88","percent of total billed charges",""
"SCREW BONE 5.0X57.5MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2026.98","1216.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1078.76","53.22","","554.28","554.28","554.28","16","235.74","1568.88","percent of total billed charges",""
"SCREW BONE 5.0X57.5MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2026.98","1216.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1274.97","62.9","","619.64","173.09","2370.64","150","235.74","1568.88","percent of total billed charges",""
"SCREW BONE 5.0X57.5MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10033885","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2026.98","1216.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1568.88","77.4","","303.98","303.98","5854.79","1 through 10","235.74","1568.88","percent of total billed charges",""
"SCREW BONE 5.5X110MM COMPRESSION TITANIUMCANNNULATED HEADLESS LONG THREAD","SUP-ITM-10289445","CDM","C1713","HCPCS","0278","RC","","","","both","","","3654.70","2192.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","425.04","3106.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5.5X110MM COMPRESSION TITANIUMCANNNULATED HEADLESS LONG THREAD","SUP-ITM-10289445","CDM","C1713","HCPCS","0278","RC","","","","both","","","3654.70","2192.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","425.04","3106.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5.5X110MM COMPRESSION TITANIUMCANNNULATED HEADLESS LONG THREAD","SUP-ITM-10289445","CDM","C1713","HCPCS","0278","RC","","","","both","","","3654.70","2192.82","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2079.52","56.9","","812.12","238.65","1587.46","163","425.04","3106.5","percent of total billed charges",""
"SCREW BONE 5.5X110MM COMPRESSION TITANIUMCANNNULATED HEADLESS LONG THREAD","SUP-ITM-10289445","CDM","C1713","HCPCS","0278","RC","","","","both","","","3654.70","2192.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","425.04","11.63","","112.68","112.68","146.99","38","425.04","3106.5","percent of total billed charges",""
"SCREW BONE 5.5X110MM COMPRESSION TITANIUMCANNNULATED HEADLESS LONG THREAD","SUP-ITM-10289445","CDM","C1713","HCPCS","0278","RC","","","","both","","","3654.70","2192.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2828.74","77.4","","303.98","303.98","5854.79","1 through 10","425.04","3106.5","percent of total billed charges",""
"SCREW BONE 5.5X110MM COMPRESSION TITANIUMCANNNULATED HEADLESS LONG THREAD","SUP-ITM-10289445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3654.70","2192.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","425.04","11.63","","112.68","112.68","146.99","38","425.04","2828.74","percent of total billed charges",""
"SCREW BONE 5.5X110MM COMPRESSION TITANIUMCANNNULATED HEADLESS LONG THREAD","SUP-ITM-10289445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3654.70","2192.82","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2294.42","62.78","","780.86","208.94","10480.28","15","425.04","2828.74","percent of total billed charges",""
"SCREW BONE 5.5X110MM COMPRESSION TITANIUMCANNNULATED HEADLESS LONG THREAD","SUP-ITM-10289445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3654.70","2192.82","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1597.83","43.72","","179.76","179.76","179.76","1 through 10","425.04","2828.74","percent of total billed charges",""
"SCREW BONE 5.5X110MM COMPRESSION TITANIUMCANNNULATED HEADLESS LONG THREAD","SUP-ITM-10289445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3654.70","2192.82","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2657.70","72.72","","2355.45","298.99","3965.19","155","425.04","2828.74","percent of total billed charges",""
"SCREW BONE 5.5X110MM COMPRESSION TITANIUMCANNNULATED HEADLESS LONG THREAD","SUP-ITM-10289445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3654.70","2192.82","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2657.70","72.72","","3643.09","3643.09","3643.09","1 through 10","425.04","2828.74","percent of total billed charges",""
"SCREW BONE 5.5X110MM COMPRESSION TITANIUMCANNNULATED HEADLESS LONG THREAD","SUP-ITM-10289445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3654.70","2192.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1945.03","53.22","","554.28","554.28","554.28","16","425.04","2828.74","percent of total billed charges",""
"SCREW BONE 5.5X110MM COMPRESSION TITANIUMCANNNULATED HEADLESS LONG THREAD","SUP-ITM-10289445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3654.70","2192.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2298.81","62.9","","619.64","173.09","2370.64","150","425.04","2828.74","percent of total billed charges",""
"SCREW BONE 5.5X110MM COMPRESSION TITANIUMCANNNULATED HEADLESS LONG THREAD","SUP-ITM-10289445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3654.70","2192.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2828.74","77.4","","303.98","303.98","5854.79","1 through 10","425.04","2828.74","percent of total billed charges",""
"SCREW BONE 5.5X30MM GRIPTION TF ACETABULAR LOCKING","SUP-ITM-10198038","CDM","C1713","HCPCS","0278","RC","","","","both","","","373.14","223.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","43.4","317.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5.5X30MM GRIPTION TF ACETABULAR LOCKING","SUP-ITM-10198038","CDM","C1713","HCPCS","0278","RC","","","","both","","","373.14","223.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","43.4","317.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5.5X30MM GRIPTION TF ACETABULAR LOCKING","SUP-ITM-10198038","CDM","C1713","HCPCS","0278","RC","","","","both","","","373.14","223.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","212.32","56.9","","812.12","238.65","1587.46","163","43.4","317.17","percent of total billed charges",""
"SCREW BONE 5.5X30MM GRIPTION TF ACETABULAR LOCKING","SUP-ITM-10198038","CDM","C1713","HCPCS","0278","RC","","","","both","","","373.14","223.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","43.40","11.63","","112.68","112.68","146.99","38","43.4","317.17","percent of total billed charges",""
"SCREW BONE 5.5X30MM GRIPTION TF ACETABULAR LOCKING","SUP-ITM-10198038","CDM","C1713","HCPCS","0278","RC","","","","both","","","373.14","223.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","288.81","77.4","","303.98","303.98","5854.79","1 through 10","43.4","317.17","percent of total billed charges",""
"SCREW BONE 5.5X30MM GRIPTION TF ACETABULAR LOCKING","SUP-ITM-10198038","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","373.14","223.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","43.40","11.63","","112.68","112.68","146.99","38","43.4","288.81","percent of total billed charges",""
"SCREW BONE 5.5X30MM GRIPTION TF ACETABULAR LOCKING","SUP-ITM-10198038","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","373.14","223.88","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","234.26","62.78","","780.86","208.94","10480.28","15","43.4","288.81","percent of total billed charges",""
"SCREW BONE 5.5X30MM GRIPTION TF ACETABULAR LOCKING","SUP-ITM-10198038","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","373.14","223.88","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","163.14","43.72","","179.76","179.76","179.76","1 through 10","43.4","288.81","percent of total billed charges",""
"SCREW BONE 5.5X30MM GRIPTION TF ACETABULAR LOCKING","SUP-ITM-10198038","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","373.14","223.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","271.35","72.72","","2355.45","298.99","3965.19","155","43.4","288.81","percent of total billed charges",""
"SCREW BONE 5.5X30MM GRIPTION TF ACETABULAR LOCKING","SUP-ITM-10198038","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","373.14","223.88","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","271.35","72.72","","3643.09","3643.09","3643.09","1 through 10","43.4","288.81","percent of total billed charges",""
"SCREW BONE 5.5X30MM GRIPTION TF ACETABULAR LOCKING","SUP-ITM-10198038","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","373.14","223.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","198.59","53.22","","554.28","554.28","554.28","16","43.4","288.81","percent of total billed charges",""
"SCREW BONE 5.5X30MM GRIPTION TF ACETABULAR LOCKING","SUP-ITM-10198038","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","373.14","223.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","234.71","62.9","","619.64","173.09","2370.64","150","43.4","288.81","percent of total billed charges",""
"SCREW BONE 5.5X30MM GRIPTION TF ACETABULAR LOCKING","SUP-ITM-10198038","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","373.14","223.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","288.81","77.4","","303.98","303.98","5854.79","1 through 10","43.4","288.81","percent of total billed charges",""
"SCREW BONE 5.5X30MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10030706","CDM","C1889","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","321.45","2349.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5.5X30MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10030706","CDM","C1889","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","321.45","2349.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5.5X30MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10030706","CDM","C1889","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1572.72","56.9","","0.63","0.63","0.63","1 through 10","321.45","2349.4","percent of total billed charges",""
"SCREW BONE 5.5X30MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10030706","CDM","C1889","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","398.57","14.42","","317.14","317.14","317.14","1 through 10","321.45","2349.4","percent of total billed charges",""
"SCREW BONE 5.5X30MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10030706","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","398.57","14.42","","317.14","317.14","317.14","1 through 10","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 5.5X30MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10030706","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1735.24","62.78","","1125.09","1125.09","1125.09","1 through 10","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 5.5X30MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10030706","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2009.98","72.72","","4732.50","1617.43","14180.40","1 through 10","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 5.5X30MM SPINE HORIZON LEGACY SPINAL SYSTEM TI MULTIAXIAL","SUP-ITM-10030706","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1738.56","62.9","","3896.20","3341.38","3896.20","1 through 10","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 5.5X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111144","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","321.45","2349.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5.5X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111144","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","321.45","2349.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5.5X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111144","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1572.72","56.9","","812.12","238.65","1587.46","163","321.45","2349.4","percent of total billed charges",""
"SCREW BONE 5.5X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111144","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.45","11.63","","112.68","112.68","146.99","38","321.45","2349.4","percent of total billed charges",""
"SCREW BONE 5.5X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111144","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2139.34","77.4","","303.98","303.98","5854.79","1 through 10","321.45","2349.4","percent of total billed charges",""
"SCREW BONE 5.5X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.45","11.63","","112.68","112.68","146.99","38","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 5.5X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1735.24","62.78","","780.86","208.94","10480.28","15","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 5.5X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1208.42","43.72","","179.76","179.76","179.76","1 through 10","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 5.5X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2009.98","72.72","","2355.45","298.99","3965.19","155","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 5.5X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2009.98","72.72","","3643.09","3643.09","3643.09","1 through 10","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 5.5X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1471.00","53.22","","554.28","554.28","554.28","16","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 5.5X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1738.56","62.9","","619.64","173.09","2370.64","150","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 5.5X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111144","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2139.34","77.4","","303.98","303.98","5854.79","1 through 10","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.25","310.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","60.27","440.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.25","310.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","60.27","440.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.25","310.95","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","294.88","56.9","","812.12","238.65","1587.46","163","60.27","440.51","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.25","310.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","60.27","11.63","","112.68","112.68","146.99","38","60.27","440.51","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.25","310.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","401.13","77.4","","303.98","303.98","5854.79","1 through 10","60.27","440.51","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","60.27","11.63","","112.68","112.68","146.99","38","60.27","401.13","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","325.36","62.78","","780.86","208.94","10480.28","15","60.27","401.13","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","226.58","43.72","","179.76","179.76","179.76","1 through 10","60.27","401.13","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","376.87","72.72","","2355.45","298.99","3965.19","155","60.27","401.13","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","376.87","72.72","","3643.09","3643.09","3643.09","1 through 10","60.27","401.13","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","275.81","53.22","","554.28","554.28","554.28","16","60.27","401.13","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","325.98","62.9","","619.64","173.09","2370.64","150","60.27","401.13","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","401.13","77.4","","303.98","303.98","5854.79","1 through 10","60.27","401.13","percent of total billed charges",""
"SCREW BONE 5.5X55MM HEADLESS","SUP-ITM-10239320","CDM","C1713","HCPCS","0278","RC","","","","both","","","6564.50","3938.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","763.45","5579.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5.5X55MM HEADLESS","SUP-ITM-10239320","CDM","C1713","HCPCS","0278","RC","","","","both","","","6564.50","3938.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","763.45","5579.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5.5X55MM HEADLESS","SUP-ITM-10239320","CDM","C1713","HCPCS","0278","RC","","","","both","","","6564.50","3938.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3735.20","56.9","","812.12","238.65","1587.46","163","763.45","5579.83","percent of total billed charges",""
"SCREW BONE 5.5X55MM HEADLESS","SUP-ITM-10239320","CDM","C1713","HCPCS","0278","RC","","","","both","","","6564.50","3938.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","763.45","11.63","","112.68","112.68","146.99","38","763.45","5579.83","percent of total billed charges",""
"SCREW BONE 5.5X55MM HEADLESS","SUP-ITM-10239320","CDM","C1713","HCPCS","0278","RC","","","","both","","","6564.50","3938.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5080.92","77.4","","303.98","303.98","5854.79","1 through 10","763.45","5579.83","percent of total billed charges",""
"SCREW BONE 5.5X55MM HEADLESS","SUP-ITM-10239320","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6564.50","3938.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","763.45","11.63","","112.68","112.68","146.99","38","763.45","5080.92","percent of total billed charges",""
"SCREW BONE 5.5X55MM HEADLESS","SUP-ITM-10239320","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6564.50","3938.70","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4121.19","62.78","","780.86","208.94","10480.28","15","763.45","5080.92","percent of total billed charges",""
"SCREW BONE 5.5X55MM HEADLESS","SUP-ITM-10239320","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6564.50","3938.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2870.00","43.72","","179.76","179.76","179.76","1 through 10","763.45","5080.92","percent of total billed charges",""
"SCREW BONE 5.5X55MM HEADLESS","SUP-ITM-10239320","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6564.50","3938.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4773.70","72.72","","2355.45","298.99","3965.19","155","763.45","5080.92","percent of total billed charges",""
"SCREW BONE 5.5X55MM HEADLESS","SUP-ITM-10239320","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6564.50","3938.70","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4773.70","72.72","","3643.09","3643.09","3643.09","1 through 10","763.45","5080.92","percent of total billed charges",""
"SCREW BONE 5.5X55MM HEADLESS","SUP-ITM-10239320","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6564.50","3938.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3493.63","53.22","","554.28","554.28","554.28","16","763.45","5080.92","percent of total billed charges",""
"SCREW BONE 5.5X55MM HEADLESS","SUP-ITM-10239320","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6564.50","3938.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4129.07","62.9","","619.64","173.09","2370.64","150","763.45","5080.92","percent of total billed charges",""
"SCREW BONE 5.5X55MM HEADLESS","SUP-ITM-10239320","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6564.50","3938.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5080.92","77.4","","303.98","303.98","5854.79","1 through 10","763.45","5080.92","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.25","310.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","60.27","440.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.25","310.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","60.27","440.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.25","310.95","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","294.88","56.9","","812.12","238.65","1587.46","163","60.27","440.51","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.25","310.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","60.27","11.63","","112.68","112.68","146.99","38","60.27","440.51","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","both","","","518.25","310.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","401.13","77.4","","303.98","303.98","5854.79","1 through 10","60.27","440.51","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","60.27","11.63","","112.68","112.68","146.99","38","60.27","401.13","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","325.36","62.78","","780.86","208.94","10480.28","15","60.27","401.13","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","226.58","43.72","","179.76","179.76","179.76","1 through 10","60.27","401.13","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","376.87","72.72","","2355.45","298.99","3965.19","155","60.27","401.13","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","376.87","72.72","","3643.09","3643.09","3643.09","1 through 10","60.27","401.13","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","275.81","53.22","","554.28","554.28","554.28","16","60.27","401.13","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","325.98","62.9","","619.64","173.09","2370.64","150","60.27","401.13","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","518.25","310.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","401.13","77.4","","303.98","303.98","5854.79","1 through 10","60.27","401.13","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","both","","","409.07","245.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","47.57","347.71","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","both","","","409.07","245.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","47.57","347.71","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","both","","","409.07","245.44","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","232.76","56.9","","812.12","238.65","1587.46","163","47.57","347.71","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","both","","","409.07","245.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","47.57","11.63","","112.68","112.68","146.99","38","47.57","347.71","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","both","","","409.07","245.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","316.62","77.4","","303.98","303.98","5854.79","1 through 10","47.57","347.71","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","47.57","11.63","","112.68","112.68","146.99","38","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","256.81","62.78","","780.86","208.94","10480.28","15","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","178.85","43.72","","179.76","179.76","179.76","1 through 10","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","297.48","72.72","","2355.45","298.99","3965.19","155","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","297.48","72.72","","3643.09","3643.09","3643.09","1 through 10","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","217.71","53.22","","554.28","554.28","554.28","16","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","257.31","62.9","","619.64","173.09","2370.64","150","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X120MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038610","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","316.62","77.4","","303.98","303.98","5854.79","1 through 10","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","both","","","409.07","245.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","47.57","347.71","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","both","","","409.07","245.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","47.57","347.71","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","both","","","409.07","245.44","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","232.76","56.9","","812.12","238.65","1587.46","163","47.57","347.71","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","both","","","409.07","245.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","47.57","11.63","","112.68","112.68","146.99","38","47.57","347.71","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","both","","","409.07","245.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","316.62","77.4","","303.98","303.98","5854.79","1 through 10","47.57","347.71","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","47.57","11.63","","112.68","112.68","146.99","38","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","256.81","62.78","","780.86","208.94","10480.28","15","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","178.85","43.72","","179.76","179.76","179.76","1 through 10","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","297.48","72.72","","2355.45","298.99","3965.19","155","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","297.48","72.72","","3643.09","3643.09","3643.09","1 through 10","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","217.71","53.22","","554.28","554.28","554.28","16","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","257.31","62.9","","619.64","173.09","2370.64","150","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","316.62","77.4","","303.98","303.98","5854.79","1 through 10","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038642","CDM","C1713","HCPCS","0278","RC","","","","both","","","1592.82","955.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","185.24","1353.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038642","CDM","C1713","HCPCS","0278","RC","","","","both","","","1592.82","955.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","185.24","1353.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038642","CDM","C1713","HCPCS","0278","RC","","","","both","","","1592.82","955.69","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","906.31","56.9","","812.12","238.65","1587.46","163","185.24","1353.9","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038642","CDM","C1713","HCPCS","0278","RC","","","","both","","","1592.82","955.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","185.24","11.63","","112.68","112.68","146.99","38","185.24","1353.9","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038642","CDM","C1713","HCPCS","0278","RC","","","","both","","","1592.82","955.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1232.84","77.4","","303.98","303.98","5854.79","1 through 10","185.24","1353.9","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038642","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1592.82","955.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","185.24","11.63","","112.68","112.68","146.99","38","185.24","1232.84","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038642","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1592.82","955.69","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","999.97","62.78","","780.86","208.94","10480.28","15","185.24","1232.84","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038642","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1592.82","955.69","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","696.38","43.72","","179.76","179.76","179.76","1 through 10","185.24","1232.84","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038642","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1592.82","955.69","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1158.30","72.72","","2355.45","298.99","3965.19","155","185.24","1232.84","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038642","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1592.82","955.69","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1158.30","72.72","","3643.09","3643.09","3643.09","1 through 10","185.24","1232.84","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038642","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1592.82","955.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","847.70","53.22","","554.28","554.28","554.28","16","185.24","1232.84","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038642","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1592.82","955.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1001.88","62.9","","619.64","173.09","2370.64","150","185.24","1232.84","percent of total billed charges",""
"SCREW BONE 5X125MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038642","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1592.82","955.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1232.84","77.4","","303.98","303.98","5854.79","1 through 10","185.24","1232.84","percent of total billed charges",""
"SCREW BONE 5X150MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10004527","CDM","C1713","HCPCS","0278","RC","","","","both","","","409.07","245.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","47.57","347.71","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X150MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10004527","CDM","C1713","HCPCS","0278","RC","","","","both","","","409.07","245.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","47.57","347.71","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X150MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10004527","CDM","C1713","HCPCS","0278","RC","","","","both","","","409.07","245.44","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","232.76","56.9","","812.12","238.65","1587.46","163","47.57","347.71","percent of total billed charges",""
"SCREW BONE 5X150MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10004527","CDM","C1713","HCPCS","0278","RC","","","","both","","","409.07","245.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","47.57","11.63","","112.68","112.68","146.99","38","47.57","347.71","percent of total billed charges",""
"SCREW BONE 5X150MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10004527","CDM","C1713","HCPCS","0278","RC","","","","both","","","409.07","245.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","316.62","77.4","","303.98","303.98","5854.79","1 through 10","47.57","347.71","percent of total billed charges",""
"SCREW BONE 5X150MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10004527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","47.57","11.63","","112.68","112.68","146.99","38","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X150MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10004527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","256.81","62.78","","780.86","208.94","10480.28","15","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X150MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10004527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","178.85","43.72","","179.76","179.76","179.76","1 through 10","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X150MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10004527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","297.48","72.72","","2355.45","298.99","3965.19","155","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X150MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10004527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","297.48","72.72","","3643.09","3643.09","3643.09","1 through 10","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X150MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10004527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","217.71","53.22","","554.28","554.28","554.28","16","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X150MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10004527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","257.31","62.9","","619.64","173.09","2370.64","150","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X150MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10004527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","409.07","245.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","316.62","77.4","","303.98","303.98","5854.79","1 through 10","47.57","316.62","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1078.58","647.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","125.44","916.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1078.58","647.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","125.44","916.79","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1078.58","647.15","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","613.71","56.9","","812.12","238.65","1587.46","163","125.44","916.79","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1078.58","647.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","125.44","11.63","","112.68","112.68","146.99","38","125.44","916.79","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","both","","","1078.58","647.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","834.82","77.4","","303.98","303.98","5854.79","1 through 10","125.44","916.79","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1078.58","647.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","125.44","11.63","","112.68","112.68","146.99","38","125.44","834.82","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1078.58","647.15","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","677.13","62.78","","780.86","208.94","10480.28","15","125.44","834.82","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1078.58","647.15","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","471.56","43.72","","179.76","179.76","179.76","1 through 10","125.44","834.82","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1078.58","647.15","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","784.34","72.72","","2355.45","298.99","3965.19","155","125.44","834.82","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1078.58","647.15","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","784.34","72.72","","3643.09","3643.09","3643.09","1 through 10","125.44","834.82","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1078.58","647.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","574.02","53.22","","554.28","554.28","554.28","16","125.44","834.82","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1078.58","647.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","678.43","62.9","","619.64","173.09","2370.64","150","125.44","834.82","percent of total billed charges",""
"SCREW BONE 5X16MM CONDYLAR VA LCP SS VARIABLE ANGLE LOCKING SELF TAPPING T25 STARDRIVE RECESS","SUP-ITM-10095410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1078.58","647.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","834.82","77.4","","303.98","303.98","5854.79","1 through 10","125.44","834.82","percent of total billed charges",""
"SCREW BONE 5X16MM SS LOCKING SELF TAPPING FULL THREAD T25 5 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10007388","CDM","C1713","HCPCS","0278","RC","","","","both","","","697.98","418.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","81.18","593.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X16MM SS LOCKING SELF TAPPING FULL THREAD T25 5 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10007388","CDM","C1713","HCPCS","0278","RC","","","","both","","","697.98","418.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","81.18","593.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X16MM SS LOCKING SELF TAPPING FULL THREAD T25 5 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10007388","CDM","C1713","HCPCS","0278","RC","","","","both","","","697.98","418.79","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","397.15","56.9","","812.12","238.65","1587.46","163","81.18","593.28","percent of total billed charges",""
"SCREW BONE 5X16MM SS LOCKING SELF TAPPING FULL THREAD T25 5 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10007388","CDM","C1713","HCPCS","0278","RC","","","","both","","","697.98","418.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","81.18","11.63","","112.68","112.68","146.99","38","81.18","593.28","percent of total billed charges",""
"SCREW BONE 5X16MM SS LOCKING SELF TAPPING FULL THREAD T25 5 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10007388","CDM","C1713","HCPCS","0278","RC","","","","both","","","697.98","418.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","540.24","77.4","","303.98","303.98","5854.79","1 through 10","81.18","593.28","percent of total billed charges",""
"SCREW BONE 5X16MM SS LOCKING SELF TAPPING FULL THREAD T25 5 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10007388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","697.98","418.79","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","81.18","11.63","","112.68","112.68","146.99","38","81.18","540.24","percent of total billed charges",""
"SCREW BONE 5X16MM SS LOCKING SELF TAPPING FULL THREAD T25 5 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10007388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","697.98","418.79","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","438.19","62.78","","780.86","208.94","10480.28","15","81.18","540.24","percent of total billed charges",""
"SCREW BONE 5X16MM SS LOCKING SELF TAPPING FULL THREAD T25 5 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10007388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","697.98","418.79","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","305.16","43.72","","179.76","179.76","179.76","1 through 10","81.18","540.24","percent of total billed charges",""
"SCREW BONE 5X16MM SS LOCKING SELF TAPPING FULL THREAD T25 5 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10007388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","697.98","418.79","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","507.57","72.72","","2355.45","298.99","3965.19","155","81.18","540.24","percent of total billed charges",""
"SCREW BONE 5X16MM SS LOCKING SELF TAPPING FULL THREAD T25 5 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10007388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","697.98","418.79","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","507.57","72.72","","3643.09","3643.09","3643.09","1 through 10","81.18","540.24","percent of total billed charges",""
"SCREW BONE 5X16MM SS LOCKING SELF TAPPING FULL THREAD T25 5 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10007388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","697.98","418.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","371.46","53.22","","554.28","554.28","554.28","16","81.18","540.24","percent of total billed charges",""
"SCREW BONE 5X16MM SS LOCKING SELF TAPPING FULL THREAD T25 5 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10007388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","697.98","418.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","439.03","62.9","","619.64","173.09","2370.64","150","81.18","540.24","percent of total billed charges",""
"SCREW BONE 5X16MM SS LOCKING SELF TAPPING FULL THREAD T25 5 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10007388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","697.98","418.79","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","540.24","77.4","","303.98","303.98","5854.79","1 through 10","81.18","540.24","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","473.20","283.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","55.03","402.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","473.20","283.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","55.03","402.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","473.20","283.92","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","269.25","56.9","","812.12","238.65","1587.46","163","55.03","402.22","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","473.20","283.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","55.03","11.63","","112.68","112.68","146.99","38","55.03","402.22","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","473.20","283.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","366.26","77.4","","303.98","303.98","5854.79","1 through 10","55.03","402.22","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","473.20","283.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","55.03","11.63","","112.68","112.68","146.99","38","55.03","366.26","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","473.20","283.92","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","297.07","62.78","","780.86","208.94","10480.28","15","55.03","366.26","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","473.20","283.92","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","206.88","43.72","","179.76","179.76","179.76","1 through 10","55.03","366.26","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","473.20","283.92","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","344.11","72.72","","2355.45","298.99","3965.19","155","55.03","366.26","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","473.20","283.92","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","344.11","72.72","","3643.09","3643.09","3643.09","1 through 10","55.03","366.26","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","473.20","283.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","251.84","53.22","","554.28","554.28","554.28","16","55.03","366.26","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","473.20","283.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","297.64","62.9","","619.64","173.09","2370.64","150","55.03","366.26","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","473.20","283.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","366.26","77.4","","303.98","303.98","5854.79","1 through 10","55.03","366.26","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.42","843.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","163.45","1194.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.42","843.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","163.45","1194.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.42","843.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","799.68","56.9","","812.12","238.65","1587.46","163","163.45","1194.61","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.42","843.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","163.45","11.63","","112.68","112.68","146.99","38","163.45","1194.61","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.42","843.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1087.80","77.4","","303.98","303.98","5854.79","1 through 10","163.45","1194.61","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.42","843.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","163.45","11.63","","112.68","112.68","146.99","38","163.45","1087.8","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.42","843.25","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","882.32","62.78","","780.86","208.94","10480.28","15","163.45","1087.8","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.42","843.25","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","614.45","43.72","","179.76","179.76","179.76","1 through 10","163.45","1087.8","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.42","843.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1022.02","72.72","","2355.45","298.99","3965.19","155","163.45","1087.8","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.42","843.25","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1022.02","72.72","","3643.09","3643.09","3643.09","1 through 10","163.45","1087.8","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.42","843.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","747.96","53.22","","554.28","554.28","554.28","16","163.45","1087.8","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.42","843.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","884.01","62.9","","619.64","173.09","2370.64","150","163.45","1087.8","percent of total billed charges",""
"SCREW BONE 5X20MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.42","843.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1087.80","77.4","","303.98","303.98","5854.79","1 through 10","163.45","1087.8","percent of total billed charges",""
"SCREW BONE 5X25MM CANNULATED LOCKING TITANIUM","SUP-ITM-10040323","CDM","C1713","HCPCS","0278","RC","","","","both","","","1122.39","673.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","130.53","954.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X25MM CANNULATED LOCKING TITANIUM","SUP-ITM-10040323","CDM","C1713","HCPCS","0278","RC","","","","both","","","1122.39","673.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","130.53","954.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X25MM CANNULATED LOCKING TITANIUM","SUP-ITM-10040323","CDM","C1713","HCPCS","0278","RC","","","","both","","","1122.39","673.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","638.64","56.9","","812.12","238.65","1587.46","163","130.53","954.03","percent of total billed charges",""
"SCREW BONE 5X25MM CANNULATED LOCKING TITANIUM","SUP-ITM-10040323","CDM","C1713","HCPCS","0278","RC","","","","both","","","1122.39","673.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","130.53","11.63","","112.68","112.68","146.99","38","130.53","954.03","percent of total billed charges",""
"SCREW BONE 5X25MM CANNULATED LOCKING TITANIUM","SUP-ITM-10040323","CDM","C1713","HCPCS","0278","RC","","","","both","","","1122.39","673.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","868.73","77.4","","303.98","303.98","5854.79","1 through 10","130.53","954.03","percent of total billed charges",""
"SCREW BONE 5X25MM CANNULATED LOCKING TITANIUM","SUP-ITM-10040323","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","130.53","11.63","","112.68","112.68","146.99","38","130.53","868.73","percent of total billed charges",""
"SCREW BONE 5X25MM CANNULATED LOCKING TITANIUM","SUP-ITM-10040323","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","704.64","62.78","","780.86","208.94","10480.28","15","130.53","868.73","percent of total billed charges",""
"SCREW BONE 5X25MM CANNULATED LOCKING TITANIUM","SUP-ITM-10040323","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","490.71","43.72","","179.76","179.76","179.76","1 through 10","130.53","868.73","percent of total billed charges",""
"SCREW BONE 5X25MM CANNULATED LOCKING TITANIUM","SUP-ITM-10040323","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","816.20","72.72","","2355.45","298.99","3965.19","155","130.53","868.73","percent of total billed charges",""
"SCREW BONE 5X25MM CANNULATED LOCKING TITANIUM","SUP-ITM-10040323","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","816.20","72.72","","3643.09","3643.09","3643.09","1 through 10","130.53","868.73","percent of total billed charges",""
"SCREW BONE 5X25MM CANNULATED LOCKING TITANIUM","SUP-ITM-10040323","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","597.34","53.22","","554.28","554.28","554.28","16","130.53","868.73","percent of total billed charges",""
"SCREW BONE 5X25MM CANNULATED LOCKING TITANIUM","SUP-ITM-10040323","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","705.98","62.9","","619.64","173.09","2370.64","150","130.53","868.73","percent of total billed charges",""
"SCREW BONE 5X25MM CANNULATED LOCKING TITANIUM","SUP-ITM-10040323","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1122.39","673.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","868.73","77.4","","303.98","303.98","5854.79","1 through 10","130.53","868.73","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","both","","","3109.50","1865.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","361.63","2643.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","both","","","3109.50","1865.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","361.63","2643.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","both","","","3109.50","1865.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1769.31","56.9","","812.12","238.65","1587.46","163","361.63","2643.08","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","both","","","3109.50","1865.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","361.63","11.63","","112.68","112.68","146.99","38","361.63","2643.08","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","both","","","3109.50","1865.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2406.75","77.4","","303.98","303.98","5854.79","1 through 10","361.63","2643.08","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","361.63","11.63","","112.68","112.68","146.99","38","361.63","2406.75","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1952.14","62.78","","780.86","208.94","10480.28","15","361.63","2406.75","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1359.47","43.72","","179.76","179.76","179.76","1 through 10","361.63","2406.75","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2261.23","72.72","","2355.45","298.99","3965.19","155","361.63","2406.75","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2261.23","72.72","","3643.09","3643.09","3643.09","1 through 10","361.63","2406.75","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1654.88","53.22","","554.28","554.28","554.28","16","361.63","2406.75","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1955.88","62.9","","619.64","173.09","2370.64","150","361.63","2406.75","percent of total billed charges",""
"SCREW BONE 5X25MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2406.75","77.4","","303.98","303.98","5854.79","1 through 10","361.63","2406.75","percent of total billed charges",""
"SCREW BONE 5X26MM STARDRIVE TITANIUM LOCKING SELF TAPPING FULL THREAD T25 RECESS","SUP-ITM-10040130","CDM","C1713","HCPCS","0278","RC","","","","both","","","772.12","463.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","89.8","656.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X26MM STARDRIVE TITANIUM LOCKING SELF TAPPING FULL THREAD T25 RECESS","SUP-ITM-10040130","CDM","C1713","HCPCS","0278","RC","","","","both","","","772.12","463.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","89.8","656.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X26MM STARDRIVE TITANIUM LOCKING SELF TAPPING FULL THREAD T25 RECESS","SUP-ITM-10040130","CDM","C1713","HCPCS","0278","RC","","","","both","","","772.12","463.27","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","439.34","56.9","","812.12","238.65","1587.46","163","89.8","656.3","percent of total billed charges",""
"SCREW BONE 5X26MM STARDRIVE TITANIUM LOCKING SELF TAPPING FULL THREAD T25 RECESS","SUP-ITM-10040130","CDM","C1713","HCPCS","0278","RC","","","","both","","","772.12","463.27","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","89.80","11.63","","112.68","112.68","146.99","38","89.8","656.3","percent of total billed charges",""
"SCREW BONE 5X26MM STARDRIVE TITANIUM LOCKING SELF TAPPING FULL THREAD T25 RECESS","SUP-ITM-10040130","CDM","C1713","HCPCS","0278","RC","","","","both","","","772.12","463.27","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","597.62","77.4","","303.98","303.98","5854.79","1 through 10","89.8","656.3","percent of total billed charges",""
"SCREW BONE 5X26MM STARDRIVE TITANIUM LOCKING SELF TAPPING FULL THREAD T25 RECESS","SUP-ITM-10040130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","772.12","463.27","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","89.80","11.63","","112.68","112.68","146.99","38","89.8","597.62","percent of total billed charges",""
"SCREW BONE 5X26MM STARDRIVE TITANIUM LOCKING SELF TAPPING FULL THREAD T25 RECESS","SUP-ITM-10040130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","772.12","463.27","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","484.74","62.78","","780.86","208.94","10480.28","15","89.8","597.62","percent of total billed charges",""
"SCREW BONE 5X26MM STARDRIVE TITANIUM LOCKING SELF TAPPING FULL THREAD T25 RECESS","SUP-ITM-10040130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","772.12","463.27","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","337.57","43.72","","179.76","179.76","179.76","1 through 10","89.8","597.62","percent of total billed charges",""
"SCREW BONE 5X26MM STARDRIVE TITANIUM LOCKING SELF TAPPING FULL THREAD T25 RECESS","SUP-ITM-10040130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","772.12","463.27","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","561.49","72.72","","2355.45","298.99","3965.19","155","89.8","597.62","percent of total billed charges",""
"SCREW BONE 5X26MM STARDRIVE TITANIUM LOCKING SELF TAPPING FULL THREAD T25 RECESS","SUP-ITM-10040130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","772.12","463.27","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","561.49","72.72","","3643.09","3643.09","3643.09","1 through 10","89.8","597.62","percent of total billed charges",""
"SCREW BONE 5X26MM STARDRIVE TITANIUM LOCKING SELF TAPPING FULL THREAD T25 RECESS","SUP-ITM-10040130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","772.12","463.27","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","410.92","53.22","","554.28","554.28","554.28","16","89.8","597.62","percent of total billed charges",""
"SCREW BONE 5X26MM STARDRIVE TITANIUM LOCKING SELF TAPPING FULL THREAD T25 RECESS","SUP-ITM-10040130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","772.12","463.27","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","485.66","62.9","","619.64","173.09","2370.64","150","89.8","597.62","percent of total billed charges",""
"SCREW BONE 5X26MM STARDRIVE TITANIUM LOCKING SELF TAPPING FULL THREAD T25 RECESS","SUP-ITM-10040130","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","772.12","463.27","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","597.62","77.4","","303.98","303.98","5854.79","1 through 10","89.8","597.62","percent of total billed charges",""
"SCREW BONE 5X28MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.88","727.13","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","140.94","1030.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X28MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.88","727.13","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","140.94","1030.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X28MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.88","727.13","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","689.56","56.9","","812.12","238.65","1587.46","163","140.94","1030.1","percent of total billed charges",""
"SCREW BONE 5X28MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.88","727.13","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","140.94","11.63","","112.68","112.68","146.99","38","140.94","1030.1","percent of total billed charges",""
"SCREW BONE 5X28MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097289","CDM","C1713","HCPCS","0278","RC","","","","both","","","1211.88","727.13","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","938.00","77.4","","303.98","303.98","5854.79","1 through 10","140.94","1030.1","percent of total billed charges",""
"SCREW BONE 5X28MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1211.88","727.13","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","140.94","11.63","","112.68","112.68","146.99","38","140.94","938","percent of total billed charges",""
"SCREW BONE 5X28MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1211.88","727.13","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","760.82","62.78","","780.86","208.94","10480.28","15","140.94","938","percent of total billed charges",""
"SCREW BONE 5X28MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1211.88","727.13","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","529.83","43.72","","179.76","179.76","179.76","1 through 10","140.94","938","percent of total billed charges",""
"SCREW BONE 5X28MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1211.88","727.13","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","881.28","72.72","","2355.45","298.99","3965.19","155","140.94","938","percent of total billed charges",""
"SCREW BONE 5X28MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1211.88","727.13","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","881.28","72.72","","3643.09","3643.09","3643.09","1 through 10","140.94","938","percent of total billed charges",""
"SCREW BONE 5X28MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1211.88","727.13","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","644.96","53.22","","554.28","554.28","554.28","16","140.94","938","percent of total billed charges",""
"SCREW BONE 5X28MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1211.88","727.13","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","762.27","62.9","","619.64","173.09","2370.64","150","140.94","938","percent of total billed charges",""
"SCREW BONE 5X28MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1211.88","727.13","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","938.00","77.4","","303.98","303.98","5854.79","1 through 10","140.94","938","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","both","","","869.28","521.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","101.1","738.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","both","","","869.28","521.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","101.1","738.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","both","","","869.28","521.57","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","494.62","56.9","","812.12","238.65","1587.46","163","101.1","738.89","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","both","","","869.28","521.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","101.10","11.63","","112.68","112.68","146.99","38","101.1","738.89","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","both","","","869.28","521.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","672.82","77.4","","303.98","303.98","5854.79","1 through 10","101.1","738.89","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","869.28","521.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","101.10","11.63","","112.68","112.68","146.99","38","101.1","672.82","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","869.28","521.57","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","545.73","62.78","","780.86","208.94","10480.28","15","101.1","672.82","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","869.28","521.57","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","380.05","43.72","","179.76","179.76","179.76","1 through 10","101.1","672.82","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","869.28","521.57","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","632.14","72.72","","2355.45","298.99","3965.19","155","101.1","672.82","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","869.28","521.57","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","632.14","72.72","","3643.09","3643.09","3643.09","1 through 10","101.1","672.82","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","869.28","521.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","462.63","53.22","","554.28","554.28","554.28","16","101.1","672.82","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","869.28","521.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","546.78","62.9","","619.64","173.09","2370.64","150","101.1","672.82","percent of total billed charges",""
"SCREW BONE 5X32MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","869.28","521.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","672.82","77.4","","303.98","303.98","5854.79","1 through 10","101.1","672.82","percent of total billed charges",""
"SCREW BONE 5X32MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1240.00","744.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","144.21","1054","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X32MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1240.00","744.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","144.21","1054","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X32MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1240.00","744.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","705.56","56.9","","812.12","238.65","1587.46","163","144.21","1054","percent of total billed charges",""
"SCREW BONE 5X32MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1240.00","744.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","144.21","11.63","","112.68","112.68","146.99","38","144.21","1054","percent of total billed charges",""
"SCREW BONE 5X32MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1240.00","744.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","959.76","77.4","","303.98","303.98","5854.79","1 through 10","144.21","1054","percent of total billed charges",""
"SCREW BONE 5X32MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1240.00","744.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","144.21","11.63","","112.68","112.68","146.99","38","144.21","959.76","percent of total billed charges",""
"SCREW BONE 5X32MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1240.00","744.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","778.47","62.78","","780.86","208.94","10480.28","15","144.21","959.76","percent of total billed charges",""
"SCREW BONE 5X32MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1240.00","744.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","542.13","43.72","","179.76","179.76","179.76","1 through 10","144.21","959.76","percent of total billed charges",""
"SCREW BONE 5X32MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1240.00","744.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","901.73","72.72","","2355.45","298.99","3965.19","155","144.21","959.76","percent of total billed charges",""
"SCREW BONE 5X32MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1240.00","744.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","901.73","72.72","","3643.09","3643.09","3643.09","1 through 10","144.21","959.76","percent of total billed charges",""
"SCREW BONE 5X32MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1240.00","744.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","659.93","53.22","","554.28","554.28","554.28","16","144.21","959.76","percent of total billed charges",""
"SCREW BONE 5X32MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1240.00","744.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","779.96","62.9","","619.64","173.09","2370.64","150","144.21","959.76","percent of total billed charges",""
"SCREW BONE 5X32MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS GOLD","SUP-ITM-10097290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1240.00","744.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","959.76","77.4","","303.98","303.98","5854.79","1 through 10","144.21","959.76","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING IM NAIL","SUP-ITM-10296349","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","816.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","158.27","1156.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X36MM LOCKING IM NAIL","SUP-ITM-10296349","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","816.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","158.27","1156.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X36MM LOCKING IM NAIL","SUP-ITM-10296349","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","816.52","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","774.33","56.9","","812.12","238.65","1587.46","163","158.27","1156.73","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING IM NAIL","SUP-ITM-10296349","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","816.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","158.27","11.63","","112.68","112.68","146.99","38","158.27","1156.73","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING IM NAIL","SUP-ITM-10296349","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","816.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1053.31","77.4","","303.98","303.98","5854.79","1 through 10","158.27","1156.73","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING IM NAIL","SUP-ITM-10296349","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","158.27","11.63","","112.68","112.68","146.99","38","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING IM NAIL","SUP-ITM-10296349","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","854.35","62.78","","780.86","208.94","10480.28","15","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING IM NAIL","SUP-ITM-10296349","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","594.97","43.72","","179.76","179.76","179.76","1 through 10","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING IM NAIL","SUP-ITM-10296349","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","989.62","72.72","","2355.45","298.99","3965.19","155","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING IM NAIL","SUP-ITM-10296349","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","989.62","72.72","","3643.09","3643.09","3643.09","1 through 10","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING IM NAIL","SUP-ITM-10296349","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","724.25","53.22","","554.28","554.28","554.28","16","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING IM NAIL","SUP-ITM-10296349","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","855.98","62.9","","619.64","173.09","2370.64","150","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING IM NAIL","SUP-ITM-10296349","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1053.31","77.4","","303.98","303.98","5854.79","1 through 10","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","1124.95","674.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","130.83","956.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","1124.95","674.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","130.83","956.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","1124.95","674.97","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","640.10","56.9","","812.12","238.65","1587.46","163","130.83","956.21","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","1124.95","674.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","130.83","11.63","","112.68","112.68","146.99","38","130.83","956.21","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","1124.95","674.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","870.71","77.4","","303.98","303.98","5854.79","1 through 10","130.83","956.21","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","130.83","11.63","","112.68","112.68","146.99","38","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","706.24","62.78","","780.86","208.94","10480.28","15","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","491.83","43.72","","179.76","179.76","179.76","1 through 10","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","818.06","72.72","","2355.45","298.99","3965.19","155","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","818.06","72.72","","3643.09","3643.09","3643.09","1 through 10","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","598.70","53.22","","554.28","554.28","554.28","16","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","707.59","62.9","","619.64","173.09","2370.64","150","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","870.71","77.4","","303.98","303.98","5854.79","1 through 10","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X37MM CANCELLOUS LOCKING DUAL CORE T25 STARDRIVE INTRAMEDULLARY NAIL TITANIUM","SUP-ITM-10097291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1240.00","744.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","144.21","1054","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X37MM CANCELLOUS LOCKING DUAL CORE T25 STARDRIVE INTRAMEDULLARY NAIL TITANIUM","SUP-ITM-10097291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1240.00","744.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","144.21","1054","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X37MM CANCELLOUS LOCKING DUAL CORE T25 STARDRIVE INTRAMEDULLARY NAIL TITANIUM","SUP-ITM-10097291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1240.00","744.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","705.56","56.9","","812.12","238.65","1587.46","163","144.21","1054","percent of total billed charges",""
"SCREW BONE 5X37MM CANCELLOUS LOCKING DUAL CORE T25 STARDRIVE INTRAMEDULLARY NAIL TITANIUM","SUP-ITM-10097291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1240.00","744.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","144.21","11.63","","112.68","112.68","146.99","38","144.21","1054","percent of total billed charges",""
"SCREW BONE 5X37MM CANCELLOUS LOCKING DUAL CORE T25 STARDRIVE INTRAMEDULLARY NAIL TITANIUM","SUP-ITM-10097291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1240.00","744.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","959.76","77.4","","303.98","303.98","5854.79","1 through 10","144.21","1054","percent of total billed charges",""
"SCREW BONE 5X37MM CANCELLOUS LOCKING DUAL CORE T25 STARDRIVE INTRAMEDULLARY NAIL TITANIUM","SUP-ITM-10097291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1240.00","744.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","144.21","11.63","","112.68","112.68","146.99","38","144.21","959.76","percent of total billed charges",""
"SCREW BONE 5X37MM CANCELLOUS LOCKING DUAL CORE T25 STARDRIVE INTRAMEDULLARY NAIL TITANIUM","SUP-ITM-10097291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1240.00","744.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","778.47","62.78","","780.86","208.94","10480.28","15","144.21","959.76","percent of total billed charges",""
"SCREW BONE 5X37MM CANCELLOUS LOCKING DUAL CORE T25 STARDRIVE INTRAMEDULLARY NAIL TITANIUM","SUP-ITM-10097291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1240.00","744.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","542.13","43.72","","179.76","179.76","179.76","1 through 10","144.21","959.76","percent of total billed charges",""
"SCREW BONE 5X37MM CANCELLOUS LOCKING DUAL CORE T25 STARDRIVE INTRAMEDULLARY NAIL TITANIUM","SUP-ITM-10097291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1240.00","744.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","901.73","72.72","","2355.45","298.99","3965.19","155","144.21","959.76","percent of total billed charges",""
"SCREW BONE 5X37MM CANCELLOUS LOCKING DUAL CORE T25 STARDRIVE INTRAMEDULLARY NAIL TITANIUM","SUP-ITM-10097291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1240.00","744.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","901.73","72.72","","3643.09","3643.09","3643.09","1 through 10","144.21","959.76","percent of total billed charges",""
"SCREW BONE 5X37MM CANCELLOUS LOCKING DUAL CORE T25 STARDRIVE INTRAMEDULLARY NAIL TITANIUM","SUP-ITM-10097291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1240.00","744.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","659.93","53.22","","554.28","554.28","554.28","16","144.21","959.76","percent of total billed charges",""
"SCREW BONE 5X37MM CANCELLOUS LOCKING DUAL CORE T25 STARDRIVE INTRAMEDULLARY NAIL TITANIUM","SUP-ITM-10097291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1240.00","744.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","779.96","62.9","","619.64","173.09","2370.64","150","144.21","959.76","percent of total billed charges",""
"SCREW BONE 5X37MM CANCELLOUS LOCKING DUAL CORE T25 STARDRIVE INTRAMEDULLARY NAIL TITANIUM","SUP-ITM-10097291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1240.00","744.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","959.76","77.4","","303.98","303.98","5854.79","1 through 10","144.21","959.76","percent of total billed charges",""
"SCREW BONE 5X38MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030479","CDM","C1713","HCPCS","0278","RC","","","","both","","","1124.95","674.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","130.83","956.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X38MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030479","CDM","C1713","HCPCS","0278","RC","","","","both","","","1124.95","674.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","130.83","956.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X38MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030479","CDM","C1713","HCPCS","0278","RC","","","","both","","","1124.95","674.97","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","640.10","56.9","","812.12","238.65","1587.46","163","130.83","956.21","percent of total billed charges",""
"SCREW BONE 5X38MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030479","CDM","C1713","HCPCS","0278","RC","","","","both","","","1124.95","674.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","130.83","11.63","","112.68","112.68","146.99","38","130.83","956.21","percent of total billed charges",""
"SCREW BONE 5X38MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030479","CDM","C1713","HCPCS","0278","RC","","","","both","","","1124.95","674.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","870.71","77.4","","303.98","303.98","5854.79","1 through 10","130.83","956.21","percent of total billed charges",""
"SCREW BONE 5X38MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","130.83","11.63","","112.68","112.68","146.99","38","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X38MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","706.24","62.78","","780.86","208.94","10480.28","15","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X38MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","491.83","43.72","","179.76","179.76","179.76","1 through 10","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X38MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","818.06","72.72","","2355.45","298.99","3965.19","155","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X38MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","818.06","72.72","","3643.09","3643.09","3643.09","1 through 10","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X38MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","598.70","53.22","","554.28","554.28","554.28","16","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X38MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","707.59","62.9","","619.64","173.09","2370.64","150","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X38MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","870.71","77.4","","303.98","303.98","5854.79","1 through 10","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X40MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3109.50","1865.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","361.63","2643.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X40MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3109.50","1865.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","361.63","2643.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X40MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3109.50","1865.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1769.31","56.9","","812.12","238.65","1587.46","163","361.63","2643.08","percent of total billed charges",""
"SCREW BONE 5X40MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3109.50","1865.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","361.63","11.63","","112.68","112.68","146.99","38","361.63","2643.08","percent of total billed charges",""
"SCREW BONE 5X40MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3109.50","1865.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2406.75","77.4","","303.98","303.98","5854.79","1 through 10","361.63","2643.08","percent of total billed charges",""
"SCREW BONE 5X40MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","361.63","11.63","","112.68","112.68","146.99","38","361.63","2406.75","percent of total billed charges",""
"SCREW BONE 5X40MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1952.14","62.78","","780.86","208.94","10480.28","15","361.63","2406.75","percent of total billed charges",""
"SCREW BONE 5X40MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1359.47","43.72","","179.76","179.76","179.76","1 through 10","361.63","2406.75","percent of total billed charges",""
"SCREW BONE 5X40MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2261.23","72.72","","2355.45","298.99","3965.19","155","361.63","2406.75","percent of total billed charges",""
"SCREW BONE 5X40MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2261.23","72.72","","3643.09","3643.09","3643.09","1 through 10","361.63","2406.75","percent of total billed charges",""
"SCREW BONE 5X40MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1654.88","53.22","","554.28","554.28","554.28","16","361.63","2406.75","percent of total billed charges",""
"SCREW BONE 5X40MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1955.88","62.9","","619.64","173.09","2370.64","150","361.63","2406.75","percent of total billed charges",""
"SCREW BONE 5X40MM CORTICAL TRIGEN TITANIUM ANTEGRADE INTERNAL HEX CAPTURED GOLD","SUP-ITM-10006195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3109.50","1865.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2406.75","77.4","","303.98","303.98","5854.79","1 through 10","361.63","2406.75","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.29","535.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","103.77","758.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.29","535.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","103.77","758.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.29","535.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","507.71","56.9","","812.12","238.65","1587.46","163","103.77","758.45","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.29","535.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","103.77","11.63","","112.68","112.68","146.99","38","103.77","758.45","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.29","535.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","690.63","77.4","","303.98","303.98","5854.79","1 through 10","103.77","758.45","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","892.29","535.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","103.77","11.63","","112.68","112.68","146.99","38","103.77","690.63","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","892.29","535.37","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","560.18","62.78","","780.86","208.94","10480.28","15","103.77","690.63","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","892.29","535.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","390.11","43.72","","179.76","179.76","179.76","1 through 10","103.77","690.63","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","892.29","535.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","648.87","72.72","","2355.45","298.99","3965.19","155","103.77","690.63","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","892.29","535.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","648.87","72.72","","3643.09","3643.09","3643.09","1 through 10","103.77","690.63","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","892.29","535.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","474.88","53.22","","554.28","554.28","554.28","16","103.77","690.63","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","892.29","535.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","561.25","62.9","","619.64","173.09","2370.64","150","103.77","690.63","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","892.29","535.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","690.63","77.4","","303.98","303.98","5854.79","1 through 10","103.77","690.63","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","816.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","158.27","1156.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","816.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","158.27","1156.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","816.52","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","774.33","56.9","","812.12","238.65","1587.46","163","158.27","1156.73","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","816.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","158.27","11.63","","112.68","112.68","146.99","38","158.27","1156.73","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","816.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1053.31","77.4","","303.98","303.98","5854.79","1 through 10","158.27","1156.73","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","158.27","11.63","","112.68","112.68","146.99","38","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","854.35","62.78","","780.86","208.94","10480.28","15","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","594.97","43.72","","179.76","179.76","179.76","1 through 10","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","989.62","72.72","","2355.45","298.99","3965.19","155","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","989.62","72.72","","3643.09","3643.09","3643.09","1 through 10","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","724.25","53.22","","554.28","554.28","554.28","16","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","855.98","62.9","","619.64","173.09","2370.64","150","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING IM NAIL","SUP-ITM-10296346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1053.31","77.4","","303.98","303.98","5854.79","1 through 10","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","2026.98","1216.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","235.74","1722.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","2026.98","1216.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","235.74","1722.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","2026.98","1216.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1153.35","56.9","","812.12","238.65","1587.46","163","235.74","1722.93","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","2026.98","1216.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","235.74","11.63","","112.68","112.68","146.99","38","235.74","1722.93","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","2026.98","1216.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1568.88","77.4","","303.98","303.98","5854.79","1 through 10","235.74","1722.93","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2026.98","1216.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","235.74","11.63","","112.68","112.68","146.99","38","235.74","1568.88","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2026.98","1216.19","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1272.54","62.78","","780.86","208.94","10480.28","15","235.74","1568.88","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2026.98","1216.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","886.20","43.72","","179.76","179.76","179.76","1 through 10","235.74","1568.88","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2026.98","1216.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1474.02","72.72","","2355.45","298.99","3965.19","155","235.74","1568.88","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2026.98","1216.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1474.02","72.72","","3643.09","3643.09","3643.09","1 through 10","235.74","1568.88","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2026.98","1216.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1078.76","53.22","","554.28","554.28","554.28","16","235.74","1568.88","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2026.98","1216.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1274.97","62.9","","619.64","173.09","2370.64","150","235.74","1568.88","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2026.98","1216.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1568.88","77.4","","303.98","303.98","5854.79","1 through 10","235.74","1568.88","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","both","","","1124.95","674.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","130.83","956.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","both","","","1124.95","674.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","130.83","956.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","both","","","1124.95","674.97","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","640.10","56.9","","812.12","238.65","1587.46","163","130.83","956.21","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","both","","","1124.95","674.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","130.83","11.63","","112.68","112.68","146.99","38","130.83","956.21","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","both","","","1124.95","674.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","870.71","77.4","","303.98","303.98","5854.79","1 through 10","130.83","956.21","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","130.83","11.63","","112.68","112.68","146.99","38","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","706.24","62.78","","780.86","208.94","10480.28","15","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","491.83","43.72","","179.76","179.76","179.76","1 through 10","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","818.06","72.72","","2355.45","298.99","3965.19","155","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","818.06","72.72","","3643.09","3643.09","3643.09","1 through 10","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","598.70","53.22","","554.28","554.28","554.28","16","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","707.59","62.9","","619.64","173.09","2370.64","150","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1124.95","674.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","870.71","77.4","","303.98","303.98","5854.79","1 through 10","130.83","870.71","percent of total billed charges",""
"SCREW BONE 5X44MM TITANIUM ANG STABLE LOCKING SELF TAP T25 RECESS STARDRIVE","SUP-ITM-10097367","CDM","C1713","HCPCS","0278","RC","","","","both","","","1063.59","638.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","123.7","904.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X44MM TITANIUM ANG STABLE LOCKING SELF TAP T25 RECESS STARDRIVE","SUP-ITM-10097367","CDM","C1713","HCPCS","0278","RC","","","","both","","","1063.59","638.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","123.7","904.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X44MM TITANIUM ANG STABLE LOCKING SELF TAP T25 RECESS STARDRIVE","SUP-ITM-10097367","CDM","C1713","HCPCS","0278","RC","","","","both","","","1063.59","638.15","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","605.18","56.9","","812.12","238.65","1587.46","163","123.7","904.05","percent of total billed charges",""
"SCREW BONE 5X44MM TITANIUM ANG STABLE LOCKING SELF TAP T25 RECESS STARDRIVE","SUP-ITM-10097367","CDM","C1713","HCPCS","0278","RC","","","","both","","","1063.59","638.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","123.70","11.63","","112.68","112.68","146.99","38","123.7","904.05","percent of total billed charges",""
"SCREW BONE 5X44MM TITANIUM ANG STABLE LOCKING SELF TAP T25 RECESS STARDRIVE","SUP-ITM-10097367","CDM","C1713","HCPCS","0278","RC","","","","both","","","1063.59","638.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","823.22","77.4","","303.98","303.98","5854.79","1 through 10","123.7","904.05","percent of total billed charges",""
"SCREW BONE 5X44MM TITANIUM ANG STABLE LOCKING SELF TAP T25 RECESS STARDRIVE","SUP-ITM-10097367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1063.59","638.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","123.70","11.63","","112.68","112.68","146.99","38","123.7","823.22","percent of total billed charges",""
"SCREW BONE 5X44MM TITANIUM ANG STABLE LOCKING SELF TAP T25 RECESS STARDRIVE","SUP-ITM-10097367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1063.59","638.15","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","667.72","62.78","","780.86","208.94","10480.28","15","123.7","823.22","percent of total billed charges",""
"SCREW BONE 5X44MM TITANIUM ANG STABLE LOCKING SELF TAP T25 RECESS STARDRIVE","SUP-ITM-10097367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1063.59","638.15","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","465.00","43.72","","179.76","179.76","179.76","1 through 10","123.7","823.22","percent of total billed charges",""
"SCREW BONE 5X44MM TITANIUM ANG STABLE LOCKING SELF TAP T25 RECESS STARDRIVE","SUP-ITM-10097367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1063.59","638.15","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","773.44","72.72","","2355.45","298.99","3965.19","155","123.7","823.22","percent of total billed charges",""
"SCREW BONE 5X44MM TITANIUM ANG STABLE LOCKING SELF TAP T25 RECESS STARDRIVE","SUP-ITM-10097367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1063.59","638.15","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","773.44","72.72","","3643.09","3643.09","3643.09","1 through 10","123.7","823.22","percent of total billed charges",""
"SCREW BONE 5X44MM TITANIUM ANG STABLE LOCKING SELF TAP T25 RECESS STARDRIVE","SUP-ITM-10097367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1063.59","638.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","566.04","53.22","","554.28","554.28","554.28","16","123.7","823.22","percent of total billed charges",""
"SCREW BONE 5X44MM TITANIUM ANG STABLE LOCKING SELF TAP T25 RECESS STARDRIVE","SUP-ITM-10097367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1063.59","638.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","669.00","62.9","","619.64","173.09","2370.64","150","123.7","823.22","percent of total billed charges",""
"SCREW BONE 5X44MM TITANIUM ANG STABLE LOCKING SELF TAP T25 RECESS STARDRIVE","SUP-ITM-10097367","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1063.59","638.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","823.22","77.4","","303.98","303.98","5854.79","1 through 10","123.7","823.22","percent of total billed charges",""
"SCREW BONE 5X46MM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE TI","SUP-ITM-10296786","CDM","C1713","HCPCS","0278","RC","","","","both","","","981.77","589.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","114.18","834.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X46MM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE TI","SUP-ITM-10296786","CDM","C1713","HCPCS","0278","RC","","","","both","","","981.77","589.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","114.18","834.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X46MM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE TI","SUP-ITM-10296786","CDM","C1713","HCPCS","0278","RC","","","","both","","","981.77","589.06","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","558.63","56.9","","812.12","238.65","1587.46","163","114.18","834.5","percent of total billed charges",""
"SCREW BONE 5X46MM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE TI","SUP-ITM-10296786","CDM","C1713","HCPCS","0278","RC","","","","both","","","981.77","589.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","114.18","11.63","","112.68","112.68","146.99","38","114.18","834.5","percent of total billed charges",""
"SCREW BONE 5X46MM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE TI","SUP-ITM-10296786","CDM","C1713","HCPCS","0278","RC","","","","both","","","981.77","589.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","759.89","77.4","","303.98","303.98","5854.79","1 through 10","114.18","834.5","percent of total billed charges",""
"SCREW BONE 5X46MM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE TI","SUP-ITM-10296786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","114.18","11.63","","112.68","112.68","146.99","38","114.18","759.89","percent of total billed charges",""
"SCREW BONE 5X46MM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE TI","SUP-ITM-10296786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","616.36","62.78","","780.86","208.94","10480.28","15","114.18","759.89","percent of total billed charges",""
"SCREW BONE 5X46MM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE TI","SUP-ITM-10296786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","429.23","43.72","","179.76","179.76","179.76","1 through 10","114.18","759.89","percent of total billed charges",""
"SCREW BONE 5X46MM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE TI","SUP-ITM-10296786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","713.94","72.72","","2355.45","298.99","3965.19","155","114.18","759.89","percent of total billed charges",""
"SCREW BONE 5X46MM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE TI","SUP-ITM-10296786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","713.94","72.72","","3643.09","3643.09","3643.09","1 through 10","114.18","759.89","percent of total billed charges",""
"SCREW BONE 5X46MM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE TI","SUP-ITM-10296786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","522.50","53.22","","554.28","554.28","554.28","16","114.18","759.89","percent of total billed charges",""
"SCREW BONE 5X46MM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE TI","SUP-ITM-10296786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","617.53","62.9","","619.64","173.09","2370.64","150","114.18","759.89","percent of total billed charges",""
"SCREW BONE 5X46MM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE TI","SUP-ITM-10296786","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","759.89","77.4","","303.98","303.98","5854.79","1 through 10","114.18","759.89","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.93","625.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","121.29","886.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.93","625.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","121.29","886.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.93","625.76","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","593.43","56.9","","812.12","238.65","1587.46","163","121.29","886.49","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.93","625.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","121.29","11.63","","112.68","112.68","146.99","38","121.29","886.49","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","both","","","1042.93","625.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","807.23","77.4","","303.98","303.98","5854.79","1 through 10","121.29","886.49","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.93","625.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","121.29","11.63","","112.68","112.68","146.99","38","121.29","807.23","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.93","625.76","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","654.75","62.78","","780.86","208.94","10480.28","15","121.29","807.23","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.93","625.76","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","455.97","43.72","","179.76","179.76","179.76","1 through 10","121.29","807.23","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.93","625.76","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","758.42","72.72","","2355.45","298.99","3965.19","155","121.29","807.23","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.93","625.76","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","758.42","72.72","","3643.09","3643.09","3643.09","1 through 10","121.29","807.23","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.93","625.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","555.05","53.22","","554.28","554.28","554.28","16","121.29","807.23","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.93","625.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","656.00","62.9","","619.64","173.09","2370.64","150","121.29","807.23","percent of total billed charges",""
"SCREW BONE 5X48MM SELF-TAPPING VA LOCKING STARDRIVE RECESS","SUP-ITM-10095426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1042.93","625.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","807.23","77.4","","303.98","303.98","5854.79","1 through 10","121.29","807.23","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","1022.68","613.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","118.94","869.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","1022.68","613.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","118.94","869.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","1022.68","613.61","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","581.90","56.9","","812.12","238.65","1587.46","163","118.94","869.28","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","1022.68","613.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","118.94","11.63","","112.68","112.68","146.99","38","118.94","869.28","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","1022.68","613.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","791.55","77.4","","303.98","303.98","5854.79","1 through 10","118.94","869.28","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1022.68","613.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","118.94","11.63","","112.68","112.68","146.99","38","118.94","791.55","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1022.68","613.61","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","642.04","62.78","","780.86","208.94","10480.28","15","118.94","791.55","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1022.68","613.61","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","447.12","43.72","","179.76","179.76","179.76","1 through 10","118.94","791.55","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1022.68","613.61","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","743.69","72.72","","2355.45","298.99","3965.19","155","118.94","791.55","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1022.68","613.61","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","743.69","72.72","","3643.09","3643.09","3643.09","1 through 10","118.94","791.55","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1022.68","613.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","544.27","53.22","","554.28","554.28","554.28","16","118.94","791.55","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1022.68","613.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","643.27","62.9","","619.64","173.09","2370.64","150","118.94","791.55","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1022.68","613.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","791.55","77.4","","303.98","303.98","5854.79","1 through 10","118.94","791.55","percent of total billed charges",""
"SCREW BONE 5X55MM LOCKING SELF-TAPPING TITANIUM T25 STARDRIVE","SUP-ITM-10297505","CDM","C1713","HCPCS","0278","RC","","","","both","","","981.77","589.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","114.18","834.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X55MM LOCKING SELF-TAPPING TITANIUM T25 STARDRIVE","SUP-ITM-10297505","CDM","C1713","HCPCS","0278","RC","","","","both","","","981.77","589.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","114.18","834.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X55MM LOCKING SELF-TAPPING TITANIUM T25 STARDRIVE","SUP-ITM-10297505","CDM","C1713","HCPCS","0278","RC","","","","both","","","981.77","589.06","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","558.63","56.9","","812.12","238.65","1587.46","163","114.18","834.5","percent of total billed charges",""
"SCREW BONE 5X55MM LOCKING SELF-TAPPING TITANIUM T25 STARDRIVE","SUP-ITM-10297505","CDM","C1713","HCPCS","0278","RC","","","","both","","","981.77","589.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","114.18","11.63","","112.68","112.68","146.99","38","114.18","834.5","percent of total billed charges",""
"SCREW BONE 5X55MM LOCKING SELF-TAPPING TITANIUM T25 STARDRIVE","SUP-ITM-10297505","CDM","C1713","HCPCS","0278","RC","","","","both","","","981.77","589.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","759.89","77.4","","303.98","303.98","5854.79","1 through 10","114.18","834.5","percent of total billed charges",""
"SCREW BONE 5X55MM LOCKING SELF-TAPPING TITANIUM T25 STARDRIVE","SUP-ITM-10297505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","114.18","11.63","","112.68","112.68","146.99","38","114.18","759.89","percent of total billed charges",""
"SCREW BONE 5X55MM LOCKING SELF-TAPPING TITANIUM T25 STARDRIVE","SUP-ITM-10297505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","616.36","62.78","","780.86","208.94","10480.28","15","114.18","759.89","percent of total billed charges",""
"SCREW BONE 5X55MM LOCKING SELF-TAPPING TITANIUM T25 STARDRIVE","SUP-ITM-10297505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","429.23","43.72","","179.76","179.76","179.76","1 through 10","114.18","759.89","percent of total billed charges",""
"SCREW BONE 5X55MM LOCKING SELF-TAPPING TITANIUM T25 STARDRIVE","SUP-ITM-10297505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","713.94","72.72","","2355.45","298.99","3965.19","155","114.18","759.89","percent of total billed charges",""
"SCREW BONE 5X55MM LOCKING SELF-TAPPING TITANIUM T25 STARDRIVE","SUP-ITM-10297505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","713.94","72.72","","3643.09","3643.09","3643.09","1 through 10","114.18","759.89","percent of total billed charges",""
"SCREW BONE 5X55MM LOCKING SELF-TAPPING TITANIUM T25 STARDRIVE","SUP-ITM-10297505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","522.50","53.22","","554.28","554.28","554.28","16","114.18","759.89","percent of total billed charges",""
"SCREW BONE 5X55MM LOCKING SELF-TAPPING TITANIUM T25 STARDRIVE","SUP-ITM-10297505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","617.53","62.9","","619.64","173.09","2370.64","150","114.18","759.89","percent of total billed charges",""
"SCREW BONE 5X55MM LOCKING SELF-TAPPING TITANIUM T25 STARDRIVE","SUP-ITM-10297505","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","981.77","589.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","759.89","77.4","","303.98","303.98","5854.79","1 through 10","114.18","759.89","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","1022.68","613.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","118.94","869.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","1022.68","613.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","118.94","869.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","1022.68","613.61","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","581.90","56.9","","812.12","238.65","1587.46","163","118.94","869.28","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","1022.68","613.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","118.94","11.63","","112.68","112.68","146.99","38","118.94","869.28","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","1022.68","613.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","791.55","77.4","","303.98","303.98","5854.79","1 through 10","118.94","869.28","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1022.68","613.61","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","118.94","11.63","","112.68","112.68","146.99","38","118.94","791.55","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1022.68","613.61","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","642.04","62.78","","780.86","208.94","10480.28","15","118.94","791.55","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1022.68","613.61","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","447.12","43.72","","179.76","179.76","179.76","1 through 10","118.94","791.55","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1022.68","613.61","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","743.69","72.72","","2355.45","298.99","3965.19","155","118.94","791.55","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1022.68","613.61","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","743.69","72.72","","3643.09","3643.09","3643.09","1 through 10","118.94","791.55","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1022.68","613.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","544.27","53.22","","554.28","554.28","554.28","16","118.94","791.55","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1022.68","613.61","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","643.27","62.9","","619.64","173.09","2370.64","150","118.94","791.55","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1022.68","613.61","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","791.55","77.4","","303.98","303.98","5854.79","1 through 10","118.94","791.55","percent of total billed charges",""
"SCREW BONE 5X60MM CANCELLOUS TITANIUM LOCKING DUAL CORE T25 STARDRIVE RECESS GOLD","SUP-ITM-10036945","CDM","C1713","HCPCS","0278","RC","","","","both","","","1242.56","745.54","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","144.51","1056.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X60MM CANCELLOUS TITANIUM LOCKING DUAL CORE T25 STARDRIVE RECESS GOLD","SUP-ITM-10036945","CDM","C1713","HCPCS","0278","RC","","","","both","","","1242.56","745.54","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","144.51","1056.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X60MM CANCELLOUS TITANIUM LOCKING DUAL CORE T25 STARDRIVE RECESS GOLD","SUP-ITM-10036945","CDM","C1713","HCPCS","0278","RC","","","","both","","","1242.56","745.54","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","707.02","56.9","","812.12","238.65","1587.46","163","144.51","1056.18","percent of total billed charges",""
"SCREW BONE 5X60MM CANCELLOUS TITANIUM LOCKING DUAL CORE T25 STARDRIVE RECESS GOLD","SUP-ITM-10036945","CDM","C1713","HCPCS","0278","RC","","","","both","","","1242.56","745.54","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","144.51","11.63","","112.68","112.68","146.99","38","144.51","1056.18","percent of total billed charges",""
"SCREW BONE 5X60MM CANCELLOUS TITANIUM LOCKING DUAL CORE T25 STARDRIVE RECESS GOLD","SUP-ITM-10036945","CDM","C1713","HCPCS","0278","RC","","","","both","","","1242.56","745.54","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","961.74","77.4","","303.98","303.98","5854.79","1 through 10","144.51","1056.18","percent of total billed charges",""
"SCREW BONE 5X60MM CANCELLOUS TITANIUM LOCKING DUAL CORE T25 STARDRIVE RECESS GOLD","SUP-ITM-10036945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.56","745.54","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","144.51","11.63","","112.68","112.68","146.99","38","144.51","961.74","percent of total billed charges",""
"SCREW BONE 5X60MM CANCELLOUS TITANIUM LOCKING DUAL CORE T25 STARDRIVE RECESS GOLD","SUP-ITM-10036945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.56","745.54","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","780.08","62.78","","780.86","208.94","10480.28","15","144.51","961.74","percent of total billed charges",""
"SCREW BONE 5X60MM CANCELLOUS TITANIUM LOCKING DUAL CORE T25 STARDRIVE RECESS GOLD","SUP-ITM-10036945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.56","745.54","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","543.25","43.72","","179.76","179.76","179.76","1 through 10","144.51","961.74","percent of total billed charges",""
"SCREW BONE 5X60MM CANCELLOUS TITANIUM LOCKING DUAL CORE T25 STARDRIVE RECESS GOLD","SUP-ITM-10036945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.56","745.54","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","903.59","72.72","","2355.45","298.99","3965.19","155","144.51","961.74","percent of total billed charges",""
"SCREW BONE 5X60MM CANCELLOUS TITANIUM LOCKING DUAL CORE T25 STARDRIVE RECESS GOLD","SUP-ITM-10036945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.56","745.54","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","903.59","72.72","","3643.09","3643.09","3643.09","1 through 10","144.51","961.74","percent of total billed charges",""
"SCREW BONE 5X60MM CANCELLOUS TITANIUM LOCKING DUAL CORE T25 STARDRIVE RECESS GOLD","SUP-ITM-10036945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.56","745.54","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","661.29","53.22","","554.28","554.28","554.28","16","144.51","961.74","percent of total billed charges",""
"SCREW BONE 5X60MM CANCELLOUS TITANIUM LOCKING DUAL CORE T25 STARDRIVE RECESS GOLD","SUP-ITM-10036945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.56","745.54","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","781.57","62.9","","619.64","173.09","2370.64","150","144.51","961.74","percent of total billed charges",""
"SCREW BONE 5X60MM CANCELLOUS TITANIUM LOCKING DUAL CORE T25 STARDRIVE RECESS GOLD","SUP-ITM-10036945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1242.56","745.54","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","961.74","77.4","","303.98","303.98","5854.79","1 through 10","144.51","961.74","percent of total billed charges",""
"SCREW BONE 5X60MM CANNULATED CONICAL TITANIUM","SUP-ITM-10040342","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.62","828.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","160.57","1173.53","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X60MM CANNULATED CONICAL TITANIUM","SUP-ITM-10040342","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.62","828.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","160.57","1173.53","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X60MM CANNULATED CONICAL TITANIUM","SUP-ITM-10040342","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.62","828.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","785.57","56.9","","812.12","238.65","1587.46","163","160.57","1173.53","percent of total billed charges",""
"SCREW BONE 5X60MM CANNULATED CONICAL TITANIUM","SUP-ITM-10040342","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.62","828.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","160.57","11.63","","112.68","112.68","146.99","38","160.57","1173.53","percent of total billed charges",""
"SCREW BONE 5X60MM CANNULATED CONICAL TITANIUM","SUP-ITM-10040342","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.62","828.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1068.60","77.4","","303.98","303.98","5854.79","1 through 10","160.57","1173.53","percent of total billed charges",""
"SCREW BONE 5X60MM CANNULATED CONICAL TITANIUM","SUP-ITM-10040342","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1380.62","828.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","160.57","11.63","","112.68","112.68","146.99","38","160.57","1068.6","percent of total billed charges",""
"SCREW BONE 5X60MM CANNULATED CONICAL TITANIUM","SUP-ITM-10040342","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1380.62","828.37","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","866.75","62.78","","780.86","208.94","10480.28","15","160.57","1068.6","percent of total billed charges",""
"SCREW BONE 5X60MM CANNULATED CONICAL TITANIUM","SUP-ITM-10040342","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1380.62","828.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","603.61","43.72","","179.76","179.76","179.76","1 through 10","160.57","1068.6","percent of total billed charges",""
"SCREW BONE 5X60MM CANNULATED CONICAL TITANIUM","SUP-ITM-10040342","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1380.62","828.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1003.99","72.72","","2355.45","298.99","3965.19","155","160.57","1068.6","percent of total billed charges",""
"SCREW BONE 5X60MM CANNULATED CONICAL TITANIUM","SUP-ITM-10040342","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1380.62","828.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1003.99","72.72","","3643.09","3643.09","3643.09","1 through 10","160.57","1068.6","percent of total billed charges",""
"SCREW BONE 5X60MM CANNULATED CONICAL TITANIUM","SUP-ITM-10040342","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1380.62","828.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","734.77","53.22","","554.28","554.28","554.28","16","160.57","1068.6","percent of total billed charges",""
"SCREW BONE 5X60MM CANNULATED CONICAL TITANIUM","SUP-ITM-10040342","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1380.62","828.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","868.41","62.9","","619.64","173.09","2370.64","150","160.57","1068.6","percent of total billed charges",""
"SCREW BONE 5X60MM CANNULATED CONICAL TITANIUM","SUP-ITM-10040342","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1380.62","828.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1068.60","77.4","","303.98","303.98","5854.79","1 through 10","160.57","1068.6","percent of total billed charges",""
"SCREW BONE 5X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1012.45","607.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","117.75","860.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1012.45","607.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","117.75","860.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1012.45","607.47","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","576.08","56.9","","812.12","238.65","1587.46","163","117.75","860.58","percent of total billed charges",""
"SCREW BONE 5X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1012.45","607.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","117.75","11.63","","112.68","112.68","146.99","38","117.75","860.58","percent of total billed charges",""
"SCREW BONE 5X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1012.45","607.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","783.64","77.4","","303.98","303.98","5854.79","1 through 10","117.75","860.58","percent of total billed charges",""
"SCREW BONE 5X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1012.45","607.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","117.75","11.63","","112.68","112.68","146.99","38","117.75","783.64","percent of total billed charges",""
"SCREW BONE 5X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1012.45","607.47","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","635.62","62.78","","780.86","208.94","10480.28","15","117.75","783.64","percent of total billed charges",""
"SCREW BONE 5X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1012.45","607.47","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","442.64","43.72","","179.76","179.76","179.76","1 through 10","117.75","783.64","percent of total billed charges",""
"SCREW BONE 5X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1012.45","607.47","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","736.25","72.72","","2355.45","298.99","3965.19","155","117.75","783.64","percent of total billed charges",""
"SCREW BONE 5X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1012.45","607.47","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","736.25","72.72","","3643.09","3643.09","3643.09","1 through 10","117.75","783.64","percent of total billed charges",""
"SCREW BONE 5X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1012.45","607.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","538.83","53.22","","554.28","554.28","554.28","16","117.75","783.64","percent of total billed charges",""
"SCREW BONE 5X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1012.45","607.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","636.83","62.9","","619.64","173.09","2370.64","150","117.75","783.64","percent of total billed charges",""
"SCREW BONE 5X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1012.45","607.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","783.64","77.4","","303.98","303.98","5854.79","1 through 10","117.75","783.64","percent of total billed charges",""
"SCREW BONE 5X60MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011632","CDM","C1713","HCPCS","0278","RC","","","","both","","","1250.23","750.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","145.4","1062.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X60MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011632","CDM","C1713","HCPCS","0278","RC","","","","both","","","1250.23","750.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","145.4","1062.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X60MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011632","CDM","C1713","HCPCS","0278","RC","","","","both","","","1250.23","750.14","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","711.38","56.9","","812.12","238.65","1587.46","163","145.4","1062.7","percent of total billed charges",""
"SCREW BONE 5X60MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011632","CDM","C1713","HCPCS","0278","RC","","","","both","","","1250.23","750.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","145.40","11.63","","112.68","112.68","146.99","38","145.4","1062.7","percent of total billed charges",""
"SCREW BONE 5X60MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011632","CDM","C1713","HCPCS","0278","RC","","","","both","","","1250.23","750.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","967.68","77.4","","303.98","303.98","5854.79","1 through 10","145.4","1062.7","percent of total billed charges",""
"SCREW BONE 5X60MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1250.23","750.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","145.40","11.63","","112.68","112.68","146.99","38","145.4","967.68","percent of total billed charges",""
"SCREW BONE 5X60MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1250.23","750.14","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","784.89","62.78","","780.86","208.94","10480.28","15","145.4","967.68","percent of total billed charges",""
"SCREW BONE 5X60MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1250.23","750.14","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","546.60","43.72","","179.76","179.76","179.76","1 through 10","145.4","967.68","percent of total billed charges",""
"SCREW BONE 5X60MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1250.23","750.14","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","909.17","72.72","","2355.45","298.99","3965.19","155","145.4","967.68","percent of total billed charges",""
"SCREW BONE 5X60MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1250.23","750.14","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","909.17","72.72","","3643.09","3643.09","3643.09","1 through 10","145.4","967.68","percent of total billed charges",""
"SCREW BONE 5X60MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1250.23","750.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","665.37","53.22","","554.28","554.28","554.28","16","145.4","967.68","percent of total billed charges",""
"SCREW BONE 5X60MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1250.23","750.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","786.39","62.9","","619.64","173.09","2370.64","150","145.4","967.68","percent of total billed charges",""
"SCREW BONE 5X60MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1250.23","750.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","967.68","77.4","","303.98","303.98","5854.79","1 through 10","145.4","967.68","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","both","","","986.89","592.13","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","114.78","838.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","both","","","986.89","592.13","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","114.78","838.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","both","","","986.89","592.13","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","561.54","56.9","","812.12","238.65","1587.46","163","114.78","838.86","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","both","","","986.89","592.13","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","114.78","11.63","","112.68","112.68","146.99","38","114.78","838.86","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","both","","","986.89","592.13","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","763.85","77.4","","303.98","303.98","5854.79","1 through 10","114.78","838.86","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","986.89","592.13","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","114.78","11.63","","112.68","112.68","146.99","38","114.78","763.85","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","986.89","592.13","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","619.57","62.78","","780.86","208.94","10480.28","15","114.78","763.85","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","986.89","592.13","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","431.47","43.72","","179.76","179.76","179.76","1 through 10","114.78","763.85","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","986.89","592.13","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","717.67","72.72","","2355.45","298.99","3965.19","155","114.78","763.85","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","986.89","592.13","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","717.67","72.72","","3643.09","3643.09","3643.09","1 through 10","114.78","763.85","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","986.89","592.13","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","525.22","53.22","","554.28","554.28","554.28","16","114.78","763.85","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","986.89","592.13","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","620.75","62.9","","619.64","173.09","2370.64","150","114.78","763.85","percent of total billed charges",""
"SCREW BONE 5X75MM LOCKING DUAL CORE T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10019463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","986.89","592.13","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","763.85","77.4","","303.98","303.98","5854.79","1 through 10","114.78","763.85","percent of total billed charges",""
"SCREW BONE 5X78MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10294955","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","816.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","158.27","1156.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X78MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10294955","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","816.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","158.27","1156.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X78MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10294955","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","816.52","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","774.33","56.9","","812.12","238.65","1587.46","163","158.27","1156.73","percent of total billed charges",""
"SCREW BONE 5X78MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10294955","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","816.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","158.27","11.63","","112.68","112.68","146.99","38","158.27","1156.73","percent of total billed charges",""
"SCREW BONE 5X78MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10294955","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","816.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1053.31","77.4","","303.98","303.98","5854.79","1 through 10","158.27","1156.73","percent of total billed charges",""
"SCREW BONE 5X78MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10294955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","158.27","11.63","","112.68","112.68","146.99","38","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X78MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10294955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","854.35","62.78","","780.86","208.94","10480.28","15","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X78MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10294955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","594.97","43.72","","179.76","179.76","179.76","1 through 10","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X78MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10294955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","989.62","72.72","","2355.45","298.99","3965.19","155","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X78MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10294955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","989.62","72.72","","3643.09","3643.09","3643.09","1 through 10","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X78MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10294955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","724.25","53.22","","554.28","554.28","554.28","16","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X78MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10294955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","855.98","62.9","","619.64","173.09","2370.64","150","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X78MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10294955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1053.31","77.4","","303.98","303.98","5854.79","1 through 10","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X82MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288219","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","816.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","158.27","1156.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X82MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288219","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","816.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","158.27","1156.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X82MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288219","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","816.52","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","774.33","56.9","","812.12","238.65","1587.46","163","158.27","1156.73","percent of total billed charges",""
"SCREW BONE 5X82MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288219","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","816.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","158.27","11.63","","112.68","112.68","146.99","38","158.27","1156.73","percent of total billed charges",""
"SCREW BONE 5X82MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288219","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","816.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1053.31","77.4","","303.98","303.98","5854.79","1 through 10","158.27","1156.73","percent of total billed charges",""
"SCREW BONE 5X82MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","158.27","11.63","","112.68","112.68","146.99","38","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X82MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","854.35","62.78","","780.86","208.94","10480.28","15","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X82MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","594.97","43.72","","179.76","179.76","179.76","1 through 10","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X82MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","989.62","72.72","","2355.45","298.99","3965.19","155","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X82MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","989.62","72.72","","3643.09","3643.09","3643.09","1 through 10","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X82MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","724.25","53.22","","554.28","554.28","554.28","16","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X82MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","855.98","62.9","","619.64","173.09","2370.64","150","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X82MM XL25 LOCKING MEDULLARY NAIL COMPATIBLE","SUP-ITM-10288219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","816.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1053.31","77.4","","303.98","303.98","5854.79","1 through 10","158.27","1053.31","percent of total billed charges",""
"SCREW BONE 5X8MM STARDRIVE SS LOCKING SELF TAPPING RECESS","SUP-ITM-10097263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1797.64","1078.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","209.07","1527.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X8MM STARDRIVE SS LOCKING SELF TAPPING RECESS","SUP-ITM-10097263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1797.64","1078.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","209.07","1527.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X8MM STARDRIVE SS LOCKING SELF TAPPING RECESS","SUP-ITM-10097263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1797.64","1078.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1022.86","56.9","","812.12","238.65","1587.46","163","209.07","1527.99","percent of total billed charges",""
"SCREW BONE 5X8MM STARDRIVE SS LOCKING SELF TAPPING RECESS","SUP-ITM-10097263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1797.64","1078.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","209.07","11.63","","112.68","112.68","146.99","38","209.07","1527.99","percent of total billed charges",""
"SCREW BONE 5X8MM STARDRIVE SS LOCKING SELF TAPPING RECESS","SUP-ITM-10097263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1797.64","1078.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1391.37","77.4","","303.98","303.98","5854.79","1 through 10","209.07","1527.99","percent of total billed charges",""
"SCREW BONE 5X8MM STARDRIVE SS LOCKING SELF TAPPING RECESS","SUP-ITM-10097263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1797.64","1078.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","209.07","11.63","","112.68","112.68","146.99","38","209.07","1391.37","percent of total billed charges",""
"SCREW BONE 5X8MM STARDRIVE SS LOCKING SELF TAPPING RECESS","SUP-ITM-10097263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1797.64","1078.58","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1128.56","62.78","","780.86","208.94","10480.28","15","209.07","1391.37","percent of total billed charges",""
"SCREW BONE 5X8MM STARDRIVE SS LOCKING SELF TAPPING RECESS","SUP-ITM-10097263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1797.64","1078.58","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","785.93","43.72","","179.76","179.76","179.76","1 through 10","209.07","1391.37","percent of total billed charges",""
"SCREW BONE 5X8MM STARDRIVE SS LOCKING SELF TAPPING RECESS","SUP-ITM-10097263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1797.64","1078.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1307.24","72.72","","2355.45","298.99","3965.19","155","209.07","1391.37","percent of total billed charges",""
"SCREW BONE 5X8MM STARDRIVE SS LOCKING SELF TAPPING RECESS","SUP-ITM-10097263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1797.64","1078.58","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1307.24","72.72","","3643.09","3643.09","3643.09","1 through 10","209.07","1391.37","percent of total billed charges",""
"SCREW BONE 5X8MM STARDRIVE SS LOCKING SELF TAPPING RECESS","SUP-ITM-10097263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1797.64","1078.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","956.70","53.22","","554.28","554.28","554.28","16","209.07","1391.37","percent of total billed charges",""
"SCREW BONE 5X8MM STARDRIVE SS LOCKING SELF TAPPING RECESS","SUP-ITM-10097263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1797.64","1078.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1130.72","62.9","","619.64","173.09","2370.64","150","209.07","1391.37","percent of total billed charges",""
"SCREW BONE 5X8MM STARDRIVE SS LOCKING SELF TAPPING RECESS","SUP-ITM-10097263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1797.64","1078.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1391.37","77.4","","303.98","303.98","5854.79","1 through 10","209.07","1391.37","percent of total billed charges",""
"SCREW BONE 5X95MM SS CANNULATED VARIABLE ANGLE LOCKING","SUP-ITM-10097273","CDM","C1713","HCPCS","0278","RC","","","","both","","","1699.58","1019.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","197.66","1444.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X95MM SS CANNULATED VARIABLE ANGLE LOCKING","SUP-ITM-10097273","CDM","C1713","HCPCS","0278","RC","","","","both","","","1699.58","1019.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","197.66","1444.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 5X95MM SS CANNULATED VARIABLE ANGLE LOCKING","SUP-ITM-10097273","CDM","C1713","HCPCS","0278","RC","","","","both","","","1699.58","1019.75","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","967.06","56.9","","812.12","238.65","1587.46","163","197.66","1444.64","percent of total billed charges",""
"SCREW BONE 5X95MM SS CANNULATED VARIABLE ANGLE LOCKING","SUP-ITM-10097273","CDM","C1713","HCPCS","0278","RC","","","","both","","","1699.58","1019.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","197.66","11.63","","112.68","112.68","146.99","38","197.66","1444.64","percent of total billed charges",""
"SCREW BONE 5X95MM SS CANNULATED VARIABLE ANGLE LOCKING","SUP-ITM-10097273","CDM","C1713","HCPCS","0278","RC","","","","both","","","1699.58","1019.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1315.47","77.4","","303.98","303.98","5854.79","1 through 10","197.66","1444.64","percent of total billed charges",""
"SCREW BONE 5X95MM SS CANNULATED VARIABLE ANGLE LOCKING","SUP-ITM-10097273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1699.58","1019.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","197.66","11.63","","112.68","112.68","146.99","38","197.66","1315.47","percent of total billed charges",""
"SCREW BONE 5X95MM SS CANNULATED VARIABLE ANGLE LOCKING","SUP-ITM-10097273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1699.58","1019.75","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1067.00","62.78","","780.86","208.94","10480.28","15","197.66","1315.47","percent of total billed charges",""
"SCREW BONE 5X95MM SS CANNULATED VARIABLE ANGLE LOCKING","SUP-ITM-10097273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1699.58","1019.75","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","743.06","43.72","","179.76","179.76","179.76","1 through 10","197.66","1315.47","percent of total billed charges",""
"SCREW BONE 5X95MM SS CANNULATED VARIABLE ANGLE LOCKING","SUP-ITM-10097273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1699.58","1019.75","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1235.93","72.72","","2355.45","298.99","3965.19","155","197.66","1315.47","percent of total billed charges",""
"SCREW BONE 5X95MM SS CANNULATED VARIABLE ANGLE LOCKING","SUP-ITM-10097273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1699.58","1019.75","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1235.93","72.72","","3643.09","3643.09","3643.09","1 through 10","197.66","1315.47","percent of total billed charges",""
"SCREW BONE 5X95MM SS CANNULATED VARIABLE ANGLE LOCKING","SUP-ITM-10097273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1699.58","1019.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","904.52","53.22","","554.28","554.28","554.28","16","197.66","1315.47","percent of total billed charges",""
"SCREW BONE 5X95MM SS CANNULATED VARIABLE ANGLE LOCKING","SUP-ITM-10097273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1699.58","1019.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1069.04","62.9","","619.64","173.09","2370.64","150","197.66","1315.47","percent of total billed charges",""
"SCREW BONE 5X95MM SS CANNULATED VARIABLE ANGLE LOCKING","SUP-ITM-10097273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1699.58","1019.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1315.47","77.4","","303.98","303.98","5854.79","1 through 10","197.66","1315.47","percent of total billed charges",""
"SCREW BONE 6.0X14X11MM SPINE GRAFT TISSUE CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10028232","CDM","C1889","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","562.54","4111.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.0X14X11MM SPINE GRAFT TISSUE CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10028232","CDM","C1889","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","562.54","4111.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.0X14X11MM SPINE GRAFT TISSUE CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10028232","CDM","C1889","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2752.25","56.9","","0.63","0.63","0.63","1 through 10","562.54","4111.45","percent of total billed charges",""
"SCREW BONE 6.0X14X11MM SPINE GRAFT TISSUE CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10028232","CDM","C1889","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","697.50","14.42","","317.14","317.14","317.14","1 through 10","562.54","4111.45","percent of total billed charges",""
"SCREW BONE 6.0X14X11MM SPINE GRAFT TISSUE CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10028232","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","697.50","14.42","","317.14","317.14","317.14","1 through 10","562.54","3743.84","percent of total billed charges",""
"SCREW BONE 6.0X14X11MM SPINE GRAFT TISSUE CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10028232","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3036.67","62.78","","1125.09","1125.09","1125.09","1 through 10","562.54","3743.84","percent of total billed charges",""
"SCREW BONE 6.0X14X11MM SPINE GRAFT TISSUE CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10028232","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3517.47","72.72","","4732.50","1617.43","14180.40","1 through 10","562.54","3743.84","percent of total billed charges",""
"SCREW BONE 6.0X14X11MM SPINE GRAFT TISSUE CORNERSTONE LASER CORTICAL CANCELLOUS","SUP-ITM-10028232","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3042.47","62.9","","3896.20","3341.38","3896.20","1 through 10","562.54","3743.84","percent of total billed charges",""
"SCREW BONE 6.0X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111148","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","321.45","2349.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.0X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111148","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","321.45","2349.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.0X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111148","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1572.72","56.9","","812.12","238.65","1587.46","163","321.45","2349.4","percent of total billed charges",""
"SCREW BONE 6.0X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111148","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.45","11.63","","112.68","112.68","146.99","38","321.45","2349.4","percent of total billed charges",""
"SCREW BONE 6.0X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111148","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2139.34","77.4","","303.98","303.98","5854.79","1 through 10","321.45","2349.4","percent of total billed charges",""
"SCREW BONE 6.0X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.45","11.63","","112.68","112.68","146.99","38","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 6.0X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1735.24","62.78","","780.86","208.94","10480.28","15","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 6.0X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1208.42","43.72","","179.76","179.76","179.76","1 through 10","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 6.0X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2009.98","72.72","","2355.45","298.99","3965.19","155","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 6.0X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2009.98","72.72","","3643.09","3643.09","3643.09","1 through 10","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 6.0X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1471.00","53.22","","554.28","554.28","554.28","16","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 6.0X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1738.56","62.9","","619.64","173.09","2370.64","150","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 6.0X30MM SPINE SOVEREIGN TITANIUM FIXED ANGLE","SUP-ITM-10111148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2139.34","77.4","","303.98","303.98","5854.79","1 through 10","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","both","","","1152.04","691.22","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","133.98","979.23","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","both","","","1152.04","691.22","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","133.98","979.23","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","both","","","1152.04","691.22","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","655.51","56.9","","812.12","238.65","1587.46","163","133.98","979.23","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","both","","","1152.04","691.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","133.98","11.63","","112.68","112.68","146.99","38","133.98","979.23","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","both","","","1152.04","691.22","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","891.68","77.4","","303.98","303.98","5854.79","1 through 10","133.98","979.23","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1152.04","691.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","133.98","11.63","","112.68","112.68","146.99","38","133.98","891.68","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1152.04","691.22","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","723.25","62.78","","780.86","208.94","10480.28","15","133.98","891.68","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1152.04","691.22","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","503.67","43.72","","179.76","179.76","179.76","1 through 10","133.98","891.68","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1152.04","691.22","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","837.76","72.72","","2355.45","298.99","3965.19","155","133.98","891.68","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1152.04","691.22","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","837.76","72.72","","3643.09","3643.09","3643.09","1 through 10","133.98","891.68","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1152.04","691.22","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","613.12","53.22","","554.28","554.28","554.28","16","133.98","891.68","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1152.04","691.22","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","724.63","62.9","","619.64","173.09","2370.64","150","133.98","891.68","percent of total billed charges",""
"SCREW BONE 6.5X140MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1152.04","691.22","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","891.68","77.4","","303.98","303.98","5854.79","1 through 10","133.98","891.68","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037292","CDM","C1713","HCPCS","0278","RC","","","","both","","","1121.08","672.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","130.38","952.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X20MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037292","CDM","C1713","HCPCS","0278","RC","","","","both","","","1121.08","672.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","130.38","952.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X20MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037292","CDM","C1713","HCPCS","0278","RC","","","","both","","","1121.08","672.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","637.89","56.9","","812.12","238.65","1587.46","163","130.38","952.92","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037292","CDM","C1713","HCPCS","0278","RC","","","","both","","","1121.08","672.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","130.38","11.63","","112.68","112.68","146.99","38","130.38","952.92","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037292","CDM","C1713","HCPCS","0278","RC","","","","both","","","1121.08","672.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","867.72","77.4","","303.98","303.98","5854.79","1 through 10","130.38","952.92","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1121.08","672.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","130.38","11.63","","112.68","112.68","146.99","38","130.38","867.72","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1121.08","672.65","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","703.81","62.78","","780.86","208.94","10480.28","15","130.38","867.72","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1121.08","672.65","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","490.14","43.72","","179.76","179.76","179.76","1 through 10","130.38","867.72","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1121.08","672.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","815.25","72.72","","2355.45","298.99","3965.19","155","130.38","867.72","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1121.08","672.65","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","815.25","72.72","","3643.09","3643.09","3643.09","1 through 10","130.38","867.72","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1121.08","672.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","596.64","53.22","","554.28","554.28","554.28","16","130.38","867.72","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1121.08","672.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","705.16","62.9","","619.64","173.09","2370.64","150","130.38","867.72","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10037292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1121.08","672.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","867.72","77.4","","303.98","303.98","5854.79","1 through 10","130.38","867.72","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.58","157.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","30.54","223.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.58","157.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","30.54","223.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.58","157.55","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","149.41","56.9","","812.12","238.65","1587.46","163","30.54","223.19","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.58","157.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","30.54","11.63","","112.68","112.68","146.99","38","30.54","223.19","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.58","157.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","203.24","77.4","","303.98","303.98","5854.79","1 through 10","30.54","223.19","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","30.54","11.63","","112.68","112.68","146.99","38","30.54","203.24","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","164.85","62.78","","780.86","208.94","10480.28","15","30.54","203.24","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","114.80","43.72","","179.76","179.76","179.76","1 through 10","30.54","203.24","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","190.95","72.72","","2355.45","298.99","3965.19","155","30.54","203.24","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","190.95","72.72","","3643.09","3643.09","3643.09","1 through 10","30.54","203.24","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","139.75","53.22","","554.28","554.28","554.28","16","30.54","203.24","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","165.16","62.9","","619.64","173.09","2370.64","150","30.54","203.24","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.58","157.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","203.24","77.4","","303.98","303.98","5854.79","1 through 10","30.54","203.24","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","both","","","172.75","103.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","20.09","146.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","both","","","172.75","103.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","20.09","146.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","both","","","172.75","103.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","98.29","56.9","","812.12","238.65","1587.46","163","20.09","146.84","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","both","","","172.75","103.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.09","11.63","","112.68","112.68","146.99","38","20.09","146.84","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","both","","","172.75","103.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","133.71","77.4","","303.98","303.98","5854.79","1 through 10","20.09","146.84","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.09","11.63","","112.68","112.68","146.99","38","20.09","133.71","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","108.45","62.78","","780.86","208.94","10480.28","15","20.09","133.71","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","75.53","43.72","","179.76","179.76","179.76","1 through 10","20.09","133.71","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","125.62","72.72","","2355.45","298.99","3965.19","155","20.09","133.71","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","125.62","72.72","","3643.09","3643.09","3643.09","1 through 10","20.09","133.71","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","91.94","53.22","","554.28","554.28","554.28","16","20.09","133.71","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","108.66","62.9","","619.64","173.09","2370.64","150","20.09","133.71","percent of total billed charges",""
"SCREW BONE 6.5X25MM LOW PROFILE","SUP-ITM-10208606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","133.71","77.4","","303.98","303.98","5854.79","1 through 10","20.09","133.71","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","both","","","1563.32","937.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","181.81","1328.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","both","","","1563.32","937.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","181.81","1328.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","both","","","1563.32","937.99","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","889.53","56.9","","812.12","238.65","1587.46","163","181.81","1328.82","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","both","","","1563.32","937.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","181.81","11.63","","112.68","112.68","146.99","38","181.81","1328.82","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","both","","","1563.32","937.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1210.01","77.4","","303.98","303.98","5854.79","1 through 10","181.81","1328.82","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1563.32","937.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","181.81","11.63","","112.68","112.68","146.99","38","181.81","1210.01","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1563.32","937.99","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","981.45","62.78","","780.86","208.94","10480.28","15","181.81","1210.01","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1563.32","937.99","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","683.48","43.72","","179.76","179.76","179.76","1 through 10","181.81","1210.01","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1563.32","937.99","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1136.85","72.72","","2355.45","298.99","3965.19","155","181.81","1210.01","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1563.32","937.99","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1136.85","72.72","","3643.09","3643.09","3643.09","1 through 10","181.81","1210.01","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1563.32","937.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","832.00","53.22","","554.28","554.28","554.28","16","181.81","1210.01","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1563.32","937.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","983.33","62.9","","619.64","173.09","2370.64","150","181.81","1210.01","percent of total billed charges",""
"SCREW BONE 6.5X30MM COMPRESSION SS 16MM THREAD HEADLESS","SUP-ITM-10095350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1563.32","937.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1210.01","77.4","","303.98","303.98","5854.79","1 through 10","181.81","1210.01","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2252.66","1351.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","261.98","1914.76","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2252.66","1351.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","261.98","1914.76","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2252.66","1351.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1281.76","56.9","","812.12","238.65","1587.46","163","261.98","1914.76","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2252.66","1351.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","261.98","11.63","","112.68","112.68","146.99","38","261.98","1914.76","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2252.66","1351.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1743.56","77.4","","303.98","303.98","5854.79","1 through 10","261.98","1914.76","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2252.66","1351.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","261.98","11.63","","112.68","112.68","146.99","38","261.98","1743.56","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2252.66","1351.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1414.22","62.78","","780.86","208.94","10480.28","15","261.98","1743.56","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2252.66","1351.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","984.86","43.72","","179.76","179.76","179.76","1 through 10","261.98","1743.56","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2252.66","1351.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1638.13","72.72","","2355.45","298.99","3965.19","155","261.98","1743.56","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2252.66","1351.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1638.13","72.72","","3643.09","3643.09","3643.09","1 through 10","261.98","1743.56","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2252.66","1351.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1198.87","53.22","","554.28","554.28","554.28","16","261.98","1743.56","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2252.66","1351.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1416.92","62.9","","619.64","173.09","2370.64","150","261.98","1743.56","percent of total billed charges",""
"SCREW BONE 6.5X35MM CENTRAL","SUP-ITM-10215302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2252.66","1351.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1743.56","77.4","","303.98","303.98","5854.79","1 through 10","261.98","1743.56","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","172.75","103.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","20.09","146.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","172.75","103.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","20.09","146.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","172.75","103.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","98.29","56.9","","812.12","238.65","1587.46","163","20.09","146.84","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","172.75","103.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.09","11.63","","112.68","112.68","146.99","38","20.09","146.84","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","172.75","103.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","133.71","77.4","","303.98","303.98","5854.79","1 through 10","20.09","146.84","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.09","11.63","","112.68","112.68","146.99","38","20.09","133.71","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","108.45","62.78","","780.86","208.94","10480.28","15","20.09","133.71","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","75.53","43.72","","179.76","179.76","179.76","1 through 10","20.09","133.71","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","125.62","72.72","","2355.45","298.99","3965.19","155","20.09","133.71","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","125.62","72.72","","3643.09","3643.09","3643.09","1 through 10","20.09","133.71","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","91.94","53.22","","554.28","554.28","554.28","16","20.09","133.71","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","108.66","62.9","","619.64","173.09","2370.64","150","20.09","133.71","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","133.71","77.4","","303.98","303.98","5854.79","1 through 10","20.09","133.71","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10027185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3938.70","2363.22","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","458.07","3347.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X60MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10027185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3938.70","2363.22","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","458.07","3347.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X60MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10027185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3938.70","2363.22","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2241.12","56.9","","812.12","238.65","1587.46","163","458.07","3347.9","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10027185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3938.70","2363.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","458.07","11.63","","112.68","112.68","146.99","38","458.07","3347.9","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10027185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3938.70","2363.22","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3048.55","77.4","","303.98","303.98","5854.79","1 through 10","458.07","3347.9","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10027185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3938.70","2363.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","458.07","11.63","","112.68","112.68","146.99","38","458.07","3048.55","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10027185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3938.70","2363.22","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2472.72","62.78","","780.86","208.94","10480.28","15","458.07","3048.55","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10027185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3938.70","2363.22","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1722.00","43.72","","179.76","179.76","179.76","1 through 10","458.07","3048.55","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10027185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3938.70","2363.22","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2864.22","72.72","","2355.45","298.99","3965.19","155","458.07","3048.55","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10027185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3938.70","2363.22","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2864.22","72.72","","3643.09","3643.09","3643.09","1 through 10","458.07","3048.55","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10027185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3938.70","2363.22","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2096.18","53.22","","554.28","554.28","554.28","16","458.07","3048.55","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10027185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3938.70","2363.22","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2477.44","62.9","","619.64","173.09","2370.64","150","458.07","3048.55","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10027185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3938.70","2363.22","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3048.55","77.4","","303.98","303.98","5854.79","1 through 10","458.07","3048.55","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","1121.08","672.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","130.38","952.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","1121.08","672.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","130.38","952.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","1121.08","672.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","637.89","56.9","","812.12","238.65","1587.46","163","130.38","952.92","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","1121.08","672.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","130.38","11.63","","112.68","112.68","146.99","38","130.38","952.92","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","1121.08","672.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","867.72","77.4","","303.98","303.98","5854.79","1 through 10","130.38","952.92","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1121.08","672.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","130.38","11.63","","112.68","112.68","146.99","38","130.38","867.72","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1121.08","672.65","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","703.81","62.78","","780.86","208.94","10480.28","15","130.38","867.72","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1121.08","672.65","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","490.14","43.72","","179.76","179.76","179.76","1 through 10","130.38","867.72","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1121.08","672.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","815.25","72.72","","2355.45","298.99","3965.19","155","130.38","867.72","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1121.08","672.65","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","815.25","72.72","","3643.09","3643.09","3643.09","1 through 10","130.38","867.72","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1121.08","672.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","596.64","53.22","","554.28","554.28","554.28","16","130.38","867.72","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1121.08","672.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","705.16","62.9","","619.64","173.09","2370.64","150","130.38","867.72","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1121.08","672.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","867.72","77.4","","303.98","303.98","5854.79","1 through 10","130.38","867.72","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","both","","","3654.70","2192.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","425.04","3106.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","both","","","3654.70","2192.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","425.04","3106.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","both","","","3654.70","2192.82","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2079.52","56.9","","812.12","238.65","1587.46","163","425.04","3106.5","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","both","","","3654.70","2192.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","425.04","11.63","","112.68","112.68","146.99","38","425.04","3106.5","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","both","","","3654.70","2192.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2828.74","77.4","","303.98","303.98","5854.79","1 through 10","425.04","3106.5","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3654.70","2192.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","425.04","11.63","","112.68","112.68","146.99","38","425.04","2828.74","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3654.70","2192.82","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2294.42","62.78","","780.86","208.94","10480.28","15","425.04","2828.74","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3654.70","2192.82","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1597.83","43.72","","179.76","179.76","179.76","1 through 10","425.04","2828.74","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3654.70","2192.82","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2657.70","72.72","","2355.45","298.99","3965.19","155","425.04","2828.74","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3654.70","2192.82","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2657.70","72.72","","3643.09","3643.09","3643.09","1 through 10","425.04","2828.74","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3654.70","2192.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1945.03","53.22","","554.28","554.28","554.28","16","425.04","2828.74","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3654.70","2192.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2298.81","62.9","","619.64","173.09","2370.64","150","425.04","2828.74","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3654.70","2192.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2828.74","77.4","","303.98","303.98","5854.79","1 through 10","425.04","2828.74","percent of total billed charges",""
"SCREW BONE 6.5X75MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10020503","CDM","C1713","HCPCS","0278","RC","","","","both","","","3938.70","2363.22","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","458.07","3347.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X75MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10020503","CDM","C1713","HCPCS","0278","RC","","","","both","","","3938.70","2363.22","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","458.07","3347.9","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X75MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10020503","CDM","C1713","HCPCS","0278","RC","","","","both","","","3938.70","2363.22","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2241.12","56.9","","812.12","238.65","1587.46","163","458.07","3347.9","percent of total billed charges",""
"SCREW BONE 6.5X75MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10020503","CDM","C1713","HCPCS","0278","RC","","","","both","","","3938.70","2363.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","458.07","11.63","","112.68","112.68","146.99","38","458.07","3347.9","percent of total billed charges",""
"SCREW BONE 6.5X75MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10020503","CDM","C1713","HCPCS","0278","RC","","","","both","","","3938.70","2363.22","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3048.55","77.4","","303.98","303.98","5854.79","1 through 10","458.07","3347.9","percent of total billed charges",""
"SCREW BONE 6.5X75MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10020503","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3938.70","2363.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","458.07","11.63","","112.68","112.68","146.99","38","458.07","3048.55","percent of total billed charges",""
"SCREW BONE 6.5X75MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10020503","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3938.70","2363.22","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2472.72","62.78","","780.86","208.94","10480.28","15","458.07","3048.55","percent of total billed charges",""
"SCREW BONE 6.5X75MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10020503","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3938.70","2363.22","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1722.00","43.72","","179.76","179.76","179.76","1 through 10","458.07","3048.55","percent of total billed charges",""
"SCREW BONE 6.5X75MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10020503","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3938.70","2363.22","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2864.22","72.72","","2355.45","298.99","3965.19","155","458.07","3048.55","percent of total billed charges",""
"SCREW BONE 6.5X75MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10020503","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3938.70","2363.22","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2864.22","72.72","","3643.09","3643.09","3643.09","1 through 10","458.07","3048.55","percent of total billed charges",""
"SCREW BONE 6.5X75MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10020503","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3938.70","2363.22","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2096.18","53.22","","554.28","554.28","554.28","16","458.07","3048.55","percent of total billed charges",""
"SCREW BONE 6.5X75MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10020503","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3938.70","2363.22","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2477.44","62.9","","619.64","173.09","2370.64","150","458.07","3048.55","percent of total billed charges",""
"SCREW BONE 6.5X75MM CANNULATED SS PARTIAL THREAD","SUP-ITM-10020503","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3938.70","2363.22","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3048.55","77.4","","303.98","303.98","5854.79","1 through 10","458.07","3048.55","percent of total billed charges",""
"SCREW BONE 6.5X90MM COMPRESSION 32MM THREAD SS HEADLESS","SUP-ITM-10097238","CDM","C1713","HCPCS","0278","RC","","","","both","","","1786.65","1071.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","207.79","1518.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X90MM COMPRESSION 32MM THREAD SS HEADLESS","SUP-ITM-10097238","CDM","C1713","HCPCS","0278","RC","","","","both","","","1786.65","1071.99","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","207.79","1518.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 6.5X90MM COMPRESSION 32MM THREAD SS HEADLESS","SUP-ITM-10097238","CDM","C1713","HCPCS","0278","RC","","","","both","","","1786.65","1071.99","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1016.60","56.9","","812.12","238.65","1587.46","163","207.79","1518.65","percent of total billed charges",""
"SCREW BONE 6.5X90MM COMPRESSION 32MM THREAD SS HEADLESS","SUP-ITM-10097238","CDM","C1713","HCPCS","0278","RC","","","","both","","","1786.65","1071.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","207.79","11.63","","112.68","112.68","146.99","38","207.79","1518.65","percent of total billed charges",""
"SCREW BONE 6.5X90MM COMPRESSION 32MM THREAD SS HEADLESS","SUP-ITM-10097238","CDM","C1713","HCPCS","0278","RC","","","","both","","","1786.65","1071.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1382.87","77.4","","303.98","303.98","5854.79","1 through 10","207.79","1518.65","percent of total billed charges",""
"SCREW BONE 6.5X90MM COMPRESSION 32MM THREAD SS HEADLESS","SUP-ITM-10097238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1786.65","1071.99","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","207.79","11.63","","112.68","112.68","146.99","38","207.79","1382.87","percent of total billed charges",""
"SCREW BONE 6.5X90MM COMPRESSION 32MM THREAD SS HEADLESS","SUP-ITM-10097238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1786.65","1071.99","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1121.66","62.78","","780.86","208.94","10480.28","15","207.79","1382.87","percent of total billed charges",""
"SCREW BONE 6.5X90MM COMPRESSION 32MM THREAD SS HEADLESS","SUP-ITM-10097238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1786.65","1071.99","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","781.12","43.72","","179.76","179.76","179.76","1 through 10","207.79","1382.87","percent of total billed charges",""
"SCREW BONE 6.5X90MM COMPRESSION 32MM THREAD SS HEADLESS","SUP-ITM-10097238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1786.65","1071.99","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1299.25","72.72","","2355.45","298.99","3965.19","155","207.79","1382.87","percent of total billed charges",""
"SCREW BONE 6.5X90MM COMPRESSION 32MM THREAD SS HEADLESS","SUP-ITM-10097238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1786.65","1071.99","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1299.25","72.72","","3643.09","3643.09","3643.09","1 through 10","207.79","1382.87","percent of total billed charges",""
"SCREW BONE 6.5X90MM COMPRESSION 32MM THREAD SS HEADLESS","SUP-ITM-10097238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1786.65","1071.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","950.86","53.22","","554.28","554.28","554.28","16","207.79","1382.87","percent of total billed charges",""
"SCREW BONE 6.5X90MM COMPRESSION 32MM THREAD SS HEADLESS","SUP-ITM-10097238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1786.65","1071.99","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1123.80","62.9","","619.64","173.09","2370.64","150","207.79","1382.87","percent of total billed charges",""
"SCREW BONE 6.5X90MM COMPRESSION 32MM THREAD SS HEADLESS","SUP-ITM-10097238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1786.65","1071.99","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1382.87","77.4","","303.98","303.98","5854.79","1 through 10","207.79","1382.87","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","1114.44","668.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","129.61","947.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","1114.44","668.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","129.61","947.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","1114.44","668.66","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","634.12","56.9","","812.12","238.65","1587.46","163","129.61","947.27","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","1114.44","668.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","129.61","11.63","","112.68","112.68","146.99","38","129.61","947.27","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","1114.44","668.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","862.58","77.4","","303.98","303.98","5854.79","1 through 10","129.61","947.27","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1114.44","668.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","129.61","11.63","","112.68","112.68","146.99","38","129.61","862.58","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1114.44","668.66","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","699.65","62.78","","780.86","208.94","10480.28","15","129.61","862.58","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1114.44","668.66","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","487.23","43.72","","179.76","179.76","179.76","1 through 10","129.61","862.58","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1114.44","668.66","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","810.42","72.72","","2355.45","298.99","3965.19","155","129.61","862.58","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1114.44","668.66","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","810.42","72.72","","3643.09","3643.09","3643.09","1 through 10","129.61","862.58","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1114.44","668.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","593.10","53.22","","554.28","554.28","554.28","16","129.61","862.58","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1114.44","668.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","700.98","62.9","","619.64","173.09","2370.64","150","129.61","862.58","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1114.44","668.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","862.58","77.4","","303.98","303.98","5854.79","1 through 10","129.61","862.58","percent of total billed charges",""
"SCREW BONE 7.3X135MM SS CANNULATED SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10094958","CDM","C1713","HCPCS","0278","RC","","","","both","","","1149.82","689.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","133.72","977.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 7.3X135MM SS CANNULATED SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10094958","CDM","C1713","HCPCS","0278","RC","","","","both","","","1149.82","689.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","133.72","977.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 7.3X135MM SS CANNULATED SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10094958","CDM","C1713","HCPCS","0278","RC","","","","both","","","1149.82","689.89","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","654.25","56.9","","812.12","238.65","1587.46","163","133.72","977.35","percent of total billed charges",""
"SCREW BONE 7.3X135MM SS CANNULATED SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10094958","CDM","C1713","HCPCS","0278","RC","","","","both","","","1149.82","689.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","133.72","11.63","","112.68","112.68","146.99","38","133.72","977.35","percent of total billed charges",""
"SCREW BONE 7.3X135MM SS CANNULATED SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10094958","CDM","C1713","HCPCS","0278","RC","","","","both","","","1149.82","689.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","889.96","77.4","","303.98","303.98","5854.79","1 through 10","133.72","977.35","percent of total billed charges",""
"SCREW BONE 7.3X135MM SS CANNULATED SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10094958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1149.82","689.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","133.72","11.63","","112.68","112.68","146.99","38","133.72","889.96","percent of total billed charges",""
"SCREW BONE 7.3X135MM SS CANNULATED SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10094958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1149.82","689.89","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","721.86","62.78","","780.86","208.94","10480.28","15","133.72","889.96","percent of total billed charges",""
"SCREW BONE 7.3X135MM SS CANNULATED SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10094958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1149.82","689.89","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","502.70","43.72","","179.76","179.76","179.76","1 through 10","133.72","889.96","percent of total billed charges",""
"SCREW BONE 7.3X135MM SS CANNULATED SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10094958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1149.82","689.89","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","836.15","72.72","","2355.45","298.99","3965.19","155","133.72","889.96","percent of total billed charges",""
"SCREW BONE 7.3X135MM SS CANNULATED SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10094958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1149.82","689.89","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","836.15","72.72","","3643.09","3643.09","3643.09","1 through 10","133.72","889.96","percent of total billed charges",""
"SCREW BONE 7.3X135MM SS CANNULATED SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10094958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1149.82","689.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","611.93","53.22","","554.28","554.28","554.28","16","133.72","889.96","percent of total billed charges",""
"SCREW BONE 7.3X135MM SS CANNULATED SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10094958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1149.82","689.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","723.24","62.9","","619.64","173.09","2370.64","150","133.72","889.96","percent of total billed charges",""
"SCREW BONE 7.3X135MM SS CANNULATED SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10094958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1149.82","689.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","889.96","77.4","","303.98","303.98","5854.79","1 through 10","133.72","889.96","percent of total billed charges",""
"SCREW BONE 7.3X25MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022656","CDM","C1713","HCPCS","0278","RC","","","","both","","","1367.83","820.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","159.08","1162.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 7.3X25MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022656","CDM","C1713","HCPCS","0278","RC","","","","both","","","1367.83","820.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","159.08","1162.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 7.3X25MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022656","CDM","C1713","HCPCS","0278","RC","","","","both","","","1367.83","820.70","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","778.30","56.9","","812.12","238.65","1587.46","163","159.08","1162.66","percent of total billed charges",""
"SCREW BONE 7.3X25MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022656","CDM","C1713","HCPCS","0278","RC","","","","both","","","1367.83","820.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","159.08","11.63","","112.68","112.68","146.99","38","159.08","1162.66","percent of total billed charges",""
"SCREW BONE 7.3X25MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022656","CDM","C1713","HCPCS","0278","RC","","","","both","","","1367.83","820.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1058.70","77.4","","303.98","303.98","5854.79","1 through 10","159.08","1162.66","percent of total billed charges",""
"SCREW BONE 7.3X25MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1367.83","820.70","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","159.08","11.63","","112.68","112.68","146.99","38","159.08","1058.7","percent of total billed charges",""
"SCREW BONE 7.3X25MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1367.83","820.70","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","858.72","62.78","","780.86","208.94","10480.28","15","159.08","1058.7","percent of total billed charges",""
"SCREW BONE 7.3X25MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1367.83","820.70","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","598.02","43.72","","179.76","179.76","179.76","1 through 10","159.08","1058.7","percent of total billed charges",""
"SCREW BONE 7.3X25MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1367.83","820.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","994.69","72.72","","2355.45","298.99","3965.19","155","159.08","1058.7","percent of total billed charges",""
"SCREW BONE 7.3X25MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1367.83","820.70","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","994.69","72.72","","3643.09","3643.09","3643.09","1 through 10","159.08","1058.7","percent of total billed charges",""
"SCREW BONE 7.3X25MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1367.83","820.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","727.96","53.22","","554.28","554.28","554.28","16","159.08","1058.7","percent of total billed charges",""
"SCREW BONE 7.3X25MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1367.83","820.70","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","860.37","62.9","","619.64","173.09","2370.64","150","159.08","1058.7","percent of total billed charges",""
"SCREW BONE 7.3X25MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10022656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1367.83","820.70","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1058.70","77.4","","303.98","303.98","5854.79","1 through 10","159.08","1058.7","percent of total billed charges",""
"SCREW BONE 7.5X50MM SPINE PEDICLE MULTIAXIAL CD HORIZON LEGACY SS","SUP-ITM-10060737","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","321.45","2349.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 7.5X50MM SPINE PEDICLE MULTIAXIAL CD HORIZON LEGACY SS","SUP-ITM-10060737","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","321.45","2349.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 7.5X50MM SPINE PEDICLE MULTIAXIAL CD HORIZON LEGACY SS","SUP-ITM-10060737","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1572.72","56.9","","812.12","238.65","1587.46","163","321.45","2349.4","percent of total billed charges",""
"SCREW BONE 7.5X50MM SPINE PEDICLE MULTIAXIAL CD HORIZON LEGACY SS","SUP-ITM-10060737","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.45","11.63","","112.68","112.68","146.99","38","321.45","2349.4","percent of total billed charges",""
"SCREW BONE 7.5X50MM SPINE PEDICLE MULTIAXIAL CD HORIZON LEGACY SS","SUP-ITM-10060737","CDM","C1713","HCPCS","0278","RC","","","","both","","","2764.00","1658.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2139.34","77.4","","303.98","303.98","5854.79","1 through 10","321.45","2349.4","percent of total billed charges",""
"SCREW BONE 7.5X50MM SPINE PEDICLE MULTIAXIAL CD HORIZON LEGACY SS","SUP-ITM-10060737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.45","11.63","","112.68","112.68","146.99","38","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 7.5X50MM SPINE PEDICLE MULTIAXIAL CD HORIZON LEGACY SS","SUP-ITM-10060737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1735.24","62.78","","780.86","208.94","10480.28","15","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 7.5X50MM SPINE PEDICLE MULTIAXIAL CD HORIZON LEGACY SS","SUP-ITM-10060737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1208.42","43.72","","179.76","179.76","179.76","1 through 10","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 7.5X50MM SPINE PEDICLE MULTIAXIAL CD HORIZON LEGACY SS","SUP-ITM-10060737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2009.98","72.72","","2355.45","298.99","3965.19","155","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 7.5X50MM SPINE PEDICLE MULTIAXIAL CD HORIZON LEGACY SS","SUP-ITM-10060737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2009.98","72.72","","3643.09","3643.09","3643.09","1 through 10","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 7.5X50MM SPINE PEDICLE MULTIAXIAL CD HORIZON LEGACY SS","SUP-ITM-10060737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1471.00","53.22","","554.28","554.28","554.28","16","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 7.5X50MM SPINE PEDICLE MULTIAXIAL CD HORIZON LEGACY SS","SUP-ITM-10060737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1738.56","62.9","","619.64","173.09","2370.64","150","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 7.5X50MM SPINE PEDICLE MULTIAXIAL CD HORIZON LEGACY SS","SUP-ITM-10060737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2764.00","1658.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2139.34","77.4","","303.98","303.98","5854.79","1 through 10","321.45","2139.34","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.76","871.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","168.96","1234.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.76","871.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","168.96","1234.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.76","871.66","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","826.62","56.9","","812.12","238.65","1587.46","163","168.96","1234.85","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.76","871.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","168.96","11.63","","112.68","112.68","146.99","38","168.96","1234.85","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.76","871.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1124.44","77.4","","303.98","303.98","5854.79","1 through 10","168.96","1234.85","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1452.76","871.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","168.96","11.63","","112.68","112.68","146.99","38","168.96","1124.44","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1452.76","871.66","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","912.04","62.78","","780.86","208.94","10480.28","15","168.96","1124.44","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1452.76","871.66","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","635.15","43.72","","179.76","179.76","179.76","1 through 10","168.96","1124.44","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1452.76","871.66","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1056.45","72.72","","2355.45","298.99","3965.19","155","168.96","1124.44","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1452.76","871.66","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1056.45","72.72","","3643.09","3643.09","3643.09","1 through 10","168.96","1124.44","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1452.76","871.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","773.16","53.22","","554.28","554.28","554.28","16","168.96","1124.44","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1452.76","871.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","913.79","62.9","","619.64","173.09","2370.64","150","168.96","1124.44","percent of total billed charges",""
"SCREW BONE 7X100MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10001512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1452.76","871.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1124.44","77.4","","303.98","303.98","5854.79","1 through 10","168.96","1124.44","percent of total billed charges",""
"SCREW BONE 7X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037274","CDM","C1713","HCPCS","0278","RC","","","","both","","","1494.77","896.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","173.84","1270.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 7X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037274","CDM","C1713","HCPCS","0278","RC","","","","both","","","1494.77","896.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","173.84","1270.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 7X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037274","CDM","C1713","HCPCS","0278","RC","","","","both","","","1494.77","896.86","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","850.52","56.9","","812.12","238.65","1587.46","163","173.84","1270.55","percent of total billed charges",""
"SCREW BONE 7X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037274","CDM","C1713","HCPCS","0278","RC","","","","both","","","1494.77","896.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","173.84","11.63","","112.68","112.68","146.99","38","173.84","1270.55","percent of total billed charges",""
"SCREW BONE 7X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037274","CDM","C1713","HCPCS","0278","RC","","","","both","","","1494.77","896.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1156.95","77.4","","303.98","303.98","5854.79","1 through 10","173.84","1270.55","percent of total billed charges",""
"SCREW BONE 7X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1494.77","896.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","173.84","11.63","","112.68","112.68","146.99","38","173.84","1156.95","percent of total billed charges",""
"SCREW BONE 7X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1494.77","896.86","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","938.42","62.78","","780.86","208.94","10480.28","15","173.84","1156.95","percent of total billed charges",""
"SCREW BONE 7X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1494.77","896.86","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","653.51","43.72","","179.76","179.76","179.76","1 through 10","173.84","1156.95","percent of total billed charges",""
"SCREW BONE 7X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1494.77","896.86","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1087.00","72.72","","2355.45","298.99","3965.19","155","173.84","1156.95","percent of total billed charges",""
"SCREW BONE 7X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1494.77","896.86","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1087.00","72.72","","3643.09","3643.09","3643.09","1 through 10","173.84","1156.95","percent of total billed charges",""
"SCREW BONE 7X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1494.77","896.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","795.52","53.22","","554.28","554.28","554.28","16","173.84","1156.95","percent of total billed charges",""
"SCREW BONE 7X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1494.77","896.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","940.21","62.9","","619.64","173.09","2370.64","150","173.84","1156.95","percent of total billed charges",""
"SCREW BONE 7X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1494.77","896.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1156.95","77.4","","303.98","303.98","5854.79","1 through 10","173.84","1156.95","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1494.77","896.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","173.84","1270.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1494.77","896.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","173.84","1270.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1494.77","896.86","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","850.52","56.9","","812.12","238.65","1587.46","163","173.84","1270.55","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1494.77","896.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","173.84","11.63","","112.68","112.68","146.99","38","173.84","1270.55","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","both","","","1494.77","896.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1156.95","77.4","","303.98","303.98","5854.79","1 through 10","173.84","1270.55","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1494.77","896.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","173.84","11.63","","112.68","112.68","146.99","38","173.84","1156.95","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1494.77","896.86","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","938.42","62.78","","780.86","208.94","10480.28","15","173.84","1156.95","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1494.77","896.86","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","653.51","43.72","","179.76","179.76","179.76","1 through 10","173.84","1156.95","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1494.77","896.86","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1087.00","72.72","","2355.45","298.99","3965.19","155","173.84","1156.95","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1494.77","896.86","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1087.00","72.72","","3643.09","3643.09","3643.09","1 through 10","173.84","1156.95","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1494.77","896.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","795.52","53.22","","554.28","554.28","554.28","16","173.84","1156.95","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1494.77","896.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","940.21","62.9","","619.64","173.09","2370.64","150","173.84","1156.95","percent of total billed charges",""
"SCREW BONE 7X150MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET FLAT","SUP-ITM-10037277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1494.77","896.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1156.95","77.4","","303.98","303.98","5854.79","1 through 10","173.84","1156.95","percent of total billed charges",""
"SCREW BONE 7X25MM CANNULATED RCI TITANIUM BLUNT THREAD 8MM HEAD","SUP-ITM-10049305","CDM","C1713","HCPCS","0278","RC","","","","both","","","1658.40","995.04","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","192.87","1409.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 7X25MM CANNULATED RCI TITANIUM BLUNT THREAD 8MM HEAD","SUP-ITM-10049305","CDM","C1713","HCPCS","0278","RC","","","","both","","","1658.40","995.04","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","192.87","1409.64","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 7X25MM CANNULATED RCI TITANIUM BLUNT THREAD 8MM HEAD","SUP-ITM-10049305","CDM","C1713","HCPCS","0278","RC","","","","both","","","1658.40","995.04","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","943.63","56.9","","812.12","238.65","1587.46","163","192.87","1409.64","percent of total billed charges",""
"SCREW BONE 7X25MM CANNULATED RCI TITANIUM BLUNT THREAD 8MM HEAD","SUP-ITM-10049305","CDM","C1713","HCPCS","0278","RC","","","","both","","","1658.40","995.04","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","192.87","11.63","","112.68","112.68","146.99","38","192.87","1409.64","percent of total billed charges",""
"SCREW BONE 7X25MM CANNULATED RCI TITANIUM BLUNT THREAD 8MM HEAD","SUP-ITM-10049305","CDM","C1713","HCPCS","0278","RC","","","","both","","","1658.40","995.04","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1283.60","77.4","","303.98","303.98","5854.79","1 through 10","192.87","1409.64","percent of total billed charges",""
"SCREW BONE 7X25MM CANNULATED RCI TITANIUM BLUNT THREAD 8MM HEAD","SUP-ITM-10049305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1658.40","995.04","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","192.87","11.63","","112.68","112.68","146.99","38","192.87","1283.6","percent of total billed charges",""
"SCREW BONE 7X25MM CANNULATED RCI TITANIUM BLUNT THREAD 8MM HEAD","SUP-ITM-10049305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1658.40","995.04","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1041.14","62.78","","780.86","208.94","10480.28","15","192.87","1283.6","percent of total billed charges",""
"SCREW BONE 7X25MM CANNULATED RCI TITANIUM BLUNT THREAD 8MM HEAD","SUP-ITM-10049305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1658.40","995.04","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","725.05","43.72","","179.76","179.76","179.76","1 through 10","192.87","1283.6","percent of total billed charges",""
"SCREW BONE 7X25MM CANNULATED RCI TITANIUM BLUNT THREAD 8MM HEAD","SUP-ITM-10049305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1658.40","995.04","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1205.99","72.72","","2355.45","298.99","3965.19","155","192.87","1283.6","percent of total billed charges",""
"SCREW BONE 7X25MM CANNULATED RCI TITANIUM BLUNT THREAD 8MM HEAD","SUP-ITM-10049305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1658.40","995.04","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1205.99","72.72","","3643.09","3643.09","3643.09","1 through 10","192.87","1283.6","percent of total billed charges",""
"SCREW BONE 7X25MM CANNULATED RCI TITANIUM BLUNT THREAD 8MM HEAD","SUP-ITM-10049305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1658.40","995.04","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","882.60","53.22","","554.28","554.28","554.28","16","192.87","1283.6","percent of total billed charges",""
"SCREW BONE 7X25MM CANNULATED RCI TITANIUM BLUNT THREAD 8MM HEAD","SUP-ITM-10049305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1658.40","995.04","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1043.13","62.9","","619.64","173.09","2370.64","150","192.87","1283.6","percent of total billed charges",""
"SCREW BONE 7X25MM CANNULATED RCI TITANIUM BLUNT THREAD 8MM HEAD","SUP-ITM-10049305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1658.40","995.04","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1283.60","77.4","","303.98","303.98","5854.79","1 through 10","192.87","1283.6","percent of total billed charges",""
"SCREW BONE 7X60MM XL COMPRESSION FT","SUP-ITM-10274380","CDM","C1713","HCPCS","0278","RC","","","","both","","","4802.45","2881.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","558.52","4082.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 7X60MM XL COMPRESSION FT","SUP-ITM-10274380","CDM","C1713","HCPCS","0278","RC","","","","both","","","4802.45","2881.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","558.52","4082.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 7X60MM XL COMPRESSION FT","SUP-ITM-10274380","CDM","C1713","HCPCS","0278","RC","","","","both","","","4802.45","2881.47","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2732.59","56.9","","812.12","238.65","1587.46","163","558.52","4082.08","percent of total billed charges",""
"SCREW BONE 7X60MM XL COMPRESSION FT","SUP-ITM-10274380","CDM","C1713","HCPCS","0278","RC","","","","both","","","4802.45","2881.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","558.52","11.63","","112.68","112.68","146.99","38","558.52","4082.08","percent of total billed charges",""
"SCREW BONE 7X60MM XL COMPRESSION FT","SUP-ITM-10274380","CDM","C1713","HCPCS","0278","RC","","","","both","","","4802.45","2881.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3717.10","77.4","","303.98","303.98","5854.79","1 through 10","558.52","4082.08","percent of total billed charges",""
"SCREW BONE 7X60MM XL COMPRESSION FT","SUP-ITM-10274380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4802.45","2881.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","558.52","11.63","","112.68","112.68","146.99","38","558.52","3717.1","percent of total billed charges",""
"SCREW BONE 7X60MM XL COMPRESSION FT","SUP-ITM-10274380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4802.45","2881.47","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3014.98","62.78","","780.86","208.94","10480.28","15","558.52","3717.1","percent of total billed charges",""
"SCREW BONE 7X60MM XL COMPRESSION FT","SUP-ITM-10274380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4802.45","2881.47","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2099.63","43.72","","179.76","179.76","179.76","1 through 10","558.52","3717.1","percent of total billed charges",""
"SCREW BONE 7X60MM XL COMPRESSION FT","SUP-ITM-10274380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4802.45","2881.47","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3492.34","72.72","","2355.45","298.99","3965.19","155","558.52","3717.1","percent of total billed charges",""
"SCREW BONE 7X60MM XL COMPRESSION FT","SUP-ITM-10274380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4802.45","2881.47","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3492.34","72.72","","3643.09","3643.09","3643.09","1 through 10","558.52","3717.1","percent of total billed charges",""
"SCREW BONE 7X60MM XL COMPRESSION FT","SUP-ITM-10274380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4802.45","2881.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2555.86","53.22","","554.28","554.28","554.28","16","558.52","3717.1","percent of total billed charges",""
"SCREW BONE 7X60MM XL COMPRESSION FT","SUP-ITM-10274380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4802.45","2881.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3020.74","62.9","","619.64","173.09","2370.64","150","558.52","3717.1","percent of total billed charges",""
"SCREW BONE 7X60MM XL COMPRESSION FT","SUP-ITM-10274380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4802.45","2881.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3717.10","77.4","","303.98","303.98","5854.79","1 through 10","558.52","3717.1","percent of total billed charges",""
"SCREW BONE 85MM ANTIROTATION FEMORAL NECK SYSTEM","SUP-ITM-10296785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1414.34","848.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","164.49","1202.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 85MM ANTIROTATION FEMORAL NECK SYSTEM","SUP-ITM-10296785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1414.34","848.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","164.49","1202.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 85MM ANTIROTATION FEMORAL NECK SYSTEM","SUP-ITM-10296785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1414.34","848.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","804.76","56.9","","812.12","238.65","1587.46","163","164.49","1202.19","percent of total billed charges",""
"SCREW BONE 85MM ANTIROTATION FEMORAL NECK SYSTEM","SUP-ITM-10296785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1414.34","848.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","164.49","11.63","","112.68","112.68","146.99","38","164.49","1202.19","percent of total billed charges",""
"SCREW BONE 85MM ANTIROTATION FEMORAL NECK SYSTEM","SUP-ITM-10296785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1414.34","848.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1094.70","77.4","","303.98","303.98","5854.79","1 through 10","164.49","1202.19","percent of total billed charges",""
"SCREW BONE 85MM ANTIROTATION FEMORAL NECK SYSTEM","SUP-ITM-10296785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1414.34","848.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","164.49","11.63","","112.68","112.68","146.99","38","164.49","1094.7","percent of total billed charges",""
"SCREW BONE 85MM ANTIROTATION FEMORAL NECK SYSTEM","SUP-ITM-10296785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1414.34","848.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","887.92","62.78","","780.86","208.94","10480.28","15","164.49","1094.7","percent of total billed charges",""
"SCREW BONE 85MM ANTIROTATION FEMORAL NECK SYSTEM","SUP-ITM-10296785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1414.34","848.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","618.35","43.72","","179.76","179.76","179.76","1 through 10","164.49","1094.7","percent of total billed charges",""
"SCREW BONE 85MM ANTIROTATION FEMORAL NECK SYSTEM","SUP-ITM-10296785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1414.34","848.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1028.51","72.72","","2355.45","298.99","3965.19","155","164.49","1094.7","percent of total billed charges",""
"SCREW BONE 85MM ANTIROTATION FEMORAL NECK SYSTEM","SUP-ITM-10296785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1414.34","848.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1028.51","72.72","","3643.09","3643.09","3643.09","1 through 10","164.49","1094.7","percent of total billed charges",""
"SCREW BONE 85MM ANTIROTATION FEMORAL NECK SYSTEM","SUP-ITM-10296785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1414.34","848.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","752.71","53.22","","554.28","554.28","554.28","16","164.49","1094.7","percent of total billed charges",""
"SCREW BONE 85MM ANTIROTATION FEMORAL NECK SYSTEM","SUP-ITM-10296785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1414.34","848.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","889.62","62.9","","619.64","173.09","2370.64","150","164.49","1094.7","percent of total billed charges",""
"SCREW BONE 85MM ANTIROTATION FEMORAL NECK SYSTEM","SUP-ITM-10296785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1414.34","848.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1094.70","77.4","","303.98","303.98","5854.79","1 through 10","164.49","1094.7","percent of total billed charges",""
"SCREW BONE 8X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING LOCKING","SUP-ITM-10080117","CDM","C1713","HCPCS","0278","RC","","","","both","","","967.40","580.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","112.51","822.29","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 8X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING LOCKING","SUP-ITM-10080117","CDM","C1713","HCPCS","0278","RC","","","","both","","","967.40","580.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","112.51","822.29","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 8X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING LOCKING","SUP-ITM-10080117","CDM","C1713","HCPCS","0278","RC","","","","both","","","967.40","580.44","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","550.45","56.9","","812.12","238.65","1587.46","163","112.51","822.29","percent of total billed charges",""
"SCREW BONE 8X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING LOCKING","SUP-ITM-10080117","CDM","C1713","HCPCS","0278","RC","","","","both","","","967.40","580.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","112.51","11.63","","112.68","112.68","146.99","38","112.51","822.29","percent of total billed charges",""
"SCREW BONE 8X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING LOCKING","SUP-ITM-10080117","CDM","C1713","HCPCS","0278","RC","","","","both","","","967.40","580.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","748.77","77.4","","303.98","303.98","5854.79","1 through 10","112.51","822.29","percent of total billed charges",""
"SCREW BONE 8X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING LOCKING","SUP-ITM-10080117","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","967.40","580.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","112.51","11.63","","112.68","112.68","146.99","38","112.51","748.77","percent of total billed charges",""
"SCREW BONE 8X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING LOCKING","SUP-ITM-10080117","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","967.40","580.44","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","607.33","62.78","","780.86","208.94","10480.28","15","112.51","748.77","percent of total billed charges",""
"SCREW BONE 8X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING LOCKING","SUP-ITM-10080117","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","967.40","580.44","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","422.95","43.72","","179.76","179.76","179.76","1 through 10","112.51","748.77","percent of total billed charges",""
"SCREW BONE 8X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING LOCKING","SUP-ITM-10080117","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","967.40","580.44","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","703.49","72.72","","2355.45","298.99","3965.19","155","112.51","748.77","percent of total billed charges",""
"SCREW BONE 8X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING LOCKING","SUP-ITM-10080117","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","967.40","580.44","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","703.49","72.72","","3643.09","3643.09","3643.09","1 through 10","112.51","748.77","percent of total billed charges",""
"SCREW BONE 8X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING LOCKING","SUP-ITM-10080117","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","967.40","580.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","514.85","53.22","","554.28","554.28","554.28","16","112.51","748.77","percent of total billed charges",""
"SCREW BONE 8X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING LOCKING","SUP-ITM-10080117","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","967.40","580.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","608.49","62.9","","619.64","173.09","2370.64","150","112.51","748.77","percent of total billed charges",""
"SCREW BONE 8X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING LOCKING","SUP-ITM-10080117","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","967.40","580.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","748.77","77.4","","303.98","303.98","5854.79","1 through 10","112.51","748.77","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","both","","","1068.70","641.22","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","124.29","908.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","both","","","1068.70","641.22","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","124.29","908.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","both","","","1068.70","641.22","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","608.09","56.9","","812.12","238.65","1587.46","163","124.29","908.4","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","both","","","1068.70","641.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","124.29","11.63","","112.68","112.68","146.99","38","124.29","908.4","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","both","","","1068.70","641.22","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","827.17","77.4","","303.98","303.98","5854.79","1 through 10","124.29","908.4","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1068.70","641.22","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","124.29","11.63","","112.68","112.68","146.99","38","124.29","827.17","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1068.70","641.22","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","670.93","62.78","","780.86","208.94","10480.28","15","124.29","827.17","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1068.70","641.22","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","467.24","43.72","","179.76","179.76","179.76","1 through 10","124.29","827.17","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1068.70","641.22","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","777.16","72.72","","2355.45","298.99","3965.19","155","124.29","827.17","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1068.70","641.22","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","777.16","72.72","","3643.09","3643.09","3643.09","1 through 10","124.29","827.17","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1068.70","641.22","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","568.76","53.22","","554.28","554.28","554.28","16","124.29","827.17","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1068.70","641.22","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","672.21","62.9","","619.64","173.09","2370.64","150","124.29","827.17","percent of total billed charges",""
"SCREW BONE 8X5MM LOCKING PERIPROSTHESIS SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1068.70","641.22","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","827.17","77.4","","303.98","303.98","5854.79","1 through 10","124.29","827.17","percent of total billed charges",""
"SCREW BONE 9X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033427","CDM","C1713","HCPCS","0278","RC","","","","both","","","992.76","595.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","115.46","843.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 9X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033427","CDM","C1713","HCPCS","0278","RC","","","","both","","","992.76","595.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","115.46","843.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE 9X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033427","CDM","C1713","HCPCS","0278","RC","","","","both","","","992.76","595.66","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","564.88","56.9","","812.12","238.65","1587.46","163","115.46","843.85","percent of total billed charges",""
"SCREW BONE 9X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033427","CDM","C1713","HCPCS","0278","RC","","","","both","","","992.76","595.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","115.46","11.63","","112.68","112.68","146.99","38","115.46","843.85","percent of total billed charges",""
"SCREW BONE 9X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033427","CDM","C1713","HCPCS","0278","RC","","","","both","","","992.76","595.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","768.40","77.4","","303.98","303.98","5854.79","1 through 10","115.46","843.85","percent of total billed charges",""
"SCREW BONE 9X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","992.76","595.66","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","115.46","11.63","","112.68","112.68","146.99","38","115.46","768.4","percent of total billed charges",""
"SCREW BONE 9X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","992.76","595.66","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","623.25","62.78","","780.86","208.94","10480.28","15","115.46","768.4","percent of total billed charges",""
"SCREW BONE 9X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","992.76","595.66","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","434.03","43.72","","179.76","179.76","179.76","1 through 10","115.46","768.4","percent of total billed charges",""
"SCREW BONE 9X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","992.76","595.66","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","721.94","72.72","","2355.45","298.99","3965.19","155","115.46","768.4","percent of total billed charges",""
"SCREW BONE 9X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","992.76","595.66","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","721.94","72.72","","3643.09","3643.09","3643.09","1 through 10","115.46","768.4","percent of total billed charges",""
"SCREW BONE 9X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","992.76","595.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","528.35","53.22","","554.28","554.28","554.28","16","115.46","768.4","percent of total billed charges",""
"SCREW BONE 9X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","992.76","595.66","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","624.45","62.9","","619.64","173.09","2370.64","150","115.46","768.4","percent of total billed charges",""
"SCREW BONE 9X25MM KNEE BIOSTEON CANNULATED BIOABSORBABLE FULL THREAD WEDGE INTERFERENCE UNIVERSAL HA PLLA","SUP-ITM-10033427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","992.76","595.66","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","768.40","77.4","","303.98","303.98","5854.79","1 through 10","115.46","768.4","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","635.72","381.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","73.93","540.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","635.72","381.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","73.93","540.36","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","635.72","381.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","361.72","56.9","","812.12","238.65","1587.46","163","73.93","540.36","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","635.72","381.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","73.93","11.63","","112.68","112.68","146.99","38","73.93","540.36","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","635.72","381.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","492.05","77.4","","303.98","303.98","5854.79","1 through 10","73.93","540.36","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","635.72","381.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","73.93","11.63","","112.68","112.68","146.99","38","73.93","492.05","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","635.72","381.43","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","399.11","62.78","","780.86","208.94","10480.28","15","73.93","492.05","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","635.72","381.43","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","277.94","43.72","","179.76","179.76","179.76","1 through 10","73.93","492.05","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","635.72","381.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","462.30","72.72","","2355.45","298.99","3965.19","155","73.93","492.05","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","635.72","381.43","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","462.30","72.72","","3643.09","3643.09","3643.09","1 through 10","73.93","492.05","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","635.72","381.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","338.33","53.22","","554.28","554.28","554.28","16","73.93","492.05","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","635.72","381.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","399.87","62.9","","619.64","173.09","2370.64","150","73.93","492.05","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","635.72","381.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","492.05","77.4","","303.98","303.98","5854.79","1 through 10","73.93","492.05","percent of total billed charges",""
"SCREW BONE SIZE 0 ASSEMBLY HUMERAL AEQUALIS FLEX REVIVE","SUP-ITM-10269600","CDM","C1776","HCPCS","0278","RC","","","","both","","","5341.43","3204.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","621.21","4540.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BONE SIZE 0 ASSEMBLY HUMERAL AEQUALIS FLEX REVIVE","SUP-ITM-10269600","CDM","C1776","HCPCS","0278","RC","","","","both","","","5341.43","3204.86","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3039.27","56.9","","2911.53","1863.86","5209.05","65","621.21","4540.22","percent of total billed charges",""
"SCREW BONE SIZE 0 ASSEMBLY HUMERAL AEQUALIS FLEX REVIVE","SUP-ITM-10269600","CDM","C1776","HCPCS","0278","RC","","","","both","","","5341.43","3204.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","621.21","11.63","","400.94","400.94","400.94","1 through 10","621.21","4540.22","percent of total billed charges",""
"SCREW BONE SIZE 0 ASSEMBLY HUMERAL AEQUALIS FLEX REVIVE","SUP-ITM-10269600","CDM","C1776","HCPCS","0278","RC","","","","both","","","5341.43","3204.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4134.27","77.4","","5214.50","5214.50","16415.28","1 through 10","621.21","4540.22","percent of total billed charges",""
"SCREW BONE SIZE 0 ASSEMBLY HUMERAL AEQUALIS FLEX REVIVE","SUP-ITM-10269600","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5341.43","3204.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","621.21","11.63","","400.94","400.94","400.94","1 through 10","621.21","4134.27","percent of total billed charges",""
"SCREW BONE SIZE 0 ASSEMBLY HUMERAL AEQUALIS FLEX REVIVE","SUP-ITM-10269600","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5341.43","3204.86","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2335.27","43.72","","1543.33","1543.33","1671.61","1 through 10","621.21","4134.27","percent of total billed charges",""
"SCREW BONE SIZE 0 ASSEMBLY HUMERAL AEQUALIS FLEX REVIVE","SUP-ITM-10269600","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5341.43","3204.86","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3884.29","72.72","","3700.21","2382.07","6427.18","53","621.21","4134.27","percent of total billed charges",""
"SCREW BONE SIZE 0 ASSEMBLY HUMERAL AEQUALIS FLEX REVIVE","SUP-ITM-10269600","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5341.43","3204.86","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3884.29","72.72","","12685.80","12685.80","12685.80","1 through 10","621.21","4134.27","percent of total billed charges",""
"SCREW BONE SIZE 0 ASSEMBLY HUMERAL AEQUALIS FLEX REVIVE","SUP-ITM-10269600","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5341.43","3204.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3359.76","62.9","","3408.87","2784.05","9859.40","46","621.21","4134.27","percent of total billed charges",""
"SCREW BONE SIZE 0 ASSEMBLY HUMERAL AEQUALIS FLEX REVIVE","SUP-ITM-10269600","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5341.43","3204.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4134.27","77.4","","5214.50","5214.50","16415.28","1 through 10","621.21","4134.27","percent of total billed charges",""
"SCREW BS CNMAS 8.5X60 TC S","SUP-ITM-10259108","CDM","C1713","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","642.91","4698.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BS CNMAS 8.5X60 TC S","SUP-ITM-10259108","CDM","C1713","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","642.91","4698.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW BS CNMAS 8.5X60 TC S","SUP-ITM-10259108","CDM","C1713","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3145.43","56.9","","812.12","238.65","1587.46","163","642.91","4698.8","percent of total billed charges",""
"SCREW BS CNMAS 8.5X60 TC S","SUP-ITM-10259108","CDM","C1713","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","642.91","11.63","","112.68","112.68","146.99","38","642.91","4698.8","percent of total billed charges",""
"SCREW BS CNMAS 8.5X60 TC S","SUP-ITM-10259108","CDM","C1713","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4278.67","77.4","","303.98","303.98","5854.79","1 through 10","642.91","4698.8","percent of total billed charges",""
"SCREW BS CNMAS 8.5X60 TC S","SUP-ITM-10259108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","642.91","11.63","","112.68","112.68","146.99","38","642.91","4278.67","percent of total billed charges",""
"SCREW BS CNMAS 8.5X60 TC S","SUP-ITM-10259108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3470.48","62.78","","780.86","208.94","10480.28","15","642.91","4278.67","percent of total billed charges",""
"SCREW BS CNMAS 8.5X60 TC S","SUP-ITM-10259108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2416.84","43.72","","179.76","179.76","179.76","1 through 10","642.91","4278.67","percent of total billed charges",""
"SCREW BS CNMAS 8.5X60 TC S","SUP-ITM-10259108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4019.96","72.72","","2355.45","298.99","3965.19","155","642.91","4278.67","percent of total billed charges",""
"SCREW BS CNMAS 8.5X60 TC S","SUP-ITM-10259108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4019.96","72.72","","3643.09","3643.09","3643.09","1 through 10","642.91","4278.67","percent of total billed charges",""
"SCREW BS CNMAS 8.5X60 TC S","SUP-ITM-10259108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2942.00","53.22","","554.28","554.28","554.28","16","642.91","4278.67","percent of total billed charges",""
"SCREW BS CNMAS 8.5X60 TC S","SUP-ITM-10259108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3477.11","62.9","","619.64","173.09","2370.64","150","642.91","4278.67","percent of total billed charges",""
"SCREW BS CNMAS 8.5X60 TC S","SUP-ITM-10259108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4278.67","77.4","","303.98","303.98","5854.79","1 through 10","642.91","4278.67","percent of total billed charges",""
"SCREW COMPOSITE 60 9X25MM INTERFERENCE","SUP-ITM-10146830","CDM","C1713","HCPCS","0278","RC","","","","both","","","2647.64","1588.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","307.92","2250.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW COMPOSITE 60 9X25MM INTERFERENCE","SUP-ITM-10146830","CDM","C1713","HCPCS","0278","RC","","","","both","","","2647.64","1588.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","307.92","2250.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW COMPOSITE 60 9X25MM INTERFERENCE","SUP-ITM-10146830","CDM","C1713","HCPCS","0278","RC","","","","both","","","2647.64","1588.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1506.51","56.9","","812.12","238.65","1587.46","163","307.92","2250.49","percent of total billed charges",""
"SCREW COMPOSITE 60 9X25MM INTERFERENCE","SUP-ITM-10146830","CDM","C1713","HCPCS","0278","RC","","","","both","","","2647.64","1588.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","307.92","11.63","","112.68","112.68","146.99","38","307.92","2250.49","percent of total billed charges",""
"SCREW COMPOSITE 60 9X25MM INTERFERENCE","SUP-ITM-10146830","CDM","C1713","HCPCS","0278","RC","","","","both","","","2647.64","1588.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2049.27","77.4","","303.98","303.98","5854.79","1 through 10","307.92","2250.49","percent of total billed charges",""
"SCREW COMPOSITE 60 9X25MM INTERFERENCE","SUP-ITM-10146830","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2647.64","1588.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","307.92","11.63","","112.68","112.68","146.99","38","307.92","2049.27","percent of total billed charges",""
"SCREW COMPOSITE 60 9X25MM INTERFERENCE","SUP-ITM-10146830","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2647.64","1588.58","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1662.19","62.78","","780.86","208.94","10480.28","15","307.92","2049.27","percent of total billed charges",""
"SCREW COMPOSITE 60 9X25MM INTERFERENCE","SUP-ITM-10146830","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2647.64","1588.58","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1157.55","43.72","","179.76","179.76","179.76","1 through 10","307.92","2049.27","percent of total billed charges",""
"SCREW COMPOSITE 60 9X25MM INTERFERENCE","SUP-ITM-10146830","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2647.64","1588.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1925.36","72.72","","2355.45","298.99","3965.19","155","307.92","2049.27","percent of total billed charges",""
"SCREW COMPOSITE 60 9X25MM INTERFERENCE","SUP-ITM-10146830","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2647.64","1588.58","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1925.36","72.72","","3643.09","3643.09","3643.09","1 through 10","307.92","2049.27","percent of total billed charges",""
"SCREW COMPOSITE 60 9X25MM INTERFERENCE","SUP-ITM-10146830","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2647.64","1588.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1409.07","53.22","","554.28","554.28","554.28","16","307.92","2049.27","percent of total billed charges",""
"SCREW COMPOSITE 60 9X25MM INTERFERENCE","SUP-ITM-10146830","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2647.64","1588.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1665.37","62.9","","619.64","173.09","2370.64","150","307.92","2049.27","percent of total billed charges",""
"SCREW COMPOSITE 60 9X25MM INTERFERENCE","SUP-ITM-10146830","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2647.64","1588.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2049.27","77.4","","303.98","303.98","5854.79","1 through 10","307.92","2049.27","percent of total billed charges",""
"SCREW CONNECTING F/LCKNG ATTACHMENT PL/SD","SUP-ITM-10074533","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.82","570.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","110.58","808.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW CONNECTING F/LCKNG ATTACHMENT PL/SD","SUP-ITM-10074533","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.82","570.49","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","110.58","808.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW CONNECTING F/LCKNG ATTACHMENT PL/SD","SUP-ITM-10074533","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.82","570.49","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","541.02","56.9","","812.12","238.65","1587.46","163","110.58","808.2","percent of total billed charges",""
"SCREW CONNECTING F/LCKNG ATTACHMENT PL/SD","SUP-ITM-10074533","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.82","570.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","110.58","11.63","","112.68","112.68","146.99","38","110.58","808.2","percent of total billed charges",""
"SCREW CONNECTING F/LCKNG ATTACHMENT PL/SD","SUP-ITM-10074533","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.82","570.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","735.93","77.4","","303.98","303.98","5854.79","1 through 10","110.58","808.2","percent of total billed charges",""
"SCREW CONNECTING F/LCKNG ATTACHMENT PL/SD","SUP-ITM-10074533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","950.82","570.49","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","110.58","11.63","","112.68","112.68","146.99","38","110.58","735.93","percent of total billed charges",""
"SCREW CONNECTING F/LCKNG ATTACHMENT PL/SD","SUP-ITM-10074533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","950.82","570.49","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","596.92","62.78","","780.86","208.94","10480.28","15","110.58","735.93","percent of total billed charges",""
"SCREW CONNECTING F/LCKNG ATTACHMENT PL/SD","SUP-ITM-10074533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","950.82","570.49","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","415.70","43.72","","179.76","179.76","179.76","1 through 10","110.58","735.93","percent of total billed charges",""
"SCREW CONNECTING F/LCKNG ATTACHMENT PL/SD","SUP-ITM-10074533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","950.82","570.49","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","691.44","72.72","","2355.45","298.99","3965.19","155","110.58","735.93","percent of total billed charges",""
"SCREW CONNECTING F/LCKNG ATTACHMENT PL/SD","SUP-ITM-10074533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","950.82","570.49","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","691.44","72.72","","3643.09","3643.09","3643.09","1 through 10","110.58","735.93","percent of total billed charges",""
"SCREW CONNECTING F/LCKNG ATTACHMENT PL/SD","SUP-ITM-10074533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","950.82","570.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","506.03","53.22","","554.28","554.28","554.28","16","110.58","735.93","percent of total billed charges",""
"SCREW CONNECTING F/LCKNG ATTACHMENT PL/SD","SUP-ITM-10074533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","950.82","570.49","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","598.07","62.9","","619.64","173.09","2370.64","150","110.58","735.93","percent of total billed charges",""
"SCREW CONNECTING F/LCKNG ATTACHMENT PL/SD","SUP-ITM-10074533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","950.82","570.49","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","735.93","77.4","","303.98","303.98","5854.79","1 through 10","110.58","735.93","percent of total billed charges",""
"SCREW CONNECTING REPLACEMENT VA-LOCKING PPFX COMPATIBLE","SUP-ITM-10297579","CDM","C1713","HCPCS","0278","RC","","","","both","","","1315.11","789.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","152.95","1117.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW CONNECTING REPLACEMENT VA-LOCKING PPFX COMPATIBLE","SUP-ITM-10297579","CDM","C1713","HCPCS","0278","RC","","","","both","","","1315.11","789.07","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","152.95","1117.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW CONNECTING REPLACEMENT VA-LOCKING PPFX COMPATIBLE","SUP-ITM-10297579","CDM","C1713","HCPCS","0278","RC","","","","both","","","1315.11","789.07","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","748.30","56.9","","812.12","238.65","1587.46","163","152.95","1117.84","percent of total billed charges",""
"SCREW CONNECTING REPLACEMENT VA-LOCKING PPFX COMPATIBLE","SUP-ITM-10297579","CDM","C1713","HCPCS","0278","RC","","","","both","","","1315.11","789.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","152.95","11.63","","112.68","112.68","146.99","38","152.95","1117.84","percent of total billed charges",""
"SCREW CONNECTING REPLACEMENT VA-LOCKING PPFX COMPATIBLE","SUP-ITM-10297579","CDM","C1713","HCPCS","0278","RC","","","","both","","","1315.11","789.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1017.90","77.4","","303.98","303.98","5854.79","1 through 10","152.95","1117.84","percent of total billed charges",""
"SCREW CONNECTING REPLACEMENT VA-LOCKING PPFX COMPATIBLE","SUP-ITM-10297579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1315.11","789.07","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","152.95","11.63","","112.68","112.68","146.99","38","152.95","1017.9","percent of total billed charges",""
"SCREW CONNECTING REPLACEMENT VA-LOCKING PPFX COMPATIBLE","SUP-ITM-10297579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1315.11","789.07","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","825.63","62.78","","780.86","208.94","10480.28","15","152.95","1017.9","percent of total billed charges",""
"SCREW CONNECTING REPLACEMENT VA-LOCKING PPFX COMPATIBLE","SUP-ITM-10297579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1315.11","789.07","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","574.97","43.72","","179.76","179.76","179.76","1 through 10","152.95","1017.9","percent of total billed charges",""
"SCREW CONNECTING REPLACEMENT VA-LOCKING PPFX COMPATIBLE","SUP-ITM-10297579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1315.11","789.07","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","956.35","72.72","","2355.45","298.99","3965.19","155","152.95","1017.9","percent of total billed charges",""
"SCREW CONNECTING REPLACEMENT VA-LOCKING PPFX COMPATIBLE","SUP-ITM-10297579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1315.11","789.07","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","956.35","72.72","","3643.09","3643.09","3643.09","1 through 10","152.95","1017.9","percent of total billed charges",""
"SCREW CONNECTING REPLACEMENT VA-LOCKING PPFX COMPATIBLE","SUP-ITM-10297579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1315.11","789.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","699.90","53.22","","554.28","554.28","554.28","16","152.95","1017.9","percent of total billed charges",""
"SCREW CONNECTING REPLACEMENT VA-LOCKING PPFX COMPATIBLE","SUP-ITM-10297579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1315.11","789.07","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","827.20","62.9","","619.64","173.09","2370.64","150","152.95","1017.9","percent of total billed charges",""
"SCREW CONNECTING REPLACEMENT VA-LOCKING PPFX COMPATIBLE","SUP-ITM-10297579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1315.11","789.07","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1017.90","77.4","","303.98","303.98","5854.79","1 through 10","152.95","1017.9","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","both","","","3226.97","1936.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","375.3","2742.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","both","","","3226.97","1936.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","375.3","2742.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","both","","","3226.97","1936.18","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1836.15","56.9","","812.12","238.65","1587.46","163","375.3","2742.92","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","both","","","3226.97","1936.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","375.30","11.63","","112.68","112.68","146.99","38","375.3","2742.92","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","both","","","3226.97","1936.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2497.67","77.4","","303.98","303.98","5854.79","1 through 10","375.3","2742.92","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","375.30","11.63","","112.68","112.68","146.99","38","375.3","2497.67","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2025.89","62.78","","780.86","208.94","10480.28","15","375.3","2497.67","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1410.83","43.72","","179.76","179.76","179.76","1 through 10","375.3","2497.67","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2346.65","72.72","","2355.45","298.99","3965.19","155","375.3","2497.67","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2346.65","72.72","","3643.09","3643.09","3643.09","1 through 10","375.3","2497.67","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1717.39","53.22","","554.28","554.28","554.28","16","375.3","2497.67","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2029.76","62.9","","619.64","173.09","2370.64","150","375.3","2497.67","percent of total billed charges",""
"SCREW DISTAL 15X10MM SIZE 6 WEDGE FEMORAL KNEE ON LEGION","SUP-ITM-10022737","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3226.97","1936.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2497.67","77.4","","303.98","303.98","5854.79","1 through 10","375.3","2497.67","percent of total billed charges",""
"SCREW INTERFERENCE 7X14MM QUATTRO BOLT TENODESIS","SUP-ITM-10216300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.75","1665.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","322.82","2359.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW INTERFERENCE 7X14MM QUATTRO BOLT TENODESIS","SUP-ITM-10216300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.75","1665.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","322.82","2359.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW INTERFERENCE 7X14MM QUATTRO BOLT TENODESIS","SUP-ITM-10216300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.75","1665.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1579.40","56.9","","812.12","238.65","1587.46","163","322.82","2359.39","percent of total billed charges",""
"SCREW INTERFERENCE 7X14MM QUATTRO BOLT TENODESIS","SUP-ITM-10216300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.75","1665.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","322.82","11.63","","112.68","112.68","146.99","38","322.82","2359.39","percent of total billed charges",""
"SCREW INTERFERENCE 7X14MM QUATTRO BOLT TENODESIS","SUP-ITM-10216300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.75","1665.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2148.43","77.4","","303.98","303.98","5854.79","1 through 10","322.82","2359.39","percent of total billed charges",""
"SCREW INTERFERENCE 7X14MM QUATTRO BOLT TENODESIS","SUP-ITM-10216300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.75","1665.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","322.82","11.63","","112.68","112.68","146.99","38","322.82","2148.43","percent of total billed charges",""
"SCREW INTERFERENCE 7X14MM QUATTRO BOLT TENODESIS","SUP-ITM-10216300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.75","1665.45","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1742.62","62.78","","780.86","208.94","10480.28","15","322.82","2148.43","percent of total billed charges",""
"SCREW INTERFERENCE 7X14MM QUATTRO BOLT TENODESIS","SUP-ITM-10216300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.75","1665.45","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1213.56","43.72","","179.76","179.76","179.76","1 through 10","322.82","2148.43","percent of total billed charges",""
"SCREW INTERFERENCE 7X14MM QUATTRO BOLT TENODESIS","SUP-ITM-10216300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.75","1665.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2018.53","72.72","","2355.45","298.99","3965.19","155","322.82","2148.43","percent of total billed charges",""
"SCREW INTERFERENCE 7X14MM QUATTRO BOLT TENODESIS","SUP-ITM-10216300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.75","1665.45","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2018.53","72.72","","3643.09","3643.09","3643.09","1 through 10","322.82","2148.43","percent of total billed charges",""
"SCREW INTERFERENCE 7X14MM QUATTRO BOLT TENODESIS","SUP-ITM-10216300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.75","1665.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1477.25","53.22","","554.28","554.28","554.28","16","322.82","2148.43","percent of total billed charges",""
"SCREW INTERFERENCE 7X14MM QUATTRO BOLT TENODESIS","SUP-ITM-10216300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.75","1665.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1745.95","62.9","","619.64","173.09","2370.64","150","322.82","2148.43","percent of total billed charges",""
"SCREW INTERFERENCE 7X14MM QUATTRO BOLT TENODESIS","SUP-ITM-10216300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.75","1665.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2148.43","77.4","","303.98","303.98","5854.79","1 through 10","322.82","2148.43","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","both","","","5477.07","3286.24","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","636.98","4655.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","both","","","5477.07","3286.24","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","636.98","4655.51","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","both","","","5477.07","3286.24","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3116.45","56.9","","812.12","238.65","1587.46","163","636.98","4655.51","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","both","","","5477.07","3286.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","636.98","11.63","","112.68","112.68","146.99","38","636.98","4655.51","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","both","","","5477.07","3286.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4239.25","77.4","","303.98","303.98","5854.79","1 through 10","636.98","4655.51","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5477.07","3286.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","636.98","11.63","","112.68","112.68","146.99","38","636.98","4239.25","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5477.07","3286.24","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3438.50","62.78","","780.86","208.94","10480.28","15","636.98","4239.25","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5477.07","3286.24","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2394.58","43.72","","179.76","179.76","179.76","1 through 10","636.98","4239.25","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5477.07","3286.24","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3982.93","72.72","","2355.45","298.99","3965.19","155","636.98","4239.25","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5477.07","3286.24","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3982.93","72.72","","3643.09","3643.09","3643.09","1 through 10","636.98","4239.25","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5477.07","3286.24","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2914.90","53.22","","554.28","554.28","554.28","16","636.98","4239.25","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5477.07","3286.24","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3445.08","62.9","","619.64","173.09","2370.64","150","636.98","4239.25","percent of total billed charges",""
"SCREW PLATE 0.3MM SMALL FLOOR ORBITAL MATRIXMIDFACE TITANIUM ANATOMIC","SUP-ITM-10100540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5477.07","3286.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4239.25","77.4","","303.98","303.98","5854.79","1 through 10","636.98","4239.25","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","both","","","1497.54","898.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","174.16","1272.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","both","","","1497.54","898.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","174.16","1272.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","both","","","1497.54","898.52","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","852.10","56.9","","812.12","238.65","1587.46","163","174.16","1272.91","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","both","","","1497.54","898.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","174.16","11.63","","112.68","112.68","146.99","38","174.16","1272.91","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","both","","","1497.54","898.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1159.10","77.4","","303.98","303.98","5854.79","1 through 10","174.16","1272.91","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1497.54","898.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","174.16","11.63","","112.68","112.68","146.99","38","174.16","1159.1","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1497.54","898.52","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","940.16","62.78","","780.86","208.94","10480.28","15","174.16","1159.1","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1497.54","898.52","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","654.72","43.72","","179.76","179.76","179.76","1 through 10","174.16","1159.1","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1497.54","898.52","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1089.01","72.72","","2355.45","298.99","3965.19","155","174.16","1159.1","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1497.54","898.52","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1089.01","72.72","","3643.09","3643.09","3643.09","1 through 10","174.16","1159.1","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1497.54","898.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","796.99","53.22","","554.28","554.28","554.28","16","174.16","1159.1","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1497.54","898.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","941.95","62.9","","619.64","173.09","2370.64","150","174.16","1159.1","percent of total billed charges",""
"SCREW SELF-TAPPING 5.0 PERIPRO VAL/SD/14","SUP-ITM-10095406","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1497.54","898.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1159.10","77.4","","303.98","303.98","5854.79","1 through 10","174.16","1159.1","percent of total billed charges",""
"SCREW SET 5.5/6.0MM SOLERA VOYAGER","SUP-ITM-10212590","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.95","186.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","36.16","264.31","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW SET 5.5/6.0MM SOLERA VOYAGER","SUP-ITM-10212590","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.95","186.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","36.16","264.31","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW SET 5.5/6.0MM SOLERA VOYAGER","SUP-ITM-10212590","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.95","186.57","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","176.93","56.9","","812.12","238.65","1587.46","163","36.16","264.31","percent of total billed charges",""
"SCREW SET 5.5/6.0MM SOLERA VOYAGER","SUP-ITM-10212590","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.95","186.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","36.16","11.63","","112.68","112.68","146.99","38","36.16","264.31","percent of total billed charges",""
"SCREW SET 5.5/6.0MM SOLERA VOYAGER","SUP-ITM-10212590","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.95","186.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","240.68","77.4","","303.98","303.98","5854.79","1 through 10","36.16","264.31","percent of total billed charges",""
"SCREW SET 5.5/6.0MM SOLERA VOYAGER","SUP-ITM-10212590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","310.95","186.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","36.16","11.63","","112.68","112.68","146.99","38","36.16","240.68","percent of total billed charges",""
"SCREW SET 5.5/6.0MM SOLERA VOYAGER","SUP-ITM-10212590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","310.95","186.57","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","195.21","62.78","","780.86","208.94","10480.28","15","36.16","240.68","percent of total billed charges",""
"SCREW SET 5.5/6.0MM SOLERA VOYAGER","SUP-ITM-10212590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","310.95","186.57","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","135.95","43.72","","179.76","179.76","179.76","1 through 10","36.16","240.68","percent of total billed charges",""
"SCREW SET 5.5/6.0MM SOLERA VOYAGER","SUP-ITM-10212590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","310.95","186.57","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","226.12","72.72","","2355.45","298.99","3965.19","155","36.16","240.68","percent of total billed charges",""
"SCREW SET 5.5/6.0MM SOLERA VOYAGER","SUP-ITM-10212590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","310.95","186.57","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","226.12","72.72","","3643.09","3643.09","3643.09","1 through 10","36.16","240.68","percent of total billed charges",""
"SCREW SET 5.5/6.0MM SOLERA VOYAGER","SUP-ITM-10212590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","310.95","186.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","165.49","53.22","","554.28","554.28","554.28","16","36.16","240.68","percent of total billed charges",""
"SCREW SET 5.5/6.0MM SOLERA VOYAGER","SUP-ITM-10212590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","310.95","186.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","195.59","62.9","","619.64","173.09","2370.64","150","36.16","240.68","percent of total billed charges",""
"SCREW SET 5.5/6.0MM SOLERA VOYAGER","SUP-ITM-10212590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","310.95","186.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","240.68","77.4","","303.98","303.98","5854.79","1 through 10","36.16","240.68","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.72","370.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","71.72","524.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.72","370.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","71.72","524.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.72","370.03","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","350.91","56.9","","812.12","238.65","1587.46","163","71.72","524.21","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.72","370.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.72","11.63","","112.68","112.68","146.99","38","71.72","524.21","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","both","","","616.72","370.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","477.34","77.4","","303.98","303.98","5854.79","1 through 10","71.72","524.21","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.72","11.63","","112.68","112.68","146.99","38","71.72","477.34","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","387.18","62.78","","780.86","208.94","10480.28","15","71.72","477.34","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","269.63","43.72","","179.76","179.76","179.76","1 through 10","71.72","477.34","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","448.48","72.72","","2355.45","298.99","3965.19","155","71.72","477.34","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","448.48","72.72","","3643.09","3643.09","3643.09","1 through 10","71.72","477.34","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","328.22","53.22","","554.28","554.28","554.28","16","71.72","477.34","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","387.92","62.9","","619.64","173.09","2370.64","150","71.72","477.34","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","616.72","370.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","477.34","77.4","","303.98","303.98","5854.79","1 through 10","71.72","477.34","percent of total billed charges",""
"SCREW SPINAL 5.5X20MM LUMBAR STAND ALONE INDEPENDENCE VARIABLE ANGLE","SUP-ITM-10051668","CDM","C1889","HCPCS","0278","RC","","","","both","","","1153.97","692.38","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","134.21","980.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW SPINAL 5.5X20MM LUMBAR STAND ALONE INDEPENDENCE VARIABLE ANGLE","SUP-ITM-10051668","CDM","C1889","HCPCS","0278","RC","","","","both","","","1153.97","692.38","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","134.21","980.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW SPINAL 5.5X20MM LUMBAR STAND ALONE INDEPENDENCE VARIABLE ANGLE","SUP-ITM-10051668","CDM","C1889","HCPCS","0278","RC","","","","both","","","1153.97","692.38","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","656.61","56.9","","0.63","0.63","0.63","1 through 10","134.21","980.87","percent of total billed charges",""
"SCREW SPINAL 5.5X20MM LUMBAR STAND ALONE INDEPENDENCE VARIABLE ANGLE","SUP-ITM-10051668","CDM","C1889","HCPCS","0278","RC","","","","both","","","1153.97","692.38","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","166.40","14.42","","317.14","317.14","317.14","1 through 10","134.21","980.87","percent of total billed charges",""
"SCREW SPINAL 5.5X20MM LUMBAR STAND ALONE INDEPENDENCE VARIABLE ANGLE","SUP-ITM-10051668","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1153.97","692.38","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","166.40","14.42","","317.14","317.14","317.14","1 through 10","134.21","893.17","percent of total billed charges",""
"SCREW SPINAL 5.5X20MM LUMBAR STAND ALONE INDEPENDENCE VARIABLE ANGLE","SUP-ITM-10051668","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1153.97","692.38","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","724.46","62.78","","1125.09","1125.09","1125.09","1 through 10","134.21","893.17","percent of total billed charges",""
"SCREW SPINAL 5.5X20MM LUMBAR STAND ALONE INDEPENDENCE VARIABLE ANGLE","SUP-ITM-10051668","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1153.97","692.38","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","839.17","72.72","","4732.50","1617.43","14180.40","1 through 10","134.21","893.17","percent of total billed charges",""
"SCREW SPINAL 5.5X20MM LUMBAR STAND ALONE INDEPENDENCE VARIABLE ANGLE","SUP-ITM-10051668","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1153.97","692.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","725.85","62.9","","3896.20","3341.38","3896.20","1 through 10","134.21","893.17","percent of total billed charges",""
"SCREW SPINE 3.5X16MM MULTI AXIAL 3603516","SUP-ITM-10260152","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","401.82","2936.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW SPINE 3.5X16MM MULTI AXIAL 3603516","SUP-ITM-10260152","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","401.82","2936.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW SPINE 3.5X16MM MULTI AXIAL 3603516","SUP-ITM-10260152","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1965.90","56.9","","812.12","238.65","1587.46","163","401.82","2936.75","percent of total billed charges",""
"SCREW SPINE 3.5X16MM MULTI AXIAL 3603516","SUP-ITM-10260152","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","401.82","11.63","","112.68","112.68","146.99","38","401.82","2936.75","percent of total billed charges",""
"SCREW SPINE 3.5X16MM MULTI AXIAL 3603516","SUP-ITM-10260152","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2674.17","77.4","","303.98","303.98","5854.79","1 through 10","401.82","2936.75","percent of total billed charges",""
"SCREW SPINE 3.5X16MM MULTI AXIAL 3603516","SUP-ITM-10260152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","401.82","11.63","","112.68","112.68","146.99","38","401.82","2674.17","percent of total billed charges",""
"SCREW SPINE 3.5X16MM MULTI AXIAL 3603516","SUP-ITM-10260152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2169.05","62.78","","780.86","208.94","10480.28","15","401.82","2674.17","percent of total billed charges",""
"SCREW SPINE 3.5X16MM MULTI AXIAL 3603516","SUP-ITM-10260152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1510.53","43.72","","179.76","179.76","179.76","1 through 10","401.82","2674.17","percent of total billed charges",""
"SCREW SPINE 3.5X16MM MULTI AXIAL 3603516","SUP-ITM-10260152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2512.48","72.72","","2355.45","298.99","3965.19","155","401.82","2674.17","percent of total billed charges",""
"SCREW SPINE 3.5X16MM MULTI AXIAL 3603516","SUP-ITM-10260152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2512.48","72.72","","3643.09","3643.09","3643.09","1 through 10","401.82","2674.17","percent of total billed charges",""
"SCREW SPINE 3.5X16MM MULTI AXIAL 3603516","SUP-ITM-10260152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1838.75","53.22","","554.28","554.28","554.28","16","401.82","2674.17","percent of total billed charges",""
"SCREW SPINE 3.5X16MM MULTI AXIAL 3603516","SUP-ITM-10260152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2173.20","62.9","","619.64","173.09","2370.64","150","401.82","2674.17","percent of total billed charges",""
"SCREW SPINE 3.5X16MM MULTI AXIAL 3603516","SUP-ITM-10260152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2674.17","77.4","","303.98","303.98","5854.79","1 through 10","401.82","2674.17","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","401.82","2936.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","401.82","2936.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1965.90","56.9","","812.12","238.65","1587.46","163","401.82","2936.75","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","401.82","11.63","","112.68","112.68","146.99","38","401.82","2936.75","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","both","","","3455.00","2073.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2674.17","77.4","","303.98","303.98","5854.79","1 through 10","401.82","2936.75","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","401.82","11.63","","112.68","112.68","146.99","38","401.82","2674.17","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2169.05","62.78","","780.86","208.94","10480.28","15","401.82","2674.17","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1510.53","43.72","","179.76","179.76","179.76","1 through 10","401.82","2674.17","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2512.48","72.72","","2355.45","298.99","3965.19","155","401.82","2674.17","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2512.48","72.72","","3643.09","3643.09","3643.09","1 through 10","401.82","2674.17","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1838.75","53.22","","554.28","554.28","554.28","16","401.82","2674.17","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2173.20","62.9","","619.64","173.09","2370.64","150","401.82","2674.17","percent of total billed charges",""
"SCREW SPINE 3.5X20MM INFINITY MULTI AXIAL","SUP-ITM-10260150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3455.00","2073.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2674.17","77.4","","303.98","303.98","5854.79","1 through 10","401.82","2674.17","percent of total billed charges",""
"SCREW SPINE 5.5X25MM INTERBODY FUSION DEVICE","SUP-ITM-10259703","CDM","C1713","HCPCS","0278","RC","","","","both","","","1727.50","1036.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","200.91","1468.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW SPINE 5.5X25MM INTERBODY FUSION DEVICE","SUP-ITM-10259703","CDM","C1713","HCPCS","0278","RC","","","","both","","","1727.50","1036.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","200.91","1468.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW SPINE 5.5X25MM INTERBODY FUSION DEVICE","SUP-ITM-10259703","CDM","C1713","HCPCS","0278","RC","","","","both","","","1727.50","1036.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","982.95","56.9","","812.12","238.65","1587.46","163","200.91","1468.38","percent of total billed charges",""
"SCREW SPINE 5.5X25MM INTERBODY FUSION DEVICE","SUP-ITM-10259703","CDM","C1713","HCPCS","0278","RC","","","","both","","","1727.50","1036.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","200.91","11.63","","112.68","112.68","146.99","38","200.91","1468.38","percent of total billed charges",""
"SCREW SPINE 5.5X25MM INTERBODY FUSION DEVICE","SUP-ITM-10259703","CDM","C1713","HCPCS","0278","RC","","","","both","","","1727.50","1036.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1337.09","77.4","","303.98","303.98","5854.79","1 through 10","200.91","1468.38","percent of total billed charges",""
"SCREW SPINE 5.5X25MM INTERBODY FUSION DEVICE","SUP-ITM-10259703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1727.50","1036.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","200.91","11.63","","112.68","112.68","146.99","38","200.91","1337.09","percent of total billed charges",""
"SCREW SPINE 5.5X25MM INTERBODY FUSION DEVICE","SUP-ITM-10259703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1727.50","1036.50","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1084.52","62.78","","780.86","208.94","10480.28","15","200.91","1337.09","percent of total billed charges",""
"SCREW SPINE 5.5X25MM INTERBODY FUSION DEVICE","SUP-ITM-10259703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1727.50","1036.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","755.26","43.72","","179.76","179.76","179.76","1 through 10","200.91","1337.09","percent of total billed charges",""
"SCREW SPINE 5.5X25MM INTERBODY FUSION DEVICE","SUP-ITM-10259703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1727.50","1036.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1256.24","72.72","","2355.45","298.99","3965.19","155","200.91","1337.09","percent of total billed charges",""
"SCREW SPINE 5.5X25MM INTERBODY FUSION DEVICE","SUP-ITM-10259703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1727.50","1036.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1256.24","72.72","","3643.09","3643.09","3643.09","1 through 10","200.91","1337.09","percent of total billed charges",""
"SCREW SPINE 5.5X25MM INTERBODY FUSION DEVICE","SUP-ITM-10259703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1727.50","1036.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","919.38","53.22","","554.28","554.28","554.28","16","200.91","1337.09","percent of total billed charges",""
"SCREW SPINE 5.5X25MM INTERBODY FUSION DEVICE","SUP-ITM-10259703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1727.50","1036.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1086.60","62.9","","619.64","173.09","2370.64","150","200.91","1337.09","percent of total billed charges",""
"SCREW SPINE 5.5X25MM INTERBODY FUSION DEVICE","SUP-ITM-10259703","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1727.50","1036.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1337.09","77.4","","303.98","303.98","5854.79","1 through 10","200.91","1337.09","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","both","","","4387.85","2632.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","510.31","3729.67","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","both","","","4387.85","2632.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","510.31","3729.67","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","both","","","4387.85","2632.71","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2496.69","56.9","","812.12","238.65","1587.46","163","510.31","3729.67","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","both","","","4387.85","2632.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","510.31","11.63","","112.68","112.68","146.99","38","510.31","3729.67","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","both","","","4387.85","2632.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3396.20","77.4","","303.98","303.98","5854.79","1 through 10","510.31","3729.67","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4387.85","2632.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","510.31","11.63","","112.68","112.68","146.99","38","510.31","3396.2","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4387.85","2632.71","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2754.69","62.78","","780.86","208.94","10480.28","15","510.31","3396.2","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4387.85","2632.71","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1918.37","43.72","","179.76","179.76","179.76","1 through 10","510.31","3396.2","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4387.85","2632.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3190.84","72.72","","2355.45","298.99","3965.19","155","510.31","3396.2","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4387.85","2632.71","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3190.84","72.72","","3643.09","3643.09","3643.09","1 through 10","510.31","3396.2","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4387.85","2632.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2335.21","53.22","","554.28","554.28","554.28","16","510.31","3396.2","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4387.85","2632.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2759.96","62.9","","619.64","173.09","2370.64","150","510.31","3396.2","percent of total billed charges",""
"SCREW SPINE 6.5X50MM VOYAGER PEDICLE","SUP-ITM-10212632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4387.85","2632.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3396.20","77.4","","303.98","303.98","5854.79","1 through 10","510.31","3396.2","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0300","RC","","","","inpatient","","","28.00","16.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","21.52","76.86","","17.01","17.01","17.01","1 through 10","18.54","21.52","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","28.00","16.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","19.54","69.8","","18.85","16.98","18.85","98","1.76","23.8","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","28.00","16.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","23.80","85","","68.11","22.95","68.11","11","1.76","23.8","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","outpatient","","","28.00","16.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","17.58","62.78","","16.95","16.95","16.95","1 through 10","2.51","21.67","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","outpatient","","","28.00","16.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","12.24","43.72","","11.80","11.80","23.60","1 through 10","2.51","21.67","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","outpatient","","","28.00","16.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","20.36","72.72","","19.63","19.63","19.63","180","2.51","21.67","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","outpatient","","","28.00","16.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","20.36","72.72","","19.63","19.63","19.63","1 through 10","2.51","21.67","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","outpatient","","","28.00","16.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","14.90","53.22","","14.39","14.39","14.39","11","2.51","21.67","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","outpatient","","","28.00","16.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","17.61","62.9","","17.01","17.01","17.01","169","2.51","21.67","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","outpatient","","","28.00","16.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","21.67","77.4","","20.93","20.92","20.93","64","2.51","21.67","percent of total billed charges",""
"Sed Rate RBC Non Auto","PX-30001123","CDM","85651","CPT","0300","RC","","","","inpatient","","","53.00","31.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","40.74","76.86","","30.90","30.90","30.90","1 through 10","35.09","40.74","percent of total billed charges",""
"Sed Rate RBC Non Auto","PX-30001123","CDM","85651","CPT","0305","RC","","","","both","","","53.00","31.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","36.99","69.8","","35.60","32.08","35.60","64","2.78","45.05","percent of total billed charges",""
"Sed Rate RBC Non Auto","PX-30001123","CDM","85651","CPT","0305","RC","","","","both","","","53.00","31.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","45.05","85","","43.35","5.98","43.35","1 through 10","2.78","45.05","percent of total billed charges",""
"Sed Rate RBC Non Auto","PX-30001123","CDM","85651","CPT","0305","RC","","","","outpatient","","","53.00","31.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","33.27","62.78","","32.02","32.02","32.02","1 through 10","3.3","41.02","percent of total billed charges",""
"Sed Rate RBC Non Auto","PX-30001123","CDM","85651","CPT","0305","RC","","","","outpatient","","","53.00","31.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","23.17","43.72","","22.30","22.30","22.30","1 through 10","3.3","41.02","percent of total billed charges",""
"Sed Rate RBC Non Auto","PX-30001123","CDM","85651","CPT","0305","RC","","","","outpatient","","","53.00","31.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","38.54","72.72","","37.09","37.09","222.54","120","3.3","41.02","percent of total billed charges",""
"Sed Rate RBC Non Auto","PX-30001123","CDM","85651","CPT","0305","RC","","","","outpatient","","","53.00","31.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","38.54","72.72","","37.09","37.09","37.09","1 through 10","3.3","41.02","percent of total billed charges",""
"Sed Rate RBC Non Auto","PX-30001123","CDM","85651","CPT","0305","RC","","","","outpatient","","","53.00","31.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","28.21","53.22","","27.19","26.15","27.19","1 through 10","3.3","41.02","percent of total billed charges",""
"Sed Rate RBC Non Auto","PX-30001123","CDM","85651","CPT","0305","RC","","","","outpatient","","","53.00","31.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","33.34","62.9","","32.13","32.13","64.26","146","3.3","41.02","percent of total billed charges",""
"Sed Rate RBC Non Auto","PX-30001123","CDM","85651","CPT","0305","RC","","","","outpatient","","","53.00","31.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","41.02","77.4","","39.53","39.51","39.53","36","3.3","41.02","percent of total billed charges",""
"Sed Rate RBC Non Auto","PX-30001123","CDM","85651","CPT","0305","RC","","","","outpatient","","","53.00","31.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","38.54","72.72","","37.09","37.09","37.09","1 through 10","3.3","41.02","percent of total billed charges",""
"Seizures With McC","100","MS-DRG","","","","","","","","inpatient","","","55969.90","33581.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","28980.11","","Fee schedule rate ($28,980.11). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","28981.27","28981.27","28981.27","1 through 10","3975","73598.59","case rate",""
"Seizures With McC","100","MS-DRG","","","","","","","","inpatient","","","55969.90","33581.94","MEDICARE [2001]","HB WDH MEDICARE","15169.27","","Case rate ($15,169.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,035.33, add-ons for qualifying new technology services are included. If operating cost exceeds $17,953.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,881.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,648.42 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,590.46 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,075.98. The transfer capital threshold is the transfer adjustment factor * $1,075.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15424.98","0.05","15465.05","1 through 10","3975","73598.59","other","Inpatient DRG"
"Seizures With McC","100","MS-DRG","","","","","","","","inpatient","","","55969.90","33581.94","TRICARE [160005]","HB WDH MEDICARE","15169.27","","Case rate ($15,169.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,035.33, add-ons for qualifying new technology services are included. If operating cost exceeds $17,953.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,881.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,648.42 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,590.46 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,075.98. The transfer capital threshold is the transfer adjustment factor * $1,075.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15403.35","15403.35","15403.35","1 through 10","3975","73598.59","other","Inpatient DRG"
"Seizures With McC","100","MS-DRG","","","","","","","","inpatient","","","55969.90","33581.94","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","15169.27","","Case rate ($15,169.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,035.33, add-ons for qualifying new technology services are included. If operating cost exceeds $17,953.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,881.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,648.42 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,590.46 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,075.98. The transfer capital threshold is the transfer adjustment factor * $1,075.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15424.98","15424.98","15464.02","1 through 10","3975","73598.59","other","Inpatient DRG"
"Seizures With McC","100","MS-DRG","","","","","","","","inpatient","","","55969.90","33581.94","WELLSENSE NH [1050]","HB WDH MEDICARE","15169.27","","Case rate ($15,169.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,035.33, add-ons for qualifying new technology services are included. If operating cost exceeds $17,953.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,881.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $13,648.42 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,590.46 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,075.98. The transfer capital threshold is the transfer adjustment factor * $1,075.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15919.91","15919.91","15919.91","1 through 10","3975","73598.59","other","Inpatient DRG"
"Seizures Without McC","101","MS-DRG","","","","","","","","inpatient","","","34376.17","20625.70","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","7160.69","","Case rate ($7,306.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,778.38, add-ons for qualifying new technology services are included. If operating cost exceeds $10,696.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,306.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,360.52 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,333.51 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $501.43. The transfer capital threshold is the transfer adjustment factor * $501.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7417.64","7417.64","7417.64","1 through 10","3975","34298.89","other","Inpatient DRG"
"Seizures Without McC","101","MS-DRG","","","","","","","","inpatient","","","34376.17","20625.70","MARTIN'S POINT [160007]","HB WDH MEDICARE","7306.83","","Case rate ($7,306.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,778.38, add-ons for qualifying new technology services are included. If operating cost exceeds $10,696.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,306.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,360.52 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,333.51 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $501.43. The transfer capital threshold is the transfer adjustment factor * $501.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7258.33","7258.33","7258.33","1 through 10","3975","34298.89","other","Inpatient DRG"
"Seizures Without McC","101","MS-DRG","","","","","","","","inpatient","","","34376.17","20625.70","MEDICARE [2001]","HB WDH MEDICARE","7306.83","","Case rate ($7,306.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,778.38, add-ons for qualifying new technology services are included. If operating cost exceeds $10,696.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,306.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,360.52 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,333.51 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $501.43. The transfer capital threshold is the transfer adjustment factor * $501.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7399.52","5609.58","7417.64","12","3975","34298.89","other","Inpatient DRG"
"Seizures Without McC","101","MS-DRG","","","","","","","","inpatient","","","34376.17","20625.70","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7306.83","","Case rate ($7,306.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,778.38, add-ons for qualifying new technology services are included. If operating cost exceeds $10,696.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,306.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,360.52 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,333.51 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $501.43. The transfer capital threshold is the transfer adjustment factor * $501.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7399.52","7307.36","15139.59","1 through 10","3975","34298.89","other","Inpatient DRG"
"Selenium","PX-30000669","CDM","84255","CPT","0301","RC","","","","both","","","294.00","176.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","205.21","69.8","","178.64","178.64","178.64","1 through 10","16.59","249.9","percent of total billed charges",""
"Selenium","PX-30000669","CDM","84255","CPT","0301","RC","","","","outpatient","","","294.00","176.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","213.80","72.72","","206.52","206.52","206.52","1 through 10","23.79","227.56","percent of total billed charges",""
"Selenium","PX-30000669","CDM","84255","CPT","0301","RC","","","","outpatient","","","294.00","176.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","184.93","62.9","","178.92","178.92","178.92","1 through 10","23.79","227.56","percent of total billed charges",""
"Semen Analysis Complete","PX-30000139","CDM","89320","CPT","0300","RC","","","","both","","","181.00","108.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","126.34","69.8","","122.15","110.08","122.15","13","8","153.85","percent of total billed charges",""
"Semen Analysis Complete","PX-30000139","CDM","89320","CPT","0300","RC","","","","both","","","181.00","108.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","153.85","85","","122.15","122.15","122.15","1 through 10","8","153.85","percent of total billed charges",""
"Semen Analysis Complete","PX-30000139","CDM","89320","CPT","0300","RC","","","","outpatient","","","181.00","108.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","131.62","72.72","","127.26","127.26","127.26","16","14.45","140.09","percent of total billed charges",""
"Semen Analysis Complete","PX-30000139","CDM","89320","CPT","0300","RC","","","","outpatient","","","181.00","108.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","131.62","72.72","","127.26","127.26","127.26","1 through 10","14.45","140.09","percent of total billed charges",""
"Semen Analysis Complete","PX-30000139","CDM","89320","CPT","0300","RC","","","","outpatient","","","181.00","108.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","113.85","62.9","","110.25","110.25","110.25","16","14.45","140.09","percent of total billed charges",""
"Semen Analysis Complete","PX-30000139","CDM","89320","CPT","0300","RC","","","","outpatient","","","181.00","108.60","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","131.62","72.72","","127.26","127.26","127.26","1 through 10","14.45","140.09","percent of total billed charges",""
"Semen Analysis Complete","PX-30000139","CDM","89320","CPT","0300","RC","","","","outpatient","","","181.00","108.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","140.09","77.4","","135.63","135.63","135.63","1 through 10","14.45","140.09","percent of total billed charges",""
"Semen Motility/Count W/O Huhner","PX-30000138","CDM","89310","CPT","0300","RC","","","","both","","","130.00","78.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","90.74","69.8","","87.95","79.25","87.95","1 through 10","5.6","110.5","percent of total billed charges",""
"Semen Motility/Count W/O Huhner","PX-30000138","CDM","89310","CPT","0300","RC","","","","outpatient","","","130.00","78.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","81.61","62.78","","79.10","79.10","79.10","1 through 10","10.3","100.62","percent of total billed charges",""
"Semen Motility/Count W/O Huhner","PX-30000138","CDM","89310","CPT","0300","RC","","","","outpatient","","","130.00","78.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","94.54","72.72","","91.63","88.29","91.63","1 through 10","10.3","100.62","percent of total billed charges",""
"Semen Motility/Count W/O Huhner","PX-30000138","CDM","89310","CPT","0300","RC","","","","outpatient","","","130.00","78.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","81.77","62.9","","79.38","79.38","79.38","15","10.3","100.62","percent of total billed charges",""
"Semen Motility/Count W/O Huhner","PX-30000138","CDM","89310","CPT","0300","RC","","","","outpatient","","","130.00","78.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","100.62","77.4","","97.65","97.65","97.65","1 through 10","10.3","100.62","percent of total billed charges",""
"SENSOR STIMULATOR 54X9.0MM SPINAL CORD RESTORE NEURO SURESCAN MRI SAFE RECHARGEABLE OCTAPOLAR CONNECTOR","SUP-ITM-10124360","CDM","C1820","HCPCS","0278","RC","","","","both","","","38368.88","23021.33","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","52982.00","26491.00","52982.00","1 through 10","4462.3","32613.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SENSOR STIMULATOR 54X9.0MM SPINAL CORD RESTORE NEURO SURESCAN MRI SAFE RECHARGEABLE OCTAPOLAR CONNECTOR","SUP-ITM-10124360","CDM","C1820","HCPCS","0278","RC","","","","both","","","38368.88","23021.33","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","21831.89","56.9","","45220.14","36256.68","45220.14","1 through 10","4462.3","32613.55","percent of total billed charges",""
"SENSOR STIMULATOR 54X9.0MM SPINAL CORD RESTORE NEURO SURESCAN MRI SAFE RECHARGEABLE OCTAPOLAR CONNECTOR","SUP-ITM-10124360","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","38368.88","23021.33","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","27901.85","72.72","","18421.60","18421.60","18421.60","1 through 10","4462.3","29697.51","percent of total billed charges",""
"SEPTAL BUTTON NASAL 2 PART 152","SUP-ITM-10216619","CDM","L8699","HCPCS","0278","RC","","","","both","","","2053.24","1231.94","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","292.76","292.76","292.76","1 through 10","238.79","1745.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","","","","inpatient","","","174797.23","104878.34","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","54051.22","","Case rate ($52,991.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $48,944.73, add-ons for qualifying new technology services are included. If operating cost exceeds $52,862.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $51,644.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $48,706.71 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $48,499.85 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,839.81. The transfer capital threshold is the transfer adjustment factor * $3,839.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","53072.25","53072.25","53072.25","1 through 10","4637","262649.09","other","Inpatient DRG"
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","","","","inpatient","","","174797.23","104878.34","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","51931.56","","Case rate ($52,991.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $48,944.73, add-ons for qualifying new technology services are included. If operating cost exceeds $52,862.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $51,644.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $48,706.71 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $48,499.85 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,839.81. The transfer capital threshold is the transfer adjustment factor * $3,839.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","52050.30","52050.30","52050.30","1 through 10","4637","262649.09","other","Inpatient DRG"
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","","","","inpatient","","","174797.23","104878.34","MEDICARE [2001]","HB WDH MEDICARE","52991.39","","Case rate ($52,991.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $48,944.73, add-ons for qualifying new technology services are included. If operating cost exceeds $52,862.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $51,644.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $48,706.71 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $48,499.85 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,839.81. The transfer capital threshold is the transfer adjustment factor * $3,839.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","53072.25","53072.25","53072.25","1 through 10","4637","262649.09","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","50882.88","30529.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","39801.83","","Fee schedule rate ($39,801.83). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","40203.43","40203.43","40203.43","1 through 10","4637","73815.19","case rate",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","50883.18","30529.91","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","15516.85","","Case rate ($15,212.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,075.33, add-ons for qualifying new technology services are included. If operating cost exceeds $17,993.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,884.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,688.59 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,630.45 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.14. The transfer capital threshold is the transfer adjustment factor * $1,079.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","12561.71","6632.15","15288.50","1 through 10","4637","73815.19","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","50883.18","30529.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","73815.19","","Fee schedule rate ($73,815.19). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","52316.15","31616.29","67093.96","1 through 10","4637","73815.19","case rate",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","50883.18","30529.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","29065.39","","Fee schedule rate ($29,065.39). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","28642.59","24930.61","28750.22","1 through 10","4637","73815.19","case rate",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","50883.18","30529.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","14908.35","","Case rate ($15,212.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,075.33, add-ons for qualifying new technology services are included. If operating cost exceeds $17,993.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,884.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,688.59 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,630.45 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.14. The transfer capital threshold is the transfer adjustment factor * $1,079.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","14978.45","14944.93","15249.93","19","4637","73815.19","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","50883.18","30529.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","58790.31","","Fee schedule rate ($58,790.31). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","28665.30","22928.53","57935.12","11","4637","73815.19","case rate",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","50883.18","30529.91","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","15668.98","","Case rate ($15,212.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,075.33, add-ons for qualifying new technology services are included. If operating cost exceeds $17,993.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,884.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,688.59 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,630.45 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.14. The transfer capital threshold is the transfer adjustment factor * $1,079.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","28011.30","5930.16","58615.06","14","4637","73815.19","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","50883.18","30529.91","MARTIN'S POINT [160007]","HB WDH MEDICARE","15212.60","","Case rate ($15,212.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,075.33, add-ons for qualifying new technology services are included. If operating cost exceeds $17,993.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,884.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,688.59 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,630.45 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.14. The transfer capital threshold is the transfer adjustment factor * $1,079.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15012.73","12426.78","16646.57","23","4637","73815.19","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","50883.18","30529.91","MEDICARE [2001]","HB WDH MEDICARE","15212.60","","Case rate ($15,212.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,075.33, add-ons for qualifying new technology services are included. If operating cost exceeds $17,993.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,884.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,688.59 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,630.45 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.14. The transfer capital threshold is the transfer adjustment factor * $1,079.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15249.93","0.05","15288.50","236","4637","73815.19","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","50883.18","30529.91","TRICARE [160005]","HB WDH MEDICARE","15212.60","","Case rate ($15,212.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,075.33, add-ons for qualifying new technology services are included. If operating cost exceeds $17,993.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,884.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,688.59 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,630.45 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.14. The transfer capital threshold is the transfer adjustment factor * $1,079.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15846.57","1327.78","15846.57","1 through 10","4637","73815.19","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","50883.18","30529.91","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","15212.60","","Case rate ($15,212.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,075.33, add-ons for qualifying new technology services are included. If operating cost exceeds $17,993.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,884.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,688.59 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,630.45 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.14. The transfer capital threshold is the transfer adjustment factor * $1,079.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14984.74","6539.31","15288.50","54","4637","73815.19","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","50883.18","30529.91","WELLSENSE NH [1050]","HB WDH MEDICARE","15212.60","","Case rate ($15,212.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $14,075.33, add-ons for qualifying new technology services are included. If operating cost exceeds $17,993.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,884.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,688.59 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $13,630.45 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,079.14. The transfer capital threshold is the transfer adjustment factor * $1,079.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15739.27","9814.18","15775.67","1 through 10","4637","73815.19","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","28947.05","17368.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","38885.50","","Fee schedule rate ($38,885.50). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","38222.54","38222.54","38222.54","1 through 10","3975","38885.5","case rate",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","28947.05","17368.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","15311.52","","Fee schedule rate ($15,311.52). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","12568.65","12568.65","12568.65","1 through 10","3975","38885.5","case rate",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","28947.05","17368.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","8059.96","","Case rate ($8,224.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,625.33, add-ons for qualifying new technology services are included. If operating cost exceeds $11,543.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,373.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,211.08 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,180.46 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $568.49. The transfer capital threshold is the transfer adjustment factor * $568.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","8224.25","8079.63","8244.52","1 through 10","3975","38885.5","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","28947.05","17368.23","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","30970.46","","Fee schedule rate ($30,970.46). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","24399.67","16970.63","30442.44","1 through 10","3975","38885.5","case rate",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","28947.05","17368.23","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","8471.18","","Case rate ($8,224.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,625.33, add-ons for qualifying new technology services are included. If operating cost exceeds $11,543.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,373.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,211.08 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,180.46 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $568.49. The transfer capital threshold is the transfer adjustment factor * $568.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","28864.54","28864.54","28864.54","1 through 10","3975","38885.5","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","28947.05","17368.23","MARTIN'S POINT [160007]","HB WDH MEDICARE","8224.45","","Case rate ($8,224.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,625.33, add-ons for qualifying new technology services are included. If operating cost exceeds $11,543.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,373.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,211.08 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,180.46 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $568.49. The transfer capital threshold is the transfer adjustment factor * $568.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8081.20","8079.63","8109.63","1 through 10","3975","38885.5","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","28947.05","17368.23","MEDICARE [2001]","HB WDH MEDICARE","8224.45","","Case rate ($8,224.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,625.33, add-ons for qualifying new technology services are included. If operating cost exceeds $11,543.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,373.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,211.08 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,180.46 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $568.49. The transfer capital threshold is the transfer adjustment factor * $568.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8224.25","0.05","8244.52","48","3975","38885.5","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","28947.05","17368.23","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","8224.45","","Case rate ($8,224.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,625.33, add-ons for qualifying new technology services are included. If operating cost exceeds $11,543.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,373.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,211.08 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,180.46 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $568.49. The transfer capital threshold is the transfer adjustment factor * $568.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8099.27","7129.94","8244.52","11","3975","38885.5","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","28947.05","17368.23","WELLSENSE NH [1050]","HB WDH MEDICARE","8224.45","","Case rate ($8,224.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,625.33, add-ons for qualifying new technology services are included. If operating cost exceeds $11,543.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,373.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $7,211.08 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,180.46 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $568.49. The transfer capital threshold is the transfer adjustment factor * $568.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8528.56","8528.56","8528.56","1 through 10","3975","38885.5","other","Inpatient DRG"
"Serotonin","PX-30000670","CDM","84260","CPT","0301","RC","","","","outpatient","","","357.00","214.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","259.61","72.72","","250.88","250.88","250.88","1 through 10","28.87","276.32","percent of total billed charges",""
"SET CATHETER 7FR 2.8MM .035IN 9SIDEHOLE DRAINAGE PIGTAIL ALPHA CURVE NASAL BILIARY","SUP-ITM-10001362","CDM","C1729","HCPCS","0272","RC","","","","both","","","1057.23","634.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","122.96","11.63","","19.51","17.34","54.47","21","122.96","898.65","percent of total billed charges",""
"SET CATHETER 7FR 2.8MM .035IN 9SIDEHOLE DRAINAGE PIGTAIL ALPHA CURVE NASAL BILIARY","SUP-ITM-10001362","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1057.23","634.34","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","122.96","11.63","","19.51","17.34","54.47","21","122.96","818.3","percent of total billed charges",""
"SET CATHETER 7FR 2.8MM .035IN 9SIDEHOLE DRAINAGE PIGTAIL ALPHA CURVE NASAL BILIARY","SUP-ITM-10001362","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1057.23","634.34","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","462.22","43.72","","61.93","61.93","61.93","1 through 10","122.96","818.3","percent of total billed charges",""
"SET CATHETER 7FR 2.8MM .035IN 9SIDEHOLE DRAINAGE PIGTAIL ALPHA CURVE NASAL BILIARY","SUP-ITM-10001362","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1057.23","634.34","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","768.82","72.72","","330.75","267.63","330.75","1 through 10","122.96","818.3","percent of total billed charges",""
"SET CATHETER 7FR 2.8MM .035IN 9SIDEHOLE DRAINAGE PIGTAIL ALPHA CURVE NASAL BILIARY","SUP-ITM-10001362","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1057.23","634.34","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","665.00","62.9","","89.25","87.07","231.86","1 through 10","122.96","818.3","percent of total billed charges",""
"SET CATHETER 7FR 2.8MM .035IN 9SIDEHOLE DRAINAGE PIGTAIL ALPHA CURVE NASAL BILIARY","SUP-ITM-10001362","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1057.23","634.34","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","768.82","72.72","","267.63","267.63","267.63","1 through 10","122.96","818.3","percent of total billed charges",""
"SET DECOMPRESSION 14FR 175CM COLON CATHETER 10PORT 6FR 182CM GUIDING GUIDEWIRE","SUP-ITM-10001352","CDM","C1729","HCPCS","0272","RC","","","","both","","","1347.45","808.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","156.71","11.63","","19.51","17.34","54.47","21","156.71","1145.33","percent of total billed charges",""
"SET DECOMPRESSION 14FR 175CM COLON CATHETER 10PORT 6FR 182CM GUIDING GUIDEWIRE","SUP-ITM-10001352","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1347.45","808.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","156.71","11.63","","19.51","17.34","54.47","21","156.71","1042.93","percent of total billed charges",""
"SET DECOMPRESSION 14FR 175CM COLON CATHETER 10PORT 6FR 182CM GUIDING GUIDEWIRE","SUP-ITM-10001352","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1347.45","808.47","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","589.11","43.72","","61.93","61.93","61.93","1 through 10","156.71","1042.93","percent of total billed charges",""
"SET DECOMPRESSION 14FR 175CM COLON CATHETER 10PORT 6FR 182CM GUIDING GUIDEWIRE","SUP-ITM-10001352","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1347.45","808.47","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","979.87","72.72","","330.75","267.63","330.75","1 through 10","156.71","1042.93","percent of total billed charges",""
"SET DECOMPRESSION 14FR 175CM COLON CATHETER 10PORT 6FR 182CM GUIDING GUIDEWIRE","SUP-ITM-10001352","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1347.45","808.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","847.55","62.9","","89.25","87.07","231.86","1 through 10","156.71","1042.93","percent of total billed charges",""
"SET DECOMPRESSION 14FR 175CM COLON CATHETER 10PORT 6FR 182CM GUIDING GUIDEWIRE","SUP-ITM-10001352","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1347.45","808.47","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","979.87","72.72","","267.63","267.63","267.63","1 through 10","156.71","1042.93","percent of total billed charges",""
"SET DILATOR 15 18MM 5.5CM L 180 20 30 3.5ATM .035IN BALLOON ENDOSCOPIC GASTROINTESTINAL DIA OBLONG FIL","SUP-ITM-10022780","CDM","C1726","HCPCS","0272","RC","","","","both","","","1334.25","800.55","AETNA [1001]","HB WDH AETNA COMMERCIAL","931.31","69.8","","166.96","137.81","825.49","1 through 10","155.17","1134.11","percent of total billed charges",""
"SET DILATOR 15 18MM 5.5CM L 180 20 30 3.5ATM .035IN BALLOON ENDOSCOPIC GASTROINTESTINAL DIA OBLONG FIL","SUP-ITM-10022780","CDM","C1726","HCPCS","0272","RC","","","","both","","","1334.25","800.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1716.86","1716.86","1716.86","1 through 10","155.17","1134.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET DILATOR 15 18MM 5.5CM L 180 20 30 3.5ATM .035IN BALLOON ENDOSCOPIC GASTROINTESTINAL DIA OBLONG FIL","SUP-ITM-10022780","CDM","C1726","HCPCS","0272","RC","","","","both","","","1334.25","800.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","4281.09","1182.65","4281.09","1 through 10","155.17","1134.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET DILATOR 15 18MM 5.5CM L 180 20 30 3.5ATM .035IN BALLOON ENDOSCOPIC GASTROINTESTINAL DIA OBLONG FIL","SUP-ITM-10022780","CDM","C1726","HCPCS","0272","RC","","","","both","","","1334.25","800.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","155.17","11.63","","262.01","27.19","426.66","1 through 10","155.17","1134.11","percent of total billed charges",""
"SET DILATOR 15 18MM 5.5CM L 180 20 30 3.5ATM .035IN BALLOON ENDOSCOPIC GASTROINTESTINAL DIA OBLONG FIL","SUP-ITM-10022780","CDM","C1726","HCPCS","0272","RC","","","","both","","","1334.25","800.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1032.71","77.4","","1411.46","916.55","1411.46","1 through 10","155.17","1134.11","percent of total billed charges",""
"SET DILATOR 15 18MM 5.5CM L 180 20 30 3.5ATM .035IN BALLOON ENDOSCOPIC GASTROINTESTINAL DIA OBLONG FIL","SUP-ITM-10022780","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1334.25","800.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","155.17","11.63","","262.01","27.19","426.66","1 through 10","155.17","1032.71","percent of total billed charges",""
"SET DILATOR 15 18MM 5.5CM L 180 20 30 3.5ATM .035IN BALLOON ENDOSCOPIC GASTROINTESTINAL DIA OBLONG FIL","SUP-ITM-10022780","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1334.25","800.55","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","583.33","43.72","","517.05","517.05","517.05","1 through 10","155.17","1032.71","percent of total billed charges",""
"SET DILATOR 15 18MM 5.5CM L 180 20 30 3.5ATM .035IN BALLOON ENDOSCOPIC GASTROINTESTINAL DIA OBLONG FIL","SUP-ITM-10022780","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1334.25","800.55","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","970.27","72.72","","1556.61","860.02","1914.17","1 through 10","155.17","1032.71","percent of total billed charges",""
"SET DILATOR 15 18MM 5.5CM L 180 20 30 3.5ATM .035IN BALLOON ENDOSCOPIC GASTROINTESTINAL DIA OBLONG FIL","SUP-ITM-10022780","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1334.25","800.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","839.24","62.9","","1348.55","745.07","1348.55","19","155.17","1032.71","percent of total billed charges",""
"SET DILATOR 15 18MM 5.5CM L 180 20 30 3.5ATM .035IN BALLOON ENDOSCOPIC GASTROINTESTINAL DIA OBLONG FIL","SUP-ITM-10022780","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1334.25","800.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1032.71","77.4","","1411.46","916.55","1411.46","1 through 10","155.17","1032.71","percent of total billed charges",""
"SET DILATOR 15 18MM 5.5CM L 180 20 30 3.5ATM .035IN BALLOON ENDOSCOPIC GASTROINTESTINAL DIA OBLONG FIL","SUP-ITM-10022780","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1334.25","800.55","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","970.27","72.72","","860.02","860.02","860.02","1 through 10","155.17","1032.71","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","both","","","4164.86","2498.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","484.37","3540.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","both","","","4164.86","2498.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","484.37","3540.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","both","","","4164.86","2498.92","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2369.81","56.9","","812.12","238.65","1587.46","163","484.37","3540.13","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","both","","","4164.86","2498.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","484.37","11.63","","112.68","112.68","146.99","38","484.37","3540.13","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","both","","","4164.86","2498.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3223.60","77.4","","303.98","303.98","5854.79","1 through 10","484.37","3540.13","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4164.86","2498.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","484.37","11.63","","112.68","112.68","146.99","38","484.37","3223.6","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4164.86","2498.92","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2614.70","62.78","","780.86","208.94","10480.28","15","484.37","3223.6","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4164.86","2498.92","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1820.88","43.72","","179.76","179.76","179.76","1 through 10","484.37","3223.6","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4164.86","2498.92","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3028.69","72.72","","2355.45","298.99","3965.19","155","484.37","3223.6","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4164.86","2498.92","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3028.69","72.72","","3643.09","3643.09","3643.09","1 through 10","484.37","3223.6","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4164.86","2498.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2216.54","53.22","","554.28","554.28","554.28","16","484.37","3223.6","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4164.86","2498.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2619.70","62.9","","619.64","173.09","2370.64","150","484.37","3223.6","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4164.86","2498.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3223.60","77.4","","303.98","303.98","5854.79","1 through 10","484.37","3223.6","percent of total billed charges",""
"SET INTRODUCER 6CM 5FR ADULT SHEATH PINNACLE R/O II MARKER RADIOPAQUE DILATOR MINI GUIDEWIRE BX/10EA","SUP-ITM-10076159","CDM","C1894","HCPCS","0272","RC","","","","both","","","152.02","91.21","AETNA [1001]","HB WDH AETNA COMMERCIAL","106.11","69.8","","94.15","94.15","427.63","1 through 10","17.68","129.22","percent of total billed charges",""
"SET INTRODUCER 6CM 5FR ADULT SHEATH PINNACLE R/O II MARKER RADIOPAQUE DILATOR MINI GUIDEWIRE BX/10EA","SUP-ITM-10076159","CDM","C1894","HCPCS","0272","RC","","","","both","","","152.02","91.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","17.68","129.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET INTRODUCER 6CM 5FR ADULT SHEATH PINNACLE R/O II MARKER RADIOPAQUE DILATOR MINI GUIDEWIRE BX/10EA","SUP-ITM-10076159","CDM","C1894","HCPCS","0272","RC","","","","both","","","152.02","91.21","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","86.50","56.9","","401.89","65.85","401.89","1 through 10","17.68","129.22","percent of total billed charges",""
"SET INTRODUCER 6CM 5FR ADULT SHEATH PINNACLE R/O II MARKER RADIOPAQUE DILATOR MINI GUIDEWIRE BX/10EA","SUP-ITM-10076159","CDM","C1894","HCPCS","0272","RC","","","","both","","","152.02","91.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","17.68","11.63","","49.19","10.57","114.40","19","17.68","129.22","percent of total billed charges",""
"SET INTRODUCER 6CM 5FR ADULT SHEATH PINNACLE R/O II MARKER RADIOPAQUE DILATOR MINI GUIDEWIRE BX/10EA","SUP-ITM-10076159","CDM","C1894","HCPCS","0272","RC","","","","both","","","152.02","91.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","117.66","77.4","","200.75","81.67","643.86","11","17.68","129.22","percent of total billed charges",""
"SET INTRODUCER 6CM 5FR ADULT SHEATH PINNACLE R/O II MARKER RADIOPAQUE DILATOR MINI GUIDEWIRE BX/10EA","SUP-ITM-10076159","CDM","C1894","HCPCS","0272","RC","","","","both","","","152.02","91.21","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","17.68","129.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET INTRODUCER 6CM 5FR ADULT SHEATH PINNACLE R/O II MARKER RADIOPAQUE DILATOR MINI GUIDEWIRE BX/10EA","SUP-ITM-10076159","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","152.02","91.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","17.68","11.63","","49.19","10.57","114.40","19","17.68","117.66","percent of total billed charges",""
"SET INTRODUCER 6CM 5FR ADULT SHEATH PINNACLE R/O II MARKER RADIOPAQUE DILATOR MINI GUIDEWIRE BX/10EA","SUP-ITM-10076159","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","152.02","91.21","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","95.44","62.78","","93.27","93.27","93.27","1 through 10","17.68","117.66","percent of total billed charges",""
"SET INTRODUCER 6CM 5FR ADULT SHEATH PINNACLE R/O II MARKER RADIOPAQUE DILATOR MINI GUIDEWIRE BX/10EA","SUP-ITM-10076159","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","152.02","91.21","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","66.46","43.72","","363.22","363.22","363.22","1 through 10","17.68","117.66","percent of total billed charges",""
"SET INTRODUCER 6CM 5FR ADULT SHEATH PINNACLE R/O II MARKER RADIOPAQUE DILATOR MINI GUIDEWIRE BX/10EA","SUP-ITM-10076159","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","152.02","91.21","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","110.55","72.72","","271.85","111.24","551.69","14","17.68","117.66","percent of total billed charges",""
"SET INTRODUCER 6CM 5FR ADULT SHEATH PINNACLE R/O II MARKER RADIOPAQUE DILATOR MINI GUIDEWIRE BX/10EA","SUP-ITM-10076159","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","152.02","91.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","95.62","62.9","","706.53","93.60","938.00","53","17.68","117.66","percent of total billed charges",""
"SET INTRODUCER 6CM 5FR ADULT SHEATH PINNACLE R/O II MARKER RADIOPAQUE DILATOR MINI GUIDEWIRE BX/10EA","SUP-ITM-10076159","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","152.02","91.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","117.66","77.4","","200.75","81.67","643.86","11","17.68","117.66","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","both","","","518.18","310.91","AETNA [1001]","HB WDH AETNA COMMERCIAL","361.69","69.8","","94.15","94.15","427.63","1 through 10","60.26","440.45","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","both","","","518.18","310.91","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","60.26","440.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","both","","","518.18","310.91","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","294.84","56.9","","401.89","65.85","401.89","1 through 10","60.26","440.45","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","both","","","518.18","310.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","60.26","11.63","","49.19","10.57","114.40","19","60.26","440.45","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","both","","","518.18","310.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","401.07","77.4","","200.75","81.67","643.86","11","60.26","440.45","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","both","","","518.18","310.91","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","60.26","440.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","518.18","310.91","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","60.26","11.63","","49.19","10.57","114.40","19","60.26","401.07","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","518.18","310.91","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","325.31","62.78","","93.27","93.27","93.27","1 through 10","60.26","401.07","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","518.18","310.91","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","226.55","43.72","","363.22","363.22","363.22","1 through 10","60.26","401.07","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","518.18","310.91","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","376.82","72.72","","271.85","111.24","551.69","14","60.26","401.07","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","518.18","310.91","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","325.94","62.9","","706.53","93.60","938.00","53","60.26","401.07","percent of total billed charges",""
"SET INTRODUCER FLEXOR 10FR 40CM .038IN CHECK-FLO DILATOR TIP RADIOPAQUE BAND HEMOSTASIS VALVE GUIDING NOT IMPLANTABLE BALLOON CLOSED NON TAPERED END CATHETER","SUP-ITM-10012673","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","518.18","310.91","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","401.07","77.4","","200.75","81.67","643.86","11","60.26","401.07","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 24CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000118","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.04","182.42","AETNA [1001]","HB WDH AETNA COMMERCIAL","212.22","69.8","","94.15","94.15","427.63","1 through 10","35.36","258.43","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 24CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000118","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.04","182.42","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","35.36","258.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET INTRODUCER SUPER ARROW-FLEX 6FR 24CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000118","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.04","182.42","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","173.00","56.9","","401.89","65.85","401.89","1 through 10","35.36","258.43","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 24CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000118","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.04","182.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","35.36","11.63","","49.19","10.57","114.40","19","35.36","258.43","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 24CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000118","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.04","182.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","235.33","77.4","","200.75","81.67","643.86","11","35.36","258.43","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 24CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000118","CDM","C1894","HCPCS","0272","RC","","","","both","","","304.04","182.42","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","35.36","258.43","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET INTRODUCER SUPER ARROW-FLEX 6FR 24CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000118","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","304.04","182.42","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","35.36","11.63","","49.19","10.57","114.40","19","35.36","235.33","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 24CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000118","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","304.04","182.42","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","190.88","62.78","","93.27","93.27","93.27","1 through 10","35.36","235.33","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 24CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000118","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","304.04","182.42","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","132.93","43.72","","363.22","363.22","363.22","1 through 10","35.36","235.33","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 24CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000118","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","304.04","182.42","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","221.10","72.72","","271.85","111.24","551.69","14","35.36","235.33","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 24CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000118","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","304.04","182.42","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","191.24","62.9","","706.53","93.60","938.00","53","35.36","235.33","percent of total billed charges",""
"SET INTRODUCER SUPER ARROW-FLEX 6FR 24CM HEMOSTATIC VALVE PERCUTANEOUS SHEATH INTEGRAL SIDE PORT ATTACHED 3WAY STOPCOCK RADIOPAQUE TIP GREEN CS/5EA","SUP-ITM-10000118","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","304.04","182.42","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","235.33","77.4","","200.75","81.67","643.86","11","35.36","235.33","percent of total billed charges",""
"SET NEEDLE 12CM 18GA INTRODUCER SHEATH PCNL RENAL PELVIS","SUP-ITM-10155774","CDM","C1894","HCPCS","0272","RC","","","","both","","","214.42","128.65","AETNA [1001]","HB WDH AETNA COMMERCIAL","149.67","69.8","","94.15","94.15","427.63","1 through 10","24.94","182.26","percent of total billed charges",""
"SET NEEDLE 12CM 18GA INTRODUCER SHEATH PCNL RENAL PELVIS","SUP-ITM-10155774","CDM","C1894","HCPCS","0272","RC","","","","both","","","214.42","128.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","24.94","182.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET NEEDLE 12CM 18GA INTRODUCER SHEATH PCNL RENAL PELVIS","SUP-ITM-10155774","CDM","C1894","HCPCS","0272","RC","","","","both","","","214.42","128.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","122.00","56.9","","401.89","65.85","401.89","1 through 10","24.94","182.26","percent of total billed charges",""
"SET NEEDLE 12CM 18GA INTRODUCER SHEATH PCNL RENAL PELVIS","SUP-ITM-10155774","CDM","C1894","HCPCS","0272","RC","","","","both","","","214.42","128.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","24.94","11.63","","49.19","10.57","114.40","19","24.94","182.26","percent of total billed charges",""
"SET NEEDLE 12CM 18GA INTRODUCER SHEATH PCNL RENAL PELVIS","SUP-ITM-10155774","CDM","C1894","HCPCS","0272","RC","","","","both","","","214.42","128.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","165.96","77.4","","200.75","81.67","643.86","11","24.94","182.26","percent of total billed charges",""
"SET NEEDLE 12CM 18GA INTRODUCER SHEATH PCNL RENAL PELVIS","SUP-ITM-10155774","CDM","C1894","HCPCS","0272","RC","","","","both","","","214.42","128.65","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","24.94","182.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET NEEDLE 12CM 18GA INTRODUCER SHEATH PCNL RENAL PELVIS","SUP-ITM-10155774","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","214.42","128.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","24.94","11.63","","49.19","10.57","114.40","19","24.94","165.96","percent of total billed charges",""
"SET NEEDLE 12CM 18GA INTRODUCER SHEATH PCNL RENAL PELVIS","SUP-ITM-10155774","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","214.42","128.65","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","134.61","62.78","","93.27","93.27","93.27","1 through 10","24.94","165.96","percent of total billed charges",""
"SET NEEDLE 12CM 18GA INTRODUCER SHEATH PCNL RENAL PELVIS","SUP-ITM-10155774","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","214.42","128.65","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","93.74","43.72","","363.22","363.22","363.22","1 through 10","24.94","165.96","percent of total billed charges",""
"SET NEEDLE 12CM 18GA INTRODUCER SHEATH PCNL RENAL PELVIS","SUP-ITM-10155774","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","214.42","128.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","155.93","72.72","","271.85","111.24","551.69","14","24.94","165.96","percent of total billed charges",""
"SET NEEDLE 12CM 18GA INTRODUCER SHEATH PCNL RENAL PELVIS","SUP-ITM-10155774","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","214.42","128.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","134.87","62.9","","706.53","93.60","938.00","53","24.94","165.96","percent of total billed charges",""
"SET NEEDLE 12CM 18GA INTRODUCER SHEATH PCNL RENAL PELVIS","SUP-ITM-10155774","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","214.42","128.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","165.96","77.4","","200.75","81.67","643.86","11","24.94","165.96","percent of total billed charges",""
"SET NEEDLE 18GA 20CM INTRODUCER","SUP-ITM-10155775","CDM","C1894","HCPCS","0272","RC","","","","both","","","278.75","167.25","AETNA [1001]","HB WDH AETNA COMMERCIAL","194.57","69.8","","94.15","94.15","427.63","1 through 10","32.42","236.94","percent of total billed charges",""
"SET NEEDLE 18GA 20CM INTRODUCER","SUP-ITM-10155775","CDM","C1894","HCPCS","0272","RC","","","","both","","","278.75","167.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","32.42","236.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET NEEDLE 18GA 20CM INTRODUCER","SUP-ITM-10155775","CDM","C1894","HCPCS","0272","RC","","","","both","","","278.75","167.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","158.61","56.9","","401.89","65.85","401.89","1 through 10","32.42","236.94","percent of total billed charges",""
"SET NEEDLE 18GA 20CM INTRODUCER","SUP-ITM-10155775","CDM","C1894","HCPCS","0272","RC","","","","both","","","278.75","167.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","32.42","11.63","","49.19","10.57","114.40","19","32.42","236.94","percent of total billed charges",""
"SET NEEDLE 18GA 20CM INTRODUCER","SUP-ITM-10155775","CDM","C1894","HCPCS","0272","RC","","","","both","","","278.75","167.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","215.75","77.4","","200.75","81.67","643.86","11","32.42","236.94","percent of total billed charges",""
"SET NEEDLE 18GA 20CM INTRODUCER","SUP-ITM-10155775","CDM","C1894","HCPCS","0272","RC","","","","both","","","278.75","167.25","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","32.42","236.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET NEEDLE 18GA 20CM INTRODUCER","SUP-ITM-10155775","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","278.75","167.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","32.42","11.63","","49.19","10.57","114.40","19","32.42","215.75","percent of total billed charges",""
"SET NEEDLE 18GA 20CM INTRODUCER","SUP-ITM-10155775","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","278.75","167.25","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","175.00","62.78","","93.27","93.27","93.27","1 through 10","32.42","215.75","percent of total billed charges",""
"SET NEEDLE 18GA 20CM INTRODUCER","SUP-ITM-10155775","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","278.75","167.25","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","121.87","43.72","","363.22","363.22","363.22","1 through 10","32.42","215.75","percent of total billed charges",""
"SET NEEDLE 18GA 20CM INTRODUCER","SUP-ITM-10155775","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","278.75","167.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","202.71","72.72","","271.85","111.24","551.69","14","32.42","215.75","percent of total billed charges",""
"SET NEEDLE 18GA 20CM INTRODUCER","SUP-ITM-10155775","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","278.75","167.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","175.33","62.9","","706.53","93.60","938.00","53","32.42","215.75","percent of total billed charges",""
"SET NEEDLE 18GA 20CM INTRODUCER","SUP-ITM-10155775","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","278.75","167.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","215.75","77.4","","200.75","81.67","643.86","11","32.42","215.75","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","both","","","2591.25","1554.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","301.36","2202.56","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","both","","","2591.25","1554.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","301.36","2202.56","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","both","","","2591.25","1554.75","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1474.42","56.9","","812.12","238.65","1587.46","163","301.36","2202.56","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","both","","","2591.25","1554.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","301.36","11.63","","112.68","112.68","146.99","38","301.36","2202.56","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","both","","","2591.25","1554.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2005.63","77.4","","303.98","303.98","5854.79","1 through 10","301.36","2202.56","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2591.25","1554.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","301.36","11.63","","112.68","112.68","146.99","38","301.36","2005.63","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2591.25","1554.75","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1626.79","62.78","","780.86","208.94","10480.28","15","301.36","2005.63","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2591.25","1554.75","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1132.89","43.72","","179.76","179.76","179.76","1 through 10","301.36","2005.63","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2591.25","1554.75","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1884.36","72.72","","2355.45","298.99","3965.19","155","301.36","2005.63","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2591.25","1554.75","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1884.36","72.72","","3643.09","3643.09","3643.09","1 through 10","301.36","2005.63","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2591.25","1554.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1379.06","53.22","","554.28","554.28","554.28","16","301.36","2005.63","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2591.25","1554.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1629.90","62.9","","619.64","173.09","2370.64","150","301.36","2005.63","percent of total billed charges",""
"SET NEEDLE ARTHROSCOPY FAST FIX 360 MENISCAL REPAIR NONABSORBABLE STRAIGHT","SUP-ITM-10094729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2591.25","1554.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2005.63","77.4","","303.98","303.98","5854.79","1 through 10","301.36","2005.63","percent of total billed charges",""
"SET PROBE LOCALIZER 20 DRAPE KT/20EA","SUP-ITM-10212395","CDM","C1819","HCPCS","0278","RC","","","","both","","","1893.34","1136.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1893.34","1893.34","1893.34","1 through 10","220.2","1609.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET PROBE LOCALIZER 20 DRAPE KT/20EA","SUP-ITM-10212395","CDM","C1819","HCPCS","0278","RC","","","","both","","","1893.34","1136.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","1893.34","1893.34","1893.34","1 through 10","220.2","1609.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET PROBE LOCALIZER 20 DRAPE KT/20EA","SUP-ITM-10212395","CDM","C1819","HCPCS","0278","RC","","","","both","","","1893.34","1136.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1077.31","56.9","","926.29","239.45","3231.93","63","220.2","1609.34","percent of total billed charges",""
"SET PROBE LOCALIZER 20 DRAPE KT/20EA","SUP-ITM-10212395","CDM","C1819","HCPCS","0278","RC","","","","both","","","1893.34","1136.00","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","1077.31","56.9","","2154.62","2154.62","2154.62","1 through 10","220.2","1609.34","percent of total billed charges",""
"SET PROBE LOCALIZER 20 DRAPE KT/20EA","SUP-ITM-10212395","CDM","C1819","HCPCS","0278","RC","","","","both","","","1893.34","1136.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","220.20","11.63","","73.84","65.64","73.84","1 through 10","220.2","1609.34","percent of total billed charges",""
"SET PROBE LOCALIZER 20 DRAPE KT/20EA","SUP-ITM-10212395","CDM","C1819","HCPCS","0278","RC","","","","both","","","1893.34","1136.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","1609.34","85","","813.48","813.48","813.48","1 through 10","220.2","1609.34","percent of total billed charges",""
"SET PROBE LOCALIZER 20 DRAPE KT/20EA","SUP-ITM-10212395","CDM","C1819","HCPCS","0278","RC","","","","both","","","1893.34","1136.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1465.45","77.4","","415.57","314.89","2101.58","1 through 10","220.2","1609.34","percent of total billed charges",""
"SET PROBE LOCALIZER 20 DRAPE KT/20EA","SUP-ITM-10212395","CDM","C1819","HCPCS","0278","RC","","","","outpatient","","","1893.34","1136.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","220.20","11.63","","73.84","65.64","73.84","1 through 10","220.2","1465.45","percent of total billed charges",""
"SET PROBE LOCALIZER 20 DRAPE KT/20EA","SUP-ITM-10212395","CDM","C1819","HCPCS","0278","RC","","","","outpatient","","","1893.34","1136.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1188.64","62.78","","3565.92","1188.64","3565.92","1 through 10","220.2","1465.45","percent of total billed charges",""
"SET PROBE LOCALIZER 20 DRAPE KT/20EA","SUP-ITM-10212395","CDM","C1819","HCPCS","0278","RC","","","","outpatient","","","1893.34","1136.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","827.77","43.72","","2483.31","2483.31","2483.31","1 through 10","220.2","1465.45","percent of total billed charges",""
"SET PROBE LOCALIZER 20 DRAPE KT/20EA","SUP-ITM-10212395","CDM","C1819","HCPCS","0278","RC","","","","outpatient","","","1893.34","1136.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1376.84","72.72","","4130.51","389.94","4130.52","28","220.2","1465.45","percent of total billed charges",""
"SET PROBE LOCALIZER 20 DRAPE KT/20EA","SUP-ITM-10212395","CDM","C1819","HCPCS","0278","RC","","","","outpatient","","","1893.34","1136.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1376.84","72.72","","389.94","389.94","389.94","1 through 10","220.2","1465.45","percent of total billed charges",""
"SET PROBE LOCALIZER 20 DRAPE KT/20EA","SUP-ITM-10212395","CDM","C1819","HCPCS","0278","RC","","","","outpatient","","","1893.34","1136.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1190.91","62.9","","795.35","337.82","1192.81","40","220.2","1465.45","percent of total billed charges",""
"SET PROBE LOCALIZER 20 DRAPE KT/20EA","SUP-ITM-10212395","CDM","C1819","HCPCS","0278","RC","","","","outpatient","","","1893.34","1136.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1465.45","77.4","","415.57","314.89","2101.58","1 through 10","220.2","1465.45","percent of total billed charges",""
"SET PROBE LOCALIZER 20 DRAPE KT/20EA","SUP-ITM-10212395","CDM","C1819","HCPCS","0278","RC","","","","outpatient","","","1893.34","1136.00","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","1376.84","72.72","","1414.81","1414.81","1414.81","1 through 10","220.2","1465.45","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.95","186.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","36.16","264.31","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.95","186.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","36.16","264.31","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.95","186.57","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","176.93","56.9","","812.12","238.65","1587.46","163","36.16","264.31","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.95","186.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","36.16","11.63","","112.68","112.68","146.99","38","36.16","264.31","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.95","186.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","240.68","77.4","","303.98","303.98","5854.79","1 through 10","36.16","264.31","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","310.95","186.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","36.16","11.63","","112.68","112.68","146.99","38","36.16","240.68","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","310.95","186.57","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","195.21","62.78","","780.86","208.94","10480.28","15","36.16","240.68","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","310.95","186.57","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","135.95","43.72","","179.76","179.76","179.76","1 through 10","36.16","240.68","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","310.95","186.57","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","226.12","72.72","","2355.45","298.99","3965.19","155","36.16","240.68","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","310.95","186.57","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","226.12","72.72","","3643.09","3643.09","3643.09","1 through 10","36.16","240.68","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","310.95","186.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","165.49","53.22","","554.28","554.28","554.28","16","36.16","240.68","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","310.95","186.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","195.59","62.9","","619.64","173.09","2370.64","150","36.16","240.68","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","310.95","186.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","240.68","77.4","","303.98","303.98","5854.79","1 through 10","36.16","240.68","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.50","207.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","40.18","293.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.50","207.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","40.18","293.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.50","207.30","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","196.59","56.9","","812.12","238.65","1587.46","163","40.18","293.68","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.50","207.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.18","11.63","","112.68","112.68","146.99","38","40.18","293.68","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.50","207.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","267.42","77.4","","303.98","303.98","5854.79","1 through 10","40.18","293.68","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.18","11.63","","112.68","112.68","146.99","38","40.18","267.42","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","216.90","62.78","","780.86","208.94","10480.28","15","40.18","267.42","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","151.05","43.72","","179.76","179.76","179.76","1 through 10","40.18","267.42","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","251.25","72.72","","2355.45","298.99","3965.19","155","40.18","267.42","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","251.25","72.72","","3643.09","3643.09","3643.09","1 through 10","40.18","267.42","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","183.88","53.22","","554.28","554.28","554.28","16","40.18","267.42","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","217.32","62.9","","619.64","173.09","2370.64","150","40.18","267.42","percent of total billed charges",""
"SET SCREW M6 SPINE INFINITY","SUP-ITM-10288173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","267.42","77.4","","303.98","303.98","5854.79","1 through 10","40.18","267.42","percent of total billed charges",""
"SET SCREW SPINE VERTEX SELECT TITANIUM LOCKING","SUP-ITM-10018153","CDM","C1889","HCPCS","0278","RC","","","","both","","","310.95","186.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","36.16","264.31","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET SCREW SPINE VERTEX SELECT TITANIUM LOCKING","SUP-ITM-10018153","CDM","C1889","HCPCS","0278","RC","","","","both","","","310.95","186.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","36.16","264.31","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET SCREW SPINE VERTEX SELECT TITANIUM LOCKING","SUP-ITM-10018153","CDM","C1889","HCPCS","0278","RC","","","","both","","","310.95","186.57","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","176.93","56.9","","0.63","0.63","0.63","1 through 10","36.16","264.31","percent of total billed charges",""
"SET SCREW SPINE VERTEX SELECT TITANIUM LOCKING","SUP-ITM-10018153","CDM","C1889","HCPCS","0278","RC","","","","both","","","310.95","186.57","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","44.84","14.42","","317.14","317.14","317.14","1 through 10","36.16","264.31","percent of total billed charges",""
"SET SCREW SPINE VERTEX SELECT TITANIUM LOCKING","SUP-ITM-10018153","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","310.95","186.57","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","44.84","14.42","","317.14","317.14","317.14","1 through 10","36.16","240.68","percent of total billed charges",""
"SET SCREW SPINE VERTEX SELECT TITANIUM LOCKING","SUP-ITM-10018153","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","310.95","186.57","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","195.21","62.78","","1125.09","1125.09","1125.09","1 through 10","36.16","240.68","percent of total billed charges",""
"SET SCREW SPINE VERTEX SELECT TITANIUM LOCKING","SUP-ITM-10018153","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","310.95","186.57","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","226.12","72.72","","4732.50","1617.43","14180.40","1 through 10","36.16","240.68","percent of total billed charges",""
"SET SCREW SPINE VERTEX SELECT TITANIUM LOCKING","SUP-ITM-10018153","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","310.95","186.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","195.59","62.9","","3896.20","3341.38","3896.20","1 through 10","36.16","240.68","percent of total billed charges",""
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","both","","","2241.40","1344.84","AETNA [1001]","HB WDH AETNA COMMERCIAL","1564.50","69.8","","166.96","137.81","825.49","1 through 10","260.67","1905.19","percent of total billed charges",""
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","both","","","2241.40","1344.84","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1716.86","1716.86","1716.86","1 through 10","260.67","1905.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","both","","","2241.40","1344.84","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","4281.09","1182.65","4281.09","1 through 10","260.67","1905.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","both","","","2241.40","1344.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","260.67","11.63","","262.01","27.19","426.66","1 through 10","260.67","1905.19","percent of total billed charges",""
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","both","","","2241.40","1344.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1734.84","77.4","","1411.46","916.55","1411.46","1 through 10","260.67","1905.19","percent of total billed charges",""
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2241.40","1344.84","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","260.67","11.63","","262.01","27.19","426.66","1 through 10","260.67","1734.84","percent of total billed charges",""
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2241.40","1344.84","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","979.94","43.72","","517.05","517.05","517.05","1 through 10","260.67","1734.84","percent of total billed charges",""
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2241.40","1344.84","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1629.95","72.72","","1556.61","860.02","1914.17","1 through 10","260.67","1734.84","percent of total billed charges",""
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2241.40","1344.84","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1409.84","62.9","","1348.55","745.07","1348.55","19","260.67","1734.84","percent of total billed charges",""
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2241.40","1344.84","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1734.84","77.4","","1411.46","916.55","1411.46","1 through 10","260.67","1734.84","percent of total billed charges",""
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","2241.40","1344.84","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","1629.95","72.72","","860.02","860.02","860.02","1 through 10","260.67","1734.84","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","2090.28","1254.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","243.1","1776.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","2090.28","1254.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","243.1","1776.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","2090.28","1254.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1189.37","56.9","","812.12","238.65","1587.46","163","243.1","1776.74","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","2090.28","1254.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","243.10","11.63","","112.68","112.68","146.99","38","243.1","1776.74","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","2090.28","1254.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1617.88","77.4","","303.98","303.98","5854.79","1 through 10","243.1","1776.74","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2090.28","1254.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","243.10","11.63","","112.68","112.68","146.99","38","243.1","1617.88","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2090.28","1254.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1312.28","62.78","","780.86","208.94","10480.28","15","243.1","1617.88","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2090.28","1254.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","913.87","43.72","","179.76","179.76","179.76","1 through 10","243.1","1617.88","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2090.28","1254.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1520.05","72.72","","2355.45","298.99","3965.19","155","243.1","1617.88","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2090.28","1254.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1520.05","72.72","","3643.09","3643.09","3643.09","1 through 10","243.1","1617.88","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2090.28","1254.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1112.45","53.22","","554.28","554.28","554.28","16","243.1","1617.88","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2090.28","1254.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1314.79","62.9","","619.64","173.09","2370.64","150","243.1","1617.88","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2090.28","1254.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1617.88","77.4","","303.98","303.98","5854.79","1 through 10","243.1","1617.88","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","1952.08","1171.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","227.03","1659.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","1952.08","1171.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","227.03","1659.27","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","1952.08","1171.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1110.73","56.9","","812.12","238.65","1587.46","163","227.03","1659.27","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","1952.08","1171.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","227.03","11.63","","112.68","112.68","146.99","38","227.03","1659.27","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","1952.08","1171.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1510.91","77.4","","303.98","303.98","5854.79","1 through 10","227.03","1659.27","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1952.08","1171.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","227.03","11.63","","112.68","112.68","146.99","38","227.03","1510.91","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1952.08","1171.25","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1225.52","62.78","","780.86","208.94","10480.28","15","227.03","1510.91","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1952.08","1171.25","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","853.45","43.72","","179.76","179.76","179.76","1 through 10","227.03","1510.91","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1952.08","1171.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1419.55","72.72","","2355.45","298.99","3965.19","155","227.03","1510.91","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1952.08","1171.25","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1419.55","72.72","","3643.09","3643.09","3643.09","1 through 10","227.03","1510.91","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1952.08","1171.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1038.90","53.22","","554.28","554.28","554.28","16","227.03","1510.91","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1952.08","1171.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1227.86","62.9","","619.64","173.09","2370.64","150","227.03","1510.91","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1952.08","1171.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1510.91","77.4","","303.98","303.98","5854.79","1 through 10","227.03","1510.91","percent of total billed charges",""
"SET SLING OBTURATOR TVT PASSER ATRAUMATIC WINGED GUIDE TENSION FREE SYSTEM CS/1BX/1EA","SUP-ITM-10022018","CDM","C1771","HCPCS","0278","RC","","","","both","","","5281.94","3169.16","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","6680.45","6680.45","6680.45","1 through 10","614.29","4489.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET SLING OBTURATOR TVT PASSER ATRAUMATIC WINGED GUIDE TENSION FREE SYSTEM CS/1BX/1EA","SUP-ITM-10022018","CDM","C1771","HCPCS","0278","RC","","","","both","","","5281.94","3169.16","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3005.42","56.9","","3801.18","3767.54","4248.00","1 through 10","614.29","4489.65","percent of total billed charges",""
"SET SLING OBTURATOR TVT PASSER ATRAUMATIC WINGED GUIDE TENSION FREE SYSTEM CS/1BX/1EA","SUP-ITM-10022018","CDM","C1771","HCPCS","0278","RC","","","","both","","","5281.94","3169.16","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4088.22","77.4","","5750.52","5177.35","5750.52","1 through 10","614.29","4489.65","percent of total billed charges",""
"SET SLING OBTURATOR TVT PASSER ATRAUMATIC WINGED GUIDE TENSION FREE SYSTEM CS/1BX/1EA","SUP-ITM-10022018","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","5281.94","3169.16","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3316.00","62.78","","12581.94","12581.94","12581.94","1 through 10","614.29","4088.22","percent of total billed charges",""
"SET SLING OBTURATOR TVT PASSER ATRAUMATIC WINGED GUIDE TENSION FREE SYSTEM CS/1BX/1EA","SUP-ITM-10022018","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","5281.94","3169.16","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3841.03","72.72","","4858.02","4858.02","4858.02","1 through 10","614.29","4088.22","percent of total billed charges",""
"SET SLING OBTURATOR TVT PASSER ATRAUMATIC WINGED GUIDE TENSION FREE SYSTEM CS/1BX/1EA","SUP-ITM-10022018","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","5281.94","3169.16","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3322.34","62.9","","4208.68","4208.68","4208.68","1 through 10","614.29","4088.22","percent of total billed charges",""
"SET SLING OBTURATOR TVT PASSER ATRAUMATIC WINGED GUIDE TENSION FREE SYSTEM CS/1BX/1EA","SUP-ITM-10022018","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","5281.94","3169.16","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4088.22","77.4","","5750.52","5177.35","5750.52","1 through 10","614.29","4088.22","percent of total billed charges",""
"SET STENT 8.5FRX9CM PANCREATIC FLAP GUIDEWIRE PUSH GUIDING CATHETER GEENEN","SUP-ITM-10073808","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","1133.24","679.94","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","824.09","72.72","","324.46","324.46","324.46","1 through 10","131.8","877.13","percent of total billed charges",""
"SET TIP 4FRX13 20 7CM 0.018IN INTRODUCER CATHETER SHEATH NITINOL GUIDEWIRE VESSEL DILATOR","SUP-ITM-10087029","CDM","C1769","HCPCS","0272","RC","","","","both","","","303.97","182.38","AETNA [1001]","HB WDH AETNA COMMERCIAL","212.17","69.8","","279.80","225.71","279.80","16","35.35","258.37","percent of total billed charges",""
"SET TIP 4FRX13 20 7CM 0.018IN INTRODUCER CATHETER SHEATH NITINOL GUIDEWIRE VESSEL DILATOR","SUP-ITM-10087029","CDM","C1769","HCPCS","0272","RC","","","","both","","","303.97","182.38","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","35.35","258.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET TIP 4FRX13 20 7CM 0.018IN INTRODUCER CATHETER SHEATH NITINOL GUIDEWIRE VESSEL DILATOR","SUP-ITM-10087029","CDM","C1769","HCPCS","0272","RC","","","","both","","","303.97","182.38","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","172.96","56.9","","18.95","9.41","1260.18","1 through 10","35.35","258.37","percent of total billed charges",""
"SET TIP 4FRX13 20 7CM 0.018IN INTRODUCER CATHETER SHEATH NITINOL GUIDEWIRE VESSEL DILATOR","SUP-ITM-10087029","CDM","C1769","HCPCS","0272","RC","","","","both","","","303.97","182.38","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","35.35","11.63","","37.78","11.63","183.64","21","35.35","258.37","percent of total billed charges",""
"SET TIP 4FRX13 20 7CM 0.018IN INTRODUCER CATHETER SHEATH NITINOL GUIDEWIRE VESSEL DILATOR","SUP-ITM-10087029","CDM","C1769","HCPCS","0272","RC","","","","both","","","303.97","182.38","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","235.27","77.4","","225.79","68.39","1154.35","11","35.35","258.37","percent of total billed charges",""
"SET TIP 4FRX13 20 7CM 0.018IN INTRODUCER CATHETER SHEATH NITINOL GUIDEWIRE VESSEL DILATOR","SUP-ITM-10087029","CDM","C1769","HCPCS","0272","RC","","","","both","","","303.97","182.38","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","35.35","258.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SET TIP 4FRX13 20 7CM 0.018IN INTRODUCER CATHETER SHEATH NITINOL GUIDEWIRE VESSEL DILATOR","SUP-ITM-10087029","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","303.97","182.38","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","35.35","11.63","","37.78","11.63","183.64","21","35.35","235.27","percent of total billed charges",""
"SET TIP 4FRX13 20 7CM 0.018IN INTRODUCER CATHETER SHEATH NITINOL GUIDEWIRE VESSEL DILATOR","SUP-ITM-10087029","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","303.97","182.38","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","190.83","62.78","","123.83","114.55","572.63","1 through 10","35.35","235.27","percent of total billed charges",""
"SET TIP 4FRX13 20 7CM 0.018IN INTRODUCER CATHETER SHEATH NITINOL GUIDEWIRE VESSEL DILATOR","SUP-ITM-10087029","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","303.97","182.38","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","132.90","43.72","","127.38","127.38","148.03","1 through 10","35.35","235.27","percent of total billed charges",""
"SET TIP 4FRX13 20 7CM 0.018IN INTRODUCER CATHETER SHEATH NITINOL GUIDEWIRE VESSEL DILATOR","SUP-ITM-10087029","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","303.97","182.38","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","221.05","72.72","","196.34","62.16","1727.00","33","35.35","235.27","percent of total billed charges",""
"SET TIP 4FRX13 20 7CM 0.018IN INTRODUCER CATHETER SHEATH NITINOL GUIDEWIRE VESSEL DILATOR","SUP-ITM-10087029","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","303.97","182.38","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","221.05","72.72","","173.00","173.00","173.00","1 through 10","35.35","235.27","percent of total billed charges",""
"SET TIP 4FRX13 20 7CM 0.018IN INTRODUCER CATHETER SHEATH NITINOL GUIDEWIRE VESSEL DILATOR","SUP-ITM-10087029","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","303.97","182.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","161.77","53.22","","205.24","190.08","205.24","1 through 10","35.35","235.27","percent of total billed charges",""
"SET TIP 4FRX13 20 7CM 0.018IN INTRODUCER CATHETER SHEATH NITINOL GUIDEWIRE VESSEL DILATOR","SUP-ITM-10087029","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","303.97","182.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","191.20","62.9","","305.08","81.02","4529.24","103","35.35","235.27","percent of total billed charges",""
"SET TIP 4FRX13 20 7CM 0.018IN INTRODUCER CATHETER SHEATH NITINOL GUIDEWIRE VESSEL DILATOR","SUP-ITM-10087029","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","303.97","182.38","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","235.27","77.4","","225.79","68.39","1154.35","11","35.35","235.27","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","both","","","119.00","71.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","83.06","69.8","","80.27","72.34","80.27","49","14.12","112.86","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","both","","","119.00","71.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","101.15","85","","19.55","15.97","19.55","1 through 10","14.12","112.86","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","outpatient","","","119.00","71.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","74.71","62.78","","72.20","72.20","72.20","1 through 10","20.26","92.11","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","outpatient","","","119.00","71.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","52.03","43.72","","50.28","50.28","50.28","1 through 10","20.26","92.11","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","outpatient","","","119.00","71.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","86.54","72.72","","83.63","83.63","83.63","87","20.26","92.11","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","outpatient","","","119.00","71.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","86.54","72.72","","83.63","83.63","83.63","1 through 10","20.26","92.11","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","outpatient","","","119.00","71.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","63.33","53.22","","61.31","61.31","61.31","1 through 10","20.26","92.11","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","outpatient","","","119.00","71.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","74.85","62.9","","72.45","72.45","72.45","105","20.26","92.11","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","outpatient","","","119.00","71.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","92.11","77.4","","89.13","89.13","89.13","41","20.26","92.11","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","outpatient","","","119.00","71.40","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","86.54","72.72","","83.63","83.63","83.63","1 through 10","20.26","92.11","percent of total billed charges",""
"SHAFT FIBULA 200MM 8 15 TO IMPLANT HUMAN TISSUE BONE FROZEN","SUP-ITM-10010277","CDM","C1889","HCPCS","0278","RC","","","","both","","","6477.99","3886.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","753.39","5506.29","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHAFT FIBULA 200MM 8 15 TO IMPLANT HUMAN TISSUE BONE FROZEN","SUP-ITM-10010277","CDM","C1889","HCPCS","0278","RC","","","","both","","","6477.99","3886.79","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","753.39","5506.29","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHAFT FIBULA 200MM 8 15 TO IMPLANT HUMAN TISSUE BONE FROZEN","SUP-ITM-10010277","CDM","C1889","HCPCS","0278","RC","","","","both","","","6477.99","3886.79","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3685.98","56.9","","0.63","0.63","0.63","1 through 10","753.39","5506.29","percent of total billed charges",""
"SHAFT FIBULA 200MM 8 15 TO IMPLANT HUMAN TISSUE BONE FROZEN","SUP-ITM-10010277","CDM","C1889","HCPCS","0278","RC","","","","both","","","6477.99","3886.79","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","934.13","14.42","","317.14","317.14","317.14","1 through 10","753.39","5506.29","percent of total billed charges",""
"SHAFT FIBULA 200MM 8 15 TO IMPLANT HUMAN TISSUE BONE FROZEN","SUP-ITM-10010277","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6477.99","3886.79","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","934.13","14.42","","317.14","317.14","317.14","1 through 10","753.39","5013.96","percent of total billed charges",""
"SHAFT FIBULA 200MM 8 15 TO IMPLANT HUMAN TISSUE BONE FROZEN","SUP-ITM-10010277","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6477.99","3886.79","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4066.88","62.78","","1125.09","1125.09","1125.09","1 through 10","753.39","5013.96","percent of total billed charges",""
"SHAFT FIBULA 200MM 8 15 TO IMPLANT HUMAN TISSUE BONE FROZEN","SUP-ITM-10010277","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6477.99","3886.79","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4710.79","72.72","","4732.50","1617.43","14180.40","1 through 10","753.39","5013.96","percent of total billed charges",""
"SHAFT FIBULA 200MM 8 15 TO IMPLANT HUMAN TISSUE BONE FROZEN","SUP-ITM-10010277","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6477.99","3886.79","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4074.66","62.9","","3896.20","3341.38","3896.20","1 through 10","753.39","5013.96","percent of total billed charges",""
"SHAFT FIBULA 8 15X80MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010287","CDM","C1889","HCPCS","0278","RC","","","","both","","","3966.75","2380.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","461.33","3371.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHAFT FIBULA 8 15X80MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010287","CDM","C1889","HCPCS","0278","RC","","","","both","","","3966.75","2380.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","461.33","3371.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHAFT FIBULA 8 15X80MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010287","CDM","C1889","HCPCS","0278","RC","","","","both","","","3966.75","2380.05","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2257.08","56.9","","0.63","0.63","0.63","1 through 10","461.33","3371.74","percent of total billed charges",""
"SHAFT FIBULA 8 15X80MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010287","CDM","C1889","HCPCS","0278","RC","","","","both","","","3966.75","2380.05","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","572.01","14.42","","317.14","317.14","317.14","1 through 10","461.33","3371.74","percent of total billed charges",""
"SHAFT FIBULA 8 15X80MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010287","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3966.75","2380.05","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","572.01","14.42","","317.14","317.14","317.14","1 through 10","461.33","3070.26","percent of total billed charges",""
"SHAFT FIBULA 8 15X80MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010287","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3966.75","2380.05","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2490.33","62.78","","1125.09","1125.09","1125.09","1 through 10","461.33","3070.26","percent of total billed charges",""
"SHAFT FIBULA 8 15X80MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010287","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3966.75","2380.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2884.62","72.72","","4732.50","1617.43","14180.40","1 through 10","461.33","3070.26","percent of total billed charges",""
"SHAFT FIBULA 8 15X80MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010287","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3966.75","2380.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2495.09","62.9","","3896.20","3341.38","3896.20","1 through 10","461.33","3070.26","percent of total billed charges",""
"SHAFT FIBULAR 100MM TISSUE HUMAN PRESERVON MATRIX GRAFT LF MERCURY FREE STERILE","SUP-ITM-10267681","CDM","C1889","HCPCS","0278","RC","","","","both","","","4331.81","2599.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","503.79","3682.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHAFT FIBULAR 100MM TISSUE HUMAN PRESERVON MATRIX GRAFT LF MERCURY FREE STERILE","SUP-ITM-10267681","CDM","C1889","HCPCS","0278","RC","","","","both","","","4331.81","2599.09","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","503.79","3682.04","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHAFT FIBULAR 100MM TISSUE HUMAN PRESERVON MATRIX GRAFT LF MERCURY FREE STERILE","SUP-ITM-10267681","CDM","C1889","HCPCS","0278","RC","","","","both","","","4331.81","2599.09","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2464.80","56.9","","0.63","0.63","0.63","1 through 10","503.79","3682.04","percent of total billed charges",""
"SHAFT FIBULAR 100MM TISSUE HUMAN PRESERVON MATRIX GRAFT LF MERCURY FREE STERILE","SUP-ITM-10267681","CDM","C1889","HCPCS","0278","RC","","","","both","","","4331.81","2599.09","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","624.65","14.42","","317.14","317.14","317.14","1 through 10","503.79","3682.04","percent of total billed charges",""
"SHAFT FIBULAR 100MM TISSUE HUMAN PRESERVON MATRIX GRAFT LF MERCURY FREE STERILE","SUP-ITM-10267681","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4331.81","2599.09","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","624.65","14.42","","317.14","317.14","317.14","1 through 10","503.79","3352.82","percent of total billed charges",""
"SHAFT FIBULAR 100MM TISSUE HUMAN PRESERVON MATRIX GRAFT LF MERCURY FREE STERILE","SUP-ITM-10267681","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4331.81","2599.09","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2719.51","62.78","","1125.09","1125.09","1125.09","1 through 10","503.79","3352.82","percent of total billed charges",""
"SHAFT FIBULAR 100MM TISSUE HUMAN PRESERVON MATRIX GRAFT LF MERCURY FREE STERILE","SUP-ITM-10267681","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4331.81","2599.09","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3150.09","72.72","","4732.50","1617.43","14180.40","1 through 10","503.79","3352.82","percent of total billed charges",""
"SHAFT FIBULAR 100MM TISSUE HUMAN PRESERVON MATRIX GRAFT LF MERCURY FREE STERILE","SUP-ITM-10267681","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4331.81","2599.09","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2724.71","62.9","","3896.20","3341.38","3896.20","1 through 10","503.79","3352.82","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","7259.63","4355.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","844.29","6170.69","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","7259.63","4355.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","844.29","6170.69","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","7259.63","4355.78","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4130.73","56.9","","812.12","238.65","1587.46","163","844.29","6170.69","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","7259.63","4355.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","844.29","11.63","","112.68","112.68","146.99","38","844.29","6170.69","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","7259.63","4355.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5618.95","77.4","","303.98","303.98","5854.79","1 through 10","844.29","6170.69","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7259.63","4355.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","844.29","11.63","","112.68","112.68","146.99","38","844.29","5618.95","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7259.63","4355.78","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4557.60","62.78","","780.86","208.94","10480.28","15","844.29","5618.95","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7259.63","4355.78","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3173.91","43.72","","179.76","179.76","179.76","1 through 10","844.29","5618.95","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7259.63","4355.78","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5279.20","72.72","","2355.45","298.99","3965.19","155","844.29","5618.95","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7259.63","4355.78","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5279.20","72.72","","3643.09","3643.09","3643.09","1 through 10","844.29","5618.95","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7259.63","4355.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3863.58","53.22","","554.28","554.28","554.28","16","844.29","5618.95","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7259.63","4355.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4566.31","62.9","","619.64","173.09","2370.64","150","844.29","5618.95","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7259.63","4355.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5618.95","77.4","","303.98","303.98","5854.79","1 through 10","844.29","5618.95","percent of total billed charges",""
"SHEATH ACCESS 11FR 13 36CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027238","CDM","C1894","HCPCS","0272","RC","","","","both","","","1069.60","641.76","AETNA [1001]","HB WDH AETNA COMMERCIAL","746.58","69.8","","94.15","94.15","427.63","1 through 10","124.39","909.16","percent of total billed charges",""
"SHEATH ACCESS 11FR 13 36CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027238","CDM","C1894","HCPCS","0272","RC","","","","both","","","1069.60","641.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","124.39","909.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH ACCESS 11FR 13 36CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027238","CDM","C1894","HCPCS","0272","RC","","","","both","","","1069.60","641.76","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","608.60","56.9","","401.89","65.85","401.89","1 through 10","124.39","909.16","percent of total billed charges",""
"SHEATH ACCESS 11FR 13 36CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027238","CDM","C1894","HCPCS","0272","RC","","","","both","","","1069.60","641.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","124.39","11.63","","49.19","10.57","114.40","19","124.39","909.16","percent of total billed charges",""
"SHEATH ACCESS 11FR 13 36CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027238","CDM","C1894","HCPCS","0272","RC","","","","both","","","1069.60","641.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","827.87","77.4","","200.75","81.67","643.86","11","124.39","909.16","percent of total billed charges",""
"SHEATH ACCESS 11FR 13 36CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027238","CDM","C1894","HCPCS","0272","RC","","","","both","","","1069.60","641.76","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","124.39","909.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH ACCESS 11FR 13 36CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027238","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1069.60","641.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","124.39","11.63","","49.19","10.57","114.40","19","124.39","827.87","percent of total billed charges",""
"SHEATH ACCESS 11FR 13 36CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027238","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1069.60","641.76","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","671.49","62.78","","93.27","93.27","93.27","1 through 10","124.39","827.87","percent of total billed charges",""
"SHEATH ACCESS 11FR 13 36CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027238","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1069.60","641.76","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","467.63","43.72","","363.22","363.22","363.22","1 through 10","124.39","827.87","percent of total billed charges",""
"SHEATH ACCESS 11FR 13 36CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027238","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1069.60","641.76","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","777.81","72.72","","271.85","111.24","551.69","14","124.39","827.87","percent of total billed charges",""
"SHEATH ACCESS 11FR 13 36CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027238","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1069.60","641.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","672.78","62.9","","706.53","93.60","938.00","53","124.39","827.87","percent of total billed charges",""
"SHEATH ACCESS 11FR 13 36CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027238","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1069.60","641.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","827.87","77.4","","200.75","81.67","643.86","11","124.39","827.87","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","5348.34","3209.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","3733.14","69.8","","94.15","94.15","427.63","1 through 10","622.01","4546.09","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","5348.34","3209.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","622.01","4546.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","5348.34","3209.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3043.21","56.9","","401.89","65.85","401.89","1 through 10","622.01","4546.09","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","5348.34","3209.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","622.01","11.63","","49.19","10.57","114.40","19","622.01","4546.09","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","5348.34","3209.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4139.62","77.4","","200.75","81.67","643.86","11","622.01","4546.09","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","both","","","5348.34","3209.00","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","622.01","4546.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","5348.34","3209.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","622.01","11.63","","49.19","10.57","114.40","19","622.01","4139.62","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","5348.34","3209.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3357.69","62.78","","93.27","93.27","93.27","1 through 10","622.01","4139.62","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","5348.34","3209.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2338.29","43.72","","363.22","363.22","363.22","1 through 10","622.01","4139.62","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","5348.34","3209.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3889.31","72.72","","271.85","111.24","551.69","14","622.01","4139.62","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","5348.34","3209.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3364.11","62.9","","706.53","93.60","938.00","53","622.01","4139.62","percent of total billed charges",""
"SHEATH DRYSEAL 12FR 4MM 45CM FLEX INTRODUCER","SUP-ITM-10169110","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","5348.34","3209.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4139.62","77.4","","200.75","81.67","643.86","11","622.01","4139.62","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","3178.60","1907.16","AETNA [1001]","HB WDH AETNA COMMERCIAL","2218.66","69.8","","94.15","94.15","427.63","1 through 10","369.67","2701.81","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","3178.60","1907.16","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","369.67","2701.81","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","3178.60","1907.16","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1808.62","56.9","","401.89","65.85","401.89","1 through 10","369.67","2701.81","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","3178.60","1907.16","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","369.67","11.63","","49.19","10.57","114.40","19","369.67","2701.81","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","3178.60","1907.16","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2460.24","77.4","","200.75","81.67","643.86","11","369.67","2701.81","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","both","","","3178.60","1907.16","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","369.67","2701.81","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3178.60","1907.16","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","369.67","11.63","","49.19","10.57","114.40","19","369.67","2460.24","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3178.60","1907.16","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1995.53","62.78","","93.27","93.27","93.27","1 through 10","369.67","2460.24","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3178.60","1907.16","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1389.68","43.72","","363.22","363.22","363.22","1 through 10","369.67","2460.24","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3178.60","1907.16","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2311.48","72.72","","271.85","111.24","551.69","14","369.67","2460.24","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3178.60","1907.16","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1999.34","62.9","","706.53","93.60","938.00","53","369.67","2460.24","percent of total billed charges",""
"SHEATH DRYSEAL 16FR 5.3MM 33CM FLEX INTRODUCER","SUP-ITM-10169114","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3178.60","1907.16","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2460.24","77.4","","200.75","81.67","643.86","11","369.67","2460.24","percent of total billed charges",""
"SHEATH GUIDING 6.0FR 45CM PERIPHERAL PINNACLE DESTINATION HYDROPHILIC COATED CCV VALVE LIMA SHAPE","SUP-ITM-10065014","CDM","C1887","HCPCS","0272","RC","","","","both","","","573.53","344.12","AETNA [1001]","HB WDH AETNA COMMERCIAL","400.32","69.8","","211.78","89.23","211.78","1 through 10","66.7","487.5","percent of total billed charges",""
"SHEATH GUIDING 6.0FR 45CM PERIPHERAL PINNACLE DESTINATION HYDROPHILIC COATED CCV VALVE LIMA SHAPE","SUP-ITM-10065014","CDM","C1887","HCPCS","0272","RC","","","","both","","","573.53","344.12","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","326.34","56.9","","383.50","68.20","383.50","1 through 10","66.7","487.5","percent of total billed charges",""
"SHEATH GUIDING 6.0FR 45CM PERIPHERAL PINNACLE DESTINATION HYDROPHILIC COATED CCV VALVE LIMA SHAPE","SUP-ITM-10065014","CDM","C1887","HCPCS","0272","RC","","","","both","","","573.53","344.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","66.70","11.63","","8.44","7.37","15.65","12","66.7","487.5","percent of total billed charges",""
"SHEATH GUIDING 6.0FR 45CM PERIPHERAL PINNACLE DESTINATION HYDROPHILIC COATED CCV VALVE LIMA SHAPE","SUP-ITM-10065014","CDM","C1887","HCPCS","0272","RC","","","","both","","","573.53","344.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","443.91","77.4","","41.50","41.50","214.21","1 through 10","66.7","487.5","percent of total billed charges",""
"SHEATH GUIDING 6.0FR 45CM PERIPHERAL PINNACLE DESTINATION HYDROPHILIC COATED CCV VALVE LIMA SHAPE","SUP-ITM-10065014","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","573.53","344.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","66.70","11.63","","8.44","7.37","15.65","12","66.7","443.91","percent of total billed charges",""
"SHEATH GUIDING 6.0FR 45CM PERIPHERAL PINNACLE DESTINATION HYDROPHILIC COATED CCV VALVE LIMA SHAPE","SUP-ITM-10065014","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","573.53","344.12","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","417.07","72.72","","92.96","38.94","158.55","24","66.7","443.91","percent of total billed charges",""
"SHEATH GUIDING 6.0FR 45CM PERIPHERAL PINNACLE DESTINATION HYDROPHILIC COATED CCV VALVE LIMA SHAPE","SUP-ITM-10065014","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","573.53","344.12","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","360.75","62.9","","208.96","33.74","457.91","69","66.7","443.91","percent of total billed charges",""
"SHEATH GUIDING 6.0FR 45CM PERIPHERAL PINNACLE DESTINATION HYDROPHILIC COATED CCV VALVE LIMA SHAPE","SUP-ITM-10065014","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","573.53","344.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","443.91","77.4","","41.50","41.50","214.21","1 through 10","66.7","443.91","percent of total billed charges",""
"SHEATH GUIDING 7FR 90CM PINNACLE DESTINATION CROSS CUT MULTIPURPOSE","SUP-ITM-10284020","CDM","C1894","HCPCS","0272","RC","","","","both","","","670.27","402.16","AETNA [1001]","HB WDH AETNA COMMERCIAL","467.85","69.8","","94.15","94.15","427.63","1 through 10","77.95","569.73","percent of total billed charges",""
"SHEATH GUIDING 7FR 90CM PINNACLE DESTINATION CROSS CUT MULTIPURPOSE","SUP-ITM-10284020","CDM","C1894","HCPCS","0272","RC","","","","both","","","670.27","402.16","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","77.95","569.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH GUIDING 7FR 90CM PINNACLE DESTINATION CROSS CUT MULTIPURPOSE","SUP-ITM-10284020","CDM","C1894","HCPCS","0272","RC","","","","both","","","670.27","402.16","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","381.38","56.9","","401.89","65.85","401.89","1 through 10","77.95","569.73","percent of total billed charges",""
"SHEATH GUIDING 7FR 90CM PINNACLE DESTINATION CROSS CUT MULTIPURPOSE","SUP-ITM-10284020","CDM","C1894","HCPCS","0272","RC","","","","both","","","670.27","402.16","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","77.95","11.63","","49.19","10.57","114.40","19","77.95","569.73","percent of total billed charges",""
"SHEATH GUIDING 7FR 90CM PINNACLE DESTINATION CROSS CUT MULTIPURPOSE","SUP-ITM-10284020","CDM","C1894","HCPCS","0272","RC","","","","both","","","670.27","402.16","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","518.79","77.4","","200.75","81.67","643.86","11","77.95","569.73","percent of total billed charges",""
"SHEATH GUIDING 7FR 90CM PINNACLE DESTINATION CROSS CUT MULTIPURPOSE","SUP-ITM-10284020","CDM","C1894","HCPCS","0272","RC","","","","both","","","670.27","402.16","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","77.95","569.73","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH GUIDING 7FR 90CM PINNACLE DESTINATION CROSS CUT MULTIPURPOSE","SUP-ITM-10284020","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","670.27","402.16","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","77.95","11.63","","49.19","10.57","114.40","19","77.95","518.79","percent of total billed charges",""
"SHEATH GUIDING 7FR 90CM PINNACLE DESTINATION CROSS CUT MULTIPURPOSE","SUP-ITM-10284020","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","670.27","402.16","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","420.80","62.78","","93.27","93.27","93.27","1 through 10","77.95","518.79","percent of total billed charges",""
"SHEATH GUIDING 7FR 90CM PINNACLE DESTINATION CROSS CUT MULTIPURPOSE","SUP-ITM-10284020","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","670.27","402.16","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","293.04","43.72","","363.22","363.22","363.22","1 through 10","77.95","518.79","percent of total billed charges",""
"SHEATH GUIDING 7FR 90CM PINNACLE DESTINATION CROSS CUT MULTIPURPOSE","SUP-ITM-10284020","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","670.27","402.16","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","487.42","72.72","","271.85","111.24","551.69","14","77.95","518.79","percent of total billed charges",""
"SHEATH GUIDING 7FR 90CM PINNACLE DESTINATION CROSS CUT MULTIPURPOSE","SUP-ITM-10284020","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","670.27","402.16","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","421.60","62.9","","706.53","93.60","938.00","53","77.95","518.79","percent of total billed charges",""
"SHEATH GUIDING 7FR 90CM PINNACLE DESTINATION CROSS CUT MULTIPURPOSE","SUP-ITM-10284020","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","670.27","402.16","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","518.79","77.4","","200.75","81.67","643.86","11","77.95","518.79","percent of total billed charges",""
"SHEATH PINNACLE 5FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076165","CDM","C1894","HCPCS","0272","RC","","","","both","","","158.93","95.36","AETNA [1001]","HB WDH AETNA COMMERCIAL","110.93","69.8","","94.15","94.15","427.63","1 through 10","18.48","135.09","percent of total billed charges",""
"SHEATH PINNACLE 5FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076165","CDM","C1894","HCPCS","0272","RC","","","","both","","","158.93","95.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","18.48","135.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH PINNACLE 5FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076165","CDM","C1894","HCPCS","0272","RC","","","","both","","","158.93","95.36","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","90.43","56.9","","401.89","65.85","401.89","1 through 10","18.48","135.09","percent of total billed charges",""
"SHEATH PINNACLE 5FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076165","CDM","C1894","HCPCS","0272","RC","","","","both","","","158.93","95.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","18.48","11.63","","49.19","10.57","114.40","19","18.48","135.09","percent of total billed charges",""
"SHEATH PINNACLE 5FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076165","CDM","C1894","HCPCS","0272","RC","","","","both","","","158.93","95.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","123.01","77.4","","200.75","81.67","643.86","11","18.48","135.09","percent of total billed charges",""
"SHEATH PINNACLE 5FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076165","CDM","C1894","HCPCS","0272","RC","","","","both","","","158.93","95.36","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","18.48","135.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH PINNACLE 5FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076165","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","158.93","95.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","18.48","11.63","","49.19","10.57","114.40","19","18.48","123.01","percent of total billed charges",""
"SHEATH PINNACLE 5FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076165","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","158.93","95.36","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","99.78","62.78","","93.27","93.27","93.27","1 through 10","18.48","123.01","percent of total billed charges",""
"SHEATH PINNACLE 5FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076165","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","158.93","95.36","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","69.48","43.72","","363.22","363.22","363.22","1 through 10","18.48","123.01","percent of total billed charges",""
"SHEATH PINNACLE 5FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076165","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","158.93","95.36","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","115.57","72.72","","271.85","111.24","551.69","14","18.48","123.01","percent of total billed charges",""
"SHEATH PINNACLE 5FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076165","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","158.93","95.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","99.97","62.9","","706.53","93.60","938.00","53","18.48","123.01","percent of total billed charges",""
"SHEATH PINNACLE 5FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076165","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","158.93","95.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","123.01","77.4","","200.75","81.67","643.86","11","18.48","123.01","percent of total billed charges",""
"SHEATH PINNACLE 5FR 25CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076175","CDM","C1894","HCPCS","0272","RC","","","","both","","","179.66","107.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","125.40","69.8","","94.15","94.15","427.63","1 through 10","20.89","152.71","percent of total billed charges",""
"SHEATH PINNACLE 5FR 25CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076175","CDM","C1894","HCPCS","0272","RC","","","","both","","","179.66","107.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","20.89","152.71","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH PINNACLE 5FR 25CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076175","CDM","C1894","HCPCS","0272","RC","","","","both","","","179.66","107.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","102.23","56.9","","401.89","65.85","401.89","1 through 10","20.89","152.71","percent of total billed charges",""
"SHEATH PINNACLE 5FR 25CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076175","CDM","C1894","HCPCS","0272","RC","","","","both","","","179.66","107.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.89","11.63","","49.19","10.57","114.40","19","20.89","152.71","percent of total billed charges",""
"SHEATH PINNACLE 5FR 25CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076175","CDM","C1894","HCPCS","0272","RC","","","","both","","","179.66","107.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","139.06","77.4","","200.75","81.67","643.86","11","20.89","152.71","percent of total billed charges",""
"SHEATH PINNACLE 5FR 25CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076175","CDM","C1894","HCPCS","0272","RC","","","","both","","","179.66","107.80","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","20.89","152.71","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH PINNACLE 5FR 25CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076175","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","179.66","107.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.89","11.63","","49.19","10.57","114.40","19","20.89","139.06","percent of total billed charges",""
"SHEATH PINNACLE 5FR 25CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076175","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","179.66","107.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","112.79","62.78","","93.27","93.27","93.27","1 through 10","20.89","139.06","percent of total billed charges",""
"SHEATH PINNACLE 5FR 25CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076175","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","179.66","107.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","78.55","43.72","","363.22","363.22","363.22","1 through 10","20.89","139.06","percent of total billed charges",""
"SHEATH PINNACLE 5FR 25CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076175","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","179.66","107.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","130.65","72.72","","271.85","111.24","551.69","14","20.89","139.06","percent of total billed charges",""
"SHEATH PINNACLE 5FR 25CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076175","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","179.66","107.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","113.01","62.9","","706.53","93.60","938.00","53","20.89","139.06","percent of total billed charges",""
"SHEATH PINNACLE 5FR 25CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076175","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","179.66","107.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","139.06","77.4","","200.75","81.67","643.86","11","20.89","139.06","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM .035IN INTRODUCER DILATOR MINI GUIDEWIRE PERIPHERAL BX/10EA","SUP-ITM-10027125","CDM","C1894","HCPCS","0272","RC","","","","both","","","62.19","37.31","AETNA [1001]","HB WDH AETNA COMMERCIAL","43.41","69.8","","94.15","94.15","427.63","1 through 10","7.23","52.86","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM .035IN INTRODUCER DILATOR MINI GUIDEWIRE PERIPHERAL BX/10EA","SUP-ITM-10027125","CDM","C1894","HCPCS","0272","RC","","","","both","","","62.19","37.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","7.23","52.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH PINNACLE 6FR 10CM 2.5CM .035IN INTRODUCER DILATOR MINI GUIDEWIRE PERIPHERAL BX/10EA","SUP-ITM-10027125","CDM","C1894","HCPCS","0272","RC","","","","both","","","62.19","37.31","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","35.39","56.9","","401.89","65.85","401.89","1 through 10","7.23","52.86","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM .035IN INTRODUCER DILATOR MINI GUIDEWIRE PERIPHERAL BX/10EA","SUP-ITM-10027125","CDM","C1894","HCPCS","0272","RC","","","","both","","","62.19","37.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","7.23","11.63","","49.19","10.57","114.40","19","7.23","52.86","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM .035IN INTRODUCER DILATOR MINI GUIDEWIRE PERIPHERAL BX/10EA","SUP-ITM-10027125","CDM","C1894","HCPCS","0272","RC","","","","both","","","62.19","37.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","48.14","77.4","","200.75","81.67","643.86","11","7.23","52.86","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM .035IN INTRODUCER DILATOR MINI GUIDEWIRE PERIPHERAL BX/10EA","SUP-ITM-10027125","CDM","C1894","HCPCS","0272","RC","","","","both","","","62.19","37.31","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","7.23","52.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH PINNACLE 6FR 10CM 2.5CM .035IN INTRODUCER DILATOR MINI GUIDEWIRE PERIPHERAL BX/10EA","SUP-ITM-10027125","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","62.19","37.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","7.23","11.63","","49.19","10.57","114.40","19","7.23","48.14","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM .035IN INTRODUCER DILATOR MINI GUIDEWIRE PERIPHERAL BX/10EA","SUP-ITM-10027125","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","62.19","37.31","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","39.04","62.78","","93.27","93.27","93.27","1 through 10","7.23","48.14","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM .035IN INTRODUCER DILATOR MINI GUIDEWIRE PERIPHERAL BX/10EA","SUP-ITM-10027125","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","62.19","37.31","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","27.19","43.72","","363.22","363.22","363.22","1 through 10","7.23","48.14","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM .035IN INTRODUCER DILATOR MINI GUIDEWIRE PERIPHERAL BX/10EA","SUP-ITM-10027125","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","62.19","37.31","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","45.22","72.72","","271.85","111.24","551.69","14","7.23","48.14","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM .035IN INTRODUCER DILATOR MINI GUIDEWIRE PERIPHERAL BX/10EA","SUP-ITM-10027125","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","62.19","37.31","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","39.12","62.9","","706.53","93.60","938.00","53","7.23","48.14","percent of total billed charges",""
"SHEATH PINNACLE 6FR 10CM 2.5CM .035IN INTRODUCER DILATOR MINI GUIDEWIRE PERIPHERAL BX/10EA","SUP-ITM-10027125","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","62.19","37.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","48.14","77.4","","200.75","81.67","643.86","11","7.23","48.14","percent of total billed charges",""
"SHEATH PINNACLE 6FR 6CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10008595","CDM","C1894","HCPCS","0272","RC","","","","both","","","138.20","82.92","AETNA [1001]","HB WDH AETNA COMMERCIAL","96.46","69.8","","94.15","94.15","427.63","1 through 10","16.07","117.47","percent of total billed charges",""
"SHEATH PINNACLE 6FR 6CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10008595","CDM","C1894","HCPCS","0272","RC","","","","both","","","138.20","82.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","16.07","117.47","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH PINNACLE 6FR 6CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10008595","CDM","C1894","HCPCS","0272","RC","","","","both","","","138.20","82.92","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","78.64","56.9","","401.89","65.85","401.89","1 through 10","16.07","117.47","percent of total billed charges",""
"SHEATH PINNACLE 6FR 6CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10008595","CDM","C1894","HCPCS","0272","RC","","","","both","","","138.20","82.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16.07","11.63","","49.19","10.57","114.40","19","16.07","117.47","percent of total billed charges",""
"SHEATH PINNACLE 6FR 6CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10008595","CDM","C1894","HCPCS","0272","RC","","","","both","","","138.20","82.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","106.97","77.4","","200.75","81.67","643.86","11","16.07","117.47","percent of total billed charges",""
"SHEATH PINNACLE 6FR 6CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10008595","CDM","C1894","HCPCS","0272","RC","","","","both","","","138.20","82.92","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","16.07","117.47","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH PINNACLE 6FR 6CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10008595","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","138.20","82.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16.07","11.63","","49.19","10.57","114.40","19","16.07","106.97","percent of total billed charges",""
"SHEATH PINNACLE 6FR 6CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10008595","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","138.20","82.92","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","86.76","62.78","","93.27","93.27","93.27","1 through 10","16.07","106.97","percent of total billed charges",""
"SHEATH PINNACLE 6FR 6CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10008595","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","138.20","82.92","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","60.42","43.72","","363.22","363.22","363.22","1 through 10","16.07","106.97","percent of total billed charges",""
"SHEATH PINNACLE 6FR 6CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10008595","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","138.20","82.92","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","100.50","72.72","","271.85","111.24","551.69","14","16.07","106.97","percent of total billed charges",""
"SHEATH PINNACLE 6FR 6CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10008595","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","138.20","82.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","86.93","62.9","","706.53","93.60","938.00","53","16.07","106.97","percent of total billed charges",""
"SHEATH PINNACLE 6FR 6CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10008595","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","138.20","82.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","106.97","77.4","","200.75","81.67","643.86","11","16.07","106.97","percent of total billed charges",""
"SHEATH PINNACLE 8FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076166","CDM","C1894","HCPCS","0272","RC","","","","both","","","158.93","95.36","AETNA [1001]","HB WDH AETNA COMMERCIAL","110.93","69.8","","94.15","94.15","427.63","1 through 10","18.48","135.09","percent of total billed charges",""
"SHEATH PINNACLE 8FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076166","CDM","C1894","HCPCS","0272","RC","","","","both","","","158.93","95.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","18.48","135.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH PINNACLE 8FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076166","CDM","C1894","HCPCS","0272","RC","","","","both","","","158.93","95.36","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","90.43","56.9","","401.89","65.85","401.89","1 through 10","18.48","135.09","percent of total billed charges",""
"SHEATH PINNACLE 8FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076166","CDM","C1894","HCPCS","0272","RC","","","","both","","","158.93","95.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","18.48","11.63","","49.19","10.57","114.40","19","18.48","135.09","percent of total billed charges",""
"SHEATH PINNACLE 8FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076166","CDM","C1894","HCPCS","0272","RC","","","","both","","","158.93","95.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","123.01","77.4","","200.75","81.67","643.86","11","18.48","135.09","percent of total billed charges",""
"SHEATH PINNACLE 8FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076166","CDM","C1894","HCPCS","0272","RC","","","","both","","","158.93","95.36","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","18.48","135.09","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH PINNACLE 8FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076166","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","158.93","95.36","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","18.48","11.63","","49.19","10.57","114.40","19","18.48","123.01","percent of total billed charges",""
"SHEATH PINNACLE 8FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076166","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","158.93","95.36","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","99.78","62.78","","93.27","93.27","93.27","1 through 10","18.48","123.01","percent of total billed charges",""
"SHEATH PINNACLE 8FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076166","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","158.93","95.36","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","69.48","43.72","","363.22","363.22","363.22","1 through 10","18.48","123.01","percent of total billed charges",""
"SHEATH PINNACLE 8FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076166","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","158.93","95.36","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","115.57","72.72","","271.85","111.24","551.69","14","18.48","123.01","percent of total billed charges",""
"SHEATH PINNACLE 8FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076166","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","158.93","95.36","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","99.97","62.9","","706.53","93.60","938.00","53","18.48","123.01","percent of total billed charges",""
"SHEATH PINNACLE 8FR 10CM 2.5CM DILATOR R/O II RADIOPAQUE MARKER NO MINI GUIDEWIRE PERIPHERAL INTRODUCER VASCULAR BX/10EA","SUP-ITM-10076166","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","158.93","95.36","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","123.01","77.4","","200.75","81.67","643.86","11","18.48","123.01","percent of total billed charges",""
"SHEATH PINNACLE 8FR 25CM 2.5CM INTRODUCER DILATOR NO MINI GUIDEWIRE CORONARY BX/10EA","SUP-ITM-10076141","CDM","C1894","HCPCS","0272","RC","","","","both","","","124.38","74.63","AETNA [1001]","HB WDH AETNA COMMERCIAL","86.82","69.8","","94.15","94.15","427.63","1 through 10","14.47","105.72","percent of total billed charges",""
"SHEATH PINNACLE 8FR 25CM 2.5CM INTRODUCER DILATOR NO MINI GUIDEWIRE CORONARY BX/10EA","SUP-ITM-10076141","CDM","C1894","HCPCS","0272","RC","","","","both","","","124.38","74.63","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","14.47","105.72","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH PINNACLE 8FR 25CM 2.5CM INTRODUCER DILATOR NO MINI GUIDEWIRE CORONARY BX/10EA","SUP-ITM-10076141","CDM","C1894","HCPCS","0272","RC","","","","both","","","124.38","74.63","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","70.77","56.9","","401.89","65.85","401.89","1 through 10","14.47","105.72","percent of total billed charges",""
"SHEATH PINNACLE 8FR 25CM 2.5CM INTRODUCER DILATOR NO MINI GUIDEWIRE CORONARY BX/10EA","SUP-ITM-10076141","CDM","C1894","HCPCS","0272","RC","","","","both","","","124.38","74.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","14.47","11.63","","49.19","10.57","114.40","19","14.47","105.72","percent of total billed charges",""
"SHEATH PINNACLE 8FR 25CM 2.5CM INTRODUCER DILATOR NO MINI GUIDEWIRE CORONARY BX/10EA","SUP-ITM-10076141","CDM","C1894","HCPCS","0272","RC","","","","both","","","124.38","74.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","96.27","77.4","","200.75","81.67","643.86","11","14.47","105.72","percent of total billed charges",""
"SHEATH PINNACLE 8FR 25CM 2.5CM INTRODUCER DILATOR NO MINI GUIDEWIRE CORONARY BX/10EA","SUP-ITM-10076141","CDM","C1894","HCPCS","0272","RC","","","","both","","","124.38","74.63","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","14.47","105.72","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH PINNACLE 8FR 25CM 2.5CM INTRODUCER DILATOR NO MINI GUIDEWIRE CORONARY BX/10EA","SUP-ITM-10076141","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","124.38","74.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","14.47","11.63","","49.19","10.57","114.40","19","14.47","96.27","percent of total billed charges",""
"SHEATH PINNACLE 8FR 25CM 2.5CM INTRODUCER DILATOR NO MINI GUIDEWIRE CORONARY BX/10EA","SUP-ITM-10076141","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","124.38","74.63","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","78.09","62.78","","93.27","93.27","93.27","1 through 10","14.47","96.27","percent of total billed charges",""
"SHEATH PINNACLE 8FR 25CM 2.5CM INTRODUCER DILATOR NO MINI GUIDEWIRE CORONARY BX/10EA","SUP-ITM-10076141","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","124.38","74.63","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","54.38","43.72","","363.22","363.22","363.22","1 through 10","14.47","96.27","percent of total billed charges",""
"SHEATH PINNACLE 8FR 25CM 2.5CM INTRODUCER DILATOR NO MINI GUIDEWIRE CORONARY BX/10EA","SUP-ITM-10076141","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","124.38","74.63","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","90.45","72.72","","271.85","111.24","551.69","14","14.47","96.27","percent of total billed charges",""
"SHEATH PINNACLE 8FR 25CM 2.5CM INTRODUCER DILATOR NO MINI GUIDEWIRE CORONARY BX/10EA","SUP-ITM-10076141","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","124.38","74.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","78.24","62.9","","706.53","93.60","938.00","53","14.47","96.27","percent of total billed charges",""
"SHEATH PINNACLE 8FR 25CM 2.5CM INTRODUCER DILATOR NO MINI GUIDEWIRE CORONARY BX/10EA","SUP-ITM-10076141","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","124.38","74.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","96.27","77.4","","200.75","81.67","643.86","11","14.47","96.27","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 6FR 65CM GUIDING STRAIGHT CROSS CUT VALVE DILATOR NO MINI GUIDEWIRE","SUP-ITM-10065016","CDM","C1887","HCPCS","0272","RC","","","","both","","","656.45","393.87","AETNA [1001]","HB WDH AETNA COMMERCIAL","458.20","69.8","","211.78","89.23","211.78","1 through 10","76.35","557.98","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 6FR 65CM GUIDING STRAIGHT CROSS CUT VALVE DILATOR NO MINI GUIDEWIRE","SUP-ITM-10065016","CDM","C1887","HCPCS","0272","RC","","","","both","","","656.45","393.87","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","373.52","56.9","","383.50","68.20","383.50","1 through 10","76.35","557.98","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 6FR 65CM GUIDING STRAIGHT CROSS CUT VALVE DILATOR NO MINI GUIDEWIRE","SUP-ITM-10065016","CDM","C1887","HCPCS","0272","RC","","","","both","","","656.45","393.87","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","76.35","11.63","","8.44","7.37","15.65","12","76.35","557.98","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 6FR 65CM GUIDING STRAIGHT CROSS CUT VALVE DILATOR NO MINI GUIDEWIRE","SUP-ITM-10065016","CDM","C1887","HCPCS","0272","RC","","","","both","","","656.45","393.87","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","508.09","77.4","","41.50","41.50","214.21","1 through 10","76.35","557.98","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 6FR 65CM GUIDING STRAIGHT CROSS CUT VALVE DILATOR NO MINI GUIDEWIRE","SUP-ITM-10065016","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","656.45","393.87","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","76.35","11.63","","8.44","7.37","15.65","12","76.35","508.09","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 6FR 65CM GUIDING STRAIGHT CROSS CUT VALVE DILATOR NO MINI GUIDEWIRE","SUP-ITM-10065016","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","656.45","393.87","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","477.37","72.72","","92.96","38.94","158.55","24","76.35","508.09","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 6FR 65CM GUIDING STRAIGHT CROSS CUT VALVE DILATOR NO MINI GUIDEWIRE","SUP-ITM-10065016","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","656.45","393.87","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","412.91","62.9","","208.96","33.74","457.91","69","76.35","508.09","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 6FR 65CM GUIDING STRAIGHT CROSS CUT VALVE DILATOR NO MINI GUIDEWIRE","SUP-ITM-10065016","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","656.45","393.87","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","508.09","77.4","","41.50","41.50","214.21","1 through 10","76.35","508.09","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 6FR 90CM GUIDING STRAIGHT CURVE CROSS CUT VALVE","SUP-ITM-10065017","CDM","C1887","HCPCS","0272","RC","","","","both","","","670.27","402.16","AETNA [1001]","HB WDH AETNA COMMERCIAL","467.85","69.8","","211.78","89.23","211.78","1 through 10","77.95","569.73","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 6FR 90CM GUIDING STRAIGHT CURVE CROSS CUT VALVE","SUP-ITM-10065017","CDM","C1887","HCPCS","0272","RC","","","","both","","","670.27","402.16","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","381.38","56.9","","383.50","68.20","383.50","1 through 10","77.95","569.73","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 6FR 90CM GUIDING STRAIGHT CURVE CROSS CUT VALVE","SUP-ITM-10065017","CDM","C1887","HCPCS","0272","RC","","","","both","","","670.27","402.16","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","77.95","11.63","","8.44","7.37","15.65","12","77.95","569.73","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 6FR 90CM GUIDING STRAIGHT CURVE CROSS CUT VALVE","SUP-ITM-10065017","CDM","C1887","HCPCS","0272","RC","","","","both","","","670.27","402.16","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","518.79","77.4","","41.50","41.50","214.21","1 through 10","77.95","569.73","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 6FR 90CM GUIDING STRAIGHT CURVE CROSS CUT VALVE","SUP-ITM-10065017","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","670.27","402.16","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","77.95","11.63","","8.44","7.37","15.65","12","77.95","518.79","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 6FR 90CM GUIDING STRAIGHT CURVE CROSS CUT VALVE","SUP-ITM-10065017","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","670.27","402.16","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","487.42","72.72","","92.96","38.94","158.55","24","77.95","518.79","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 6FR 90CM GUIDING STRAIGHT CURVE CROSS CUT VALVE","SUP-ITM-10065017","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","670.27","402.16","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","421.60","62.9","","208.96","33.74","457.91","69","77.95","518.79","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 6FR 90CM GUIDING STRAIGHT CURVE CROSS CUT VALVE","SUP-ITM-10065017","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","670.27","402.16","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","518.79","77.4","","41.50","41.50","214.21","1 through 10","77.95","518.79","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 7FR 45CM GUIDING STRAIGHT CROSS CUT VALVE DILATOR NO MINI GUIDEWIRE","SUP-ITM-10012198","CDM","C1887","HCPCS","0272","RC","","","","both","","","573.53","344.12","AETNA [1001]","HB WDH AETNA COMMERCIAL","400.32","69.8","","211.78","89.23","211.78","1 through 10","66.7","487.5","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 7FR 45CM GUIDING STRAIGHT CROSS CUT VALVE DILATOR NO MINI GUIDEWIRE","SUP-ITM-10012198","CDM","C1887","HCPCS","0272","RC","","","","both","","","573.53","344.12","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","326.34","56.9","","383.50","68.20","383.50","1 through 10","66.7","487.5","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 7FR 45CM GUIDING STRAIGHT CROSS CUT VALVE DILATOR NO MINI GUIDEWIRE","SUP-ITM-10012198","CDM","C1887","HCPCS","0272","RC","","","","both","","","573.53","344.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","66.70","11.63","","8.44","7.37","15.65","12","66.7","487.5","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 7FR 45CM GUIDING STRAIGHT CROSS CUT VALVE DILATOR NO MINI GUIDEWIRE","SUP-ITM-10012198","CDM","C1887","HCPCS","0272","RC","","","","both","","","573.53","344.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","443.91","77.4","","41.50","41.50","214.21","1 through 10","66.7","487.5","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 7FR 45CM GUIDING STRAIGHT CROSS CUT VALVE DILATOR NO MINI GUIDEWIRE","SUP-ITM-10012198","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","573.53","344.12","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","66.70","11.63","","8.44","7.37","15.65","12","66.7","443.91","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 7FR 45CM GUIDING STRAIGHT CROSS CUT VALVE DILATOR NO MINI GUIDEWIRE","SUP-ITM-10012198","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","573.53","344.12","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","417.07","72.72","","92.96","38.94","158.55","24","66.7","443.91","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 7FR 45CM GUIDING STRAIGHT CROSS CUT VALVE DILATOR NO MINI GUIDEWIRE","SUP-ITM-10012198","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","573.53","344.12","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","360.75","62.9","","208.96","33.74","457.91","69","66.7","443.91","percent of total billed charges",""
"SHEATH PINNACLE DESTINATION 7FR 45CM GUIDING STRAIGHT CROSS CUT VALVE DILATOR NO MINI GUIDEWIRE","SUP-ITM-10012198","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","573.53","344.12","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","443.91","77.4","","41.50","41.50","214.21","1 through 10","66.7","443.91","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","both","","","602.14","361.28","AETNA [1001]","HB WDH AETNA COMMERCIAL","420.29","69.8","","94.15","94.15","427.63","1 through 10","70.03","511.82","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","both","","","602.14","361.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","70.03","511.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","both","","","602.14","361.28","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","342.62","56.9","","401.89","65.85","401.89","1 through 10","70.03","511.82","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","both","","","602.14","361.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","70.03","11.63","","49.19","10.57","114.40","19","70.03","511.82","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","both","","","602.14","361.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","466.06","77.4","","200.75","81.67","643.86","11","70.03","511.82","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","both","","","602.14","361.28","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","70.03","511.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","602.14","361.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","70.03","11.63","","49.19","10.57","114.40","19","70.03","466.06","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","602.14","361.28","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","378.02","62.78","","93.27","93.27","93.27","1 through 10","70.03","466.06","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","602.14","361.28","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","263.26","43.72","","363.22","363.22","363.22","1 through 10","70.03","466.06","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","602.14","361.28","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","437.88","72.72","","271.85","111.24","551.69","14","70.03","466.06","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","602.14","361.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","378.75","62.9","","706.53","93.60","938.00","53","70.03","466.06","percent of total billed charges",""
"SHEATH RENAL 30FR 17.0CM RADIOPAQUE MARKER","SUP-ITM-10024716","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","602.14","361.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","466.06","77.4","","200.75","81.67","643.86","11","70.03","466.06","percent of total billed charges",""
"SHEATH URETERAL 10.7FR 35CM ACCESS FLEXOR AQ HYDROPHILIC COATED","SUP-ITM-10158587","CDM","C1894","HCPCS","0272","RC","","","","both","","","1069.67","641.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","746.63","69.8","","94.15","94.15","427.63","1 through 10","124.4","909.22","percent of total billed charges",""
"SHEATH URETERAL 10.7FR 35CM ACCESS FLEXOR AQ HYDROPHILIC COATED","SUP-ITM-10158587","CDM","C1894","HCPCS","0272","RC","","","","both","","","1069.67","641.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","124.4","909.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH URETERAL 10.7FR 35CM ACCESS FLEXOR AQ HYDROPHILIC COATED","SUP-ITM-10158587","CDM","C1894","HCPCS","0272","RC","","","","both","","","1069.67","641.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","608.64","56.9","","401.89","65.85","401.89","1 through 10","124.4","909.22","percent of total billed charges",""
"SHEATH URETERAL 10.7FR 35CM ACCESS FLEXOR AQ HYDROPHILIC COATED","SUP-ITM-10158587","CDM","C1894","HCPCS","0272","RC","","","","both","","","1069.67","641.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","124.40","11.63","","49.19","10.57","114.40","19","124.4","909.22","percent of total billed charges",""
"SHEATH URETERAL 10.7FR 35CM ACCESS FLEXOR AQ HYDROPHILIC COATED","SUP-ITM-10158587","CDM","C1894","HCPCS","0272","RC","","","","both","","","1069.67","641.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","827.92","77.4","","200.75","81.67","643.86","11","124.4","909.22","percent of total billed charges",""
"SHEATH URETERAL 10.7FR 35CM ACCESS FLEXOR AQ HYDROPHILIC COATED","SUP-ITM-10158587","CDM","C1894","HCPCS","0272","RC","","","","both","","","1069.67","641.80","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","124.4","909.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH URETERAL 10.7FR 35CM ACCESS FLEXOR AQ HYDROPHILIC COATED","SUP-ITM-10158587","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1069.67","641.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","124.40","11.63","","49.19","10.57","114.40","19","124.4","827.92","percent of total billed charges",""
"SHEATH URETERAL 10.7FR 35CM ACCESS FLEXOR AQ HYDROPHILIC COATED","SUP-ITM-10158587","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1069.67","641.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","671.54","62.78","","93.27","93.27","93.27","1 through 10","124.4","827.92","percent of total billed charges",""
"SHEATH URETERAL 10.7FR 35CM ACCESS FLEXOR AQ HYDROPHILIC COATED","SUP-ITM-10158587","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1069.67","641.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","467.66","43.72","","363.22","363.22","363.22","1 through 10","124.4","827.92","percent of total billed charges",""
"SHEATH URETERAL 10.7FR 35CM ACCESS FLEXOR AQ HYDROPHILIC COATED","SUP-ITM-10158587","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1069.67","641.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","777.86","72.72","","271.85","111.24","551.69","14","124.4","827.92","percent of total billed charges",""
"SHEATH URETERAL 10.7FR 35CM ACCESS FLEXOR AQ HYDROPHILIC COATED","SUP-ITM-10158587","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1069.67","641.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","672.82","62.9","","706.53","93.60","938.00","53","124.4","827.92","percent of total billed charges",""
"SHEATH URETERAL 10.7FR 35CM ACCESS FLEXOR AQ HYDROPHILIC COATED","SUP-ITM-10158587","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1069.67","641.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","827.92","77.4","","200.75","81.67","643.86","11","124.4","827.92","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","both","","","1153.21","691.93","AETNA [1001]","HB WDH AETNA COMMERCIAL","804.94","69.8","","50.27","50.27","50.27","1 through 10","134.12","980.23","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","both","","","1153.21","691.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","64.87","64.87","64.87","1 through 10","134.12","980.23","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","both","","","1153.21","691.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","134.12","11.63","","28.87","11.98","61.67","1 through 10","134.12","980.23","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","both","","","1153.21","691.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","892.58","77.4","","162.47","162.47","162.47","1 through 10","134.12","980.23","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","1153.21","691.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","134.12","11.63","","28.87","11.98","61.67","1 through 10","134.12","892.58","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","1153.21","691.93","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","723.99","62.78","","40.73","40.73","40.73","1 through 10","134.12","892.58","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","1153.21","691.93","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","504.18","43.72","","91.66","74.28","91.66","1 through 10","134.12","892.58","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","1153.21","691.93","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","838.61","72.72","","152.45","47.17","239.03","1 through 10","134.12","892.58","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","1153.21","691.93","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","838.61","72.72","","152.45","152.45","152.45","1 through 10","134.12","892.58","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","1153.21","691.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","613.74","53.22","","72.98","72.98","72.98","1 through 10","134.12","892.58","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","1153.21","691.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","725.37","62.9","","211.13","40.87","215.56","13","134.12","892.58","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","1153.21","691.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","892.58","77.4","","162.47","162.47","162.47","1 through 10","134.12","892.58","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","1153.21","691.93","AETNA [1001]","HB WDH AETNA COMMERCIAL","804.94","69.8","","94.15","94.15","427.63","1 through 10","134.12","980.23","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","1153.21","691.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","134.12","980.23","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","1153.21","691.93","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","656.18","56.9","","401.89","65.85","401.89","1 through 10","134.12","980.23","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","1153.21","691.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","134.12","11.63","","49.19","10.57","114.40","19","134.12","980.23","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","1153.21","691.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","892.58","77.4","","200.75","81.67","643.86","11","134.12","980.23","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","both","","","1153.21","691.93","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","134.12","980.23","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1153.21","691.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","134.12","11.63","","49.19","10.57","114.40","19","134.12","892.58","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1153.21","691.93","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","723.99","62.78","","93.27","93.27","93.27","1 through 10","134.12","892.58","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1153.21","691.93","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","504.18","43.72","","363.22","363.22","363.22","1 through 10","134.12","892.58","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1153.21","691.93","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","838.61","72.72","","271.85","111.24","551.69","14","134.12","892.58","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1153.21","691.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","725.37","62.9","","706.53","93.60","938.00","53","134.12","892.58","percent of total billed charges",""
"SHEATH URETERAL 13FR 11X46CM ACCESS NAVIGATOR HD HYDROPHILIC COATED SS COIL DUAL DUROMETER DILATOR","SUP-ITM-10115605","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1153.21","691.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","892.58","77.4","","200.75","81.67","643.86","11","134.12","892.58","percent of total billed charges",""
"SHEATH UROLOGICAL 12FR 28CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016041","CDM","C1894","HCPCS","0272","RC","","","","both","","","1062.07","637.24","AETNA [1001]","HB WDH AETNA COMMERCIAL","741.32","69.8","","94.15","94.15","427.63","1 through 10","123.52","902.76","percent of total billed charges",""
"SHEATH UROLOGICAL 12FR 28CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016041","CDM","C1894","HCPCS","0272","RC","","","","both","","","1062.07","637.24","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","123.52","902.76","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH UROLOGICAL 12FR 28CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016041","CDM","C1894","HCPCS","0272","RC","","","","both","","","1062.07","637.24","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","604.32","56.9","","401.89","65.85","401.89","1 through 10","123.52","902.76","percent of total billed charges",""
"SHEATH UROLOGICAL 12FR 28CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016041","CDM","C1894","HCPCS","0272","RC","","","","both","","","1062.07","637.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","123.52","11.63","","49.19","10.57","114.40","19","123.52","902.76","percent of total billed charges",""
"SHEATH UROLOGICAL 12FR 28CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016041","CDM","C1894","HCPCS","0272","RC","","","","both","","","1062.07","637.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","822.04","77.4","","200.75","81.67","643.86","11","123.52","902.76","percent of total billed charges",""
"SHEATH UROLOGICAL 12FR 28CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016041","CDM","C1894","HCPCS","0272","RC","","","","both","","","1062.07","637.24","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","123.52","902.76","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEATH UROLOGICAL 12FR 28CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016041","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1062.07","637.24","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","123.52","11.63","","49.19","10.57","114.40","19","123.52","822.04","percent of total billed charges",""
"SHEATH UROLOGICAL 12FR 28CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016041","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1062.07","637.24","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","666.77","62.78","","93.27","93.27","93.27","1 through 10","123.52","822.04","percent of total billed charges",""
"SHEATH UROLOGICAL 12FR 28CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016041","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1062.07","637.24","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","464.34","43.72","","363.22","363.22","363.22","1 through 10","123.52","822.04","percent of total billed charges",""
"SHEATH UROLOGICAL 12FR 28CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016041","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1062.07","637.24","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","772.34","72.72","","271.85","111.24","551.69","14","123.52","822.04","percent of total billed charges",""
"SHEATH UROLOGICAL 12FR 28CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016041","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1062.07","637.24","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","668.04","62.9","","706.53","93.60","938.00","53","123.52","822.04","percent of total billed charges",""
"SHEATH UROLOGICAL 12FR 28CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016041","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1062.07","637.24","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","822.04","77.4","","200.75","81.67","643.86","11","123.52","822.04","percent of total billed charges",""
"SHEET FLAT 3INX6 MESH SURGICAL PERMANENT HERNIA REPAIR CS/3EA","SUP-ITM-10157621","CDM","C1781","HCPCS","0278","RC","","","","both","","","366.23","219.74","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1674.02","1674.02","1674.02","1 through 10","42.59","311.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHEET FLAT 3INX6 MESH SURGICAL PERMANENT HERNIA REPAIR CS/3EA","SUP-ITM-10157621","CDM","C1781","HCPCS","0278","RC","","","","both","","","366.23","219.74","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","208.38","56.9","","1333.47","776.80","2316.37","34","42.59","311.3","percent of total billed charges",""
"SHEET FLAT 3INX6 MESH SURGICAL PERMANENT HERNIA REPAIR CS/3EA","SUP-ITM-10157621","CDM","C1781","HCPCS","0278","RC","","","","both","","","366.23","219.74","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","42.59","11.63","","348.38","187.99","380.51","1 through 10","42.59","311.3","percent of total billed charges",""
"SHEET FLAT 3INX6 MESH SURGICAL PERMANENT HERNIA REPAIR CS/3EA","SUP-ITM-10157621","CDM","C1781","HCPCS","0278","RC","","","","both","","","366.23","219.74","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","230.36","62.9","","1793.12","860.08","3673.04","20","42.59","311.3","percent of total billed charges",""
"SHEET FLAT 3INX6 MESH SURGICAL PERMANENT HERNIA REPAIR CS/3EA","SUP-ITM-10157621","CDM","C1781","HCPCS","0278","RC","","","","both","","","366.23","219.74","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","283.46","77.4","","1107.52","186.36","4312.65","1 through 10","42.59","311.3","percent of total billed charges",""
"SHEET FLAT 3INX6 MESH SURGICAL PERMANENT HERNIA REPAIR CS/3EA","SUP-ITM-10157621","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","366.23","219.74","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","42.59","11.63","","348.38","187.99","380.51","1 through 10","42.59","266.32","percent of total billed charges",""
"SHEET FLAT 3INX6 MESH SURGICAL PERMANENT HERNIA REPAIR CS/3EA","SUP-ITM-10157621","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","366.23","219.74","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","229.92","62.78","","9719.10","2943.96","9719.10","1 through 10","42.59","266.32","percent of total billed charges",""
"SHEET FLAT 3INX6 MESH SURGICAL PERMANENT HERNIA REPAIR CS/3EA","SUP-ITM-10157621","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","366.23","219.74","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","266.32","72.72","","2009.48","1217.35","3752.64","17","42.59","266.32","percent of total billed charges",""
"SHELL PROCOTYL 52MM PRIME BF QUAD GROUP E BIOFOAM TI","SUP-ITM-10267746","CDM","C1776","HCPCS","0278","RC","","","","both","","","4954.47","2972.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","576.2","4211.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHELL PROCOTYL 52MM PRIME BF QUAD GROUP E BIOFOAM TI","SUP-ITM-10267746","CDM","C1776","HCPCS","0278","RC","","","","both","","","4954.47","2972.68","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2819.09","56.9","","2911.53","1863.86","5209.05","65","576.2","4211.3","percent of total billed charges",""
"SHELL PROCOTYL 52MM PRIME BF QUAD GROUP E BIOFOAM TI","SUP-ITM-10267746","CDM","C1776","HCPCS","0278","RC","","","","both","","","4954.47","2972.68","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","576.20","11.63","","400.94","400.94","400.94","1 through 10","576.2","4211.3","percent of total billed charges",""
"SHELL PROCOTYL 52MM PRIME BF QUAD GROUP E BIOFOAM TI","SUP-ITM-10267746","CDM","C1776","HCPCS","0278","RC","","","","both","","","4954.47","2972.68","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3834.76","77.4","","5214.50","5214.50","16415.28","1 through 10","576.2","4211.3","percent of total billed charges",""
"SHELL PROCOTYL 52MM PRIME BF QUAD GROUP E BIOFOAM TI","SUP-ITM-10267746","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4954.47","2972.68","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","576.20","11.63","","400.94","400.94","400.94","1 through 10","576.2","3834.76","percent of total billed charges",""
"SHELL PROCOTYL 52MM PRIME BF QUAD GROUP E BIOFOAM TI","SUP-ITM-10267746","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4954.47","2972.68","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2166.09","43.72","","1543.33","1543.33","1671.61","1 through 10","576.2","3834.76","percent of total billed charges",""
"SHELL PROCOTYL 52MM PRIME BF QUAD GROUP E BIOFOAM TI","SUP-ITM-10267746","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4954.47","2972.68","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3602.89","72.72","","3700.21","2382.07","6427.18","53","576.2","3834.76","percent of total billed charges",""
"SHELL PROCOTYL 52MM PRIME BF QUAD GROUP E BIOFOAM TI","SUP-ITM-10267746","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4954.47","2972.68","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3602.89","72.72","","12685.80","12685.80","12685.80","1 through 10","576.2","3834.76","percent of total billed charges",""
"SHELL PROCOTYL 52MM PRIME BF QUAD GROUP E BIOFOAM TI","SUP-ITM-10267746","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4954.47","2972.68","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3116.36","62.9","","3408.87","2784.05","9859.40","46","576.2","3834.76","percent of total billed charges",""
"SHELL PROCOTYL 52MM PRIME BF QUAD GROUP E BIOFOAM TI","SUP-ITM-10267746","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4954.47","2972.68","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3834.76","77.4","","5214.50","5214.50","16415.28","1 through 10","576.2","3834.76","percent of total billed charges",""
"SHELL PROCOTYL 60MM PRIME BF QUAD GROUP E BIOFOAM TI","SUP-ITM-10269630","CDM","C1776","HCPCS","0278","RC","","","","both","","","4954.47","2972.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","576.2","4211.3","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHELL PROCOTYL 60MM PRIME BF QUAD GROUP E BIOFOAM TI","SUP-ITM-10269630","CDM","C1776","HCPCS","0278","RC","","","","both","","","4954.47","2972.68","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2819.09","56.9","","2911.53","1863.86","5209.05","65","576.2","4211.3","percent of total billed charges",""
"SHELL PROCOTYL 60MM PRIME BF QUAD GROUP E BIOFOAM TI","SUP-ITM-10269630","CDM","C1776","HCPCS","0278","RC","","","","both","","","4954.47","2972.68","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","576.20","11.63","","400.94","400.94","400.94","1 through 10","576.2","4211.3","percent of total billed charges",""
"SHELL PROCOTYL 60MM PRIME BF QUAD GROUP E BIOFOAM TI","SUP-ITM-10269630","CDM","C1776","HCPCS","0278","RC","","","","both","","","4954.47","2972.68","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3834.76","77.4","","5214.50","5214.50","16415.28","1 through 10","576.2","4211.3","percent of total billed charges",""
"SHELL PROCOTYL 60MM PRIME BF QUAD GROUP E BIOFOAM TI","SUP-ITM-10269630","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4954.47","2972.68","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","576.20","11.63","","400.94","400.94","400.94","1 through 10","576.2","3834.76","percent of total billed charges",""
"SHELL PROCOTYL 60MM PRIME BF QUAD GROUP E BIOFOAM TI","SUP-ITM-10269630","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4954.47","2972.68","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2166.09","43.72","","1543.33","1543.33","1671.61","1 through 10","576.2","3834.76","percent of total billed charges",""
"SHELL PROCOTYL 60MM PRIME BF QUAD GROUP E BIOFOAM TI","SUP-ITM-10269630","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4954.47","2972.68","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3602.89","72.72","","3700.21","2382.07","6427.18","53","576.2","3834.76","percent of total billed charges",""
"SHELL PROCOTYL 60MM PRIME BF QUAD GROUP E BIOFOAM TI","SUP-ITM-10269630","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4954.47","2972.68","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3602.89","72.72","","12685.80","12685.80","12685.80","1 through 10","576.2","3834.76","percent of total billed charges",""
"SHELL PROCOTYL 60MM PRIME BF QUAD GROUP E BIOFOAM TI","SUP-ITM-10269630","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4954.47","2972.68","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3116.36","62.9","","3408.87","2784.05","9859.40","46","576.2","3834.76","percent of total billed charges",""
"SHELL PROCOTYL 60MM PRIME BF QUAD GROUP E BIOFOAM TI","SUP-ITM-10269630","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4954.47","2972.68","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3834.76","77.4","","5214.50","5214.50","16415.28","1 through 10","576.2","3834.76","percent of total billed charges",""
"SHOULDER 48X18MM AEQUALIS ASCEND TITANIUM OFFSET LOW","SUP-ITM-10136063","CDM","C1776","HCPCS","0278","RC","","","","both","","","7275.00","4365.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","846.08","6183.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER 48X18MM AEQUALIS ASCEND TITANIUM OFFSET LOW","SUP-ITM-10136063","CDM","C1776","HCPCS","0278","RC","","","","both","","","7275.00","4365.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4139.48","56.9","","2911.53","1863.86","5209.05","65","846.08","6183.75","percent of total billed charges",""
"SHOULDER 48X18MM AEQUALIS ASCEND TITANIUM OFFSET LOW","SUP-ITM-10136063","CDM","C1776","HCPCS","0278","RC","","","","both","","","7275.00","4365.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","846.08","11.63","","400.94","400.94","400.94","1 through 10","846.08","6183.75","percent of total billed charges",""
"SHOULDER 48X18MM AEQUALIS ASCEND TITANIUM OFFSET LOW","SUP-ITM-10136063","CDM","C1776","HCPCS","0278","RC","","","","both","","","7275.00","4365.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5630.85","77.4","","5214.50","5214.50","16415.28","1 through 10","846.08","6183.75","percent of total billed charges",""
"SHOULDER 48X18MM AEQUALIS ASCEND TITANIUM OFFSET LOW","SUP-ITM-10136063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","846.08","11.63","","400.94","400.94","400.94","1 through 10","846.08","5630.85","percent of total billed charges",""
"SHOULDER 48X18MM AEQUALIS ASCEND TITANIUM OFFSET LOW","SUP-ITM-10136063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3180.63","43.72","","1543.33","1543.33","1671.61","1 through 10","846.08","5630.85","percent of total billed charges",""
"SHOULDER 48X18MM AEQUALIS ASCEND TITANIUM OFFSET LOW","SUP-ITM-10136063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5290.38","72.72","","3700.21","2382.07","6427.18","53","846.08","5630.85","percent of total billed charges",""
"SHOULDER 48X18MM AEQUALIS ASCEND TITANIUM OFFSET LOW","SUP-ITM-10136063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5290.38","72.72","","12685.80","12685.80","12685.80","1 through 10","846.08","5630.85","percent of total billed charges",""
"SHOULDER 48X18MM AEQUALIS ASCEND TITANIUM OFFSET LOW","SUP-ITM-10136063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4575.98","62.9","","3408.87","2784.05","9859.40","46","846.08","5630.85","percent of total billed charges",""
"SHOULDER 48X18MM AEQUALIS ASCEND TITANIUM OFFSET LOW","SUP-ITM-10136063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5630.85","77.4","","5214.50","5214.50","16415.28","1 through 10","846.08","5630.85","percent of total billed charges",""
"SHOULDER 53MM SHORT EQUINOXE BETA","SUP-ITM-10195090","CDM","C1776","HCPCS","0278","RC","","","","both","","","3593.20","2155.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","417.89","3054.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER 53MM SHORT EQUINOXE BETA","SUP-ITM-10195090","CDM","C1776","HCPCS","0278","RC","","","","both","","","3593.20","2155.92","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2044.53","56.9","","2911.53","1863.86","5209.05","65","417.89","3054.22","percent of total billed charges",""
"SHOULDER 53MM SHORT EQUINOXE BETA","SUP-ITM-10195090","CDM","C1776","HCPCS","0278","RC","","","","both","","","3593.20","2155.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","417.89","11.63","","400.94","400.94","400.94","1 through 10","417.89","3054.22","percent of total billed charges",""
"SHOULDER 53MM SHORT EQUINOXE BETA","SUP-ITM-10195090","CDM","C1776","HCPCS","0278","RC","","","","both","","","3593.20","2155.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2781.14","77.4","","5214.50","5214.50","16415.28","1 through 10","417.89","3054.22","percent of total billed charges",""
"SHOULDER 53MM SHORT EQUINOXE BETA","SUP-ITM-10195090","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3593.20","2155.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","417.89","11.63","","400.94","400.94","400.94","1 through 10","417.89","2781.14","percent of total billed charges",""
"SHOULDER 53MM SHORT EQUINOXE BETA","SUP-ITM-10195090","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3593.20","2155.92","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1570.95","43.72","","1543.33","1543.33","1671.61","1 through 10","417.89","2781.14","percent of total billed charges",""
"SHOULDER 53MM SHORT EQUINOXE BETA","SUP-ITM-10195090","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3593.20","2155.92","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2612.98","72.72","","3700.21","2382.07","6427.18","53","417.89","2781.14","percent of total billed charges",""
"SHOULDER 53MM SHORT EQUINOXE BETA","SUP-ITM-10195090","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3593.20","2155.92","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2612.98","72.72","","12685.80","12685.80","12685.80","1 through 10","417.89","2781.14","percent of total billed charges",""
"SHOULDER 53MM SHORT EQUINOXE BETA","SUP-ITM-10195090","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3593.20","2155.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2260.12","62.9","","3408.87","2784.05","9859.40","46","417.89","2781.14","percent of total billed charges",""
"SHOULDER 53MM SHORT EQUINOXE BETA","SUP-ITM-10195090","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3593.20","2155.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2781.14","77.4","","5214.50","5214.50","16415.28","1 through 10","417.89","2781.14","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","10908.00","6544.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1268.6","9271.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","10908.00","6544.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6206.65","56.9","","2911.53","1863.86","5209.05","65","1268.6","9271.8","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","10908.00","6544.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1268.60","11.63","","400.94","400.94","400.94","1 through 10","1268.6","9271.8","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","10908.00","6544.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8442.79","77.4","","5214.50","5214.50","16415.28","1 through 10","1268.6","9271.8","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10908.00","6544.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1268.60","11.63","","400.94","400.94","400.94","1 through 10","1268.6","8442.79","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10908.00","6544.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4768.98","43.72","","1543.33","1543.33","1671.61","1 through 10","1268.6","8442.79","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10908.00","6544.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7932.30","72.72","","3700.21","2382.07","6427.18","53","1268.6","8442.79","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10908.00","6544.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7932.30","72.72","","12685.80","12685.80","12685.80","1 through 10","1268.6","8442.79","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10908.00","6544.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6861.13","62.9","","3408.87","2784.05","9859.40","46","1268.6","8442.79","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10908.00","6544.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8442.79","77.4","","5214.50","5214.50","16415.28","1 through 10","1268.6","8442.79","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","7638.75","4583.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","888.39","6492.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","7638.75","4583.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4346.45","56.9","","2911.53","1863.86","5209.05","65","888.39","6492.94","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","7638.75","4583.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","888.39","11.63","","400.94","400.94","400.94","1 through 10","888.39","6492.94","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","7638.75","4583.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5912.39","77.4","","5214.50","5214.50","16415.28","1 through 10","888.39","6492.94","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7638.75","4583.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","888.39","11.63","","400.94","400.94","400.94","1 through 10","888.39","5912.39","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7638.75","4583.25","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3339.66","43.72","","1543.33","1543.33","1671.61","1 through 10","888.39","5912.39","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7638.75","4583.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5554.90","72.72","","3700.21","2382.07","6427.18","53","888.39","5912.39","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7638.75","4583.25","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5554.90","72.72","","12685.80","12685.80","12685.80","1 through 10","888.39","5912.39","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7638.75","4583.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4804.77","62.9","","3408.87","2784.05","9859.40","46","888.39","5912.39","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7638.75","4583.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5912.39","77.4","","5214.50","5214.50","16415.28","1 through 10","888.39","5912.39","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","both","","","7638.75","4583.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","888.39","6492.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","both","","","7638.75","4583.25","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4346.45","56.9","","2911.53","1863.86","5209.05","65","888.39","6492.94","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","both","","","7638.75","4583.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","888.39","11.63","","400.94","400.94","400.94","1 through 10","888.39","6492.94","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","both","","","7638.75","4583.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5912.39","77.4","","5214.50","5214.50","16415.28","1 through 10","888.39","6492.94","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7638.75","4583.25","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","888.39","11.63","","400.94","400.94","400.94","1 through 10","888.39","5912.39","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7638.75","4583.25","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3339.66","43.72","","1543.33","1543.33","1671.61","1 through 10","888.39","5912.39","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7638.75","4583.25","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5554.90","72.72","","3700.21","2382.07","6427.18","53","888.39","5912.39","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7638.75","4583.25","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5554.90","72.72","","12685.80","12685.80","12685.80","1 through 10","888.39","5912.39","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7638.75","4583.25","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4804.77","62.9","","3408.87","2784.05","9859.40","46","888.39","5912.39","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM COMPREHENSIVE TITANIUM ALLOY REVERSE","SUP-ITM-10091061","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7638.75","4583.25","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5912.39","77.4","","5214.50","5214.50","16415.28","1 through 10","888.39","5912.39","percent of total billed charges",""
"SHOULDER BASEPLATE 36MMX25 AEQUALIS REVERSED TITANIUM CENTERED","SUP-ITM-10192115","CDM","C1776","HCPCS","0278","RC","","","","both","","","13784.48","8270.69","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1603.14","11716.81","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER BASEPLATE 36MMX25 AEQUALIS REVERSED TITANIUM CENTERED","SUP-ITM-10192115","CDM","C1776","HCPCS","0278","RC","","","","both","","","13784.48","8270.69","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7843.37","56.9","","2911.53","1863.86","5209.05","65","1603.14","11716.81","percent of total billed charges",""
"SHOULDER BASEPLATE 36MMX25 AEQUALIS REVERSED TITANIUM CENTERED","SUP-ITM-10192115","CDM","C1776","HCPCS","0278","RC","","","","both","","","13784.48","8270.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1603.14","11.63","","400.94","400.94","400.94","1 through 10","1603.14","11716.81","percent of total billed charges",""
"SHOULDER BASEPLATE 36MMX25 AEQUALIS REVERSED TITANIUM CENTERED","SUP-ITM-10192115","CDM","C1776","HCPCS","0278","RC","","","","both","","","13784.48","8270.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10669.19","77.4","","5214.50","5214.50","16415.28","1 through 10","1603.14","11716.81","percent of total billed charges",""
"SHOULDER BASEPLATE 36MMX25 AEQUALIS REVERSED TITANIUM CENTERED","SUP-ITM-10192115","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13784.48","8270.69","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1603.14","11.63","","400.94","400.94","400.94","1 through 10","1603.14","10669.19","percent of total billed charges",""
"SHOULDER BASEPLATE 36MMX25 AEQUALIS REVERSED TITANIUM CENTERED","SUP-ITM-10192115","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13784.48","8270.69","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","6026.57","43.72","","1543.33","1543.33","1671.61","1 through 10","1603.14","10669.19","percent of total billed charges",""
"SHOULDER BASEPLATE 36MMX25 AEQUALIS REVERSED TITANIUM CENTERED","SUP-ITM-10192115","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13784.48","8270.69","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10024.07","72.72","","3700.21","2382.07","6427.18","53","1603.14","10669.19","percent of total billed charges",""
"SHOULDER BASEPLATE 36MMX25 AEQUALIS REVERSED TITANIUM CENTERED","SUP-ITM-10192115","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13784.48","8270.69","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","10024.07","72.72","","12685.80","12685.80","12685.80","1 through 10","1603.14","10669.19","percent of total billed charges",""
"SHOULDER BASEPLATE 36MMX25 AEQUALIS REVERSED TITANIUM CENTERED","SUP-ITM-10192115","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13784.48","8270.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8670.44","62.9","","3408.87","2784.05","9859.40","46","1603.14","10669.19","percent of total billed charges",""
"SHOULDER BASEPLATE 36MMX25 AEQUALIS REVERSED TITANIUM CENTERED","SUP-ITM-10192115","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","13784.48","8270.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10669.19","77.4","","5214.50","5214.50","16415.28","1 through 10","1603.14","10669.19","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","both","","","6151.74","3691.04","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","715.45","5228.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","both","","","6151.74","3691.04","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3500.34","56.9","","2911.53","1863.86","5209.05","65","715.45","5228.98","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","both","","","6151.74","3691.04","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","715.45","11.63","","400.94","400.94","400.94","1 through 10","715.45","5228.98","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","both","","","6151.74","3691.04","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4761.45","77.4","","5214.50","5214.50","16415.28","1 through 10","715.45","5228.98","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6151.74","3691.04","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","715.45","11.63","","400.94","400.94","400.94","1 through 10","715.45","4761.45","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6151.74","3691.04","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2689.54","43.72","","1543.33","1543.33","1671.61","1 through 10","715.45","4761.45","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6151.74","3691.04","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4473.55","72.72","","3700.21","2382.07","6427.18","53","715.45","4761.45","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6151.74","3691.04","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4473.55","72.72","","12685.80","12685.80","12685.80","1 through 10","715.45","4761.45","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6151.74","3691.04","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3869.44","62.9","","3408.87","2784.05","9859.40","46","715.45","4761.45","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6151.74","3691.04","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4761.45","77.4","","5214.50","5214.50","16415.28","1 through 10","715.45","4761.45","percent of total billed charges",""
"SHOULDER BASEPLATE GLENOID EQUINOXE SUPERIOR POSTERIOR AUGMENT L RS","SUP-ITM-10194995","CDM","C1776","HCPCS","0278","RC","","","","both","","","8637.85","5182.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1004.58","7342.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER BASEPLATE GLENOID EQUINOXE SUPERIOR POSTERIOR AUGMENT L RS","SUP-ITM-10194995","CDM","C1776","HCPCS","0278","RC","","","","both","","","8637.85","5182.71","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4914.94","56.9","","2911.53","1863.86","5209.05","65","1004.58","7342.17","percent of total billed charges",""
"SHOULDER BASEPLATE GLENOID EQUINOXE SUPERIOR POSTERIOR AUGMENT L RS","SUP-ITM-10194995","CDM","C1776","HCPCS","0278","RC","","","","both","","","8637.85","5182.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1004.58","11.63","","400.94","400.94","400.94","1 through 10","1004.58","7342.17","percent of total billed charges",""
"SHOULDER BASEPLATE GLENOID EQUINOXE SUPERIOR POSTERIOR AUGMENT L RS","SUP-ITM-10194995","CDM","C1776","HCPCS","0278","RC","","","","both","","","8637.85","5182.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6685.70","77.4","","5214.50","5214.50","16415.28","1 through 10","1004.58","7342.17","percent of total billed charges",""
"SHOULDER BASEPLATE GLENOID EQUINOXE SUPERIOR POSTERIOR AUGMENT L RS","SUP-ITM-10194995","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1004.58","11.63","","400.94","400.94","400.94","1 through 10","1004.58","6685.7","percent of total billed charges",""
"SHOULDER BASEPLATE GLENOID EQUINOXE SUPERIOR POSTERIOR AUGMENT L RS","SUP-ITM-10194995","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3776.47","43.72","","1543.33","1543.33","1671.61","1 through 10","1004.58","6685.7","percent of total billed charges",""
"SHOULDER BASEPLATE GLENOID EQUINOXE SUPERIOR POSTERIOR AUGMENT L RS","SUP-ITM-10194995","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6281.44","72.72","","3700.21","2382.07","6427.18","53","1004.58","6685.7","percent of total billed charges",""
"SHOULDER BASEPLATE GLENOID EQUINOXE SUPERIOR POSTERIOR AUGMENT L RS","SUP-ITM-10194995","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6281.44","72.72","","12685.80","12685.80","12685.80","1 through 10","1004.58","6685.7","percent of total billed charges",""
"SHOULDER BASEPLATE GLENOID EQUINOXE SUPERIOR POSTERIOR AUGMENT L RS","SUP-ITM-10194995","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5433.21","62.9","","3408.87","2784.05","9859.40","46","1004.58","6685.7","percent of total billed charges",""
"SHOULDER BASEPLATE GLENOID EQUINOXE SUPERIOR POSTERIOR AUGMENT L RS","SUP-ITM-10194995","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6685.70","77.4","","5214.50","5214.50","16415.28","1 through 10","1004.58","6685.7","percent of total billed charges",""
"SHOULDER BASEPLATE SM 8DEG RT GLENOID REVERSE AUGMENT POSTERIOR","SUP-ITM-10282838","CDM","C1776","HCPCS","0278","RC","","","","both","","","8637.85","5182.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1004.58","7342.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER BASEPLATE SM 8DEG RT GLENOID REVERSE AUGMENT POSTERIOR","SUP-ITM-10282838","CDM","C1776","HCPCS","0278","RC","","","","both","","","8637.85","5182.71","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4914.94","56.9","","2911.53","1863.86","5209.05","65","1004.58","7342.17","percent of total billed charges",""
"SHOULDER BASEPLATE SM 8DEG RT GLENOID REVERSE AUGMENT POSTERIOR","SUP-ITM-10282838","CDM","C1776","HCPCS","0278","RC","","","","both","","","8637.85","5182.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1004.58","11.63","","400.94","400.94","400.94","1 through 10","1004.58","7342.17","percent of total billed charges",""
"SHOULDER BASEPLATE SM 8DEG RT GLENOID REVERSE AUGMENT POSTERIOR","SUP-ITM-10282838","CDM","C1776","HCPCS","0278","RC","","","","both","","","8637.85","5182.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6685.70","77.4","","5214.50","5214.50","16415.28","1 through 10","1004.58","7342.17","percent of total billed charges",""
"SHOULDER BASEPLATE SM 8DEG RT GLENOID REVERSE AUGMENT POSTERIOR","SUP-ITM-10282838","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1004.58","11.63","","400.94","400.94","400.94","1 through 10","1004.58","6685.7","percent of total billed charges",""
"SHOULDER BASEPLATE SM 8DEG RT GLENOID REVERSE AUGMENT POSTERIOR","SUP-ITM-10282838","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3776.47","43.72","","1543.33","1543.33","1671.61","1 through 10","1004.58","6685.7","percent of total billed charges",""
"SHOULDER BASEPLATE SM 8DEG RT GLENOID REVERSE AUGMENT POSTERIOR","SUP-ITM-10282838","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6281.44","72.72","","3700.21","2382.07","6427.18","53","1004.58","6685.7","percent of total billed charges",""
"SHOULDER BASEPLATE SM 8DEG RT GLENOID REVERSE AUGMENT POSTERIOR","SUP-ITM-10282838","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6281.44","72.72","","12685.80","12685.80","12685.80","1 through 10","1004.58","6685.7","percent of total billed charges",""
"SHOULDER BASEPLATE SM 8DEG RT GLENOID REVERSE AUGMENT POSTERIOR","SUP-ITM-10282838","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5433.21","62.9","","3408.87","2784.05","9859.40","46","1004.58","6685.7","percent of total billed charges",""
"SHOULDER BASEPLATE SM 8DEG RT GLENOID REVERSE AUGMENT POSTERIOR","SUP-ITM-10282838","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6685.70","77.4","","5214.50","5214.50","16415.28","1 through 10","1004.58","6685.7","percent of total billed charges",""
"SHOULDER CAGE 25MM RESURFACING EQUINOXE","SUP-ITM-10195005","CDM","C1776","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","241.09","1762.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER CAGE 25MM RESURFACING EQUINOXE","SUP-ITM-10195005","CDM","C1776","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1179.54","56.9","","2911.53","1863.86","5209.05","65","241.09","1762.05","percent of total billed charges",""
"SHOULDER CAGE 25MM RESURFACING EQUINOXE","SUP-ITM-10195005","CDM","C1776","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","241.09","11.63","","400.94","400.94","400.94","1 through 10","241.09","1762.05","percent of total billed charges",""
"SHOULDER CAGE 25MM RESURFACING EQUINOXE","SUP-ITM-10195005","CDM","C1776","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1604.50","77.4","","5214.50","5214.50","16415.28","1 through 10","241.09","1762.05","percent of total billed charges",""
"SHOULDER CAGE 25MM RESURFACING EQUINOXE","SUP-ITM-10195005","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","241.09","11.63","","400.94","400.94","400.94","1 through 10","241.09","1604.5","percent of total billed charges",""
"SHOULDER CAGE 25MM RESURFACING EQUINOXE","SUP-ITM-10195005","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","906.32","43.72","","1543.33","1543.33","1671.61","1 through 10","241.09","1604.5","percent of total billed charges",""
"SHOULDER CAGE 25MM RESURFACING EQUINOXE","SUP-ITM-10195005","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1507.49","72.72","","3700.21","2382.07","6427.18","53","241.09","1604.5","percent of total billed charges",""
"SHOULDER CAGE 25MM RESURFACING EQUINOXE","SUP-ITM-10195005","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1507.49","72.72","","12685.80","12685.80","12685.80","1 through 10","241.09","1604.5","percent of total billed charges",""
"SHOULDER CAGE 25MM RESURFACING EQUINOXE","SUP-ITM-10195005","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1303.92","62.9","","3408.87","2784.05","9859.40","46","241.09","1604.5","percent of total billed charges",""
"SHOULDER CAGE 25MM RESURFACING EQUINOXE","SUP-ITM-10195005","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1604.50","77.4","","5214.50","5214.50","16415.28","1 through 10","241.09","1604.5","percent of total billed charges",""
"SHOULDER CAGE 30MM RESURFACING","SUP-ITM-10195006","CDM","C1776","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","241.09","1762.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER CAGE 30MM RESURFACING","SUP-ITM-10195006","CDM","C1776","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1179.54","56.9","","2911.53","1863.86","5209.05","65","241.09","1762.05","percent of total billed charges",""
"SHOULDER CAGE 30MM RESURFACING","SUP-ITM-10195006","CDM","C1776","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","241.09","11.63","","400.94","400.94","400.94","1 through 10","241.09","1762.05","percent of total billed charges",""
"SHOULDER CAGE 30MM RESURFACING","SUP-ITM-10195006","CDM","C1776","HCPCS","0278","RC","","","","both","","","2073.00","1243.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1604.50","77.4","","5214.50","5214.50","16415.28","1 through 10","241.09","1762.05","percent of total billed charges",""
"SHOULDER CAGE 30MM RESURFACING","SUP-ITM-10195006","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","241.09","11.63","","400.94","400.94","400.94","1 through 10","241.09","1604.5","percent of total billed charges",""
"SHOULDER CAGE 30MM RESURFACING","SUP-ITM-10195006","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","906.32","43.72","","1543.33","1543.33","1671.61","1 through 10","241.09","1604.5","percent of total billed charges",""
"SHOULDER CAGE 30MM RESURFACING","SUP-ITM-10195006","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1507.49","72.72","","3700.21","2382.07","6427.18","53","241.09","1604.5","percent of total billed charges",""
"SHOULDER CAGE 30MM RESURFACING","SUP-ITM-10195006","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1507.49","72.72","","12685.80","12685.80","12685.80","1 through 10","241.09","1604.5","percent of total billed charges",""
"SHOULDER CAGE 30MM RESURFACING","SUP-ITM-10195006","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1303.92","62.9","","3408.87","2784.05","9859.40","46","241.09","1604.5","percent of total billed charges",""
"SHOULDER CAGE 30MM RESURFACING","SUP-ITM-10195006","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2073.00","1243.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1604.50","77.4","","5214.50","5214.50","16415.28","1 through 10","241.09","1604.5","percent of total billed charges",""
"SHOULDER CAGE LG EXACTECH EQUINOXE BETA","SUP-ITM-10195019","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.50","3928.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","761.47","5565.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER CAGE LG EXACTECH EQUINOXE BETA","SUP-ITM-10195019","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.50","3928.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3725.53","56.9","","2911.53","1863.86","5209.05","65","761.47","5565.38","percent of total billed charges",""
"SHOULDER CAGE LG EXACTECH EQUINOXE BETA","SUP-ITM-10195019","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.50","3928.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","761.47","11.63","","400.94","400.94","400.94","1 through 10","761.47","5565.38","percent of total billed charges",""
"SHOULDER CAGE LG EXACTECH EQUINOXE BETA","SUP-ITM-10195019","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.50","3928.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5067.77","77.4","","5214.50","5214.50","16415.28","1 through 10","761.47","5565.38","percent of total billed charges",""
"SHOULDER CAGE LG EXACTECH EQUINOXE BETA","SUP-ITM-10195019","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.50","3928.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","761.47","11.63","","400.94","400.94","400.94","1 through 10","761.47","5067.77","percent of total billed charges",""
"SHOULDER CAGE LG EXACTECH EQUINOXE BETA","SUP-ITM-10195019","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.50","3928.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2862.57","43.72","","1543.33","1543.33","1671.61","1 through 10","761.47","5067.77","percent of total billed charges",""
"SHOULDER CAGE LG EXACTECH EQUINOXE BETA","SUP-ITM-10195019","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.50","3928.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4761.34","72.72","","3700.21","2382.07","6427.18","53","761.47","5067.77","percent of total billed charges",""
"SHOULDER CAGE LG EXACTECH EQUINOXE BETA","SUP-ITM-10195019","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.50","3928.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4761.34","72.72","","12685.80","12685.80","12685.80","1 through 10","761.47","5067.77","percent of total billed charges",""
"SHOULDER CAGE LG EXACTECH EQUINOXE BETA","SUP-ITM-10195019","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.50","3928.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4118.38","62.9","","3408.87","2784.05","9859.40","46","761.47","5067.77","percent of total billed charges",""
"SHOULDER CAGE LG EXACTECH EQUINOXE BETA","SUP-ITM-10195019","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.50","3928.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5067.77","77.4","","5214.50","5214.50","16415.28","1 through 10","761.47","5067.77","percent of total billed charges",""
"SHOULDER CAGE LG GLENOID AUGMENTED EQUINOXE LEFT","SUP-ITM-10195007","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.50","3928.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","761.47","5565.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER CAGE LG GLENOID AUGMENTED EQUINOXE LEFT","SUP-ITM-10195007","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.50","3928.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3725.53","56.9","","2911.53","1863.86","5209.05","65","761.47","5565.38","percent of total billed charges",""
"SHOULDER CAGE LG GLENOID AUGMENTED EQUINOXE LEFT","SUP-ITM-10195007","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.50","3928.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","761.47","11.63","","400.94","400.94","400.94","1 through 10","761.47","5565.38","percent of total billed charges",""
"SHOULDER CAGE LG GLENOID AUGMENTED EQUINOXE LEFT","SUP-ITM-10195007","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.50","3928.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5067.77","77.4","","5214.50","5214.50","16415.28","1 through 10","761.47","5565.38","percent of total billed charges",""
"SHOULDER CAGE LG GLENOID AUGMENTED EQUINOXE LEFT","SUP-ITM-10195007","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.50","3928.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","761.47","11.63","","400.94","400.94","400.94","1 through 10","761.47","5067.77","percent of total billed charges",""
"SHOULDER CAGE LG GLENOID AUGMENTED EQUINOXE LEFT","SUP-ITM-10195007","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.50","3928.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2862.57","43.72","","1543.33","1543.33","1671.61","1 through 10","761.47","5067.77","percent of total billed charges",""
"SHOULDER CAGE LG GLENOID AUGMENTED EQUINOXE LEFT","SUP-ITM-10195007","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.50","3928.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4761.34","72.72","","3700.21","2382.07","6427.18","53","761.47","5067.77","percent of total billed charges",""
"SHOULDER CAGE LG GLENOID AUGMENTED EQUINOXE LEFT","SUP-ITM-10195007","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.50","3928.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4761.34","72.72","","12685.80","12685.80","12685.80","1 through 10","761.47","5067.77","percent of total billed charges",""
"SHOULDER CAGE LG GLENOID AUGMENTED EQUINOXE LEFT","SUP-ITM-10195007","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.50","3928.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4118.38","62.9","","3408.87","2784.05","9859.40","46","761.47","5067.77","percent of total billed charges",""
"SHOULDER CAGE LG GLENOID AUGMENTED EQUINOXE LEFT","SUP-ITM-10195007","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.50","3928.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5067.77","77.4","","5214.50","5214.50","16415.28","1 through 10","761.47","5067.77","percent of total billed charges",""
"SHOULDER CAGE XL GLENOID AUGMENTED EQUINOXE LEFT","SUP-ITM-10195010","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.50","3928.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","761.47","5565.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER CAGE XL GLENOID AUGMENTED EQUINOXE LEFT","SUP-ITM-10195010","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.50","3928.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3725.53","56.9","","2911.53","1863.86","5209.05","65","761.47","5565.38","percent of total billed charges",""
"SHOULDER CAGE XL GLENOID AUGMENTED EQUINOXE LEFT","SUP-ITM-10195010","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.50","3928.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","761.47","11.63","","400.94","400.94","400.94","1 through 10","761.47","5565.38","percent of total billed charges",""
"SHOULDER CAGE XL GLENOID AUGMENTED EQUINOXE LEFT","SUP-ITM-10195010","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.50","3928.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5067.77","77.4","","5214.50","5214.50","16415.28","1 through 10","761.47","5565.38","percent of total billed charges",""
"SHOULDER CAGE XL GLENOID AUGMENTED EQUINOXE LEFT","SUP-ITM-10195010","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.50","3928.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","761.47","11.63","","400.94","400.94","400.94","1 through 10","761.47","5067.77","percent of total billed charges",""
"SHOULDER CAGE XL GLENOID AUGMENTED EQUINOXE LEFT","SUP-ITM-10195010","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.50","3928.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2862.57","43.72","","1543.33","1543.33","1671.61","1 through 10","761.47","5067.77","percent of total billed charges",""
"SHOULDER CAGE XL GLENOID AUGMENTED EQUINOXE LEFT","SUP-ITM-10195010","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.50","3928.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4761.34","72.72","","3700.21","2382.07","6427.18","53","761.47","5067.77","percent of total billed charges",""
"SHOULDER CAGE XL GLENOID AUGMENTED EQUINOXE LEFT","SUP-ITM-10195010","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.50","3928.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4761.34","72.72","","12685.80","12685.80","12685.80","1 through 10","761.47","5067.77","percent of total billed charges",""
"SHOULDER CAGE XL GLENOID AUGMENTED EQUINOXE LEFT","SUP-ITM-10195010","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.50","3928.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4118.38","62.9","","3408.87","2784.05","9859.40","46","761.47","5067.77","percent of total billed charges",""
"SHOULDER CAGE XL GLENOID AUGMENTED EQUINOXE LEFT","SUP-ITM-10195010","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.50","3928.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5067.77","77.4","","5214.50","5214.50","16415.28","1 through 10","761.47","5067.77","percent of total billed charges",""
"SHOULDER GLENOID BASEPLATE EQUINOXE SMALL REVERSE LEFT","SUP-ITM-10286874","CDM","C1776","HCPCS","0278","RC","","","","both","","","8637.85","5182.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1004.58","7342.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER GLENOID BASEPLATE EQUINOXE SMALL REVERSE LEFT","SUP-ITM-10286874","CDM","C1776","HCPCS","0278","RC","","","","both","","","8637.85","5182.71","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4914.94","56.9","","2911.53","1863.86","5209.05","65","1004.58","7342.17","percent of total billed charges",""
"SHOULDER GLENOID BASEPLATE EQUINOXE SMALL REVERSE LEFT","SUP-ITM-10286874","CDM","C1776","HCPCS","0278","RC","","","","both","","","8637.85","5182.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1004.58","11.63","","400.94","400.94","400.94","1 through 10","1004.58","7342.17","percent of total billed charges",""
"SHOULDER GLENOID BASEPLATE EQUINOXE SMALL REVERSE LEFT","SUP-ITM-10286874","CDM","C1776","HCPCS","0278","RC","","","","both","","","8637.85","5182.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6685.70","77.4","","5214.50","5214.50","16415.28","1 through 10","1004.58","7342.17","percent of total billed charges",""
"SHOULDER GLENOID BASEPLATE EQUINOXE SMALL REVERSE LEFT","SUP-ITM-10286874","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1004.58","11.63","","400.94","400.94","400.94","1 through 10","1004.58","6685.7","percent of total billed charges",""
"SHOULDER GLENOID BASEPLATE EQUINOXE SMALL REVERSE LEFT","SUP-ITM-10286874","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3776.47","43.72","","1543.33","1543.33","1671.61","1 through 10","1004.58","6685.7","percent of total billed charges",""
"SHOULDER GLENOID BASEPLATE EQUINOXE SMALL REVERSE LEFT","SUP-ITM-10286874","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6281.44","72.72","","3700.21","2382.07","6427.18","53","1004.58","6685.7","percent of total billed charges",""
"SHOULDER GLENOID BASEPLATE EQUINOXE SMALL REVERSE LEFT","SUP-ITM-10286874","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6281.44","72.72","","12685.80","12685.80","12685.80","1 through 10","1004.58","6685.7","percent of total billed charges",""
"SHOULDER GLENOID BASEPLATE EQUINOXE SMALL REVERSE LEFT","SUP-ITM-10286874","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5433.21","62.9","","3408.87","2784.05","9859.40","46","1004.58","6685.7","percent of total billed charges",""
"SHOULDER GLENOID BASEPLATE EQUINOXE SMALL REVERSE LEFT","SUP-ITM-10286874","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6685.70","77.4","","5214.50","5214.50","16415.28","1 through 10","1004.58","6685.7","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM PLUS 3MM HUMERAL COMPREHENSIVE TITANIUM","SUP-ITM-10159451","CDM","C1776","HCPCS","0278","RC","","","","both","","","6151.74","3691.04","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","715.45","5228.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER GLENOSPHERE 36MM PLUS 3MM HUMERAL COMPREHENSIVE TITANIUM","SUP-ITM-10159451","CDM","C1776","HCPCS","0278","RC","","","","both","","","6151.74","3691.04","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3500.34","56.9","","2911.53","1863.86","5209.05","65","715.45","5228.98","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM PLUS 3MM HUMERAL COMPREHENSIVE TITANIUM","SUP-ITM-10159451","CDM","C1776","HCPCS","0278","RC","","","","both","","","6151.74","3691.04","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","715.45","11.63","","400.94","400.94","400.94","1 through 10","715.45","5228.98","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM PLUS 3MM HUMERAL COMPREHENSIVE TITANIUM","SUP-ITM-10159451","CDM","C1776","HCPCS","0278","RC","","","","both","","","6151.74","3691.04","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4761.45","77.4","","5214.50","5214.50","16415.28","1 through 10","715.45","5228.98","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM PLUS 3MM HUMERAL COMPREHENSIVE TITANIUM","SUP-ITM-10159451","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6151.74","3691.04","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","715.45","11.63","","400.94","400.94","400.94","1 through 10","715.45","4761.45","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM PLUS 3MM HUMERAL COMPREHENSIVE TITANIUM","SUP-ITM-10159451","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6151.74","3691.04","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2689.54","43.72","","1543.33","1543.33","1671.61","1 through 10","715.45","4761.45","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM PLUS 3MM HUMERAL COMPREHENSIVE TITANIUM","SUP-ITM-10159451","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6151.74","3691.04","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4473.55","72.72","","3700.21","2382.07","6427.18","53","715.45","4761.45","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM PLUS 3MM HUMERAL COMPREHENSIVE TITANIUM","SUP-ITM-10159451","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6151.74","3691.04","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4473.55","72.72","","12685.80","12685.80","12685.80","1 through 10","715.45","4761.45","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM PLUS 3MM HUMERAL COMPREHENSIVE TITANIUM","SUP-ITM-10159451","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6151.74","3691.04","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3869.44","62.9","","3408.87","2784.05","9859.40","46","715.45","4761.45","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM PLUS 3MM HUMERAL COMPREHENSIVE TITANIUM","SUP-ITM-10159451","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6151.74","3691.04","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4761.45","77.4","","5214.50","5214.50","16415.28","1 through 10","715.45","4761.45","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM SM REVERSE EQUINOXE","SUP-ITM-10282065","CDM","C1776","HCPCS","0278","RC","","","","both","","","5858.80","3515.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","681.38","4979.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER GLENOSPHERE 36MM SM REVERSE EQUINOXE","SUP-ITM-10282065","CDM","C1776","HCPCS","0278","RC","","","","both","","","5858.80","3515.28","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3333.66","56.9","","2911.53","1863.86","5209.05","65","681.38","4979.98","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM SM REVERSE EQUINOXE","SUP-ITM-10282065","CDM","C1776","HCPCS","0278","RC","","","","both","","","5858.80","3515.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","681.38","11.63","","400.94","400.94","400.94","1 through 10","681.38","4979.98","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM SM REVERSE EQUINOXE","SUP-ITM-10282065","CDM","C1776","HCPCS","0278","RC","","","","both","","","5858.80","3515.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4534.71","77.4","","5214.50","5214.50","16415.28","1 through 10","681.38","4979.98","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM SM REVERSE EQUINOXE","SUP-ITM-10282065","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5858.80","3515.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","681.38","11.63","","400.94","400.94","400.94","1 through 10","681.38","4534.71","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM SM REVERSE EQUINOXE","SUP-ITM-10282065","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5858.80","3515.28","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2561.47","43.72","","1543.33","1543.33","1671.61","1 through 10","681.38","4534.71","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM SM REVERSE EQUINOXE","SUP-ITM-10282065","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5858.80","3515.28","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4260.52","72.72","","3700.21","2382.07","6427.18","53","681.38","4534.71","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM SM REVERSE EQUINOXE","SUP-ITM-10282065","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5858.80","3515.28","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4260.52","72.72","","12685.80","12685.80","12685.80","1 through 10","681.38","4534.71","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM SM REVERSE EQUINOXE","SUP-ITM-10282065","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5858.80","3515.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3685.19","62.9","","3408.87","2784.05","9859.40","46","681.38","4534.71","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36MM SM REVERSE EQUINOXE","SUP-ITM-10282065","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5858.80","3515.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4534.71","77.4","","5214.50","5214.50","16415.28","1 through 10","681.38","4534.71","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL EXQUINOXE","SUP-ITM-10195076","CDM","C1776","HCPCS","0278","RC","","","","both","","","11615.75","6969.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1350.91","9873.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER HEAD 44MM HUMERAL EXQUINOXE","SUP-ITM-10195076","CDM","C1776","HCPCS","0278","RC","","","","both","","","11615.75","6969.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6609.36","56.9","","2911.53","1863.86","5209.05","65","1350.91","9873.39","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL EXQUINOXE","SUP-ITM-10195076","CDM","C1776","HCPCS","0278","RC","","","","both","","","11615.75","6969.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1350.91","11.63","","400.94","400.94","400.94","1 through 10","1350.91","9873.39","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL EXQUINOXE","SUP-ITM-10195076","CDM","C1776","HCPCS","0278","RC","","","","both","","","11615.75","6969.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8990.59","77.4","","5214.50","5214.50","16415.28","1 through 10","1350.91","9873.39","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL EXQUINOXE","SUP-ITM-10195076","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11615.75","6969.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1350.91","11.63","","400.94","400.94","400.94","1 through 10","1350.91","8990.59","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL EXQUINOXE","SUP-ITM-10195076","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11615.75","6969.45","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","5078.41","43.72","","1543.33","1543.33","1671.61","1 through 10","1350.91","8990.59","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL EXQUINOXE","SUP-ITM-10195076","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11615.75","6969.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8446.97","72.72","","3700.21","2382.07","6427.18","53","1350.91","8990.59","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL EXQUINOXE","SUP-ITM-10195076","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11615.75","6969.45","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","8446.97","72.72","","12685.80","12685.80","12685.80","1 through 10","1350.91","8990.59","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL EXQUINOXE","SUP-ITM-10195076","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11615.75","6969.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7306.31","62.9","","3408.87","2784.05","9859.40","46","1350.91","8990.59","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL EXQUINOXE","SUP-ITM-10195076","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11615.75","6969.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8990.59","77.4","","5214.50","5214.50","16415.28","1 through 10","1350.91","8990.59","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","5858.80","3515.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","681.38","4979.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","5858.80","3515.28","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3333.66","56.9","","2911.53","1863.86","5209.05","65","681.38","4979.98","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","5858.80","3515.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","681.38","11.63","","400.94","400.94","400.94","1 through 10","681.38","4979.98","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","5858.80","3515.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4534.71","77.4","","5214.50","5214.50","16415.28","1 through 10","681.38","4979.98","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5858.80","3515.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","681.38","11.63","","400.94","400.94","400.94","1 through 10","681.38","4534.71","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5858.80","3515.28","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2561.47","43.72","","1543.33","1543.33","1671.61","1 through 10","681.38","4534.71","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5858.80","3515.28","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4260.52","72.72","","3700.21","2382.07","6427.18","53","681.38","4534.71","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5858.80","3515.28","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4260.52","72.72","","12685.80","12685.80","12685.80","1 through 10","681.38","4534.71","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5858.80","3515.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3685.19","62.9","","3408.87","2784.05","9859.40","46","681.38","4534.71","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5858.80","3515.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4534.71","77.4","","5214.50","5214.50","16415.28","1 through 10","681.38","4534.71","percent of total billed charges",""
"SHOULDER IMPLANT 25.1X42MM GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10195069","CDM","C1776","HCPCS","0278","RC","","","","both","","","5858.80","3515.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","681.38","4979.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER IMPLANT 25.1X42MM GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10195069","CDM","C1776","HCPCS","0278","RC","","","","both","","","5858.80","3515.28","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3333.66","56.9","","2911.53","1863.86","5209.05","65","681.38","4979.98","percent of total billed charges",""
"SHOULDER IMPLANT 25.1X42MM GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10195069","CDM","C1776","HCPCS","0278","RC","","","","both","","","5858.80","3515.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","681.38","11.63","","400.94","400.94","400.94","1 through 10","681.38","4979.98","percent of total billed charges",""
"SHOULDER IMPLANT 25.1X42MM GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10195069","CDM","C1776","HCPCS","0278","RC","","","","both","","","5858.80","3515.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4534.71","77.4","","5214.50","5214.50","16415.28","1 through 10","681.38","4979.98","percent of total billed charges",""
"SHOULDER IMPLANT 25.1X42MM GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10195069","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5858.80","3515.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","681.38","11.63","","400.94","400.94","400.94","1 through 10","681.38","4534.71","percent of total billed charges",""
"SHOULDER IMPLANT 25.1X42MM GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10195069","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5858.80","3515.28","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2561.47","43.72","","1543.33","1543.33","1671.61","1 through 10","681.38","4534.71","percent of total billed charges",""
"SHOULDER IMPLANT 25.1X42MM GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10195069","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5858.80","3515.28","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4260.52","72.72","","3700.21","2382.07","6427.18","53","681.38","4534.71","percent of total billed charges",""
"SHOULDER IMPLANT 25.1X42MM GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10195069","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5858.80","3515.28","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4260.52","72.72","","12685.80","12685.80","12685.80","1 through 10","681.38","4534.71","percent of total billed charges",""
"SHOULDER IMPLANT 25.1X42MM GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10195069","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5858.80","3515.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3685.19","62.9","","3408.87","2784.05","9859.40","46","681.38","4534.71","percent of total billed charges",""
"SHOULDER IMPLANT 25.1X42MM GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10195069","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5858.80","3515.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4534.71","77.4","","5214.50","5214.50","16415.28","1 through 10","681.38","4534.71","percent of total billed charges",""
"SHOULDER IMPLANT 25X36MM SPHERE GLENOID AEQUALIS CENTERED","SUP-ITM-10083827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","564.06","4122.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER IMPLANT 25X36MM SPHERE GLENOID AEQUALIS CENTERED","SUP-ITM-10083827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2759.65","56.9","","2911.53","1863.86","5209.05","65","564.06","4122.5","percent of total billed charges",""
"SHOULDER IMPLANT 25X36MM SPHERE GLENOID AEQUALIS CENTERED","SUP-ITM-10083827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.06","11.63","","400.94","400.94","400.94","1 through 10","564.06","4122.5","percent of total billed charges",""
"SHOULDER IMPLANT 25X36MM SPHERE GLENOID AEQUALIS CENTERED","SUP-ITM-10083827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3753.90","77.4","","5214.50","5214.50","16415.28","1 through 10","564.06","4122.5","percent of total billed charges",""
"SHOULDER IMPLANT 25X36MM SPHERE GLENOID AEQUALIS CENTERED","SUP-ITM-10083827","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.06","11.63","","400.94","400.94","400.94","1 through 10","564.06","3753.9","percent of total billed charges",""
"SHOULDER IMPLANT 25X36MM SPHERE GLENOID AEQUALIS CENTERED","SUP-ITM-10083827","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2120.42","43.72","","1543.33","1543.33","1671.61","1 through 10","564.06","3753.9","percent of total billed charges",""
"SHOULDER IMPLANT 25X36MM SPHERE GLENOID AEQUALIS CENTERED","SUP-ITM-10083827","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3526.92","72.72","","3700.21","2382.07","6427.18","53","564.06","3753.9","percent of total billed charges",""
"SHOULDER IMPLANT 25X36MM SPHERE GLENOID AEQUALIS CENTERED","SUP-ITM-10083827","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3526.92","72.72","","12685.80","12685.80","12685.80","1 through 10","564.06","3753.9","percent of total billed charges",""
"SHOULDER IMPLANT 25X36MM SPHERE GLENOID AEQUALIS CENTERED","SUP-ITM-10083827","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3050.65","62.9","","3408.87","2784.05","9859.40","46","564.06","3753.9","percent of total billed charges",""
"SHOULDER IMPLANT 25X36MM SPHERE GLENOID AEQUALIS CENTERED","SUP-ITM-10083827","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3753.90","77.4","","5214.50","5214.50","16415.28","1 through 10","564.06","3753.9","percent of total billed charges",""
"SHOULDER IMPLANT 38MM GLENOID GLENOSPHERE EXPANDED LATERAL OFFSET PLUS 4","SUP-ITM-10195071","CDM","C1776","HCPCS","0278","RC","","","","both","","","7798.80","4679.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","907","6628.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER IMPLANT 38MM GLENOID GLENOSPHERE EXPANDED LATERAL OFFSET PLUS 4","SUP-ITM-10195071","CDM","C1776","HCPCS","0278","RC","","","","both","","","7798.80","4679.28","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4437.52","56.9","","2911.53","1863.86","5209.05","65","907","6628.98","percent of total billed charges",""
"SHOULDER IMPLANT 38MM GLENOID GLENOSPHERE EXPANDED LATERAL OFFSET PLUS 4","SUP-ITM-10195071","CDM","C1776","HCPCS","0278","RC","","","","both","","","7798.80","4679.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","907.00","11.63","","400.94","400.94","400.94","1 through 10","907","6628.98","percent of total billed charges",""
"SHOULDER IMPLANT 38MM GLENOID GLENOSPHERE EXPANDED LATERAL OFFSET PLUS 4","SUP-ITM-10195071","CDM","C1776","HCPCS","0278","RC","","","","both","","","7798.80","4679.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6036.27","77.4","","5214.50","5214.50","16415.28","1 through 10","907","6628.98","percent of total billed charges",""
"SHOULDER IMPLANT 38MM GLENOID GLENOSPHERE EXPANDED LATERAL OFFSET PLUS 4","SUP-ITM-10195071","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7798.80","4679.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","907.00","11.63","","400.94","400.94","400.94","1 through 10","907","6036.27","percent of total billed charges",""
"SHOULDER IMPLANT 38MM GLENOID GLENOSPHERE EXPANDED LATERAL OFFSET PLUS 4","SUP-ITM-10195071","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7798.80","4679.28","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3409.64","43.72","","1543.33","1543.33","1671.61","1 through 10","907","6036.27","percent of total billed charges",""
"SHOULDER IMPLANT 38MM GLENOID GLENOSPHERE EXPANDED LATERAL OFFSET PLUS 4","SUP-ITM-10195071","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7798.80","4679.28","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5671.29","72.72","","3700.21","2382.07","6427.18","53","907","6036.27","percent of total billed charges",""
"SHOULDER IMPLANT 38MM GLENOID GLENOSPHERE EXPANDED LATERAL OFFSET PLUS 4","SUP-ITM-10195071","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7798.80","4679.28","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5671.29","72.72","","12685.80","12685.80","12685.80","1 through 10","907","6036.27","percent of total billed charges",""
"SHOULDER IMPLANT 38MM GLENOID GLENOSPHERE EXPANDED LATERAL OFFSET PLUS 4","SUP-ITM-10195071","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7798.80","4679.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4905.45","62.9","","3408.87","2784.05","9859.40","46","907","6036.27","percent of total billed charges",""
"SHOULDER IMPLANT 38MM GLENOID GLENOSPHERE EXPANDED LATERAL OFFSET PLUS 4","SUP-ITM-10195071","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7798.80","4679.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6036.27","77.4","","5214.50","5214.50","16415.28","1 through 10","907","6036.27","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","482.18","3524.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2359.07","56.9","","2911.53","1863.86","5209.05","65","482.18","3524.1","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","482.18","11.63","","400.94","400.94","400.94","1 through 10","482.18","3524.1","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","4146.00","2487.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3209.00","77.4","","5214.50","5214.50","16415.28","1 through 10","482.18","3524.1","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","482.18","11.63","","400.94","400.94","400.94","1 through 10","482.18","3209","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1812.63","43.72","","1543.33","1543.33","1671.61","1 through 10","482.18","3209","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3014.97","72.72","","3700.21","2382.07","6427.18","53","482.18","3209","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3014.97","72.72","","12685.80","12685.80","12685.80","1 through 10","482.18","3209","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2607.83","62.9","","3408.87","2784.05","9859.40","46","482.18","3209","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4146.00","2487.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3209.00","77.4","","5214.50","5214.50","16415.28","1 through 10","482.18","3209","percent of total billed charges",""
"SHOULDER KIT 11MM 125 46 22 .8G IMPLANT INTERSPACE GENTAMICIN BASE STEM HEAD","SUP-ITM-10049199","CDM","C1776","HCPCS","0278","RC","","","","both","","","16280.19","9768.11","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1893.39","13838.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER KIT 11MM 125 46 22 .8G IMPLANT INTERSPACE GENTAMICIN BASE STEM HEAD","SUP-ITM-10049199","CDM","C1776","HCPCS","0278","RC","","","","both","","","16280.19","9768.11","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","9263.43","56.9","","2911.53","1863.86","5209.05","65","1893.39","13838.16","percent of total billed charges",""
"SHOULDER KIT 11MM 125 46 22 .8G IMPLANT INTERSPACE GENTAMICIN BASE STEM HEAD","SUP-ITM-10049199","CDM","C1776","HCPCS","0278","RC","","","","both","","","16280.19","9768.11","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1893.39","11.63","","400.94","400.94","400.94","1 through 10","1893.39","13838.16","percent of total billed charges",""
"SHOULDER KIT 11MM 125 46 22 .8G IMPLANT INTERSPACE GENTAMICIN BASE STEM HEAD","SUP-ITM-10049199","CDM","C1776","HCPCS","0278","RC","","","","both","","","16280.19","9768.11","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12600.87","77.4","","5214.50","5214.50","16415.28","1 through 10","1893.39","13838.16","percent of total billed charges",""
"SHOULDER KIT 11MM 125 46 22 .8G IMPLANT INTERSPACE GENTAMICIN BASE STEM HEAD","SUP-ITM-10049199","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16280.19","9768.11","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1893.39","11.63","","400.94","400.94","400.94","1 through 10","1893.39","12600.87","percent of total billed charges",""
"SHOULDER KIT 11MM 125 46 22 .8G IMPLANT INTERSPACE GENTAMICIN BASE STEM HEAD","SUP-ITM-10049199","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16280.19","9768.11","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","7117.70","43.72","","1543.33","1543.33","1671.61","1 through 10","1893.39","12600.87","percent of total billed charges",""
"SHOULDER KIT 11MM 125 46 22 .8G IMPLANT INTERSPACE GENTAMICIN BASE STEM HEAD","SUP-ITM-10049199","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16280.19","9768.11","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","11838.95","72.72","","3700.21","2382.07","6427.18","53","1893.39","12600.87","percent of total billed charges",""
"SHOULDER KIT 11MM 125 46 22 .8G IMPLANT INTERSPACE GENTAMICIN BASE STEM HEAD","SUP-ITM-10049199","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16280.19","9768.11","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","11838.95","72.72","","12685.80","12685.80","12685.80","1 through 10","1893.39","12600.87","percent of total billed charges",""
"SHOULDER KIT 11MM 125 46 22 .8G IMPLANT INTERSPACE GENTAMICIN BASE STEM HEAD","SUP-ITM-10049199","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16280.19","9768.11","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","10240.24","62.9","","3408.87","2784.05","9859.40","46","1893.39","12600.87","percent of total billed charges",""
"SHOULDER KIT 11MM 125 46 22 .8G IMPLANT INTERSPACE GENTAMICIN BASE STEM HEAD","SUP-ITM-10049199","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16280.19","9768.11","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12600.87","77.4","","5214.50","5214.50","16415.28","1 through 10","1893.39","12600.87","percent of total billed charges",""
"SHOULDER KIT 41MM SMALL CEMENT SPACER CEMEX INTERSPACE","SUP-ITM-10173792","CDM","C1776","HCPCS","0278","RC","","","","both","","","16280.19","9768.11","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1893.39","13838.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER KIT 41MM SMALL CEMENT SPACER CEMEX INTERSPACE","SUP-ITM-10173792","CDM","C1776","HCPCS","0278","RC","","","","both","","","16280.19","9768.11","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","9263.43","56.9","","2911.53","1863.86","5209.05","65","1893.39","13838.16","percent of total billed charges",""
"SHOULDER KIT 41MM SMALL CEMENT SPACER CEMEX INTERSPACE","SUP-ITM-10173792","CDM","C1776","HCPCS","0278","RC","","","","both","","","16280.19","9768.11","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1893.39","11.63","","400.94","400.94","400.94","1 through 10","1893.39","13838.16","percent of total billed charges",""
"SHOULDER KIT 41MM SMALL CEMENT SPACER CEMEX INTERSPACE","SUP-ITM-10173792","CDM","C1776","HCPCS","0278","RC","","","","both","","","16280.19","9768.11","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12600.87","77.4","","5214.50","5214.50","16415.28","1 through 10","1893.39","13838.16","percent of total billed charges",""
"SHOULDER KIT 41MM SMALL CEMENT SPACER CEMEX INTERSPACE","SUP-ITM-10173792","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16280.19","9768.11","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1893.39","11.63","","400.94","400.94","400.94","1 through 10","1893.39","12600.87","percent of total billed charges",""
"SHOULDER KIT 41MM SMALL CEMENT SPACER CEMEX INTERSPACE","SUP-ITM-10173792","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16280.19","9768.11","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","7117.70","43.72","","1543.33","1543.33","1671.61","1 through 10","1893.39","12600.87","percent of total billed charges",""
"SHOULDER KIT 41MM SMALL CEMENT SPACER CEMEX INTERSPACE","SUP-ITM-10173792","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16280.19","9768.11","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","11838.95","72.72","","3700.21","2382.07","6427.18","53","1893.39","12600.87","percent of total billed charges",""
"SHOULDER KIT 41MM SMALL CEMENT SPACER CEMEX INTERSPACE","SUP-ITM-10173792","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16280.19","9768.11","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","11838.95","72.72","","12685.80","12685.80","12685.80","1 through 10","1893.39","12600.87","percent of total billed charges",""
"SHOULDER KIT 41MM SMALL CEMENT SPACER CEMEX INTERSPACE","SUP-ITM-10173792","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16280.19","9768.11","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","10240.24","62.9","","3408.87","2784.05","9859.40","46","1893.39","12600.87","percent of total billed charges",""
"SHOULDER KIT 41MM SMALL CEMENT SPACER CEMEX INTERSPACE","SUP-ITM-10173792","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16280.19","9768.11","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12600.87","77.4","","5214.50","5214.50","16415.28","1 through 10","1893.39","12600.87","percent of total billed charges",""
"SHOULDER LINER 40MM 6 65DEG TRABECULAR METAL REVERSE RETENTIVE","SUP-ITM-10199792","CDM","C1776","HCPCS","0278","RC","","","","both","","","5412.60","3247.56","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","629.49","4600.71","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER LINER 40MM 6 65DEG TRABECULAR METAL REVERSE RETENTIVE","SUP-ITM-10199792","CDM","C1776","HCPCS","0278","RC","","","","both","","","5412.60","3247.56","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3079.77","56.9","","2911.53","1863.86","5209.05","65","629.49","4600.71","percent of total billed charges",""
"SHOULDER LINER 40MM 6 65DEG TRABECULAR METAL REVERSE RETENTIVE","SUP-ITM-10199792","CDM","C1776","HCPCS","0278","RC","","","","both","","","5412.60","3247.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","629.49","11.63","","400.94","400.94","400.94","1 through 10","629.49","4600.71","percent of total billed charges",""
"SHOULDER LINER 40MM 6 65DEG TRABECULAR METAL REVERSE RETENTIVE","SUP-ITM-10199792","CDM","C1776","HCPCS","0278","RC","","","","both","","","5412.60","3247.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4189.35","77.4","","5214.50","5214.50","16415.28","1 through 10","629.49","4600.71","percent of total billed charges",""
"SHOULDER LINER 40MM 6 65DEG TRABECULAR METAL REVERSE RETENTIVE","SUP-ITM-10199792","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5412.60","3247.56","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","629.49","11.63","","400.94","400.94","400.94","1 through 10","629.49","4189.35","percent of total billed charges",""
"SHOULDER LINER 40MM 6 65DEG TRABECULAR METAL REVERSE RETENTIVE","SUP-ITM-10199792","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5412.60","3247.56","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2366.39","43.72","","1543.33","1543.33","1671.61","1 through 10","629.49","4189.35","percent of total billed charges",""
"SHOULDER LINER 40MM 6 65DEG TRABECULAR METAL REVERSE RETENTIVE","SUP-ITM-10199792","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5412.60","3247.56","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3936.04","72.72","","3700.21","2382.07","6427.18","53","629.49","4189.35","percent of total billed charges",""
"SHOULDER LINER 40MM 6 65DEG TRABECULAR METAL REVERSE RETENTIVE","SUP-ITM-10199792","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5412.60","3247.56","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3936.04","72.72","","12685.80","12685.80","12685.80","1 through 10","629.49","4189.35","percent of total billed charges",""
"SHOULDER LINER 40MM 6 65DEG TRABECULAR METAL REVERSE RETENTIVE","SUP-ITM-10199792","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5412.60","3247.56","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3404.53","62.9","","3408.87","2784.05","9859.40","46","629.49","4189.35","percent of total billed charges",""
"SHOULDER LINER 40MM 6 65DEG TRABECULAR METAL REVERSE RETENTIVE","SUP-ITM-10199792","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5412.60","3247.56","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4189.35","77.4","","5214.50","5214.50","16415.28","1 through 10","629.49","4189.35","percent of total billed charges",""
"SHOULDER LINER 42MM EQUINOXE REVERSE HUMERAL","SUP-ITM-10321179","CDM","C1776","HCPCS","0278","RC","","","","both","","","5154.86","3092.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","599.51","4381.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER LINER 42MM EQUINOXE REVERSE HUMERAL","SUP-ITM-10321179","CDM","C1776","HCPCS","0278","RC","","","","both","","","5154.86","3092.92","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2933.12","56.9","","2911.53","1863.86","5209.05","65","599.51","4381.63","percent of total billed charges",""
"SHOULDER LINER 42MM EQUINOXE REVERSE HUMERAL","SUP-ITM-10321179","CDM","C1776","HCPCS","0278","RC","","","","both","","","5154.86","3092.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","599.51","11.63","","400.94","400.94","400.94","1 through 10","599.51","4381.63","percent of total billed charges",""
"SHOULDER LINER 42MM EQUINOXE REVERSE HUMERAL","SUP-ITM-10321179","CDM","C1776","HCPCS","0278","RC","","","","both","","","5154.86","3092.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3989.86","77.4","","5214.50","5214.50","16415.28","1 through 10","599.51","4381.63","percent of total billed charges",""
"SHOULDER LINER 42MM EQUINOXE REVERSE HUMERAL","SUP-ITM-10321179","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5154.86","3092.92","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","599.51","11.63","","400.94","400.94","400.94","1 through 10","599.51","3989.86","percent of total billed charges",""
"SHOULDER LINER 42MM EQUINOXE REVERSE HUMERAL","SUP-ITM-10321179","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5154.86","3092.92","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2253.70","43.72","","1543.33","1543.33","1671.61","1 through 10","599.51","3989.86","percent of total billed charges",""
"SHOULDER LINER 42MM EQUINOXE REVERSE HUMERAL","SUP-ITM-10321179","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5154.86","3092.92","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3748.61","72.72","","3700.21","2382.07","6427.18","53","599.51","3989.86","percent of total billed charges",""
"SHOULDER LINER 42MM EQUINOXE REVERSE HUMERAL","SUP-ITM-10321179","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5154.86","3092.92","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3748.61","72.72","","12685.80","12685.80","12685.80","1 through 10","599.51","3989.86","percent of total billed charges",""
"SHOULDER LINER 42MM EQUINOXE REVERSE HUMERAL","SUP-ITM-10321179","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5154.86","3092.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3242.41","62.9","","3408.87","2784.05","9859.40","46","599.51","3989.86","percent of total billed charges",""
"SHOULDER LINER 42MM EQUINOXE REVERSE HUMERAL","SUP-ITM-10321179","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5154.86","3092.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3989.86","77.4","","5214.50","5214.50","16415.28","1 through 10","599.51","3989.86","percent of total billed charges",""
"SHOULDER PLATE 1.5MM ANATOMIC EQUINOXE REPLICATOR","SUP-ITM-10195029","CDM","C1776","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","562.54","4111.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER PLATE 1.5MM ANATOMIC EQUINOXE REPLICATOR","SUP-ITM-10195029","CDM","C1776","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2752.25","56.9","","2911.53","1863.86","5209.05","65","562.54","4111.45","percent of total billed charges",""
"SHOULDER PLATE 1.5MM ANATOMIC EQUINOXE REPLICATOR","SUP-ITM-10195029","CDM","C1776","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","562.54","11.63","","400.94","400.94","400.94","1 through 10","562.54","4111.45","percent of total billed charges",""
"SHOULDER PLATE 1.5MM ANATOMIC EQUINOXE REPLICATOR","SUP-ITM-10195029","CDM","C1776","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3743.84","77.4","","5214.50","5214.50","16415.28","1 through 10","562.54","4111.45","percent of total billed charges",""
"SHOULDER PLATE 1.5MM ANATOMIC EQUINOXE REPLICATOR","SUP-ITM-10195029","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","562.54","11.63","","400.94","400.94","400.94","1 through 10","562.54","3743.84","percent of total billed charges",""
"SHOULDER PLATE 1.5MM ANATOMIC EQUINOXE REPLICATOR","SUP-ITM-10195029","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2114.74","43.72","","1543.33","1543.33","1671.61","1 through 10","562.54","3743.84","percent of total billed charges",""
"SHOULDER PLATE 1.5MM ANATOMIC EQUINOXE REPLICATOR","SUP-ITM-10195029","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3517.47","72.72","","3700.21","2382.07","6427.18","53","562.54","3743.84","percent of total billed charges",""
"SHOULDER PLATE 1.5MM ANATOMIC EQUINOXE REPLICATOR","SUP-ITM-10195029","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3517.47","72.72","","12685.80","12685.80","12685.80","1 through 10","562.54","3743.84","percent of total billed charges",""
"SHOULDER PLATE 1.5MM ANATOMIC EQUINOXE REPLICATOR","SUP-ITM-10195029","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3042.47","62.9","","3408.87","2784.05","9859.40","46","562.54","3743.84","percent of total billed charges",""
"SHOULDER PLATE 1.5MM ANATOMIC EQUINOXE REPLICATOR","SUP-ITM-10195029","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3743.84","77.4","","5214.50","5214.50","16415.28","1 through 10","562.54","3743.84","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","6018.03","3610.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","699.9","5115.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","6018.03","3610.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","699.9","5115.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","6018.03","3610.82","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3424.26","56.9","","812.12","238.65","1587.46","163","699.9","5115.33","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","6018.03","3610.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","699.90","11.63","","112.68","112.68","146.99","38","699.9","5115.33","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","6018.03","3610.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4657.96","77.4","","303.98","303.98","5854.79","1 through 10","699.9","5115.33","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6018.03","3610.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","699.90","11.63","","112.68","112.68","146.99","38","699.9","4657.96","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6018.03","3610.82","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3778.12","62.78","","780.86","208.94","10480.28","15","699.9","4657.96","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6018.03","3610.82","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2631.08","43.72","","179.76","179.76","179.76","1 through 10","699.9","4657.96","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6018.03","3610.82","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4376.31","72.72","","2355.45","298.99","3965.19","155","699.9","4657.96","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6018.03","3610.82","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4376.31","72.72","","3643.09","3643.09","3643.09","1 through 10","699.9","4657.96","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6018.03","3610.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3202.80","53.22","","554.28","554.28","554.28","16","699.9","4657.96","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6018.03","3610.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3785.34","62.9","","619.64","173.09","2370.64","150","699.9","4657.96","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6018.03","3610.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4657.96","77.4","","303.98","303.98","5854.79","1 through 10","699.9","4657.96","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","6685.87","4011.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","777.57","5682.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","6685.87","4011.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","777.57","5682.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","6685.87","4011.52","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3804.26","56.9","","812.12","238.65","1587.46","163","777.57","5682.99","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","6685.87","4011.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","777.57","11.63","","112.68","112.68","146.99","38","777.57","5682.99","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","6685.87","4011.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5174.86","77.4","","303.98","303.98","5854.79","1 through 10","777.57","5682.99","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6685.87","4011.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","777.57","11.63","","112.68","112.68","146.99","38","777.57","5174.86","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6685.87","4011.52","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4197.39","62.78","","780.86","208.94","10480.28","15","777.57","5174.86","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6685.87","4011.52","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2923.06","43.72","","179.76","179.76","179.76","1 through 10","777.57","5174.86","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6685.87","4011.52","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4861.96","72.72","","2355.45","298.99","3965.19","155","777.57","5174.86","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6685.87","4011.52","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4861.96","72.72","","3643.09","3643.09","3643.09","1 through 10","777.57","5174.86","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6685.87","4011.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3558.22","53.22","","554.28","554.28","554.28","16","777.57","5174.86","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6685.87","4011.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4205.41","62.9","","619.64","173.09","2370.64","150","777.57","5174.86","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6685.87","4011.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5174.86","77.4","","303.98","303.98","5854.79","1 through 10","777.57","5174.86","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","6923.33","4154.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","805.18","5884.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","6923.33","4154.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","805.18","5884.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","6923.33","4154.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3939.37","56.9","","812.12","238.65","1587.46","163","805.18","5884.83","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","6923.33","4154.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","805.18","11.63","","112.68","112.68","146.99","38","805.18","5884.83","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","6923.33","4154.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5358.66","77.4","","303.98","303.98","5854.79","1 through 10","805.18","5884.83","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6923.33","4154.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","805.18","11.63","","112.68","112.68","146.99","38","805.18","5358.66","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6923.33","4154.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4346.47","62.78","","780.86","208.94","10480.28","15","805.18","5358.66","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6923.33","4154.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3026.88","43.72","","179.76","179.76","179.76","1 through 10","805.18","5358.66","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6923.33","4154.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5034.65","72.72","","2355.45","298.99","3965.19","155","805.18","5358.66","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6923.33","4154.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5034.65","72.72","","3643.09","3643.09","3643.09","1 through 10","805.18","5358.66","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6923.33","4154.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3684.60","53.22","","554.28","554.28","554.28","16","805.18","5358.66","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6923.33","4154.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4354.77","62.9","","619.64","173.09","2370.64","150","805.18","5358.66","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6923.33","4154.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5358.66","77.4","","303.98","303.98","5854.79","1 through 10","805.18","5358.66","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","8231.47","4938.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","957.32","6996.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","8231.47","4938.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","957.32","6996.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","8231.47","4938.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4683.71","56.9","","812.12","238.65","1587.46","163","957.32","6996.75","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","8231.47","4938.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","957.32","11.63","","112.68","112.68","146.99","38","957.32","6996.75","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","8231.47","4938.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6371.16","77.4","","303.98","303.98","5854.79","1 through 10","957.32","6996.75","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8231.47","4938.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","957.32","11.63","","112.68","112.68","146.99","38","957.32","6371.16","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8231.47","4938.88","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5167.72","62.78","","780.86","208.94","10480.28","15","957.32","6371.16","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8231.47","4938.88","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3598.80","43.72","","179.76","179.76","179.76","1 through 10","957.32","6371.16","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8231.47","4938.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5985.92","72.72","","2355.45","298.99","3965.19","155","957.32","6371.16","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8231.47","4938.88","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5985.92","72.72","","3643.09","3643.09","3643.09","1 through 10","957.32","6371.16","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8231.47","4938.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4380.79","53.22","","554.28","554.28","554.28","16","957.32","6371.16","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8231.47","4938.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5177.59","62.9","","619.64","173.09","2370.64","150","957.32","6371.16","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8231.47","4938.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6371.16","77.4","","303.98","303.98","5854.79","1 through 10","957.32","6371.16","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","both","","","6178.80","3707.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","718.59","5251.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","both","","","6178.80","3707.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","718.59","5251.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","both","","","6178.80","3707.28","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3515.74","56.9","","812.12","238.65","1587.46","163","718.59","5251.98","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","both","","","6178.80","3707.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","718.59","11.63","","112.68","112.68","146.99","38","718.59","5251.98","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","both","","","6178.80","3707.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4782.39","77.4","","303.98","303.98","5854.79","1 through 10","718.59","5251.98","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6178.80","3707.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","718.59","11.63","","112.68","112.68","146.99","38","718.59","4782.39","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6178.80","3707.28","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3879.05","62.78","","780.86","208.94","10480.28","15","718.59","4782.39","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6178.80","3707.28","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2701.37","43.72","","179.76","179.76","179.76","1 through 10","718.59","4782.39","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6178.80","3707.28","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4493.22","72.72","","2355.45","298.99","3965.19","155","718.59","4782.39","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6178.80","3707.28","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4493.22","72.72","","3643.09","3643.09","3643.09","1 through 10","718.59","4782.39","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6178.80","3707.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3288.36","53.22","","554.28","554.28","554.28","16","718.59","4782.39","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6178.80","3707.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3886.47","62.9","","619.64","173.09","2370.64","150","718.59","4782.39","percent of total billed charges",""
"SHOULDER PLATE 3.5X142MM LONG 5 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10019902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6178.80","3707.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4782.39","77.4","","303.98","303.98","5854.79","1 through 10","718.59","4782.39","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","6697.85","4018.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","778.96","5693.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","6697.85","4018.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","778.96","5693.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","6697.85","4018.71","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3811.08","56.9","","812.12","238.65","1587.46","163","778.96","5693.17","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","6697.85","4018.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","778.96","11.63","","112.68","112.68","146.99","38","778.96","5693.17","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","6697.85","4018.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5184.14","77.4","","303.98","303.98","5854.79","1 through 10","778.96","5693.17","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6697.85","4018.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","778.96","11.63","","112.68","112.68","146.99","38","778.96","5184.14","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6697.85","4018.71","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4204.91","62.78","","780.86","208.94","10480.28","15","778.96","5184.14","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6697.85","4018.71","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2928.30","43.72","","179.76","179.76","179.76","1 through 10","778.96","5184.14","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6697.85","4018.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4870.68","72.72","","2355.45","298.99","3965.19","155","778.96","5184.14","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6697.85","4018.71","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4870.68","72.72","","3643.09","3643.09","3643.09","1 through 10","778.96","5184.14","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6697.85","4018.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3564.60","53.22","","554.28","554.28","554.28","16","778.96","5184.14","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6697.85","4018.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4212.95","62.9","","619.64","173.09","2370.64","150","778.96","5184.14","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6697.85","4018.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5184.14","77.4","","303.98","303.98","5854.79","1 through 10","778.96","5184.14","percent of total billed charges",""
"SHOULDER PLATE 8DEG LEFT GLENOID AUGMENT POSTERIOR SM REVERSE EQUINOXE","SUP-ITM-10282064","CDM","C1776","HCPCS","0278","RC","","","","both","","","8637.85","5182.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1004.58","7342.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER PLATE 8DEG LEFT GLENOID AUGMENT POSTERIOR SM REVERSE EQUINOXE","SUP-ITM-10282064","CDM","C1776","HCPCS","0278","RC","","","","both","","","8637.85","5182.71","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4914.94","56.9","","2911.53","1863.86","5209.05","65","1004.58","7342.17","percent of total billed charges",""
"SHOULDER PLATE 8DEG LEFT GLENOID AUGMENT POSTERIOR SM REVERSE EQUINOXE","SUP-ITM-10282064","CDM","C1776","HCPCS","0278","RC","","","","both","","","8637.85","5182.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1004.58","11.63","","400.94","400.94","400.94","1 through 10","1004.58","7342.17","percent of total billed charges",""
"SHOULDER PLATE 8DEG LEFT GLENOID AUGMENT POSTERIOR SM REVERSE EQUINOXE","SUP-ITM-10282064","CDM","C1776","HCPCS","0278","RC","","","","both","","","8637.85","5182.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6685.70","77.4","","5214.50","5214.50","16415.28","1 through 10","1004.58","7342.17","percent of total billed charges",""
"SHOULDER PLATE 8DEG LEFT GLENOID AUGMENT POSTERIOR SM REVERSE EQUINOXE","SUP-ITM-10282064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1004.58","11.63","","400.94","400.94","400.94","1 through 10","1004.58","6685.7","percent of total billed charges",""
"SHOULDER PLATE 8DEG LEFT GLENOID AUGMENT POSTERIOR SM REVERSE EQUINOXE","SUP-ITM-10282064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3776.47","43.72","","1543.33","1543.33","1671.61","1 through 10","1004.58","6685.7","percent of total billed charges",""
"SHOULDER PLATE 8DEG LEFT GLENOID AUGMENT POSTERIOR SM REVERSE EQUINOXE","SUP-ITM-10282064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6281.44","72.72","","3700.21","2382.07","6427.18","53","1004.58","6685.7","percent of total billed charges",""
"SHOULDER PLATE 8DEG LEFT GLENOID AUGMENT POSTERIOR SM REVERSE EQUINOXE","SUP-ITM-10282064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6281.44","72.72","","12685.80","12685.80","12685.80","1 through 10","1004.58","6685.7","percent of total billed charges",""
"SHOULDER PLATE 8DEG LEFT GLENOID AUGMENT POSTERIOR SM REVERSE EQUINOXE","SUP-ITM-10282064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5433.21","62.9","","3408.87","2784.05","9859.40","46","1004.58","6685.7","percent of total billed charges",""
"SHOULDER PLATE 8DEG LEFT GLENOID AUGMENT POSTERIOR SM REVERSE EQUINOXE","SUP-ITM-10282064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6685.70","77.4","","5214.50","5214.50","16415.28","1 through 10","1004.58","6685.7","percent of total billed charges",""
"SHOULDER PLATE SM GLENOID REVERSE SUPERIOR AUGMENT","SUP-ITM-10283177","CDM","C1776","HCPCS","0278","RC","","","","both","","","8637.85","5182.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1004.58","7342.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER PLATE SM GLENOID REVERSE SUPERIOR AUGMENT","SUP-ITM-10283177","CDM","C1776","HCPCS","0278","RC","","","","both","","","8637.85","5182.71","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4914.94","56.9","","2911.53","1863.86","5209.05","65","1004.58","7342.17","percent of total billed charges",""
"SHOULDER PLATE SM GLENOID REVERSE SUPERIOR AUGMENT","SUP-ITM-10283177","CDM","C1776","HCPCS","0278","RC","","","","both","","","8637.85","5182.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1004.58","11.63","","400.94","400.94","400.94","1 through 10","1004.58","7342.17","percent of total billed charges",""
"SHOULDER PLATE SM GLENOID REVERSE SUPERIOR AUGMENT","SUP-ITM-10283177","CDM","C1776","HCPCS","0278","RC","","","","both","","","8637.85","5182.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6685.70","77.4","","5214.50","5214.50","16415.28","1 through 10","1004.58","7342.17","percent of total billed charges",""
"SHOULDER PLATE SM GLENOID REVERSE SUPERIOR AUGMENT","SUP-ITM-10283177","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1004.58","11.63","","400.94","400.94","400.94","1 through 10","1004.58","6685.7","percent of total billed charges",""
"SHOULDER PLATE SM GLENOID REVERSE SUPERIOR AUGMENT","SUP-ITM-10283177","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3776.47","43.72","","1543.33","1543.33","1671.61","1 through 10","1004.58","6685.7","percent of total billed charges",""
"SHOULDER PLATE SM GLENOID REVERSE SUPERIOR AUGMENT","SUP-ITM-10283177","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6281.44","72.72","","3700.21","2382.07","6427.18","53","1004.58","6685.7","percent of total billed charges",""
"SHOULDER PLATE SM GLENOID REVERSE SUPERIOR AUGMENT","SUP-ITM-10283177","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6281.44","72.72","","12685.80","12685.80","12685.80","1 through 10","1004.58","6685.7","percent of total billed charges",""
"SHOULDER PLATE SM GLENOID REVERSE SUPERIOR AUGMENT","SUP-ITM-10283177","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5433.21","62.9","","3408.87","2784.05","9859.40","46","1004.58","6685.7","percent of total billed charges",""
"SHOULDER PLATE SM GLENOID REVERSE SUPERIOR AUGMENT","SUP-ITM-10283177","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8637.85","5182.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6685.70","77.4","","5214.50","5214.50","16415.28","1 through 10","1004.58","6685.7","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","564.06","4122.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2759.65","56.9","","2911.53","1863.86","5209.05","65","564.06","4122.5","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.06","11.63","","400.94","400.94","400.94","1 through 10","564.06","4122.5","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3753.90","77.4","","5214.50","5214.50","16415.28","1 through 10","564.06","4122.5","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.06","11.63","","400.94","400.94","400.94","1 through 10","564.06","3753.9","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2120.42","43.72","","1543.33","1543.33","1671.61","1 through 10","564.06","3753.9","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3526.92","72.72","","3700.21","2382.07","6427.18","53","564.06","3753.9","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3526.92","72.72","","12685.80","12685.80","12685.80","1 through 10","564.06","3753.9","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3050.65","62.9","","3408.87","2784.05","9859.40","46","564.06","3753.9","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3753.90","77.4","","5214.50","5214.50","16415.28","1 through 10","564.06","3753.9","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","both","","","6391.75","3835.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","743.36","5432.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","both","","","6391.75","3835.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","743.36","5432.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","both","","","6391.75","3835.05","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3636.91","56.9","","812.12","238.65","1587.46","163","743.36","5432.99","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","both","","","6391.75","3835.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","743.36","11.63","","112.68","112.68","146.99","38","743.36","5432.99","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","both","","","6391.75","3835.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4947.21","77.4","","303.98","303.98","5854.79","1 through 10","743.36","5432.99","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6391.75","3835.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","743.36","11.63","","112.68","112.68","146.99","38","743.36","4947.21","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6391.75","3835.05","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4012.74","62.78","","780.86","208.94","10480.28","15","743.36","4947.21","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6391.75","3835.05","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2794.47","43.72","","179.76","179.76","179.76","1 through 10","743.36","4947.21","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6391.75","3835.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4648.08","72.72","","2355.45","298.99","3965.19","155","743.36","4947.21","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6391.75","3835.05","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4648.08","72.72","","3643.09","3643.09","3643.09","1 through 10","743.36","4947.21","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6391.75","3835.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3401.69","53.22","","554.28","554.28","554.28","16","743.36","4947.21","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6391.75","3835.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4020.41","62.9","","619.64","173.09","2370.64","150","743.36","4947.21","percent of total billed charges",""
"SHOULDER POST 29MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS TITANIUM CENTER REVERSED PEG","SUP-ITM-10019894","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6391.75","3835.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4947.21","77.4","","303.98","303.98","5854.79","1 through 10","743.36","4947.21","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","564.06","4122.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2759.65","56.9","","2911.53","1863.86","5209.05","65","564.06","4122.5","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.06","11.63","","400.94","400.94","400.94","1 through 10","564.06","4122.5","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","2910.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3753.90","77.4","","5214.50","5214.50","16415.28","1 through 10","564.06","4122.5","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","564.06","11.63","","400.94","400.94","400.94","1 through 10","564.06","3753.9","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2120.42","43.72","","1543.33","1543.33","1671.61","1 through 10","564.06","3753.9","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3526.92","72.72","","3700.21","2382.07","6427.18","53","564.06","3753.9","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3526.92","72.72","","12685.80","12685.80","12685.80","1 through 10","564.06","3753.9","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3050.65","62.9","","3408.87","2784.05","9859.40","46","564.06","3753.9","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","2910.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3753.90","77.4","","5214.50","5214.50","16415.28","1 through 10","564.06","3753.9","percent of total billed charges",""
"SHOULDER STEM 11MMX130 IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10188568","CDM","C1776","HCPCS","0278","RC","","","","both","","","21411.00","12846.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","2490.1","18199.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER STEM 11MMX130 IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10188568","CDM","C1776","HCPCS","0278","RC","","","","both","","","21411.00","12846.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","12182.86","56.9","","2911.53","1863.86","5209.05","65","2490.1","18199.35","percent of total billed charges",""
"SHOULDER STEM 11MMX130 IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10188568","CDM","C1776","HCPCS","0278","RC","","","","both","","","21411.00","12846.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2490.10","11.63","","400.94","400.94","400.94","1 through 10","2490.1","18199.35","percent of total billed charges",""
"SHOULDER STEM 11MMX130 IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10188568","CDM","C1776","HCPCS","0278","RC","","","","both","","","21411.00","12846.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","16572.11","77.4","","5214.50","5214.50","16415.28","1 through 10","2490.1","18199.35","percent of total billed charges",""
"SHOULDER STEM 11MMX130 IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10188568","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","21411.00","12846.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2490.10","11.63","","400.94","400.94","400.94","1 through 10","2490.1","16572.11","percent of total billed charges",""
"SHOULDER STEM 11MMX130 IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10188568","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","21411.00","12846.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","9360.89","43.72","","1543.33","1543.33","1671.61","1 through 10","2490.1","16572.11","percent of total billed charges",""
"SHOULDER STEM 11MMX130 IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10188568","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","21411.00","12846.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","15570.08","72.72","","3700.21","2382.07","6427.18","53","2490.1","16572.11","percent of total billed charges",""
"SHOULDER STEM 11MMX130 IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10188568","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","21411.00","12846.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","15570.08","72.72","","12685.80","12685.80","12685.80","1 through 10","2490.1","16572.11","percent of total billed charges",""
"SHOULDER STEM 11MMX130 IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10188568","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","21411.00","12846.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","13467.52","62.9","","3408.87","2784.05","9859.40","46","2490.1","16572.11","percent of total billed charges",""
"SHOULDER STEM 11MMX130 IMPLANT REVERSE FRACTURE HUM","SUP-ITM-10188568","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","21411.00","12846.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","16572.11","77.4","","5214.50","5214.50","16415.28","1 through 10","2490.1","16572.11","percent of total billed charges",""
"SHOULDER STEM 13MM PRIMARY STD COMPR REVERSE 01","SUP-ITM-10113711","CDM","C1776","HCPCS","0278","RC","","","","both","","","10435.32","6261.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1213.63","8870.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER STEM 13MM PRIMARY STD COMPR REVERSE 01","SUP-ITM-10113711","CDM","C1776","HCPCS","0278","RC","","","","both","","","10435.32","6261.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5937.70","56.9","","2911.53","1863.86","5209.05","65","1213.63","8870.02","percent of total billed charges",""
"SHOULDER STEM 13MM PRIMARY STD COMPR REVERSE 01","SUP-ITM-10113711","CDM","C1776","HCPCS","0278","RC","","","","both","","","10435.32","6261.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1213.63","11.63","","400.94","400.94","400.94","1 through 10","1213.63","8870.02","percent of total billed charges",""
"SHOULDER STEM 13MM PRIMARY STD COMPR REVERSE 01","SUP-ITM-10113711","CDM","C1776","HCPCS","0278","RC","","","","both","","","10435.32","6261.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8076.94","77.4","","5214.50","5214.50","16415.28","1 through 10","1213.63","8870.02","percent of total billed charges",""
"SHOULDER STEM 13MM PRIMARY STD COMPR REVERSE 01","SUP-ITM-10113711","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10435.32","6261.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1213.63","11.63","","400.94","400.94","400.94","1 through 10","1213.63","8076.94","percent of total billed charges",""
"SHOULDER STEM 13MM PRIMARY STD COMPR REVERSE 01","SUP-ITM-10113711","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10435.32","6261.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4562.32","43.72","","1543.33","1543.33","1671.61","1 through 10","1213.63","8076.94","percent of total billed charges",""
"SHOULDER STEM 13MM PRIMARY STD COMPR REVERSE 01","SUP-ITM-10113711","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10435.32","6261.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7588.56","72.72","","3700.21","2382.07","6427.18","53","1213.63","8076.94","percent of total billed charges",""
"SHOULDER STEM 13MM PRIMARY STD COMPR REVERSE 01","SUP-ITM-10113711","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10435.32","6261.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7588.56","72.72","","12685.80","12685.80","12685.80","1 through 10","1213.63","8076.94","percent of total billed charges",""
"SHOULDER STEM 13MM PRIMARY STD COMPR REVERSE 01","SUP-ITM-10113711","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10435.32","6261.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6563.82","62.9","","3408.87","2784.05","9859.40","46","1213.63","8076.94","percent of total billed charges",""
"SHOULDER STEM 13MM PRIMARY STD COMPR REVERSE 01","SUP-ITM-10113711","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10435.32","6261.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8076.94","77.4","","5214.50","5214.50","16415.28","1 through 10","1213.63","8076.94","percent of total billed charges",""
"SHOULDER STEM 14MM SHORT EQUINOXE PRESERVE","SUP-ITM-10195026","CDM","C1776","HCPCS","0278","RC","","","","both","","","11654.55","6992.73","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1355.42","9906.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER STEM 14MM SHORT EQUINOXE PRESERVE","SUP-ITM-10195026","CDM","C1776","HCPCS","0278","RC","","","","both","","","11654.55","6992.73","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6631.44","56.9","","2911.53","1863.86","5209.05","65","1355.42","9906.37","percent of total billed charges",""
"SHOULDER STEM 14MM SHORT EQUINOXE PRESERVE","SUP-ITM-10195026","CDM","C1776","HCPCS","0278","RC","","","","both","","","11654.55","6992.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1355.42","11.63","","400.94","400.94","400.94","1 through 10","1355.42","9906.37","percent of total billed charges",""
"SHOULDER STEM 14MM SHORT EQUINOXE PRESERVE","SUP-ITM-10195026","CDM","C1776","HCPCS","0278","RC","","","","both","","","11654.55","6992.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9020.62","77.4","","5214.50","5214.50","16415.28","1 through 10","1355.42","9906.37","percent of total billed charges",""
"SHOULDER STEM 14MM SHORT EQUINOXE PRESERVE","SUP-ITM-10195026","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11654.55","6992.73","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1355.42","11.63","","400.94","400.94","400.94","1 through 10","1355.42","9020.62","percent of total billed charges",""
"SHOULDER STEM 14MM SHORT EQUINOXE PRESERVE","SUP-ITM-10195026","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11654.55","6992.73","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","5095.37","43.72","","1543.33","1543.33","1671.61","1 through 10","1355.42","9020.62","percent of total billed charges",""
"SHOULDER STEM 14MM SHORT EQUINOXE PRESERVE","SUP-ITM-10195026","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11654.55","6992.73","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8475.19","72.72","","3700.21","2382.07","6427.18","53","1355.42","9020.62","percent of total billed charges",""
"SHOULDER STEM 14MM SHORT EQUINOXE PRESERVE","SUP-ITM-10195026","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11654.55","6992.73","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","8475.19","72.72","","12685.80","12685.80","12685.80","1 through 10","1355.42","9020.62","percent of total billed charges",""
"SHOULDER STEM 14MM SHORT EQUINOXE PRESERVE","SUP-ITM-10195026","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11654.55","6992.73","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7330.71","62.9","","3408.87","2784.05","9859.40","46","1355.42","9020.62","percent of total billed charges",""
"SHOULDER STEM 14MM SHORT EQUINOXE PRESERVE","SUP-ITM-10195026","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11654.55","6992.73","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9020.62","77.4","","5214.50","5214.50","16415.28","1 through 10","1355.42","9020.62","percent of total billed charges",""
"SHOULDER STEM 6.5MM DIAMETERX100 AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10019892","CDM","C1776","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1128.11","8245","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER STEM 6.5MM DIAMETERX100 AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10019892","CDM","C1776","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5519.30","56.9","","2911.53","1863.86","5209.05","65","1128.11","8245","percent of total billed charges",""
"SHOULDER STEM 6.5MM DIAMETERX100 AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10019892","CDM","C1776","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1128.11","11.63","","400.94","400.94","400.94","1 through 10","1128.11","8245","percent of total billed charges",""
"SHOULDER STEM 6.5MM DIAMETERX100 AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10019892","CDM","C1776","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7507.80","77.4","","5214.50","5214.50","16415.28","1 through 10","1128.11","8245","percent of total billed charges",""
"SHOULDER STEM 6.5MM DIAMETERX100 AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10019892","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1128.11","11.63","","400.94","400.94","400.94","1 through 10","1128.11","7507.8","percent of total billed charges",""
"SHOULDER STEM 6.5MM DIAMETERX100 AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10019892","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4240.84","43.72","","1543.33","1543.33","1671.61","1 through 10","1128.11","7507.8","percent of total billed charges",""
"SHOULDER STEM 6.5MM DIAMETERX100 AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10019892","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7053.84","72.72","","3700.21","2382.07","6427.18","53","1128.11","7507.8","percent of total billed charges",""
"SHOULDER STEM 6.5MM DIAMETERX100 AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10019892","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7053.84","72.72","","12685.80","12685.80","12685.80","1 through 10","1128.11","7507.8","percent of total billed charges",""
"SHOULDER STEM 6.5MM DIAMETERX100 AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10019892","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6101.30","62.9","","3408.87","2784.05","9859.40","46","1128.11","7507.8","percent of total billed charges",""
"SHOULDER STEM 6.5MM DIAMETERX100 AEQUALIS REVERSED II COBALT CEMENTED","SUP-ITM-10019892","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7507.80","77.4","","5214.50","5214.50","16415.28","1 through 10","1128.11","7507.8","percent of total billed charges",""
"SHOULDER STEM 6X75MM COMPREHENSIVE TITANIUM SEGMENTAL REVISION SCREW","SUP-ITM-10122548","CDM","C1776","HCPCS","0278","RC","","","","both","","","10808.62","6485.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1257.04","9187.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER STEM 6X75MM COMPREHENSIVE TITANIUM SEGMENTAL REVISION SCREW","SUP-ITM-10122548","CDM","C1776","HCPCS","0278","RC","","","","both","","","10808.62","6485.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6150.10","56.9","","2911.53","1863.86","5209.05","65","1257.04","9187.33","percent of total billed charges",""
"SHOULDER STEM 6X75MM COMPREHENSIVE TITANIUM SEGMENTAL REVISION SCREW","SUP-ITM-10122548","CDM","C1776","HCPCS","0278","RC","","","","both","","","10808.62","6485.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1257.04","11.63","","400.94","400.94","400.94","1 through 10","1257.04","9187.33","percent of total billed charges",""
"SHOULDER STEM 6X75MM COMPREHENSIVE TITANIUM SEGMENTAL REVISION SCREW","SUP-ITM-10122548","CDM","C1776","HCPCS","0278","RC","","","","both","","","10808.62","6485.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8365.87","77.4","","5214.50","5214.50","16415.28","1 through 10","1257.04","9187.33","percent of total billed charges",""
"SHOULDER STEM 6X75MM COMPREHENSIVE TITANIUM SEGMENTAL REVISION SCREW","SUP-ITM-10122548","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10808.62","6485.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1257.04","11.63","","400.94","400.94","400.94","1 through 10","1257.04","8365.87","percent of total billed charges",""
"SHOULDER STEM 6X75MM COMPREHENSIVE TITANIUM SEGMENTAL REVISION SCREW","SUP-ITM-10122548","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10808.62","6485.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4725.53","43.72","","1543.33","1543.33","1671.61","1 through 10","1257.04","8365.87","percent of total billed charges",""
"SHOULDER STEM 6X75MM COMPREHENSIVE TITANIUM SEGMENTAL REVISION SCREW","SUP-ITM-10122548","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10808.62","6485.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7860.03","72.72","","3700.21","2382.07","6427.18","53","1257.04","8365.87","percent of total billed charges",""
"SHOULDER STEM 6X75MM COMPREHENSIVE TITANIUM SEGMENTAL REVISION SCREW","SUP-ITM-10122548","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10808.62","6485.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7860.03","72.72","","12685.80","12685.80","12685.80","1 through 10","1257.04","8365.87","percent of total billed charges",""
"SHOULDER STEM 6X75MM COMPREHENSIVE TITANIUM SEGMENTAL REVISION SCREW","SUP-ITM-10122548","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10808.62","6485.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6798.62","62.9","","3408.87","2784.05","9859.40","46","1257.04","8365.87","percent of total billed charges",""
"SHOULDER STEM 6X75MM COMPREHENSIVE TITANIUM SEGMENTAL REVISION SCREW","SUP-ITM-10122548","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10808.62","6485.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8365.87","77.4","","5214.50","5214.50","16415.28","1 through 10","1257.04","8365.87","percent of total billed charges",""
"SHOULDER STEM 7X100MM EQUINOXE TITANIUM PRESS FIT PRIMARY","SUP-ITM-10195022","CDM","C1776","HCPCS","0278","RC","","","","both","","","9389.60","5633.76","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1092.01","7981.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER STEM 7X100MM EQUINOXE TITANIUM PRESS FIT PRIMARY","SUP-ITM-10195022","CDM","C1776","HCPCS","0278","RC","","","","both","","","9389.60","5633.76","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5342.68","56.9","","2911.53","1863.86","5209.05","65","1092.01","7981.16","percent of total billed charges",""
"SHOULDER STEM 7X100MM EQUINOXE TITANIUM PRESS FIT PRIMARY","SUP-ITM-10195022","CDM","C1776","HCPCS","0278","RC","","","","both","","","9389.60","5633.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1092.01","11.63","","400.94","400.94","400.94","1 through 10","1092.01","7981.16","percent of total billed charges",""
"SHOULDER STEM 7X100MM EQUINOXE TITANIUM PRESS FIT PRIMARY","SUP-ITM-10195022","CDM","C1776","HCPCS","0278","RC","","","","both","","","9389.60","5633.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7267.55","77.4","","5214.50","5214.50","16415.28","1 through 10","1092.01","7981.16","percent of total billed charges",""
"SHOULDER STEM 7X100MM EQUINOXE TITANIUM PRESS FIT PRIMARY","SUP-ITM-10195022","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9389.60","5633.76","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1092.01","11.63","","400.94","400.94","400.94","1 through 10","1092.01","7267.55","percent of total billed charges",""
"SHOULDER STEM 7X100MM EQUINOXE TITANIUM PRESS FIT PRIMARY","SUP-ITM-10195022","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9389.60","5633.76","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4105.13","43.72","","1543.33","1543.33","1671.61","1 through 10","1092.01","7267.55","percent of total billed charges",""
"SHOULDER STEM 7X100MM EQUINOXE TITANIUM PRESS FIT PRIMARY","SUP-ITM-10195022","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9389.60","5633.76","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6828.12","72.72","","3700.21","2382.07","6427.18","53","1092.01","7267.55","percent of total billed charges",""
"SHOULDER STEM 7X100MM EQUINOXE TITANIUM PRESS FIT PRIMARY","SUP-ITM-10195022","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9389.60","5633.76","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6828.12","72.72","","12685.80","12685.80","12685.80","1 through 10","1092.01","7267.55","percent of total billed charges",""
"SHOULDER STEM 7X100MM EQUINOXE TITANIUM PRESS FIT PRIMARY","SUP-ITM-10195022","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9389.60","5633.76","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5906.06","62.9","","3408.87","2784.05","9859.40","46","1092.01","7267.55","percent of total billed charges",""
"SHOULDER STEM 7X100MM EQUINOXE TITANIUM PRESS FIT PRIMARY","SUP-ITM-10195022","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9389.60","5633.76","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7267.55","77.4","","5214.50","5214.50","16415.28","1 through 10","1092.01","7267.55","percent of total billed charges",""
"SHOULDER TRAY INSERT SURGICAL FLEX ASCEND REVERSED OFFSET LOW PLUS 6","SUP-ITM-10136024","CDM","C1776","HCPCS","0278","RC","","","","both","","","6219.00","3731.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","723.27","5286.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SHOULDER TRAY INSERT SURGICAL FLEX ASCEND REVERSED OFFSET LOW PLUS 6","SUP-ITM-10136024","CDM","C1776","HCPCS","0278","RC","","","","both","","","6219.00","3731.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3538.61","56.9","","2911.53","1863.86","5209.05","65","723.27","5286.15","percent of total billed charges",""
"SHOULDER TRAY INSERT SURGICAL FLEX ASCEND REVERSED OFFSET LOW PLUS 6","SUP-ITM-10136024","CDM","C1776","HCPCS","0278","RC","","","","both","","","6219.00","3731.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","723.27","11.63","","400.94","400.94","400.94","1 through 10","723.27","5286.15","percent of total billed charges",""
"SHOULDER TRAY INSERT SURGICAL FLEX ASCEND REVERSED OFFSET LOW PLUS 6","SUP-ITM-10136024","CDM","C1776","HCPCS","0278","RC","","","","both","","","6219.00","3731.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4813.51","77.4","","5214.50","5214.50","16415.28","1 through 10","723.27","5286.15","percent of total billed charges",""
"SHOULDER TRAY INSERT SURGICAL FLEX ASCEND REVERSED OFFSET LOW PLUS 6","SUP-ITM-10136024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","723.27","11.63","","400.94","400.94","400.94","1 through 10","723.27","4813.51","percent of total billed charges",""
"SHOULDER TRAY INSERT SURGICAL FLEX ASCEND REVERSED OFFSET LOW PLUS 6","SUP-ITM-10136024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2718.95","43.72","","1543.33","1543.33","1671.61","1 through 10","723.27","4813.51","percent of total billed charges",""
"SHOULDER TRAY INSERT SURGICAL FLEX ASCEND REVERSED OFFSET LOW PLUS 6","SUP-ITM-10136024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4522.46","72.72","","3700.21","2382.07","6427.18","53","723.27","4813.51","percent of total billed charges",""
"SHOULDER TRAY INSERT SURGICAL FLEX ASCEND REVERSED OFFSET LOW PLUS 6","SUP-ITM-10136024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4522.46","72.72","","12685.80","12685.80","12685.80","1 through 10","723.27","4813.51","percent of total billed charges",""
"SHOULDER TRAY INSERT SURGICAL FLEX ASCEND REVERSED OFFSET LOW PLUS 6","SUP-ITM-10136024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3911.75","62.9","","3408.87","2784.05","9859.40","46","723.27","4813.51","percent of total billed charges",""
"SHOULDER TRAY INSERT SURGICAL FLEX ASCEND REVERSED OFFSET LOW PLUS 6","SUP-ITM-10136024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4813.51","77.4","","5214.50","5214.50","16415.28","1 through 10","723.27","4813.51","percent of total billed charges",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","","","","inpatient","","","83062.47","49837.48","MEDICARE [2001]","HB WDH MEDICARE","16253.37","","Case rate ($16,253.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,035.95, add-ons for qualifying new technology services are included. If operating cost exceeds $18,954.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,960.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $14,653.31 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,591.08 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,155.20. The transfer capital threshold is the transfer adjustment factor * $1,155.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15243.13","15243.13","15243.13","1 through 10","3975","79017.41","other","Inpatient DRG"
"Sickle Cell RBC","PX-30001125","CDM","85660","CPT","0305","RC","","","","both","","","78.00","46.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","54.44","69.8","","52.35","52.35","52.35","1 through 10","3.58","66.3","percent of total billed charges",""
"Sickle Cell RBC","PX-30001125","CDM","85660","CPT","0305","RC","","","","both","","","78.00","46.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","66.30","85","","28.60","28.60","28.60","1 through 10","3.58","66.3","percent of total billed charges",""
"Sickle Cell RBC","PX-30001125","CDM","85660","CPT","0305","RC","","","","outpatient","","","78.00","46.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","56.72","72.72","","54.54","54.54","54.54","1 through 10","5.14","60.37","percent of total billed charges",""
"Sickle Cell RBC","PX-30001125","CDM","85660","CPT","0305","RC","","","","outpatient","","","78.00","46.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","49.06","62.9","","47.25","47.25","47.25","1 through 10","5.14","60.37","percent of total billed charges",""
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1577.00","946.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","1100.75","69.8","","1062.36","1062.36","1062.36","1 through 10","897.31","6087.46","percent of total billed charges",""
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1577.00","946.20","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","971.57","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","890.51","890.51","890.51","1 through 10","897.31","6087.46","other","OPPS APC"
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1577.00","946.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","897.31","56.9","","866.02","866.02","866.02","1 through 10","897.31","6087.46","percent of total billed charges",""
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1577.00","946.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","981.09","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","970.59","970.59","970.59","1 through 10","897.31","6087.46","other","OPPS APC"
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1577.00","946.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","933.58","933.58","933.58","1 through 10","897.31","6087.46","other","OPPS APC"
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1577.00","946.20","MEDICARE [2001]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","952.63","952.63","952.63","1 through 10","897.31","6087.46","other","OPPS APC"
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","outpatient","","","1577.00","946.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","991.93","62.9","","958.86","958.86","958.86","1 through 10","183.41","1220.6","percent of total billed charges",""
"Sigmoidoscopy Flx Ablation Tumor Polyp/Oth Les","PX-75000414","CDM","45346","CPT","0750","RC","","","","both","","","4476.00","2685.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","603.68","603.68","603.68","1 through 10","1207.22","7872.71","other","OPPS APC"
"Sigmoidoscopy Rem Tumor/Polyp Snare","PX-75000187","CDM","45338","CPT","0750","RC","","","","both","","","3522.00","2113.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","7872.71","","Case rate ($7,872.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4385.11","4382.40","4385.11","1 through 10","1207.22","7872.71","other","OPPS APC"
"Sigmoidoscopy Rem Tumor/Polyp Snare","PX-75000187","CDM","45338","CPT","0750","RC","","","","both","","","3522.00","2113.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1207.22","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1232.00","1232.00","1232.00","1 through 10","1207.22","7872.71","other","OPPS APC"
"Sigmoidoscopy Rem Tumor/Polyp Snare","PX-75000187","CDM","45338","CPT","0750","RC","","","","both","","","3522.00","2113.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1231.86","","APC Price ($1,231.86). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1207.36","1207.36","1207.36","1 through 10","1207.22","7872.71","other","OPPS APC"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","2175.00","1305.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","6087.46","","Case rate ($6,087.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5603.81","3226.40","5603.81","1 through 10","933.47","6087.46","other","OPPS APC"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","2175.00","1305.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","2621.26","","Case rate ($2,621.26). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2387.00","2387.00","2387.00","1 through 10","933.47","6087.46","other","OPPS APC"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","2175.00","1305.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","4920.44","","Case rate ($4,920.44). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2400.20","2400.20","2400.20","1 through 10","933.47","6087.46","other","OPPS APC"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","2175.00","1305.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","981.09","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","970.59","961.59","970.59","1 through 10","933.47","6087.46","other","OPPS APC"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","2175.00","1305.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","940.58","940.58","940.58","1 through 10","933.47","6087.46","other","OPPS APC"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","2175.00","1305.00","MEDICARE [2001]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","952.63","890.51","952.63","1 through 10","933.47","6087.46","other","OPPS APC"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","2175.00","1305.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","952.63","933.58","952.63","1 through 10","933.47","6087.46","other","OPPS APC"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","outpatient","","","2175.00","1305.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","2555.79","2555.79","2555.79","1 through 10","252.95","1683.45","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","outpatient","","","2175.00","1305.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","252.95","11.63","","247.92","247.92","247.92","1 through 10","252.95","1683.45","percent of total billed charges",""
"Sigmoidoscopy W/Ultrasound","PX-75000190","CDM","45341","CPT","0750","RC","","","","both","","","6191.00","3714.60","MEDICARE [2001]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","952.63","890.51","952.63","1 through 10","933.47","6087.46","other","OPPS APC"
"Sigmoidoscopy W/Ultrasound","PX-75000190","CDM","45341","CPT","0750","RC","","","","both","","","6191.00","3714.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","952.52","","APC Price ($952.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","933.58","933.58","933.58","1 through 10","933.47","6087.46","other","OPPS APC"
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With McC","555","MS-DRG","","","","","","","","inpatient","","","40785.98","24471.59","MEDICARE [2001]","HB WDH MEDICARE","10493.77","","Case rate ($10,493.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,719.89, add-ons for qualifying new technology services are included. If operating cost exceeds $13,638.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,539.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,314.58 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,275.02 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $734.32. The transfer capital threshold is the transfer adjustment factor * $734.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10632.81","10632.81","10632.81","1 through 10","3975","50228.53","other","Inpatient DRG"
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without McC","556","MS-DRG","","","","","","","","inpatient","","","28112.81","16867.69","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","6894.64","","Case rate ($6,759.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,273.16, add-ons for qualifying new technology services are included. If operating cost exceeds $10,191.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,266.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,853.15 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,828.29 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $461.43. The transfer capital threshold is the transfer adjustment factor * $461.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","6622.21","6622.21","6622.21","1 through 10","3975","31562.88","other","Inpatient DRG"
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without McC","556","MS-DRG","","","","","","","","inpatient","","","28112.81","16867.69","MEDICARE [2001]","HB WDH MEDICARE","6759.45","","Case rate ($6,759.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,273.16, add-ons for qualifying new technology services are included. If operating cost exceeds $10,191.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,266.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,853.15 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,828.29 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $461.43. The transfer capital threshold is the transfer adjustment factor * $461.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","279.62","0.05","6621.79","1 through 10","3975","31562.88","other","Inpatient DRG"
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without McC","556","MS-DRG","","","","","","","","inpatient","","","28112.81","16867.69","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6759.45","","Case rate ($6,759.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,273.16, add-ons for qualifying new technology services are included. If operating cost exceeds $10,191.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,266.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $5,853.15 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,828.29 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $461.43. The transfer capital threshold is the transfer adjustment factor * $461.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6621.79","6621.79","6621.79","1 through 10","3975","31562.88","other","Inpatient DRG"
"Signs And Symptoms With McC","947","MS-DRG","","","","","","","","inpatient","","","42126.41","25275.85","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","10297.31","","Case rate ($10,095.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,352.20, add-ons for qualifying new technology services are included. If operating cost exceeds $13,270.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,510.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,945.32 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,907.33 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.21. The transfer capital threshold is the transfer adjustment factor * $705.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","10149.84","10149.84","10149.84","1 through 10","3975","48237.33","other","Inpatient DRG"
"Signs And Symptoms With McC","947","MS-DRG","","","","","","","","inpatient","","","42126.41","25275.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","18993.88","","Fee schedule rate ($18,993.88). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","18775.85","18775.85","18775.85","1 through 10","3975","48237.33","case rate",""
"Signs And Symptoms With McC","947","MS-DRG","","","","","","","","inpatient","","","42126.41","25275.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","9893.49","","Case rate ($10,095.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,352.20, add-ons for qualifying new technology services are included. If operating cost exceeds $13,270.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,510.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,945.32 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,907.33 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.21. The transfer capital threshold is the transfer adjustment factor * $705.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","9971.68","9971.68","9971.68","1 through 10","3975","48237.33","other","Inpatient DRG"
"Signs And Symptoms With McC","947","MS-DRG","","","","","","","","inpatient","","","42126.41","25275.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","38418.75","","Fee schedule rate ($38,418.75). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","10264.25","10264.25","10264.25","1 through 10","3975","48237.33","case rate",""
"Signs And Symptoms With McC","947","MS-DRG","","","","","","","","inpatient","","","42126.41","25275.85","MEDICARE [2001]","HB WDH MEDICARE","10095.40","","Case rate ($10,095.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,352.20, add-ons for qualifying new technology services are included. If operating cost exceeds $13,270.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,510.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,945.32 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,907.33 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.21. The transfer capital threshold is the transfer adjustment factor * $705.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10175.18","8334.19","10175.18","1 through 10","3975","48237.33","other","Inpatient DRG"
"Signs And Symptoms With McC","947","MS-DRG","","","","","","","","inpatient","","","42126.41","25275.85","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","10095.40","","Case rate ($10,095.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,352.20, add-ons for qualifying new technology services are included. If operating cost exceeds $13,270.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,510.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $8,945.32 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,907.33 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.21. The transfer capital threshold is the transfer adjustment factor * $705.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","9986.40","9986.40","9986.40","1 through 10","3975","48237.33","other","Inpatient DRG"
"Signs And Symptoms Without McC","948","MS-DRG","","","","","","","","inpatient","","","32724.11","19634.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","11977.79","","Fee schedule rate ($11,977.79). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","11598.05","11598.05","11598.05","1 through 10","3975","30419.08","case rate",""
"Signs And Symptoms Without McC","948","MS-DRG","","","","","","","","inpatient","","","32724.11","19634.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","24227.36","","Fee schedule rate ($24,227.36). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","23459.28","23459.28","23459.28","1 through 10","3975","30419.08","case rate",""
"Signs And Symptoms Without McC","948","MS-DRG","","","","","","","","inpatient","","","32724.11","19634.47","MARTIN'S POINT [160007]","HB WDH MEDICARE","6530.62","","Case rate ($6,530.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,061.95, add-ons for qualifying new technology services are included. If operating cost exceeds $9,980.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,249.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,641.04 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,617.08 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $444.71. The transfer capital threshold is the transfer adjustment factor * $444.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7780.23","7780.23","7780.23","1 through 10","3975","30419.08","other","Inpatient DRG"
"Signs And Symptoms Without McC","948","MS-DRG","","","","","","","","inpatient","","","32724.11","19634.47","MEDICARE [2001]","HB WDH MEDICARE","6530.62","","Case rate ($6,530.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,061.95, add-ons for qualifying new technology services are included. If operating cost exceeds $9,980.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,249.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,641.04 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,617.08 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $444.71. The transfer capital threshold is the transfer adjustment factor * $444.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5068.10","0.05","6455.34","14","3975","30419.08","other","Inpatient DRG"
"Signs And Symptoms Without McC","948","MS-DRG","","","","","","","","inpatient","","","32724.11","19634.47","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6530.62","","Case rate ($6,530.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,061.95, add-ons for qualifying new technology services are included. If operating cost exceeds $9,980.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,249.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $5,641.04 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,617.08 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $444.71. The transfer capital threshold is the transfer adjustment factor * $444.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6439.72","6439.72","6455.76","1 through 10","3975","30419.08","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","25682.80","15409.68","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","6703.11","","Case rate ($6,571.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,099.84, add-ons for qualifying new technology services are included. If operating cost exceeds $10,018.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,252.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,679.09 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,654.97 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.71. The transfer capital threshold is the transfer adjustment factor * $447.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","6648.27","6648.27","6648.27","1 through 10","3975","30624.28","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","25682.80","15409.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","6440.25","","Case rate ($6,571.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,099.84, add-ons for qualifying new technology services are included. If operating cost exceeds $10,018.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,252.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,679.09 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,654.97 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.71. The transfer capital threshold is the transfer adjustment factor * $447.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6632.15","6632.15","6632.15","1 through 10","3975","30624.28","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","25682.80","15409.68","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","24390.79","","Fee schedule rate ($24,390.79). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","24212.22","24212.22","24212.22","1 through 10","3975","30624.28","case rate",""
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","25682.80","15409.68","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","6768.83","","Case rate ($6,571.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,099.84, add-ons for qualifying new technology services are included. If operating cost exceeds $10,018.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,252.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,679.09 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,654.97 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.71. The transfer capital threshold is the transfer adjustment factor * $447.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","15845.55","15845.55","15845.55","1 through 10","3975","30624.28","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","25682.80","15409.68","MARTIN'S POINT [160007]","HB WDH MEDICARE","6571.68","","Case rate ($6,571.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,099.84, add-ons for qualifying new technology services are included. If operating cost exceeds $10,018.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,252.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,679.09 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,654.97 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.71. The transfer capital threshold is the transfer adjustment factor * $447.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6530.30","6530.30","6530.30","1 through 10","3975","30624.28","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","25682.80","15409.68","MEDICARE [2001]","HB WDH MEDICARE","6571.68","","Case rate ($6,571.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,099.84, add-ons for qualifying new technology services are included. If operating cost exceeds $10,018.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,252.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,679.09 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,654.97 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.71. The transfer capital threshold is the transfer adjustment factor * $447.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6632.15","0.05","6648.27","19","3975","30624.28","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","25682.80","15409.68","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6571.68","","Case rate ($6,571.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,099.84, add-ons for qualifying new technology services are included. If operating cost exceeds $10,018.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,252.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $5,679.09 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,654.97 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $447.71. The transfer capital threshold is the transfer adjustment factor * $447.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6535.61","6499.51","6648.27","13","3975","30624.28","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","25682.80","15409.68","WELLPOINT [1015]","HB WDH ANTHEM PPO","24390.79","","Fee schedule rate ($24,390.79). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","24212.22","24212.22","24212.22","1 through 10","3975","30624.28","case rate",""
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","29417.02","17650.21","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","10646.27","","Case rate ($10,437.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,667.97, add-ons for qualifying new technology services are included. If operating cost exceeds $13,586.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,535.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,262.43 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,223.10 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $730.21. The transfer capital threshold is the transfer adjustment factor * $730.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 102%.","10387.56","10387.56","10387.56","1 through 10","3975","49947.33","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","29417.02","17650.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","49947.33","","Fee schedule rate ($49,947.33). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","13672.36","13672.36","13672.36","1 through 10","3975","49947.33","case rate",""
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","29417.02","17650.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","19667.21","","Fee schedule rate ($19,667.21). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","19235.69","19235.69","19235.69","1 through 10","3975","49947.33","case rate",""
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","29417.02","17650.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","10228.77","","Case rate ($10,437.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,667.97, add-ons for qualifying new technology services are included. If operating cost exceeds $13,586.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,535.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,262.43 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,223.10 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $730.21. The transfer capital threshold is the transfer adjustment factor * $730.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","10213.33","10179.81","37320.39","1 through 10","3975","49947.33","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","29417.02","17650.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","39780.68","","Fee schedule rate ($39,780.68). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","38907.85","38907.85","38907.85","1 through 10","3975","49947.33","case rate",""
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","29417.02","17650.21","HARVARD PILGRIM [120001]","HB WDH MEDICARE","10437.52","","Case rate ($10,437.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,667.97, add-ons for qualifying new technology services are included. If operating cost exceeds $13,586.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,535.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,262.43 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,223.10 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $730.21. The transfer capital threshold is the transfer adjustment factor * $730.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","25442.25","25442.25","25442.25","1 through 10","3975","49947.33","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","29417.02","17650.21","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","10750.65","","Case rate ($10,437.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,667.97, add-ons for qualifying new technology services are included. If operating cost exceeds $13,586.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,535.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,262.43 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,223.10 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $730.21. The transfer capital threshold is the transfer adjustment factor * $730.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","10501.95","9965.89","42202.00","1 through 10","3975","49947.33","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","29417.02","17650.21","MARTIN'S POINT [160007]","HB WDH MEDICARE","10437.52","","Case rate ($10,437.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,667.97, add-ons for qualifying new technology services are included. If operating cost exceeds $13,586.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,535.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,262.43 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,223.10 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $730.21. The transfer capital threshold is the transfer adjustment factor * $730.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10217.31","7175.24","10645.19","15","3975","49947.33","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","29417.02","17650.21","MEDICARE [2001]","HB WDH MEDICARE","10437.52","","Case rate ($10,437.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,667.97, add-ons for qualifying new technology services are included. If operating cost exceeds $13,586.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,535.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,262.43 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,223.10 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $730.21. The transfer capital threshold is the transfer adjustment factor * $730.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10387.56","7901.86","10413.47","88","3975","49947.33","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","29417.02","17650.21","TRICARE [160005]","HB WDH MEDICARE","10437.52","","Case rate ($10,437.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,667.97, add-ons for qualifying new technology services are included. If operating cost exceeds $13,586.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,535.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,262.43 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,223.10 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $730.21. The transfer capital threshold is the transfer adjustment factor * $730.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5044.77","5044.77","5044.77","1 through 10","3975","49947.33","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","29417.02","17650.21","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","10437.52","","Case rate ($10,437.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,667.97, add-ons for qualifying new technology services are included. If operating cost exceeds $13,586.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,535.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,262.43 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,223.10 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $730.21. The transfer capital threshold is the transfer adjustment factor * $730.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10219.31","5307.85","12444.33","33","3975","49947.33","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","29417.02","17650.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","26932.06","","Fee schedule rate ($26,932.06). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","23829.21","23829.21","23829.21","1 through 10","3975","49947.33","case rate",""
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","29417.02","17650.21","WELLSENSE NH [1050]","HB WDH MEDICARE","10437.52","","Case rate ($10,437.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,667.97, add-ons for qualifying new technology services are included. If operating cost exceeds $13,586.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,535.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $9,262.43 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,223.10 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $730.21. The transfer capital threshold is the transfer adjustment factor * $730.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10715.46","10715.46","10715.46","1 through 10","3975","49947.33","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy Without Cc/McC","195","MS-DRG","","","","","","","","inpatient","","","12336.41","7401.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","23883.06","","Fee schedule rate ($23,883.06). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","10476.62","10476.62","11235.83","1 through 10","3975","23883.06","case rate",""
"Simple Pneumonia And Pleurisy Without Cc/McC","195","MS-DRG","","","","","","","","inpatient","","","12336.41","7401.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","9404.17","","Fee schedule rate ($9,404.17). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","9090.13","9090.13","9090.13","1 through 10","3975","23883.06","case rate",""
"Simple Pneumonia And Pleurisy Without Cc/McC","195","MS-DRG","","","","","","","","inpatient","","","12336.41","7401.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","19021.73","","Fee schedule rate ($19,021.73). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","12588.94","12588.94","12588.94","1 through 10","3975","23883.06","case rate",""
"Simple Pneumonia And Pleurisy Without Cc/McC","195","MS-DRG","","","","","","","","inpatient","","","12336.41","7401.85","MEDICARE [2001]","HB WDH MEDICARE","5223.00","","Case rate ($5,223). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $4,855.03, add-ons for qualifying new technology services are included. If operating cost exceeds $8,773.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,154.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,428.97 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,410.16 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $349.16. The transfer capital threshold is the transfer adjustment factor * $349.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5155.64","5155.64","5155.64","1 through 10","3975","23883.06","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy Without Cc/McC","195","MS-DRG","","","","","","","","inpatient","","","12336.41","7401.85","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","5223.00","","Case rate ($5,223). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $4,855.03, add-ons for qualifying new technology services are included. If operating cost exceeds $8,773.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,154.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,428.97 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,410.16 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $349.16. The transfer capital threshold is the transfer adjustment factor * $349.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5143.40","5143.40","5143.40","1 through 10","3975","23883.06","other","Inpatient DRG"
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","","","","inpatient","","","120249.66","72149.80","MEDICARE [2001]","HB WDH MEDICARE","31010.47","","Case rate ($31,010.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $28,656.58, add-ons for qualifying new technology services are included. If operating cost exceeds $32,574.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,038.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $28,332.03 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $28,211.70 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,233.56. The transfer capital threshold is the transfer adjustment factor * $2,233.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","0.05","1 through 10","3975","152779.4","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical Without McC","451","MS-DRG","","","","","","","","inpatient","","","95947.65","57568.59","MARTIN'S POINT [160007]","HB WDH MEDICARE","25003.77","","Case rate ($25,003.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $23,112.47, add-ons for qualifying new technology services are included. If operating cost exceeds $27,030.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,599.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $22,764.28 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $22,667.60 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,794.63. The transfer capital threshold is the transfer adjustment factor * $1,794.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18936.07","18936.07","18936.07","1 through 10","3975","122755.52","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical Without McC","451","MS-DRG","","","","","","","","inpatient","","","95947.65","57568.59","MEDICARE [2001]","HB WDH MEDICARE","25003.77","","Case rate ($25,003.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $23,112.47, add-ons for qualifying new technology services are included. If operating cost exceeds $27,030.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,599.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $22,764.28 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $22,667.60 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,794.63. The transfer capital threshold is the transfer adjustment factor * $1,794.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23730.38","0.05","23791.05","1 through 10","3975","122755.52","other","Inpatient DRG"
"SIZER CENTERED ALTO CONCISE PARTIAL INCLUDED TI SILICONE","SUP-ITM-10232019","CDM","L8613","HCPCS","0274","RC","","","","outpatient","","","2865.92","1719.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1802.66","62.9","","2038.65","2038.65","2038.65","1 through 10","1525.24","2218.22","percent of total billed charges",""
"Skin Debridement With Cc","571","MS-DRG","","","","","","","","inpatient","","","67291.80","40375.08","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","13023.41","","Case rate ($13,289.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,300.03, add-ons for qualifying new technology services are included. If operating cost exceeds $16,218.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,743.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,905.72 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,855.16 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $938.59. The transfer capital threshold is the transfer adjustment factor * $938.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","1378.82","1378.82","1378.82","1 through 10","3975","64201.17","other","Inpatient DRG"
"Skin Debridement With Cc","571","MS-DRG","","","","","","","","inpatient","","","67291.80","40375.08","MEDICARE [2001]","HB WDH MEDICARE","13289.19","","Case rate ($13,289.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,300.03, add-ons for qualifying new technology services are included. If operating cost exceeds $16,218.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,743.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,905.72 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,855.16 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $938.59. The transfer capital threshold is the transfer adjustment factor * $938.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13111.23","13111.23","13111.23","1 through 10","3975","64201.17","other","Inpatient DRG"
"Skin Debridement With McC","570","MS-DRG","","","","","","","","inpatient","","","69398.20","41638.92","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","22348.29","","Case rate ($22,804.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $21,082.46, add-ons for qualifying new technology services are included. If operating cost exceeds $25,000.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,438.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $20,725.61 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $20,637.59 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,633.91. The transfer capital threshold is the transfer adjustment factor * $1,633.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","20623.78","20623.78","20623.78","1 through 10","3975","111762.09","other","Inpatient DRG"
"Skin Debridement With McC","570","MS-DRG","","","","","","","","inpatient","","","69398.20","41638.92","MEDICARE [2001]","HB WDH MEDICARE","22804.38","","Case rate ($22,804.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $21,082.46, add-ons for qualifying new technology services are included. If operating cost exceeds $25,000.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,438.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $20,725.61 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $20,637.59 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,633.91. The transfer capital threshold is the transfer adjustment factor * $1,633.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20623.78","20623.78","20623.78","1 through 10","3975","111762.09","other","Inpatient DRG"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","","","","inpatient","","","43815.88","26289.53","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","14505.36","","Case rate ($14,082.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,032.60, add-ons for qualifying new technology services are included. If operating cost exceeds $16,950.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,801.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $12,641.42 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,587.73 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.59. The transfer capital threshold is the transfer adjustment factor * $996.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","21211.48","21211.48","21211.48","1 through 10","3975","68168.38","other","Inpatient DRG"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","","","","inpatient","","","43815.88","26289.53","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","14082.87","","Case rate ($14,082.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,032.60, add-ons for qualifying new technology services are included. If operating cost exceeds $16,950.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,801.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $12,641.42 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,587.73 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $996.59. The transfer capital threshold is the transfer adjustment factor * $996.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","8334.56","8334.56","8334.56","1 through 10","3975","68168.38","other","Inpatient DRG"
"Skin Grafts For Injuries With Cc/McC","904","MS-DRG","","","","","","","","inpatient","","","70135.74","42081.44","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","28369.38","","Case rate ($28,369.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $26,218.89, add-ons for qualifying new technology services are included. If operating cost exceeds $30,137.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,845.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. The base transfer operating payment is the transfer adjustment factor * $25,883.94 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $25,774.01 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,040.57. The transfer capital threshold is the transfer adjustment factor * $2,040.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","15424.70","15424.70","15424.70","1 through 10","3975","139578.17","other","Inpatient DRG"
"Skin Test Tuberculosis Intradermal","PX-30000875","CDM","86580","CPT","0302","RC","","","","both","","","80.00","48.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","55.84","69.8","","53.75","53.75","53.75","1 through 10","25.07","163.55","percent of total billed charges",""
"SLEEVE FEMORAL 0MM HIP TANDEM COBALT UNIPOLAR 12/14 TAPER PLUS","SUP-ITM-10015366","CDM","C1776","HCPCS","0278","RC","","","","both","","","373.14","223.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","43.4","317.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SLEEVE FEMORAL 0MM HIP TANDEM COBALT UNIPOLAR 12/14 TAPER PLUS","SUP-ITM-10015366","CDM","C1776","HCPCS","0278","RC","","","","both","","","373.14","223.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","212.32","56.9","","2911.53","1863.86","5209.05","65","43.4","317.17","percent of total billed charges",""
"SLEEVE FEMORAL 0MM HIP TANDEM COBALT UNIPOLAR 12/14 TAPER PLUS","SUP-ITM-10015366","CDM","C1776","HCPCS","0278","RC","","","","both","","","373.14","223.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","43.40","11.63","","400.94","400.94","400.94","1 through 10","43.4","317.17","percent of total billed charges",""
"SLEEVE FEMORAL 0MM HIP TANDEM COBALT UNIPOLAR 12/14 TAPER PLUS","SUP-ITM-10015366","CDM","C1776","HCPCS","0278","RC","","","","both","","","373.14","223.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","288.81","77.4","","5214.50","5214.50","16415.28","1 through 10","43.4","317.17","percent of total billed charges",""
"SLEEVE FEMORAL 0MM HIP TANDEM COBALT UNIPOLAR 12/14 TAPER PLUS","SUP-ITM-10015366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","373.14","223.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","43.40","11.63","","400.94","400.94","400.94","1 through 10","43.4","288.81","percent of total billed charges",""
"SLEEVE FEMORAL 0MM HIP TANDEM COBALT UNIPOLAR 12/14 TAPER PLUS","SUP-ITM-10015366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","373.14","223.88","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","163.14","43.72","","1543.33","1543.33","1671.61","1 through 10","43.4","288.81","percent of total billed charges",""
"SLEEVE FEMORAL 0MM HIP TANDEM COBALT UNIPOLAR 12/14 TAPER PLUS","SUP-ITM-10015366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","373.14","223.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","271.35","72.72","","3700.21","2382.07","6427.18","53","43.4","288.81","percent of total billed charges",""
"SLEEVE FEMORAL 0MM HIP TANDEM COBALT UNIPOLAR 12/14 TAPER PLUS","SUP-ITM-10015366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","373.14","223.88","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","271.35","72.72","","12685.80","12685.80","12685.80","1 through 10","43.4","288.81","percent of total billed charges",""
"SLEEVE FEMORAL 0MM HIP TANDEM COBALT UNIPOLAR 12/14 TAPER PLUS","SUP-ITM-10015366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","373.14","223.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","234.71","62.9","","3408.87","2784.05","9859.40","46","43.4","288.81","percent of total billed charges",""
"SLEEVE FEMORAL 0MM HIP TANDEM COBALT UNIPOLAR 12/14 TAPER PLUS","SUP-ITM-10015366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","373.14","223.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","288.81","77.4","","5214.50","5214.50","16415.28","1 through 10","43.4","288.81","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","7275.00","4365.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","846.08","6183.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","7275.00","4365.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4139.48","56.9","","2911.53","1863.86","5209.05","65","846.08","6183.75","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","7275.00","4365.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","846.08","11.63","","400.94","400.94","400.94","1 through 10","846.08","6183.75","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","7275.00","4365.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5630.85","77.4","","5214.50","5214.50","16415.28","1 through 10","846.08","6183.75","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","846.08","11.63","","400.94","400.94","400.94","1 through 10","846.08","5630.85","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3180.63","43.72","","1543.33","1543.33","1671.61","1 through 10","846.08","5630.85","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5290.38","72.72","","3700.21","2382.07","6427.18","53","846.08","5630.85","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5290.38","72.72","","12685.80","12685.80","12685.80","1 through 10","846.08","5630.85","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4575.98","62.9","","3408.87","2784.05","9859.40","46","846.08","5630.85","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5630.85","77.4","","5214.50","5214.50","16415.28","1 through 10","846.08","5630.85","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.75","103.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","20.09","146.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.75","103.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","98.29","56.9","","2911.53","1863.86","5209.05","65","20.09","146.84","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.75","103.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.09","11.63","","400.94","400.94","400.94","1 through 10","20.09","146.84","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.75","103.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","133.71","77.4","","5214.50","5214.50","16415.28","1 through 10","20.09","146.84","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.09","11.63","","400.94","400.94","400.94","1 through 10","20.09","133.71","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","75.53","43.72","","1543.33","1543.33","1671.61","1 through 10","20.09","133.71","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","125.62","72.72","","3700.21","2382.07","6427.18","53","20.09","133.71","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","125.62","72.72","","12685.80","12685.80","12685.80","1 through 10","20.09","133.71","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","108.66","62.9","","3408.87","2784.05","9859.40","46","20.09","133.71","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","133.71","77.4","","5214.50","5214.50","16415.28","1 through 10","20.09","133.71","percent of total billed charges",""
"SLEEVE FEMORAL 8.0MM HIP UNITRAX V40 TITANIUM ADJUSTABLE TAPER STANDARD PLUS","SUP-ITM-10035834","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.75","103.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","20.09","146.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SLEEVE FEMORAL 8.0MM HIP UNITRAX V40 TITANIUM ADJUSTABLE TAPER STANDARD PLUS","SUP-ITM-10035834","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.75","103.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","98.29","56.9","","2911.53","1863.86","5209.05","65","20.09","146.84","percent of total billed charges",""
"SLEEVE FEMORAL 8.0MM HIP UNITRAX V40 TITANIUM ADJUSTABLE TAPER STANDARD PLUS","SUP-ITM-10035834","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.75","103.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.09","11.63","","400.94","400.94","400.94","1 through 10","20.09","146.84","percent of total billed charges",""
"SLEEVE FEMORAL 8.0MM HIP UNITRAX V40 TITANIUM ADJUSTABLE TAPER STANDARD PLUS","SUP-ITM-10035834","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.75","103.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","133.71","77.4","","5214.50","5214.50","16415.28","1 through 10","20.09","146.84","percent of total billed charges",""
"SLEEVE FEMORAL 8.0MM HIP UNITRAX V40 TITANIUM ADJUSTABLE TAPER STANDARD PLUS","SUP-ITM-10035834","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","20.09","11.63","","400.94","400.94","400.94","1 through 10","20.09","133.71","percent of total billed charges",""
"SLEEVE FEMORAL 8.0MM HIP UNITRAX V40 TITANIUM ADJUSTABLE TAPER STANDARD PLUS","SUP-ITM-10035834","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","75.53","43.72","","1543.33","1543.33","1671.61","1 through 10","20.09","133.71","percent of total billed charges",""
"SLEEVE FEMORAL 8.0MM HIP UNITRAX V40 TITANIUM ADJUSTABLE TAPER STANDARD PLUS","SUP-ITM-10035834","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","125.62","72.72","","3700.21","2382.07","6427.18","53","20.09","133.71","percent of total billed charges",""
"SLEEVE FEMORAL 8.0MM HIP UNITRAX V40 TITANIUM ADJUSTABLE TAPER STANDARD PLUS","SUP-ITM-10035834","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","125.62","72.72","","12685.80","12685.80","12685.80","1 through 10","20.09","133.71","percent of total billed charges",""
"SLEEVE FEMORAL 8.0MM HIP UNITRAX V40 TITANIUM ADJUSTABLE TAPER STANDARD PLUS","SUP-ITM-10035834","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","108.66","62.9","","3408.87","2784.05","9859.40","46","20.09","133.71","percent of total billed charges",""
"SLEEVE FEMORAL 8.0MM HIP UNITRAX V40 TITANIUM ADJUSTABLE TAPER STANDARD PLUS","SUP-ITM-10035834","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.75","103.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","133.71","77.4","","5214.50","5214.50","16415.28","1 through 10","20.09","133.71","percent of total billed charges",""
"SLEEVE FEMORAL SZ 18D LG S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10004619","CDM","C1776","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","642.91","4698.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SLEEVE FEMORAL SZ 18D LG S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10004619","CDM","C1776","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3145.43","56.9","","2911.53","1863.86","5209.05","65","642.91","4698.8","percent of total billed charges",""
"SLEEVE FEMORAL SZ 18D LG S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10004619","CDM","C1776","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","642.91","11.63","","400.94","400.94","400.94","1 through 10","642.91","4698.8","percent of total billed charges",""
"SLEEVE FEMORAL SZ 18D LG S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10004619","CDM","C1776","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4278.67","77.4","","5214.50","5214.50","16415.28","1 through 10","642.91","4698.8","percent of total billed charges",""
"SLEEVE FEMORAL SZ 18D LG S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10004619","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","642.91","11.63","","400.94","400.94","400.94","1 through 10","642.91","4278.67","percent of total billed charges",""
"SLEEVE FEMORAL SZ 18D LG S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10004619","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2416.84","43.72","","1543.33","1543.33","1671.61","1 through 10","642.91","4278.67","percent of total billed charges",""
"SLEEVE FEMORAL SZ 18D LG S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10004619","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4019.96","72.72","","3700.21","2382.07","6427.18","53","642.91","4278.67","percent of total billed charges",""
"SLEEVE FEMORAL SZ 18D LG S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10004619","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4019.96","72.72","","12685.80","12685.80","12685.80","1 through 10","642.91","4278.67","percent of total billed charges",""
"SLEEVE FEMORAL SZ 18D LG S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10004619","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3477.11","62.9","","3408.87","2784.05","9859.40","46","642.91","4278.67","percent of total billed charges",""
"SLEEVE FEMORAL SZ 18D LG S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10004619","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4278.67","77.4","","5214.50","5214.50","16415.28","1 through 10","642.91","4278.67","percent of total billed charges",""
"SLEEVE SCREW 5MM BONE LOCKING BIOREABSORBABLE PK/2EA","SUP-ITM-10097865","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.61","293.77","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","56.94","416.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SLEEVE SCREW 5MM BONE LOCKING BIOREABSORBABLE PK/2EA","SUP-ITM-10097865","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.61","293.77","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","56.94","416.17","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SLEEVE SCREW 5MM BONE LOCKING BIOREABSORBABLE PK/2EA","SUP-ITM-10097865","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.61","293.77","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","278.59","56.9","","812.12","238.65","1587.46","163","56.94","416.17","percent of total billed charges",""
"SLEEVE SCREW 5MM BONE LOCKING BIOREABSORBABLE PK/2EA","SUP-ITM-10097865","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.61","293.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","56.94","11.63","","112.68","112.68","146.99","38","56.94","416.17","percent of total billed charges",""
"SLEEVE SCREW 5MM BONE LOCKING BIOREABSORBABLE PK/2EA","SUP-ITM-10097865","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.61","293.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","378.96","77.4","","303.98","303.98","5854.79","1 through 10","56.94","416.17","percent of total billed charges",""
"SLEEVE SCREW 5MM BONE LOCKING BIOREABSORBABLE PK/2EA","SUP-ITM-10097865","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","489.61","293.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","56.94","11.63","","112.68","112.68","146.99","38","56.94","378.96","percent of total billed charges",""
"SLEEVE SCREW 5MM BONE LOCKING BIOREABSORBABLE PK/2EA","SUP-ITM-10097865","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","489.61","293.77","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","307.38","62.78","","780.86","208.94","10480.28","15","56.94","378.96","percent of total billed charges",""
"SLEEVE SCREW 5MM BONE LOCKING BIOREABSORBABLE PK/2EA","SUP-ITM-10097865","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","489.61","293.77","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","214.06","43.72","","179.76","179.76","179.76","1 through 10","56.94","378.96","percent of total billed charges",""
"SLEEVE SCREW 5MM BONE LOCKING BIOREABSORBABLE PK/2EA","SUP-ITM-10097865","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","489.61","293.77","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","356.04","72.72","","2355.45","298.99","3965.19","155","56.94","378.96","percent of total billed charges",""
"SLEEVE SCREW 5MM BONE LOCKING BIOREABSORBABLE PK/2EA","SUP-ITM-10097865","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","489.61","293.77","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","356.04","72.72","","3643.09","3643.09","3643.09","1 through 10","56.94","378.96","percent of total billed charges",""
"SLEEVE SCREW 5MM BONE LOCKING BIOREABSORBABLE PK/2EA","SUP-ITM-10097865","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","489.61","293.77","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","260.57","53.22","","554.28","554.28","554.28","16","56.94","378.96","percent of total billed charges",""
"SLEEVE SCREW 5MM BONE LOCKING BIOREABSORBABLE PK/2EA","SUP-ITM-10097865","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","489.61","293.77","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","307.96","62.9","","619.64","173.09","2370.64","150","56.94","378.96","percent of total billed charges",""
"SLEEVE SCREW 5MM BONE LOCKING BIOREABSORBABLE PK/2EA","SUP-ITM-10097865","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","489.61","293.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","378.96","77.4","","303.98","303.98","5854.79","1 through 10","56.94","378.96","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS CEMENTED","SUP-ITM-10025313","CDM","C1776","HCPCS","0278","RC","","","","both","","","7275.00","4365.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","846.08","6183.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS CEMENTED","SUP-ITM-10025313","CDM","C1776","HCPCS","0278","RC","","","","both","","","7275.00","4365.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4139.48","56.9","","2911.53","1863.86","5209.05","65","846.08","6183.75","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS CEMENTED","SUP-ITM-10025313","CDM","C1776","HCPCS","0278","RC","","","","both","","","7275.00","4365.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","846.08","11.63","","400.94","400.94","400.94","1 through 10","846.08","6183.75","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS CEMENTED","SUP-ITM-10025313","CDM","C1776","HCPCS","0278","RC","","","","both","","","7275.00","4365.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5630.85","77.4","","5214.50","5214.50","16415.28","1 through 10","846.08","6183.75","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS CEMENTED","SUP-ITM-10025313","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","846.08","11.63","","400.94","400.94","400.94","1 through 10","846.08","5630.85","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS CEMENTED","SUP-ITM-10025313","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3180.63","43.72","","1543.33","1543.33","1671.61","1 through 10","846.08","5630.85","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS CEMENTED","SUP-ITM-10025313","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5290.38","72.72","","3700.21","2382.07","6427.18","53","846.08","5630.85","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS CEMENTED","SUP-ITM-10025313","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5290.38","72.72","","12685.80","12685.80","12685.80","1 through 10","846.08","5630.85","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS CEMENTED","SUP-ITM-10025313","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4575.98","62.9","","3408.87","2784.05","9859.40","46","846.08","5630.85","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS CEMENTED","SUP-ITM-10025313","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7275.00","4365.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5630.85","77.4","","5214.50","5214.50","16415.28","1 through 10","846.08","5630.85","percent of total billed charges",""
"SLING INCONTINENCE 7 3/ 4CM ALTIS POLYPROPYLENE MESH LOW ELASTICITY SINGLE INCISION","SUP-ITM-10118025","CDM","C1771","HCPCS","0278","RC","","","","both","","","7085.85","4251.51","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","6680.45","6680.45","6680.45","1 through 10","824.08","6022.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SLING INCONTINENCE 7 3/ 4CM ALTIS POLYPROPYLENE MESH LOW ELASTICITY SINGLE INCISION","SUP-ITM-10118025","CDM","C1771","HCPCS","0278","RC","","","","both","","","7085.85","4251.51","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4031.85","56.9","","3801.18","3767.54","4248.00","1 through 10","824.08","6022.97","percent of total billed charges",""
"SLING INCONTINENCE 7 3/ 4CM ALTIS POLYPROPYLENE MESH LOW ELASTICITY SINGLE INCISION","SUP-ITM-10118025","CDM","C1771","HCPCS","0278","RC","","","","both","","","7085.85","4251.51","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5484.45","77.4","","5750.52","5177.35","5750.52","1 through 10","824.08","6022.97","percent of total billed charges",""
"SLING INCONTINENCE 7 3/ 4CM ALTIS POLYPROPYLENE MESH LOW ELASTICITY SINGLE INCISION","SUP-ITM-10118025","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","7085.85","4251.51","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4448.50","62.78","","12581.94","12581.94","12581.94","1 through 10","824.08","5484.45","percent of total billed charges",""
"SLING INCONTINENCE 7 3/ 4CM ALTIS POLYPROPYLENE MESH LOW ELASTICITY SINGLE INCISION","SUP-ITM-10118025","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","7085.85","4251.51","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5152.83","72.72","","4858.02","4858.02","4858.02","1 through 10","824.08","5484.45","percent of total billed charges",""
"SLING INCONTINENCE 7 3/ 4CM ALTIS POLYPROPYLENE MESH LOW ELASTICITY SINGLE INCISION","SUP-ITM-10118025","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","7085.85","4251.51","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4457.00","62.9","","4208.68","4208.68","4208.68","1 through 10","824.08","5484.45","percent of total billed charges",""
"SLING INCONTINENCE 7 3/ 4CM ALTIS POLYPROPYLENE MESH LOW ELASTICITY SINGLE INCISION","SUP-ITM-10118025","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","7085.85","4251.51","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5484.45","77.4","","5750.52","5177.35","5750.52","1 through 10","824.08","5484.45","percent of total billed charges",""
"SLING SHOULDER 13 15IN UNIVERSAL LG ULTRA III MESH PADDED DEROTATION STRAP","SUP-ITM-10018171","CDM","L3670","HCPCS","0274","RC","","","","outpatient","","","319.93","191.96","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","232.65","72.72","","221.60","221.60","221.60","1 through 10","37.21","247.63","percent of total billed charges",""
"SLING SHOULDER 13 15IN UNIVERSAL LG ULTRA III MESH PADDED DEROTATION STRAP","SUP-ITM-10018171","CDM","L3670","HCPCS","0274","RC","","","","outpatient","","","319.93","191.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","201.24","62.9","","191.98","191.98","191.98","1 through 10","37.21","247.63","percent of total billed charges",""
"SLING URINARY INCONTINENCE FEMALE STRESS TRT SYSTEM STERILE","SUP-ITM-10027228","CDM","C1771","HCPCS","0278","RC","","","","both","","","13816.80","8290.08","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","6680.45","6680.45","6680.45","1 through 10","1606.89","11744.28","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SLING URINARY INCONTINENCE FEMALE STRESS TRT SYSTEM STERILE","SUP-ITM-10027228","CDM","C1771","HCPCS","0278","RC","","","","both","","","13816.80","8290.08","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7861.76","56.9","","3801.18","3767.54","4248.00","1 through 10","1606.89","11744.28","percent of total billed charges",""
"SLING URINARY INCONTINENCE FEMALE STRESS TRT SYSTEM STERILE","SUP-ITM-10027228","CDM","C1771","HCPCS","0278","RC","","","","both","","","13816.80","8290.08","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10694.20","77.4","","5750.52","5177.35","5750.52","1 through 10","1606.89","11744.28","percent of total billed charges",""
"SLING URINARY INCONTINENCE FEMALE STRESS TRT SYSTEM STERILE","SUP-ITM-10027228","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","13816.80","8290.08","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","8674.19","62.78","","12581.94","12581.94","12581.94","1 through 10","1606.89","10694.2","percent of total billed charges",""
"SLING URINARY INCONTINENCE FEMALE STRESS TRT SYSTEM STERILE","SUP-ITM-10027228","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","13816.80","8290.08","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10047.58","72.72","","4858.02","4858.02","4858.02","1 through 10","1606.89","10694.2","percent of total billed charges",""
"SLING URINARY INCONTINENCE FEMALE STRESS TRT SYSTEM STERILE","SUP-ITM-10027228","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","13816.80","8290.08","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8690.77","62.9","","4208.68","4208.68","4208.68","1 through 10","1606.89","10694.2","percent of total billed charges",""
"SLING URINARY INCONTINENCE FEMALE STRESS TRT SYSTEM STERILE","SUP-ITM-10027228","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","13816.80","8290.08","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10694.20","77.4","","5750.52","5177.35","5750.52","1 through 10","1606.89","10694.2","percent of total billed charges",""
"Slm Epstein Barr Pcr Quant 87799","PX-30003321","CDM","87799","CPT","0300","RC","","","","outpatient","","","230.00","138.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","100.56","43.72","","97.06","97.06","97.06","1 through 10","51.91","178.02","percent of total billed charges",""
"Slm Epstein Barr Pcr Quant 87799","PX-30003321","CDM","87799","CPT","0300","RC","","","","outpatient","","","230.00","138.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","167.26","72.72","","161.44","161.44","484.32","15","51.91","178.02","percent of total billed charges",""
"Slm Epstein Barr Pcr Quant 87799","PX-30003321","CDM","87799","CPT","0300","RC","","","","outpatient","","","230.00","138.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","122.41","53.22","","118.35","118.35","118.35","1 through 10","51.91","178.02","percent of total billed charges",""
"Slm Epstein Barr Pcr Quant 87799","PX-30003321","CDM","87799","CPT","0300","RC","","","","outpatient","","","230.00","138.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","144.67","62.9","","139.86","139.86","419.58","44","51.91","178.02","percent of total billed charges",""
"Slm Epstein Barr Pcr Quant 87799","PX-30003321","CDM","87799","CPT","0300","RC","","","","outpatient","","","230.00","138.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","178.02","77.4","","172.05","172.05","172.05","1 through 10","51.91","178.02","percent of total billed charges",""
"Smear Acid Fast/Fluorescent Stain","PX-30001193","CDM","87206","CPT","0306","RC","","","","both","","","37.00","22.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","25.83","69.8","","25.13","25.13","25.13","1 through 10","3.5","31.45","percent of total billed charges",""
"Smear Acid Fast/Fluorescent Stain","PX-30001193","CDM","87206","CPT","0306","RC","","","","outpatient","","","37.00","22.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","16.18","43.72","","15.74","15.74","15.74","1 through 10","5.01","28.64","percent of total billed charges",""
"Smear Acid Fast/Fluorescent Stain","PX-30001193","CDM","87206","CPT","0306","RC","","","","outpatient","","","37.00","22.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","26.91","72.72","","26.18","26.18","78.54","11","5.01","28.64","percent of total billed charges",""
"Smear Acid Fast/Fluorescent Stain","PX-30001193","CDM","87206","CPT","0306","RC","","","","outpatient","","","37.00","22.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","23.27","62.9","","68.04","68.04","68.04","1 through 10","5.01","28.64","percent of total billed charges",""
"Smear Acid Fast/Fluorescent Stain","PX-30001193","CDM","87206","CPT","0306","RC","","","","outpatient","","","37.00","22.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","28.64","77.4","","27.90","27.88","27.90","1 through 10","5.01","28.64","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0300","RC","","","","inpatient","","","36.00","21.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","27.67","76.86","","22.05","22.05","22.05","1 through 10","23.83","27.67","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","both","","","36.00","21.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","25.13","69.8","","24.43","22.02","24.43","48","2.78","30.6","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","both","","","36.00","21.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","25.13","69.8","","24.43","24.43","24.43","1 through 10","2.78","30.6","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","both","","","36.00","21.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","30.60","85","","24.43","24.43","24.43","1 through 10","2.78","30.6","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","outpatient","","","36.00","21.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","22.60","62.78","","21.97","21.97","65.91","1 through 10","3.98","27.86","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","outpatient","","","36.00","21.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","15.74","43.72","","15.30","15.30","15.30","1 through 10","3.98","27.86","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","outpatient","","","36.00","21.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","26.18","72.72","","25.45","25.45","25.45","58","3.98","27.86","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","outpatient","","","36.00","21.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","26.18","72.72","","25.45","25.45","25.45","1 through 10","3.98","27.86","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","outpatient","","","36.00","21.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","19.16","53.22","","18.66","18.66","18.66","1 through 10","3.98","27.86","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","outpatient","","","36.00","21.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","22.64","62.9","","22.05","22.05","83.56","69","3.98","27.86","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","outpatient","","","36.00","21.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","27.86","77.4","","27.13","27.13","27.13","25","3.98","27.86","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","outpatient","","","36.00","21.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","26.18","72.72","","25.45","25.45","25.45","1 through 10","3.98","27.86","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","both","","","77.00","46.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","53.75","69.8","","46.55","10.14","51.65","14","5.79","65.45","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","outpatient","","","77.00","46.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","48.34","62.78","","46.46","46.46","46.46","1 through 10","8.28","59.6","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","outpatient","","","77.00","46.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","55.99","72.72","","53.81","53.81","161.43","23","8.28","59.6","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","outpatient","","","77.00","46.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","55.99","72.72","","53.81","53.81","53.81","1 through 10","8.28","59.6","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","outpatient","","","77.00","46.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","40.98","53.22","","39.45","39.45","39.45","1 through 10","8.28","59.6","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","outpatient","","","77.00","46.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","48.43","62.9","","46.62","46.62","46.62","31","8.28","59.6","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","outpatient","","","77.00","46.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","59.60","77.4","","57.35","57.35","57.35","1 through 10","8.28","59.6","percent of total billed charges",""
"Smear Wet Mount Infectious Agent","PX-30001196","CDM","87210","CPT","0306","RC","","","","both","","","40.00","24.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","27.92","69.8","","27.22","27.22","27.22","1 through 10","3.78","34","percent of total billed charges",""
"Smear Wet Mount Infectious Agent","PX-30001196","CDM","87210","CPT","0306","RC","","","","both","","","40.00","24.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","27.92","69.8","","27.22","27.22","27.22","1 through 10","3.78","34","percent of total billed charges",""
"Smear Wet Mount Infectious Agent","PX-30001196","CDM","87210","CPT","0306","RC","","","","outpatient","","","40.00","24.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","29.09","72.72","","28.36","28.36","28.36","22","3.83","30.96","percent of total billed charges",""
"Smear Wet Mount Infectious Agent","PX-30001196","CDM","87210","CPT","0306","RC","","","","outpatient","","","40.00","24.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","25.16","62.9","","24.57","24.57","24.57","24","3.83","30.96","percent of total billed charges",""
"Smear Wet Mount Infectious Agent","PX-30001196","CDM","87210","CPT","0306","RC","","","","outpatient","","","40.00","24.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","30.96","77.4","","30.23","30.23","30.23","1 through 10","3.83","30.96","percent of total billed charges",""
"Smear Wet Mount Infectious Agent","PX-30001196","CDM","87210","CPT","0306","RC","","","","outpatient","","","40.00","24.00","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","29.09","72.72","","28.36","28.36","28.36","1 through 10","3.83","30.96","percent of total billed charges",""
"SNARE RETRIEVAL SPYGLASS","SUP-ITM-10212309","CDM","C1889","HCPCS","0272","RC","","","","both","","","3612.41","2167.45","AETNA [1001]","HB WDH AETNA COMMERCIAL","2521.46","69.8","","1552.48","1552.48","1552.48","1 through 10","420.12","3070.55","percent of total billed charges",""
"SNARE RETRIEVAL SPYGLASS","SUP-ITM-10212309","CDM","C1889","HCPCS","0272","RC","","","","both","","","3612.41","2167.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","420.12","3070.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SNARE RETRIEVAL SPYGLASS","SUP-ITM-10212309","CDM","C1889","HCPCS","0272","RC","","","","both","","","3612.41","2167.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","420.12","3070.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SNARE RETRIEVAL SPYGLASS","SUP-ITM-10212309","CDM","C1889","HCPCS","0272","RC","","","","both","","","3612.41","2167.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2055.46","56.9","","0.63","0.63","0.63","1 through 10","420.12","3070.55","percent of total billed charges",""
"SNARE RETRIEVAL SPYGLASS","SUP-ITM-10212309","CDM","C1889","HCPCS","0272","RC","","","","both","","","3612.41","2167.45","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","520.91","14.42","","317.14","317.14","317.14","1 through 10","420.12","3070.55","percent of total billed charges",""
"SNARE RETRIEVAL SPYGLASS","SUP-ITM-10212309","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","3612.41","2167.45","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","520.91","14.42","","317.14","317.14","317.14","1 through 10","420.12","2796.01","percent of total billed charges",""
"SNARE RETRIEVAL SPYGLASS","SUP-ITM-10212309","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","3612.41","2167.45","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2267.87","62.78","","1125.09","1125.09","1125.09","1 through 10","420.12","2796.01","percent of total billed charges",""
"SNARE RETRIEVAL SPYGLASS","SUP-ITM-10212309","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","3612.41","2167.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2626.94","72.72","","4732.50","1617.43","14180.40","1 through 10","420.12","2796.01","percent of total billed charges",""
"SNARE RETRIEVAL SPYGLASS","SUP-ITM-10212309","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","3612.41","2167.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2272.21","62.9","","3896.20","3341.38","3896.20","1 through 10","420.12","2796.01","percent of total billed charges",""
"SNARE VASCULAR 7FR 27 TO 45MM 120CM 100CM ENSNARE NITINOL 3 INTERLACED LOOP","SUP-ITM-10011428","CDM","C1773","HCPCS","0272","RC","","","","both","","","2321.76","1393.06","AETNA [1001]","HB WDH AETNA COMMERCIAL","1620.59","69.8","","421.75","101.11","421.75","1 through 10","270.02","1973.5","percent of total billed charges",""
"SNARE VASCULAR 7FR 27 TO 45MM 120CM 100CM ENSNARE NITINOL 3 INTERLACED LOOP","SUP-ITM-10011428","CDM","C1773","HCPCS","0272","RC","","","","both","","","2321.76","1393.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1032.01","1032.01","1032.01","1 through 10","270.02","1973.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SNARE VASCULAR 7FR 27 TO 45MM 120CM 100CM ENSNARE NITINOL 3 INTERLACED LOOP","SUP-ITM-10011428","CDM","C1773","HCPCS","0272","RC","","","","both","","","2321.76","1393.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1797.04","77.4","","468.85","468.85","468.85","1 through 10","270.02","1973.5","percent of total billed charges",""
"SNARE VASCULAR 7FR 27 TO 45MM 120CM 100CM ENSNARE NITINOL 3 INTERLACED LOOP","SUP-ITM-10011428","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","2321.76","1393.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1460.39","62.9","","381.13","381.13","381.13","1 through 10","270.02","1797.04","percent of total billed charges",""
"SNARE VASCULAR 7FR 27 TO 45MM 120CM 100CM ENSNARE NITINOL 3 INTERLACED LOOP","SUP-ITM-10011428","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","2321.76","1393.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1797.04","77.4","","468.85","468.85","468.85","1 through 10","270.02","1797.04","percent of total billed charges",""
"SNARE VASCULAR 7FRX18-30MM 100CM TORQUE DEVICE INTRODUCER CATHETER ATRIEVE NITINOL","SUP-ITM-10080220","CDM","C1773","HCPCS","0272","RC","","","","both","","","2066.09","1239.65","AETNA [1001]","HB WDH AETNA COMMERCIAL","1442.13","69.8","","421.75","101.11","421.75","1 through 10","240.29","1756.18","percent of total billed charges",""
"SNARE VASCULAR 7FRX18-30MM 100CM TORQUE DEVICE INTRODUCER CATHETER ATRIEVE NITINOL","SUP-ITM-10080220","CDM","C1773","HCPCS","0272","RC","","","","both","","","2066.09","1239.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1032.01","1032.01","1032.01","1 through 10","240.29","1756.18","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SNARE VASCULAR 7FRX18-30MM 100CM TORQUE DEVICE INTRODUCER CATHETER ATRIEVE NITINOL","SUP-ITM-10080220","CDM","C1773","HCPCS","0272","RC","","","","both","","","2066.09","1239.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1599.15","77.4","","468.85","468.85","468.85","1 through 10","240.29","1756.18","percent of total billed charges",""
"SNARE VASCULAR 7FRX18-30MM 100CM TORQUE DEVICE INTRODUCER CATHETER ATRIEVE NITINOL","SUP-ITM-10080220","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","2066.09","1239.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1299.57","62.9","","381.13","381.13","381.13","1 through 10","240.29","1599.15","percent of total billed charges",""
"SNARE VASCULAR 7FRX18-30MM 100CM TORQUE DEVICE INTRODUCER CATHETER ATRIEVE NITINOL","SUP-ITM-10080220","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","2066.09","1239.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1599.15","77.4","","468.85","468.85","468.85","1 through 10","240.29","1599.15","percent of total billed charges",""
"Sodium Serum/Plasma/Whole Blood","PX-30000674","CDM","84295","CPT","0301","RC","","","","both","","","68.00","40.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","47.46","69.8","","46.07","46.07","46.07","1 through 10","3.13","57.8","percent of total billed charges",""
"Sodium Serum/Plasma/Whole Blood","PX-30000674","CDM","84295","CPT","0301","RC","","","","outpatient","","","68.00","40.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","49.45","72.72","","48.00","48.00","48.00","1 through 10","4.34","52.63","percent of total billed charges",""
"Sodium Serum/Plasma/Whole Blood","PX-30000674","CDM","84295","CPT","0301","RC","","","","outpatient","","","68.00","40.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","42.77","62.9","","41.58","41.58","83.16","1 through 10","4.34","52.63","percent of total billed charges",""
"Sodium Serum/Plasma/Whole Blood","PX-30000674","CDM","84295","CPT","0301","RC","","","","outpatient","","","68.00","40.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","52.63","77.4","","51.15","51.15","51.15","1 through 10","4.34","52.63","percent of total billed charges",""
"Sodium Urine","PX-30000675","CDM","84300","CPT","0301","RC","","","","both","","","69.00","41.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","48.16","69.8","","46.77","12.11","46.77","1 through 10","3.29","58.65","percent of total billed charges",""
"Sodium Urine","PX-30000675","CDM","84300","CPT","0301","RC","","","","both","","","69.00","41.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","43.40","62.9","","42.21","42.21","42.21","1 through 10","3.29","58.65","percent of total billed charges",""
"Sodium Urine","PX-30000675","CDM","84300","CPT","0301","RC","","","","both","","","69.00","41.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","53.41","77.4","","51.93","51.93","51.93","1 through 10","3.29","58.65","percent of total billed charges",""
"Sodium Urine","PX-30000675","CDM","84300","CPT","0301","RC","","","","outpatient","","","69.00","41.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","30.17","43.72","","87.87","87.87","87.87","1 through 10","4.53","50.18","percent of total billed charges",""
"Sodium Urine","PX-30000675","CDM","84300","CPT","0301","RC","","","","outpatient","","","69.00","41.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","50.18","72.72","","48.72","48.72","48.72","11","4.53","50.18","percent of total billed charges",""
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","","","","inpatient","","","64118.15","38470.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","26156.61","","Fee schedule rate ($26,156.61). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","26052.92","26052.92","26052.92","1 through 10","3975","66427.97","case rate",""
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","","","","inpatient","","","64118.15","38470.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","52906.74","","Fee schedule rate ($52,906.74). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","52697.01","52697.01","52697.01","1 through 10","3975","66427.97","case rate",""
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","","","","inpatient","","","64118.15","38470.89","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","14146.73","","Case rate ($13,734.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,711.22, add-ons for qualifying new technology services are included. If operating cost exceeds $16,629.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,776.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,318.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,266.36 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.15. The transfer capital threshold is the transfer adjustment factor * $971.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","11808.53","11808.53","11808.53","1 through 10","3975","66427.97","other","Inpatient DRG"
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","","","","inpatient","","","64118.15","38470.89","MEDICARE [2001]","HB WDH MEDICARE","13734.69","","Case rate ($13,734.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,711.22, add-ons for qualifying new technology services are included. If operating cost exceeds $16,629.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,776.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,318.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,266.36 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.15. The transfer capital threshold is the transfer adjustment factor * $971.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13946.43","13946.43","13946.43","1 through 10","3975","66427.97","other","Inpatient DRG"
"Soft Tissue Procedures With McC","500","MS-DRG","","","","","","","","inpatient","","","101619.97","60971.98","MEDICARE [2001]","HB WDH MEDICARE","24505.05","","Case rate ($24,505.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $22,652.16, add-ons for qualifying new technology services are included. If operating cost exceeds $26,570.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,563.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $22,302.00 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $22,207.29 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,758.18. The transfer capital threshold is the transfer adjustment factor * $1,758.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","24354.41","24354.41","24354.41","1 through 10","3975","120262.72","other","Inpatient DRG"
"Soft Tissue Procedures Without Cc/McC","502","MS-DRG","","","","","","","","inpatient","","","41926.79","25156.07","MEDICARE [2001]","HB WDH MEDICARE","10676.99","","Case rate ($10,676.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,889.01, add-ons for qualifying new technology services are included. If operating cost exceeds $13,807.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,552.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $9,484.41 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,444.13 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $747.71. The transfer capital threshold is the transfer adjustment factor * $747.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10987.45","10987.45","10987.45","1 through 10","3975","51144.33","other","Inpatient DRG"
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","both","","","115.00","69.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","80.27","69.8","","73.99","69.82","77.48","1 through 10","13.82","109.86","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","outpatient","","","115.00","69.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","50.28","43.72","","48.53","48.53","48.53","1 through 10","15.75","89.01","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","outpatient","","","115.00","69.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","83.63","72.72","","80.72","80.72","80.72","1 through 10","15.75","89.01","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","outpatient","","","115.00","69.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","83.63","72.72","","80.72","80.72","80.72","1 through 10","15.75","89.01","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","outpatient","","","115.00","69.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","61.20","53.22","","59.17","59.17","59.17","1 through 10","15.75","89.01","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","outpatient","","","115.00","69.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","72.34","62.9","","69.93","69.93","209.79","13","15.75","89.01","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","outpatient","","","115.00","69.00","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","83.63","72.72","","86.03","86.03","86.03","1 through 10","15.75","89.01","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","outpatient","","","115.00","69.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","89.01","77.4","","86.03","72.82","86.03","1 through 10","15.75","89.01","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","both","","","160.00","160.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","","69.8","69.8% of billed. Includes an additional $51.31 of payment.","104.70","51.31","104.70","28","33.35","136","other","COVID Test CPT 87635"
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","both","","","160.00","160.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","91.04","56.9","","85.35","70.66","131.07","85","33.35","136","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","both","","","160.00","160.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","","69.8","69.8% of billed. Includes an additional $51.31 of payment.","127.50","104.70","127.50","1 through 10","33.35","136","other","COVID Test CPT 87635"
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","both","","","160.00","160.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","136.00","85","","127.50","127.50","127.50","1 through 10","33.35","136","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","outpatient","","","160.00","160.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","23.07","14.42","","54.49","54.49","54.49","1 through 10","18.61","123.84","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","outpatient","","","160.00","160.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","18.61","11.63","","53.96","45.27","135.81","137","18.61","123.84","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","outpatient","","","160.00","160.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","123.84","77.4","","116.25","116.25","116.26","18","18.61","123.84","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","outpatient","","","160.00","160.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","18.61","11.63","","161.73","161.73","161.73","1 through 10","18.61","123.84","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","both","","","112.00","112.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","","69.8","69.8% of billed. Includes an additional $51.31 of payment.","104.70","51.31","104.70","28","33.35","95.2","other","COVID Test CPT 87635"
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","both","","","112.00","112.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","63.73","56.9","","85.35","70.66","131.07","85","33.35","95.2","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","both","","","112.00","112.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","","69.8","69.8% of billed. Includes an additional $51.31 of payment.","127.50","104.70","127.50","1 through 10","33.35","95.2","other","COVID Test CPT 87635"
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","both","","","112.00","112.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","95.20","85","","127.50","127.50","127.50","1 through 10","33.35","95.2","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","outpatient","","","112.00","112.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","16.15","14.42","","54.49","54.49","54.49","1 through 10","13.03","86.69","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","outpatient","","","112.00","112.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","13.03","11.63","","53.96","45.27","135.81","137","13.03","86.69","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","outpatient","","","112.00","112.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","86.69","77.4","","116.25","116.25","116.26","18","13.03","86.69","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","outpatient","","","112.00","112.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","13.03","11.63","","161.73","161.73","161.73","1 through 10","13.03","86.69","percent of total billed charges",""
"SPACER 13MM X 20MM AEQUALIS FLEX REVIVE HRS","SUP-ITM-10321136","CDM","C1776","HCPCS","0278","RC","","","","both","","","10413.10","6247.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1211.04","8851.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPACER 13MM X 20MM AEQUALIS FLEX REVIVE HRS","SUP-ITM-10321136","CDM","C1776","HCPCS","0278","RC","","","","both","","","10413.10","6247.86","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5925.05","56.9","","2911.53","1863.86","5209.05","65","1211.04","8851.14","percent of total billed charges",""
"SPACER 13MM X 20MM AEQUALIS FLEX REVIVE HRS","SUP-ITM-10321136","CDM","C1776","HCPCS","0278","RC","","","","both","","","10413.10","6247.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1211.04","11.63","","400.94","400.94","400.94","1 through 10","1211.04","8851.14","percent of total billed charges",""
"SPACER 13MM X 20MM AEQUALIS FLEX REVIVE HRS","SUP-ITM-10321136","CDM","C1776","HCPCS","0278","RC","","","","both","","","10413.10","6247.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8059.74","77.4","","5214.50","5214.50","16415.28","1 through 10","1211.04","8851.14","percent of total billed charges",""
"SPACER 13MM X 20MM AEQUALIS FLEX REVIVE HRS","SUP-ITM-10321136","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10413.10","6247.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1211.04","11.63","","400.94","400.94","400.94","1 through 10","1211.04","8059.74","percent of total billed charges",""
"SPACER 13MM X 20MM AEQUALIS FLEX REVIVE HRS","SUP-ITM-10321136","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10413.10","6247.86","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4552.61","43.72","","1543.33","1543.33","1671.61","1 through 10","1211.04","8059.74","percent of total billed charges",""
"SPACER 13MM X 20MM AEQUALIS FLEX REVIVE HRS","SUP-ITM-10321136","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10413.10","6247.86","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7572.41","72.72","","3700.21","2382.07","6427.18","53","1211.04","8059.74","percent of total billed charges",""
"SPACER 13MM X 20MM AEQUALIS FLEX REVIVE HRS","SUP-ITM-10321136","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10413.10","6247.86","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7572.41","72.72","","12685.80","12685.80","12685.80","1 through 10","1211.04","8059.74","percent of total billed charges",""
"SPACER 13MM X 20MM AEQUALIS FLEX REVIVE HRS","SUP-ITM-10321136","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10413.10","6247.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6549.84","62.9","","3408.87","2784.05","9859.40","46","1211.04","8059.74","percent of total billed charges",""
"SPACER 13MM X 20MM AEQUALIS FLEX REVIVE HRS","SUP-ITM-10321136","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10413.10","6247.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8059.74","77.4","","5214.50","5214.50","16415.28","1 through 10","1211.04","8059.74","percent of total billed charges",""
"SPACER TRIAL 5MM SM 6DEG ENDOSKELETON TC NANOLOCK","SUP-ITM-10287925","CDM","C1821","HCPCS","0278","RC","","","","both","","","5335.00","3201.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3035.62","56.9","","166.05","166.05","166.05","1 through 10","620.46","4534.75","percent of total billed charges",""
"SPACER TRIAL 6MM SM 6DEG ENDOSKELETON TC NANOLOCK","SUP-ITM-10287926","CDM","C1821","HCPCS","0278","RC","","","","both","","","5335.00","3201.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3035.62","56.9","","166.05","166.05","166.05","1 through 10","620.46","4534.75","percent of total billed charges",""
"SPACER TRIAL 9MM SM 6DEG ENDOSKELETON TC NANOLOCK","SUP-ITM-10287929","CDM","C1821","HCPCS","0278","RC","","","","both","","","5335.00","3201.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3035.62","56.9","","166.05","166.05","166.05","1 through 10","620.46","4534.75","percent of total billed charges",""
"Spec Stain Incls Bodies/Parasites","PX-30001194","CDM","87207","CPT","0306","RC","","","","both","","","92.00","55.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","64.22","69.8","","57.24","55.98","62.12","1 through 10","3.89","78.2","percent of total billed charges",""
"Spec Stain Incls Bodies/Parasites","PX-30001194","CDM","87207","CPT","0306","RC","","","","outpatient","","","92.00","55.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","66.90","72.72","","790.46","64.72","790.46","1 through 10","7.18","71.21","percent of total billed charges",""
"Spec Stain Incls Bodies/Parasites","PX-30001194","CDM","87207","CPT","0306","RC","","","","outpatient","","","92.00","55.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","57.87","62.9","","107.20","56.07","168.21","1 through 10","7.18","71.21","percent of total billed charges",""
"Spec Stain Incls Bodies/Parasites","PX-30001194","CDM","87207","CPT","0306","RC","","","","outpatient","","","92.00","55.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","71.21","77.4","","68.91","64.72","68.98","1 through 10","7.18","71.21","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","outpatient","","","311.00","186.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","135.97","43.72","","131.60","131.60","131.60","1 through 10","36.17","240.71","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","outpatient","","","311.00","186.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","226.16","72.72","","218.89","218.89","437.77","18","36.17","240.71","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","outpatient","","","311.00","186.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","165.51","53.22","","160.47","160.46","160.47","1 through 10","36.17","240.71","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","outpatient","","","311.00","186.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","195.62","62.9","","189.63","189.63","568.89","22","36.17","240.71","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","outpatient","","","311.00","186.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","240.71","77.4","","233.28","233.28","233.28","1 through 10","36.17","240.71","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","260.00","156.00","MEDICARE [2001]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","134.69","134.69","134.69","1 through 10","131.98","860.68","other","OPPS APC"
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","260.00","156.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","134.67","","APC Price ($134.67). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","58.41","58.41","58.41","1 through 10","131.98","860.68","other","OPPS APC"
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","outpatient","","","260.00","156.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","113.67","43.72","","109.74","109.74","109.74","1 through 10","30.24","201.24","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","outpatient","","","260.00","156.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","189.07","72.72","","182.53","182.53","182.53","37","30.24","201.24","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","outpatient","","","260.00","156.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","138.37","53.22","","133.81","133.81","133.81","1 through 10","30.24","201.24","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","outpatient","","","260.00","156.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","163.54","62.9","","158.13","158.13","474.39","46","30.24","201.24","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","outpatient","","","260.00","156.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","201.24","77.4","","194.53","194.53","194.53","13","30.24","201.24","percent of total billed charges",""
"Speech Sound Lang Comprehen","PX-44000060","CDM","92523","CPT","0444","RC","","","","both","","","1435.00","861.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","1001.63","69.8","","966.73","966.73","966.73","1 through 10","157.54","1219.75","percent of total billed charges",""
"Speech Sound Lang Comprehen","PX-44000060","CDM","92523","CPT","0444","RC","","","","both","","","1435.00","861.00","TRICARE [160005]","HB WDH MEDICARE","225.58","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($225.58). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($175.91). Each line will be capped at the line billed amount.","230.63","230.63","230.63","1 through 10","157.54","1219.75","fee schedule",""
"Speech Sound Lang Comprehen","PX-44000060","CDM","92523","CPT","0444","RC","","","","both","","","1435.00","861.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","225.58","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($225.58). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($175.91). Each line will be capped at the line billed amount.","222.83","222.33","226.02","1 through 10","157.54","1219.75","fee schedule",""
"Speech Sound Lang Comprehen","PX-44000060","CDM","92523","CPT","0444","RC","","","","outpatient","","","1435.00","861.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","902.62","62.9","","2617.65","872.55","2617.65","1 through 10","166.89","1110.69","percent of total billed charges",""
"Speech Sound Lang Comprehen","PX-44000060","CDM","92523","CPT","0444","RC","","","","outpatient","","","1435.00","861.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","166.89","11.63","","163.59","163.59","163.59","1 through 10","166.89","1110.69","percent of total billed charges",""
"SPINAL ENDPLATE 20X20MM 4DEG LOWER FORTIFY TITANIUM LOCKING LORDOTIC","SUP-ITM-10135104","CDM","C1889","HCPCS","0278","RC","","","","both","","","5251.60","3150.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","610.76","4463.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINAL ENDPLATE 20X20MM 4DEG LOWER FORTIFY TITANIUM LOCKING LORDOTIC","SUP-ITM-10135104","CDM","C1889","HCPCS","0278","RC","","","","both","","","5251.60","3150.96","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","610.76","4463.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINAL ENDPLATE 20X20MM 4DEG LOWER FORTIFY TITANIUM LOCKING LORDOTIC","SUP-ITM-10135104","CDM","C1889","HCPCS","0278","RC","","","","both","","","5251.60","3150.96","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2988.16","56.9","","0.63","0.63","0.63","1 through 10","610.76","4463.86","percent of total billed charges",""
"SPINAL ENDPLATE 20X20MM 4DEG LOWER FORTIFY TITANIUM LOCKING LORDOTIC","SUP-ITM-10135104","CDM","C1889","HCPCS","0278","RC","","","","both","","","5251.60","3150.96","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","757.28","14.42","","317.14","317.14","317.14","1 through 10","610.76","4463.86","percent of total billed charges",""
"SPINAL ENDPLATE 20X20MM 4DEG LOWER FORTIFY TITANIUM LOCKING LORDOTIC","SUP-ITM-10135104","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5251.60","3150.96","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","757.28","14.42","","317.14","317.14","317.14","1 through 10","610.76","4064.74","percent of total billed charges",""
"SPINAL ENDPLATE 20X20MM 4DEG LOWER FORTIFY TITANIUM LOCKING LORDOTIC","SUP-ITM-10135104","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5251.60","3150.96","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3296.95","62.78","","1125.09","1125.09","1125.09","1 through 10","610.76","4064.74","percent of total billed charges",""
"SPINAL ENDPLATE 20X20MM 4DEG LOWER FORTIFY TITANIUM LOCKING LORDOTIC","SUP-ITM-10135104","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5251.60","3150.96","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3818.96","72.72","","4732.50","1617.43","14180.40","1 through 10","610.76","4064.74","percent of total billed charges",""
"SPINAL ENDPLATE 20X20MM 4DEG LOWER FORTIFY TITANIUM LOCKING LORDOTIC","SUP-ITM-10135104","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5251.60","3150.96","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3303.26","62.9","","3896.20","3341.38","3896.20","1 through 10","610.76","4064.74","percent of total billed charges",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions Without Cc/McC","458","MS-DRG","","","","","","","","inpatient","","","70765.21","42459.13","MEDICARE [2001]","HB WDH MEDICARE","32166.78","","Case rate ($32,166.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $29,723.85, add-ons for qualifying new technology services are included. If operating cost exceeds $33,642.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,123.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $29,403.86 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $29,278.98 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,318.06. The transfer capital threshold is the transfer adjustment factor * $2,318.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","33111.42","33111.42","33111.42","1 through 10","3975","158559.22","other","Inpatient DRG"
"SPINAL ROD 25X41X46X14MM FIXATION CORTICAL G-LOK UHMWPE LOOP","SUP-ITM-10191484","CDM","C1713","HCPCS","0278","RC","","","","both","","","2245.75","1347.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","261.18","1908.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINAL ROD 25X41X46X14MM FIXATION CORTICAL G-LOK UHMWPE LOOP","SUP-ITM-10191484","CDM","C1713","HCPCS","0278","RC","","","","both","","","2245.75","1347.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","261.18","1908.89","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINAL ROD 25X41X46X14MM FIXATION CORTICAL G-LOK UHMWPE LOOP","SUP-ITM-10191484","CDM","C1713","HCPCS","0278","RC","","","","both","","","2245.75","1347.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1277.83","56.9","","812.12","238.65","1587.46","163","261.18","1908.89","percent of total billed charges",""
"SPINAL ROD 25X41X46X14MM FIXATION CORTICAL G-LOK UHMWPE LOOP","SUP-ITM-10191484","CDM","C1713","HCPCS","0278","RC","","","","both","","","2245.75","1347.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","261.18","11.63","","112.68","112.68","146.99","38","261.18","1908.89","percent of total billed charges",""
"SPINAL ROD 25X41X46X14MM FIXATION CORTICAL G-LOK UHMWPE LOOP","SUP-ITM-10191484","CDM","C1713","HCPCS","0278","RC","","","","both","","","2245.75","1347.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1738.21","77.4","","303.98","303.98","5854.79","1 through 10","261.18","1908.89","percent of total billed charges",""
"SPINAL ROD 25X41X46X14MM FIXATION CORTICAL G-LOK UHMWPE LOOP","SUP-ITM-10191484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2245.75","1347.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","261.18","11.63","","112.68","112.68","146.99","38","261.18","1738.21","percent of total billed charges",""
"SPINAL ROD 25X41X46X14MM FIXATION CORTICAL G-LOK UHMWPE LOOP","SUP-ITM-10191484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2245.75","1347.45","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1409.88","62.78","","780.86","208.94","10480.28","15","261.18","1738.21","percent of total billed charges",""
"SPINAL ROD 25X41X46X14MM FIXATION CORTICAL G-LOK UHMWPE LOOP","SUP-ITM-10191484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2245.75","1347.45","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","981.84","43.72","","179.76","179.76","179.76","1 through 10","261.18","1738.21","percent of total billed charges",""
"SPINAL ROD 25X41X46X14MM FIXATION CORTICAL G-LOK UHMWPE LOOP","SUP-ITM-10191484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2245.75","1347.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1633.11","72.72","","2355.45","298.99","3965.19","155","261.18","1738.21","percent of total billed charges",""
"SPINAL ROD 25X41X46X14MM FIXATION CORTICAL G-LOK UHMWPE LOOP","SUP-ITM-10191484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2245.75","1347.45","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1633.11","72.72","","3643.09","3643.09","3643.09","1 through 10","261.18","1738.21","percent of total billed charges",""
"SPINAL ROD 25X41X46X14MM FIXATION CORTICAL G-LOK UHMWPE LOOP","SUP-ITM-10191484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2245.75","1347.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1195.19","53.22","","554.28","554.28","554.28","16","261.18","1738.21","percent of total billed charges",""
"SPINAL ROD 25X41X46X14MM FIXATION CORTICAL G-LOK UHMWPE LOOP","SUP-ITM-10191484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2245.75","1347.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1412.58","62.9","","619.64","173.09","2370.64","150","261.18","1738.21","percent of total billed charges",""
"SPINAL ROD 25X41X46X14MM FIXATION CORTICAL G-LOK UHMWPE LOOP","SUP-ITM-10191484","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2245.75","1347.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1738.21","77.4","","303.98","303.98","5854.79","1 through 10","261.18","1738.21","percent of total billed charges",""
"SPINAL ROD 5.5X40MM CURVED TITANIUM","SUP-ITM-10246228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.50","621.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","120.54","881.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINAL ROD 5.5X40MM CURVED TITANIUM","SUP-ITM-10246228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.50","621.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","120.54","881.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINAL ROD 5.5X40MM CURVED TITANIUM","SUP-ITM-10246228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.50","621.90","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","589.77","56.9","","812.12","238.65","1587.46","163","120.54","881.03","percent of total billed charges",""
"SPINAL ROD 5.5X40MM CURVED TITANIUM","SUP-ITM-10246228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.50","621.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","120.54","11.63","","112.68","112.68","146.99","38","120.54","881.03","percent of total billed charges",""
"SPINAL ROD 5.5X40MM CURVED TITANIUM","SUP-ITM-10246228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.50","621.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","802.25","77.4","","303.98","303.98","5854.79","1 through 10","120.54","881.03","percent of total billed charges",""
"SPINAL ROD 5.5X40MM CURVED TITANIUM","SUP-ITM-10246228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","120.54","11.63","","112.68","112.68","146.99","38","120.54","802.25","percent of total billed charges",""
"SPINAL ROD 5.5X40MM CURVED TITANIUM","SUP-ITM-10246228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","650.71","62.78","","780.86","208.94","10480.28","15","120.54","802.25","percent of total billed charges",""
"SPINAL ROD 5.5X40MM CURVED TITANIUM","SUP-ITM-10246228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","453.16","43.72","","179.76","179.76","179.76","1 through 10","120.54","802.25","percent of total billed charges",""
"SPINAL ROD 5.5X40MM CURVED TITANIUM","SUP-ITM-10246228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","753.74","72.72","","2355.45","298.99","3965.19","155","120.54","802.25","percent of total billed charges",""
"SPINAL ROD 5.5X40MM CURVED TITANIUM","SUP-ITM-10246228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","753.74","72.72","","3643.09","3643.09","3643.09","1 through 10","120.54","802.25","percent of total billed charges",""
"SPINAL ROD 5.5X40MM CURVED TITANIUM","SUP-ITM-10246228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","551.63","53.22","","554.28","554.28","554.28","16","120.54","802.25","percent of total billed charges",""
"SPINAL ROD 5.5X40MM CURVED TITANIUM","SUP-ITM-10246228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","651.96","62.9","","619.64","173.09","2370.64","150","120.54","802.25","percent of total billed charges",""
"SPINAL ROD 5.5X40MM CURVED TITANIUM","SUP-ITM-10246228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","802.25","77.4","","303.98","303.98","5854.79","1 through 10","120.54","802.25","percent of total billed charges",""
"SPINAL SPACER 11MM SM 8DEG LUMBAR STAND ALONE INDEPENDENCE","SUP-ITM-10051675","CDM","C1889","HCPCS","0278","RC","","","","both","","","14948.00","8968.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","1738.45","12705.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINAL SPACER 11MM SM 8DEG LUMBAR STAND ALONE INDEPENDENCE","SUP-ITM-10051675","CDM","C1889","HCPCS","0278","RC","","","","both","","","14948.00","8968.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","1738.45","12705.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINAL SPACER 11MM SM 8DEG LUMBAR STAND ALONE INDEPENDENCE","SUP-ITM-10051675","CDM","C1889","HCPCS","0278","RC","","","","both","","","14948.00","8968.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","8505.41","56.9","","0.63","0.63","0.63","1 through 10","1738.45","12705.8","percent of total billed charges",""
"SPINAL SPACER 11MM SM 8DEG LUMBAR STAND ALONE INDEPENDENCE","SUP-ITM-10051675","CDM","C1889","HCPCS","0278","RC","","","","both","","","14948.00","8968.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2155.50","14.42","","317.14","317.14","317.14","1 through 10","1738.45","12705.8","percent of total billed charges",""
"SPINAL SPACER 11MM SM 8DEG LUMBAR STAND ALONE INDEPENDENCE","SUP-ITM-10051675","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","14948.00","8968.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2155.50","14.42","","317.14","317.14","317.14","1 through 10","1738.45","11569.75","percent of total billed charges",""
"SPINAL SPACER 11MM SM 8DEG LUMBAR STAND ALONE INDEPENDENCE","SUP-ITM-10051675","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","14948.00","8968.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","9384.35","62.78","","1125.09","1125.09","1125.09","1 through 10","1738.45","11569.75","percent of total billed charges",""
"SPINAL SPACER 11MM SM 8DEG LUMBAR STAND ALONE INDEPENDENCE","SUP-ITM-10051675","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","14948.00","8968.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10870.19","72.72","","4732.50","1617.43","14180.40","1 through 10","1738.45","11569.75","percent of total billed charges",""
"SPINAL SPACER 11MM SM 8DEG LUMBAR STAND ALONE INDEPENDENCE","SUP-ITM-10051675","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","14948.00","8968.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","9402.29","62.9","","3896.20","3341.38","3896.20","1 through 10","1738.45","11569.75","percent of total billed charges",""
"SPINAL SPACER SM 14X12X5MM 5DEG NOVEL-XS PEEK","SUP-ITM-10041982","CDM","C1889","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","562.54","4111.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINAL SPACER SM 14X12X5MM 5DEG NOVEL-XS PEEK","SUP-ITM-10041982","CDM","C1889","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","562.54","4111.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINAL SPACER SM 14X12X5MM 5DEG NOVEL-XS PEEK","SUP-ITM-10041982","CDM","C1889","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2752.25","56.9","","0.63","0.63","0.63","1 through 10","562.54","4111.45","percent of total billed charges",""
"SPINAL SPACER SM 14X12X5MM 5DEG NOVEL-XS PEEK","SUP-ITM-10041982","CDM","C1889","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","697.50","14.42","","317.14","317.14","317.14","1 through 10","562.54","4111.45","percent of total billed charges",""
"SPINAL SPACER SM 14X12X5MM 5DEG NOVEL-XS PEEK","SUP-ITM-10041982","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","697.50","14.42","","317.14","317.14","317.14","1 through 10","562.54","3743.84","percent of total billed charges",""
"SPINAL SPACER SM 14X12X5MM 5DEG NOVEL-XS PEEK","SUP-ITM-10041982","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3036.67","62.78","","1125.09","1125.09","1125.09","1 through 10","562.54","3743.84","percent of total billed charges",""
"SPINAL SPACER SM 14X12X5MM 5DEG NOVEL-XS PEEK","SUP-ITM-10041982","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3517.47","72.72","","4732.50","1617.43","14180.40","1 through 10","562.54","3743.84","percent of total billed charges",""
"SPINAL SPACER SM 14X12X5MM 5DEG NOVEL-XS PEEK","SUP-ITM-10041982","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3042.47","62.9","","3896.20","3341.38","3896.20","1 through 10","562.54","3743.84","percent of total billed charges",""
"SPINE CAGE 10X18X55MM 10DEG MODULUS XL","SUP-ITM-10212298","CDM","C1821","HCPCS","0278","RC","","","","both","","","15049.00","9029.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","8562.88","56.9","","166.05","166.05","166.05","1 through 10","1750.2","12791.65","percent of total billed charges",""
"SPINE CAGE 3.5X14MM ENDOSKELETON TCS BONE SCREW NONLOCKING","SUP-ITM-10259555","CDM","C1889","HCPCS","0278","RC","","","","both","","","691.00","414.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","80.36","587.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE CAGE 3.5X14MM ENDOSKELETON TCS BONE SCREW NONLOCKING","SUP-ITM-10259555","CDM","C1889","HCPCS","0278","RC","","","","both","","","691.00","414.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","80.36","587.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE CAGE 3.5X14MM ENDOSKELETON TCS BONE SCREW NONLOCKING","SUP-ITM-10259555","CDM","C1889","HCPCS","0278","RC","","","","both","","","691.00","414.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","393.18","56.9","","0.63","0.63","0.63","1 through 10","80.36","587.35","percent of total billed charges",""
"SPINE CAGE 3.5X14MM ENDOSKELETON TCS BONE SCREW NONLOCKING","SUP-ITM-10259555","CDM","C1889","HCPCS","0278","RC","","","","both","","","691.00","414.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","99.64","14.42","","317.14","317.14","317.14","1 through 10","80.36","587.35","percent of total billed charges",""
"SPINE CAGE 3.5X14MM ENDOSKELETON TCS BONE SCREW NONLOCKING","SUP-ITM-10259555","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","99.64","14.42","","317.14","317.14","317.14","1 through 10","80.36","534.83","percent of total billed charges",""
"SPINE CAGE 3.5X14MM ENDOSKELETON TCS BONE SCREW NONLOCKING","SUP-ITM-10259555","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","433.81","62.78","","1125.09","1125.09","1125.09","1 through 10","80.36","534.83","percent of total billed charges",""
"SPINE CAGE 3.5X14MM ENDOSKELETON TCS BONE SCREW NONLOCKING","SUP-ITM-10259555","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","502.50","72.72","","4732.50","1617.43","14180.40","1 through 10","80.36","534.83","percent of total billed charges",""
"SPINE CAGE 3.5X14MM ENDOSKELETON TCS BONE SCREW NONLOCKING","SUP-ITM-10259555","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","691.00","414.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","434.64","62.9","","3896.20","3341.38","3896.20","1 through 10","80.36","534.83","percent of total billed charges",""
"SPINE CONNECTOR 10MM VERTEX SELECT OFFSET CLOSE","SUP-ITM-10081887","CDM","C1889","HCPCS","0278","RC","","","","both","","","1001.95","601.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","116.53","851.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE CONNECTOR 10MM VERTEX SELECT OFFSET CLOSE","SUP-ITM-10081887","CDM","C1889","HCPCS","0278","RC","","","","both","","","1001.95","601.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","116.53","851.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE CONNECTOR 10MM VERTEX SELECT OFFSET CLOSE","SUP-ITM-10081887","CDM","C1889","HCPCS","0278","RC","","","","both","","","1001.95","601.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","570.11","56.9","","0.63","0.63","0.63","1 through 10","116.53","851.66","percent of total billed charges",""
"SPINE CONNECTOR 10MM VERTEX SELECT OFFSET CLOSE","SUP-ITM-10081887","CDM","C1889","HCPCS","0278","RC","","","","both","","","1001.95","601.17","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","144.48","14.42","","317.14","317.14","317.14","1 through 10","116.53","851.66","percent of total billed charges",""
"SPINE CONNECTOR 10MM VERTEX SELECT OFFSET CLOSE","SUP-ITM-10081887","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1001.95","601.17","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","144.48","14.42","","317.14","317.14","317.14","1 through 10","116.53","775.51","percent of total billed charges",""
"SPINE CONNECTOR 10MM VERTEX SELECT OFFSET CLOSE","SUP-ITM-10081887","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1001.95","601.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","629.02","62.78","","1125.09","1125.09","1125.09","1 through 10","116.53","775.51","percent of total billed charges",""
"SPINE CONNECTOR 10MM VERTEX SELECT OFFSET CLOSE","SUP-ITM-10081887","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1001.95","601.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","728.62","72.72","","4732.50","1617.43","14180.40","1 through 10","116.53","775.51","percent of total billed charges",""
"SPINE CONNECTOR 10MM VERTEX SELECT OFFSET CLOSE","SUP-ITM-10081887","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1001.95","601.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","630.23","62.9","","3896.20","3341.38","3896.20","1 through 10","116.53","775.51","percent of total billed charges",""
"SPINE IMPLANT 12MM SUPERION INDIRECT DECOMPRESSION SYSTEM","SUP-ITM-10281293","CDM","C1821","HCPCS","0278","RC","","","","both","","","29488.20","17692.92","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","16778.79","56.9","","166.05","166.05","166.05","1 through 10","3429.48","25064.97","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","both","","","2556.70","1534.02","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","297.34","2173.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","both","","","2556.70","1534.02","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","297.34","2173.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","both","","","2556.70","1534.02","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1454.76","56.9","","812.12","238.65","1587.46","163","297.34","2173.2","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","both","","","2556.70","1534.02","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","297.34","11.63","","112.68","112.68","146.99","38","297.34","2173.2","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","both","","","2556.70","1534.02","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1978.89","77.4","","303.98","303.98","5854.79","1 through 10","297.34","2173.2","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2556.70","1534.02","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","297.34","11.63","","112.68","112.68","146.99","38","297.34","1978.89","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2556.70","1534.02","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1605.10","62.78","","780.86","208.94","10480.28","15","297.34","1978.89","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2556.70","1534.02","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1117.79","43.72","","179.76","179.76","179.76","1 through 10","297.34","1978.89","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2556.70","1534.02","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1859.23","72.72","","2355.45","298.99","3965.19","155","297.34","1978.89","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2556.70","1534.02","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1859.23","72.72","","3643.09","3643.09","3643.09","1 through 10","297.34","1978.89","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2556.70","1534.02","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1360.68","53.22","","554.28","554.28","554.28","16","297.34","1978.89","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2556.70","1534.02","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1608.16","62.9","","619.64","173.09","2370.64","150","297.34","1978.89","percent of total billed charges",""
"SPINE PLATE 10MM CENTERPIECE TITANIUM OPEN DOOR","SUP-ITM-10019196","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2556.70","1534.02","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1978.89","77.4","","303.98","303.98","5854.79","1 through 10","297.34","1978.89","percent of total billed charges",""
"SPINE PLATE 12MM XLIF MODULUS DUAL SIDED MOD","SUP-ITM-10275378","CDM","C1821","HCPCS","0278","RC","","","","both","","","10185.00","6111.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5795.27","56.9","","166.05","166.05","166.05","1 through 10","1184.52","8657.25","percent of total billed charges",""
"SPINE PLATE 2.15X.TO 54.7 75MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10061138","CDM","C1713","HCPCS","0278","RC","","","","both","","","3074.95","1844.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","357.62","2613.71","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE PLATE 2.15X.TO 54.7 75MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10061138","CDM","C1713","HCPCS","0278","RC","","","","both","","","3074.95","1844.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","357.62","2613.71","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE PLATE 2.15X.TO 54.7 75MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10061138","CDM","C1713","HCPCS","0278","RC","","","","both","","","3074.95","1844.97","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1749.65","56.9","","812.12","238.65","1587.46","163","357.62","2613.71","percent of total billed charges",""
"SPINE PLATE 2.15X.TO 54.7 75MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10061138","CDM","C1713","HCPCS","0278","RC","","","","both","","","3074.95","1844.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","357.62","11.63","","112.68","112.68","146.99","38","357.62","2613.71","percent of total billed charges",""
"SPINE PLATE 2.15X.TO 54.7 75MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10061138","CDM","C1713","HCPCS","0278","RC","","","","both","","","3074.95","1844.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2380.01","77.4","","303.98","303.98","5854.79","1 through 10","357.62","2613.71","percent of total billed charges",""
"SPINE PLATE 2.15X.TO 54.7 75MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10061138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3074.95","1844.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","357.62","11.63","","112.68","112.68","146.99","38","357.62","2380.01","percent of total billed charges",""
"SPINE PLATE 2.15X.TO 54.7 75MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10061138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3074.95","1844.97","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1930.45","62.78","","780.86","208.94","10480.28","15","357.62","2380.01","percent of total billed charges",""
"SPINE PLATE 2.15X.TO 54.7 75MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10061138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3074.95","1844.97","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1344.37","43.72","","179.76","179.76","179.76","1 through 10","357.62","2380.01","percent of total billed charges",""
"SPINE PLATE 2.15X.TO 54.7 75MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10061138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3074.95","1844.97","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2236.10","72.72","","2355.45","298.99","3965.19","155","357.62","2380.01","percent of total billed charges",""
"SPINE PLATE 2.15X.TO 54.7 75MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10061138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3074.95","1844.97","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2236.10","72.72","","3643.09","3643.09","3643.09","1 through 10","357.62","2380.01","percent of total billed charges",""
"SPINE PLATE 2.15X.TO 54.7 75MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10061138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3074.95","1844.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1636.49","53.22","","554.28","554.28","554.28","16","357.62","2380.01","percent of total billed charges",""
"SPINE PLATE 2.15X.TO 54.7 75MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10061138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3074.95","1844.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1934.14","62.9","","619.64","173.09","2370.64","150","357.62","2380.01","percent of total billed charges",""
"SPINE PLATE 2.15X.TO 54.7 75MM CROSSLINK TSRH TITANIUM MULTI SPAN LOW PROFILE","SUP-ITM-10061138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3074.95","1844.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2380.01","77.4","","303.98","303.98","5854.79","1 through 10","357.62","2380.01","percent of total billed charges",""
"SPINE PLATE 5.5MMX.TO .2.15 2.95IN CROSSLINK TSRH SS LOW PROFILE","SUP-ITM-10061119","CDM","C1713","HCPCS","0278","RC","","","","both","","","3074.95","1844.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","357.62","2613.71","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE PLATE 5.5MMX.TO .2.15 2.95IN CROSSLINK TSRH SS LOW PROFILE","SUP-ITM-10061119","CDM","C1713","HCPCS","0278","RC","","","","both","","","3074.95","1844.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","357.62","2613.71","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE PLATE 5.5MMX.TO .2.15 2.95IN CROSSLINK TSRH SS LOW PROFILE","SUP-ITM-10061119","CDM","C1713","HCPCS","0278","RC","","","","both","","","3074.95","1844.97","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1749.65","56.9","","812.12","238.65","1587.46","163","357.62","2613.71","percent of total billed charges",""
"SPINE PLATE 5.5MMX.TO .2.15 2.95IN CROSSLINK TSRH SS LOW PROFILE","SUP-ITM-10061119","CDM","C1713","HCPCS","0278","RC","","","","both","","","3074.95","1844.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","357.62","11.63","","112.68","112.68","146.99","38","357.62","2613.71","percent of total billed charges",""
"SPINE PLATE 5.5MMX.TO .2.15 2.95IN CROSSLINK TSRH SS LOW PROFILE","SUP-ITM-10061119","CDM","C1713","HCPCS","0278","RC","","","","both","","","3074.95","1844.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2380.01","77.4","","303.98","303.98","5854.79","1 through 10","357.62","2613.71","percent of total billed charges",""
"SPINE PLATE 5.5MMX.TO .2.15 2.95IN CROSSLINK TSRH SS LOW PROFILE","SUP-ITM-10061119","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3074.95","1844.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","357.62","11.63","","112.68","112.68","146.99","38","357.62","2380.01","percent of total billed charges",""
"SPINE PLATE 5.5MMX.TO .2.15 2.95IN CROSSLINK TSRH SS LOW PROFILE","SUP-ITM-10061119","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3074.95","1844.97","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1930.45","62.78","","780.86","208.94","10480.28","15","357.62","2380.01","percent of total billed charges",""
"SPINE PLATE 5.5MMX.TO .2.15 2.95IN CROSSLINK TSRH SS LOW PROFILE","SUP-ITM-10061119","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3074.95","1844.97","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1344.37","43.72","","179.76","179.76","179.76","1 through 10","357.62","2380.01","percent of total billed charges",""
"SPINE PLATE 5.5MMX.TO .2.15 2.95IN CROSSLINK TSRH SS LOW PROFILE","SUP-ITM-10061119","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3074.95","1844.97","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2236.10","72.72","","2355.45","298.99","3965.19","155","357.62","2380.01","percent of total billed charges",""
"SPINE PLATE 5.5MMX.TO .2.15 2.95IN CROSSLINK TSRH SS LOW PROFILE","SUP-ITM-10061119","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3074.95","1844.97","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2236.10","72.72","","3643.09","3643.09","3643.09","1 through 10","357.62","2380.01","percent of total billed charges",""
"SPINE PLATE 5.5MMX.TO .2.15 2.95IN CROSSLINK TSRH SS LOW PROFILE","SUP-ITM-10061119","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3074.95","1844.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1636.49","53.22","","554.28","554.28","554.28","16","357.62","2380.01","percent of total billed charges",""
"SPINE PLATE 5.5MMX.TO .2.15 2.95IN CROSSLINK TSRH SS LOW PROFILE","SUP-ITM-10061119","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3074.95","1844.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1934.14","62.9","","619.64","173.09","2370.64","150","357.62","2380.01","percent of total billed charges",""
"SPINE PLATE 5.5MMX.TO .2.15 2.95IN CROSSLINK TSRH SS LOW PROFILE","SUP-ITM-10061119","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3074.95","1844.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2380.01","77.4","","303.98","303.98","5854.79","1 through 10","357.62","2380.01","percent of total billed charges",""
"SPINE PLATE 8MM XLIF MODULUS DUAL SIDED MOD","SUP-ITM-10275380","CDM","C1821","HCPCS","0278","RC","","","","both","","","10185.00","6111.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5795.27","56.9","","166.05","166.05","166.05","1 through 10","1184.52","8657.25","percent of total billed charges",""
"SPINE ROD 3.5X240MM SPINAL VERTEX PREBENT OCCIPITO CERVICO THORACIC TITANIUM PRECUT","SUP-ITM-10077266","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.50","621.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","120.54","881.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE ROD 3.5X240MM SPINAL VERTEX PREBENT OCCIPITO CERVICO THORACIC TITANIUM PRECUT","SUP-ITM-10077266","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.50","621.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","120.54","881.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE ROD 3.5X240MM SPINAL VERTEX PREBENT OCCIPITO CERVICO THORACIC TITANIUM PRECUT","SUP-ITM-10077266","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.50","621.90","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","589.77","56.9","","0.63","0.63","0.63","1 through 10","120.54","881.03","percent of total billed charges",""
"SPINE ROD 3.5X240MM SPINAL VERTEX PREBENT OCCIPITO CERVICO THORACIC TITANIUM PRECUT","SUP-ITM-10077266","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.50","621.90","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","149.46","14.42","","317.14","317.14","317.14","1 through 10","120.54","881.03","percent of total billed charges",""
"SPINE ROD 3.5X240MM SPINAL VERTEX PREBENT OCCIPITO CERVICO THORACIC TITANIUM PRECUT","SUP-ITM-10077266","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","149.46","14.42","","317.14","317.14","317.14","1 through 10","120.54","802.25","percent of total billed charges",""
"SPINE ROD 3.5X240MM SPINAL VERTEX PREBENT OCCIPITO CERVICO THORACIC TITANIUM PRECUT","SUP-ITM-10077266","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","650.71","62.78","","1125.09","1125.09","1125.09","1 through 10","120.54","802.25","percent of total billed charges",""
"SPINE ROD 3.5X240MM SPINAL VERTEX PREBENT OCCIPITO CERVICO THORACIC TITANIUM PRECUT","SUP-ITM-10077266","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","753.74","72.72","","4732.50","1617.43","14180.40","1 through 10","120.54","802.25","percent of total billed charges",""
"SPINE ROD 3.5X240MM SPINAL VERTEX PREBENT OCCIPITO CERVICO THORACIC TITANIUM PRECUT","SUP-ITM-10077266","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","651.96","62.9","","3896.20","3341.38","3896.20","1 through 10","120.54","802.25","percent of total billed charges",""
"SPINE ROD 3.5X70MM PRE CUT","SUP-ITM-10260128","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.50","621.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","120.54","881.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE ROD 3.5X70MM PRE CUT","SUP-ITM-10260128","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.50","621.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","120.54","881.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE ROD 3.5X70MM PRE CUT","SUP-ITM-10260128","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.50","621.90","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","589.77","56.9","","812.12","238.65","1587.46","163","120.54","881.03","percent of total billed charges",""
"SPINE ROD 3.5X70MM PRE CUT","SUP-ITM-10260128","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.50","621.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","120.54","11.63","","112.68","112.68","146.99","38","120.54","881.03","percent of total billed charges",""
"SPINE ROD 3.5X70MM PRE CUT","SUP-ITM-10260128","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.50","621.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","802.25","77.4","","303.98","303.98","5854.79","1 through 10","120.54","881.03","percent of total billed charges",""
"SPINE ROD 3.5X70MM PRE CUT","SUP-ITM-10260128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","120.54","11.63","","112.68","112.68","146.99","38","120.54","802.25","percent of total billed charges",""
"SPINE ROD 3.5X70MM PRE CUT","SUP-ITM-10260128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","650.71","62.78","","780.86","208.94","10480.28","15","120.54","802.25","percent of total billed charges",""
"SPINE ROD 3.5X70MM PRE CUT","SUP-ITM-10260128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","453.16","43.72","","179.76","179.76","179.76","1 through 10","120.54","802.25","percent of total billed charges",""
"SPINE ROD 3.5X70MM PRE CUT","SUP-ITM-10260128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","753.74","72.72","","2355.45","298.99","3965.19","155","120.54","802.25","percent of total billed charges",""
"SPINE ROD 3.5X70MM PRE CUT","SUP-ITM-10260128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","753.74","72.72","","3643.09","3643.09","3643.09","1 through 10","120.54","802.25","percent of total billed charges",""
"SPINE ROD 3.5X70MM PRE CUT","SUP-ITM-10260128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","551.63","53.22","","554.28","554.28","554.28","16","120.54","802.25","percent of total billed charges",""
"SPINE ROD 3.5X70MM PRE CUT","SUP-ITM-10260128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","651.96","62.9","","619.64","173.09","2370.64","150","120.54","802.25","percent of total billed charges",""
"SPINE ROD 3.5X70MM PRE CUT","SUP-ITM-10260128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","802.25","77.4","","303.98","303.98","5854.79","1 through 10","120.54","802.25","percent of total billed charges",""
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","both","","","281.24","168.74","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","32.71","239.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","both","","","281.24","168.74","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","32.71","239.05","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","both","","","281.24","168.74","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","160.03","56.9","","0.63","0.63","0.63","1 through 10","32.71","239.05","percent of total billed charges",""
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","both","","","281.24","168.74","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","40.55","14.42","","317.14","317.14","317.14","1 through 10","32.71","239.05","percent of total billed charges",""
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","281.24","168.74","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","40.55","14.42","","317.14","317.14","317.14","1 through 10","32.71","217.68","percent of total billed charges",""
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","281.24","168.74","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","176.56","62.78","","1125.09","1125.09","1125.09","1 through 10","32.71","217.68","percent of total billed charges",""
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","281.24","168.74","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","204.52","72.72","","4732.50","1617.43","14180.40","1 through 10","32.71","217.68","percent of total billed charges",""
"SPINE ROD 4MM 140 FIXATION CARBON FIBER EXTERNAL","SUP-ITM-10094947","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","281.24","168.74","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","176.90","62.9","","3896.20","3341.38","3896.20","1 through 10","32.71","217.68","percent of total billed charges",""
"SPINE ROD 5.5X500MM SPINAL LEGACY TITANIUM PREBENT CURVED THORACIC LUMBAR SACRAL","SUP-ITM-10018305","CDM","C1889","HCPCS","0278","RC","","","","both","","","1382.00","829.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","160.73","1174.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE ROD 5.5X500MM SPINAL LEGACY TITANIUM PREBENT CURVED THORACIC LUMBAR SACRAL","SUP-ITM-10018305","CDM","C1889","HCPCS","0278","RC","","","","both","","","1382.00","829.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","160.73","1174.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE ROD 5.5X500MM SPINAL LEGACY TITANIUM PREBENT CURVED THORACIC LUMBAR SACRAL","SUP-ITM-10018305","CDM","C1889","HCPCS","0278","RC","","","","both","","","1382.00","829.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","786.36","56.9","","0.63","0.63","0.63","1 through 10","160.73","1174.7","percent of total billed charges",""
"SPINE ROD 5.5X500MM SPINAL LEGACY TITANIUM PREBENT CURVED THORACIC LUMBAR SACRAL","SUP-ITM-10018305","CDM","C1889","HCPCS","0278","RC","","","","both","","","1382.00","829.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","199.28","14.42","","317.14","317.14","317.14","1 through 10","160.73","1174.7","percent of total billed charges",""
"SPINE ROD 5.5X500MM SPINAL LEGACY TITANIUM PREBENT CURVED THORACIC LUMBAR SACRAL","SUP-ITM-10018305","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1382.00","829.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","199.28","14.42","","317.14","317.14","317.14","1 through 10","160.73","1069.67","percent of total billed charges",""
"SPINE ROD 5.5X500MM SPINAL LEGACY TITANIUM PREBENT CURVED THORACIC LUMBAR SACRAL","SUP-ITM-10018305","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1382.00","829.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","867.62","62.78","","1125.09","1125.09","1125.09","1 through 10","160.73","1069.67","percent of total billed charges",""
"SPINE ROD 5.5X500MM SPINAL LEGACY TITANIUM PREBENT CURVED THORACIC LUMBAR SACRAL","SUP-ITM-10018305","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1382.00","829.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1004.99","72.72","","4732.50","1617.43","14180.40","1 through 10","160.73","1069.67","percent of total billed charges",""
"SPINE ROD 5.5X500MM SPINAL LEGACY TITANIUM PREBENT CURVED THORACIC LUMBAR SACRAL","SUP-ITM-10018305","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1382.00","829.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","869.28","62.9","","3896.20","3341.38","3896.20","1 through 10","160.73","1069.67","percent of total billed charges",""
"SPINE ROD 50X5.5MM RELINE MAS TITANIUM LORDOTIC","SUP-ITM-10170410","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.50","621.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","120.54","881.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE ROD 50X5.5MM RELINE MAS TITANIUM LORDOTIC","SUP-ITM-10170410","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.50","621.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","120.54","881.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE ROD 50X5.5MM RELINE MAS TITANIUM LORDOTIC","SUP-ITM-10170410","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.50","621.90","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","589.77","56.9","","0.63","0.63","0.63","1 through 10","120.54","881.03","percent of total billed charges",""
"SPINE ROD 50X5.5MM RELINE MAS TITANIUM LORDOTIC","SUP-ITM-10170410","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.50","621.90","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","149.46","14.42","","317.14","317.14","317.14","1 through 10","120.54","881.03","percent of total billed charges",""
"SPINE ROD 50X5.5MM RELINE MAS TITANIUM LORDOTIC","SUP-ITM-10170410","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","149.46","14.42","","317.14","317.14","317.14","1 through 10","120.54","802.25","percent of total billed charges",""
"SPINE ROD 50X5.5MM RELINE MAS TITANIUM LORDOTIC","SUP-ITM-10170410","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","650.71","62.78","","1125.09","1125.09","1125.09","1 through 10","120.54","802.25","percent of total billed charges",""
"SPINE ROD 50X5.5MM RELINE MAS TITANIUM LORDOTIC","SUP-ITM-10170410","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","753.74","72.72","","4732.50","1617.43","14180.40","1 through 10","120.54","802.25","percent of total billed charges",""
"SPINE ROD 50X5.5MM RELINE MAS TITANIUM LORDOTIC","SUP-ITM-10170410","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1036.50","621.90","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","651.96","62.9","","3896.20","3341.38","3896.20","1 through 10","120.54","802.25","percent of total billed charges",""
"SPINE ROD MED CONNECTOR CROSSLINK VERTEX SELECT TI","SUP-ITM-10081875","CDM","C1889","HCPCS","0278","RC","","","","both","","","3074.95","1844.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","357.62","2613.71","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE ROD MED CONNECTOR CROSSLINK VERTEX SELECT TI","SUP-ITM-10081875","CDM","C1889","HCPCS","0278","RC","","","","both","","","3074.95","1844.97","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","357.62","2613.71","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE ROD MED CONNECTOR CROSSLINK VERTEX SELECT TI","SUP-ITM-10081875","CDM","C1889","HCPCS","0278","RC","","","","both","","","3074.95","1844.97","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1749.65","56.9","","0.63","0.63","0.63","1 through 10","357.62","2613.71","percent of total billed charges",""
"SPINE ROD MED CONNECTOR CROSSLINK VERTEX SELECT TI","SUP-ITM-10081875","CDM","C1889","HCPCS","0278","RC","","","","both","","","3074.95","1844.97","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","443.41","14.42","","317.14","317.14","317.14","1 through 10","357.62","2613.71","percent of total billed charges",""
"SPINE ROD MED CONNECTOR CROSSLINK VERTEX SELECT TI","SUP-ITM-10081875","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3074.95","1844.97","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","443.41","14.42","","317.14","317.14","317.14","1 through 10","357.62","2380.01","percent of total billed charges",""
"SPINE ROD MED CONNECTOR CROSSLINK VERTEX SELECT TI","SUP-ITM-10081875","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3074.95","1844.97","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1930.45","62.78","","1125.09","1125.09","1125.09","1 through 10","357.62","2380.01","percent of total billed charges",""
"SPINE ROD MED CONNECTOR CROSSLINK VERTEX SELECT TI","SUP-ITM-10081875","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3074.95","1844.97","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2236.10","72.72","","4732.50","1617.43","14180.40","1 through 10","357.62","2380.01","percent of total billed charges",""
"SPINE ROD MED CONNECTOR CROSSLINK VERTEX SELECT TI","SUP-ITM-10081875","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3074.95","1844.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1934.14","62.9","","3896.20","3341.38","3896.20","1 through 10","357.62","2380.01","percent of total billed charges",""
"SPINE SPACER 0MMX2.4 TO 2.7 PLATE WEDGE VA LCP STAINLESS LOCKING OPENING OSTEOTOMY","SUP-ITM-10095282","CDM","C1713","HCPCS","0278","RC","","","","both","","","5266.80","3160.08","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","612.53","4476.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE SPACER 0MMX2.4 TO 2.7 PLATE WEDGE VA LCP STAINLESS LOCKING OPENING OSTEOTOMY","SUP-ITM-10095282","CDM","C1713","HCPCS","0278","RC","","","","both","","","5266.80","3160.08","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","612.53","4476.78","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE SPACER 0MMX2.4 TO 2.7 PLATE WEDGE VA LCP STAINLESS LOCKING OPENING OSTEOTOMY","SUP-ITM-10095282","CDM","C1713","HCPCS","0278","RC","","","","both","","","5266.80","3160.08","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2996.81","56.9","","812.12","238.65","1587.46","163","612.53","4476.78","percent of total billed charges",""
"SPINE SPACER 0MMX2.4 TO 2.7 PLATE WEDGE VA LCP STAINLESS LOCKING OPENING OSTEOTOMY","SUP-ITM-10095282","CDM","C1713","HCPCS","0278","RC","","","","both","","","5266.80","3160.08","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","612.53","11.63","","112.68","112.68","146.99","38","612.53","4476.78","percent of total billed charges",""
"SPINE SPACER 0MMX2.4 TO 2.7 PLATE WEDGE VA LCP STAINLESS LOCKING OPENING OSTEOTOMY","SUP-ITM-10095282","CDM","C1713","HCPCS","0278","RC","","","","both","","","5266.80","3160.08","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4076.50","77.4","","303.98","303.98","5854.79","1 through 10","612.53","4476.78","percent of total billed charges",""
"SPINE SPACER 0MMX2.4 TO 2.7 PLATE WEDGE VA LCP STAINLESS LOCKING OPENING OSTEOTOMY","SUP-ITM-10095282","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5266.80","3160.08","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","612.53","11.63","","112.68","112.68","146.99","38","612.53","4076.5","percent of total billed charges",""
"SPINE SPACER 0MMX2.4 TO 2.7 PLATE WEDGE VA LCP STAINLESS LOCKING OPENING OSTEOTOMY","SUP-ITM-10095282","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5266.80","3160.08","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3306.50","62.78","","780.86","208.94","10480.28","15","612.53","4076.5","percent of total billed charges",""
"SPINE SPACER 0MMX2.4 TO 2.7 PLATE WEDGE VA LCP STAINLESS LOCKING OPENING OSTEOTOMY","SUP-ITM-10095282","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5266.80","3160.08","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2302.64","43.72","","179.76","179.76","179.76","1 through 10","612.53","4076.5","percent of total billed charges",""
"SPINE SPACER 0MMX2.4 TO 2.7 PLATE WEDGE VA LCP STAINLESS LOCKING OPENING OSTEOTOMY","SUP-ITM-10095282","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5266.80","3160.08","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3830.02","72.72","","2355.45","298.99","3965.19","155","612.53","4076.5","percent of total billed charges",""
"SPINE SPACER 0MMX2.4 TO 2.7 PLATE WEDGE VA LCP STAINLESS LOCKING OPENING OSTEOTOMY","SUP-ITM-10095282","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5266.80","3160.08","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3830.02","72.72","","3643.09","3643.09","3643.09","1 through 10","612.53","4076.5","percent of total billed charges",""
"SPINE SPACER 0MMX2.4 TO 2.7 PLATE WEDGE VA LCP STAINLESS LOCKING OPENING OSTEOTOMY","SUP-ITM-10095282","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5266.80","3160.08","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2802.99","53.22","","554.28","554.28","554.28","16","612.53","4076.5","percent of total billed charges",""
"SPINE SPACER 0MMX2.4 TO 2.7 PLATE WEDGE VA LCP STAINLESS LOCKING OPENING OSTEOTOMY","SUP-ITM-10095282","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5266.80","3160.08","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3312.82","62.9","","619.64","173.09","2370.64","150","612.53","4076.5","percent of total billed charges",""
"SPINE SPACER 0MMX2.4 TO 2.7 PLATE WEDGE VA LCP STAINLESS LOCKING OPENING OSTEOTOMY","SUP-ITM-10095282","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5266.80","3160.08","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4076.50","77.4","","303.98","303.98","5854.79","1 through 10","612.53","4076.5","percent of total billed charges",""
"SPINE SPACER 11X9 26MM LG 4DEG COROENT PEEK IMPACTED NARROW","SUP-ITM-10077076","CDM","C1889","HCPCS","0278","RC","","","","both","","","10670.00","6402.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","1240.92","9069.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE SPACER 11X9 26MM LG 4DEG COROENT PEEK IMPACTED NARROW","SUP-ITM-10077076","CDM","C1889","HCPCS","0278","RC","","","","both","","","10670.00","6402.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","1240.92","9069.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE SPACER 11X9 26MM LG 4DEG COROENT PEEK IMPACTED NARROW","SUP-ITM-10077076","CDM","C1889","HCPCS","0278","RC","","","","both","","","10670.00","6402.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6071.23","56.9","","0.63","0.63","0.63","1 through 10","1240.92","9069.5","percent of total billed charges",""
"SPINE SPACER 11X9 26MM LG 4DEG COROENT PEEK IMPACTED NARROW","SUP-ITM-10077076","CDM","C1889","HCPCS","0278","RC","","","","both","","","10670.00","6402.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1538.61","14.42","","317.14","317.14","317.14","1 through 10","1240.92","9069.5","percent of total billed charges",""
"SPINE SPACER 11X9 26MM LG 4DEG COROENT PEEK IMPACTED NARROW","SUP-ITM-10077076","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10670.00","6402.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1538.61","14.42","","317.14","317.14","317.14","1 through 10","1240.92","8258.58","percent of total billed charges",""
"SPINE SPACER 11X9 26MM LG 4DEG COROENT PEEK IMPACTED NARROW","SUP-ITM-10077076","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10670.00","6402.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6698.63","62.78","","1125.09","1125.09","1125.09","1 through 10","1240.92","8258.58","percent of total billed charges",""
"SPINE SPACER 11X9 26MM LG 4DEG COROENT PEEK IMPACTED NARROW","SUP-ITM-10077076","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10670.00","6402.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7759.22","72.72","","4732.50","1617.43","14180.40","1 through 10","1240.92","8258.58","percent of total billed charges",""
"SPINE SPACER 11X9 26MM LG 4DEG COROENT PEEK IMPACTED NARROW","SUP-ITM-10077076","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10670.00","6402.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6711.43","62.9","","3896.20","3341.38","3896.20","1 through 10","1240.92","8258.58","percent of total billed charges",""
"SPINE SPACER 6X24MM TITAN ADAPTIX","SUP-ITM-10283112","CDM","C1889","HCPCS","0278","RC","","","","both","","","18180.00","10908.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","2114.33","15453","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE SPACER 6X24MM TITAN ADAPTIX","SUP-ITM-10283112","CDM","C1889","HCPCS","0278","RC","","","","both","","","18180.00","10908.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","2114.33","15453","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE SPACER 6X24MM TITAN ADAPTIX","SUP-ITM-10283112","CDM","C1889","HCPCS","0278","RC","","","","both","","","18180.00","10908.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","10344.42","56.9","","0.63","0.63","0.63","1 through 10","2114.33","15453","percent of total billed charges",""
"SPINE SPACER 6X24MM TITAN ADAPTIX","SUP-ITM-10283112","CDM","C1889","HCPCS","0278","RC","","","","both","","","18180.00","10908.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2621.56","14.42","","317.14","317.14","317.14","1 through 10","2114.33","15453","percent of total billed charges",""
"SPINE SPACER 6X24MM TITAN ADAPTIX","SUP-ITM-10283112","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","18180.00","10908.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2621.56","14.42","","317.14","317.14","317.14","1 through 10","2114.33","14071.32","percent of total billed charges",""
"SPINE SPACER 6X24MM TITAN ADAPTIX","SUP-ITM-10283112","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","18180.00","10908.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","11413.40","62.78","","1125.09","1125.09","1125.09","1 through 10","2114.33","14071.32","percent of total billed charges",""
"SPINE SPACER 6X24MM TITAN ADAPTIX","SUP-ITM-10283112","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","18180.00","10908.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","13220.50","72.72","","4732.50","1617.43","14180.40","1 through 10","2114.33","14071.32","percent of total billed charges",""
"SPINE SPACER 6X24MM TITAN ADAPTIX","SUP-ITM-10283112","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","18180.00","10908.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","11435.22","62.9","","3896.20","3341.38","3896.20","1 through 10","2114.33","14071.32","percent of total billed charges",""
"SPINE SPACER 7X24MM ADAPTIX TITAN NANOLOCK","SUP-ITM-10283113","CDM","C1821","HCPCS","0278","RC","","","","both","","","18180.00","10908.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","10344.42","56.9","","166.05","166.05","166.05","1 through 10","2114.33","15453","percent of total billed charges",""
"SPINE SPACER 8.0X18 50MM XL 10DEG PEEK COROENT EXTRA LORDOTIC INTERBODY","SUP-ITM-10031151","CDM","C1889","HCPCS","0278","RC","","","","both","","","15049.00","9029.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","1750.2","12791.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE SPACER 8.0X18 50MM XL 10DEG PEEK COROENT EXTRA LORDOTIC INTERBODY","SUP-ITM-10031151","CDM","C1889","HCPCS","0278","RC","","","","both","","","15049.00","9029.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","1750.2","12791.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE SPACER 8.0X18 50MM XL 10DEG PEEK COROENT EXTRA LORDOTIC INTERBODY","SUP-ITM-10031151","CDM","C1889","HCPCS","0278","RC","","","","both","","","15049.00","9029.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","8562.88","56.9","","0.63","0.63","0.63","1 through 10","1750.2","12791.65","percent of total billed charges",""
"SPINE SPACER 8.0X18 50MM XL 10DEG PEEK COROENT EXTRA LORDOTIC INTERBODY","SUP-ITM-10031151","CDM","C1889","HCPCS","0278","RC","","","","both","","","15049.00","9029.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2170.07","14.42","","317.14","317.14","317.14","1 through 10","1750.2","12791.65","percent of total billed charges",""
"SPINE SPACER 8.0X18 50MM XL 10DEG PEEK COROENT EXTRA LORDOTIC INTERBODY","SUP-ITM-10031151","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","15049.00","9029.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2170.07","14.42","","317.14","317.14","317.14","1 through 10","1750.2","11647.93","percent of total billed charges",""
"SPINE SPACER 8.0X18 50MM XL 10DEG PEEK COROENT EXTRA LORDOTIC INTERBODY","SUP-ITM-10031151","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","15049.00","9029.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","9447.76","62.78","","1125.09","1125.09","1125.09","1 through 10","1750.2","11647.93","percent of total billed charges",""
"SPINE SPACER 8.0X18 50MM XL 10DEG PEEK COROENT EXTRA LORDOTIC INTERBODY","SUP-ITM-10031151","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","15049.00","9029.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10943.63","72.72","","4732.50","1617.43","14180.40","1 through 10","1750.2","11647.93","percent of total billed charges",""
"SPINE SPACER 8.0X18 50MM XL 10DEG PEEK COROENT EXTRA LORDOTIC INTERBODY","SUP-ITM-10031151","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","15049.00","9029.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","9465.82","62.9","","3896.20","3341.38","3896.20","1 through 10","1750.2","11647.93","percent of total billed charges",""
"SPINE SPACER 8X14 11MM CORNERSTONE ASR ALLOGRAFT CORTICAL CANCELLOUS BLOCK","SUP-ITM-10088960","CDM","C1889","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","562.54","4111.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE SPACER 8X14 11MM CORNERSTONE ASR ALLOGRAFT CORTICAL CANCELLOUS BLOCK","SUP-ITM-10088960","CDM","C1889","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","562.54","4111.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE SPACER 8X14 11MM CORNERSTONE ASR ALLOGRAFT CORTICAL CANCELLOUS BLOCK","SUP-ITM-10088960","CDM","C1889","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2752.25","56.9","","0.63","0.63","0.63","1 through 10","562.54","4111.45","percent of total billed charges",""
"SPINE SPACER 8X14 11MM CORNERSTONE ASR ALLOGRAFT CORTICAL CANCELLOUS BLOCK","SUP-ITM-10088960","CDM","C1889","HCPCS","0278","RC","","","","both","","","4837.00","2902.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","697.50","14.42","","317.14","317.14","317.14","1 through 10","562.54","4111.45","percent of total billed charges",""
"SPINE SPACER 8X14 11MM CORNERSTONE ASR ALLOGRAFT CORTICAL CANCELLOUS BLOCK","SUP-ITM-10088960","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","697.50","14.42","","317.14","317.14","317.14","1 through 10","562.54","3743.84","percent of total billed charges",""
"SPINE SPACER 8X14 11MM CORNERSTONE ASR ALLOGRAFT CORTICAL CANCELLOUS BLOCK","SUP-ITM-10088960","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3036.67","62.78","","1125.09","1125.09","1125.09","1 through 10","562.54","3743.84","percent of total billed charges",""
"SPINE SPACER 8X14 11MM CORNERSTONE ASR ALLOGRAFT CORTICAL CANCELLOUS BLOCK","SUP-ITM-10088960","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3517.47","72.72","","4732.50","1617.43","14180.40","1 through 10","562.54","3743.84","percent of total billed charges",""
"SPINE SPACER 8X14 11MM CORNERSTONE ASR ALLOGRAFT CORTICAL CANCELLOUS BLOCK","SUP-ITM-10088960","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4837.00","2902.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3042.47","62.9","","3896.20","3341.38","3896.20","1 through 10","562.54","3743.84","percent of total billed charges",""
"SPINE SPACER 8X18 55MM XL COROENT F PEEK STAND ALONE","SUP-ITM-10057511","CDM","C1889","HCPCS","0278","RC","","","","both","","","17149.80","10289.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","1994.52","14577.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE SPACER 8X18 55MM XL COROENT F PEEK STAND ALONE","SUP-ITM-10057511","CDM","C1889","HCPCS","0278","RC","","","","both","","","17149.80","10289.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","1994.52","14577.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE SPACER 8X18 55MM XL COROENT F PEEK STAND ALONE","SUP-ITM-10057511","CDM","C1889","HCPCS","0278","RC","","","","both","","","17149.80","10289.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","9758.24","56.9","","0.63","0.63","0.63","1 through 10","1994.52","14577.33","percent of total billed charges",""
"SPINE SPACER 8X18 55MM XL COROENT F PEEK STAND ALONE","SUP-ITM-10057511","CDM","C1889","HCPCS","0278","RC","","","","both","","","17149.80","10289.88","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2473.00","14.42","","317.14","317.14","317.14","1 through 10","1994.52","14577.33","percent of total billed charges",""
"SPINE SPACER 8X18 55MM XL COROENT F PEEK STAND ALONE","SUP-ITM-10057511","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","17149.80","10289.88","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2473.00","14.42","","317.14","317.14","317.14","1 through 10","1994.52","13273.95","percent of total billed charges",""
"SPINE SPACER 8X18 55MM XL COROENT F PEEK STAND ALONE","SUP-ITM-10057511","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","17149.80","10289.88","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","10766.64","62.78","","1125.09","1125.09","1125.09","1 through 10","1994.52","13273.95","percent of total billed charges",""
"SPINE SPACER 8X18 55MM XL COROENT F PEEK STAND ALONE","SUP-ITM-10057511","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","17149.80","10289.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","12471.33","72.72","","4732.50","1617.43","14180.40","1 through 10","1994.52","13273.95","percent of total billed charges",""
"SPINE SPACER 8X18 55MM XL COROENT F PEEK STAND ALONE","SUP-ITM-10057511","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","17149.80","10289.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","10787.22","62.9","","3896.20","3341.38","3896.20","1 through 10","1994.52","13273.95","percent of total billed charges",""
"SPINE SPACER LG 10MM 8DEG PERIMETER","SUP-ITM-10110681","CDM","C1889","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","1128.11","8245","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE SPACER LG 10MM 8DEG PERIMETER","SUP-ITM-10110681","CDM","C1889","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","1128.11","8245","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPINE SPACER LG 10MM 8DEG PERIMETER","SUP-ITM-10110681","CDM","C1889","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5519.30","56.9","","0.63","0.63","0.63","1 through 10","1128.11","8245","percent of total billed charges",""
"SPINE SPACER LG 10MM 8DEG PERIMETER","SUP-ITM-10110681","CDM","C1889","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1398.74","14.42","","317.14","317.14","317.14","1 through 10","1128.11","8245","percent of total billed charges",""
"SPINE SPACER LG 10MM 8DEG PERIMETER","SUP-ITM-10110681","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1398.74","14.42","","317.14","317.14","317.14","1 through 10","1128.11","7507.8","percent of total billed charges",""
"SPINE SPACER LG 10MM 8DEG PERIMETER","SUP-ITM-10110681","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6089.66","62.78","","1125.09","1125.09","1125.09","1 through 10","1128.11","7507.8","percent of total billed charges",""
"SPINE SPACER LG 10MM 8DEG PERIMETER","SUP-ITM-10110681","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7053.84","72.72","","4732.50","1617.43","14180.40","1 through 10","1128.11","7507.8","percent of total billed charges",""
"SPINE SPACER LG 10MM 8DEG PERIMETER","SUP-ITM-10110681","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6101.30","62.9","","3896.20","3341.38","3896.20","1 through 10","1128.11","7507.8","percent of total billed charges",""
"Spirometry/Pft Cplx","PX-46000021","CDM","94070","CPT","0460","RC","","","","both","","","1218.00","730.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2079.19","","Case rate ($2,079.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2012.94","2012.94","2012.94","1 through 10","318.83","2079.19","other","OPPS APC"
"Spirometry/Pft Cplx","PX-46000021","CDM","94070","CPT","0460","RC","","","","both","","","1218.00","730.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","895.30","","Case rate ($895.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","873.47","873.47","873.47","1 through 10","318.83","2079.19","other","OPPS APC"
"Spirometry/Pft Cplx","PX-46000021","CDM","94070","CPT","0460","RC","","","","both","","","1218.00","730.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","318.83","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","325.38","320.17","325.38","1 through 10","318.83","2079.19","other","OPPS APC"
"Spirometry/Pft Cplx","PX-46000021","CDM","94070","CPT","0460","RC","","","","both","","","1218.00","730.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","693.04","56.9","","668.58","540.04","2493.30","1 through 10","318.83","2079.19","percent of total billed charges",""
"Spirometry/Pft Cplx","PX-46000021","CDM","94070","CPT","0460","RC","","","","both","","","1218.00","730.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","325.38","319.85","325.38","1 through 10","318.83","2079.19","other","OPPS APC"
"Spirometry/Pft Cplx","PX-46000021","CDM","94070","CPT","0460","RC","","","","both","","","1218.00","730.80","MEDICARE [2001]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","325.38","305.82","976.14","20","318.83","2079.19","other","OPPS APC"
"Spirometry/Pft Cplx","PX-46000021","CDM","94070","CPT","0460","RC","","","","both","","","1218.00","730.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","319.38","300.61","325.38","1 through 10","318.83","2079.19","other","OPPS APC"
"Spirometry/Pft Cplx","PX-46000021","CDM","94070","CPT","0460","RC","","","","outpatient","","","1218.00","730.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","141.65","11.63","","161.80","143.82","161.80","1 through 10","141.65","942.73","percent of total billed charges",""
"Spirometry/Pft Cplx","PX-46000021","CDM","94070","CPT","0460","RC","","","","outpatient","","","1218.00","730.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","532.51","43.72","","513.71","513.71","513.71","1 through 10","141.65","942.73","percent of total billed charges",""
"Spirometry/Pft Cplx","PX-46000021","CDM","94070","CPT","0460","RC","","","","outpatient","","","1218.00","730.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","885.73","72.72","","854.46","854.46","854.46","1 through 10","141.65","942.73","percent of total billed charges",""
"Spirometry/Pft Cplx","PX-46000021","CDM","94070","CPT","0460","RC","","","","outpatient","","","1218.00","730.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","885.73","72.72","","854.46","854.46","854.46","1 through 10","141.65","942.73","percent of total billed charges",""
"Spirometry/Pft Cplx","PX-46000021","CDM","94070","CPT","0460","RC","","","","outpatient","","","1218.00","730.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","766.12","62.9","","740.25","740.25","740.25","1 through 10","141.65","942.73","percent of total billed charges",""
"Spirometry/Pft Cplx","PX-46000021","CDM","94070","CPT","0460","RC","","","","outpatient","","","1218.00","730.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","141.65","11.63","","138.79","138.79","138.79","1 through 10","141.65","942.73","percent of total billed charges",""
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","910.00","546.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","635.18","69.8","","612.84","612.84","612.84","1 through 10","318.83","2079.19","percent of total billed charges",""
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","910.00","546.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2079.19","","Case rate ($2,079.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1962.83","1962.83","2028.48","26","318.83","2079.19","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","910.00","546.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","895.30","","Case rate ($895.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","873.47","856.04","873.47","50","318.83","2079.19","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","910.00","546.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","318.83","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","320.17","318.87","325.38","59","318.83","2079.19","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","910.00","546.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1680.59","","Case rate ($1,680.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1639.59","873.47","1639.59","25","318.83","2079.19","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","910.00","546.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","517.79","56.9","","499.58","499.58","499.58","50","318.83","2079.19","percent of total billed charges",""
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","910.00","546.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","335.10","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","329.44","328.44","329.44","31","318.83","2079.19","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","910.00","546.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","319.85","319.20","325.38","90","318.83","2079.19","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","910.00","546.00","MEDICARE [2001]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","325.38","325.38","325.38","303","318.83","2079.19","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","910.00","546.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","773.50","85","","499.58","489.86","499.58","1 through 10","318.83","2079.19","percent of total billed charges",""
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","910.00","546.00","TRICARE [160005]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","325.38","325.38","325.38","1 through 10","318.83","2079.19","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","910.00","546.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","319.88","318.88","325.38","146","318.83","2079.19","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","910.00","546.00","WELLSENSE NH [1050]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","334.82","334.82","341.65","13","318.83","2079.19","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","outpatient","","","910.00","546.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","131.22","14.42","","126.61","108.52","126.61","22","105.83","704.34","percent of total billed charges",""
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","outpatient","","","910.00","546.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","105.83","11.63","","107.47","103.70","120.90","35","105.83","704.34","percent of total billed charges",""
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","outpatient","","","910.00","546.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","397.85","43.72","","383.86","383.86","383.86","1 through 10","105.83","704.34","percent of total billed charges",""
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","outpatient","","","910.00","546.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","661.75","72.72","","638.48","638.48","638.48","20","105.83","704.34","percent of total billed charges",""
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","outpatient","","","910.00","546.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","661.75","72.72","","638.48","638.48","638.48","1 through 10","105.83","704.34","percent of total billed charges",""
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","outpatient","","","910.00","546.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","572.39","62.9","","553.14","553.14","553.14","43","105.83","704.34","percent of total billed charges",""
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","outpatient","","","910.00","546.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","704.34","77.4","","680.45","638.48","680.45","14","105.83","704.34","percent of total billed charges",""
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","outpatient","","","910.00","546.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","105.83","11.63","","103.70","103.70","515.40","24","105.83","704.34","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","306.00","183.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","213.59","69.8","","205.91","205.91","205.91","1 through 10","160.19","1044.65","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","306.00","183.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1044.65","","Case rate ($1,044.65). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","295.00","295.00","1019.18","18","160.19","1044.65","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","306.00","183.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","449.83","","Case rate ($449.83). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","295.00","295.00","438.86","42","160.19","1044.65","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","306.00","183.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","160.19","","APC Price ($163.46). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","160.21","160.21","277.92","12","160.19","1044.65","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","306.00","183.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","844.38","","Case rate ($844.38). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","295.00","295.00","295.00","20","160.19","1044.65","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","306.00","183.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","174.11","56.9","","167.86","167.86","167.86","16","160.19","1044.65","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","306.00","183.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","168.37","","APC Price ($163.46). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","166.01","166.01","166.01","1 through 10","160.19","1044.65","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","306.00","183.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","163.46","","APC Price ($163.46). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","160.21","160.21","163.48","23","160.19","1044.65","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","306.00","183.60","MEDICARE [2001]","HB WDH MEDICARE","163.46","","APC Price ($163.46). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","163.48","163.48","163.48","61","160.19","1044.65","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","306.00","183.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","163.46","","APC Price ($163.46). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","160.72","160.22","161.22","17","160.19","1044.65","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","306.00","183.60","WELLSENSE NH [1050]","HB WDH MEDICARE","163.46","","APC Price ($163.46). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","168.22","168.22","168.22","1 through 10","160.19","1044.65","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","outpatient","","","306.00","183.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","44.13","14.42","","42.54","36.46","42.54","1 through 10","35.59","236.84","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","outpatient","","","306.00","183.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","35.59","11.63","","40.62","34.84","104.52","71","35.59","236.84","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","outpatient","","","306.00","183.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","192.11","62.78","","185.20","185.20","185.20","1 through 10","35.59","236.84","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","outpatient","","","306.00","183.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","222.52","72.72","","214.52","214.52","413.02","1 through 10","35.59","236.84","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","outpatient","","","306.00","183.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","222.52","72.72","","214.52","214.52","214.52","1 through 10","35.59","236.84","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","outpatient","","","306.00","183.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","192.47","62.9","","185.85","185.85","185.85","15","35.59","236.84","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","outpatient","","","306.00","183.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","236.84","77.4","","228.63","228.63","228.63","1 through 10","35.59","236.84","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","outpatient","","","306.00","183.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","35.59","11.63","","34.84","34.84","174.20","46","35.59","236.84","percent of total billed charges",""
"SPOOL HUMERAL SMALL ELBOW CENTERED LATITUDE","SUP-ITM-10267021","CDM","C1776","HCPCS","0278","RC","","","","both","","","8783.35","5270.01","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1021.5","7465.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SPOOL HUMERAL SMALL ELBOW CENTERED LATITUDE","SUP-ITM-10267021","CDM","C1776","HCPCS","0278","RC","","","","both","","","8783.35","5270.01","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4997.73","56.9","","2911.53","1863.86","5209.05","65","1021.5","7465.85","percent of total billed charges",""
"SPOOL HUMERAL SMALL ELBOW CENTERED LATITUDE","SUP-ITM-10267021","CDM","C1776","HCPCS","0278","RC","","","","both","","","8783.35","5270.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1021.50","11.63","","400.94","400.94","400.94","1 through 10","1021.5","7465.85","percent of total billed charges",""
"SPOOL HUMERAL SMALL ELBOW CENTERED LATITUDE","SUP-ITM-10267021","CDM","C1776","HCPCS","0278","RC","","","","both","","","8783.35","5270.01","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6798.31","77.4","","5214.50","5214.50","16415.28","1 through 10","1021.5","7465.85","percent of total billed charges",""
"SPOOL HUMERAL SMALL ELBOW CENTERED LATITUDE","SUP-ITM-10267021","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8783.35","5270.01","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1021.50","11.63","","400.94","400.94","400.94","1 through 10","1021.5","6798.31","percent of total billed charges",""
"SPOOL HUMERAL SMALL ELBOW CENTERED LATITUDE","SUP-ITM-10267021","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8783.35","5270.01","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3840.08","43.72","","1543.33","1543.33","1671.61","1 through 10","1021.5","6798.31","percent of total billed charges",""
"SPOOL HUMERAL SMALL ELBOW CENTERED LATITUDE","SUP-ITM-10267021","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8783.35","5270.01","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6387.25","72.72","","3700.21","2382.07","6427.18","53","1021.5","6798.31","percent of total billed charges",""
"SPOOL HUMERAL SMALL ELBOW CENTERED LATITUDE","SUP-ITM-10267021","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8783.35","5270.01","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6387.25","72.72","","12685.80","12685.80","12685.80","1 through 10","1021.5","6798.31","percent of total billed charges",""
"SPOOL HUMERAL SMALL ELBOW CENTERED LATITUDE","SUP-ITM-10267021","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8783.35","5270.01","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5524.73","62.9","","3408.87","2784.05","9859.40","46","1021.5","6798.31","percent of total billed charges",""
"SPOOL HUMERAL SMALL ELBOW CENTERED LATITUDE","SUP-ITM-10267021","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8783.35","5270.01","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6798.31","77.4","","5214.50","5214.50","16415.28","1 through 10","1021.5","6798.31","percent of total billed charges",""
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/McC","537","MS-DRG","","","","","","","","inpatient","","","18765.59","11259.35","MEDICARE [2001]","HB WDH MEDICARE","7699.87","","Case rate ($7,699.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,141.16, add-ons for qualifying new technology services are included. If operating cost exceeds $11,059.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,335.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $6,724.85 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,696.29 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.16. The transfer capital threshold is the transfer adjustment factor * $530.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","444.93","444.93","444.93","1 through 10","3975","36263.5","other","Inpatient DRG"
"Srh Ag Detect Ia Mult","PX-30003328","CDM","87449","CPT","0300","RC","","","","both","","","103.00","61.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","71.89","69.8","","62.90","62.90","64.92","1 through 10","7.79","87.55","percent of total billed charges",""
"Srh Ag Detect Ia Mult","PX-30003328","CDM","87449","CPT","0300","RC","","","","inpatient","","","103.00","61.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","79.17","76.86","","63.00","63.00","63.00","1 through 10","68.19","79.17","percent of total billed charges",""
"Srh Ag Detect Ia Mult","PX-30003328","CDM","87449","CPT","0300","RC","","","","outpatient","","","103.00","61.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","74.90","72.72","","72.72","72.72","72.72","1 through 10","10.68","79.72","percent of total billed charges",""
"Srh Ag Detect Ia Mult","PX-30003328","CDM","87449","CPT","0300","RC","","","","outpatient","","","103.00","61.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","64.79","62.9","","63.00","63.00","63.00","1 through 10","10.68","79.72","percent of total billed charges",""
"Srh Ag Detect Ia Mult","PX-30003328","CDM","87449","CPT","0300","RC","","","","outpatient","","","103.00","61.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","79.72","77.4","","77.50","77.50","77.50","1 through 10","10.68","79.72","percent of total billed charges",""
"St Eval Oral/Swallow Function","PX-44000011","CDM","92610","CPT","0444","RC","","","","both","","","532.00","319.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","371.34","69.8","","358.07","322.68","358.07","1 through 10","69.63","452.2","percent of total billed charges",""
"St Eval Oral/Swallow Function","PX-44000011","CDM","92610","CPT","0444","RC","","","","outpatient","","","532.00","319.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","334.63","62.9","","969.57","323.19","969.57","1 through 10","61.87","411.77","percent of total billed charges",""
"St Eval Oral/Swallow Function","PX-44000011","CDM","92610","CPT","0444","RC","","","","outpatient","","","532.00","319.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","61.87","11.63","","60.60","60.60","60.60","1 through 10","61.87","411.77","percent of total billed charges",""
"St Eval Swallow Video/Fluoro","PX-44000012","CDM","92611","CPT","0444","RC","","","","both","","","661.00","396.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","461.38","69.8","","445.32","401.30","445.32","1 through 10","90.28","561.85","percent of total billed charges",""
"St Eval Swallow Video/Fluoro","PX-44000012","CDM","92611","CPT","0444","RC","","","","both","","","661.00","396.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","561.85","85","","126.39","126.39","126.39","1 through 10","90.28","561.85","percent of total billed charges",""
"St Eval Swallow Video/Fluoro","PX-44000012","CDM","92611","CPT","0444","RC","","","","outpatient","","","661.00","396.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","415.77","62.9","","401.94","401.94","401.94","1 through 10","76.87","511.61","percent of total billed charges",""
"St Eval Swallow Video/Fluoro","PX-44000012","CDM","92611","CPT","0444","RC","","","","outpatient","","","661.00","396.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","76.87","11.63","","75.36","75.36","75.36","1 through 10","76.87","511.61","percent of total billed charges",""
"St Evaluation Aphasia per Hr","PX-44000020","CDM","96105","CPT","0444","RC","","","","outpatient","","","765.00","459.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","556.31","72.72","","536.67","536.67","536.67","1 through 10","88.97","592.11","percent of total billed charges",""
"St Evaluation Aphasia per Hr","PX-44000020","CDM","96105","CPT","0444","RC","","","","outpatient","","","765.00","459.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","481.19","62.9","","464.94","464.94","464.94","1 through 10","88.97","592.11","percent of total billed charges",""
"St Evaluation Aphasia per Hr","PX-44000020","CDM","96105","CPT","0444","RC","","","","outpatient","","","765.00","459.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","88.97","11.63","","87.17","87.17","87.17","1 through 10","88.97","592.11","percent of total billed charges",""
"St Treat Swallow/Oral","PX-44000001","CDM","92526","CPT","0441","RC","","","","both","","","365.00","219.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","83.71","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($83.71). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($63.81). Each line will be capped at the line billed amount.","82.68","82.21","84.40","14","83.71","385.06","fee schedule",""
"St Treat Swallow/Oral","PX-44000001","CDM","92526","CPT","0441","RC","","","","outpatient","","","365.00","219.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","229.59","62.9","","221.76","221.76","443.52","1 through 10","42.45","282.51","percent of total billed charges",""
"St Treat Swallow/Oral","PX-44000001","CDM","92526","CPT","0441","RC","","","","outpatient","","","365.00","219.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","42.45","11.63","","41.58","41.58","41.58","1 through 10","42.45","282.51","percent of total billed charges",""
"St Treatment Speech/Lang/Comm Ind","PX-44000005","CDM","92507","CPT","0441","RC","","","","both","","","577.00","346.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","388.79","388.79","388.79","15","75.74","490.45","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"St Treatment Speech/Lang/Comm Ind","PX-44000005","CDM","92507","CPT","0441","RC","","","","both","","","577.00","346.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","361.55","361.55","361.55","1 through 10","75.74","490.45","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"St Treatment Speech/Lang/Comm Ind","PX-44000005","CDM","92507","CPT","0441","RC","","","","both","","","577.00","346.20","TRICARE [160005]","HB WDH MEDICARE","75.74","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($75.74). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($59.18). Each line will be capped at the line billed amount.","76.03","76.03","77.21","1 through 10","75.74","490.45","fee schedule",""
"St Treatment Speech/Lang/Comm Ind","PX-44000005","CDM","92507","CPT","0441","RC","","","","both","","","577.00","346.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","75.74","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($75.74). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($59.18). Each line will be capped at the line billed amount.","74.91","74.51","75.67","93","75.74","490.45","fee schedule",""
"St Treatment Speech/Lang/Comm Ind","PX-44000005","CDM","92507","CPT","0441","RC","","","","outpatient","","","577.00","346.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","419.59","72.72","","405.05","405.05","405.05","1 through 10","67.11","446.6","percent of total billed charges",""
"St Treatment Speech/Lang/Comm Ind","PX-44000005","CDM","92507","CPT","0441","RC","","","","outpatient","","","577.00","346.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","362.93","62.9","","350.91","350.91","350.91","36","67.11","446.6","percent of total billed charges",""
"St Treatment Speech/Lang/Comm Ind","PX-44000005","CDM","92507","CPT","0441","RC","","","","outpatient","","","577.00","346.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","67.11","11.63","","65.79","65.79","65.79","18","67.11","446.6","percent of total billed charges",""
"Standardized Cognitive Prformance Testiing, per Hr (Gn)","PX-44000087","CDM","96125","CPT","0440","RC","","","","both","","","808.00","484.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","100.54","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($100.54). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($78.30). Each line will be capped at the line billed amount.","99.31","98.91","99.41","1 through 10","100.54","686.8","fee schedule",""
"Standardized Cognitive Prformance Testiing, per Hr (Gn)","PX-44000087","CDM","96125","CPT","0440","RC","","","","outpatient","","","808.00","484.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","587.58","72.72","","567.22","567.22","567.22","1 through 10","93.97","625.39","percent of total billed charges",""
"Standardized Cognitive Prformance Testiing, per Hr (Gn)","PX-44000087","CDM","96125","CPT","0440","RC","","","","outpatient","","","808.00","484.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","508.23","62.9","","491.40","491.40","491.40","1 through 10","93.97","625.39","percent of total billed charges",""
"Standardized Cognitive Prformance Testiing, per Hr (Gn)","PX-44000087","CDM","96125","CPT","0440","RC","","","","outpatient","","","808.00","484.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","93.97","11.63","","92.13","92.13","92.13","1 through 10","93.97","625.39","percent of total billed charges",""
"STAPLE BONE 7.94X23.22MM SMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003831","CDM","C1713","HCPCS","0278","RC","","","","both","","","3765.95","2259.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","437.98","3201.06","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STAPLE BONE 7.94X23.22MM SMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003831","CDM","C1713","HCPCS","0278","RC","","","","both","","","3765.95","2259.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","437.98","3201.06","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STAPLE BONE 7.94X23.22MM SMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003831","CDM","C1713","HCPCS","0278","RC","","","","both","","","3765.95","2259.57","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2142.83","56.9","","812.12","238.65","1587.46","163","437.98","3201.06","percent of total billed charges",""
"STAPLE BONE 7.94X23.22MM SMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003831","CDM","C1713","HCPCS","0278","RC","","","","both","","","3765.95","2259.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","437.98","11.63","","112.68","112.68","146.99","38","437.98","3201.06","percent of total billed charges",""
"STAPLE BONE 7.94X23.22MM SMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003831","CDM","C1713","HCPCS","0278","RC","","","","both","","","3765.95","2259.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2914.85","77.4","","303.98","303.98","5854.79","1 through 10","437.98","3201.06","percent of total billed charges",""
"STAPLE BONE 7.94X23.22MM SMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3765.95","2259.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","437.98","11.63","","112.68","112.68","146.99","38","437.98","2914.85","percent of total billed charges",""
"STAPLE BONE 7.94X23.22MM SMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3765.95","2259.57","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2364.26","62.78","","780.86","208.94","10480.28","15","437.98","2914.85","percent of total billed charges",""
"STAPLE BONE 7.94X23.22MM SMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3765.95","2259.57","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1646.47","43.72","","179.76","179.76","179.76","1 through 10","437.98","2914.85","percent of total billed charges",""
"STAPLE BONE 7.94X23.22MM SMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3765.95","2259.57","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2738.60","72.72","","2355.45","298.99","3965.19","155","437.98","2914.85","percent of total billed charges",""
"STAPLE BONE 7.94X23.22MM SMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3765.95","2259.57","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2738.60","72.72","","3643.09","3643.09","3643.09","1 through 10","437.98","2914.85","percent of total billed charges",""
"STAPLE BONE 7.94X23.22MM SMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3765.95","2259.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2004.24","53.22","","554.28","554.28","554.28","16","437.98","2914.85","percent of total billed charges",""
"STAPLE BONE 7.94X23.22MM SMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3765.95","2259.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2368.78","62.9","","619.64","173.09","2370.64","150","437.98","2914.85","percent of total billed charges",""
"STAPLE BONE 7.94X23.22MM SMALL FIXATION RICHARDS COBALT SPIKED","SUP-ITM-10003831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3765.95","2259.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2914.85","77.4","","303.98","303.98","5854.79","1 through 10","437.98","2914.85","percent of total billed charges",""
"STEM HUMERAL 13X90MM DISTAL AEQUALIS FLEX REVIVE PTC PARTIALLY COATED","SUP-ITM-10275022","CDM","C1776","HCPCS","0278","RC","","","","both","","","16968.00","10180.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1973.38","14422.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STEM HUMERAL 13X90MM DISTAL AEQUALIS FLEX REVIVE PTC PARTIALLY COATED","SUP-ITM-10275022","CDM","C1776","HCPCS","0278","RC","","","","both","","","16968.00","10180.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","9654.79","56.9","","2911.53","1863.86","5209.05","65","1973.38","14422.8","percent of total billed charges",""
"STEM HUMERAL 13X90MM DISTAL AEQUALIS FLEX REVIVE PTC PARTIALLY COATED","SUP-ITM-10275022","CDM","C1776","HCPCS","0278","RC","","","","both","","","16968.00","10180.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1973.38","11.63","","400.94","400.94","400.94","1 through 10","1973.38","14422.8","percent of total billed charges",""
"STEM HUMERAL 13X90MM DISTAL AEQUALIS FLEX REVIVE PTC PARTIALLY COATED","SUP-ITM-10275022","CDM","C1776","HCPCS","0278","RC","","","","both","","","16968.00","10180.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","13133.23","77.4","","5214.50","5214.50","16415.28","1 through 10","1973.38","14422.8","percent of total billed charges",""
"STEM HUMERAL 13X90MM DISTAL AEQUALIS FLEX REVIVE PTC PARTIALLY COATED","SUP-ITM-10275022","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16968.00","10180.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1973.38","11.63","","400.94","400.94","400.94","1 through 10","1973.38","13133.23","percent of total billed charges",""
"STEM HUMERAL 13X90MM DISTAL AEQUALIS FLEX REVIVE PTC PARTIALLY COATED","SUP-ITM-10275022","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16968.00","10180.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","7418.41","43.72","","1543.33","1543.33","1671.61","1 through 10","1973.38","13133.23","percent of total billed charges",""
"STEM HUMERAL 13X90MM DISTAL AEQUALIS FLEX REVIVE PTC PARTIALLY COATED","SUP-ITM-10275022","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16968.00","10180.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","12339.13","72.72","","3700.21","2382.07","6427.18","53","1973.38","13133.23","percent of total billed charges",""
"STEM HUMERAL 13X90MM DISTAL AEQUALIS FLEX REVIVE PTC PARTIALLY COATED","SUP-ITM-10275022","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16968.00","10180.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","12339.13","72.72","","12685.80","12685.80","12685.80","1 through 10","1973.38","13133.23","percent of total billed charges",""
"STEM HUMERAL 13X90MM DISTAL AEQUALIS FLEX REVIVE PTC PARTIALLY COATED","SUP-ITM-10275022","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16968.00","10180.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","10672.87","62.9","","3408.87","2784.05","9859.40","46","1973.38","13133.23","percent of total billed charges",""
"STEM HUMERAL 13X90MM DISTAL AEQUALIS FLEX REVIVE PTC PARTIALLY COATED","SUP-ITM-10275022","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","16968.00","10180.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","13133.23","77.4","","5214.50","5214.50","16415.28","1 through 10","1973.38","13133.23","percent of total billed charges",""
"STENT ABDOMINAL 14X16X100MM OVATION IX ILIAC","SUP-ITM-10188419","CDM","C1874","HCPCS","0278","RC","","","","both","","","16564.00","9938.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","9424.92","56.9","","4336.72","1572.72","9255.66","15","1926.39","14079.4","percent of total billed charges",""
"STENT ABDOMINAL 14X16X100MM OVATION IX ILIAC","SUP-ITM-10188419","CDM","C1874","HCPCS","0278","RC","","","","both","","","16564.00","9938.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12820.54","77.4","","2142.10","2142.10","2142.10","1 through 10","1926.39","14079.4","percent of total billed charges",""
"STENT ABDOMINAL 14X16X100MM OVATION IX ILIAC","SUP-ITM-10188419","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","16564.00","9938.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","12045.34","72.72","","2261.23","2261.23","2261.23","1 through 10","1926.39","12820.54","percent of total billed charges",""
"STENT ABDOMINAL 14X16X100MM OVATION IX ILIAC","SUP-ITM-10188419","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","16564.00","9938.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","10418.76","62.9","","4353.04","1741.32","8465.73","1 through 10","1926.39","12820.54","percent of total billed charges",""
"STENT ABDOMINAL 14X16X100MM OVATION IX ILIAC","SUP-ITM-10188419","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","16564.00","9938.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12820.54","77.4","","2142.10","2142.10","2142.10","1 through 10","1926.39","12820.54","percent of total billed charges",""
"STENT ADVANIX 10FR 7CM RX BILIARY NAVIFLEX POLYETHYLENE PLASTIC PRELOAD TAPERED DUODENAL BEND","SUP-ITM-10139004","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","929.40","557.64","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","675.86","72.72","","324.46","324.46","324.46","1 through 10","108.09","719.36","percent of total billed charges",""
"STENT ADVANIX 5FR 3CM PANCREATIC STRAIGHT NO LEADING BARB TRAILING RADIOPAQUE MARKER","SUP-ITM-10147647","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","545.34","327.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","396.57","72.72","","324.46","324.46","324.46","1 through 10","63.42","422.09","percent of total billed charges",""
"STENT ADVANIX 8.5FR 202.5CM RX BILIARY TAPERED DUODENAL BEND POLYETHYLENE PLASTIC NAVIFLEX PRELOAD","SUP-ITM-10139018","CDM","C2617","HCPCS","0278","RC","","","","both","","","569.18","341.51","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","764.25","764.25","764.25","1 through 10","66.2","483.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STENT ADVANIX 8.5FR 202.5CM RX BILIARY TAPERED DUODENAL BEND POLYETHYLENE PLASTIC NAVIFLEX PRELOAD","SUP-ITM-10139018","CDM","C2617","HCPCS","0278","RC","","","","both","","","569.18","341.51","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","323.86","56.9","","434.86","434.86","472.36","15","66.2","483.8","percent of total billed charges",""
"STENT ADVANIX 8.5FR 202.5CM RX BILIARY TAPERED DUODENAL BEND POLYETHYLENE PLASTIC NAVIFLEX PRELOAD","SUP-ITM-10139018","CDM","C2617","HCPCS","0278","RC","","","","both","","","569.18","341.51","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","323.86","56.9","","434.86","434.86","434.86","1 through 10","66.2","483.8","percent of total billed charges",""
"STENT ADVANIX 8.5FR 202.5CM RX BILIARY TAPERED DUODENAL BEND POLYETHYLENE PLASTIC NAVIFLEX PRELOAD","SUP-ITM-10139018","CDM","C2617","HCPCS","0278","RC","","","","both","","","569.18","341.51","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","66.20","11.63","","105.24","93.54","105.24","1 through 10","66.2","483.8","percent of total billed charges",""
"STENT ADVANIX 8.5FR 202.5CM RX BILIARY TAPERED DUODENAL BEND POLYETHYLENE PLASTIC NAVIFLEX PRELOAD","SUP-ITM-10139018","CDM","C2617","HCPCS","0278","RC","","","","both","","","569.18","341.51","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","440.55","77.4","","592.29","592.29","592.29","1 through 10","66.2","483.8","percent of total billed charges",""
"STENT ADVANIX 8.5FR 202.5CM RX BILIARY TAPERED DUODENAL BEND POLYETHYLENE PLASTIC NAVIFLEX PRELOAD","SUP-ITM-10139018","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","569.18","341.51","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","66.20","11.63","","105.24","93.54","105.24","1 through 10","66.2","440.55","percent of total billed charges",""
"STENT ADVANIX 8.5FR 202.5CM RX BILIARY TAPERED DUODENAL BEND POLYETHYLENE PLASTIC NAVIFLEX PRELOAD","SUP-ITM-10139018","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","569.18","341.51","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","248.85","43.72","","334.13","334.13","334.13","1 through 10","66.2","440.55","percent of total billed charges",""
"STENT ADVANIX 8.5FR 202.5CM RX BILIARY TAPERED DUODENAL BEND POLYETHYLENE PLASTIC NAVIFLEX PRELOAD","SUP-ITM-10139018","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","569.18","341.51","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","413.91","72.72","","555.76","555.76","555.76","1 through 10","66.2","440.55","percent of total billed charges",""
"STENT ADVANIX 8.5FR 202.5CM RX BILIARY TAPERED DUODENAL BEND POLYETHYLENE PLASTIC NAVIFLEX PRELOAD","SUP-ITM-10139018","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","569.18","341.51","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","413.91","72.72","","555.76","555.76","555.76","1 through 10","66.2","440.55","percent of total billed charges",""
"STENT ADVANIX 8.5FR 202.5CM RX BILIARY TAPERED DUODENAL BEND POLYETHYLENE PLASTIC NAVIFLEX PRELOAD","SUP-ITM-10139018","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","569.18","341.51","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","302.92","53.22","","859.65","859.65","859.65","1 through 10","66.2","440.55","percent of total billed charges",""
"STENT ADVANIX 8.5FR 202.5CM RX BILIARY TAPERED DUODENAL BEND POLYETHYLENE PLASTIC NAVIFLEX PRELOAD","SUP-ITM-10139018","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","569.18","341.51","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","358.01","62.9","","481.48","481.48","481.48","1 through 10","66.2","440.55","percent of total billed charges",""
"STENT ADVANIX 8.5FR 202.5CM RX BILIARY TAPERED DUODENAL BEND POLYETHYLENE PLASTIC NAVIFLEX PRELOAD","SUP-ITM-10139018","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","569.18","341.51","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","440.55","77.4","","592.29","592.29","592.29","1 through 10","66.2","440.55","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","both","","","382.12","229.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","764.25","764.25","764.25","1 through 10","44.44","324.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","both","","","382.12","229.27","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","217.43","56.9","","434.86","434.86","472.36","15","44.44","324.8","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","both","","","382.12","229.27","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","217.43","56.9","","434.86","434.86","434.86","1 through 10","44.44","324.8","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","both","","","382.12","229.27","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","44.44","11.63","","105.24","93.54","105.24","1 through 10","44.44","324.8","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","both","","","382.12","229.27","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","295.76","77.4","","592.29","592.29","592.29","1 through 10","44.44","324.8","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","382.12","229.27","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","44.44","11.63","","105.24","93.54","105.24","1 through 10","44.44","295.76","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","382.12","229.27","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","167.06","43.72","","334.13","334.13","334.13","1 through 10","44.44","295.76","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","382.12","229.27","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","277.88","72.72","","555.76","555.76","555.76","1 through 10","44.44","295.76","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","382.12","229.27","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","277.88","72.72","","555.76","555.76","555.76","1 through 10","44.44","295.76","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","382.12","229.27","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","203.36","53.22","","859.65","859.65","859.65","1 through 10","44.44","295.76","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","382.12","229.27","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","240.35","62.9","","481.48","481.48","481.48","1 through 10","44.44","295.76","percent of total billed charges",""
"STENT BILIARY 10FR 5CM ADVANIX RX POLYETHYLENE NAVIFLEX DELIVERY SYSTEM DOUBLE PIGTAIL","SUP-ITM-10146804","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","382.12","229.27","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","295.76","77.4","","592.29","592.29","592.29","1 through 10","44.44","295.76","percent of total billed charges",""
"STENT BILIARY 12CM 7FR 0.035IN DUODENAL BEND FLEXIMA PLASTIC DELIVERY SYSTEM BARB","SUP-ITM-10138989","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","644.29","386.57","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","468.53","72.72","","324.46","324.46","324.46","1 through 10","74.93","498.68","percent of total billed charges",""
"STENT BILIARY 7FRX5CM CONTROLLED RELEASE COMPASS BDS PLASTIC IMPLANTABLE DRAINAGE OF OBSTRUCTED DUCT - DISCONTINUED REPLACED BY G22163","SUP-ITM-10134587","CDM","C2617","HCPCS","0278","RC","","","","both","","","490.61","294.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","764.25","764.25","764.25","1 through 10","57.06","417.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STENT BILIARY 7FRX5CM CONTROLLED RELEASE COMPASS BDS PLASTIC IMPLANTABLE DRAINAGE OF OBSTRUCTED DUCT - DISCONTINUED REPLACED BY G22163","SUP-ITM-10134587","CDM","C2617","HCPCS","0278","RC","","","","both","","","490.61","294.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","279.16","56.9","","434.86","434.86","472.36","15","57.06","417.02","percent of total billed charges",""
"STENT BILIARY 7FRX5CM CONTROLLED RELEASE COMPASS BDS PLASTIC IMPLANTABLE DRAINAGE OF OBSTRUCTED DUCT - DISCONTINUED REPLACED BY G22163","SUP-ITM-10134587","CDM","C2617","HCPCS","0278","RC","","","","both","","","490.61","294.37","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","279.16","56.9","","434.86","434.86","434.86","1 through 10","57.06","417.02","percent of total billed charges",""
"STENT BILIARY 7FRX5CM CONTROLLED RELEASE COMPASS BDS PLASTIC IMPLANTABLE DRAINAGE OF OBSTRUCTED DUCT - DISCONTINUED REPLACED BY G22163","SUP-ITM-10134587","CDM","C2617","HCPCS","0278","RC","","","","both","","","490.61","294.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","57.06","11.63","","105.24","93.54","105.24","1 through 10","57.06","417.02","percent of total billed charges",""
"STENT BILIARY 7FRX5CM CONTROLLED RELEASE COMPASS BDS PLASTIC IMPLANTABLE DRAINAGE OF OBSTRUCTED DUCT - DISCONTINUED REPLACED BY G22163","SUP-ITM-10134587","CDM","C2617","HCPCS","0278","RC","","","","both","","","490.61","294.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","379.73","77.4","","592.29","592.29","592.29","1 through 10","57.06","417.02","percent of total billed charges",""
"STENT BILIARY 7FRX5CM CONTROLLED RELEASE COMPASS BDS PLASTIC IMPLANTABLE DRAINAGE OF OBSTRUCTED DUCT - DISCONTINUED REPLACED BY G22163","SUP-ITM-10134587","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","490.61","294.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","57.06","11.63","","105.24","93.54","105.24","1 through 10","57.06","379.73","percent of total billed charges",""
"STENT BILIARY 7FRX5CM CONTROLLED RELEASE COMPASS BDS PLASTIC IMPLANTABLE DRAINAGE OF OBSTRUCTED DUCT - DISCONTINUED REPLACED BY G22163","SUP-ITM-10134587","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","490.61","294.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","214.49","43.72","","334.13","334.13","334.13","1 through 10","57.06","379.73","percent of total billed charges",""
"STENT BILIARY 7FRX5CM CONTROLLED RELEASE COMPASS BDS PLASTIC IMPLANTABLE DRAINAGE OF OBSTRUCTED DUCT - DISCONTINUED REPLACED BY G22163","SUP-ITM-10134587","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","490.61","294.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","356.77","72.72","","555.76","555.76","555.76","1 through 10","57.06","379.73","percent of total billed charges",""
"STENT BILIARY 7FRX5CM CONTROLLED RELEASE COMPASS BDS PLASTIC IMPLANTABLE DRAINAGE OF OBSTRUCTED DUCT - DISCONTINUED REPLACED BY G22163","SUP-ITM-10134587","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","490.61","294.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","356.77","72.72","","555.76","555.76","555.76","1 through 10","57.06","379.73","percent of total billed charges",""
"STENT BILIARY 7FRX5CM CONTROLLED RELEASE COMPASS BDS PLASTIC IMPLANTABLE DRAINAGE OF OBSTRUCTED DUCT - DISCONTINUED REPLACED BY G22163","SUP-ITM-10134587","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","490.61","294.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","261.10","53.22","","859.65","859.65","859.65","1 through 10","57.06","379.73","percent of total billed charges",""
"STENT BILIARY 7FRX5CM CONTROLLED RELEASE COMPASS BDS PLASTIC IMPLANTABLE DRAINAGE OF OBSTRUCTED DUCT - DISCONTINUED REPLACED BY G22163","SUP-ITM-10134587","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","490.61","294.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","308.59","62.9","","481.48","481.48","481.48","1 through 10","57.06","379.73","percent of total billed charges",""
"STENT BILIARY 7FRX5CM CONTROLLED RELEASE COMPASS BDS PLASTIC IMPLANTABLE DRAINAGE OF OBSTRUCTED DUCT - DISCONTINUED REPLACED BY G22163","SUP-ITM-10134587","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","490.61","294.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","379.73","77.4","","592.29","592.29","592.29","1 through 10","57.06","379.73","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 7CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000204","CDM","C2617","HCPCS","0278","RC","","","","both","","","538.98","323.39","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","764.25","764.25","764.25","1 through 10","62.68","458.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STENT COTTON-LEUNG 10FR 3.7MM 7CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000204","CDM","C2617","HCPCS","0278","RC","","","","both","","","538.98","323.39","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","306.68","56.9","","434.86","434.86","472.36","15","62.68","458.13","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 7CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000204","CDM","C2617","HCPCS","0278","RC","","","","both","","","538.98","323.39","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","306.68","56.9","","434.86","434.86","434.86","1 through 10","62.68","458.13","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 7CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000204","CDM","C2617","HCPCS","0278","RC","","","","both","","","538.98","323.39","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","62.68","11.63","","105.24","93.54","105.24","1 through 10","62.68","458.13","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 7CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000204","CDM","C2617","HCPCS","0278","RC","","","","both","","","538.98","323.39","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","417.17","77.4","","592.29","592.29","592.29","1 through 10","62.68","458.13","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 7CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000204","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","538.98","323.39","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","62.68","11.63","","105.24","93.54","105.24","1 through 10","62.68","417.17","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 7CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000204","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","538.98","323.39","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","235.64","43.72","","334.13","334.13","334.13","1 through 10","62.68","417.17","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 7CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000204","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","538.98","323.39","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","391.95","72.72","","555.76","555.76","555.76","1 through 10","62.68","417.17","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 7CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000204","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","538.98","323.39","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","391.95","72.72","","555.76","555.76","555.76","1 through 10","62.68","417.17","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 7CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000204","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","538.98","323.39","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","286.85","53.22","","859.65","859.65","859.65","1 through 10","62.68","417.17","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 7CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000204","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","538.98","323.39","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","339.02","62.9","","481.48","481.48","481.48","1 through 10","62.68","417.17","percent of total billed charges",""
"STENT COTTON-LEUNG 10FR 3.7MM 7CM .035IN OTW BILIARY CATHETER POLYETHYLENE DISTAL FLAP CURVED SHAPE TAPERED TIP","SUP-ITM-10000204","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","538.98","323.39","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","417.17","77.4","","592.29","592.29","592.29","1 through 10","62.68","417.17","percent of total billed charges",""
"STENT COVERED 10MMX38MMX120CM ICAST","SUP-ITM-10327603","CDM","C1874","HCPCS","0278","RC","","","","both","","","12102.35","7261.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6886.24","56.9","","4336.72","1572.72","9255.66","15","1407.5","10287","percent of total billed charges",""
"STENT COVERED 10MMX38MMX120CM ICAST","SUP-ITM-10327603","CDM","C1874","HCPCS","0278","RC","","","","both","","","12102.35","7261.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9367.22","77.4","","2142.10","2142.10","2142.10","1 through 10","1407.5","10287","percent of total billed charges",""
"STENT COVERED 10MMX38MMX120CM ICAST","SUP-ITM-10327603","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12102.35","7261.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8800.83","72.72","","2261.23","2261.23","2261.23","1 through 10","1407.5","9367.22","percent of total billed charges",""
"STENT COVERED 10MMX38MMX120CM ICAST","SUP-ITM-10327603","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12102.35","7261.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7612.38","62.9","","4353.04","1741.32","8465.73","1 through 10","1407.5","9367.22","percent of total billed charges",""
"STENT COVERED 10MMX38MMX120CM ICAST","SUP-ITM-10327603","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12102.35","7261.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9367.22","77.4","","2142.10","2142.10","2142.10","1 through 10","1407.5","9367.22","percent of total billed charges",""
"STENT COVERED 5MMX22MMX120CM ICAST","SUP-ITM-10327604","CDM","C1874","HCPCS","0278","RC","","","","both","","","11608.38","6965.03","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6605.17","56.9","","4336.72","1572.72","9255.66","15","1350.05","9867.12","percent of total billed charges",""
"STENT COVERED 5MMX22MMX120CM ICAST","SUP-ITM-10327604","CDM","C1874","HCPCS","0278","RC","","","","both","","","11608.38","6965.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8984.89","77.4","","2142.10","2142.10","2142.10","1 through 10","1350.05","9867.12","percent of total billed charges",""
"STENT COVERED 5MMX22MMX120CM ICAST","SUP-ITM-10327604","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11608.38","6965.03","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8441.61","72.72","","2261.23","2261.23","2261.23","1 through 10","1350.05","8984.89","percent of total billed charges",""
"STENT COVERED 5MMX22MMX120CM ICAST","SUP-ITM-10327604","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11608.38","6965.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7301.67","62.9","","4353.04","1741.32","8465.73","1 through 10","1350.05","8984.89","percent of total billed charges",""
"STENT COVERED 5MMX22MMX120CM ICAST","SUP-ITM-10327604","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11608.38","6965.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8984.89","77.4","","2142.10","2142.10","2142.10","1 through 10","1350.05","8984.89","percent of total billed charges",""
"STENT COVERED 5MMX59MMX120CM ICAST","SUP-ITM-10327609","CDM","C1874","HCPCS","0278","RC","","","","both","","","10904.08","6542.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6204.42","56.9","","4336.72","1572.72","9255.66","15","1268.14","9268.47","percent of total billed charges",""
"STENT COVERED 5MMX59MMX120CM ICAST","SUP-ITM-10327609","CDM","C1874","HCPCS","0278","RC","","","","both","","","10904.08","6542.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8439.76","77.4","","2142.10","2142.10","2142.10","1 through 10","1268.14","9268.47","percent of total billed charges",""
"STENT COVERED 5MMX59MMX120CM ICAST","SUP-ITM-10327609","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10904.08","6542.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7929.45","72.72","","2261.23","2261.23","2261.23","1 through 10","1268.14","8439.76","percent of total billed charges",""
"STENT COVERED 5MMX59MMX120CM ICAST","SUP-ITM-10327609","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10904.08","6542.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6858.67","62.9","","4353.04","1741.32","8465.73","1 through 10","1268.14","8439.76","percent of total billed charges",""
"STENT COVERED 5MMX59MMX120CM ICAST","SUP-ITM-10327609","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10904.08","6542.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8439.76","77.4","","2142.10","2142.10","2142.10","1 through 10","1268.14","8439.76","percent of total billed charges",""
"STENT COVERED 6MMX16MMX120CM ICAST","SUP-ITM-10327606","CDM","C1874","HCPCS","0278","RC","","","","both","","","11361.37","6816.82","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6464.62","56.9","","4336.72","1572.72","9255.66","15","1321.33","9657.16","percent of total billed charges",""
"STENT COVERED 6MMX16MMX120CM ICAST","SUP-ITM-10327606","CDM","C1874","HCPCS","0278","RC","","","","both","","","11361.37","6816.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8793.70","77.4","","2142.10","2142.10","2142.10","1 through 10","1321.33","9657.16","percent of total billed charges",""
"STENT COVERED 6MMX16MMX120CM ICAST","SUP-ITM-10327606","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11361.37","6816.82","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8261.99","72.72","","2261.23","2261.23","2261.23","1 through 10","1321.33","8793.7","percent of total billed charges",""
"STENT COVERED 6MMX16MMX120CM ICAST","SUP-ITM-10327606","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11361.37","6816.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7146.30","62.9","","4353.04","1741.32","8465.73","1 through 10","1321.33","8793.7","percent of total billed charges",""
"STENT COVERED 6MMX16MMX120CM ICAST","SUP-ITM-10327606","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11361.37","6816.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8793.70","77.4","","2142.10","2142.10","2142.10","1 through 10","1321.33","8793.7","percent of total billed charges",""
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","both","","","2441.58","1464.95","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","764.25","764.25","764.25","1 through 10","283.96","2075.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","both","","","2441.58","1464.95","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1389.26","56.9","","434.86","434.86","472.36","15","283.96","2075.34","percent of total billed charges",""
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","both","","","2441.58","1464.95","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","1389.26","56.9","","434.86","434.86","434.86","1 through 10","283.96","2075.34","percent of total billed charges",""
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","both","","","2441.58","1464.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","283.96","11.63","","105.24","93.54","105.24","1 through 10","283.96","2075.34","percent of total billed charges",""
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","both","","","2441.58","1464.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1889.78","77.4","","592.29","592.29","592.29","1 through 10","283.96","2075.34","percent of total billed charges",""
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","2441.58","1464.95","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","283.96","11.63","","105.24","93.54","105.24","1 through 10","283.96","1889.78","percent of total billed charges",""
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","2441.58","1464.95","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1067.46","43.72","","334.13","334.13","334.13","1 through 10","283.96","1889.78","percent of total billed charges",""
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","2441.58","1464.95","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1775.52","72.72","","555.76","555.76","555.76","1 through 10","283.96","1889.78","percent of total billed charges",""
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","2441.58","1464.95","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1775.52","72.72","","555.76","555.76","555.76","1 through 10","283.96","1889.78","percent of total billed charges",""
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","2441.58","1464.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1299.41","53.22","","859.65","859.65","859.65","1 through 10","283.96","1889.78","percent of total billed charges",""
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","2441.58","1464.95","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1535.75","62.9","","481.48","481.48","481.48","1 through 10","283.96","1889.78","percent of total billed charges",""
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","2441.58","1464.95","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1889.78","77.4","","592.29","592.29","592.29","1 through 10","283.96","1889.78","percent of total billed charges",""
"STENT ELUVIA 6MM 100MM 130CM DRUG-ELUTING VASCULAR","SUP-ITM-10269497","CDM","C1894","HCPCS","0272","RC","","","","both","","","10483.80","6290.28","AETNA [1001]","HB WDH AETNA COMMERCIAL","7317.69","69.8","","94.15","94.15","427.63","1 through 10","1219.27","8911.23","percent of total billed charges",""
"STENT ELUVIA 6MM 100MM 130CM DRUG-ELUTING VASCULAR","SUP-ITM-10269497","CDM","C1894","HCPCS","0272","RC","","","","both","","","10483.80","6290.28","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","1219.27","8911.23","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STENT ELUVIA 6MM 100MM 130CM DRUG-ELUTING VASCULAR","SUP-ITM-10269497","CDM","C1894","HCPCS","0272","RC","","","","both","","","10483.80","6290.28","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5965.28","56.9","","401.89","65.85","401.89","1 through 10","1219.27","8911.23","percent of total billed charges",""
"STENT ELUVIA 6MM 100MM 130CM DRUG-ELUTING VASCULAR","SUP-ITM-10269497","CDM","C1894","HCPCS","0272","RC","","","","both","","","10483.80","6290.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1219.27","11.63","","49.19","10.57","114.40","19","1219.27","8911.23","percent of total billed charges",""
"STENT ELUVIA 6MM 100MM 130CM DRUG-ELUTING VASCULAR","SUP-ITM-10269497","CDM","C1894","HCPCS","0272","RC","","","","both","","","10483.80","6290.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8114.46","77.4","","200.75","81.67","643.86","11","1219.27","8911.23","percent of total billed charges",""
"STENT ELUVIA 6MM 100MM 130CM DRUG-ELUTING VASCULAR","SUP-ITM-10269497","CDM","C1894","HCPCS","0272","RC","","","","both","","","10483.80","6290.28","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","1219.27","8911.23","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STENT ELUVIA 6MM 100MM 130CM DRUG-ELUTING VASCULAR","SUP-ITM-10269497","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","10483.80","6290.28","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1219.27","11.63","","49.19","10.57","114.40","19","1219.27","8114.46","percent of total billed charges",""
"STENT ELUVIA 6MM 100MM 130CM DRUG-ELUTING VASCULAR","SUP-ITM-10269497","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","10483.80","6290.28","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6581.73","62.78","","93.27","93.27","93.27","1 through 10","1219.27","8114.46","percent of total billed charges",""
"STENT ELUVIA 6MM 100MM 130CM DRUG-ELUTING VASCULAR","SUP-ITM-10269497","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","10483.80","6290.28","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4583.52","43.72","","363.22","363.22","363.22","1 through 10","1219.27","8114.46","percent of total billed charges",""
"STENT ELUVIA 6MM 100MM 130CM DRUG-ELUTING VASCULAR","SUP-ITM-10269497","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","10483.80","6290.28","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7623.82","72.72","","271.85","111.24","551.69","14","1219.27","8114.46","percent of total billed charges",""
"STENT ELUVIA 6MM 100MM 130CM DRUG-ELUTING VASCULAR","SUP-ITM-10269497","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","10483.80","6290.28","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6594.31","62.9","","706.53","93.60","938.00","53","1219.27","8114.46","percent of total billed charges",""
"STENT ELUVIA 6MM 100MM 130CM DRUG-ELUTING VASCULAR","SUP-ITM-10269497","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","10483.80","6290.28","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8114.46","77.4","","200.75","81.67","643.86","11","1219.27","8114.46","percent of total billed charges",""
"STENT ENDOVASCULAR 9FR 8X40MM 80CM CENTRAL VENOUS AV FISTULA FLUENCY PLUS EPTFE GRAFT MULTIBRADIDED DELIVERY SYSTEM","SUP-ITM-10135345","CDM","C1874","HCPCS","0278","RC","","","","both","","","11716.00","7029.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6666.40","56.9","","4336.72","1572.72","9255.66","15","1362.57","9958.6","percent of total billed charges",""
"STENT ENDOVASCULAR 9FR 8X40MM 80CM CENTRAL VENOUS AV FISTULA FLUENCY PLUS EPTFE GRAFT MULTIBRADIDED DELIVERY SYSTEM","SUP-ITM-10135345","CDM","C1874","HCPCS","0278","RC","","","","both","","","11716.00","7029.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9068.18","77.4","","2142.10","2142.10","2142.10","1 through 10","1362.57","9958.6","percent of total billed charges",""
"STENT ENDOVASCULAR 9FR 8X40MM 80CM CENTRAL VENOUS AV FISTULA FLUENCY PLUS EPTFE GRAFT MULTIBRADIDED DELIVERY SYSTEM","SUP-ITM-10135345","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11716.00","7029.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8519.88","72.72","","2261.23","2261.23","2261.23","1 through 10","1362.57","9068.18","percent of total billed charges",""
"STENT ENDOVASCULAR 9FR 8X40MM 80CM CENTRAL VENOUS AV FISTULA FLUENCY PLUS EPTFE GRAFT MULTIBRADIDED DELIVERY SYSTEM","SUP-ITM-10135345","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11716.00","7029.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7369.36","62.9","","4353.04","1741.32","8465.73","1 through 10","1362.57","9068.18","percent of total billed charges",""
"STENT ENDOVASCULAR 9FR 8X40MM 80CM CENTRAL VENOUS AV FISTULA FLUENCY PLUS EPTFE GRAFT MULTIBRADIDED DELIVERY SYSTEM","SUP-ITM-10135345","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11716.00","7029.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9068.18","77.4","","2142.10","2142.10","2142.10","1 through 10","1362.57","9068.18","percent of total billed charges",""
"STENT ESOPHAGEAL 23 28X15CM 18.5FR 120 OD23 XSEC PART COVRD PROXIMAL DISTL FLARD END WALLFLEX PERMALUME SIL IMPLANT","SUP-ITM-10049117","CDM","C1874","HCPCS","0278","RC","","","","both","","","10670.00","6402.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6071.23","56.9","","4336.72","1572.72","9255.66","15","1240.92","9069.5","percent of total billed charges",""
"STENT ESOPHAGEAL 23 28X15CM 18.5FR 120 OD23 XSEC PART COVRD PROXIMAL DISTL FLARD END WALLFLEX PERMALUME SIL IMPLANT","SUP-ITM-10049117","CDM","C1874","HCPCS","0278","RC","","","","both","","","10670.00","6402.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8258.58","77.4","","2142.10","2142.10","2142.10","1 through 10","1240.92","9069.5","percent of total billed charges",""
"STENT ESOPHAGEAL 23 28X15CM 18.5FR 120 OD23 XSEC PART COVRD PROXIMAL DISTL FLARD END WALLFLEX PERMALUME SIL IMPLANT","SUP-ITM-10049117","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10670.00","6402.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7759.22","72.72","","2261.23","2261.23","2261.23","1 through 10","1240.92","8258.58","percent of total billed charges",""
"STENT ESOPHAGEAL 23 28X15CM 18.5FR 120 OD23 XSEC PART COVRD PROXIMAL DISTL FLARD END WALLFLEX PERMALUME SIL IMPLANT","SUP-ITM-10049117","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10670.00","6402.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6711.43","62.9","","4353.04","1741.32","8465.73","1 through 10","1240.92","8258.58","percent of total billed charges",""
"STENT ESOPHAGEAL 23 28X15CM 18.5FR 120 OD23 XSEC PART COVRD PROXIMAL DISTL FLARD END WALLFLEX PERMALUME SIL IMPLANT","SUP-ITM-10049117","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10670.00","6402.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8258.58","77.4","","2142.10","2142.10","2142.10","1 through 10","1240.92","8258.58","percent of total billed charges",""
"STENT EXCLUDER 23MM 3.3CM ENDOPROSTHESIS AORTIC EPTFE","SUP-ITM-10135305","CDM","C1874","HCPCS","0278","RC","","","","both","","","12487.64","7492.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7105.47","56.9","","4336.72","1572.72","9255.66","15","1452.31","10614.49","percent of total billed charges",""
"STENT EXCLUDER 23MM 3.3CM ENDOPROSTHESIS AORTIC EPTFE","SUP-ITM-10135305","CDM","C1874","HCPCS","0278","RC","","","","both","","","12487.64","7492.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9665.43","77.4","","2142.10","2142.10","2142.10","1 through 10","1452.31","10614.49","percent of total billed charges",""
"STENT EXCLUDER 23MM 3.3CM ENDOPROSTHESIS AORTIC EPTFE","SUP-ITM-10135305","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12487.64","7492.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","9081.01","72.72","","2261.23","2261.23","2261.23","1 through 10","1452.31","9665.43","percent of total billed charges",""
"STENT EXCLUDER 23MM 3.3CM ENDOPROSTHESIS AORTIC EPTFE","SUP-ITM-10135305","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12487.64","7492.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7854.73","62.9","","4353.04","1741.32","8465.73","1 through 10","1452.31","9665.43","percent of total billed charges",""
"STENT EXCLUDER 23MM 3.3CM ENDOPROSTHESIS AORTIC EPTFE","SUP-ITM-10135305","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12487.64","7492.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9665.43","77.4","","2142.10","2142.10","2142.10","1 through 10","1452.31","9665.43","percent of total billed charges",""
"STENT EXCLUDER 31MM 14.5MM 17CM C3 COATED BIFURCATED ILIAC TRUNK IPSILATERAL EPTFE GRAFT DELIVERY SYSTEM VASCULAR","SUP-ITM-10114977","CDM","C1874","HCPCS","0278","RC","","","","both","","","25280.32","15168.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","14384.50","56.9","","4336.72","1572.72","9255.66","15","2940.1","21488.27","percent of total billed charges",""
"STENT EXCLUDER 31MM 14.5MM 17CM C3 COATED BIFURCATED ILIAC TRUNK IPSILATERAL EPTFE GRAFT DELIVERY SYSTEM VASCULAR","SUP-ITM-10114977","CDM","C1874","HCPCS","0278","RC","","","","both","","","25280.32","15168.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","19566.97","77.4","","2142.10","2142.10","2142.10","1 through 10","2940.1","21488.27","percent of total billed charges",""
"STENT EXCLUDER 31MM 14.5MM 17CM C3 COATED BIFURCATED ILIAC TRUNK IPSILATERAL EPTFE GRAFT DELIVERY SYSTEM VASCULAR","SUP-ITM-10114977","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25280.32","15168.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","18383.85","72.72","","2261.23","2261.23","2261.23","1 through 10","2940.1","19566.97","percent of total billed charges",""
"STENT EXCLUDER 31MM 14.5MM 17CM C3 COATED BIFURCATED ILIAC TRUNK IPSILATERAL EPTFE GRAFT DELIVERY SYSTEM VASCULAR","SUP-ITM-10114977","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25280.32","15168.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","15901.32","62.9","","4353.04","1741.32","8465.73","1 through 10","2940.1","19566.97","percent of total billed charges",""
"STENT EXCLUDER 31MM 14.5MM 17CM C3 COATED BIFURCATED ILIAC TRUNK IPSILATERAL EPTFE GRAFT DELIVERY SYSTEM VASCULAR","SUP-ITM-10114977","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25280.32","15168.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","19566.97","77.4","","2142.10","2142.10","2142.10","1 through 10","2940.1","19566.97","percent of total billed charges",""
"STENT FLEXIMA 8.5FR 250CM .035IN NASAL SINGLE PIGTAIL NASOBILIARY CATHETER","SUP-ITM-10139117","CDM","C2617","HCPCS","0278","RC","","","","both","","","733.08","439.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","764.25","764.25","764.25","1 through 10","85.26","623.12","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STENT FLEXIMA 8.5FR 250CM .035IN NASAL SINGLE PIGTAIL NASOBILIARY CATHETER","SUP-ITM-10139117","CDM","C2617","HCPCS","0278","RC","","","","both","","","733.08","439.85","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","417.12","56.9","","434.86","434.86","472.36","15","85.26","623.12","percent of total billed charges",""
"STENT FLEXIMA 8.5FR 250CM .035IN NASAL SINGLE PIGTAIL NASOBILIARY CATHETER","SUP-ITM-10139117","CDM","C2617","HCPCS","0278","RC","","","","both","","","733.08","439.85","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","417.12","56.9","","434.86","434.86","434.86","1 through 10","85.26","623.12","percent of total billed charges",""
"STENT FLEXIMA 8.5FR 250CM .035IN NASAL SINGLE PIGTAIL NASOBILIARY CATHETER","SUP-ITM-10139117","CDM","C2617","HCPCS","0278","RC","","","","both","","","733.08","439.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","85.26","11.63","","105.24","93.54","105.24","1 through 10","85.26","623.12","percent of total billed charges",""
"STENT FLEXIMA 8.5FR 250CM .035IN NASAL SINGLE PIGTAIL NASOBILIARY CATHETER","SUP-ITM-10139117","CDM","C2617","HCPCS","0278","RC","","","","both","","","733.08","439.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","567.40","77.4","","592.29","592.29","592.29","1 through 10","85.26","623.12","percent of total billed charges",""
"STENT FLEXIMA 8.5FR 250CM .035IN NASAL SINGLE PIGTAIL NASOBILIARY CATHETER","SUP-ITM-10139117","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","733.08","439.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","85.26","11.63","","105.24","93.54","105.24","1 through 10","85.26","567.4","percent of total billed charges",""
"STENT FLEXIMA 8.5FR 250CM .035IN NASAL SINGLE PIGTAIL NASOBILIARY CATHETER","SUP-ITM-10139117","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","733.08","439.85","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","320.50","43.72","","334.13","334.13","334.13","1 through 10","85.26","567.4","percent of total billed charges",""
"STENT FLEXIMA 8.5FR 250CM .035IN NASAL SINGLE PIGTAIL NASOBILIARY CATHETER","SUP-ITM-10139117","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","733.08","439.85","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","533.10","72.72","","555.76","555.76","555.76","1 through 10","85.26","567.4","percent of total billed charges",""
"STENT FLEXIMA 8.5FR 250CM .035IN NASAL SINGLE PIGTAIL NASOBILIARY CATHETER","SUP-ITM-10139117","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","733.08","439.85","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","533.10","72.72","","555.76","555.76","555.76","1 through 10","85.26","567.4","percent of total billed charges",""
"STENT FLEXIMA 8.5FR 250CM .035IN NASAL SINGLE PIGTAIL NASOBILIARY CATHETER","SUP-ITM-10139117","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","733.08","439.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","390.15","53.22","","859.65","859.65","859.65","1 through 10","85.26","567.4","percent of total billed charges",""
"STENT FLEXIMA 8.5FR 250CM .035IN NASAL SINGLE PIGTAIL NASOBILIARY CATHETER","SUP-ITM-10139117","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","733.08","439.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","461.11","62.9","","481.48","481.48","481.48","1 through 10","85.26","567.4","percent of total billed charges",""
"STENT FLEXIMA 8.5FR 250CM .035IN NASAL SINGLE PIGTAIL NASOBILIARY CATHETER","SUP-ITM-10139117","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","733.08","439.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","567.40","77.4","","592.29","592.29","592.29","1 through 10","85.26","567.4","percent of total billed charges",""
"STENT GRAFT 14FR 16X13 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10118021","CDM","C1874","HCPCS","0278","RC","","","","both","","","16393.00","9835.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","9327.62","56.9","","4336.72","1572.72","9255.66","15","1906.51","13934.05","percent of total billed charges",""
"STENT GRAFT 14FR 16X13 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10118021","CDM","C1874","HCPCS","0278","RC","","","","both","","","16393.00","9835.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12688.18","77.4","","2142.10","2142.10","2142.10","1 through 10","1906.51","13934.05","percent of total billed charges",""
"STENT GRAFT 14FR 16X13 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10118021","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","16393.00","9835.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","11920.99","72.72","","2261.23","2261.23","2261.23","1 through 10","1906.51","12688.18","percent of total billed charges",""
"STENT GRAFT 14FR 16X13 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10118021","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","16393.00","9835.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","10311.20","62.9","","4353.04","1741.32","8465.73","1 through 10","1906.51","12688.18","percent of total billed charges",""
"STENT GRAFT 14FR 16X13 82MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10118021","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","16393.00","9835.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12688.18","77.4","","2142.10","2142.10","2142.10","1 through 10","1906.51","12688.18","percent of total billed charges",""
"STENT GRAFT 16FRX93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10101015","CDM","C1874","HCPCS","0278","RC","","","","both","","","19537.44","11722.46","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","11116.80","56.9","","4336.72","1572.72","9255.66","15","2272.2","16606.82","percent of total billed charges",""
"STENT GRAFT 16FRX93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10101015","CDM","C1874","HCPCS","0278","RC","","","","both","","","19537.44","11722.46","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","15121.98","77.4","","2142.10","2142.10","2142.10","1 through 10","2272.2","16606.82","percent of total billed charges",""
"STENT GRAFT 16FRX93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10101015","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","19537.44","11722.46","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","14207.63","72.72","","2261.23","2261.23","2261.23","1 through 10","2272.2","15121.98","percent of total billed charges",""
"STENT GRAFT 16FRX93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10101015","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","19537.44","11722.46","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","12289.05","62.9","","4353.04","1741.32","8465.73","1 through 10","2272.2","15121.98","percent of total billed charges",""
"STENT GRAFT 16FRX93MM AORTIC ENDURANT II NITINOL POLYESTER CONTRALATERAL ILIAC LIMB","SUP-ITM-10101015","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","19537.44","11722.46","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","15121.98","77.4","","2142.10","2142.10","2142.10","1 through 10","2272.2","15121.98","percent of total billed charges",""
"STENT GRAFT 16MM 12 7CM VASCULAR EXCLUDER EPTFE BIFURCATED","SUP-ITM-10114971","CDM","C1874","HCPCS","0278","RC","","","","both","","","12596.72","7558.03","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7167.53","56.9","","4336.72","1572.72","9255.66","15","1465","10707.21","percent of total billed charges",""
"STENT GRAFT 16MM 12 7CM VASCULAR EXCLUDER EPTFE BIFURCATED","SUP-ITM-10114971","CDM","C1874","HCPCS","0278","RC","","","","both","","","12596.72","7558.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9749.86","77.4","","2142.10","2142.10","2142.10","1 through 10","1465","10707.21","percent of total billed charges",""
"STENT GRAFT 16MM 12 7CM VASCULAR EXCLUDER EPTFE BIFURCATED","SUP-ITM-10114971","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12596.72","7558.03","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","9160.33","72.72","","2261.23","2261.23","2261.23","1 through 10","1465","9749.86","percent of total billed charges",""
"STENT GRAFT 16MM 12 7CM VASCULAR EXCLUDER EPTFE BIFURCATED","SUP-ITM-10114971","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12596.72","7558.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7923.34","62.9","","4353.04","1741.32","8465.73","1 through 10","1465","9749.86","percent of total billed charges",""
"STENT GRAFT 16MM 12 7CM VASCULAR EXCLUDER EPTFE BIFURCATED","SUP-ITM-10114971","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12596.72","7558.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9749.86","77.4","","2142.10","2142.10","2142.10","1 through 10","1465","9749.86","percent of total billed charges",""
"STENT GRAFT 16MM 9.5CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114955","CDM","C1874","HCPCS","0278","RC","","","","both","","","17889.12","10733.47","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","10178.91","56.9","","4336.72","1572.72","9255.66","15","2080.5","15205.75","percent of total billed charges",""
"STENT GRAFT 16MM 9.5CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114955","CDM","C1874","HCPCS","0278","RC","","","","both","","","17889.12","10733.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","13846.18","77.4","","2142.10","2142.10","2142.10","1 through 10","2080.5","15205.75","percent of total billed charges",""
"STENT GRAFT 16MM 9.5CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114955","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","17889.12","10733.47","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","13008.97","72.72","","2261.23","2261.23","2261.23","1 through 10","2080.5","13846.18","percent of total billed charges",""
"STENT GRAFT 16MM 9.5CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114955","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","17889.12","10733.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","11252.26","62.9","","4353.04","1741.32","8465.73","1 through 10","2080.5","13846.18","percent of total billed charges",""
"STENT GRAFT 16MM 9.5CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114955","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","17889.12","10733.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","13846.18","77.4","","2142.10","2142.10","2142.10","1 through 10","2080.5","13846.18","percent of total billed charges",""
"STENT GRAFT 18FR 32X16 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101021","CDM","C1874","HCPCS","0278","RC","","","","both","","","24482.64","14689.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","13930.62","56.9","","4336.72","1572.72","9255.66","15","2847.33","20810.24","percent of total billed charges",""
"STENT GRAFT 18FR 32X16 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101021","CDM","C1874","HCPCS","0278","RC","","","","both","","","24482.64","14689.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","18949.56","77.4","","2142.10","2142.10","2142.10","1 through 10","2847.33","20810.24","percent of total billed charges",""
"STENT GRAFT 18FR 32X16 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101021","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","24482.64","14689.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","17803.78","72.72","","2261.23","2261.23","2261.23","1 through 10","2847.33","18949.56","percent of total billed charges",""
"STENT GRAFT 18FR 32X16 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101021","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","24482.64","14689.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","15399.58","62.9","","4353.04","1741.32","8465.73","1 through 10","2847.33","18949.56","percent of total billed charges",""
"STENT GRAFT 18FR 32X16 166MM AORTIC ENDURANT II NITINOL POLYESTER BIFURCATED EXTENSION","SUP-ITM-10101021","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","24482.64","14689.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","18949.56","77.4","","2142.10","2142.10","2142.10","1 through 10","2847.33","18949.56","percent of total billed charges",""
"STENT GRAFT 26MMX14.5 18CM VASCULAR EXCLUDER EPTFE C3 COATED SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135323","CDM","C1874","HCPCS","0278","RC","","","","both","","","25280.32","15168.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","14384.50","56.9","","4336.72","1572.72","9255.66","15","2940.1","21488.27","percent of total billed charges",""
"STENT GRAFT 26MMX14.5 18CM VASCULAR EXCLUDER EPTFE C3 COATED SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135323","CDM","C1874","HCPCS","0278","RC","","","","both","","","25280.32","15168.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","19566.97","77.4","","2142.10","2142.10","2142.10","1 through 10","2940.1","21488.27","percent of total billed charges",""
"STENT GRAFT 26MMX14.5 18CM VASCULAR EXCLUDER EPTFE C3 COATED SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135323","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25280.32","15168.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","18383.85","72.72","","2261.23","2261.23","2261.23","1 through 10","2940.1","19566.97","percent of total billed charges",""
"STENT GRAFT 26MMX14.5 18CM VASCULAR EXCLUDER EPTFE C3 COATED SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135323","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25280.32","15168.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","15901.32","62.9","","4353.04","1741.32","8465.73","1 through 10","2940.1","19566.97","percent of total billed charges",""
"STENT GRAFT 26MMX14.5 18CM VASCULAR EXCLUDER EPTFE C3 COATED SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135323","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25280.32","15168.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","19566.97","77.4","","2142.10","2142.10","2142.10","1 through 10","2940.1","19566.97","percent of total billed charges",""
"STENT GRAFT 27.0MM 12.0CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114968","CDM","C1874","HCPCS","0278","RC","","","","both","","","17889.12","10733.47","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","10178.91","56.9","","4336.72","1572.72","9255.66","15","2080.5","15205.75","percent of total billed charges",""
"STENT GRAFT 27.0MM 12.0CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114968","CDM","C1874","HCPCS","0278","RC","","","","both","","","17889.12","10733.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","13846.18","77.4","","2142.10","2142.10","2142.10","1 through 10","2080.5","15205.75","percent of total billed charges",""
"STENT GRAFT 27.0MM 12.0CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114968","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","17889.12","10733.47","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","13008.97","72.72","","2261.23","2261.23","2261.23","1 through 10","2080.5","13846.18","percent of total billed charges",""
"STENT GRAFT 27.0MM 12.0CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114968","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","17889.12","10733.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","11252.26","62.9","","4353.04","1741.32","8465.73","1 through 10","2080.5","13846.18","percent of total billed charges",""
"STENT GRAFT 27.0MM 12.0CM VASCULAR EXCLUDER EPTFE CONTRALATERAL LEG","SUP-ITM-10114968","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","17889.12","10733.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","13846.18","77.4","","2142.10","2142.10","2142.10","1 through 10","2080.5","13846.18","percent of total billed charges",""
"STENT GRAFT 28MM 14.5 18CM VASCULAR EXCLUDER EPTFE C3 COATED SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135331","CDM","C1874","HCPCS","0278","RC","","","","both","","","25280.32","15168.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","14384.50","56.9","","4336.72","1572.72","9255.66","15","2940.1","21488.27","percent of total billed charges",""
"STENT GRAFT 28MM 14.5 18CM VASCULAR EXCLUDER EPTFE C3 COATED SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135331","CDM","C1874","HCPCS","0278","RC","","","","both","","","25280.32","15168.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","19566.97","77.4","","2142.10","2142.10","2142.10","1 through 10","2940.1","21488.27","percent of total billed charges",""
"STENT GRAFT 28MM 14.5 18CM VASCULAR EXCLUDER EPTFE C3 COATED SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135331","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25280.32","15168.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","18383.85","72.72","","2261.23","2261.23","2261.23","1 through 10","2940.1","19566.97","percent of total billed charges",""
"STENT GRAFT 28MM 14.5 18CM VASCULAR EXCLUDER EPTFE C3 COATED SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135331","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25280.32","15168.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","15901.32","62.9","","4353.04","1741.32","8465.73","1 through 10","2940.1","19566.97","percent of total billed charges",""
"STENT GRAFT 28MM 14.5 18CM VASCULAR EXCLUDER EPTFE C3 COATED SYSTEM BIFURCATED ILIAC TRUNK IPSILATERAL LEG","SUP-ITM-10135331","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25280.32","15168.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","19566.97","77.4","","2142.10","2142.10","2142.10","1 through 10","2940.1","19566.97","percent of total billed charges",""
"STENT NASAL 5X16X19MM ALAR FLUROPLASTIC VALVE PK/2EA","SUP-ITM-10236383","CDM","C1889","HCPCS","0278","RC","","","","both","","","963.22","577.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","112.02","818.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STENT NASAL 5X16X19MM ALAR FLUROPLASTIC VALVE PK/2EA","SUP-ITM-10236383","CDM","C1889","HCPCS","0278","RC","","","","both","","","963.22","577.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","112.02","818.74","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STENT NASAL 5X16X19MM ALAR FLUROPLASTIC VALVE PK/2EA","SUP-ITM-10236383","CDM","C1889","HCPCS","0278","RC","","","","both","","","963.22","577.93","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","548.07","56.9","","0.63","0.63","0.63","1 through 10","112.02","818.74","percent of total billed charges",""
"STENT NASAL 5X16X19MM ALAR FLUROPLASTIC VALVE PK/2EA","SUP-ITM-10236383","CDM","C1889","HCPCS","0278","RC","","","","both","","","963.22","577.93","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","138.90","14.42","","317.14","317.14","317.14","1 through 10","112.02","818.74","percent of total billed charges",""
"STENT NASAL 5X16X19MM ALAR FLUROPLASTIC VALVE PK/2EA","SUP-ITM-10236383","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","963.22","577.93","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","138.90","14.42","","317.14","317.14","317.14","1 through 10","112.02","745.53","percent of total billed charges",""
"STENT NASAL 5X16X19MM ALAR FLUROPLASTIC VALVE PK/2EA","SUP-ITM-10236383","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","963.22","577.93","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","604.71","62.78","","1125.09","1125.09","1125.09","1 through 10","112.02","745.53","percent of total billed charges",""
"STENT NASAL 5X16X19MM ALAR FLUROPLASTIC VALVE PK/2EA","SUP-ITM-10236383","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","963.22","577.93","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","700.45","72.72","","4732.50","1617.43","14180.40","1 through 10","112.02","745.53","percent of total billed charges",""
"STENT NASAL 5X16X19MM ALAR FLUROPLASTIC VALVE PK/2EA","SUP-ITM-10236383","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","963.22","577.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","605.87","62.9","","3896.20","3341.38","3896.20","1 through 10","112.02","745.53","percent of total billed charges",""
"STENT PANCREATIC 10FR 9.0CM CONTOURED FLAP POLYETHYLENE NON RADIOPAQUE GEENEN","SUP-ITM-10073829","CDM","C2617","HCPCS","0278","RC","","","","both","","","621.90","373.14","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","764.25","764.25","764.25","1 through 10","72.33","528.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STENT PANCREATIC 10FR 9.0CM CONTOURED FLAP POLYETHYLENE NON RADIOPAQUE GEENEN","SUP-ITM-10073829","CDM","C2617","HCPCS","0278","RC","","","","both","","","621.90","373.14","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","353.86","56.9","","434.86","434.86","472.36","15","72.33","528.62","percent of total billed charges",""
"STENT PANCREATIC 10FR 9.0CM CONTOURED FLAP POLYETHYLENE NON RADIOPAQUE GEENEN","SUP-ITM-10073829","CDM","C2617","HCPCS","0278","RC","","","","both","","","621.90","373.14","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","353.86","56.9","","434.86","434.86","434.86","1 through 10","72.33","528.62","percent of total billed charges",""
"STENT PANCREATIC 10FR 9.0CM CONTOURED FLAP POLYETHYLENE NON RADIOPAQUE GEENEN","SUP-ITM-10073829","CDM","C2617","HCPCS","0278","RC","","","","both","","","621.90","373.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","72.33","11.63","","105.24","93.54","105.24","1 through 10","72.33","528.62","percent of total billed charges",""
"STENT PANCREATIC 10FR 9.0CM CONTOURED FLAP POLYETHYLENE NON RADIOPAQUE GEENEN","SUP-ITM-10073829","CDM","C2617","HCPCS","0278","RC","","","","both","","","621.90","373.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","481.35","77.4","","592.29","592.29","592.29","1 through 10","72.33","528.62","percent of total billed charges",""
"STENT PANCREATIC 10FR 9.0CM CONTOURED FLAP POLYETHYLENE NON RADIOPAQUE GEENEN","SUP-ITM-10073829","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","621.90","373.14","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","72.33","11.63","","105.24","93.54","105.24","1 through 10","72.33","481.35","percent of total billed charges",""
"STENT PANCREATIC 10FR 9.0CM CONTOURED FLAP POLYETHYLENE NON RADIOPAQUE GEENEN","SUP-ITM-10073829","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","621.90","373.14","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","271.89","43.72","","334.13","334.13","334.13","1 through 10","72.33","481.35","percent of total billed charges",""
"STENT PANCREATIC 10FR 9.0CM CONTOURED FLAP POLYETHYLENE NON RADIOPAQUE GEENEN","SUP-ITM-10073829","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","621.90","373.14","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","452.25","72.72","","555.76","555.76","555.76","1 through 10","72.33","481.35","percent of total billed charges",""
"STENT PANCREATIC 10FR 9.0CM CONTOURED FLAP POLYETHYLENE NON RADIOPAQUE GEENEN","SUP-ITM-10073829","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","621.90","373.14","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","452.25","72.72","","555.76","555.76","555.76","1 through 10","72.33","481.35","percent of total billed charges",""
"STENT PANCREATIC 10FR 9.0CM CONTOURED FLAP POLYETHYLENE NON RADIOPAQUE GEENEN","SUP-ITM-10073829","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","621.90","373.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","330.98","53.22","","859.65","859.65","859.65","1 through 10","72.33","481.35","percent of total billed charges",""
"STENT PANCREATIC 10FR 9.0CM CONTOURED FLAP POLYETHYLENE NON RADIOPAQUE GEENEN","SUP-ITM-10073829","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","621.90","373.14","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","391.18","62.9","","481.48","481.48","481.48","1 through 10","72.33","481.35","percent of total billed charges",""
"STENT PANCREATIC 10FR 9.0CM CONTOURED FLAP POLYETHYLENE NON RADIOPAQUE GEENEN","SUP-ITM-10073829","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","621.90","373.14","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","481.35","77.4","","592.29","592.29","592.29","1 through 10","72.33","481.35","percent of total billed charges",""
"STENT PANCREATIC 10FR NAVIFLEX RX","SUP-ITM-10147621","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","569.18","341.51","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","413.91","72.72","","324.46","324.46","324.46","1 through 10","66.2","440.55","percent of total billed charges",""
"STENT PANCREATIC 4FR 4CM ADVANIX PIGTAIL","SUP-ITM-10147710","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","545.34","327.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","396.57","72.72","","324.46","324.46","324.46","1 through 10","63.42","422.09","percent of total billed charges",""
"STENT PANCREATIC 7FR 7CM ADVANIX LB STRAIGHT","SUP-ITM-10147674","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","616.16","369.70","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","448.07","72.72","","324.46","324.46","324.46","1 through 10","71.66","476.91","percent of total billed charges",""
"STENT PERCUFLEX PLUS 4.8FR 24CM URETERAL DOUBLE PIGTAIL TAPER TIP THREADED HYDRO COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10027243","CDM","C2617","HCPCS","0278","RC","","","","both","","","1165.44","699.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","764.25","764.25","764.25","1 through 10","135.54","990.62","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STENT PERCUFLEX PLUS 4.8FR 24CM URETERAL DOUBLE PIGTAIL TAPER TIP THREADED HYDRO COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10027243","CDM","C2617","HCPCS","0278","RC","","","","both","","","1165.44","699.26","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","663.14","56.9","","434.86","434.86","472.36","15","135.54","990.62","percent of total billed charges",""
"STENT PERCUFLEX PLUS 4.8FR 24CM URETERAL DOUBLE PIGTAIL TAPER TIP THREADED HYDRO COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10027243","CDM","C2617","HCPCS","0278","RC","","","","both","","","1165.44","699.26","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","663.14","56.9","","434.86","434.86","434.86","1 through 10","135.54","990.62","percent of total billed charges",""
"STENT PERCUFLEX PLUS 4.8FR 24CM URETERAL DOUBLE PIGTAIL TAPER TIP THREADED HYDRO COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10027243","CDM","C2617","HCPCS","0278","RC","","","","both","","","1165.44","699.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","135.54","11.63","","105.24","93.54","105.24","1 through 10","135.54","990.62","percent of total billed charges",""
"STENT PERCUFLEX PLUS 4.8FR 24CM URETERAL DOUBLE PIGTAIL TAPER TIP THREADED HYDRO COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10027243","CDM","C2617","HCPCS","0278","RC","","","","both","","","1165.44","699.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","902.05","77.4","","592.29","592.29","592.29","1 through 10","135.54","990.62","percent of total billed charges",""
"STENT PERCUFLEX PLUS 4.8FR 24CM URETERAL DOUBLE PIGTAIL TAPER TIP THREADED HYDRO COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10027243","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1165.44","699.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","135.54","11.63","","105.24","93.54","105.24","1 through 10","135.54","902.05","percent of total billed charges",""
"STENT PERCUFLEX PLUS 4.8FR 24CM URETERAL DOUBLE PIGTAIL TAPER TIP THREADED HYDRO COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10027243","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1165.44","699.26","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","509.53","43.72","","334.13","334.13","334.13","1 through 10","135.54","902.05","percent of total billed charges",""
"STENT PERCUFLEX PLUS 4.8FR 24CM URETERAL DOUBLE PIGTAIL TAPER TIP THREADED HYDRO COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10027243","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1165.44","699.26","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","847.51","72.72","","555.76","555.76","555.76","1 through 10","135.54","902.05","percent of total billed charges",""
"STENT PERCUFLEX PLUS 4.8FR 24CM URETERAL DOUBLE PIGTAIL TAPER TIP THREADED HYDRO COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10027243","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1165.44","699.26","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","847.51","72.72","","555.76","555.76","555.76","1 through 10","135.54","902.05","percent of total billed charges",""
"STENT PERCUFLEX PLUS 4.8FR 24CM URETERAL DOUBLE PIGTAIL TAPER TIP THREADED HYDRO COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10027243","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1165.44","699.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","620.25","53.22","","859.65","859.65","859.65","1 through 10","135.54","902.05","percent of total billed charges",""
"STENT PERCUFLEX PLUS 4.8FR 24CM URETERAL DOUBLE PIGTAIL TAPER TIP THREADED HYDRO COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10027243","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1165.44","699.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","733.06","62.9","","481.48","481.48","481.48","1 through 10","135.54","902.05","percent of total billed charges",""
"STENT PERCUFLEX PLUS 4.8FR 24CM URETERAL DOUBLE PIGTAIL TAPER TIP THREADED HYDRO COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10027243","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1165.44","699.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","902.05","77.4","","592.29","592.29","592.29","1 through 10","135.54","902.05","percent of total billed charges",""
"STENT Q50 PLUS 10-50MM 65CM GRAFT BALLOON PLUS CENTRAL VENOUS ANGIOPLASTY VASCULAR POLYURETHANE","SUP-ITM-10114974","CDM","C1725","HCPCS","0272","RC","","","","both","","","2764.00","1658.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","1929.27","69.8","","351.75","351.75","351.75","1 through 10","321.45","2349.4","percent of total billed charges",""
"STENT Q50 PLUS 10-50MM 65CM GRAFT BALLOON PLUS CENTRAL VENOUS ANGIOPLASTY VASCULAR POLYURETHANE","SUP-ITM-10114974","CDM","C1725","HCPCS","0272","RC","","","","both","","","2764.00","1658.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1572.72","56.9","","898.30","898.30","898.30","1 through 10","321.45","2349.4","percent of total billed charges",""
"STENT Q50 PLUS 10-50MM 65CM GRAFT BALLOON PLUS CENTRAL VENOUS ANGIOPLASTY VASCULAR POLYURETHANE","SUP-ITM-10114974","CDM","C1725","HCPCS","0272","RC","","","","both","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","398.57","14.42","","64.77","64.77","64.77","1 through 10","321.45","2349.4","percent of total billed charges",""
"STENT Q50 PLUS 10-50MM 65CM GRAFT BALLOON PLUS CENTRAL VENOUS ANGIOPLASTY VASCULAR POLYURETHANE","SUP-ITM-10114974","CDM","C1725","HCPCS","0272","RC","","","","both","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.45","11.63","","145.58","110.37","145.58","1 through 10","321.45","2349.4","percent of total billed charges",""
"STENT Q50 PLUS 10-50MM 65CM GRAFT BALLOON PLUS CENTRAL VENOUS ANGIOPLASTY VASCULAR POLYURETHANE","SUP-ITM-10114974","CDM","C1725","HCPCS","0272","RC","","","","both","","","2764.00","1658.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2139.34","77.4","","348.09","348.09","348.09","1 through 10","321.45","2349.4","percent of total billed charges",""
"STENT Q50 PLUS 10-50MM 65CM GRAFT BALLOON PLUS CENTRAL VENOUS ANGIOPLASTY VASCULAR POLYURETHANE","SUP-ITM-10114974","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","398.57","14.42","","64.77","64.77","64.77","1 through 10","321.45","2139.34","percent of total billed charges",""
"STENT Q50 PLUS 10-50MM 65CM GRAFT BALLOON PLUS CENTRAL VENOUS ANGIOPLASTY VASCULAR POLYURETHANE","SUP-ITM-10114974","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","2764.00","1658.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","321.45","11.63","","145.58","110.37","145.58","1 through 10","321.45","2139.34","percent of total billed charges",""
"STENT Q50 PLUS 10-50MM 65CM GRAFT BALLOON PLUS CENTRAL VENOUS ANGIOPLASTY VASCULAR POLYURETHANE","SUP-ITM-10114974","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","2764.00","1658.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2009.98","72.72","","406.70","406.70","1055.24","1 through 10","321.45","2139.34","percent of total billed charges",""
"STENT Q50 PLUS 10-50MM 65CM GRAFT BALLOON PLUS CENTRAL VENOUS ANGIOPLASTY VASCULAR POLYURETHANE","SUP-ITM-10114974","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","2764.00","1658.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1738.56","62.9","","1069.88","677.14","4190.63","20","321.45","2139.34","percent of total billed charges",""
"STENT Q50 PLUS 10-50MM 65CM GRAFT BALLOON PLUS CENTRAL VENOUS ANGIOPLASTY VASCULAR POLYURETHANE","SUP-ITM-10114974","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","2764.00","1658.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2139.34","77.4","","348.09","348.09","348.09","1 through 10","321.45","2139.34","percent of total billed charges",""
"STENT SOLUS 10FR 4CM .035 BILIARY DOUBLE PIGTAIL PLASTIC INTRODUCER RADIOPAQUE BAND","SUP-ITM-10014013","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","1050.32","630.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","763.79","72.72","","324.46","324.46","324.46","1 through 10","122.15","812.95","percent of total billed charges",""
"STENT URETERAL 6.0FR 22CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072427","CDM","C2617","HCPCS","0278","RC","","","","both","","","1391.05","834.63","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","764.25","764.25","764.25","1 through 10","161.78","1182.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STENT URETERAL 6.0FR 22CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072427","CDM","C2617","HCPCS","0278","RC","","","","both","","","1391.05","834.63","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","791.51","56.9","","434.86","434.86","472.36","15","161.78","1182.39","percent of total billed charges",""
"STENT URETERAL 6.0FR 22CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072427","CDM","C2617","HCPCS","0278","RC","","","","both","","","1391.05","834.63","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","791.51","56.9","","434.86","434.86","434.86","1 through 10","161.78","1182.39","percent of total billed charges",""
"STENT URETERAL 6.0FR 22CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072427","CDM","C2617","HCPCS","0278","RC","","","","both","","","1391.05","834.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","161.78","11.63","","105.24","93.54","105.24","1 through 10","161.78","1182.39","percent of total billed charges",""
"STENT URETERAL 6.0FR 22CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072427","CDM","C2617","HCPCS","0278","RC","","","","both","","","1391.05","834.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1076.67","77.4","","592.29","592.29","592.29","1 through 10","161.78","1182.39","percent of total billed charges",""
"STENT URETERAL 6.0FR 22CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072427","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1391.05","834.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","161.78","11.63","","105.24","93.54","105.24","1 through 10","161.78","1076.67","percent of total billed charges",""
"STENT URETERAL 6.0FR 22CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072427","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1391.05","834.63","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","608.17","43.72","","334.13","334.13","334.13","1 through 10","161.78","1076.67","percent of total billed charges",""
"STENT URETERAL 6.0FR 22CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072427","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1391.05","834.63","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1011.57","72.72","","555.76","555.76","555.76","1 through 10","161.78","1076.67","percent of total billed charges",""
"STENT URETERAL 6.0FR 22CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072427","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1391.05","834.63","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1011.57","72.72","","555.76","555.76","555.76","1 through 10","161.78","1076.67","percent of total billed charges",""
"STENT URETERAL 6.0FR 22CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072427","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1391.05","834.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","740.32","53.22","","859.65","859.65","859.65","1 through 10","161.78","1076.67","percent of total billed charges",""
"STENT URETERAL 6.0FR 22CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072427","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1391.05","834.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","874.97","62.9","","481.48","481.48","481.48","1 through 10","161.78","1076.67","percent of total billed charges",""
"STENT URETERAL 6.0FR 22CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10072427","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1391.05","834.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1076.67","77.4","","592.29","592.29","592.29","1 through 10","161.78","1076.67","percent of total billed charges",""
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","both","","","1391.05","834.63","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","764.25","764.25","764.25","1 through 10","161.78","1182.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","both","","","1391.05","834.63","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","791.51","56.9","","434.86","434.86","472.36","15","161.78","1182.39","percent of total billed charges",""
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","both","","","1391.05","834.63","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","791.51","56.9","","434.86","434.86","434.86","1 through 10","161.78","1182.39","percent of total billed charges",""
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","both","","","1391.05","834.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","161.78","11.63","","105.24","93.54","105.24","1 through 10","161.78","1182.39","percent of total billed charges",""
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","both","","","1391.05","834.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1076.67","77.4","","592.29","592.29","592.29","1 through 10","161.78","1182.39","percent of total billed charges",""
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1391.05","834.63","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","161.78","11.63","","105.24","93.54","105.24","1 through 10","161.78","1076.67","percent of total billed charges",""
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1391.05","834.63","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","608.17","43.72","","334.13","334.13","334.13","1 through 10","161.78","1076.67","percent of total billed charges",""
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1391.05","834.63","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1011.57","72.72","","555.76","555.76","555.76","1 through 10","161.78","1076.67","percent of total billed charges",""
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1391.05","834.63","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1011.57","72.72","","555.76","555.76","555.76","1 through 10","161.78","1076.67","percent of total billed charges",""
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1391.05","834.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","740.32","53.22","","859.65","859.65","859.65","1 through 10","161.78","1076.67","percent of total billed charges",""
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1391.05","834.63","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","874.97","62.9","","481.48","481.48","481.48","1 through 10","161.78","1076.67","percent of total billed charges",""
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1391.05","834.63","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1076.67","77.4","","592.29","592.29","592.29","1 through 10","161.78","1076.67","percent of total billed charges",""
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","both","","","2440.13","1464.08","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","764.25","764.25","764.25","1 through 10","283.79","2074.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","both","","","2440.13","1464.08","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1388.43","56.9","","434.86","434.86","472.36","15","283.79","2074.11","percent of total billed charges",""
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","both","","","2440.13","1464.08","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","1388.43","56.9","","434.86","434.86","434.86","1 through 10","283.79","2074.11","percent of total billed charges",""
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","both","","","2440.13","1464.08","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","283.79","11.63","","105.24","93.54","105.24","1 through 10","283.79","2074.11","percent of total billed charges",""
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","both","","","2440.13","1464.08","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1888.66","77.4","","592.29","592.29","592.29","1 through 10","283.79","2074.11","percent of total billed charges",""
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","2440.13","1464.08","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","283.79","11.63","","105.24","93.54","105.24","1 through 10","283.79","1888.66","percent of total billed charges",""
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","2440.13","1464.08","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1066.82","43.72","","334.13","334.13","334.13","1 through 10","283.79","1888.66","percent of total billed charges",""
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","2440.13","1464.08","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1774.46","72.72","","555.76","555.76","555.76","1 through 10","283.79","1888.66","percent of total billed charges",""
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","2440.13","1464.08","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1774.46","72.72","","555.76","555.76","555.76","1 through 10","283.79","1888.66","percent of total billed charges",""
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","2440.13","1464.08","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1298.64","53.22","","859.65","859.65","859.65","1 through 10","283.79","1888.66","percent of total billed charges",""
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","2440.13","1464.08","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1534.84","62.9","","481.48","481.48","481.48","1 through 10","283.79","1888.66","percent of total billed charges",""
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","2440.13","1464.08","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1888.66","77.4","","592.29","592.29","592.29","1 through 10","283.79","1888.66","percent of total billed charges",""
"STENT URETERAL 6FRX26CM SOFT TRIA","SUP-ITM-10273863","CDM","C2617","HCPCS","0278","RC","","","","both","","","2440.13","1464.08","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","764.25","764.25","764.25","1 through 10","283.79","2074.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STENT URETERAL 6FRX26CM SOFT TRIA","SUP-ITM-10273863","CDM","C2617","HCPCS","0278","RC","","","","both","","","2440.13","1464.08","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1388.43","56.9","","434.86","434.86","472.36","15","283.79","2074.11","percent of total billed charges",""
"STENT URETERAL 6FRX26CM SOFT TRIA","SUP-ITM-10273863","CDM","C2617","HCPCS","0278","RC","","","","both","","","2440.13","1464.08","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","1388.43","56.9","","434.86","434.86","434.86","1 through 10","283.79","2074.11","percent of total billed charges",""
"STENT URETERAL 6FRX26CM SOFT TRIA","SUP-ITM-10273863","CDM","C2617","HCPCS","0278","RC","","","","both","","","2440.13","1464.08","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","283.79","11.63","","105.24","93.54","105.24","1 through 10","283.79","2074.11","percent of total billed charges",""
"STENT URETERAL 6FRX26CM SOFT TRIA","SUP-ITM-10273863","CDM","C2617","HCPCS","0278","RC","","","","both","","","2440.13","1464.08","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1888.66","77.4","","592.29","592.29","592.29","1 through 10","283.79","2074.11","percent of total billed charges",""
"STENT URETERAL 6FRX26CM SOFT TRIA","SUP-ITM-10273863","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","2440.13","1464.08","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","283.79","11.63","","105.24","93.54","105.24","1 through 10","283.79","1888.66","percent of total billed charges",""
"STENT URETERAL 6FRX26CM SOFT TRIA","SUP-ITM-10273863","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","2440.13","1464.08","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1066.82","43.72","","334.13","334.13","334.13","1 through 10","283.79","1888.66","percent of total billed charges",""
"STENT URETERAL 6FRX26CM SOFT TRIA","SUP-ITM-10273863","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","2440.13","1464.08","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1774.46","72.72","","555.76","555.76","555.76","1 through 10","283.79","1888.66","percent of total billed charges",""
"STENT URETERAL 6FRX26CM SOFT TRIA","SUP-ITM-10273863","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","2440.13","1464.08","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1774.46","72.72","","555.76","555.76","555.76","1 through 10","283.79","1888.66","percent of total billed charges",""
"STENT URETERAL 6FRX26CM SOFT TRIA","SUP-ITM-10273863","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","2440.13","1464.08","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1298.64","53.22","","859.65","859.65","859.65","1 through 10","283.79","1888.66","percent of total billed charges",""
"STENT URETERAL 6FRX26CM SOFT TRIA","SUP-ITM-10273863","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","2440.13","1464.08","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1534.84","62.9","","481.48","481.48","481.48","1 through 10","283.79","1888.66","percent of total billed charges",""
"STENT URETERAL 6FRX26CM SOFT TRIA","SUP-ITM-10273863","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","2440.13","1464.08","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1888.66","77.4","","592.29","592.29","592.29","1 through 10","283.79","1888.66","percent of total billed charges",""
"STENT URETERAL 7FR 22 TO 30CM GUIDEWIRE 0.038IN STRETCH COATED VARIABLE LENGTH","SUP-ITM-10155361","CDM","C2617","HCPCS","0278","RC","","","","both","","","1203.03","721.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","764.25","764.25","764.25","1 through 10","139.91","1022.58","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STENT URETERAL 7FR 22 TO 30CM GUIDEWIRE 0.038IN STRETCH COATED VARIABLE LENGTH","SUP-ITM-10155361","CDM","C2617","HCPCS","0278","RC","","","","both","","","1203.03","721.82","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","684.52","56.9","","434.86","434.86","472.36","15","139.91","1022.58","percent of total billed charges",""
"STENT URETERAL 7FR 22 TO 30CM GUIDEWIRE 0.038IN STRETCH COATED VARIABLE LENGTH","SUP-ITM-10155361","CDM","C2617","HCPCS","0278","RC","","","","both","","","1203.03","721.82","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","684.52","56.9","","434.86","434.86","434.86","1 through 10","139.91","1022.58","percent of total billed charges",""
"STENT URETERAL 7FR 22 TO 30CM GUIDEWIRE 0.038IN STRETCH COATED VARIABLE LENGTH","SUP-ITM-10155361","CDM","C2617","HCPCS","0278","RC","","","","both","","","1203.03","721.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","139.91","11.63","","105.24","93.54","105.24","1 through 10","139.91","1022.58","percent of total billed charges",""
"STENT URETERAL 7FR 22 TO 30CM GUIDEWIRE 0.038IN STRETCH COATED VARIABLE LENGTH","SUP-ITM-10155361","CDM","C2617","HCPCS","0278","RC","","","","both","","","1203.03","721.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","931.15","77.4","","592.29","592.29","592.29","1 through 10","139.91","1022.58","percent of total billed charges",""
"STENT URETERAL 7FR 22 TO 30CM GUIDEWIRE 0.038IN STRETCH COATED VARIABLE LENGTH","SUP-ITM-10155361","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1203.03","721.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","139.91","11.63","","105.24","93.54","105.24","1 through 10","139.91","931.15","percent of total billed charges",""
"STENT URETERAL 7FR 22 TO 30CM GUIDEWIRE 0.038IN STRETCH COATED VARIABLE LENGTH","SUP-ITM-10155361","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1203.03","721.82","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","525.96","43.72","","334.13","334.13","334.13","1 through 10","139.91","931.15","percent of total billed charges",""
"STENT URETERAL 7FR 22 TO 30CM GUIDEWIRE 0.038IN STRETCH COATED VARIABLE LENGTH","SUP-ITM-10155361","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1203.03","721.82","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","874.84","72.72","","555.76","555.76","555.76","1 through 10","139.91","931.15","percent of total billed charges",""
"STENT URETERAL 7FR 22 TO 30CM GUIDEWIRE 0.038IN STRETCH COATED VARIABLE LENGTH","SUP-ITM-10155361","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1203.03","721.82","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","874.84","72.72","","555.76","555.76","555.76","1 through 10","139.91","931.15","percent of total billed charges",""
"STENT URETERAL 7FR 22 TO 30CM GUIDEWIRE 0.038IN STRETCH COATED VARIABLE LENGTH","SUP-ITM-10155361","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1203.03","721.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","640.25","53.22","","859.65","859.65","859.65","1 through 10","139.91","931.15","percent of total billed charges",""
"STENT URETERAL 7FR 22 TO 30CM GUIDEWIRE 0.038IN STRETCH COATED VARIABLE LENGTH","SUP-ITM-10155361","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1203.03","721.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","756.71","62.9","","481.48","481.48","481.48","1 through 10","139.91","931.15","percent of total billed charges",""
"STENT URETERAL 7FR 22 TO 30CM GUIDEWIRE 0.038IN STRETCH COATED VARIABLE LENGTH","SUP-ITM-10155361","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1203.03","721.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","931.15","77.4","","592.29","592.29","592.29","1 through 10","139.91","931.15","percent of total billed charges",""
"STENT VESSEL 23X12X10MM ILIAC EXCLUDER","SUP-ITM-10166188","CDM","C1874","HCPCS","0278","RC","","","","both","","","25657.92","15394.75","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","14599.36","56.9","","4336.72","1572.72","9255.66","15","2984.02","21809.23","percent of total billed charges",""
"STENT VESSEL 23X12X10MM ILIAC EXCLUDER","SUP-ITM-10166188","CDM","C1874","HCPCS","0278","RC","","","","both","","","25657.92","15394.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","19859.23","77.4","","2142.10","2142.10","2142.10","1 through 10","2984.02","21809.23","percent of total billed charges",""
"STENT VESSEL 23X12X10MM ILIAC EXCLUDER","SUP-ITM-10166188","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25657.92","15394.75","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","18658.44","72.72","","2261.23","2261.23","2261.23","1 through 10","2984.02","19859.23","percent of total billed charges",""
"STENT VESSEL 23X12X10MM ILIAC EXCLUDER","SUP-ITM-10166188","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25657.92","15394.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","16138.83","62.9","","4353.04","1741.32","8465.73","1 through 10","2984.02","19859.23","percent of total billed charges",""
"STENT VESSEL 23X12X10MM ILIAC EXCLUDER","SUP-ITM-10166188","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","25657.92","15394.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","19859.23","77.4","","2142.10","2142.10","2142.10","1 through 10","2984.02","19859.23","percent of total billed charges",""
"STENT VIABAHN 5MM 10CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135262","CDM","C1874","HCPCS","0278","RC","","","","both","","","14410.68","8646.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","8199.68","56.9","","4336.72","1572.72","9255.66","15","1675.96","12249.08","percent of total billed charges",""
"STENT VIABAHN 5MM 10CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135262","CDM","C1874","HCPCS","0278","RC","","","","both","","","14410.68","8646.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","11153.87","77.4","","2142.10","2142.10","2142.10","1 through 10","1675.96","12249.08","percent of total billed charges",""
"STENT VIABAHN 5MM 10CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135262","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","14410.68","8646.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10479.45","72.72","","2261.23","2261.23","2261.23","1 through 10","1675.96","11153.87","percent of total billed charges",""
"STENT VIABAHN 5MM 10CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135262","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","14410.68","8646.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","9064.32","62.9","","4353.04","1741.32","8465.73","1 through 10","1675.96","11153.87","percent of total billed charges",""
"STENT VIABAHN 5MM 10CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135262","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","14410.68","8646.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","11153.87","77.4","","2142.10","2142.10","2142.10","1 through 10","1675.96","11153.87","percent of total billed charges",""
"STENT VIABAHN 6MM 15CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135268","CDM","C1874","HCPCS","0278","RC","","","","both","","","16139.80","9683.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","9183.55","56.9","","4336.72","1572.72","9255.66","15","1877.06","13718.83","percent of total billed charges",""
"STENT VIABAHN 6MM 15CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135268","CDM","C1874","HCPCS","0278","RC","","","","both","","","16139.80","9683.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12492.21","77.4","","2142.10","2142.10","2142.10","1 through 10","1877.06","13718.83","percent of total billed charges",""
"STENT VIABAHN 6MM 15CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135268","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","16139.80","9683.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","11736.86","72.72","","2261.23","2261.23","2261.23","1 through 10","1877.06","12492.21","percent of total billed charges",""
"STENT VIABAHN 6MM 15CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135268","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","16139.80","9683.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","10151.93","62.9","","4353.04","1741.32","8465.73","1 through 10","1877.06","12492.21","percent of total billed charges",""
"STENT VIABAHN 6MM 15CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135268","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","16139.80","9683.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12492.21","77.4","","2142.10","2142.10","2142.10","1 through 10","1877.06","12492.21","percent of total billed charges",""
"STENT VIABAHN 7MM 5CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135271","CDM","C1874","HCPCS","0278","RC","","","","both","","","12879.52","7727.71","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7328.45","56.9","","4336.72","1572.72","9255.66","15","1497.89","10947.59","percent of total billed charges",""
"STENT VIABAHN 7MM 5CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135271","CDM","C1874","HCPCS","0278","RC","","","","both","","","12879.52","7727.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9968.75","77.4","","2142.10","2142.10","2142.10","1 through 10","1497.89","10947.59","percent of total billed charges",""
"STENT VIABAHN 7MM 5CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135271","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12879.52","7727.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","9365.99","72.72","","2261.23","2261.23","2261.23","1 through 10","1497.89","9968.75","percent of total billed charges",""
"STENT VIABAHN 7MM 5CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135271","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12879.52","7727.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8101.22","62.9","","4353.04","1741.32","8465.73","1 through 10","1497.89","9968.75","percent of total billed charges",""
"STENT VIABAHN 7MM 5CM 120CM .018IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135271","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12879.52","7727.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9968.75","77.4","","2142.10","2142.10","2142.10","1 through 10","1497.89","9968.75","percent of total billed charges",""
"STENT VIABAHN 8MM 10CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135256","CDM","C1874","HCPCS","0278","RC","","","","both","","","13946.08","8367.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7935.32","56.9","","4336.72","1572.72","9255.66","15","1621.93","11854.17","percent of total billed charges",""
"STENT VIABAHN 8MM 10CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135256","CDM","C1874","HCPCS","0278","RC","","","","both","","","13946.08","8367.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10794.27","77.4","","2142.10","2142.10","2142.10","1 through 10","1621.93","11854.17","percent of total billed charges",""
"STENT VIABAHN 8MM 10CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135256","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","13946.08","8367.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10141.59","72.72","","2261.23","2261.23","2261.23","1 through 10","1621.93","10794.27","percent of total billed charges",""
"STENT VIABAHN 8MM 10CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135256","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","13946.08","8367.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8772.08","62.9","","4353.04","1741.32","8465.73","1 through 10","1621.93","10794.27","percent of total billed charges",""
"STENT VIABAHN 8MM 10CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135256","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","13946.08","8367.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10794.27","77.4","","2142.10","2142.10","2142.10","1 through 10","1621.93","10794.27","percent of total billed charges",""
"STENT VIABAHN 8MM 5CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135254","CDM","C1874","HCPCS","0278","RC","","","","both","","","12443.20","7465.92","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7080.18","56.9","","4336.72","1572.72","9255.66","15","1447.14","10576.72","percent of total billed charges",""
"STENT VIABAHN 8MM 5CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135254","CDM","C1874","HCPCS","0278","RC","","","","both","","","12443.20","7465.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9631.04","77.4","","2142.10","2142.10","2142.10","1 through 10","1447.14","10576.72","percent of total billed charges",""
"STENT VIABAHN 8MM 5CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135254","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12443.20","7465.92","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","9048.70","72.72","","2261.23","2261.23","2261.23","1 through 10","1447.14","9631.04","percent of total billed charges",""
"STENT VIABAHN 8MM 5CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135254","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12443.20","7465.92","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7826.77","62.9","","4353.04","1741.32","8465.73","1 through 10","1447.14","9631.04","percent of total billed charges",""
"STENT VIABAHN 8MM 5CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10135254","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","12443.20","7465.92","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9631.04","77.4","","2142.10","2142.10","2142.10","1 through 10","1447.14","9631.04","percent of total billed charges",""
"STENT VIABAHN 8MM 7.5CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10169097","CDM","C1874","HCPCS","0278","RC","","","","both","","","13946.08","8367.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","7935.32","56.9","","4336.72","1572.72","9255.66","15","1621.93","11854.17","percent of total billed charges",""
"STENT VIABAHN 8MM 7.5CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10169097","CDM","C1874","HCPCS","0278","RC","","","","both","","","13946.08","8367.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10794.27","77.4","","2142.10","2142.10","2142.10","1 through 10","1621.93","11854.17","percent of total billed charges",""
"STENT VIABAHN 8MM 7.5CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10169097","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","13946.08","8367.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10141.59","72.72","","2261.23","2261.23","2261.23","1 through 10","1621.93","10794.27","percent of total billed charges",""
"STENT VIABAHN 8MM 7.5CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10169097","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","13946.08","8367.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","8772.08","62.9","","4353.04","1741.32","8465.73","1 through 10","1621.93","10794.27","percent of total billed charges",""
"STENT VIABAHN 8MM 7.5CM 120CM .035IN ENDOPROSTHESIS HEPARIN BIOACTIVE SURFACE","SUP-ITM-10169097","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","13946.08","8367.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10794.27","77.4","","2142.10","2142.10","2142.10","1 through 10","1621.93","10794.27","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 10CM 23MM .038IN ESOPHAGEAL SILICONE PARTIALLY COVERED","SUP-ITM-10049112","CDM","C1874","HCPCS","0278","RC","","","","both","","","10670.00","6402.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6071.23","56.9","","4336.72","1572.72","9255.66","15","1240.92","9069.5","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 10CM 23MM .038IN ESOPHAGEAL SILICONE PARTIALLY COVERED","SUP-ITM-10049112","CDM","C1874","HCPCS","0278","RC","","","","both","","","10670.00","6402.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8258.58","77.4","","2142.10","2142.10","2142.10","1 through 10","1240.92","9069.5","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 10CM 23MM .038IN ESOPHAGEAL SILICONE PARTIALLY COVERED","SUP-ITM-10049112","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10670.00","6402.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7759.22","72.72","","2261.23","2261.23","2261.23","1 through 10","1240.92","8258.58","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 10CM 23MM .038IN ESOPHAGEAL SILICONE PARTIALLY COVERED","SUP-ITM-10049112","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10670.00","6402.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6711.43","62.9","","4353.04","1741.32","8465.73","1 through 10","1240.92","8258.58","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 10CM 23MM .038IN ESOPHAGEAL SILICONE PARTIALLY COVERED","SUP-ITM-10049112","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10670.00","6402.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8258.58","77.4","","2142.10","2142.10","2142.10","1 through 10","1240.92","8258.58","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 10CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073341","CDM","C1874","HCPCS","0278","RC","","","","both","","","10912.50","6547.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6209.21","56.9","","4336.72","1572.72","9255.66","15","1269.12","9275.63","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 10CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073341","CDM","C1874","HCPCS","0278","RC","","","","both","","","10912.50","6547.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8446.28","77.4","","2142.10","2142.10","2142.10","1 through 10","1269.12","9275.63","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 10CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073341","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10912.50","6547.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7935.57","72.72","","2261.23","2261.23","2261.23","1 through 10","1269.12","8446.28","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 10CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073341","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10912.50","6547.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6863.96","62.9","","4353.04","1741.32","8465.73","1 through 10","1269.12","8446.28","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 10CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073341","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10912.50","6547.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8446.28","77.4","","2142.10","2142.10","2142.10","1 through 10","1269.12","8446.28","percent of total billed charges",""
"STENT WALLFLEX 8.5FR 10MM 40MM .035IN RX BILIARY SILICONE FULLY COVERED SELF-EXP GUIDEWIRE COMPAT","SUP-ITM-10050455","CDM","C1874","HCPCS","0278","RC","","","","both","","","11640.00","6984.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6623.16","56.9","","4336.72","1572.72","9255.66","15","1353.73","9894","percent of total billed charges",""
"STENT WALLFLEX 8.5FR 10MM 40MM .035IN RX BILIARY SILICONE FULLY COVERED SELF-EXP GUIDEWIRE COMPAT","SUP-ITM-10050455","CDM","C1874","HCPCS","0278","RC","","","","both","","","11640.00","6984.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9009.36","77.4","","2142.10","2142.10","2142.10","1 through 10","1353.73","9894","percent of total billed charges",""
"STENT WALLFLEX 8.5FR 10MM 40MM .035IN RX BILIARY SILICONE FULLY COVERED SELF-EXP GUIDEWIRE COMPAT","SUP-ITM-10050455","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11640.00","6984.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8464.61","72.72","","2261.23","2261.23","2261.23","1 through 10","1353.73","9009.36","percent of total billed charges",""
"STENT WALLFLEX 8.5FR 10MM 40MM .035IN RX BILIARY SILICONE FULLY COVERED SELF-EXP GUIDEWIRE COMPAT","SUP-ITM-10050455","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11640.00","6984.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7321.56","62.9","","4353.04","1741.32","8465.73","1 through 10","1353.73","9009.36","percent of total billed charges",""
"STENT WALLFLEX 8.5FR 10MM 40MM .035IN RX BILIARY SILICONE FULLY COVERED SELF-EXP GUIDEWIRE COMPAT","SUP-ITM-10050455","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11640.00","6984.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9009.36","77.4","","2142.10","2142.10","2142.10","1 through 10","1353.73","9009.36","percent of total billed charges",""
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","14376.00","8625.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","11724.16","","Case rate ($11,724.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11301.33","11301.33","11301.33","1 through 10","1797.81","12219.6","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","14376.00","8625.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","5048.41","","Case rate ($5,048.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4925.34","4432.84","4925.34","1 through 10","1797.81","12219.6","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","14376.00","8625.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1797.81","","APC Price ($1,834.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1805.36","1738.58","1834.72","27","1797.81","12219.6","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","14376.00","8625.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","9476.53","","Case rate ($9,476.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","22153.12","22153.12","22153.12","1 through 10","1797.81","12219.6","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","14376.00","8625.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","1889.54","","APC Price ($1,834.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1859.52","1851.96","1859.52","30","1797.81","12219.6","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","14376.00","8625.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","1834.50","","APC Price ($1,834.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1803.53","1798.03","1805.36","28","1797.81","12219.6","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","14376.00","8625.60","MEDICARE [2001]","HB WDH MEDICARE","1834.50","","APC Price ($1,834.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1834.72","1834.72","1834.72","143","1797.81","12219.6","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","14376.00","8625.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","1834.50","","APC Price ($1,834.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1805.37","1798.03","1805.37","80","1797.81","12219.6","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","both","","","14376.00","8625.60","WELLSENSE NH [1050]","HB WDH MEDICARE","1834.50","","APC Price ($1,834.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1889.53","1889.53","7307.10","20","1797.81","12219.6","other","OPPS APC"
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","outpatient","","","14376.00","8625.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2073.02","14.42","","2000.34","2000.34","2000.34","1 through 10","1671.93","11127.02","percent of total billed charges",""
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","outpatient","","","14376.00","8625.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1671.93","11.63","","3503.41","1638.51","3503.41","18","1671.93","11127.02","percent of total billed charges",""
"Stereotactic Bdy Rad Thrpy Delivery","PX-33000091","CDM","77373","CPT","0333","RC","","","","outpatient","","","14376.00","8625.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10454.23","72.72","","10087.72","10087.72","10087.72","1 through 10","1671.93","11127.02","percent of total billed charges",""
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","both","","","29010.00","17406.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","51042.17","","Case rate ($51,042.17). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","27994.00","27994.00","27994.00","1 through 10","7826.92","51042.17","other","OPPS APC"
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","both","","","29010.00","17406.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","41256.90","","Case rate ($41,256.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","28678.84","28674.82","28678.84","1 through 10","7826.92","51042.17","other","OPPS APC"
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","both","","","29010.00","17406.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","7986.66","","APC Price ($7,986.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7859.77","7827.82","7859.77","1 through 10","7826.92","51042.17","other","OPPS APC"
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","both","","","29010.00","17406.00","MEDICARE [2001]","HB WDH MEDICARE","7986.66","","APC Price ($7,986.66). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7987.57","7987.57","7987.57","1 through 10","7826.92","51042.17","other","OPPS APC"
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","outpatient","","","29010.00","17406.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","21096.07","72.72","","20357.24","20357.24","20357.24","1 through 10","3373.86","22453.74","percent of total billed charges",""
"Stereotactic Radiosurgery Cmpl Lb","PX-33000090","CDM","77372","CPT","0333","RC","","","","outpatient","","","29010.00","17406.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","3373.86","11.63","","12524.51","12524.51","12524.51","1 through 10","3373.86","22453.74","percent of total billed charges",""
"STIMULATOR CLOSED-LOOP EVOKE (CLS) 24-CHANNEL UPGRADABLE RECHARGEABLE","SUP-ITM-10317737","CDM","C1826","HCPCS","0278","RC","","","","both","","","47197.64","28318.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","14133.10","14133.10","14133.10","1 through 10","5489.09","40117.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STIMULATOR CLOSED-LOOP EVOKE (CLS) 24-CHANNEL UPGRADABLE RECHARGEABLE","SUP-ITM-10317737","CDM","C1826","HCPCS","0278","RC","","","","both","","","47197.64","28318.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","47200.00","47200.00","47200.00","1 through 10","5489.09","40117.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STIMULATOR NEURO SURESCAN RECHARGER SYSTEM ANTENNA BELT","SUP-ITM-10124362","CDM","C1820","HCPCS","0278","RC","","","","both","","","8749.40","5249.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","52982.00","26491.00","52982.00","1 through 10","1017.56","7436.99","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STIMULATOR NEURO SURESCAN RECHARGER SYSTEM ANTENNA BELT","SUP-ITM-10124362","CDM","C1820","HCPCS","0278","RC","","","","both","","","8749.40","5249.64","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4978.41","56.9","","45220.14","36256.68","45220.14","1 through 10","1017.56","7436.99","percent of total billed charges",""
"STIMULATOR NEURO SURESCAN RECHARGER SYSTEM ANTENNA BELT","SUP-ITM-10124362","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","8749.40","5249.64","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","6362.56","72.72","","18421.60","18421.60","18421.60","1 through 10","1017.56","6772.04","percent of total billed charges",""
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","","","","inpatient","","","72653.54","43592.12","MEDICARE [2001]","HB WDH MEDICARE","19026.74","","Case rate ($19,026.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $17,595.73, add-ons for qualifying new technology services are included. If operating cost exceeds $21,513.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,162.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $17,224.01 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,150.86 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,357.86. The transfer capital threshold is the transfer adjustment factor * $1,357.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18766.16","18766.16","18766.16","1 through 10","3975","92879.84","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","","","","inpatient","","","72653.54","43592.12","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","19026.74","","Case rate ($19,026.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $17,595.73, add-ons for qualifying new technology services are included. If operating cost exceeds $21,513.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,162.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $17,224.01 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $17,150.86 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,357.86. The transfer capital threshold is the transfer adjustment factor * $1,357.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","18475.23","18475.23","18475.23","1 through 10","3975","92879.84","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures With McC","326","MS-DRG","","","","","","","","inpatient","","","67744.35","40646.61","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","74625.87","","Fee schedule rate ($74,625.87). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","57064.37","57064.37","57064.37","1 through 10","3975","189521.7","case rate",""
"Stomach, Esophageal And Duodenal Procedures With McC","326","MS-DRG","","","","","","","","inpatient","","","67744.35","40646.61","MEDICARE [2001]","HB WDH MEDICARE","38361.26","","Case rate ($38,361.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $35,441.28, add-ons for qualifying new technology services are included. If operating cost exceeds $39,359.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,575.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $35,145.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $34,996.41 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,770.72. The transfer capital threshold is the transfer adjustment factor * $2,770.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","27921.55","27921.55","38868.55","1 through 10","3975","189521.7","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures With McC","326","MS-DRG","","","","","","","","inpatient","","","67744.35","40646.61","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","38361.26","","Case rate ($38,361.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $35,441.28, add-ons for qualifying new technology services are included. If operating cost exceeds $39,359.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,575.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $35,145.67 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $34,996.41 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,770.72. The transfer capital threshold is the transfer adjustment factor * $2,770.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","38126.67","38126.67","38126.67","1 through 10","3975","189521.7","other","Inpatient DRG"
"Strapping Unna Boot","PX-76000725","CDM","29580","CPT","0761","RC","","","","both","","","885.00","531.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1053.58","","Case rate ($1,053.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","854.00","854.00","854.00","1 through 10","161.56","1053.58","other","OPPS APC"
"Strapping Unna Boot","PX-76000725","CDM","29580","CPT","0761","RC","","","","both","","","885.00","531.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","503.57","56.9","","485.93","485.93","485.93","1 through 10","161.56","1053.58","percent of total billed charges",""
"Strapping Unna Boot","PX-76000725","CDM","29580","CPT","0761","RC","","","","both","","","885.00","531.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","164.85","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","162.47","161.57","162.47","1 through 10","161.56","1053.58","other","OPPS APC"
"Strapping Unna Boot","PX-76000725","CDM","29580","CPT","0761","RC","","","","both","","","885.00","531.00","MEDICARE [2001]","HB WDH MEDICARE","164.85","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","164.87","153.53","164.87","26","161.56","1053.58","other","OPPS APC"
"Strapping Unna Boot","PX-76000725","CDM","29580","CPT","0761","RC","","","","both","","","885.00","531.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","164.85","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","226.16","150.77","226.16","1 through 10","161.56","1053.58","other","OPPS APC"
"Strapping Unna Boot|BILATERAL PROCEDURE","PX-76000725","CDM","29580","CPT","0761","RC","","","50","both","","","885.00","531.00","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","168.15","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","247.31","247.31","247.31","1 through 10","161.56","169.8","other","OPPS APC"
"Strapping Unna Boot|BILATERAL PROCEDURE","PX-76000725","CDM","29580","CPT","0761","RC","","","50","both","","","885.00","531.00","MEDICARE [2001]","HB WDH MEDICARE","164.85","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","247.31","247.31","741.93","15","161.56","169.8","other","OPPS APC"
"Strapping Unna Boot|BILATERAL PROCEDURE","PX-76000725","CDM","29580","CPT","0761","RC","","","50","both","","","885.00","531.00","WELLSENSE NH [1050]","HB WDH MEDICARE","164.85","","APC Price ($164.85). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","519.36","259.68","519.36","11","161.56","169.8","other","OPPS APC"
"Streptococcus Pneumoniae Igg Antibodies, 23 Serotypes, Serum","PX-30003557","CDM","86317","CPT","0302","RC","","","","both","","","80.00","48.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","55.84","69.8","","53.75","53.75","53.75","1 through 10","9.74","76.77","percent of total billed charges",""
"Streptococcus Pneumoniae Igg Antibodies, 23 Serotypes, Serum","PX-30003557","CDM","86317","CPT","0302","RC","","","","outpatient","","","80.00","48.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","58.18","72.72","","55.99","55.99","55.99","1 through 10","13.96","61.92","percent of total billed charges",""
"Streptococcus Pneumoniae Igg Antibodies, 23 Serotypes, Serum","PX-30003557","CDM","86317","CPT","0302","RC","","","","outpatient","","","80.00","48.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","50.32","62.9","","145.53","48.51","182.32","11","13.96","61.92","percent of total billed charges",""
"Streptococcus Pneumoniae Igg Antibodies, 23 Serotypes, Serum","PX-30003557","CDM","86317","CPT","0302","RC","","","","outpatient","","","80.00","48.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","61.92","77.4","","59.68","59.68","59.68","1 through 10","13.96","61.92","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1748.00","1048.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","1220.10","69.8","","1177.53","199.26","1177.53","1 through 10","252.06","2079.19","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1748.00","1048.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2079.19","","Case rate ($2,079.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1687.00","1687.00","1687.00","20","252.06","2079.19","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1748.00","1048.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","895.30","","Case rate ($895.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","856.04","786.13","873.47","45","252.06","2079.19","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1748.00","1048.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","318.83","","APC Price ($325.34). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","325.38","318.87","325.38","37","252.06","2079.19","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1748.00","1048.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1680.59","","Case rate ($1,680.59). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1639.59","873.47","1639.59","26","252.06","2079.19","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1748.00","1048.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","994.61","56.9","","959.90","959.90","2879.70","119","252.06","2079.19","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1748.00","1048.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","252.06","14.42","","243.27","208.51","243.27","31","252.06","2079.19","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1748.00","1048.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","335.10","","APC Price ($325.34). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","330.44","329.78","335.14","1 through 10","252.06","2079.19","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1748.00","1048.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","325.34","","APC Price ($325.34). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","319.85","319.85","325.38","24","252.06","2079.19","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1748.00","1048.80","MEDICARE [2001]","HB WDH MEDICARE","325.34","","APC Price ($325.34). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","325.38","305.82","325.38","42","252.06","2079.19","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1748.00","1048.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","930.29","53.22","","899.34","899.34","899.34","1 through 10","252.06","2079.19","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1748.00","1048.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1099.49","62.9","","1062.81","1062.81","3965.12","91","252.06","2079.19","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1748.00","1048.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","1485.80","85","","1095.03","1095.03","1095.03","1 through 10","252.06","2079.19","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1748.00","1048.80","TRICARE [160005]","HB WDH MEDICARE","325.34","","APC Price ($325.34). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","325.38","325.38","325.38","1 through 10","252.06","2079.19","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1748.00","1048.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","325.34","","APC Price ($325.34). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","319.88","318.88","320.18","20","252.06","2079.19","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1748.00","1048.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1352.95","77.4","","1307.43","1307.43","1307.43","28","252.06","2079.19","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","1748.00","1048.80","WELLSENSE NH [1050]","HB WDH MEDICARE","325.34","","APC Price ($325.34). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","334.82","334.82","337.70","1 through 10","252.06","2079.19","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","outpatient","","","1748.00","1048.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","203.29","11.63","","232.30","199.26","426.06","48","203.29","1271.15","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","outpatient","","","1748.00","1048.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1097.39","62.78","","1059.10","1059.10","1059.10","1 through 10","203.29","1271.15","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","outpatient","","","1748.00","1048.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","764.23","43.72","","737.56","737.56","737.56","1 through 10","203.29","1271.15","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","outpatient","","","1748.00","1048.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1271.15","72.72","","1226.79","1226.79","3680.37","70","203.29","1271.15","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","outpatient","","","1748.00","1048.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","1271.15","72.72","","1226.79","1226.79","2453.58","1 through 10","203.29","1271.15","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","outpatient","","","1748.00","1048.80","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","1271.15","72.72","","1226.79","1226.79","1226.79","1 through 10","203.29","1271.15","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","outpatient","","","1748.00","1048.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","1271.15","72.72","","1226.79","1226.79","1226.79","1 through 10","203.29","1271.15","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","outpatient","","","1748.00","1048.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","203.29","11.63","","199.26","199.26","199.26","26","203.29","1271.15","percent of total billed charges",""
"STRIP CERAMIC 12ML 10CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168399","CDM","C1713","HCPCS","0278","RC","","","","both","","","6634.71","3980.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","771.62","5639.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STRIP CERAMIC 12ML 10CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168399","CDM","C1713","HCPCS","0278","RC","","","","both","","","6634.71","3980.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","771.62","5639.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STRIP CERAMIC 12ML 10CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168399","CDM","C1713","HCPCS","0278","RC","","","","both","","","6634.71","3980.83","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3775.15","56.9","","812.12","238.65","1587.46","163","771.62","5639.5","percent of total billed charges",""
"STRIP CERAMIC 12ML 10CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168399","CDM","C1713","HCPCS","0278","RC","","","","both","","","6634.71","3980.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","771.62","11.63","","112.68","112.68","146.99","38","771.62","5639.5","percent of total billed charges",""
"STRIP CERAMIC 12ML 10CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168399","CDM","C1713","HCPCS","0278","RC","","","","both","","","6634.71","3980.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5135.27","77.4","","303.98","303.98","5854.79","1 through 10","771.62","5639.5","percent of total billed charges",""
"STRIP CERAMIC 12ML 10CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6634.71","3980.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","771.62","11.63","","112.68","112.68","146.99","38","771.62","5135.27","percent of total billed charges",""
"STRIP CERAMIC 12ML 10CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6634.71","3980.83","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4165.27","62.78","","780.86","208.94","10480.28","15","771.62","5135.27","percent of total billed charges",""
"STRIP CERAMIC 12ML 10CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6634.71","3980.83","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2900.70","43.72","","179.76","179.76","179.76","1 through 10","771.62","5135.27","percent of total billed charges",""
"STRIP CERAMIC 12ML 10CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6634.71","3980.83","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4824.76","72.72","","2355.45","298.99","3965.19","155","771.62","5135.27","percent of total billed charges",""
"STRIP CERAMIC 12ML 10CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6634.71","3980.83","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4824.76","72.72","","3643.09","3643.09","3643.09","1 through 10","771.62","5135.27","percent of total billed charges",""
"STRIP CERAMIC 12ML 10CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6634.71","3980.83","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3530.99","53.22","","554.28","554.28","554.28","16","771.62","5135.27","percent of total billed charges",""
"STRIP CERAMIC 12ML 10CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6634.71","3980.83","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4173.23","62.9","","619.64","173.09","2370.64","150","771.62","5135.27","percent of total billed charges",""
"STRIP CERAMIC 12ML 10CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6634.71","3980.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5135.27","77.4","","303.98","303.98","5854.79","1 through 10","771.62","5135.27","percent of total billed charges",""
"STRIP CERAMIC 24ML 20CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168398","CDM","C1713","HCPCS","0278","RC","","","","both","","","8838.64","5303.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1027.93","7512.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STRIP CERAMIC 24ML 20CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168398","CDM","C1713","HCPCS","0278","RC","","","","both","","","8838.64","5303.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1027.93","7512.84","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"STRIP CERAMIC 24ML 20CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168398","CDM","C1713","HCPCS","0278","RC","","","","both","","","8838.64","5303.18","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5029.19","56.9","","812.12","238.65","1587.46","163","1027.93","7512.84","percent of total billed charges",""
"STRIP CERAMIC 24ML 20CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168398","CDM","C1713","HCPCS","0278","RC","","","","both","","","8838.64","5303.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1027.93","11.63","","112.68","112.68","146.99","38","1027.93","7512.84","percent of total billed charges",""
"STRIP CERAMIC 24ML 20CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168398","CDM","C1713","HCPCS","0278","RC","","","","both","","","8838.64","5303.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6841.11","77.4","","303.98","303.98","5854.79","1 through 10","1027.93","7512.84","percent of total billed charges",""
"STRIP CERAMIC 24ML 20CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8838.64","5303.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1027.93","11.63","","112.68","112.68","146.99","38","1027.93","6841.11","percent of total billed charges",""
"STRIP CERAMIC 24ML 20CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8838.64","5303.18","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5548.90","62.78","","780.86","208.94","10480.28","15","1027.93","6841.11","percent of total billed charges",""
"STRIP CERAMIC 24ML 20CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8838.64","5303.18","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3864.25","43.72","","179.76","179.76","179.76","1 through 10","1027.93","6841.11","percent of total billed charges",""
"STRIP CERAMIC 24ML 20CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8838.64","5303.18","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6427.46","72.72","","2355.45","298.99","3965.19","155","1027.93","6841.11","percent of total billed charges",""
"STRIP CERAMIC 24ML 20CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8838.64","5303.18","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6427.46","72.72","","3643.09","3643.09","3643.09","1 through 10","1027.93","6841.11","percent of total billed charges",""
"STRIP CERAMIC 24ML 20CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8838.64","5303.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4703.92","53.22","","554.28","554.28","554.28","16","1027.93","6841.11","percent of total billed charges",""
"STRIP CERAMIC 24ML 20CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8838.64","5303.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5559.50","62.9","","619.64","173.09","2370.64","150","1027.93","6841.11","percent of total billed charges",""
"STRIP CERAMIC 24ML 20CM GRAFT BONE MASTERGRAFT SYNTHETIC","SUP-ITM-10168398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8838.64","5303.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6841.11","77.4","","303.98","303.98","5854.79","1 through 10","1027.93","6841.11","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","both","","","103.00","61.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","71.89","69.8","","69.80","69.80","69.80","1 through 10","58.61","87.55","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","both","","","103.00","61.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","58.61","56.9","","56.90","56.90","56.90","1 through 10","58.61","87.55","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","outpatient","","","103.00","61.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","74.90","72.72","","72.72","72.72","72.72","1 through 10","11.98","79.72","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","outpatient","","","103.00","61.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","64.79","62.9","","63.00","63.00","63.00","1 through 10","11.98","79.72","percent of total billed charges",""
"Strptcs Pneum Antibody Igg Serotypes Mlt Ia Quan","PX-30003842","CDM","86581","CPT","0302","RC","","","","outpatient","","","103.00","61.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","79.72","77.4","","77.50","77.49","77.50","1 through 10","11.98","79.72","percent of total billed charges",""
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","both","","","7669.00","4601.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","5352.96","69.8","","5274.09","5274.09","5274.09","1 through 10","1105.87","21229.64","percent of total billed charges",""
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","both","","","7669.00","4601.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","21229.64","","Case rate ($21,229.64). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","17686.07","17686.07","17686.07","1 through 10","1105.87","21229.64","other","OPPS APC"
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","both","","","7669.00","4601.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","9141.46","","Case rate ($9,141.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11543.08","8918.60","11543.08","1 through 10","1105.87","21229.64","other","OPPS APC"
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","both","","","7669.00","4601.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","17159.72","","Case rate ($17,159.72). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","16741.11","13357.21","16741.11","1 through 10","1105.87","21229.64","other","OPPS APC"
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","both","","","7669.00","4601.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4363.66","56.9","","6276.64","4299.36","12679.71","1 through 10","1105.87","21229.64","percent of total billed charges",""
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","both","","","7669.00","4601.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1105.87","14.42","","1590.67","1590.67","1590.67","1 through 10","1105.87","21229.64","percent of total billed charges",""
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","both","","","7669.00","4601.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4823.80","62.9","","20848.59","4760.28","20848.59","1 through 10","1105.87","21229.64","percent of total billed charges",""
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","both","","","7669.00","4601.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5935.81","77.4","","7000.00","5855.90","7000.00","1 through 10","1105.87","21229.64","percent of total billed charges",""
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","outpatient","","","7669.00","4601.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","891.90","11.63","","1338.72","308.28","1518.97","1 through 10","891.9","891.9","percent of total billed charges",""
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","outpatient","","","7669.00","4601.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","891.90","11.63","","892.48","892.48","892.48","1 through 10","891.9","891.9","percent of total billed charges",""
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","both","","","9261.00","5556.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","6464.18","69.8","","6938.50","4752.72","7699.64","1 through 10","3255.41","21229.64","percent of total billed charges",""
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","both","","","9261.00","5556.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","21229.64","","Case rate ($21,229.64). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","13476.53","11108.03","20711.90","1 through 10","3255.41","21229.64","other","OPPS APC"
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","both","","","9261.00","5556.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","9141.46","","Case rate ($9,141.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8918.60","8526.37","16474.60","12","3255.41","21229.64","other","OPPS APC"
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","both","","","9261.00","5556.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","3255.41","","APC Price ($3,321.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5647.79","3322.23","5647.79","1 through 10","3255.41","21229.64","other","OPPS APC"
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","both","","","9261.00","5556.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","17159.72","","Case rate ($17,159.72). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","13468.37","8918.60","21212.31","12","3255.41","21229.64","other","OPPS APC"
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","both","","","9261.00","5556.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5269.51","56.9","","8725.15","4299.36","8725.15","1 through 10","3255.41","21229.64","percent of total billed charges",""
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","both","","","9261.00","5556.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","3321.85","","APC Price ($3,321.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3322.23","3322.23","3322.23","1 through 10","3255.41","21229.64","other","OPPS APC"
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","both","","","9261.00","5556.60","MEDICARE [2001]","HB WDH MEDICARE","3321.85","","APC Price ($3,321.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3322.23","3322.23","3322.23","1 through 10","3255.41","21229.64","other","OPPS APC"
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","9261.00","5556.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1335.44","14.42","","1089.58","933.92","1089.58","1 through 10","1077.05","7168.01","percent of total billed charges",""
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","9261.00","5556.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1077.05","11.63","","1040.46","1040.46","1518.97","1 through 10","1077.05","7168.01","percent of total billed charges",""
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","9261.00","5556.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","16484.16","5494.72","16484.16","1 through 10","1077.05","7168.01","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","9261.00","5556.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5825.17","62.9","","14280.84","6949.53","27416.34","1 through 10","1077.05","7168.01","percent of total billed charges",""
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","9261.00","5556.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7168.01","77.4","","5855.90","5855.90","10691.36","1 through 10","1077.05","7168.01","percent of total billed charges",""
"Surg Tx Abortion Missed 2nd Trimest","PX-72000028","CDM","59821","CPT","0361","RC","","","","both","","","9186.00","5511.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","21229.64","","Case rate ($21,229.64). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","13385.66","13385.66","13385.66","1 through 10","3255.41","21229.64","other","OPPS APC"
"Surg Tx Abortion Missed 2nd Trimest","PX-72000028","CDM","59821","CPT","0361","RC","","","","both","","","9186.00","5511.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","9141.46","","Case rate ($9,141.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8526.37","8526.37","8526.37","1 through 10","3255.41","21229.64","other","OPPS APC"
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","outpatient","","","1095.00","657.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","796.28","72.72","","3804.71","3804.71","6341.18","1 through 10","127.35","847.53","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","both","","","161.00","96.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","112.38","69.8","","108.89","98.12","108.89","98","5.62","136.85","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","both","","","161.00","96.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","112.38","69.8","","108.89","108.89","108.89","1 through 10","5.62","136.85","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","both","","","161.00","96.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","136.85","85","","61.01","7.78","61.01","1 through 10","5.62","136.85","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","outpatient","","","161.00","96.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","101.08","62.78","","97.94","97.94","293.82","19","8.06","124.61","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","outpatient","","","161.00","96.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","70.39","43.72","","68.20","68.20","204.60","11","8.06","124.61","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","outpatient","","","161.00","96.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","117.08","72.72","","113.44","113.44","226.88","108","8.06","124.61","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","outpatient","","","161.00","96.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","117.08","72.72","","113.44","113.44","113.45","1 through 10","8.06","124.61","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","outpatient","","","161.00","96.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","85.68","53.22","","83.16","83.16","83.16","1 through 10","8.06","124.61","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","outpatient","","","161.00","96.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","101.27","62.9","","98.28","98.28","294.84","169","8.06","124.61","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","outpatient","","","161.00","96.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","124.61","77.4","","120.90","120.90","120.90","60","8.06","124.61","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","outpatient","","","161.00","96.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","117.08","72.72","","113.44","113.44","113.44","1 through 10","8.06","124.61","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","16.48","9.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1.92","14.01","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","16.48","9.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1.92","14.01","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","16.48","9.89","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","9.38","56.9","","812.12","238.65","1587.46","163","1.92","14.01","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","16.48","9.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1.92","11.63","","112.68","112.68","146.99","38","1.92","14.01","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","16.48","9.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12.76","77.4","","303.98","303.98","5854.79","1 through 10","1.92","14.01","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16.48","9.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1.92","11.63","","112.68","112.68","146.99","38","1.92","12.76","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16.48","9.89","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","10.35","62.78","","780.86","208.94","10480.28","15","1.92","12.76","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16.48","9.89","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","7.21","43.72","","179.76","179.76","179.76","1 through 10","1.92","12.76","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16.48","9.89","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","11.98","72.72","","2355.45","298.99","3965.19","155","1.92","12.76","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16.48","9.89","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","11.98","72.72","","3643.09","3643.09","3643.09","1 through 10","1.92","12.76","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16.48","9.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","8.77","53.22","","554.28","554.28","554.28","16","1.92","12.76","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16.48","9.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","10.37","62.9","","619.64","173.09","2370.64","150","1.92","12.76","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","16.48","9.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12.76","77.4","","303.98","303.98","5854.79","1 through 10","1.92","12.76","percent of total billed charges",""
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","32526.50","19515.90","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","7283.29","","Case rate ($7,071.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,560.86, add-ons for qualifying new technology services are included. If operating cost exceeds $10,479.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,289.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,142.07 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,115.99 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.21. The transfer capital threshold is the transfer adjustment factor * $484.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","22284.56","22284.56","22284.56","1 through 10","3975","33120.89","other","Inpatient DRG"
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","32526.50","19515.90","MARTIN'S POINT [160007]","HB WDH MEDICARE","7071.16","","Case rate ($7,071.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,560.86, add-ons for qualifying new technology services are included. If operating cost exceeds $10,479.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,289.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,142.07 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,115.99 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.21. The transfer capital threshold is the transfer adjustment factor * $484.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6886.34","6886.34","6886.34","1 through 10","3975","33120.89","other","Inpatient DRG"
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","32526.50","19515.90","MEDICARE [2001]","HB WDH MEDICARE","7071.16","","Case rate ($7,071.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,560.86, add-ons for qualifying new technology services are included. If operating cost exceeds $10,479.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,289.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,142.07 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,115.99 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.21. The transfer capital threshold is the transfer adjustment factor * $484.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7019.22","0.05","7036.35","37","3975","33120.89","other","Inpatient DRG"
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","32526.50","19515.90","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7071.16","","Case rate ($7,071.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,560.86, add-ons for qualifying new technology services are included. If operating cost exceeds $10,479.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,289.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,142.07 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,115.99 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $484.21. The transfer capital threshold is the transfer adjustment factor * $484.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6878.84","6878.84","6918.34","1 through 10","3975","33120.89","other","Inpatient DRG"
"Syphilis Vdrl/Rpr Ql","PX-30000877","CDM","86592","CPT","0302","RC","","","","both","","","69.00","41.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","48.16","69.8","","46.77","46.77","46.77","1 through 10","2.78","58.65","percent of total billed charges",""
"Syphilis Vdrl/Rpr Ql","PX-30000877","CDM","86592","CPT","0302","RC","","","","outpatient","","","69.00","41.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","43.32","62.78","","42.06","42.06","42.06","1 through 10","3.98","53.41","percent of total billed charges",""
"Syphilis Vdrl/Rpr Ql","PX-30000877","CDM","86592","CPT","0302","RC","","","","outpatient","","","69.00","41.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","50.18","72.72","","48.72","48.72","48.72","1 through 10","3.98","53.41","percent of total billed charges",""
"Syphilis Vdrl/Rpr Ql","PX-30000877","CDM","86592","CPT","0302","RC","","","","outpatient","","","69.00","41.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","43.40","62.9","","126.63","42.21","126.63","1 through 10","3.98","53.41","percent of total billed charges",""
"Syphilis Vdrl/Rpr Ql","PX-30000877","CDM","86592","CPT","0302","RC","","","","outpatient","","","69.00","41.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","53.41","77.4","","51.93","51.93","51.93","1 through 10","3.98","53.41","percent of total billed charges",""
"Syphilis Vdrl/Rpr Qn","PX-30000878","CDM","86593","CPT","0302","RC","","","","both","","","69.00","41.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","48.16","69.8","","42.14","5.01","46.77","1 through 10","2.86","58.65","percent of total billed charges",""
"Syphilis Vdrl/Rpr Qn","PX-30000878","CDM","86593","CPT","0302","RC","","","","outpatient","","","69.00","41.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","50.18","72.72","","48.72","48.72","48.72","1 through 10","5.28","53.41","percent of total billed charges",""
"Syphilis Vdrl/Rpr Qn","PX-30000878","CDM","86593","CPT","0302","RC","","","","outpatient","","","69.00","41.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","50.18","72.72","","48.72","48.72","48.72","1 through 10","5.28","53.41","percent of total billed charges",""
"Syphilis Vdrl/Rpr Qn","PX-30000878","CDM","86593","CPT","0302","RC","","","","outpatient","","","69.00","41.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","36.72","53.22","","35.72","35.72","35.72","1 through 10","5.28","53.41","percent of total billed charges",""
"Syphilis Vdrl/Rpr Qn","PX-30000878","CDM","86593","CPT","0302","RC","","","","outpatient","","","69.00","41.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","43.40","62.9","","42.21","42.21","42.21","1 through 10","5.28","53.41","percent of total billed charges",""
"Syphilis Vdrl/Rpr Qn","PX-30000878","CDM","86593","CPT","0302","RC","","","","outpatient","","","69.00","41.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","53.41","77.4","","51.93","51.93","51.93","1 through 10","5.28","53.41","percent of total billed charges",""
"SYSTEM ANCHOR 4.75MM OMEGA PEEK KNOTLESS DOUBLE-DOUBLE PK/5EA","SUP-ITM-10267013","CDM","C1713","HCPCS","0278","RC","","","","both","","","6219.00","3731.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","723.27","5286.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM ANCHOR 4.75MM OMEGA PEEK KNOTLESS DOUBLE-DOUBLE PK/5EA","SUP-ITM-10267013","CDM","C1713","HCPCS","0278","RC","","","","both","","","6219.00","3731.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","723.27","5286.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM ANCHOR 4.75MM OMEGA PEEK KNOTLESS DOUBLE-DOUBLE PK/5EA","SUP-ITM-10267013","CDM","C1713","HCPCS","0278","RC","","","","both","","","6219.00","3731.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3538.61","56.9","","812.12","238.65","1587.46","163","723.27","5286.15","percent of total billed charges",""
"SYSTEM ANCHOR 4.75MM OMEGA PEEK KNOTLESS DOUBLE-DOUBLE PK/5EA","SUP-ITM-10267013","CDM","C1713","HCPCS","0278","RC","","","","both","","","6219.00","3731.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","723.27","11.63","","112.68","112.68","146.99","38","723.27","5286.15","percent of total billed charges",""
"SYSTEM ANCHOR 4.75MM OMEGA PEEK KNOTLESS DOUBLE-DOUBLE PK/5EA","SUP-ITM-10267013","CDM","C1713","HCPCS","0278","RC","","","","both","","","6219.00","3731.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4813.51","77.4","","303.98","303.98","5854.79","1 through 10","723.27","5286.15","percent of total billed charges",""
"SYSTEM ANCHOR 4.75MM OMEGA PEEK KNOTLESS DOUBLE-DOUBLE PK/5EA","SUP-ITM-10267013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","723.27","11.63","","112.68","112.68","146.99","38","723.27","4813.51","percent of total billed charges",""
"SYSTEM ANCHOR 4.75MM OMEGA PEEK KNOTLESS DOUBLE-DOUBLE PK/5EA","SUP-ITM-10267013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3904.29","62.78","","780.86","208.94","10480.28","15","723.27","4813.51","percent of total billed charges",""
"SYSTEM ANCHOR 4.75MM OMEGA PEEK KNOTLESS DOUBLE-DOUBLE PK/5EA","SUP-ITM-10267013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2718.95","43.72","","179.76","179.76","179.76","1 through 10","723.27","4813.51","percent of total billed charges",""
"SYSTEM ANCHOR 4.75MM OMEGA PEEK KNOTLESS DOUBLE-DOUBLE PK/5EA","SUP-ITM-10267013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4522.46","72.72","","2355.45","298.99","3965.19","155","723.27","4813.51","percent of total billed charges",""
"SYSTEM ANCHOR 4.75MM OMEGA PEEK KNOTLESS DOUBLE-DOUBLE PK/5EA","SUP-ITM-10267013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4522.46","72.72","","3643.09","3643.09","3643.09","1 through 10","723.27","4813.51","percent of total billed charges",""
"SYSTEM ANCHOR 4.75MM OMEGA PEEK KNOTLESS DOUBLE-DOUBLE PK/5EA","SUP-ITM-10267013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3309.75","53.22","","554.28","554.28","554.28","16","723.27","4813.51","percent of total billed charges",""
"SYSTEM ANCHOR 4.75MM OMEGA PEEK KNOTLESS DOUBLE-DOUBLE PK/5EA","SUP-ITM-10267013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3911.75","62.9","","619.64","173.09","2370.64","150","723.27","4813.51","percent of total billed charges",""
"SYSTEM ANCHOR 4.75MM OMEGA PEEK KNOTLESS DOUBLE-DOUBLE PK/5EA","SUP-ITM-10267013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4813.51","77.4","","303.98","303.98","5854.79","1 through 10","723.27","4813.51","percent of total billed charges",""
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","both","","","14119.80","8471.88","AETNA [1001]","HB WDH AETNA COMMERCIAL","9855.62","69.8","","5077.95","5077.95","5077.95","1 through 10","1642.13","12001.83","percent of total billed charges",""
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","both","","","14119.80","8471.88","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","","27.90","27.9% of billed. Final payment is multiplied by 102%.","2017.24","1433.22","2017.24","1 through 10","1642.13","12001.83","other","OPPS APC"
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","both","","","14119.80","8471.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1613.60","1613.60","3131.77","1 through 10","1642.13","12001.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","both","","","14119.80","8471.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1613.60","1613.60","1613.60","1 through 10","1642.13","12001.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","both","","","14119.80","8471.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","","27.90","27.9% of billed. Final payment is multiplied by 98%.","1440.49","1404.56","10725.54","11","1642.13","12001.83","other","OPPS APC"
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","both","","","14119.80","8471.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","1613.60","1613.60","3131.78","14","1642.13","12001.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","both","","","14119.80","8471.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","8034.17","56.9","","4139.48","4139.47","5651.63","1 through 10","1642.13","12001.83","percent of total billed charges",""
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","both","","","14119.80","8471.88","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2036.08","14.42","","899.19","899.19","1049.06","1 through 10","1642.13","12001.83","percent of total billed charges",""
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","both","","","14119.80","8471.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1642.13","11.63","","1001.77","1001.77","1001.77","1 through 10","1642.13","12001.83","percent of total billed charges",""
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","both","","","14119.80","8471.88","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","","27.90","27.9% of billed. Final payment is multiplied by 103%.","14119.80","1552.69","14119.80","1 through 10","1642.13","12001.83","other","OPPS APC"
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","both","","","14119.80","8471.88","MEDICARE [2001]","HB WDH MEDICARE","","27.90","27.9% of billed.","1828.04","1433.22","4511.67","49","1642.13","12001.83","other","OPPS APC"
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","both","","","14119.80","8471.88","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","","27.90","27.9% of billed.","1458.84","1404.56","1816.58","20","1642.13","12001.83","other","OPPS APC"
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","both","","","14119.80","8471.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10928.73","77.4","","10942.85","10942.85","10942.85","1 through 10","1642.13","12001.83","percent of total billed charges",""
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","both","","","14119.80","8471.88","WELLSENSE NH [1050]","HB WDH MEDICARE","","27.90","27.9% of billed.","6226.53","6226.53","6226.53","1 through 10","1642.13","12001.83","other","OPPS APC"
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","outpatient","","","14119.80","8471.88","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","2036.08","14.42","","899.19","899.19","1049.06","1 through 10","1642.13","10928.73","percent of total billed charges",""
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","outpatient","","","14119.80","8471.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1642.13","11.63","","1001.77","1001.77","1001.77","1 through 10","1642.13","10928.73","percent of total billed charges",""
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","outpatient","","","14119.80","8471.88","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","8864.41","62.78","","4567.25","4567.25","4567.25","1 through 10","1642.13","10928.73","percent of total billed charges",""
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","outpatient","","","14119.80","8471.88","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","6173.18","43.72","","3180.63","3180.63","3180.63","1 through 10","1642.13","10928.73","percent of total billed charges",""
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","outpatient","","","14119.80","8471.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","10267.92","72.72","","5290.38","5290.38","5290.38","1 through 10","1642.13","10928.73","percent of total billed charges",""
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","outpatient","","","14119.80","8471.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","10928.73","77.4","","10942.85","10942.85","10942.85","1 through 10","1642.13","10928.73","percent of total billed charges",""
"SYSTEM ATC UROLIFT BX/1EA","SUP-ITM-10310909","CDM","L8699","HCPCS","0278","RC","","","","both","","","5577.50","3346.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","292.76","292.76","292.76","1 through 10","648.66","4740.88","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM CLOSURE PROGLIDE 6FR SUTURE PERCLOSE MEDICATED SNARED KNOT PUSHER TRIMMER BX/10EA","SUP-ITM-10012397","CDM","C1760","HCPCS","0278","RC","","","","both","","","1209.25","725.55","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","4664.25","4664.25","4664.25","1 through 10","140.64","1027.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM CLOSURE PROGLIDE 6FR SUTURE PERCLOSE MEDICATED SNARED KNOT PUSHER TRIMMER BX/10EA","SUP-ITM-10012397","CDM","C1760","HCPCS","0278","RC","","","","both","","","1209.25","725.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","140.64","11.63","","190.30","190.30","1451.36","1 through 10","140.64","1027.86","percent of total billed charges",""
"SYSTEM CLOSURE PROGLIDE 6FR SUTURE PERCLOSE MEDICATED SNARED KNOT PUSHER TRIMMER BX/10EA","SUP-ITM-10012397","CDM","C1760","HCPCS","0278","RC","","","","both","","","1209.25","725.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","935.96","77.4","","1204.93","1204.93","1204.93","1 through 10","140.64","1027.86","percent of total billed charges",""
"SYSTEM CLOSURE PROGLIDE 6FR SUTURE PERCLOSE MEDICATED SNARED KNOT PUSHER TRIMMER BX/10EA","SUP-ITM-10012397","CDM","C1760","HCPCS","0278","RC","","","","both","","","1209.25","725.55","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","1342.25","1342.25","1342.25","1 through 10","140.64","1027.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM CLOSURE PROGLIDE 6FR SUTURE PERCLOSE MEDICATED SNARED KNOT PUSHER TRIMMER BX/10EA","SUP-ITM-10012397","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","1209.25","725.55","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","140.64","11.63","","190.30","190.30","1451.36","1 through 10","140.64","935.96","percent of total billed charges",""
"SYSTEM CLOSURE PROGLIDE 6FR SUTURE PERCLOSE MEDICATED SNARED KNOT PUSHER TRIMMER BX/10EA","SUP-ITM-10012397","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","1209.25","725.55","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","879.37","72.72","","1130.61","1130.61","1130.61","1 through 10","140.64","935.96","percent of total billed charges",""
"SYSTEM CLOSURE PROGLIDE 6FR SUTURE PERCLOSE MEDICATED SNARED KNOT PUSHER TRIMMER BX/10EA","SUP-ITM-10012397","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","1209.25","725.55","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","760.62","62.9","","979.49","979.49","979.49","1 through 10","140.64","935.96","percent of total billed charges",""
"SYSTEM CLOSURE PROGLIDE 6FR SUTURE PERCLOSE MEDICATED SNARED KNOT PUSHER TRIMMER BX/10EA","SUP-ITM-10012397","CDM","C1760","HCPCS","0278","RC","","","","outpatient","","","1209.25","725.55","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","935.96","77.4","","1204.93","1204.93","1204.93","1 through 10","140.64","935.96","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 21MM 10MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5364","SUP-ITM-10156093","CDM","C1874","HCPCS","0278","RC","","","","both","","","18309.28","10985.57","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","10417.98","56.9","","4336.72","1572.72","9255.66","15","2129.37","15562.89","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 21MM 10MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5364","SUP-ITM-10156093","CDM","C1874","HCPCS","0278","RC","","","","both","","","18309.28","10985.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","14171.38","77.4","","2142.10","2142.10","2142.10","1 through 10","2129.37","15562.89","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 21MM 10MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5364","SUP-ITM-10156093","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","18309.28","10985.57","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","13314.51","72.72","","2261.23","2261.23","2261.23","1 through 10","2129.37","14171.38","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 21MM 10MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5364","SUP-ITM-10156093","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","18309.28","10985.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","11516.54","62.9","","4353.04","1741.32","8465.73","1 through 10","2129.37","14171.38","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 21MM 10MM 10MM 138CM STENT ELECTROCAUTERY ENHANCED 5364","SUP-ITM-10156093","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","18309.28","10985.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","14171.38","77.4","","2142.10","2142.10","2142.10","1 through 10","2129.37","14171.38","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 29MM 20MM 10MM 138CM STENT","SUP-ITM-10191770","CDM","C1874","HCPCS","0278","RC","","","","both","","","16720.76","10032.46","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","9514.11","56.9","","4336.72","1572.72","9255.66","15","1944.62","14212.65","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 29MM 20MM 10MM 138CM STENT","SUP-ITM-10191770","CDM","C1874","HCPCS","0278","RC","","","","both","","","16720.76","10032.46","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12941.87","77.4","","2142.10","2142.10","2142.10","1 through 10","1944.62","14212.65","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 29MM 20MM 10MM 138CM STENT","SUP-ITM-10191770","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","16720.76","10032.46","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","12159.34","72.72","","2261.23","2261.23","2261.23","1 through 10","1944.62","12941.87","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 29MM 20MM 10MM 138CM STENT","SUP-ITM-10191770","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","16720.76","10032.46","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","10517.36","62.9","","4353.04","1741.32","8465.73","1 through 10","1944.62","12941.87","percent of total billed charges",""
"SYSTEM DELIVERY AXIOS 10.8FR 29MM 20MM 10MM 138CM STENT","SUP-ITM-10191770","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","16720.76","10032.46","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12941.87","77.4","","2142.10","2142.10","2142.10","1 through 10","1944.62","12941.87","percent of total billed charges",""
"SYSTEM DELIVERY SINUS MINI PROPEL IMPLANT PROPEL MOMETASONE FUROATE BIOABSORBABLE","SUP-ITM-10148116","CDM","C2625","HCPCS","0278","RC","","","","outpatient","","","5626.00","3375.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4091.23","72.72","","324.46","324.46","324.46","1 through 10","654.3","4354.52","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","both","","","7250.75","4350.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","843.26","6163.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","both","","","7250.75","4350.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","843.26","6163.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","both","","","7250.75","4350.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4125.68","56.9","","812.12","238.65","1587.46","163","843.26","6163.14","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","both","","","7250.75","4350.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","843.26","11.63","","112.68","112.68","146.99","38","843.26","6163.14","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","both","","","7250.75","4350.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5612.08","77.4","","303.98","303.98","5854.79","1 through 10","843.26","6163.14","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","843.26","11.63","","112.68","112.68","146.99","38","843.26","5612.08","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4552.02","62.78","","780.86","208.94","10480.28","15","843.26","5612.08","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3170.03","43.72","","179.76","179.76","179.76","1 through 10","843.26","5612.08","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5272.75","72.72","","2355.45","298.99","3965.19","155","843.26","5612.08","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5272.75","72.72","","3643.09","3643.09","3643.09","1 through 10","843.26","5612.08","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3858.85","53.22","","554.28","554.28","554.28","16","843.26","5612.08","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4560.72","62.9","","619.64","173.09","2370.64","150","843.26","5612.08","percent of total billed charges",""
"SYSTEM IMPLANT 2.0 INTERNAL BRACE STANDARD BIOCOMPOSITE JUMPSTART DRESSING","SUP-ITM-10289466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5612.08","77.4","","303.98","303.98","5854.79","1 through 10","843.26","5612.08","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","both","","","11357.45","6814.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1320.87","9653.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","both","","","11357.45","6814.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1320.87","9653.83","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","both","","","11357.45","6814.47","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6462.39","56.9","","812.12","238.65","1587.46","163","1320.87","9653.83","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","both","","","11357.45","6814.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1320.87","11.63","","112.68","112.68","146.99","38","1320.87","9653.83","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","both","","","11357.45","6814.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8790.67","77.4","","303.98","303.98","5854.79","1 through 10","1320.87","9653.83","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11357.45","6814.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1320.87","11.63","","112.68","112.68","146.99","38","1320.87","8790.67","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11357.45","6814.47","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","7130.21","62.78","","780.86","208.94","10480.28","15","1320.87","8790.67","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11357.45","6814.47","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4965.48","43.72","","179.76","179.76","179.76","1 through 10","1320.87","8790.67","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11357.45","6814.47","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8259.14","72.72","","2355.45","298.99","3965.19","155","1320.87","8790.67","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11357.45","6814.47","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","8259.14","72.72","","3643.09","3643.09","3643.09","1 through 10","1320.87","8790.67","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11357.45","6814.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","6044.43","53.22","","554.28","554.28","554.28","16","1320.87","8790.67","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11357.45","6814.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7143.84","62.9","","619.64","173.09","2370.64","150","1320.87","8790.67","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11357.45","6814.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8790.67","77.4","","303.98","303.98","5854.79","1 through 10","1320.87","8790.67","percent of total billed charges",""
"SYSTEM IMPLANT INTERNAL BRACE LIGAMENT REPAIR FIBERTAPE SUTURE JUMPSTART DRESSING","SUP-ITM-10287403","CDM","C1713","HCPCS","0278","RC","","","","both","","","7250.75","4350.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","843.26","6163.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM IMPLANT INTERNAL BRACE LIGAMENT REPAIR FIBERTAPE SUTURE JUMPSTART DRESSING","SUP-ITM-10287403","CDM","C1713","HCPCS","0278","RC","","","","both","","","7250.75","4350.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","843.26","6163.14","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM IMPLANT INTERNAL BRACE LIGAMENT REPAIR FIBERTAPE SUTURE JUMPSTART DRESSING","SUP-ITM-10287403","CDM","C1713","HCPCS","0278","RC","","","","both","","","7250.75","4350.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4125.68","56.9","","812.12","238.65","1587.46","163","843.26","6163.14","percent of total billed charges",""
"SYSTEM IMPLANT INTERNAL BRACE LIGAMENT REPAIR FIBERTAPE SUTURE JUMPSTART DRESSING","SUP-ITM-10287403","CDM","C1713","HCPCS","0278","RC","","","","both","","","7250.75","4350.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","843.26","11.63","","112.68","112.68","146.99","38","843.26","6163.14","percent of total billed charges",""
"SYSTEM IMPLANT INTERNAL BRACE LIGAMENT REPAIR FIBERTAPE SUTURE JUMPSTART DRESSING","SUP-ITM-10287403","CDM","C1713","HCPCS","0278","RC","","","","both","","","7250.75","4350.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5612.08","77.4","","303.98","303.98","5854.79","1 through 10","843.26","6163.14","percent of total billed charges",""
"SYSTEM IMPLANT INTERNAL BRACE LIGAMENT REPAIR FIBERTAPE SUTURE JUMPSTART DRESSING","SUP-ITM-10287403","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","843.26","11.63","","112.68","112.68","146.99","38","843.26","5612.08","percent of total billed charges",""
"SYSTEM IMPLANT INTERNAL BRACE LIGAMENT REPAIR FIBERTAPE SUTURE JUMPSTART DRESSING","SUP-ITM-10287403","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4552.02","62.78","","780.86","208.94","10480.28","15","843.26","5612.08","percent of total billed charges",""
"SYSTEM IMPLANT INTERNAL BRACE LIGAMENT REPAIR FIBERTAPE SUTURE JUMPSTART DRESSING","SUP-ITM-10287403","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3170.03","43.72","","179.76","179.76","179.76","1 through 10","843.26","5612.08","percent of total billed charges",""
"SYSTEM IMPLANT INTERNAL BRACE LIGAMENT REPAIR FIBERTAPE SUTURE JUMPSTART DRESSING","SUP-ITM-10287403","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5272.75","72.72","","2355.45","298.99","3965.19","155","843.26","5612.08","percent of total billed charges",""
"SYSTEM IMPLANT INTERNAL BRACE LIGAMENT REPAIR FIBERTAPE SUTURE JUMPSTART DRESSING","SUP-ITM-10287403","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5272.75","72.72","","3643.09","3643.09","3643.09","1 through 10","843.26","5612.08","percent of total billed charges",""
"SYSTEM IMPLANT INTERNAL BRACE LIGAMENT REPAIR FIBERTAPE SUTURE JUMPSTART DRESSING","SUP-ITM-10287403","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3858.85","53.22","","554.28","554.28","554.28","16","843.26","5612.08","percent of total billed charges",""
"SYSTEM IMPLANT INTERNAL BRACE LIGAMENT REPAIR FIBERTAPE SUTURE JUMPSTART DRESSING","SUP-ITM-10287403","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4560.72","62.9","","619.64","173.09","2370.64","150","843.26","5612.08","percent of total billed charges",""
"SYSTEM IMPLANT INTERNAL BRACE LIGAMENT REPAIR FIBERTAPE SUTURE JUMPSTART DRESSING","SUP-ITM-10287403","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7250.75","4350.45","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5612.08","77.4","","303.98","303.98","5854.79","1 through 10","843.26","5612.08","percent of total billed charges",""
"SYSTEM IMPLANT NASAL 20MM LATERA ABSORBABLE","SUP-ITM-10319041","CDM","C1889","HCPCS","0278","RC","","","","both","","","9675.75","5805.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","1125.29","8224.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM IMPLANT NASAL 20MM LATERA ABSORBABLE","SUP-ITM-10319041","CDM","C1889","HCPCS","0278","RC","","","","both","","","9675.75","5805.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","1125.29","8224.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM IMPLANT NASAL 20MM LATERA ABSORBABLE","SUP-ITM-10319041","CDM","C1889","HCPCS","0278","RC","","","","both","","","9675.75","5805.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5505.50","56.9","","0.63","0.63","0.63","1 through 10","1125.29","8224.39","percent of total billed charges",""
"SYSTEM IMPLANT NASAL 20MM LATERA ABSORBABLE","SUP-ITM-10319041","CDM","C1889","HCPCS","0278","RC","","","","both","","","9675.75","5805.45","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1395.24","14.42","","317.14","317.14","317.14","1 through 10","1125.29","8224.39","percent of total billed charges",""
"SYSTEM IMPLANT NASAL 20MM LATERA ABSORBABLE","SUP-ITM-10319041","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9675.75","5805.45","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1395.24","14.42","","317.14","317.14","317.14","1 through 10","1125.29","7489.03","percent of total billed charges",""
"SYSTEM IMPLANT NASAL 20MM LATERA ABSORBABLE","SUP-ITM-10319041","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9675.75","5805.45","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6074.44","62.78","","1125.09","1125.09","1125.09","1 through 10","1125.29","7489.03","percent of total billed charges",""
"SYSTEM IMPLANT NASAL 20MM LATERA ABSORBABLE","SUP-ITM-10319041","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9675.75","5805.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7036.21","72.72","","4732.50","1617.43","14180.40","1 through 10","1125.29","7489.03","percent of total billed charges",""
"SYSTEM IMPLANT NASAL 20MM LATERA ABSORBABLE","SUP-ITM-10319041","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9675.75","5805.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6086.05","62.9","","3896.20","3341.38","3896.20","1 through 10","1125.29","7489.03","percent of total billed charges",""
"SYSTEM IMPLANT UROLIFT BX/4EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10310242","CDM","L8699","HCPCS","0278","RC","","","","both","","","4971.25","2982.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","292.76","292.76","292.76","1 through 10","578.16","4225.56","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM INTRODUCER ACCUSTICK II 21GA 6FR .038IN STRAIGHT NEEDLE STYLET LOCKING CANNULA EXTRA-STIFF PLATINUM TIP HEAVY DUTY GUIDEWIRE","SUP-ITM-10009626","CDM","C1894","HCPCS","0272","RC","","","","both","","","578.37","347.02","AETNA [1001]","HB WDH AETNA COMMERCIAL","403.70","69.8","","94.15","94.15","427.63","1 through 10","67.26","491.61","percent of total billed charges",""
"SYSTEM INTRODUCER ACCUSTICK II 21GA 6FR .038IN STRAIGHT NEEDLE STYLET LOCKING CANNULA EXTRA-STIFF PLATINUM TIP HEAVY DUTY GUIDEWIRE","SUP-ITM-10009626","CDM","C1894","HCPCS","0272","RC","","","","both","","","578.37","347.02","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","830.79","304.05","830.79","1 through 10","67.26","491.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM INTRODUCER ACCUSTICK II 21GA 6FR .038IN STRAIGHT NEEDLE STYLET LOCKING CANNULA EXTRA-STIFF PLATINUM TIP HEAVY DUTY GUIDEWIRE","SUP-ITM-10009626","CDM","C1894","HCPCS","0272","RC","","","","both","","","578.37","347.02","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","329.09","56.9","","401.89","65.85","401.89","1 through 10","67.26","491.61","percent of total billed charges",""
"SYSTEM INTRODUCER ACCUSTICK II 21GA 6FR .038IN STRAIGHT NEEDLE STYLET LOCKING CANNULA EXTRA-STIFF PLATINUM TIP HEAVY DUTY GUIDEWIRE","SUP-ITM-10009626","CDM","C1894","HCPCS","0272","RC","","","","both","","","578.37","347.02","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","67.26","11.63","","49.19","10.57","114.40","19","67.26","491.61","percent of total billed charges",""
"SYSTEM INTRODUCER ACCUSTICK II 21GA 6FR .038IN STRAIGHT NEEDLE STYLET LOCKING CANNULA EXTRA-STIFF PLATINUM TIP HEAVY DUTY GUIDEWIRE","SUP-ITM-10009626","CDM","C1894","HCPCS","0272","RC","","","","both","","","578.37","347.02","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","447.66","77.4","","200.75","81.67","643.86","11","67.26","491.61","percent of total billed charges",""
"SYSTEM INTRODUCER ACCUSTICK II 21GA 6FR .038IN STRAIGHT NEEDLE STYLET LOCKING CANNULA EXTRA-STIFF PLATINUM TIP HEAVY DUTY GUIDEWIRE","SUP-ITM-10009626","CDM","C1894","HCPCS","0272","RC","","","","both","","","578.37","347.02","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","61.36","61.36","61.36","1 through 10","67.26","491.61","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM INTRODUCER ACCUSTICK II 21GA 6FR .038IN STRAIGHT NEEDLE STYLET LOCKING CANNULA EXTRA-STIFF PLATINUM TIP HEAVY DUTY GUIDEWIRE","SUP-ITM-10009626","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","578.37","347.02","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","67.26","11.63","","49.19","10.57","114.40","19","67.26","447.66","percent of total billed charges",""
"SYSTEM INTRODUCER ACCUSTICK II 21GA 6FR .038IN STRAIGHT NEEDLE STYLET LOCKING CANNULA EXTRA-STIFF PLATINUM TIP HEAVY DUTY GUIDEWIRE","SUP-ITM-10009626","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","578.37","347.02","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","363.10","62.78","","93.27","93.27","93.27","1 through 10","67.26","447.66","percent of total billed charges",""
"SYSTEM INTRODUCER ACCUSTICK II 21GA 6FR .038IN STRAIGHT NEEDLE STYLET LOCKING CANNULA EXTRA-STIFF PLATINUM TIP HEAVY DUTY GUIDEWIRE","SUP-ITM-10009626","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","578.37","347.02","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","252.86","43.72","","363.22","363.22","363.22","1 through 10","67.26","447.66","percent of total billed charges",""
"SYSTEM INTRODUCER ACCUSTICK II 21GA 6FR .038IN STRAIGHT NEEDLE STYLET LOCKING CANNULA EXTRA-STIFF PLATINUM TIP HEAVY DUTY GUIDEWIRE","SUP-ITM-10009626","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","578.37","347.02","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","420.59","72.72","","271.85","111.24","551.69","14","67.26","447.66","percent of total billed charges",""
"SYSTEM INTRODUCER ACCUSTICK II 21GA 6FR .038IN STRAIGHT NEEDLE STYLET LOCKING CANNULA EXTRA-STIFF PLATINUM TIP HEAVY DUTY GUIDEWIRE","SUP-ITM-10009626","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","578.37","347.02","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","363.79","62.9","","706.53","93.60","938.00","53","67.26","447.66","percent of total billed charges",""
"SYSTEM INTRODUCER ACCUSTICK II 21GA 6FR .038IN STRAIGHT NEEDLE STYLET LOCKING CANNULA EXTRA-STIFF PLATINUM TIP HEAVY DUTY GUIDEWIRE","SUP-ITM-10009626","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","578.37","347.02","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","447.66","77.4","","200.75","81.67","643.86","11","67.26","447.66","percent of total billed charges",""
"SYSTEM LEAD SPRINT PNS SINGLE","SUP-ITM-10281784","CDM","C1778","HCPCS","0278","RC","","","","both","","","17875.00","10725.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","14342.00","14342.00","14342.00","1 through 10","2078.86","15193.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM LEAD SPRINT PNS SINGLE","SUP-ITM-10281784","CDM","C1778","HCPCS","0278","RC","","","","both","","","17875.00","10725.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2078.86","11.63","","2253.51","2253.51","2253.51","1 through 10","2078.86","15193.75","percent of total billed charges",""
"SYSTEM LEAD SPRINT PNS SINGLE","SUP-ITM-10281784","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","17875.00","10725.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2078.86","11.63","","2253.51","2253.51","2253.51","1 through 10","2078.86","13835.25","percent of total billed charges",""
"SYSTEM LEAD SPRINT PNS SINGLE","SUP-ITM-10281784","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","17875.00","10725.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","11243.38","62.9","","21082.95","11598.93","21082.95","1 through 10","2078.86","13835.25","percent of total billed charges",""
"SYSTEM REPAIR 15DEG CURVED UP MENISCAL AIR PLUS PC/1EA","SUP-ITM-10282121","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.25","1969.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","381.73","2789.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM REPAIR 15DEG CURVED UP MENISCAL AIR PLUS PC/1EA","SUP-ITM-10282121","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.25","1969.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","381.73","2789.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM REPAIR 15DEG CURVED UP MENISCAL AIR PLUS PC/1EA","SUP-ITM-10282121","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.25","1969.35","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1867.60","56.9","","812.12","238.65","1587.46","163","381.73","2789.91","percent of total billed charges",""
"SYSTEM REPAIR 15DEG CURVED UP MENISCAL AIR PLUS PC/1EA","SUP-ITM-10282121","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.25","1969.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","381.73","11.63","","112.68","112.68","146.99","38","381.73","2789.91","percent of total billed charges",""
"SYSTEM REPAIR 15DEG CURVED UP MENISCAL AIR PLUS PC/1EA","SUP-ITM-10282121","CDM","C1713","HCPCS","0278","RC","","","","both","","","3282.25","1969.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2540.46","77.4","","303.98","303.98","5854.79","1 through 10","381.73","2789.91","percent of total billed charges",""
"SYSTEM REPAIR 15DEG CURVED UP MENISCAL AIR PLUS PC/1EA","SUP-ITM-10282121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.25","1969.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","381.73","11.63","","112.68","112.68","146.99","38","381.73","2540.46","percent of total billed charges",""
"SYSTEM REPAIR 15DEG CURVED UP MENISCAL AIR PLUS PC/1EA","SUP-ITM-10282121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.25","1969.35","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2060.60","62.78","","780.86","208.94","10480.28","15","381.73","2540.46","percent of total billed charges",""
"SYSTEM REPAIR 15DEG CURVED UP MENISCAL AIR PLUS PC/1EA","SUP-ITM-10282121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.25","1969.35","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1435.00","43.72","","179.76","179.76","179.76","1 through 10","381.73","2540.46","percent of total billed charges",""
"SYSTEM REPAIR 15DEG CURVED UP MENISCAL AIR PLUS PC/1EA","SUP-ITM-10282121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.25","1969.35","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2386.85","72.72","","2355.45","298.99","3965.19","155","381.73","2540.46","percent of total billed charges",""
"SYSTEM REPAIR 15DEG CURVED UP MENISCAL AIR PLUS PC/1EA","SUP-ITM-10282121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.25","1969.35","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2386.85","72.72","","3643.09","3643.09","3643.09","1 through 10","381.73","2540.46","percent of total billed charges",""
"SYSTEM REPAIR 15DEG CURVED UP MENISCAL AIR PLUS PC/1EA","SUP-ITM-10282121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.25","1969.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1746.81","53.22","","554.28","554.28","554.28","16","381.73","2540.46","percent of total billed charges",""
"SYSTEM REPAIR 15DEG CURVED UP MENISCAL AIR PLUS PC/1EA","SUP-ITM-10282121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.25","1969.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2064.54","62.9","","619.64","173.09","2370.64","150","381.73","2540.46","percent of total billed charges",""
"SYSTEM REPAIR 15DEG CURVED UP MENISCAL AIR PLUS PC/1EA","SUP-ITM-10282121","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3282.25","1969.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2540.46","77.4","","303.98","303.98","5854.79","1 through 10","381.73","2540.46","percent of total billed charges",""
"SYSTEM SIS SOLYX SINGLE BLUE","SUP-ITM-10240833","CDM","C1771","HCPCS","0278","RC","","","","both","","","7844.41","4706.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","6680.45","6680.45","6680.45","1 through 10","912.3","6667.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM SIS SOLYX SINGLE BLUE","SUP-ITM-10240833","CDM","C1771","HCPCS","0278","RC","","","","both","","","7844.41","4706.65","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4463.47","56.9","","3801.18","3767.54","4248.00","1 through 10","912.3","6667.75","percent of total billed charges",""
"SYSTEM SIS SOLYX SINGLE BLUE","SUP-ITM-10240833","CDM","C1771","HCPCS","0278","RC","","","","both","","","7844.41","4706.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6071.57","77.4","","5750.52","5177.35","5750.52","1 through 10","912.3","6667.75","percent of total billed charges",""
"SYSTEM SIS SOLYX SINGLE BLUE","SUP-ITM-10240833","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","7844.41","4706.65","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4924.72","62.78","","12581.94","12581.94","12581.94","1 through 10","912.3","6071.57","percent of total billed charges",""
"SYSTEM SIS SOLYX SINGLE BLUE","SUP-ITM-10240833","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","7844.41","4706.65","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5704.45","72.72","","4858.02","4858.02","4858.02","1 through 10","912.3","6071.57","percent of total billed charges",""
"SYSTEM SIS SOLYX SINGLE BLUE","SUP-ITM-10240833","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","7844.41","4706.65","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4934.13","62.9","","4208.68","4208.68","4208.68","1 through 10","912.3","6071.57","percent of total billed charges",""
"SYSTEM SIS SOLYX SINGLE BLUE","SUP-ITM-10240833","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","7844.41","4706.65","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6071.57","77.4","","5750.52","5177.35","5750.52","1 through 10","912.3","6071.57","percent of total billed charges",""
"SYSTEM SLING FIT BLUE ADVANTAGE","SUP-ITM-10211687","CDM","C1771","HCPCS","0278","RC","","","","both","","","6680.45","4008.27","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","6680.45","6680.45","6680.45","1 through 10","776.94","5678.38","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM SLING FIT BLUE ADVANTAGE","SUP-ITM-10211687","CDM","C1771","HCPCS","0278","RC","","","","both","","","6680.45","4008.27","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3801.18","56.9","","3801.18","3767.54","4248.00","1 through 10","776.94","5678.38","percent of total billed charges",""
"SYSTEM SLING FIT BLUE ADVANTAGE","SUP-ITM-10211687","CDM","C1771","HCPCS","0278","RC","","","","both","","","6680.45","4008.27","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5170.67","77.4","","5750.52","5177.35","5750.52","1 through 10","776.94","5678.38","percent of total billed charges",""
"SYSTEM SLING FIT BLUE ADVANTAGE","SUP-ITM-10211687","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","6680.45","4008.27","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4193.99","62.78","","12581.94","12581.94","12581.94","1 through 10","776.94","5170.67","percent of total billed charges",""
"SYSTEM SLING FIT BLUE ADVANTAGE","SUP-ITM-10211687","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","6680.45","4008.27","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4858.02","72.72","","4858.02","4858.02","4858.02","1 through 10","776.94","5170.67","percent of total billed charges",""
"SYSTEM SLING FIT BLUE ADVANTAGE","SUP-ITM-10211687","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","6680.45","4008.27","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4202.00","62.9","","4208.68","4208.68","4208.68","1 through 10","776.94","5170.67","percent of total billed charges",""
"SYSTEM SLING FIT BLUE ADVANTAGE","SUP-ITM-10211687","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","6680.45","4008.27","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5170.67","77.4","","5750.52","5177.35","5750.52","1 through 10","776.94","5170.67","percent of total billed charges",""
"SYSTEM STENT 27/22MMX12CM 230CM WALLFLEX COLONIC SOFT","SUP-ITM-10280391","CDM","C1874","HCPCS","0278","RC","","","","both","","","11949.48","7169.69","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6799.25","56.9","","4336.72","1572.72","9255.66","15","1389.72","10157.06","percent of total billed charges",""
"SYSTEM STENT 27/22MMX12CM 230CM WALLFLEX COLONIC SOFT","SUP-ITM-10280391","CDM","C1874","HCPCS","0278","RC","","","","both","","","11949.48","7169.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9248.90","77.4","","2142.10","2142.10","2142.10","1 through 10","1389.72","10157.06","percent of total billed charges",""
"SYSTEM STENT 27/22MMX12CM 230CM WALLFLEX COLONIC SOFT","SUP-ITM-10280391","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11949.48","7169.69","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","8689.66","72.72","","2261.23","2261.23","2261.23","1 through 10","1389.72","9248.9","percent of total billed charges",""
"SYSTEM STENT 27/22MMX12CM 230CM WALLFLEX COLONIC SOFT","SUP-ITM-10280391","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11949.48","7169.69","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","7516.22","62.9","","4353.04","1741.32","8465.73","1 through 10","1389.72","9248.9","percent of total billed charges",""
"SYSTEM STENT 27/22MMX12CM 230CM WALLFLEX COLONIC SOFT","SUP-ITM-10280391","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","11949.48","7169.69","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","9248.90","77.4","","2142.10","2142.10","2142.10","1 through 10","1389.72","9248.9","percent of total billed charges",""
"SYSTEM STENT PERCUFLEX 8FR 24CM URETERAL DRAINAGE CATHETER PIGTAIL THREADED RADIOPAQUE NON COATED","SUP-ITM-10000421","CDM","C2617","HCPCS","0278","RC","","","","both","","","687.96","412.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","764.25","764.25","764.25","1 through 10","80.01","584.77","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM STENT PERCUFLEX 8FR 24CM URETERAL DRAINAGE CATHETER PIGTAIL THREADED RADIOPAQUE NON COATED","SUP-ITM-10000421","CDM","C2617","HCPCS","0278","RC","","","","both","","","687.96","412.78","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","391.45","56.9","","434.86","434.86","472.36","15","80.01","584.77","percent of total billed charges",""
"SYSTEM STENT PERCUFLEX 8FR 24CM URETERAL DRAINAGE CATHETER PIGTAIL THREADED RADIOPAQUE NON COATED","SUP-ITM-10000421","CDM","C2617","HCPCS","0278","RC","","","","both","","","687.96","412.78","CIGNA ALTERNATE [1018]","HB WDH CIGNA HMO / PPO / INDEM","391.45","56.9","","434.86","434.86","434.86","1 through 10","80.01","584.77","percent of total billed charges",""
"SYSTEM STENT PERCUFLEX 8FR 24CM URETERAL DRAINAGE CATHETER PIGTAIL THREADED RADIOPAQUE NON COATED","SUP-ITM-10000421","CDM","C2617","HCPCS","0278","RC","","","","both","","","687.96","412.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","80.01","11.63","","105.24","93.54","105.24","1 through 10","80.01","584.77","percent of total billed charges",""
"SYSTEM STENT PERCUFLEX 8FR 24CM URETERAL DRAINAGE CATHETER PIGTAIL THREADED RADIOPAQUE NON COATED","SUP-ITM-10000421","CDM","C2617","HCPCS","0278","RC","","","","both","","","687.96","412.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","532.48","77.4","","592.29","592.29","592.29","1 through 10","80.01","584.77","percent of total billed charges",""
"SYSTEM STENT PERCUFLEX 8FR 24CM URETERAL DRAINAGE CATHETER PIGTAIL THREADED RADIOPAQUE NON COATED","SUP-ITM-10000421","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","687.96","412.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","80.01","11.63","","105.24","93.54","105.24","1 through 10","80.01","532.48","percent of total billed charges",""
"SYSTEM STENT PERCUFLEX 8FR 24CM URETERAL DRAINAGE CATHETER PIGTAIL THREADED RADIOPAQUE NON COATED","SUP-ITM-10000421","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","687.96","412.78","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","300.78","43.72","","334.13","334.13","334.13","1 through 10","80.01","532.48","percent of total billed charges",""
"SYSTEM STENT PERCUFLEX 8FR 24CM URETERAL DRAINAGE CATHETER PIGTAIL THREADED RADIOPAQUE NON COATED","SUP-ITM-10000421","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","687.96","412.78","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","500.28","72.72","","555.76","555.76","555.76","1 through 10","80.01","532.48","percent of total billed charges",""
"SYSTEM STENT PERCUFLEX 8FR 24CM URETERAL DRAINAGE CATHETER PIGTAIL THREADED RADIOPAQUE NON COATED","SUP-ITM-10000421","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","687.96","412.78","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","500.28","72.72","","555.76","555.76","555.76","1 through 10","80.01","532.48","percent of total billed charges",""
"SYSTEM STENT PERCUFLEX 8FR 24CM URETERAL DRAINAGE CATHETER PIGTAIL THREADED RADIOPAQUE NON COATED","SUP-ITM-10000421","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","687.96","412.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","366.13","53.22","","859.65","859.65","859.65","1 through 10","80.01","532.48","percent of total billed charges",""
"SYSTEM STENT PERCUFLEX 8FR 24CM URETERAL DRAINAGE CATHETER PIGTAIL THREADED RADIOPAQUE NON COATED","SUP-ITM-10000421","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","687.96","412.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","432.73","62.9","","481.48","481.48","481.48","1 through 10","80.01","532.48","percent of total billed charges",""
"SYSTEM STENT PERCUFLEX 8FR 24CM URETERAL DRAINAGE CATHETER PIGTAIL THREADED RADIOPAQUE NON COATED","SUP-ITM-10000421","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","687.96","412.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","532.48","77.4","","592.29","592.29","592.29","1 through 10","80.01","532.48","percent of total billed charges",""
"SYSTEM STIMULATOR CLOSED-LOOP EVOKE W/60CM LEADS","SUP-ITM-10317744","CDM","C1826","HCPCS","0278","RC","","","","both","","","63720.00","38232.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","14133.10","14133.10","14133.10","1 through 10","7410.64","54162","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM STIMULATOR CLOSED-LOOP EVOKE W/60CM LEADS","SUP-ITM-10317744","CDM","C1826","HCPCS","0278","RC","","","","both","","","63720.00","38232.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","47200.00","47200.00","47200.00","1 through 10","7410.64","54162","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM STIMULATOR EVOKE G4 CLOSED LOOP","SUP-ITM-10328866","CDM","C1820","HCPCS","0278","RC","","","","both","","","63720.00","38232.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","52982.00","26491.00","52982.00","1 through 10","7410.64","54162","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM STIMULATOR EVOKE G4 CLOSED LOOP","SUP-ITM-10328866","CDM","C1820","HCPCS","0278","RC","","","","both","","","63720.00","38232.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","36256.68","56.9","","45220.14","36256.68","45220.14","1 through 10","7410.64","54162","percent of total billed charges",""
"SYSTEM STIMULATOR EVOKE G4 CLOSED LOOP","SUP-ITM-10328866","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","63720.00","38232.00","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","46337.18","72.72","","18421.60","18421.60","18421.60","1 through 10","7410.64","49319.28","percent of total billed charges",""
"SYSTEM SUSPENSION ENCORE TONGUE HYOID","SUP-ITM-10155845","CDM","C1713","HCPCS","0278","RC","","","","both","","","10908.00","6544.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1268.6","9271.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM SUSPENSION ENCORE TONGUE HYOID","SUP-ITM-10155845","CDM","C1713","HCPCS","0278","RC","","","","both","","","10908.00","6544.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1268.6","9271.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"SYSTEM SUSPENSION ENCORE TONGUE HYOID","SUP-ITM-10155845","CDM","C1713","HCPCS","0278","RC","","","","both","","","10908.00","6544.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","6206.65","56.9","","812.12","238.65","1587.46","163","1268.6","9271.8","percent of total billed charges",""
"SYSTEM SUSPENSION ENCORE TONGUE HYOID","SUP-ITM-10155845","CDM","C1713","HCPCS","0278","RC","","","","both","","","10908.00","6544.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1268.60","11.63","","112.68","112.68","146.99","38","1268.6","9271.8","percent of total billed charges",""
"SYSTEM SUSPENSION ENCORE TONGUE HYOID","SUP-ITM-10155845","CDM","C1713","HCPCS","0278","RC","","","","both","","","10908.00","6544.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8442.79","77.4","","303.98","303.98","5854.79","1 through 10","1268.6","9271.8","percent of total billed charges",""
"SYSTEM SUSPENSION ENCORE TONGUE HYOID","SUP-ITM-10155845","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10908.00","6544.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1268.60","11.63","","112.68","112.68","146.99","38","1268.6","8442.79","percent of total billed charges",""
"SYSTEM SUSPENSION ENCORE TONGUE HYOID","SUP-ITM-10155845","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10908.00","6544.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6848.04","62.78","","780.86","208.94","10480.28","15","1268.6","8442.79","percent of total billed charges",""
"SYSTEM SUSPENSION ENCORE TONGUE HYOID","SUP-ITM-10155845","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10908.00","6544.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4768.98","43.72","","179.76","179.76","179.76","1 through 10","1268.6","8442.79","percent of total billed charges",""
"SYSTEM SUSPENSION ENCORE TONGUE HYOID","SUP-ITM-10155845","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10908.00","6544.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7932.30","72.72","","2355.45","298.99","3965.19","155","1268.6","8442.79","percent of total billed charges",""
"SYSTEM SUSPENSION ENCORE TONGUE HYOID","SUP-ITM-10155845","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10908.00","6544.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7932.30","72.72","","3643.09","3643.09","3643.09","1 through 10","1268.6","8442.79","percent of total billed charges",""
"SYSTEM SUSPENSION ENCORE TONGUE HYOID","SUP-ITM-10155845","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10908.00","6544.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","5805.24","53.22","","554.28","554.28","554.28","16","1268.6","8442.79","percent of total billed charges",""
"SYSTEM SUSPENSION ENCORE TONGUE HYOID","SUP-ITM-10155845","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10908.00","6544.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6861.13","62.9","","619.64","173.09","2370.64","150","1268.6","8442.79","percent of total billed charges",""
"SYSTEM SUSPENSION ENCORE TONGUE HYOID","SUP-ITM-10155845","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10908.00","6544.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","8442.79","77.4","","303.98","303.98","5854.79","1 through 10","1268.6","8442.79","percent of total billed charges",""
"SYSTEM TRIALING 60CM EVOKE","SUP-ITM-10317742","CDM","C1897","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1128.11","11.63","","605.27","605.27","605.27","1 through 10","1128.11","8245","percent of total billed charges",""
"SYSTEM TRIALING 60CM EVOKE","SUP-ITM-10317742","CDM","C1897","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1128.11","11.63","","605.27","605.27","605.27","1 through 10","1128.11","7507.8","percent of total billed charges",""
"SYSTEM TRIALING 60CM EVOKE","SUP-ITM-10317742","CDM","C1897","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7053.84","72.72","","3596.00","3596.00","3596.00","1 through 10","1128.11","7507.8","percent of total billed charges",""
"SYSTEM TRIALING 60CM EVOKE","SUP-ITM-10317742","CDM","C1897","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6101.30","62.9","","3130.19","3115.35","3130.19","1 through 10","1128.11","7507.8","percent of total billed charges",""
"T Cells Cd4 & Cd8 W/Ratio","PX-30000853","CDM","86360","CPT","0302","RC","","","","both","","","254.00","152.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","177.29","69.8","","171.71","171.71","171.71","1 through 10","30.54","242.32","percent of total billed charges",""
"T Cells Cd4 & Cd8 W/Ratio","PX-30000853","CDM","86360","CPT","0302","RC","","","","outpatient","","","254.00","152.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","184.71","72.72","","178.89","178.89","178.89","1 through 10","12.81","196.6","percent of total billed charges",""
"T Cells Cd4 & Cd8 W/Ratio","PX-30000853","CDM","86360","CPT","0302","RC","","","","outpatient","","","254.00","152.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","159.77","62.9","","464.94","154.98","464.94","1 through 10","12.81","196.6","percent of total billed charges",""
"T Cells Cd4 & Cd8 W/Ratio","PX-30000853","CDM","86360","CPT","0302","RC","","","","outpatient","","","254.00","152.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","196.60","77.4","","190.65","190.65","190.65","1 through 10","12.81","196.6","percent of total billed charges",""
"T Cells Cd4 Count","PX-30000854","CDM","86361","CPT","0302","RC","","","","both","","","145.00","87.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","101.21","69.8","","97.72","97.72","97.72","1 through 10","17.41","138.46","percent of total billed charges",""
"T Cells Cd4 Count","PX-30000854","CDM","86361","CPT","0302","RC","","","","outpatient","","","145.00","87.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","105.44","72.72","","101.81","101.81","101.81","1 through 10","10.24","112.23","percent of total billed charges",""
"T Cells Cd4 Count","PX-30000854","CDM","86361","CPT","0302","RC","","","","outpatient","","","145.00","87.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","91.21","62.9","","88.20","88.20","88.20","1 through 10","10.24","112.23","percent of total billed charges",""
"T Cells Total","PX-30000852","CDM","86359","CPT","0302","RC","","","","both","","","204.00","122.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","142.39","69.8","","137.51","137.51","137.51","1 through 10","24.52","194.15","percent of total billed charges",""
"T Cells Total","PX-30000852","CDM","86359","CPT","0302","RC","","","","outpatient","","","204.00","122.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","148.35","72.72","","143.26","143.26","143.26","1 through 10","10.68","157.9","percent of total billed charges",""
"T Cells Total","PX-30000852","CDM","86359","CPT","0302","RC","","","","outpatient","","","204.00","122.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","128.32","62.9","","372.33","124.11","372.33","1 through 10","10.68","157.9","percent of total billed charges",""
"T Cells Total","PX-30000852","CDM","86359","CPT","0302","RC","","","","outpatient","","","204.00","122.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","157.90","77.4","","152.68","152.68","152.68","1 through 10","10.68","157.9","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.85","559.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","108.49","792.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.85","559.71","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","108.49","792.92","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.85","559.71","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","530.79","56.9","","812.12","238.65","1587.46","163","108.49","792.92","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.85","559.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","108.49","11.63","","112.68","112.68","146.99","38","108.49","792.92","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.85","559.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","722.03","77.4","","303.98","303.98","5854.79","1 through 10","108.49","792.92","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","932.85","559.71","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","108.49","11.63","","112.68","112.68","146.99","38","108.49","722.03","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","932.85","559.71","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","585.64","62.78","","780.86","208.94","10480.28","15","108.49","722.03","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","932.85","559.71","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","407.84","43.72","","179.76","179.76","179.76","1 through 10","108.49","722.03","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","932.85","559.71","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","678.37","72.72","","2355.45","298.99","3965.19","155","108.49","722.03","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","932.85","559.71","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","678.37","72.72","","3643.09","3643.09","3643.09","1 through 10","108.49","722.03","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","932.85","559.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","496.46","53.22","","554.28","554.28","554.28","16","108.49","722.03","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","932.85","559.71","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","586.76","62.9","","619.64","173.09","2370.64","150","108.49","722.03","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","932.85","559.71","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","722.03","77.4","","303.98","303.98","5854.79","1 through 10","108.49","722.03","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","both","","","73.00","43.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","50.95","69.8","","49.56","49.56","49.56","44","8.92","70.73","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","outpatient","","","73.00","43.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","31.92","43.72","","31.04","31.04","93.12","24","6.52","56.5","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","outpatient","","","73.00","43.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","53.09","72.72","","51.63","51.63","51.63","30","6.52","56.5","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","outpatient","","","73.00","43.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","38.85","53.22","","37.85","37.85","37.85","1 through 10","6.52","56.5","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","outpatient","","","73.00","43.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","45.92","62.9","","89.46","44.73","178.92","95","6.52","56.5","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","outpatient","","","73.00","43.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","56.50","77.4","","55.03","55.03","55.03","27","6.52","56.5","percent of total billed charges",""
"Tap Block Bilateral by Injection(S)","PX-51000531","CDM","64488","CPT","0761","RC","","","","outpatient","","","3428.00","2056.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","2405.58","2405.58","2405.58","1 through 10","398.68","2653.27","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1236.06","741.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","143.75","1050.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1236.06","741.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","143.75","1050.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1236.06","741.64","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","703.32","56.9","","812.12","238.65","1587.46","163","143.75","1050.65","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1236.06","741.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","143.75","11.63","","112.68","112.68","146.99","38","143.75","1050.65","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1236.06","741.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","956.71","77.4","","303.98","303.98","5854.79","1 through 10","143.75","1050.65","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1236.06","741.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","143.75","11.63","","112.68","112.68","146.99","38","143.75","956.71","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1236.06","741.64","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","776.00","62.78","","780.86","208.94","10480.28","15","143.75","956.71","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1236.06","741.64","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","540.41","43.72","","179.76","179.76","179.76","1 through 10","143.75","956.71","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1236.06","741.64","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","898.86","72.72","","2355.45","298.99","3965.19","155","143.75","956.71","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1236.06","741.64","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","898.86","72.72","","3643.09","3643.09","3643.09","1 through 10","143.75","956.71","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1236.06","741.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","657.83","53.22","","554.28","554.28","554.28","16","143.75","956.71","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1236.06","741.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","777.48","62.9","","619.64","173.09","2370.64","150","143.75","956.71","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1236.06","741.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","956.71","77.4","","303.98","303.98","5854.79","1 through 10","143.75","956.71","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.54","2101.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","407.35","2977.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.54","2101.52","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","407.35","2977.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.54","2101.52","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1992.95","56.9","","812.12","238.65","1587.46","163","407.35","2977.16","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.54","2101.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","407.35","11.63","","112.68","112.68","146.99","38","407.35","2977.16","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.54","2101.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2710.97","77.4","","303.98","303.98","5854.79","1 through 10","407.35","2977.16","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3502.54","2101.52","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","407.35","11.63","","112.68","112.68","146.99","38","407.35","2710.97","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3502.54","2101.52","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2198.89","62.78","","780.86","208.94","10480.28","15","407.35","2710.97","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3502.54","2101.52","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1531.31","43.72","","179.76","179.76","179.76","1 through 10","407.35","2710.97","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3502.54","2101.52","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2547.05","72.72","","2355.45","298.99","3965.19","155","407.35","2710.97","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3502.54","2101.52","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2547.05","72.72","","3643.09","3643.09","3643.09","1 through 10","407.35","2710.97","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3502.54","2101.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1864.05","53.22","","554.28","554.28","554.28","16","407.35","2710.97","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3502.54","2101.52","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2203.10","62.9","","619.64","173.09","2370.64","150","407.35","2710.97","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3502.54","2101.52","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2710.97","77.4","","303.98","303.98","5854.79","1 through 10","407.35","2710.97","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","both","","","649.54","389.72","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","75.54","552.11","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","both","","","649.54","389.72","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","369.59","56.9","","2911.53","1863.86","5209.05","65","75.54","552.11","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","both","","","649.54","389.72","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","75.54","11.63","","400.94","400.94","400.94","1 through 10","75.54","552.11","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","both","","","649.54","389.72","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","502.74","77.4","","5214.50","5214.50","16415.28","1 through 10","75.54","552.11","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","649.54","389.72","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","75.54","11.63","","400.94","400.94","400.94","1 through 10","75.54","502.74","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","649.54","389.72","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","283.98","43.72","","1543.33","1543.33","1671.61","1 through 10","75.54","502.74","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","649.54","389.72","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","472.35","72.72","","3700.21","2382.07","6427.18","53","75.54","502.74","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","649.54","389.72","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","472.35","72.72","","12685.80","12685.80","12685.80","1 through 10","75.54","502.74","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","649.54","389.72","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","408.56","62.9","","3408.87","2784.05","9859.40","46","75.54","502.74","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","649.54","389.72","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","502.74","77.4","","5214.50","5214.50","16415.28","1 through 10","75.54","502.74","percent of total billed charges",""
"TAPER 3.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 MINUS","SUP-ITM-10113937","CDM","C1776","HCPCS","0278","RC","","","","both","","","682.02","409.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","79.32","579.72","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TAPER 3.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 MINUS","SUP-ITM-10113937","CDM","C1776","HCPCS","0278","RC","","","","both","","","682.02","409.21","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","388.07","56.9","","2911.53","1863.86","5209.05","65","79.32","579.72","percent of total billed charges",""
"TAPER 3.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 MINUS","SUP-ITM-10113937","CDM","C1776","HCPCS","0278","RC","","","","both","","","682.02","409.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","79.32","11.63","","400.94","400.94","400.94","1 through 10","79.32","579.72","percent of total billed charges",""
"TAPER 3.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 MINUS","SUP-ITM-10113937","CDM","C1776","HCPCS","0278","RC","","","","both","","","682.02","409.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","527.88","77.4","","5214.50","5214.50","16415.28","1 through 10","79.32","579.72","percent of total billed charges",""
"TAPER 3.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 MINUS","SUP-ITM-10113937","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","682.02","409.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","79.32","11.63","","400.94","400.94","400.94","1 through 10","79.32","527.88","percent of total billed charges",""
"TAPER 3.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 MINUS","SUP-ITM-10113937","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","682.02","409.21","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","298.18","43.72","","1543.33","1543.33","1671.61","1 through 10","79.32","527.88","percent of total billed charges",""
"TAPER 3.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 MINUS","SUP-ITM-10113937","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","682.02","409.21","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","495.96","72.72","","3700.21","2382.07","6427.18","53","79.32","527.88","percent of total billed charges",""
"TAPER 3.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 MINUS","SUP-ITM-10113937","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","682.02","409.21","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","495.96","72.72","","12685.80","12685.80","12685.80","1 through 10","79.32","527.88","percent of total billed charges",""
"TAPER 3.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 MINUS","SUP-ITM-10113937","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","682.02","409.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","428.99","62.9","","3408.87","2784.05","9859.40","46","79.32","527.88","percent of total billed charges",""
"TAPER 3.0MM SLEEVE FEMORAL HIP BIOLOX DELTA OPTION TITANIUM TYPE 1 MINUS","SUP-ITM-10113937","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","682.02","409.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","527.88","77.4","","5214.50","5214.50","16415.28","1 through 10","79.32","527.88","percent of total billed charges",""
"Tau Phosphorylated Each","PX-30003839","CDM","84393","CPT","0301","RC","","","","outpatient","","","724.00","434.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","84.20","11.63","","102.75","102.75","102.75","1 through 10","84.2","560.38","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000869","CDM","86480","CPT","0302","RC","","","","both","","","335.00","201.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","233.83","69.8","","226.15","226.15","226.15","26","40.29","320.57","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000869","CDM","86480","CPT","0302","RC","","","","both","","","335.00","201.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","284.75","85","","320.57","320.57","320.57","1 through 10","40.29","320.57","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000869","CDM","86480","CPT","0302","RC","","","","outpatient","","","335.00","201.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","146.46","43.72","","141.65","141.65","141.65","1 through 10","55.42","259.29","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000869","CDM","86480","CPT","0302","RC","","","","outpatient","","","335.00","201.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","243.61","72.72","","235.61","235.61","235.61","49","55.42","259.29","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000869","CDM","86480","CPT","0302","RC","","","","outpatient","","","335.00","201.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","243.61","72.72","","235.61","235.61","235.61","1 through 10","55.42","259.29","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000869","CDM","86480","CPT","0302","RC","","","","outpatient","","","335.00","201.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","178.29","53.22","","172.72","172.72","172.72","1 through 10","55.42","259.29","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000869","CDM","86480","CPT","0302","RC","","","","outpatient","","","335.00","201.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","210.72","62.9","","204.12","204.12","612.36","78","55.42","259.29","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000869","CDM","86480","CPT","0302","RC","","","","outpatient","","","335.00","201.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","259.29","77.4","","251.10","251.10","251.10","18","55.42","259.29","percent of total billed charges",""
"Tcat Impl Wrls P-Art Prs Snr L-T Hemodyn Mntr","PX-36000447","CDM","33289","CPT","0361","RC","","","","both","","","105660.00","63396.00","MEDICARE [2001]","HB WDH MEDICARE","29700.78","","APC Price ($29,700.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29704.19","29704.19","29704.19","1 through 10","29106.77","189815.48","other","OPPS APC"
"Td Vaccine Prsrv Free 7 Yrs or Older for Im Use","PX-63601068","CDM","90714","CPT","0636","RC","","","","outpatient","","","132.76","79.66","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","19.14","14.42","","16.41","9.56","16.41","1 through 10","15.44","102.76","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","both","","","141.62","84.97","AETNA [1001]","HB WDH AETNA COMMERCIAL","91.25","64.43","","98.85","84.96","98.85","1 through 10","34.28","137.02","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","both","","","141.62","84.97","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","89.08","62.9","","89.22","89.22","446.10","12","34.28","137.02","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","both","","","141.62","84.97","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","109.61","77.4","","109.76","109.76","109.76","1 through 10","34.28","137.02","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","outpatient","","","141.62","84.97","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","20.42","14.42","","17.50","17.50","20.42","1 through 10","16.47","103.25","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","outpatient","","","141.62","84.97","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16.47","11.63","","19.50","16.73","24.66","1 through 10","16.47","103.25","percent of total billed charges",""
"Tdap Vaccine 7 Yrs/> Im","PX-63601005","CDM","90715","CPT","0636","RC","","","","outpatient","","","141.62","84.97","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16.47","11.63","","16.73","16.73","41.95","12","16.47","103.25","percent of total billed charges",""
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","both","","","2345.00","1407.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","1636.81","69.8","","1579.57","1579.57","1579.57","1 through 10","374.81","2444.27","percent of total billed charges",""
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","both","","","2345.00","1407.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2444.27","","Case rate ($2,444.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2384.66","2112.34","2384.66","1 through 10","374.81","2444.27","other","OPPS APC"
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","both","","","2345.00","1407.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1052.50","","Case rate ($1,052.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1026.84","376.38","1026.84","1 through 10","374.81","2444.27","other","OPPS APC"
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","both","","","2345.00","1407.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","374.81","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","382.50","374.85","650.25","1 through 10","374.81","2444.27","other","OPPS APC"
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","both","","","2345.00","1407.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1975.68","","Case rate ($1,975.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1891.57","1007.71","1927.49","1 through 10","374.81","2444.27","other","OPPS APC"
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","both","","","2345.00","1407.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","393.93","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","387.68","387.68","387.68","1 through 10","374.81","2444.27","other","OPPS APC"
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","both","","","2345.00","1407.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","382.50","376.38","382.50","1 through 10","374.81","2444.27","other","OPPS APC"
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","both","","","2345.00","1407.00","MEDICARE [2001]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","382.50","382.50","382.50","30","374.81","2444.27","other","OPPS APC"
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","both","","","2345.00","1407.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","376.38","374.85","382.50","1 through 10","374.81","2444.27","other","OPPS APC"
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","outpatient","","","2345.00","1407.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1705.28","72.72","","1645.65","1489.51","1645.65","1 through 10","272.72","1815.03","percent of total billed charges",""
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","outpatient","","","2345.00","1407.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1475.01","62.9","","1425.69","1425.69","1425.69","1 through 10","272.72","1815.03","percent of total billed charges",""
"Telethx Isodose Pln Cplx W/Basic Dosimetry","PX-33000103","CDM","77307","CPT","0333","RC","","","","outpatient","","","2345.00","1407.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","272.72","11.63","","267.30","267.30","267.30","1 through 10","272.72","1815.03","percent of total billed charges",""
"Telethx Isodose Pln Smpl W/Dosimetry Calculation","PX-33000102","CDM","77306","CPT","0333","RC","","","","both","","","1298.00","778.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","374.81","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","382.50","382.50","382.50","1 through 10","187.17","2444.27","other","OPPS APC"
"Telethx Isodose Pln Smpl W/Dosimetry Calculation","PX-33000102","CDM","77306","CPT","0333","RC","","","","both","","","1298.00","778.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","382.50","382.50","382.50","1 through 10","187.17","2444.27","other","OPPS APC"
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","642.91","4698.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","642.91","4698.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3145.43","56.9","","812.12","238.65","1587.46","163","642.91","4698.8","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","642.91","11.63","","112.68","112.68","146.99","38","642.91","4698.8","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","5528.00","3316.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4278.67","77.4","","303.98","303.98","5854.79","1 through 10","642.91","4698.8","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","642.91","11.63","","112.68","112.68","146.99","38","642.91","4278.67","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3470.48","62.78","","780.86","208.94","10480.28","15","642.91","4278.67","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2416.84","43.72","","179.76","179.76","179.76","1 through 10","642.91","4278.67","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4019.96","72.72","","2355.45","298.99","3965.19","155","642.91","4278.67","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4019.96","72.72","","3643.09","3643.09","3643.09","1 through 10","642.91","4278.67","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2942.00","53.22","","554.28","554.28","554.28","16","642.91","4278.67","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3477.11","62.9","","619.64","173.09","2370.64","150","642.91","4278.67","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5528.00","3316.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4278.67","77.4","","303.98","303.98","5854.79","1 through 10","642.91","4278.67","percent of total billed charges",""
"Tendonitis, Myositis And Bursitis With McC","557","MS-DRG","","","","","","","","inpatient","","","48552.99","29131.79","MARTIN'S POINT [160007]","HB WDH MEDICARE","11748.93","","Case rate ($11,748.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,878.39, add-ons for qualifying new technology services are included. If operating cost exceeds $14,796.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,631.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $10,478.02 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,433.52 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $826.04. The transfer capital threshold is the transfer adjustment factor * $826.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11915.79","11915.79","11915.79","1 through 10","3975","56502.35","other","Inpatient DRG"
"Tendonitis, Myositis And Bursitis With McC","557","MS-DRG","","","","","","","","inpatient","","","48552.99","29131.79","MEDICARE [2001]","HB WDH MEDICARE","11748.93","","Case rate ($11,748.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,878.39, add-ons for qualifying new technology services are included. If operating cost exceeds $14,796.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,631.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $10,478.02 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,433.52 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $826.04. The transfer capital threshold is the transfer adjustment factor * $826.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12138.15","12138.15","12168.61","1 through 10","3975","56502.35","other","Inpatient DRG"
"Tendonitis, Myositis And Bursitis With McC","557","MS-DRG","","","","","","","","inpatient","","","48552.99","29131.79","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","11748.93","","Case rate ($11,748.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,878.39, add-ons for qualifying new technology services are included. If operating cost exceeds $14,796.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,631.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $10,478.02 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,433.52 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $826.04. The transfer capital threshold is the transfer adjustment factor * $826.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11896.89","11896.89","11896.89","1 through 10","3975","56502.35","other","Inpatient DRG"
"Tendonitis, Myositis And Bursitis Without McC","558","MS-DRG","","","","","","","","inpatient","","","26004.45","15602.67","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","13364.84","","Fee schedule rate ($13,364.84). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","12609.69","12609.69","12609.69","1 through 10","3975","33941.69","case rate",""
"Tendonitis, Myositis And Bursitis Without McC","558","MS-DRG","","","","","","","","inpatient","","","26004.45","15602.67","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","27032.95","","Fee schedule rate ($27,032.95). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","16534.90","16534.90","16534.90","1 through 10","3975","33941.69","case rate",""
"Tendonitis, Myositis And Bursitis Without McC","558","MS-DRG","","","","","","","","inpatient","","","26004.45","15602.67","MEDICARE [2001]","HB WDH MEDICARE","7235.37","","Case rate ($7,235.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,712.43, add-ons for qualifying new technology services are included. If operating cost exceeds $10,630.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,301.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,294.28 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,267.55 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.21. The transfer capital threshold is the transfer adjustment factor * $496.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","4661.06","4661.06","4661.06","1 through 10","3975","33941.69","other","Inpatient DRG"
"Tendonitis, Myositis And Bursitis Without McC","558","MS-DRG","","","","","","","","inpatient","","","26004.45","15602.67","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7235.37","","Case rate ($7,235.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,712.43, add-ons for qualifying new technology services are included. If operating cost exceeds $10,630.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,301.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $6,294.28 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,267.55 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.21. The transfer capital threshold is the transfer adjustment factor * $496.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","4661.36","4661.36","4661.36","1 through 10","3975","33941.69","other","Inpatient DRG"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","561.00","336.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1343.24","","Case rate ($1,343.24). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","541.00","541.00","547.76","30","205.97","1343.24","other","OPPS APC"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","561.00","336.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","578.40","","Case rate ($578.40). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","541.00","541.00","564.30","40","205.97","1343.24","other","OPPS APC"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","561.00","336.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","205.97","","APC Price ($210.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","210.20","210.20","357.34","15","205.97","1343.24","other","OPPS APC"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","561.00","336.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1085.73","","Case rate ($1,085.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","541.00","541.00","1020.13","26","205.97","1343.24","other","OPPS APC"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","561.00","336.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","319.21","56.9","","307.83","307.83","307.83","39","205.97","1343.24","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","561.00","336.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","210.17","","APC Price ($210.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11.37","11.37","11.37","1 through 10","205.97","1343.24","other","OPPS APC"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","561.00","336.60","MEDICARE [2001]","HB WDH MEDICARE","210.17","","APC Price ($210.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","210.20","210.20","210.20","1 through 10","205.97","1343.24","other","OPPS APC"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","561.00","336.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","476.85","85","","721.15","721.15","721.15","1 through 10","205.97","1343.24","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","561.00","336.60","TRICARE [160005]","HB WDH MEDICARE","210.17","","APC Price ($210.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11.37","11.37","552.37","19","205.97","1343.24","other","OPPS APC"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","both","","","561.00","336.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","210.17","","APC Price ($210.17). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","210.20","191.05","210.20","1 through 10","205.97","1343.24","other","OPPS APC"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","561.00","336.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","80.90","14.42","","78.01","66.87","78.01","30","65.24","434.21","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","561.00","336.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","65.24","11.63","","74.50","63.90","191.70","76","65.24","434.21","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","561.00","336.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","","","Payment is accumulated by procedure count. Procedure 1, 62.78% of billed. Procedures 2 - 9999, 31.39% of billed.","339.64","339.64","339.64","1 through 10","65.24","434.21","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","561.00","336.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","236.53","236.53","236.53","1 through 10","65.24","434.21","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","561.00","336.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","393.42","393.42","393.42","27","65.24","434.21","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","561.00","336.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","352.87","62.9","","340.83","340.83","340.83","38","65.24","434.21","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","561.00","336.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","434.21","77.4","","419.28","393.42","419.28","1 through 10","65.24","434.21","percent of total billed charges",""
"Test Non Stress Fetal","PX-72000007","CDM","59025","CPT","0920","RC","","","","outpatient","","","561.00","336.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","65.24","11.63","","191.70","63.90","447.30","38","65.24","434.21","percent of total billed charges",""
"Testes Procedures With Cc/McC","711","MS-DRG","","","","","","","","inpatient","","","57621.42","34572.85","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","16775.42","","Case rate ($16,286.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $15,066.82, add-ons for qualifying new technology services are included. If operating cost exceeds $18,985.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,962.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,684.31 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $14,621.95 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,157.64. The transfer capital threshold is the transfer adjustment factor * $1,157.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","47853.43","47853.43","47853.43","1 through 10","3975","79184.61","other","Inpatient DRG"
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","both","","","136.00","81.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","94.93","69.8","","92.14","83.03","92.14","50","16.56","130.94","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","both","","","136.00","81.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","115.60","85","","22.92","18.33","22.92","1 through 10","16.56","130.94","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","outpatient","","","136.00","81.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","85.38","62.78","","82.87","82.87","82.87","1 through 10","22.66","105.26","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","outpatient","","","136.00","81.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","59.46","43.72","","57.71","57.71","57.71","1 through 10","22.66","105.26","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","outpatient","","","136.00","81.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","98.90","72.72","","95.99","95.99","95.99","94","22.66","105.26","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","outpatient","","","136.00","81.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","98.90","72.72","","95.99","95.99","95.99","1 through 10","22.66","105.26","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","outpatient","","","136.00","81.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","72.38","53.22","","70.37","70.37","70.37","1 through 10","22.66","105.26","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","outpatient","","","136.00","81.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","85.54","62.9","","83.16","83.16","83.16","109","22.66","105.26","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","outpatient","","","136.00","81.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","105.26","77.4","","102.30","102.30","102.30","38","22.66","105.26","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","outpatient","","","136.00","81.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","98.90","72.72","","95.99","95.99","95.99","1 through 10","22.66","105.26","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","366.00","219.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","255.47","69.8","","247.09","222.67","247.09","76","16.78","311.1","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","366.00","219.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","255.47","69.8","","247.09","247.09","247.09","1 through 10","16.78","311.1","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","366.00","219.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","311.10","85","","23.23","23.23","49.14","1 through 10","16.78","311.1","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","outpatient","","","366.00","219.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","229.77","62.78","","222.24","222.24","222.24","1 through 10","24.06","283.28","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","outpatient","","","366.00","219.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","160.02","43.72","","154.77","154.77","154.77","1 through 10","24.06","283.28","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","outpatient","","","366.00","219.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","266.16","72.72","","257.43","257.43","257.43","146","24.06","283.28","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","outpatient","","","366.00","219.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","266.16","72.72","","257.43","257.43","257.43","1 through 10","24.06","283.28","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","outpatient","","","366.00","219.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","194.79","53.22","","188.72","188.72","188.72","12","24.06","283.28","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","outpatient","","","366.00","219.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","230.21","62.9","","223.02","223.02","223.02","165","24.06","283.28","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","outpatient","","","366.00","219.60","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","266.16","72.72","","274.35","274.35","274.35","1 through 10","24.06","283.28","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","outpatient","","","366.00","219.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","283.28","77.4","","274.35","274.35","274.35","67","24.06","283.28","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","outpatient","","","366.00","219.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","266.16","72.72","","257.43","257.43","257.43","1 through 10","24.06","283.28","percent of total billed charges",""
"Ther Ivntj Cog Funcj Cntct 1st 15 Minutes","PX-43000122","CDM","97129","CPT","0431","RC","","","","outpatient","","","141.00","84.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","88.69","62.9","","85.68","85.68","85.68","19","16.4","109.13","percent of total billed charges",""
"Ther Ivntj Cog Funcj Cntct 1st 15 Minutes","PX-43000122","CDM","97129","CPT","0431","RC","","","","outpatient","","","141.00","84.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16.40","11.63","","16.07","16.07","16.07","1 through 10","16.4","109.13","percent of total billed charges",""
"Ther Ivntj Cog Funcj Cntct 1st 15 Minutes","PX-44000096","CDM","97129","CPT","0441","RC","","","","outpatient","","","141.00","84.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","88.69","62.9","","85.68","85.68","85.68","19","16.4","109.13","percent of total billed charges",""
"Ther Ivntj Cog Funcj Cntct 1st 15 Minutes","PX-44000096","CDM","97129","CPT","0441","RC","","","","outpatient","","","141.00","84.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16.40","11.63","","16.07","16.07","16.07","1 through 10","16.4","109.13","percent of total billed charges",""
"Ther Ivntj Cog Funcj Cntct Ea Addl 15 Minutes","PX-43000123","CDM","97130","CPT","0431","RC","","","","outpatient","","","135.00","81.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","84.92","62.9","","81.90","81.90","81.90","55","15.7","104.49","percent of total billed charges",""
"Ther Ivntj Cog Funcj Cntct Ea Addl 15 Minutes","PX-43000123","CDM","97130","CPT","0431","RC","","","","outpatient","","","135.00","81.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","15.70","11.63","","15.35","15.35","15.35","1 through 10","15.7","104.49","percent of total billed charges",""
"Ther Ivntj Cog Funcj Cntct Ea Addl 15 Minutes","PX-44000097","CDM","97130","CPT","0441","RC","","","","outpatient","","","135.00","81.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","84.92","62.9","","81.90","81.90","81.90","55","15.7","104.49","percent of total billed charges",""
"Ther Ivntj Cog Funcj Cntct Ea Addl 15 Minutes","PX-44000097","CDM","97130","CPT","0441","RC","","","","outpatient","","","135.00","81.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","15.70","11.63","","15.35","15.35","15.35","1 through 10","15.7","104.49","percent of total billed charges",""
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","4098.00","2458.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","2860.40","69.8","","2759.89","2759.89","2759.89","1 through 10","374.81","3572.68","percent of total billed charges",""
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","4098.00","2458.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2444.27","","Case rate ($2,444.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2384.66","2340.23","2384.66","13","374.81","3572.68","other","OPPS APC"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","4098.00","2458.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1052.50","","Case rate ($1,052.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1026.84","1026.84","3954.00","1 through 10","374.81","3572.68","other","OPPS APC"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","4098.00","2458.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","374.81","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","376.38","374.85","650.25","25","374.81","3572.68","other","OPPS APC"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","4098.00","2458.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1975.68","","Case rate ($1,975.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1734.74","1702.41","1927.49","1 through 10","374.81","3572.68","other","OPPS APC"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","4098.00","2458.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","393.93","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","387.68","386.10","387.68","11","374.81","3572.68","other","OPPS APC"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","4098.00","2458.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","376.38","374.85","382.50","20","374.81","3572.68","other","OPPS APC"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","4098.00","2458.80","MEDICARE [2001]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","382.50","360.01","1147.50","73","374.81","3572.68","other","OPPS APC"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","4098.00","2458.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","375.62","352.81","382.50","18","374.81","3572.68","other","OPPS APC"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","4098.00","2458.80","WELLPOINT [1015]","HB WDH ANTHEM PPO","1975.68","","Case rate ($1,975.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1927.49","1927.49","1927.49","1 through 10","374.81","3572.68","other","OPPS APC"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","both","","","4098.00","2458.80","WELLSENSE NH [1050]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","395.20","395.20","395.20","1 through 10","374.81","3572.68","other","OPPS APC"
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","outpatient","","","4098.00","2458.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","590.93","14.42","","570.17","570.17","570.17","1 through 10","476.6","3171.85","percent of total billed charges",""
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","outpatient","","","4098.00","2458.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","476.60","11.63","","544.47","467.03","544.47","1 through 10","476.6","3171.85","percent of total billed charges",""
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","outpatient","","","4098.00","2458.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2572.72","62.78","","2482.32","2482.32","2482.32","1 through 10","476.6","3171.85","percent of total billed charges",""
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","outpatient","","","4098.00","2458.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2980.07","72.72","","2875.35","2602.52","5535.50","13","476.6","3171.85","percent of total billed charges",""
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","outpatient","","","4098.00","2458.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2577.64","62.9","","2491.02","2491.02","9964.08","1 through 10","476.6","3171.85","percent of total billed charges",""
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","outpatient","","","4098.00","2458.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3171.85","77.4","","2875.35","2875.35","2875.35","1 through 10","476.6","3171.85","percent of total billed charges",""
"Ther Rad Simulaj-Aid Complex","PX-33000009","CDM","77290","CPT","0333","RC","","","","outpatient","","","4098.00","2458.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","476.60","11.63","","599.76","467.03","599.76","1 through 10","476.6","3171.85","percent of total billed charges",""
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2375.00","1425.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","1657.75","69.8","","1599.82","1599.82","1599.82","1 through 10","135.94","2018.75","percent of total billed charges",""
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2375.00","1425.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","886.52","","Case rate ($886.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","864.90","859.38","864.90","19","135.94","2018.75","other","OPPS APC"
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2375.00","1425.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","381.73","","Case rate ($381.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","372.43","370.05","372.43","14","135.94","2018.75","other","OPPS APC"
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2375.00","1425.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","135.94","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","136.51","135.96","138.73","31","135.94","2018.75","other","OPPS APC"
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2375.00","1425.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","716.57","","Case rate ($716.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","629.18","372.43","699.09","1 through 10","135.94","2018.75","other","OPPS APC"
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2375.00","1425.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","142.87","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","140.60","140.03","142.89","1 through 10","135.94","2018.75","other","OPPS APC"
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2375.00","1425.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","136.51","130.08","138.73","35","135.94","2018.75","other","OPPS APC"
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2375.00","1425.00","MEDICARE [2001]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","138.73","138.73","264.40","76","135.94","2018.75","other","OPPS APC"
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2375.00","1425.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","2018.75","85","","1487.74","1487.74","1487.74","1 through 10","135.94","2018.75","percent of total billed charges",""
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2375.00","1425.00","TRICARE [160005]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","138.73","138.73","138.73","1 through 10","135.94","2018.75","other","OPPS APC"
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2375.00","1425.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","136.52","135.96","138.73","19","135.94","2018.75","other","OPPS APC"
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2375.00","1425.00","WELLPOINT [1015]","HB WDH ANTHEM PPO","716.57","","Case rate ($716.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","699.09","699.09","699.09","1 through 10","135.94","2018.75","other","OPPS APC"
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","both","","","2375.00","1425.00","WELLSENSE NH [1050]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","143.34","143.34","143.34","1 through 10","135.94","2018.75","other","OPPS APC"
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","outpatient","","","2375.00","1425.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","342.48","14.42","","330.51","330.51","330.51","1 through 10","276.21","1838.25","percent of total billed charges",""
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","outpatient","","","2375.00","1425.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","276.21","11.63","","280.54","270.72","315.61","1 through 10","276.21","1838.25","percent of total billed charges",""
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","outpatient","","","2375.00","1425.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1491.03","62.78","","1438.92","1438.92","1438.92","1 through 10","276.21","1838.25","percent of total billed charges",""
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","outpatient","","","2375.00","1425.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1727.10","72.72","","1666.74","1508.59","1666.74","11","276.21","1838.25","percent of total billed charges",""
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","outpatient","","","2375.00","1425.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1493.88","62.9","","1443.96","1443.96","1443.96","15","276.21","1838.25","percent of total billed charges",""
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","outpatient","","","2375.00","1425.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1838.25","77.4","","1776.30","1666.74","1776.30","1 through 10","276.21","1838.25","percent of total billed charges",""
"Ther Rad Simulaj-Aid Simple","PX-33000007","CDM","77280","CPT","0333","RC","","","","outpatient","","","2375.00","1425.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","276.21","11.63","","270.72","217.53","270.72","1 through 10","276.21","1838.25","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30000038","CDM","80299","CPT","0300","RC","","","","both","","","103.00","61.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","71.89","69.8","","69.80","62.90","69.80","1 through 10","12.12","87.55","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30000038","CDM","80299","CPT","0300","RC","","","","outpatient","","","103.00","61.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","45.03","43.72","","43.72","43.72","43.72","1 through 10","12.76","79.72","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30000038","CDM","80299","CPT","0300","RC","","","","outpatient","","","103.00","61.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","74.90","72.72","","72.72","72.72","72.72","1 through 10","12.76","79.72","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30000038","CDM","80299","CPT","0300","RC","","","","outpatient","","","103.00","61.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","74.90","72.72","","190.53","190.53","190.53","1 through 10","12.76","79.72","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30000038","CDM","80299","CPT","0300","RC","","","","outpatient","","","103.00","61.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","54.82","53.22","","53.31","53.31","53.31","1 through 10","12.76","79.72","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30000038","CDM","80299","CPT","0300","RC","","","","outpatient","","","103.00","61.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","64.79","62.9","","63.00","63.00","189.00","13","12.76","79.72","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","226.00","135.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","157.75","69.8","","152.16","137.12","152.17","34","72.87","475.23","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","226.00","135.60","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","75.84","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","74.36","68.64","74.36","21","72.87","475.23","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","226.00","135.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","475.23","","Case rate ($475.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","463.64","446.16","463.64","24","72.87","475.23","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","226.00","135.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","204.63","","Case rate ($204.63). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","199.65","192.12","199.65","63","72.87","475.23","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","226.00","135.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","72.87","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","72.87","68.64","74.36","125","72.87","475.23","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","226.00","135.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","384.13","","Case rate ($384.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","374.75","199.65","374.75","113","72.87","475.23","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","226.00","135.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","128.59","56.9","","124.04","70.06","217.75","84","72.87","475.23","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","226.00","135.60","HARVARD PILGRIM [120001]","HB WDH MEDICARE","74.36","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","67.54","67.54","67.54","1 through 10","72.87","475.23","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","226.00","135.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","76.59","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","75.36","75.06","75.36","47","72.87","475.23","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","226.00","135.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","74.36","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","73.17","68.64","74.36","179","72.87","475.23","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","226.00","135.60","MEDICARE [2001]","HB WDH MEDICARE","74.36","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","74.36","68.64","74.36","712","72.87","475.23","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","226.00","135.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","74.36","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","74.36","67.55","74.36","195","72.87","475.23","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","226.00","135.60","WELLPOINT [1015]","HB WDH ANTHEM PPO","384.13","","Case rate ($384.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","374.75","374.75","374.75","1 through 10","72.87","475.23","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","226.00","135.60","WELLSENSE NH [1050]","HB WDH MEDICARE","74.36","","APC Price ($74.36). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","229.56","76.52","229.56","12","72.87","475.23","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","outpatient","","","226.00","135.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","32.59","14.42","","31.44","26.94","31.44","45","26.28","174.92","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","outpatient","","","226.00","135.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","26.28","11.63","","30.02","25.74","55.04","77","26.28","174.92","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","outpatient","","","226.00","135.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","142.15","62.9","","137.34","137.34","137.34","25","26.28","174.92","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","outpatient","","","226.00","135.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","174.92","77.4","","168.95","158.53","168.95","1 through 10","26.28","174.92","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","outpatient","","","226.00","135.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","26.28","11.63","","25.74","25.74","25.75","36","26.28","174.92","percent of total billed charges",""
"Therapeutic Radiology Port Images(S)","PX-33000045","CDM","77417","CPT","0333","RC","","","","both","","","189.00","113.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","107.54","56.9","","103.56","103.56","103.56","14","107.54","160.65","percent of total billed charges",""
"Therapeutic Radiology Port Images(S)","PX-33000045","CDM","77417","CPT","0333","RC","","","","outpatient","","","189.00","113.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","21.98","11.63","","21.50","21.50","22.28","1 through 10","21.98","146.29","percent of total billed charges",""
"Therapeutic Radiology Port Images(S)","PX-33000045","CDM","77417","CPT","0333","RC","","","","outpatient","","","189.00","113.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","137.44","72.72","","119.79","119.79","119.79","1 through 10","21.98","146.29","percent of total billed charges",""
"Therapeutic Radiology Port Images(S)","PX-33000045","CDM","77417","CPT","0333","RC","","","","outpatient","","","189.00","113.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","118.88","62.9","","114.66","114.66","114.66","1 through 10","21.98","146.29","percent of total billed charges",""
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-76002662","CDM","62329","CPT","0761","RC","","","","both","","","3149.00","1889.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1991.07","","Case rate ($1,991.07). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1942.53","1942.53","1942.53","1 through 10","709.05","4623.96","other","OPPS APC"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-76002662","CDM","62329","CPT","0761","RC","","","","both","","","3149.00","1889.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","723.52","","APC Price ($723.52). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","709.13","709.13","709.13","1 through 10","709.05","4623.96","other","OPPS APC"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-76002662","CDM","62329","CPT","0761","RC","","","","outpatient","","","3149.00","1889.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2289.95","72.72","","2209.96","2209.96","2209.96","1 through 10","366.23","2437.33","percent of total billed charges",""
"Thoracentesis W/Imaging Guidance","PX-76001812","CDM","32555","CPT","0761","RC","","","","both","","","2131.00","1278.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","645.93","","APC Price ($645.93). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","640.99","605.45","646.01","1 through 10","633.01","4128.13","other","OPPS APC"
"Thoracic Fascial Plane Block Bi Injection","PX-76002990","CDM","64468","CPT","0761","RC","","","","both","","","3550.00","2130.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2581.56","72.72","","2491.39","2491.39","2491.39","1 through 10","511.91","3017.5","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X26MM CAPSTONE PEEK IMPLANT","SUP-ITM-10051976","CDM","C1889","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","1128.11","8245","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"THORACOLUMBAR SPACER 12X26MM CAPSTONE PEEK IMPLANT","SUP-ITM-10051976","CDM","C1889","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","1128.11","8245","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"THORACOLUMBAR SPACER 12X26MM CAPSTONE PEEK IMPLANT","SUP-ITM-10051976","CDM","C1889","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5519.30","56.9","","0.63","0.63","0.63","1 through 10","1128.11","8245","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X26MM CAPSTONE PEEK IMPLANT","SUP-ITM-10051976","CDM","C1889","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1398.74","14.42","","317.14","317.14","317.14","1 through 10","1128.11","8245","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X26MM CAPSTONE PEEK IMPLANT","SUP-ITM-10051976","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1398.74","14.42","","317.14","317.14","317.14","1 through 10","1128.11","7507.8","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X26MM CAPSTONE PEEK IMPLANT","SUP-ITM-10051976","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6089.66","62.78","","1125.09","1125.09","1125.09","1 through 10","1128.11","7507.8","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X26MM CAPSTONE PEEK IMPLANT","SUP-ITM-10051976","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7053.84","72.72","","4732.50","1617.43","14180.40","1 through 10","1128.11","7507.8","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X26MM CAPSTONE PEEK IMPLANT","SUP-ITM-10051976","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6101.30","62.9","","3896.20","3341.38","3896.20","1 through 10","1128.11","7507.8","percent of total billed charges",""
"THORACOLUMBAR SPACER 7X26MM VERTE STACK PEEK","SUP-ITM-10110968","CDM","C1889","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","1128.11","8245","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"THORACOLUMBAR SPACER 7X26MM VERTE STACK PEEK","SUP-ITM-10110968","CDM","C1889","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","1128.11","8245","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"THORACOLUMBAR SPACER 7X26MM VERTE STACK PEEK","SUP-ITM-10110968","CDM","C1889","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5519.30","56.9","","0.63","0.63","0.63","1 through 10","1128.11","8245","percent of total billed charges",""
"THORACOLUMBAR SPACER 7X26MM VERTE STACK PEEK","SUP-ITM-10110968","CDM","C1889","HCPCS","0278","RC","","","","both","","","9700.00","5820.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1398.74","14.42","","317.14","317.14","317.14","1 through 10","1128.11","8245","percent of total billed charges",""
"THORACOLUMBAR SPACER 7X26MM VERTE STACK PEEK","SUP-ITM-10110968","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1398.74","14.42","","317.14","317.14","317.14","1 through 10","1128.11","7507.8","percent of total billed charges",""
"THORACOLUMBAR SPACER 7X26MM VERTE STACK PEEK","SUP-ITM-10110968","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6089.66","62.78","","1125.09","1125.09","1125.09","1 through 10","1128.11","7507.8","percent of total billed charges",""
"THORACOLUMBAR SPACER 7X26MM VERTE STACK PEEK","SUP-ITM-10110968","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7053.84","72.72","","4732.50","1617.43","14180.40","1 through 10","1128.11","7507.8","percent of total billed charges",""
"THORACOLUMBAR SPACER 7X26MM VERTE STACK PEEK","SUP-ITM-10110968","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9700.00","5820.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6101.30","62.9","","3896.20","3341.38","3896.20","1 through 10","1128.11","7507.8","percent of total billed charges",""
"Thrombect Venous Mechanical","PX-76001132","CDM","37187","CPT","0361","RC","","","","both","","","30995.00","18597.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","11611.21","","APC Price ($11,848.17). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","18387.37","18387.37","18387.37","1 through 10","11611.21","75720.79","other","OPPS APC"
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","both","","","86.00","51.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","60.03","69.8","","57.93","52.21","57.93","13","10.34","82.77","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","both","","","86.00","51.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","73.10","85","","82.78","82.78","82.78","1 through 10","10.34","82.77","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","outpatient","","","86.00","51.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","53.99","62.78","","52.11","52.11","52.11","1 through 10","12.99","66.56","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","outpatient","","","86.00","51.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","37.60","43.72","","36.29","36.29","36.29","1 through 10","12.99","66.56","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","outpatient","","","86.00","51.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","62.54","72.72","","60.36","60.36","228.34","39","12.99","66.56","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","outpatient","","","86.00","51.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","62.54","72.72","","60.36","60.36","60.36","1 through 10","12.99","66.56","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","outpatient","","","86.00","51.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","45.77","53.22","","44.25","44.25","44.25","1 through 10","12.99","66.56","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","outpatient","","","86.00","51.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","54.09","62.9","","52.29","52.29","52.29","36","12.99","66.56","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","outpatient","","","86.00","51.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","66.56","77.4","","64.33","64.32","64.33","14","12.99","66.56","percent of total billed charges",""
"Thyroid Activity (Tbg)","PX-30000700","CDM","84442","CPT","0301","RC","","","","outpatient","","","80.00","48.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","50.32","62.9","","48.51","48.51","48.51","1 through 10","17.73","61.92","percent of total billed charges",""
"Thyroid Hormone Uptake/Ratio","PX-30000710","CDM","84479","CPT","0301","RC","","","","both","","","93.00","55.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","64.91","69.8","","62.82","56.61","62.82","1 through 10","4.21","79.05","percent of total billed charges",""
"Thyroid Hormone Uptake/Ratio","PX-30000710","CDM","84479","CPT","0301","RC","","","","outpatient","","","93.00","55.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","40.66","43.72","","39.35","39.35","39.35","1 through 10","5.38","71.98","percent of total billed charges",""
"Thyroid Hormone Uptake/Ratio","PX-30000710","CDM","84479","CPT","0301","RC","","","","outpatient","","","93.00","55.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","67.63","72.72","","65.45","65.45","130.90","1 through 10","5.38","71.98","percent of total billed charges",""
"Thyroid Hormone Uptake/Ratio","PX-30000710","CDM","84479","CPT","0301","RC","","","","outpatient","","","93.00","55.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","58.50","62.9","","56.70","47.98","56.70","1 through 10","5.38","71.98","percent of total billed charges",""
"Thyroid Hormone Uptake/Ratio","PX-30000710","CDM","84479","CPT","0301","RC","","","","outpatient","","","93.00","55.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","71.98","77.4","","69.75","69.75","69.75","1 through 10","5.38","71.98","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0300","RC","","","","inpatient","","","239.00","143.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","183.70","76.86","","145.53","139.99","145.53","1 through 10","158.22","183.7","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","239.00","143.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","166.82","69.8","","161.24","145.30","161.24","589","10.92","203.15","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","239.00","143.40","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","166.82","69.8","","161.24","161.24","161.24","1 through 10","10.92","203.15","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","239.00","143.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","203.15","85","","56.19","23.52","196.35","35","10.92","203.15","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","239.00","143.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","150.04","62.78","","145.02","145.02","145.02","28","15.66","184.99","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","239.00","143.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","104.49","43.72","","100.99","100.99","100.99","42","15.66","184.99","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","239.00","143.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","173.80","72.72","","167.98","167.98","167.98","971","15.66","184.99","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","239.00","143.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","173.80","72.72","","167.98","167.98","167.98","45","15.66","184.99","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","239.00","143.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","127.20","53.22","","123.15","123.15","123.15","43","15.66","184.99","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","239.00","143.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","150.33","62.9","","145.53","145.53","145.53","1188","15.66","184.99","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","239.00","143.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","184.99","77.4","","179.03","179.03","179.03","414","15.66","184.99","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","239.00","143.40","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","173.80","72.72","","167.98","167.98","167.98","1 through 10","15.66","184.99","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0301","RC","","","","both","","","274.00","164.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","191.25","69.8","","166.69","57.96","184.97","14","33.06","261.88","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0301","RC","","","","both","","","274.00","164.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","232.90","85","","261.87","261.87","261.87","1 through 10","33.06","261.88","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0301","RC","","","","outpatient","","","274.00","164.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","119.79","43.72","","115.86","115.86","115.86","1 through 10","47.38","212.08","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0301","RC","","","","outpatient","","","274.00","164.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","199.25","72.72","","192.71","192.71","192.71","1 through 10","47.38","212.08","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0301","RC","","","","outpatient","","","274.00","164.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","199.25","72.72","","192.71","192.71","192.71","1 through 10","47.38","212.08","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0301","RC","","","","outpatient","","","274.00","164.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","172.35","62.9","","166.95","166.95","166.95","1 through 10","47.38","212.08","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0301","RC","","","","outpatient","","","274.00","164.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","212.08","77.4","","205.38","205.38","205.38","1 through 10","47.38","212.08","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","128.00","76.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","89.34","69.8","","86.55","78.00","86.55","172","5.86","108.8","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","128.00","76.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","89.34","69.8","","86.55","86.55","86.55","1 through 10","5.86","108.8","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","128.00","76.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","108.80","85","","46.66","15.37","46.66","1 through 10","5.86","108.8","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","outpatient","","","128.00","76.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","80.36","62.78","","77.85","54.21","77.85","1 through 10","8.4","99.07","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","outpatient","","","128.00","76.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","55.96","43.72","","54.21","54.21","54.21","12","8.4","99.07","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","outpatient","","","128.00","76.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","93.08","72.72","","90.17","90.17","90.17","241","8.4","99.07","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","outpatient","","","128.00","76.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","93.08","72.72","","90.17","90.17","90.17","14","8.4","99.07","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","outpatient","","","128.00","76.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","68.12","53.22","","66.10","66.10","66.10","1 through 10","8.4","99.07","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","outpatient","","","128.00","76.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","80.51","62.9","","78.12","78.12","124.00","332","8.4","99.07","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","outpatient","","","128.00","76.80","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","93.08","72.72","","96.10","96.09","96.10","1 through 10","8.4","99.07","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","outpatient","","","128.00","76.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","99.07","77.4","","96.10","96.10","96.10","141","8.4","99.07","percent of total billed charges",""
"Thyroxine (T-4) Total","PX-30000697","CDM","84436","CPT","0301","RC","","","","both","","","98.00","58.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","68.40","69.8","","66.31","59.76","129.13","12","4.47","83.3","percent of total billed charges",""
"Thyroxine (T-4) Total","PX-30000697","CDM","84436","CPT","0301","RC","","","","outpatient","","","98.00","58.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","42.85","43.72","","41.53","41.53","41.53","1 through 10","5.38","75.85","percent of total billed charges",""
"Thyroxine (T-4) Total","PX-30000697","CDM","84436","CPT","0301","RC","","","","outpatient","","","98.00","58.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","71.27","72.72","","69.08","69.08","138.16","19","5.38","75.85","percent of total billed charges",""
"Thyroxine (T-4) Total","PX-30000697","CDM","84436","CPT","0301","RC","","","","outpatient","","","98.00","58.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","61.64","62.9","","59.85","59.85","59.85","15","5.38","75.85","percent of total billed charges",""
"Thyroxine (T-4) Total","PX-30000697","CDM","84436","CPT","0301","RC","","","","outpatient","","","98.00","58.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","75.85","77.4","","73.63","69.08","73.63","1 through 10","5.38","75.85","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","both","","","6759.11","4055.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","786.08","5745.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","both","","","6759.11","4055.47","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","786.08","5745.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","both","","","6759.11","4055.47","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3845.93","56.9","","812.12","238.65","1587.46","163","786.08","5745.24","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","both","","","6759.11","4055.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","786.08","11.63","","112.68","112.68","146.99","38","786.08","5745.24","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","both","","","6759.11","4055.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5231.55","77.4","","303.98","303.98","5854.79","1 through 10","786.08","5745.24","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6759.11","4055.47","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","786.08","11.63","","112.68","112.68","146.99","38","786.08","5231.55","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6759.11","4055.47","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4243.37","62.78","","780.86","208.94","10480.28","15","786.08","5231.55","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6759.11","4055.47","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2955.08","43.72","","179.76","179.76","179.76","1 through 10","786.08","5231.55","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6759.11","4055.47","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4915.22","72.72","","2355.45","298.99","3965.19","155","786.08","5231.55","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6759.11","4055.47","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4915.22","72.72","","3643.09","3643.09","3643.09","1 through 10","786.08","5231.55","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6759.11","4055.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3597.20","53.22","","554.28","554.28","554.28","16","786.08","5231.55","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6759.11","4055.47","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4251.48","62.9","","619.64","173.09","2370.64","150","786.08","5231.55","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX112 6 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6759.11","4055.47","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5231.55","77.4","","303.98","303.98","5854.79","1 through 10","786.08","5231.55","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","both","","","6615.59","3969.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","769.39","5623.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","both","","","6615.59","3969.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","769.39","5623.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","both","","","6615.59","3969.35","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3764.27","56.9","","812.12","238.65","1587.46","163","769.39","5623.25","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","both","","","6615.59","3969.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","769.39","11.63","","112.68","112.68","146.99","38","769.39","5623.25","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","both","","","6615.59","3969.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5120.47","77.4","","303.98","303.98","5854.79","1 through 10","769.39","5623.25","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6615.59","3969.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","769.39","11.63","","112.68","112.68","146.99","38","769.39","5120.47","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6615.59","3969.35","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4153.27","62.78","","780.86","208.94","10480.28","15","769.39","5120.47","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6615.59","3969.35","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2892.34","43.72","","179.76","179.76","179.76","1 through 10","769.39","5120.47","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6615.59","3969.35","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4810.86","72.72","","2355.45","298.99","3965.19","155","769.39","5120.47","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6615.59","3969.35","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4810.86","72.72","","3643.09","3643.09","3643.09","1 through 10","769.39","5120.47","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6615.59","3969.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3520.82","53.22","","554.28","554.28","554.28","16","769.39","5120.47","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6615.59","3969.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4161.21","62.9","","619.64","173.09","2370.64","150","769.39","5120.47","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5MMX142 8 HOLE BONE VA LCP SS VARIABLE ANGLE ANTEROLATERAL DISTAL LEFT","SUP-ITM-10124955","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6615.59","3969.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5120.47","77.4","","303.98","303.98","5854.79","1 through 10","769.39","5120.47","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","6350.35","3810.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","738.55","5397.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","6350.35","3810.21","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","738.55","5397.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","6350.35","3810.21","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3613.35","56.9","","812.12","238.65","1587.46","163","738.55","5397.8","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","6350.35","3810.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","738.55","11.63","","112.68","112.68","146.99","38","738.55","5397.8","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","6350.35","3810.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4915.17","77.4","","303.98","303.98","5854.79","1 through 10","738.55","5397.8","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6350.35","3810.21","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","738.55","11.63","","112.68","112.68","146.99","38","738.55","4915.17","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6350.35","3810.21","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3986.75","62.78","","780.86","208.94","10480.28","15","738.55","4915.17","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6350.35","3810.21","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2776.37","43.72","","179.76","179.76","179.76","1 through 10","738.55","4915.17","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6350.35","3810.21","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4617.97","72.72","","2355.45","298.99","3965.19","155","738.55","4915.17","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6350.35","3810.21","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4617.97","72.72","","3643.09","3643.09","3643.09","1 through 10","738.55","4915.17","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6350.35","3810.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3379.66","53.22","","554.28","554.28","554.28","16","738.55","4915.17","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6350.35","3810.21","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3994.37","62.9","","619.64","173.09","2370.64","150","738.55","4915.17","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6350.35","3810.21","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4915.17","77.4","","303.98","303.98","5854.79","1 through 10","738.55","4915.17","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","both","","","871.83","523.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","101.39","741.06","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","both","","","871.83","523.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","101.39","741.06","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","both","","","871.83","523.10","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","496.07","56.9","","812.12","238.65","1587.46","163","101.39","741.06","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","both","","","871.83","523.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","101.39","11.63","","112.68","112.68","146.99","38","101.39","741.06","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","both","","","871.83","523.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","674.80","77.4","","303.98","303.98","5854.79","1 through 10","101.39","741.06","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","871.83","523.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","101.39","11.63","","112.68","112.68","146.99","38","101.39","674.8","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","871.83","523.10","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","547.33","62.78","","780.86","208.94","10480.28","15","101.39","674.8","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","871.83","523.10","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","381.16","43.72","","179.76","179.76","179.76","1 through 10","101.39","674.8","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","871.83","523.10","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","633.99","72.72","","2355.45","298.99","3965.19","155","101.39","674.8","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","871.83","523.10","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","633.99","72.72","","3643.09","3643.09","3643.09","1 through 10","101.39","674.8","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","871.83","523.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","463.99","53.22","","554.28","554.28","554.28","16","101.39","674.8","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","871.83","523.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","548.38","62.9","","619.64","173.09","2370.64","150","101.39","674.8","percent of total billed charges",""
"TIBIAL ENDCAP 0.0MM EXTENDED TIP NAIL EX TI GOLD T40 STARDRIVE","SUP-ITM-10018689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","871.83","523.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","674.80","77.4","","303.98","303.98","5854.79","1 through 10","101.39","674.8","percent of total billed charges",""
"TIBIAL ENDCAP 0MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040001","CDM","C1713","HCPCS","0278","RC","","","","both","","","871.83","523.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","101.39","741.06","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL ENDCAP 0MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040001","CDM","C1713","HCPCS","0278","RC","","","","both","","","871.83","523.10","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","101.39","741.06","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL ENDCAP 0MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040001","CDM","C1713","HCPCS","0278","RC","","","","both","","","871.83","523.10","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","496.07","56.9","","812.12","238.65","1587.46","163","101.39","741.06","percent of total billed charges",""
"TIBIAL ENDCAP 0MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040001","CDM","C1713","HCPCS","0278","RC","","","","both","","","871.83","523.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","101.39","11.63","","112.68","112.68","146.99","38","101.39","741.06","percent of total billed charges",""
"TIBIAL ENDCAP 0MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040001","CDM","C1713","HCPCS","0278","RC","","","","both","","","871.83","523.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","674.80","77.4","","303.98","303.98","5854.79","1 through 10","101.39","741.06","percent of total billed charges",""
"TIBIAL ENDCAP 0MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","871.83","523.10","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","101.39","11.63","","112.68","112.68","146.99","38","101.39","674.8","percent of total billed charges",""
"TIBIAL ENDCAP 0MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","871.83","523.10","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","547.33","62.78","","780.86","208.94","10480.28","15","101.39","674.8","percent of total billed charges",""
"TIBIAL ENDCAP 0MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","871.83","523.10","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","381.16","43.72","","179.76","179.76","179.76","1 through 10","101.39","674.8","percent of total billed charges",""
"TIBIAL ENDCAP 0MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","871.83","523.10","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","633.99","72.72","","2355.45","298.99","3965.19","155","101.39","674.8","percent of total billed charges",""
"TIBIAL ENDCAP 0MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","871.83","523.10","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","633.99","72.72","","3643.09","3643.09","3643.09","1 through 10","101.39","674.8","percent of total billed charges",""
"TIBIAL ENDCAP 0MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","871.83","523.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","463.99","53.22","","554.28","554.28","554.28","16","101.39","674.8","percent of total billed charges",""
"TIBIAL ENDCAP 0MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","871.83","523.10","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","548.38","62.9","","619.64","173.09","2370.64","150","101.39","674.8","percent of total billed charges",""
"TIBIAL ENDCAP 0MM NAIL TI T40 STARDRIVE RECESS EXTENSION","SUP-ITM-10040001","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","871.83","523.10","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","674.80","77.4","","303.98","303.98","5854.79","1 through 10","101.39","674.8","percent of total billed charges",""
"TIBIAL INSERT SZ 3 6MM IDENTITY IMPRINT PS","SUP-ITM-10283889","CDM","C1713","HCPCS","0278","RC","","","","both","","","4705.71","2823.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","547.27","3999.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL INSERT SZ 3 6MM IDENTITY IMPRINT PS","SUP-ITM-10283889","CDM","C1713","HCPCS","0278","RC","","","","both","","","4705.71","2823.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","547.27","3999.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL INSERT SZ 3 6MM IDENTITY IMPRINT PS","SUP-ITM-10283889","CDM","C1713","HCPCS","0278","RC","","","","both","","","4705.71","2823.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2677.55","56.9","","812.12","238.65","1587.46","163","547.27","3999.85","percent of total billed charges",""
"TIBIAL INSERT SZ 3 6MM IDENTITY IMPRINT PS","SUP-ITM-10283889","CDM","C1713","HCPCS","0278","RC","","","","both","","","4705.71","2823.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","547.27","11.63","","112.68","112.68","146.99","38","547.27","3999.85","percent of total billed charges",""
"TIBIAL INSERT SZ 3 6MM IDENTITY IMPRINT PS","SUP-ITM-10283889","CDM","C1713","HCPCS","0278","RC","","","","both","","","4705.71","2823.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3642.22","77.4","","303.98","303.98","5854.79","1 through 10","547.27","3999.85","percent of total billed charges",""
"TIBIAL INSERT SZ 3 6MM IDENTITY IMPRINT PS","SUP-ITM-10283889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","547.27","11.63","","112.68","112.68","146.99","38","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 3 6MM IDENTITY IMPRINT PS","SUP-ITM-10283889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2954.24","62.78","","780.86","208.94","10480.28","15","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 3 6MM IDENTITY IMPRINT PS","SUP-ITM-10283889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2057.34","43.72","","179.76","179.76","179.76","1 through 10","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 3 6MM IDENTITY IMPRINT PS","SUP-ITM-10283889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3421.99","72.72","","2355.45","298.99","3965.19","155","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 3 6MM IDENTITY IMPRINT PS","SUP-ITM-10283889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3421.99","72.72","","3643.09","3643.09","3643.09","1 through 10","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 3 6MM IDENTITY IMPRINT PS","SUP-ITM-10283889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2504.38","53.22","","554.28","554.28","554.28","16","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 3 6MM IDENTITY IMPRINT PS","SUP-ITM-10283889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2959.89","62.9","","619.64","173.09","2370.64","150","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 3 6MM IDENTITY IMPRINT PS","SUP-ITM-10283889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3642.22","77.4","","303.98","303.98","5854.79","1 through 10","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 3N 10MM IDENTITY IMPRINT PS","SUP-ITM-10283928","CDM","C1776","HCPCS","0278","RC","","","","both","","","4705.71","2823.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","547.27","3999.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL INSERT SZ 3N 10MM IDENTITY IMPRINT PS","SUP-ITM-10283928","CDM","C1776","HCPCS","0278","RC","","","","both","","","4705.71","2823.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2677.55","56.9","","2911.53","1863.86","5209.05","65","547.27","3999.85","percent of total billed charges",""
"TIBIAL INSERT SZ 3N 10MM IDENTITY IMPRINT PS","SUP-ITM-10283928","CDM","C1776","HCPCS","0278","RC","","","","both","","","4705.71","2823.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","547.27","11.63","","400.94","400.94","400.94","1 through 10","547.27","3999.85","percent of total billed charges",""
"TIBIAL INSERT SZ 3N 10MM IDENTITY IMPRINT PS","SUP-ITM-10283928","CDM","C1776","HCPCS","0278","RC","","","","both","","","4705.71","2823.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3642.22","77.4","","5214.50","5214.50","16415.28","1 through 10","547.27","3999.85","percent of total billed charges",""
"TIBIAL INSERT SZ 3N 10MM IDENTITY IMPRINT PS","SUP-ITM-10283928","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","547.27","11.63","","400.94","400.94","400.94","1 through 10","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 3N 10MM IDENTITY IMPRINT PS","SUP-ITM-10283928","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2057.34","43.72","","1543.33","1543.33","1671.61","1 through 10","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 3N 10MM IDENTITY IMPRINT PS","SUP-ITM-10283928","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3421.99","72.72","","3700.21","2382.07","6427.18","53","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 3N 10MM IDENTITY IMPRINT PS","SUP-ITM-10283928","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3421.99","72.72","","12685.80","12685.80","12685.80","1 through 10","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 3N 10MM IDENTITY IMPRINT PS","SUP-ITM-10283928","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2959.89","62.9","","3408.87","2784.05","9859.40","46","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 3N 10MM IDENTITY IMPRINT PS","SUP-ITM-10283928","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3642.22","77.4","","5214.50","5214.50","16415.28","1 through 10","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 4 6MM IDENTITY IMPRINT PS","SUP-ITM-10283891","CDM","C1776","HCPCS","0278","RC","","","","both","","","4705.71","2823.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","547.27","3999.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL INSERT SZ 4 6MM IDENTITY IMPRINT PS","SUP-ITM-10283891","CDM","C1776","HCPCS","0278","RC","","","","both","","","4705.71","2823.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2677.55","56.9","","2911.53","1863.86","5209.05","65","547.27","3999.85","percent of total billed charges",""
"TIBIAL INSERT SZ 4 6MM IDENTITY IMPRINT PS","SUP-ITM-10283891","CDM","C1776","HCPCS","0278","RC","","","","both","","","4705.71","2823.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","547.27","11.63","","400.94","400.94","400.94","1 through 10","547.27","3999.85","percent of total billed charges",""
"TIBIAL INSERT SZ 4 6MM IDENTITY IMPRINT PS","SUP-ITM-10283891","CDM","C1776","HCPCS","0278","RC","","","","both","","","4705.71","2823.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3642.22","77.4","","5214.50","5214.50","16415.28","1 through 10","547.27","3999.85","percent of total billed charges",""
"TIBIAL INSERT SZ 4 6MM IDENTITY IMPRINT PS","SUP-ITM-10283891","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","547.27","11.63","","400.94","400.94","400.94","1 through 10","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 4 6MM IDENTITY IMPRINT PS","SUP-ITM-10283891","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2057.34","43.72","","1543.33","1543.33","1671.61","1 through 10","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 4 6MM IDENTITY IMPRINT PS","SUP-ITM-10283891","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3421.99","72.72","","3700.21","2382.07","6427.18","53","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 4 6MM IDENTITY IMPRINT PS","SUP-ITM-10283891","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3421.99","72.72","","12685.80","12685.80","12685.80","1 through 10","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 4 6MM IDENTITY IMPRINT PS","SUP-ITM-10283891","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2959.89","62.9","","3408.87","2784.05","9859.40","46","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 4 6MM IDENTITY IMPRINT PS","SUP-ITM-10283891","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3642.22","77.4","","5214.50","5214.50","16415.28","1 through 10","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 6N 12MM IDENTITY IMPRINT PS","SUP-ITM-10283948","CDM","C1776","HCPCS","0278","RC","","","","both","","","4705.71","2823.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","547.27","3999.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL INSERT SZ 6N 12MM IDENTITY IMPRINT PS","SUP-ITM-10283948","CDM","C1776","HCPCS","0278","RC","","","","both","","","4705.71","2823.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2677.55","56.9","","2911.53","1863.86","5209.05","65","547.27","3999.85","percent of total billed charges",""
"TIBIAL INSERT SZ 6N 12MM IDENTITY IMPRINT PS","SUP-ITM-10283948","CDM","C1776","HCPCS","0278","RC","","","","both","","","4705.71","2823.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","547.27","11.63","","400.94","400.94","400.94","1 through 10","547.27","3999.85","percent of total billed charges",""
"TIBIAL INSERT SZ 6N 12MM IDENTITY IMPRINT PS","SUP-ITM-10283948","CDM","C1776","HCPCS","0278","RC","","","","both","","","4705.71","2823.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3642.22","77.4","","5214.50","5214.50","16415.28","1 through 10","547.27","3999.85","percent of total billed charges",""
"TIBIAL INSERT SZ 6N 12MM IDENTITY IMPRINT PS","SUP-ITM-10283948","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","547.27","11.63","","400.94","400.94","400.94","1 through 10","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 6N 12MM IDENTITY IMPRINT PS","SUP-ITM-10283948","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2057.34","43.72","","1543.33","1543.33","1671.61","1 through 10","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 6N 12MM IDENTITY IMPRINT PS","SUP-ITM-10283948","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3421.99","72.72","","3700.21","2382.07","6427.18","53","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 6N 12MM IDENTITY IMPRINT PS","SUP-ITM-10283948","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3421.99","72.72","","12685.80","12685.80","12685.80","1 through 10","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 6N 12MM IDENTITY IMPRINT PS","SUP-ITM-10283948","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2959.89","62.9","","3408.87","2784.05","9859.40","46","547.27","3642.22","percent of total billed charges",""
"TIBIAL INSERT SZ 6N 12MM IDENTITY IMPRINT PS","SUP-ITM-10283948","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4705.71","2823.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3642.22","77.4","","5214.50","5214.50","16415.28","1 through 10","547.27","3642.22","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","both","","","7778.92","4667.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","904.69","6612.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","both","","","7778.92","4667.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","904.69","6612.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","both","","","7778.92","4667.35","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4426.21","56.9","","812.12","238.65","1587.46","163","904.69","6612.08","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","both","","","7778.92","4667.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","904.69","11.63","","112.68","112.68","146.99","38","904.69","6612.08","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","both","","","7778.92","4667.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6020.88","77.4","","303.98","303.98","5854.79","1 through 10","904.69","6612.08","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7778.92","4667.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","904.69","11.63","","112.68","112.68","146.99","38","904.69","6020.88","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7778.92","4667.35","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4883.61","62.78","","780.86","208.94","10480.28","15","904.69","6020.88","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7778.92","4667.35","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3400.94","43.72","","179.76","179.76","179.76","1 through 10","904.69","6020.88","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7778.92","4667.35","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5656.83","72.72","","2355.45","298.99","3965.19","155","904.69","6020.88","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7778.92","4667.35","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5656.83","72.72","","3643.09","3643.09","3643.09","1 through 10","904.69","6020.88","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7778.92","4667.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4139.94","53.22","","554.28","554.28","554.28","16","904.69","6020.88","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7778.92","4667.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4892.94","62.9","","619.64","173.09","2370.64","150","904.69","6020.88","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 12 H TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7778.92","4667.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6020.88","77.4","","303.98","303.98","5854.79","1 through 10","904.69","6020.88","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 16 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124949","CDM","C1713","HCPCS","0278","RC","","","","both","","","9522.39","5713.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1107.45","8094.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/ 3.5MM 16 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124949","CDM","C1713","HCPCS","0278","RC","","","","both","","","9522.39","5713.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1107.45","8094.03","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/ 3.5MM 16 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124949","CDM","C1713","HCPCS","0278","RC","","","","both","","","9522.39","5713.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5418.24","56.9","","812.12","238.65","1587.46","163","1107.45","8094.03","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 16 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124949","CDM","C1713","HCPCS","0278","RC","","","","both","","","9522.39","5713.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1107.45","11.63","","112.68","112.68","146.99","38","1107.45","8094.03","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 16 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124949","CDM","C1713","HCPCS","0278","RC","","","","both","","","9522.39","5713.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7370.33","77.4","","303.98","303.98","5854.79","1 through 10","1107.45","8094.03","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 16 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9522.39","5713.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1107.45","11.63","","112.68","112.68","146.99","38","1107.45","7370.33","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 16 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9522.39","5713.43","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5978.16","62.78","","780.86","208.94","10480.28","15","1107.45","7370.33","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 16 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9522.39","5713.43","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4163.19","43.72","","179.76","179.76","179.76","1 through 10","1107.45","7370.33","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 16 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9522.39","5713.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6924.68","72.72","","2355.45","298.99","3965.19","155","1107.45","7370.33","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 16 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9522.39","5713.43","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6924.68","72.72","","3643.09","3643.09","3643.09","1 through 10","1107.45","7370.33","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 16 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9522.39","5713.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","5067.82","53.22","","554.28","554.28","554.28","16","1107.45","7370.33","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 16 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9522.39","5713.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5989.58","62.9","","619.64","173.09","2370.64","150","1107.45","7370.33","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 16 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9522.39","5713.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7370.33","77.4","","303.98","303.98","5854.79","1 through 10","1107.45","7370.33","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124945","CDM","C1713","HCPCS","0278","RC","","","","both","","","7261.71","4357.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","844.54","6172.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/ 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124945","CDM","C1713","HCPCS","0278","RC","","","","both","","","7261.71","4357.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","844.54","6172.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/ 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124945","CDM","C1713","HCPCS","0278","RC","","","","both","","","7261.71","4357.03","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4131.91","56.9","","812.12","238.65","1587.46","163","844.54","6172.45","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124945","CDM","C1713","HCPCS","0278","RC","","","","both","","","7261.71","4357.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","844.54","11.63","","112.68","112.68","146.99","38","844.54","6172.45","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124945","CDM","C1713","HCPCS","0278","RC","","","","both","","","7261.71","4357.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5620.56","77.4","","303.98","303.98","5854.79","1 through 10","844.54","6172.45","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7261.71","4357.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","844.54","11.63","","112.68","112.68","146.99","38","844.54","5620.56","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7261.71","4357.03","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4558.90","62.78","","780.86","208.94","10480.28","15","844.54","5620.56","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7261.71","4357.03","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3174.82","43.72","","179.76","179.76","179.76","1 through 10","844.54","5620.56","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7261.71","4357.03","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5280.72","72.72","","2355.45","298.99","3965.19","155","844.54","5620.56","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7261.71","4357.03","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5280.72","72.72","","3643.09","3643.09","3643.09","1 through 10","844.54","5620.56","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7261.71","4357.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3864.68","53.22","","554.28","554.28","554.28","16","844.54","5620.56","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7261.71","4357.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4567.62","62.9","","619.64","173.09","2370.64","150","844.54","5620.56","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 4 HOLE BONE TIBIA VA LCP STAINLESS ANTEROMEDIAL DISTAL RIGHT","SUP-ITM-10124945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7261.71","4357.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5620.56","77.4","","303.98","303.98","5854.79","1 through 10","844.54","5620.56","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","both","","","7334.70","4400.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","853.03","6234.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","both","","","7334.70","4400.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","853.03","6234.5","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","both","","","7334.70","4400.82","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4173.44","56.9","","812.12","238.65","1587.46","163","853.03","6234.5","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","both","","","7334.70","4400.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","853.03","11.63","","112.68","112.68","146.99","38","853.03","6234.5","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","both","","","7334.70","4400.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5677.06","77.4","","303.98","303.98","5854.79","1 through 10","853.03","6234.5","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7334.70","4400.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","853.03","11.63","","112.68","112.68","146.99","38","853.03","5677.06","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7334.70","4400.82","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4604.72","62.78","","780.86","208.94","10480.28","15","853.03","5677.06","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7334.70","4400.82","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3206.73","43.72","","179.76","179.76","179.76","1 through 10","853.03","5677.06","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7334.70","4400.82","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5333.79","72.72","","2355.45","298.99","3965.19","155","853.03","5677.06","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7334.70","4400.82","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5333.79","72.72","","3643.09","3643.09","3643.09","1 through 10","853.03","5677.06","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7334.70","4400.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3903.53","53.22","","554.28","554.28","554.28","16","853.03","5677.06","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7334.70","4400.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4613.53","62.9","","619.64","173.09","2370.64","150","853.03","5677.06","percent of total billed charges",""
"TIBIAL PLATE 2.7/ 3.5MM 6 H BONE VA LCP STAINLESS ANTEROMEDIAL DISTAL TIBIA RIGHT","SUP-ITM-10124946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7334.70","4400.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5677.06","77.4","","303.98","303.98","5854.79","1 through 10","853.03","5677.06","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 10 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124986","CDM","C1713","HCPCS","0278","RC","","","","both","","","7130.32","4278.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","829.26","6060.77","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5MM 10 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124986","CDM","C1713","HCPCS","0278","RC","","","","both","","","7130.32","4278.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","829.26","6060.77","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5MM 10 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124986","CDM","C1713","HCPCS","0278","RC","","","","both","","","7130.32","4278.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4057.15","56.9","","812.12","238.65","1587.46","163","829.26","6060.77","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 10 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124986","CDM","C1713","HCPCS","0278","RC","","","","both","","","7130.32","4278.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","829.26","11.63","","112.68","112.68","146.99","38","829.26","6060.77","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 10 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124986","CDM","C1713","HCPCS","0278","RC","","","","both","","","7130.32","4278.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5518.87","77.4","","303.98","303.98","5854.79","1 through 10","829.26","6060.77","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 10 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7130.32","4278.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","829.26","11.63","","112.68","112.68","146.99","38","829.26","5518.87","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 10 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7130.32","4278.19","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4476.41","62.78","","780.86","208.94","10480.28","15","829.26","5518.87","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 10 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7130.32","4278.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3117.38","43.72","","179.76","179.76","179.76","1 through 10","829.26","5518.87","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 10 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7130.32","4278.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5185.17","72.72","","2355.45","298.99","3965.19","155","829.26","5518.87","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 10 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7130.32","4278.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5185.17","72.72","","3643.09","3643.09","3643.09","1 through 10","829.26","5518.87","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 10 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7130.32","4278.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3794.76","53.22","","554.28","554.28","554.28","16","829.26","5518.87","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 10 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7130.32","4278.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4484.97","62.9","","619.64","173.09","2370.64","150","829.26","5518.87","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 10 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7130.32","4278.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5518.87","77.4","","303.98","303.98","5854.79","1 through 10","829.26","5518.87","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124988","CDM","C1713","HCPCS","0278","RC","","","","both","","","8319.06","4991.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","967.51","7071.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5MM 12 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124988","CDM","C1713","HCPCS","0278","RC","","","","both","","","8319.06","4991.44","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","967.51","7071.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5MM 12 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124988","CDM","C1713","HCPCS","0278","RC","","","","both","","","8319.06","4991.44","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4733.55","56.9","","812.12","238.65","1587.46","163","967.51","7071.2","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124988","CDM","C1713","HCPCS","0278","RC","","","","both","","","8319.06","4991.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","967.51","11.63","","112.68","112.68","146.99","38","967.51","7071.2","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124988","CDM","C1713","HCPCS","0278","RC","","","","both","","","8319.06","4991.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6438.95","77.4","","303.98","303.98","5854.79","1 through 10","967.51","7071.2","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8319.06","4991.44","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","967.51","11.63","","112.68","112.68","146.99","38","967.51","6438.95","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8319.06","4991.44","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5222.71","62.78","","780.86","208.94","10480.28","15","967.51","6438.95","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8319.06","4991.44","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3637.09","43.72","","179.76","179.76","179.76","1 through 10","967.51","6438.95","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8319.06","4991.44","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6049.62","72.72","","2355.45","298.99","3965.19","155","967.51","6438.95","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8319.06","4991.44","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6049.62","72.72","","3643.09","3643.09","3643.09","1 through 10","967.51","6438.95","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8319.06","4991.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4427.40","53.22","","554.28","554.28","554.28","16","967.51","6438.95","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8319.06","4991.44","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5232.69","62.9","","619.64","173.09","2370.64","150","967.51","6438.95","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8319.06","4991.44","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6438.95","77.4","","303.98","303.98","5854.79","1 through 10","967.51","6438.95","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","both","","","7824.80","4694.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","910.02","6651.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","both","","","7824.80","4694.88","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","910.02","6651.08","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","both","","","7824.80","4694.88","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4452.31","56.9","","812.12","238.65","1587.46","163","910.02","6651.08","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","both","","","7824.80","4694.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","910.02","11.63","","112.68","112.68","146.99","38","910.02","6651.08","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","both","","","7824.80","4694.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6056.40","77.4","","303.98","303.98","5854.79","1 through 10","910.02","6651.08","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7824.80","4694.88","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","910.02","11.63","","112.68","112.68","146.99","38","910.02","6056.4","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7824.80","4694.88","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4912.41","62.78","","780.86","208.94","10480.28","15","910.02","6056.4","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7824.80","4694.88","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3421.00","43.72","","179.76","179.76","179.76","1 through 10","910.02","6056.4","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7824.80","4694.88","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5690.19","72.72","","2355.45","298.99","3965.19","155","910.02","6056.4","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7824.80","4694.88","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5690.19","72.72","","3643.09","3643.09","3643.09","1 through 10","910.02","6056.4","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7824.80","4694.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4164.36","53.22","","554.28","554.28","554.28","16","910.02","6056.4","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7824.80","4694.88","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4921.80","62.9","","619.64","173.09","2370.64","150","910.02","6056.4","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 12 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124958","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7824.80","4694.88","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6056.40","77.4","","303.98","303.98","5854.79","1 through 10","910.02","6056.4","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","both","","","8731.99","5239.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1015.53","7422.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","both","","","8731.99","5239.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1015.53","7422.19","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","both","","","8731.99","5239.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4968.50","56.9","","812.12","238.65","1587.46","163","1015.53","7422.19","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","both","","","8731.99","5239.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1015.53","11.63","","112.68","112.68","146.99","38","1015.53","7422.19","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","both","","","8731.99","5239.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6758.56","77.4","","303.98","303.98","5854.79","1 through 10","1015.53","7422.19","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8731.99","5239.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1015.53","11.63","","112.68","112.68","146.99","38","1015.53","6758.56","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8731.99","5239.19","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5481.94","62.78","","780.86","208.94","10480.28","15","1015.53","6758.56","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8731.99","5239.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3817.63","43.72","","179.76","179.76","179.76","1 through 10","1015.53","6758.56","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8731.99","5239.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6349.90","72.72","","2355.45","298.99","3965.19","155","1015.53","6758.56","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8731.99","5239.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6349.90","72.72","","3643.09","3643.09","3643.09","1 through 10","1015.53","6758.56","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8731.99","5239.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4647.17","53.22","","554.28","554.28","554.28","16","1015.53","6758.56","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8731.99","5239.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5492.42","62.9","","619.64","173.09","2370.64","150","1015.53","6758.56","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8731.99","5239.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6758.56","77.4","","303.98","303.98","5854.79","1 through 10","1015.53","6758.56","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124991","CDM","C1713","HCPCS","0278","RC","","","","both","","","9276.30","5565.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1078.83","7884.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124991","CDM","C1713","HCPCS","0278","RC","","","","both","","","9276.30","5565.78","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1078.83","7884.86","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124991","CDM","C1713","HCPCS","0278","RC","","","","both","","","9276.30","5565.78","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5278.21","56.9","","812.12","238.65","1587.46","163","1078.83","7884.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124991","CDM","C1713","HCPCS","0278","RC","","","","both","","","9276.30","5565.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1078.83","11.63","","112.68","112.68","146.99","38","1078.83","7884.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124991","CDM","C1713","HCPCS","0278","RC","","","","both","","","9276.30","5565.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7179.86","77.4","","303.98","303.98","5854.79","1 through 10","1078.83","7884.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9276.30","5565.78","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1078.83","11.63","","112.68","112.68","146.99","38","1078.83","7179.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9276.30","5565.78","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5823.66","62.78","","780.86","208.94","10480.28","15","1078.83","7179.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9276.30","5565.78","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4055.60","43.72","","179.76","179.76","179.76","1 through 10","1078.83","7179.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9276.30","5565.78","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6745.73","72.72","","2355.45","298.99","3965.19","155","1078.83","7179.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9276.30","5565.78","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6745.73","72.72","","3643.09","3643.09","3643.09","1 through 10","1078.83","7179.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9276.30","5565.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4936.85","53.22","","554.28","554.28","554.28","16","1078.83","7179.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9276.30","5565.78","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5834.79","62.9","","619.64","173.09","2370.64","150","1078.83","7179.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 14 HOLE VA LCP SS MEDIAL DISTAL TIBA LEFT","SUP-ITM-10124991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9276.30","5565.78","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7179.86","77.4","","303.98","303.98","5854.79","1 through 10","1078.83","7179.86","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE TIBA VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124992","CDM","C1713","HCPCS","0278","RC","","","","both","","","9509.88","5705.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1106","8083.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5MM 16 HOLE TIBA VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124992","CDM","C1713","HCPCS","0278","RC","","","","both","","","9509.88","5705.93","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1106","8083.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5MM 16 HOLE TIBA VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124992","CDM","C1713","HCPCS","0278","RC","","","","both","","","9509.88","5705.93","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5411.12","56.9","","812.12","238.65","1587.46","163","1106","8083.4","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE TIBA VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124992","CDM","C1713","HCPCS","0278","RC","","","","both","","","9509.88","5705.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1106.00","11.63","","112.68","112.68","146.99","38","1106","8083.4","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE TIBA VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124992","CDM","C1713","HCPCS","0278","RC","","","","both","","","9509.88","5705.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7360.65","77.4","","303.98","303.98","5854.79","1 through 10","1106","8083.4","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE TIBA VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124992","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9509.88","5705.93","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1106.00","11.63","","112.68","112.68","146.99","38","1106","7360.65","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE TIBA VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124992","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9509.88","5705.93","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5970.30","62.78","","780.86","208.94","10480.28","15","1106","7360.65","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE TIBA VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124992","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9509.88","5705.93","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4157.72","43.72","","179.76","179.76","179.76","1 through 10","1106","7360.65","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE TIBA VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124992","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9509.88","5705.93","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6915.58","72.72","","2355.45","298.99","3965.19","155","1106","7360.65","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE TIBA VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124992","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9509.88","5705.93","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6915.58","72.72","","3643.09","3643.09","3643.09","1 through 10","1106","7360.65","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE TIBA VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124992","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9509.88","5705.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","5061.16","53.22","","554.28","554.28","554.28","16","1106","7360.65","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE TIBA VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124992","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9509.88","5705.93","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5981.71","62.9","","619.64","173.09","2370.64","150","1106","7360.65","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE TIBA VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124992","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9509.88","5705.93","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7360.65","77.4","","303.98","303.98","5854.79","1 through 10","1106","7360.65","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL LT","SUP-ITM-10124963","CDM","C1713","HCPCS","0278","RC","","","","both","","","9217.91","5530.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1072.04","7835.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL LT","SUP-ITM-10124963","CDM","C1713","HCPCS","0278","RC","","","","both","","","9217.91","5530.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1072.04","7835.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL LT","SUP-ITM-10124963","CDM","C1713","HCPCS","0278","RC","","","","both","","","9217.91","5530.75","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5244.99","56.9","","812.12","238.65","1587.46","163","1072.04","7835.22","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL LT","SUP-ITM-10124963","CDM","C1713","HCPCS","0278","RC","","","","both","","","9217.91","5530.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1072.04","11.63","","112.68","112.68","146.99","38","1072.04","7835.22","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL LT","SUP-ITM-10124963","CDM","C1713","HCPCS","0278","RC","","","","both","","","9217.91","5530.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7134.66","77.4","","303.98","303.98","5854.79","1 through 10","1072.04","7835.22","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL LT","SUP-ITM-10124963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9217.91","5530.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1072.04","11.63","","112.68","112.68","146.99","38","1072.04","7134.66","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL LT","SUP-ITM-10124963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9217.91","5530.75","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5787.00","62.78","","780.86","208.94","10480.28","15","1072.04","7134.66","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL LT","SUP-ITM-10124963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9217.91","5530.75","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4030.07","43.72","","179.76","179.76","179.76","1 through 10","1072.04","7134.66","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL LT","SUP-ITM-10124963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9217.91","5530.75","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6703.26","72.72","","2355.45","298.99","3965.19","155","1072.04","7134.66","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL LT","SUP-ITM-10124963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9217.91","5530.75","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6703.26","72.72","","3643.09","3643.09","3643.09","1 through 10","1072.04","7134.66","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL LT","SUP-ITM-10124963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9217.91","5530.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4905.77","53.22","","554.28","554.28","554.28","16","1072.04","7134.66","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL LT","SUP-ITM-10124963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9217.91","5530.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5798.07","62.9","","619.64","173.09","2370.64","150","1072.04","7134.66","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL LT","SUP-ITM-10124963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9217.91","5530.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7134.66","77.4","","303.98","303.98","5854.79","1 through 10","1072.04","7134.66","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124962","CDM","C1776","HCPCS","0278","RC","","","","both","","","9217.91","5530.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","1072.04","7835.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124962","CDM","C1776","HCPCS","0278","RC","","","","both","","","9217.91","5530.75","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5244.99","56.9","","2911.53","1863.86","5209.05","65","1072.04","7835.22","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124962","CDM","C1776","HCPCS","0278","RC","","","","both","","","9217.91","5530.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1072.04","11.63","","400.94","400.94","400.94","1 through 10","1072.04","7835.22","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124962","CDM","C1776","HCPCS","0278","RC","","","","both","","","9217.91","5530.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7134.66","77.4","","5214.50","5214.50","16415.28","1 through 10","1072.04","7835.22","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124962","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9217.91","5530.75","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1072.04","11.63","","400.94","400.94","400.94","1 through 10","1072.04","7134.66","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124962","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9217.91","5530.75","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4030.07","43.72","","1543.33","1543.33","1671.61","1 through 10","1072.04","7134.66","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124962","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9217.91","5530.75","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6703.26","72.72","","3700.21","2382.07","6427.18","53","1072.04","7134.66","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124962","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9217.91","5530.75","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6703.26","72.72","","12685.80","12685.80","12685.80","1 through 10","1072.04","7134.66","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124962","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9217.91","5530.75","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5798.07","62.9","","3408.87","2784.05","9859.40","46","1072.04","7134.66","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124962","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9217.91","5530.75","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7134.66","77.4","","5214.50","5214.50","16415.28","1 through 10","1072.04","7134.66","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL RT STERILE","SUP-ITM-10125011","CDM","C1713","HCPCS","0278","RC","","","","both","","","10137.62","6082.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1179.01","8616.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL RT STERILE","SUP-ITM-10125011","CDM","C1713","HCPCS","0278","RC","","","","both","","","10137.62","6082.57","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1179.01","8616.98","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL RT STERILE","SUP-ITM-10125011","CDM","C1713","HCPCS","0278","RC","","","","both","","","10137.62","6082.57","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5768.31","56.9","","812.12","238.65","1587.46","163","1179.01","8616.98","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL RT STERILE","SUP-ITM-10125011","CDM","C1713","HCPCS","0278","RC","","","","both","","","10137.62","6082.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1179.01","11.63","","112.68","112.68","146.99","38","1179.01","8616.98","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL RT STERILE","SUP-ITM-10125011","CDM","C1713","HCPCS","0278","RC","","","","both","","","10137.62","6082.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7846.52","77.4","","303.98","303.98","5854.79","1 through 10","1179.01","8616.98","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL RT STERILE","SUP-ITM-10125011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10137.62","6082.57","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1179.01","11.63","","112.68","112.68","146.99","38","1179.01","7846.52","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL RT STERILE","SUP-ITM-10125011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10137.62","6082.57","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","6364.40","62.78","","780.86","208.94","10480.28","15","1179.01","7846.52","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL RT STERILE","SUP-ITM-10125011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10137.62","6082.57","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4432.17","43.72","","179.76","179.76","179.76","1 through 10","1179.01","7846.52","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL RT STERILE","SUP-ITM-10125011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10137.62","6082.57","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","7372.08","72.72","","2355.45","298.99","3965.19","155","1179.01","7846.52","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL RT STERILE","SUP-ITM-10125011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10137.62","6082.57","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","7372.08","72.72","","3643.09","3643.09","3643.09","1 through 10","1179.01","7846.52","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL RT STERILE","SUP-ITM-10125011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10137.62","6082.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","5395.24","53.22","","554.28","554.28","554.28","16","1179.01","7846.52","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL RT STERILE","SUP-ITM-10125011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10137.62","6082.57","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","6376.56","62.9","","619.64","173.09","2370.64","150","1179.01","7846.52","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 16 HOLE VA LCP SS ANTEROLATERAL DISTAL RT STERILE","SUP-ITM-10125011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10137.62","6082.57","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7846.52","77.4","","303.98","303.98","5854.79","1 through 10","1179.01","7846.52","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 18 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124964","CDM","C1713","HCPCS","0278","RC","","","","both","","","9393.09","5635.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","1092.42","7984.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5MM 18 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124964","CDM","C1713","HCPCS","0278","RC","","","","both","","","9393.09","5635.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","1092.42","7984.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5MM 18 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124964","CDM","C1713","HCPCS","0278","RC","","","","both","","","9393.09","5635.85","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5344.67","56.9","","812.12","238.65","1587.46","163","1092.42","7984.13","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 18 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124964","CDM","C1713","HCPCS","0278","RC","","","","both","","","9393.09","5635.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1092.42","11.63","","112.68","112.68","146.99","38","1092.42","7984.13","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 18 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124964","CDM","C1713","HCPCS","0278","RC","","","","both","","","9393.09","5635.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7270.25","77.4","","303.98","303.98","5854.79","1 through 10","1092.42","7984.13","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 18 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124964","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9393.09","5635.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","1092.42","11.63","","112.68","112.68","146.99","38","1092.42","7270.25","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 18 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124964","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9393.09","5635.85","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5896.98","62.78","","780.86","208.94","10480.28","15","1092.42","7270.25","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 18 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124964","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9393.09","5635.85","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","4106.66","43.72","","179.76","179.76","179.76","1 through 10","1092.42","7270.25","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 18 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124964","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9393.09","5635.85","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6830.66","72.72","","2355.45","298.99","3965.19","155","1092.42","7270.25","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 18 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124964","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9393.09","5635.85","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6830.66","72.72","","3643.09","3643.09","3643.09","1 through 10","1092.42","7270.25","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 18 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124964","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9393.09","5635.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4999.00","53.22","","554.28","554.28","554.28","16","1092.42","7270.25","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 18 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124964","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9393.09","5635.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5908.25","62.9","","619.64","173.09","2370.64","150","1092.42","7270.25","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 18 HOLE VA LCP SS ANTEROLATERAL DISTAL RT","SUP-ITM-10124964","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9393.09","5635.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","7270.25","77.4","","303.98","303.98","5854.79","1 through 10","1092.42","7270.25","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 4 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124931","CDM","C1713","HCPCS","0278","RC","","","","both","","","6907.18","4144.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","803.31","5871.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5MM 4 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124931","CDM","C1713","HCPCS","0278","RC","","","","both","","","6907.18","4144.31","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","803.31","5871.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5MM 4 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124931","CDM","C1713","HCPCS","0278","RC","","","","both","","","6907.18","4144.31","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3930.19","56.9","","812.12","238.65","1587.46","163","803.31","5871.1","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 4 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124931","CDM","C1713","HCPCS","0278","RC","","","","both","","","6907.18","4144.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","803.31","11.63","","112.68","112.68","146.99","38","803.31","5871.1","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 4 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124931","CDM","C1713","HCPCS","0278","RC","","","","both","","","6907.18","4144.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5346.16","77.4","","303.98","303.98","5854.79","1 through 10","803.31","5871.1","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 4 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6907.18","4144.31","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","803.31","11.63","","112.68","112.68","146.99","38","803.31","5346.16","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 4 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6907.18","4144.31","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4336.33","62.78","","780.86","208.94","10480.28","15","803.31","5346.16","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 4 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6907.18","4144.31","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3019.82","43.72","","179.76","179.76","179.76","1 through 10","803.31","5346.16","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 4 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6907.18","4144.31","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5022.90","72.72","","2355.45","298.99","3965.19","155","803.31","5346.16","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 4 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6907.18","4144.31","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5022.90","72.72","","3643.09","3643.09","3643.09","1 through 10","803.31","5346.16","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 4 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6907.18","4144.31","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3676.00","53.22","","554.28","554.28","554.28","16","803.31","5346.16","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 4 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6907.18","4144.31","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4344.62","62.9","","619.64","173.09","2370.64","150","803.31","5346.16","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 4 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6907.18","4144.31","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5346.16","77.4","","303.98","303.98","5854.79","1 through 10","803.31","5346.16","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 6 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124933","CDM","C1713","HCPCS","0278","RC","","","","both","","","6984.34","4190.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","812.28","5936.69","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5MM 6 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124933","CDM","C1713","HCPCS","0278","RC","","","","both","","","6984.34","4190.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","812.28","5936.69","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5MM 6 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124933","CDM","C1713","HCPCS","0278","RC","","","","both","","","6984.34","4190.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3974.09","56.9","","812.12","238.65","1587.46","163","812.28","5936.69","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 6 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124933","CDM","C1713","HCPCS","0278","RC","","","","both","","","6984.34","4190.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","812.28","11.63","","112.68","112.68","146.99","38","812.28","5936.69","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 6 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124933","CDM","C1713","HCPCS","0278","RC","","","","both","","","6984.34","4190.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5405.88","77.4","","303.98","303.98","5854.79","1 through 10","812.28","5936.69","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 6 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6984.34","4190.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","812.28","11.63","","112.68","112.68","146.99","38","812.28","5405.88","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 6 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6984.34","4190.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4384.77","62.78","","780.86","208.94","10480.28","15","812.28","5405.88","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 6 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6984.34","4190.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3053.55","43.72","","179.76","179.76","179.76","1 through 10","812.28","5405.88","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 6 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6984.34","4190.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5079.01","72.72","","2355.45","298.99","3965.19","155","812.28","5405.88","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 6 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6984.34","4190.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5079.01","72.72","","3643.09","3643.09","3643.09","1 through 10","812.28","5405.88","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 6 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6984.34","4190.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3717.07","53.22","","554.28","554.28","554.28","16","812.28","5405.88","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 6 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6984.34","4190.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4393.15","62.9","","619.64","173.09","2370.64","150","812.28","5405.88","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5MM 6 HOLE VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6984.34","4190.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5405.88","77.4","","303.98","303.98","5854.79","1 through 10","812.28","5405.88","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","both","","","8433.76","5060.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","980.85","7168.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","both","","","8433.76","5060.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","980.85","7168.7","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","both","","","8433.76","5060.26","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4798.81","56.9","","812.12","238.65","1587.46","163","980.85","7168.7","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","both","","","8433.76","5060.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","980.85","11.63","","112.68","112.68","146.99","38","980.85","7168.7","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","both","","","8433.76","5060.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6527.73","77.4","","303.98","303.98","5854.79","1 through 10","980.85","7168.7","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8433.76","5060.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","980.85","11.63","","112.68","112.68","146.99","38","980.85","6527.73","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8433.76","5060.26","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","5294.71","62.78","","780.86","208.94","10480.28","15","980.85","6527.73","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8433.76","5060.26","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3687.24","43.72","","179.76","179.76","179.76","1 through 10","980.85","6527.73","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8433.76","5060.26","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","6133.03","72.72","","2355.45","298.99","3965.19","155","980.85","6527.73","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8433.76","5060.26","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","6133.03","72.72","","3643.09","3643.09","3643.09","1 through 10","980.85","6527.73","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8433.76","5060.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","4488.45","53.22","","554.28","554.28","554.28","16","980.85","6527.73","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8433.76","5060.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5304.84","62.9","","619.64","173.09","2370.64","150","980.85","6527.73","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X262MM 14 HOLE L VA LCP SS MEDIAL DISTAL RIGHT","SUP-ITM-10124941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8433.76","5060.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6527.73","77.4","","303.98","303.98","5854.79","1 through 10","980.85","6527.73","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","both","","","6681.94","4009.16","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","777.11","5679.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","both","","","6681.94","4009.16","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","777.11","5679.65","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","both","","","6681.94","4009.16","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3802.02","56.9","","812.12","238.65","1587.46","163","777.11","5679.65","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","both","","","6681.94","4009.16","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","777.11","11.63","","112.68","112.68","146.99","38","777.11","5679.65","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","both","","","6681.94","4009.16","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5171.82","77.4","","303.98","303.98","5854.79","1 through 10","777.11","5679.65","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6681.94","4009.16","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","777.11","11.63","","112.68","112.68","146.99","38","777.11","5171.82","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6681.94","4009.16","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4194.92","62.78","","780.86","208.94","10480.28","15","777.11","5171.82","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6681.94","4009.16","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2921.34","43.72","","179.76","179.76","179.76","1 through 10","777.11","5171.82","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6681.94","4009.16","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4859.11","72.72","","2355.45","298.99","3965.19","155","777.11","5171.82","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6681.94","4009.16","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4859.11","72.72","","3643.09","3643.09","3643.09","1 through 10","777.11","5171.82","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6681.94","4009.16","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3556.13","53.22","","554.28","554.28","554.28","16","777.11","5171.82","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6681.94","4009.16","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4202.94","62.9","","619.64","173.09","2370.64","150","777.11","5171.82","percent of total billed charges",""
"TIBIAL PLATE 2.7/3.5X82MM 4 HOLE VA LCP SS ANTEROLATERAL DISTAL RIGHT","SUP-ITM-10124950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6681.94","4009.16","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5171.82","77.4","","303.98","303.98","5854.79","1 through 10","777.11","5171.82","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /4 H /87 LG LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125102","CDM","C1713","HCPCS","0278","RC","","","","both","","","6538.04","3922.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","760.37","5557.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 3.5MM /4 H /87 LG LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125102","CDM","C1713","HCPCS","0278","RC","","","","both","","","6538.04","3922.82","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","760.37","5557.33","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 3.5MM /4 H /87 LG LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125102","CDM","C1713","HCPCS","0278","RC","","","","both","","","6538.04","3922.82","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3720.14","56.9","","812.12","238.65","1587.46","163","760.37","5557.33","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /4 H /87 LG LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125102","CDM","C1713","HCPCS","0278","RC","","","","both","","","6538.04","3922.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","760.37","11.63","","112.68","112.68","146.99","38","760.37","5557.33","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /4 H /87 LG LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125102","CDM","C1713","HCPCS","0278","RC","","","","both","","","6538.04","3922.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5060.44","77.4","","303.98","303.98","5854.79","1 through 10","760.37","5557.33","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /4 H /87 LG LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6538.04","3922.82","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","760.37","11.63","","112.68","112.68","146.99","38","760.37","5060.44","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /4 H /87 LG LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6538.04","3922.82","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4104.58","62.78","","780.86","208.94","10480.28","15","760.37","5060.44","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /4 H /87 LG LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6538.04","3922.82","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2858.43","43.72","","179.76","179.76","179.76","1 through 10","760.37","5060.44","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /4 H /87 LG LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6538.04","3922.82","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4754.46","72.72","","2355.45","298.99","3965.19","155","760.37","5060.44","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /4 H /87 LG LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6538.04","3922.82","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4754.46","72.72","","3643.09","3643.09","3643.09","1 through 10","760.37","5060.44","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /4 H /87 LG LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6538.04","3922.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3479.54","53.22","","554.28","554.28","554.28","16","760.37","5060.44","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /4 H /87 LG LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6538.04","3922.82","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4112.43","62.9","","619.64","173.09","2370.64","150","760.37","5060.44","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /4 H /87 LG LCP STAINLESS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125102","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6538.04","3922.82","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5060.44","77.4","","303.98","303.98","5854.79","1 through 10","760.37","5060.44","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","both","","","6382.50","3829.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","742.28","5425.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","both","","","6382.50","3829.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3631.64","56.9","","2911.53","1863.86","5209.05","65","742.28","5425.13","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","both","","","6382.50","3829.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","742.28","11.63","","400.94","400.94","400.94","1 through 10","742.28","5425.13","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","both","","","6382.50","3829.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4940.06","77.4","","5214.50","5214.50","16415.28","1 through 10","742.28","5425.13","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6382.50","3829.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","742.28","11.63","","400.94","400.94","400.94","1 through 10","742.28","4940.06","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6382.50","3829.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2790.43","43.72","","1543.33","1543.33","1671.61","1 through 10","742.28","4940.06","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6382.50","3829.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4641.35","72.72","","3700.21","2382.07","6427.18","53","742.28","4940.06","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6382.50","3829.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4641.35","72.72","","12685.80","12685.80","12685.80","1 through 10","742.28","4940.06","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6382.50","3829.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4014.59","62.9","","3408.87","2784.05","9859.40","46","742.28","4940.06","percent of total billed charges",""
"TIBIAL PLATE 3.5MM /6 H /117 SM 6H LCP STAINLESS VARIABLE ANGLE BEND IMAL LEFT","SUP-ITM-10125093","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6382.50","3829.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4940.06","77.4","","5214.50","5214.50","16415.28","1 through 10","742.28","4940.06","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 1 H 69 BONE TIBIA PROXIMAL POSTEROMEDIAL LCP TI","SUP-ITM-10096115","CDM","C1713","HCPCS","0278","RC","","","","both","","","6414.76","3848.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","746.04","5452.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 3.5MM 1 H 69 BONE TIBIA PROXIMAL POSTEROMEDIAL LCP TI","SUP-ITM-10096115","CDM","C1713","HCPCS","0278","RC","","","","both","","","6414.76","3848.86","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","746.04","5452.55","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 3.5MM 1 H 69 BONE TIBIA PROXIMAL POSTEROMEDIAL LCP TI","SUP-ITM-10096115","CDM","C1713","HCPCS","0278","RC","","","","both","","","6414.76","3848.86","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3650.00","56.9","","812.12","238.65","1587.46","163","746.04","5452.55","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 1 H 69 BONE TIBIA PROXIMAL POSTEROMEDIAL LCP TI","SUP-ITM-10096115","CDM","C1713","HCPCS","0278","RC","","","","both","","","6414.76","3848.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","746.04","11.63","","112.68","112.68","146.99","38","746.04","5452.55","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 1 H 69 BONE TIBIA PROXIMAL POSTEROMEDIAL LCP TI","SUP-ITM-10096115","CDM","C1713","HCPCS","0278","RC","","","","both","","","6414.76","3848.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4965.02","77.4","","303.98","303.98","5854.79","1 through 10","746.04","5452.55","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 1 H 69 BONE TIBIA PROXIMAL POSTEROMEDIAL LCP TI","SUP-ITM-10096115","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6414.76","3848.86","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","746.04","11.63","","112.68","112.68","146.99","38","746.04","4965.02","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 1 H 69 BONE TIBIA PROXIMAL POSTEROMEDIAL LCP TI","SUP-ITM-10096115","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6414.76","3848.86","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4027.19","62.78","","780.86","208.94","10480.28","15","746.04","4965.02","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 1 H 69 BONE TIBIA PROXIMAL POSTEROMEDIAL LCP TI","SUP-ITM-10096115","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6414.76","3848.86","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2804.53","43.72","","179.76","179.76","179.76","1 through 10","746.04","4965.02","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 1 H 69 BONE TIBIA PROXIMAL POSTEROMEDIAL LCP TI","SUP-ITM-10096115","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6414.76","3848.86","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4664.81","72.72","","2355.45","298.99","3965.19","155","746.04","4965.02","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 1 H 69 BONE TIBIA PROXIMAL POSTEROMEDIAL LCP TI","SUP-ITM-10096115","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6414.76","3848.86","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4664.81","72.72","","3643.09","3643.09","3643.09","1 through 10","746.04","4965.02","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 1 H 69 BONE TIBIA PROXIMAL POSTEROMEDIAL LCP TI","SUP-ITM-10096115","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6414.76","3848.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3413.94","53.22","","554.28","554.28","554.28","16","746.04","4965.02","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 1 H 69 BONE TIBIA PROXIMAL POSTEROMEDIAL LCP TI","SUP-ITM-10096115","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6414.76","3848.86","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4034.88","62.9","","619.64","173.09","2370.64","150","746.04","4965.02","percent of total billed charges",""
"TIBIAL PLATE 3.5MM 1 H 69 BONE TIBIA PROXIMAL POSTEROMEDIAL LCP TI","SUP-ITM-10096115","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6414.76","3848.86","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4965.02","77.4","","303.98","303.98","5854.79","1 through 10","746.04","4965.02","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","both","","","6382.50","3829.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","742.28","5425.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","both","","","6382.50","3829.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","742.28","5425.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","both","","","6382.50","3829.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3631.64","56.9","","812.12","238.65","1587.46","163","742.28","5425.13","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","both","","","6382.50","3829.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","742.28","11.63","","112.68","112.68","146.99","38","742.28","5425.13","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","both","","","6382.50","3829.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4940.06","77.4","","303.98","303.98","5854.79","1 through 10","742.28","5425.13","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6382.50","3829.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","742.28","11.63","","112.68","112.68","146.99","38","742.28","4940.06","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6382.50","3829.50","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4006.93","62.78","","780.86","208.94","10480.28","15","742.28","4940.06","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6382.50","3829.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2790.43","43.72","","179.76","179.76","179.76","1 through 10","742.28","4940.06","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6382.50","3829.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4641.35","72.72","","2355.45","298.99","3965.19","155","742.28","4940.06","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6382.50","3829.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4641.35","72.72","","3643.09","3643.09","3643.09","1 through 10","742.28","4940.06","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6382.50","3829.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3396.77","53.22","","554.28","554.28","554.28","16","742.28","4940.06","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6382.50","3829.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4014.59","62.9","","619.64","173.09","2370.64","150","742.28","4940.06","percent of total billed charges",""
"TIBIAL PLATE 3.5X117MM SM 6 HOLE LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10117060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6382.50","3829.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4940.06","77.4","","303.98","303.98","5854.79","1 through 10","742.28","4940.06","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","both","","","5587.64","3352.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","649.84","4749.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","both","","","5587.64","3352.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","649.84","4749.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","both","","","5587.64","3352.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3179.37","56.9","","812.12","238.65","1587.46","163","649.84","4749.49","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","both","","","5587.64","3352.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","649.84","11.63","","112.68","112.68","146.99","38","649.84","4749.49","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","both","","","5587.64","3352.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4324.83","77.4","","303.98","303.98","5854.79","1 through 10","649.84","4749.49","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5587.64","3352.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","649.84","11.63","","112.68","112.68","146.99","38","649.84","4324.83","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5587.64","3352.58","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3507.92","62.78","","780.86","208.94","10480.28","15","649.84","4324.83","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5587.64","3352.58","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2442.92","43.72","","179.76","179.76","179.76","1 through 10","649.84","4324.83","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5587.64","3352.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4063.33","72.72","","2355.45","298.99","3965.19","155","649.84","4324.83","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5587.64","3352.58","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4063.33","72.72","","3643.09","3643.09","3643.09","1 through 10","649.84","4324.83","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5587.64","3352.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2973.74","53.22","","554.28","554.28","554.28","16","649.84","4324.83","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5587.64","3352.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3514.63","62.9","","619.64","173.09","2370.64","150","649.84","4324.83","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE LCP SS MEDIAL PROXIMAL RIGHT","SUP-ITM-10021419","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5587.64","3352.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4324.83","77.4","","303.98","303.98","5854.79","1 through 10","649.84","4324.83","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","6246.07","3747.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","726.42","5309.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","6246.07","3747.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","726.42","5309.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","6246.07","3747.64","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3554.01","56.9","","812.12","238.65","1587.46","163","726.42","5309.16","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","6246.07","3747.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","726.42","11.63","","112.68","112.68","146.99","38","726.42","5309.16","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","6246.07","3747.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4834.46","77.4","","303.98","303.98","5854.79","1 through 10","726.42","5309.16","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6246.07","3747.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","726.42","11.63","","112.68","112.68","146.99","38","726.42","4834.46","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6246.07","3747.64","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3921.28","62.78","","780.86","208.94","10480.28","15","726.42","4834.46","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6246.07","3747.64","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2730.78","43.72","","179.76","179.76","179.76","1 through 10","726.42","4834.46","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6246.07","3747.64","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4542.14","72.72","","2355.45","298.99","3965.19","155","726.42","4834.46","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6246.07","3747.64","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4542.14","72.72","","3643.09","3643.09","3643.09","1 through 10","726.42","4834.46","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6246.07","3747.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3324.16","53.22","","554.28","554.28","554.28","16","726.42","4834.46","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6246.07","3747.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3928.78","62.9","","619.64","173.09","2370.64","150","726.42","4834.46","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6246.07","3747.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4834.46","77.4","","303.98","303.98","5854.79","1 through 10","726.42","4834.46","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","both","","","6446.28","3867.77","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","749.7","5479.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","both","","","6446.28","3867.77","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","749.7","5479.34","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","both","","","6446.28","3867.77","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3667.93","56.9","","812.12","238.65","1587.46","163","749.7","5479.34","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","both","","","6446.28","3867.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","749.70","11.63","","112.68","112.68","146.99","38","749.7","5479.34","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","both","","","6446.28","3867.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4989.42","77.4","","303.98","303.98","5854.79","1 through 10","749.7","5479.34","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6446.28","3867.77","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","749.70","11.63","","112.68","112.68","146.99","38","749.7","4989.42","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6446.28","3867.77","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4046.97","62.78","","780.86","208.94","10480.28","15","749.7","4989.42","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6446.28","3867.77","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2818.31","43.72","","179.76","179.76","179.76","1 through 10","749.7","4989.42","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6446.28","3867.77","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4687.73","72.72","","2355.45","298.99","3965.19","155","749.7","4989.42","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6446.28","3867.77","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4687.73","72.72","","3643.09","3643.09","3643.09","1 through 10","749.7","4989.42","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6446.28","3867.77","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3430.71","53.22","","554.28","554.28","554.28","16","749.7","4989.42","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6446.28","3867.77","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4054.71","62.9","","619.64","173.09","2370.64","150","749.7","4989.42","percent of total billed charges",""
"TIBIAL PLATE 3.5X145MM 8 HOLE PROXIMALIMAL MEDIAL LCP SS LEFT","SUP-ITM-10021422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6446.28","3867.77","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4989.42","77.4","","303.98","303.98","5854.79","1 through 10","749.7","4989.42","percent of total billed charges",""
"TIBIAL PLATE 3.5X177MM SM 10 HOLE L LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125096","CDM","C1776","HCPCS","0278","RC","","","","both","","","8016.66","4810.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","932.34","6814.16","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 3.5X177MM SM 10 HOLE L LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125096","CDM","C1776","HCPCS","0278","RC","","","","both","","","8016.66","4810.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4561.48","56.9","","2911.53","1863.86","5209.05","65","932.34","6814.16","percent of total billed charges",""
"TIBIAL PLATE 3.5X177MM SM 10 HOLE L LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125096","CDM","C1776","HCPCS","0278","RC","","","","both","","","8016.66","4810.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","932.34","11.63","","400.94","400.94","400.94","1 through 10","932.34","6814.16","percent of total billed charges",""
"TIBIAL PLATE 3.5X177MM SM 10 HOLE L LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125096","CDM","C1776","HCPCS","0278","RC","","","","both","","","8016.66","4810.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6204.89","77.4","","5214.50","5214.50","16415.28","1 through 10","932.34","6814.16","percent of total billed charges",""
"TIBIAL PLATE 3.5X177MM SM 10 HOLE L LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125096","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8016.66","4810.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","932.34","11.63","","400.94","400.94","400.94","1 through 10","932.34","6204.89","percent of total billed charges",""
"TIBIAL PLATE 3.5X177MM SM 10 HOLE L LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125096","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8016.66","4810.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3504.88","43.72","","1543.33","1543.33","1671.61","1 through 10","932.34","6204.89","percent of total billed charges",""
"TIBIAL PLATE 3.5X177MM SM 10 HOLE L LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125096","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8016.66","4810.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5829.72","72.72","","3700.21","2382.07","6427.18","53","932.34","6204.89","percent of total billed charges",""
"TIBIAL PLATE 3.5X177MM SM 10 HOLE L LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125096","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8016.66","4810.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","5829.72","72.72","","12685.80","12685.80","12685.80","1 through 10","932.34","6204.89","percent of total billed charges",""
"TIBIAL PLATE 3.5X177MM SM 10 HOLE L LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125096","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8016.66","4810.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5042.48","62.9","","3408.87","2784.05","9859.40","46","932.34","6204.89","percent of total billed charges",""
"TIBIAL PLATE 3.5X177MM SM 10 HOLE L LCP SS VARIABLE ANGLE BEND IMAL RIGHT","SUP-ITM-10125096","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8016.66","4810.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6204.89","77.4","","5214.50","5214.50","16415.28","1 through 10","932.34","6204.89","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","both","","","5513.43","3308.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","641.21","4686.42","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","both","","","5513.43","3308.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","641.21","4686.42","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","both","","","5513.43","3308.06","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3137.14","56.9","","812.12","238.65","1587.46","163","641.21","4686.42","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","both","","","5513.43","3308.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","641.21","11.63","","112.68","112.68","146.99","38","641.21","4686.42","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","both","","","5513.43","3308.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4267.39","77.4","","303.98","303.98","5854.79","1 through 10","641.21","4686.42","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5513.43","3308.06","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","641.21","11.63","","112.68","112.68","146.99","38","641.21","4267.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5513.43","3308.06","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3461.33","62.78","","780.86","208.94","10480.28","15","641.21","4267.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5513.43","3308.06","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2410.47","43.72","","179.76","179.76","179.76","1 through 10","641.21","4267.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5513.43","3308.06","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4009.37","72.72","","2355.45","298.99","3965.19","155","641.21","4267.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5513.43","3308.06","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4009.37","72.72","","3643.09","3643.09","3643.09","1 through 10","641.21","4267.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5513.43","3308.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2934.25","53.22","","554.28","554.28","554.28","16","641.21","4267.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5513.43","3308.06","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3467.95","62.9","","619.64","173.09","2370.64","150","641.21","4267.39","percent of total billed charges",""
"TIBIAL PLATE 3.5X94MM 4 HOLE LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10021418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5513.43","3308.06","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4267.39","77.4","","303.98","303.98","5854.79","1 through 10","641.21","4267.39","percent of total billed charges",""
"TIBIAL TRAY ITOTAL IDENTITY PS TI","SUP-ITM-10281671","CDM","C1776","HCPCS","0278","RC","","","","both","","","4956.70","2974.02","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","576.46","4213.2","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIBIAL TRAY ITOTAL IDENTITY PS TI","SUP-ITM-10281671","CDM","C1776","HCPCS","0278","RC","","","","both","","","4956.70","2974.02","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2820.36","56.9","","2911.53","1863.86","5209.05","65","576.46","4213.2","percent of total billed charges",""
"TIBIAL TRAY ITOTAL IDENTITY PS TI","SUP-ITM-10281671","CDM","C1776","HCPCS","0278","RC","","","","both","","","4956.70","2974.02","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","576.46","11.63","","400.94","400.94","400.94","1 through 10","576.46","4213.2","percent of total billed charges",""
"TIBIAL TRAY ITOTAL IDENTITY PS TI","SUP-ITM-10281671","CDM","C1776","HCPCS","0278","RC","","","","both","","","4956.70","2974.02","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3836.49","77.4","","5214.50","5214.50","16415.28","1 through 10","576.46","4213.2","percent of total billed charges",""
"TIBIAL TRAY ITOTAL IDENTITY PS TI","SUP-ITM-10281671","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4956.70","2974.02","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","576.46","11.63","","400.94","400.94","400.94","1 through 10","576.46","3836.49","percent of total billed charges",""
"TIBIAL TRAY ITOTAL IDENTITY PS TI","SUP-ITM-10281671","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4956.70","2974.02","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2167.07","43.72","","1543.33","1543.33","1671.61","1 through 10","576.46","3836.49","percent of total billed charges",""
"TIBIAL TRAY ITOTAL IDENTITY PS TI","SUP-ITM-10281671","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4956.70","2974.02","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3604.51","72.72","","3700.21","2382.07","6427.18","53","576.46","3836.49","percent of total billed charges",""
"TIBIAL TRAY ITOTAL IDENTITY PS TI","SUP-ITM-10281671","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4956.70","2974.02","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3604.51","72.72","","12685.80","12685.80","12685.80","1 through 10","576.46","3836.49","percent of total billed charges",""
"TIBIAL TRAY ITOTAL IDENTITY PS TI","SUP-ITM-10281671","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4956.70","2974.02","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3117.76","62.9","","3408.87","2784.05","9859.40","46","576.46","3836.49","percent of total billed charges",""
"TIBIAL TRAY ITOTAL IDENTITY PS TI","SUP-ITM-10281671","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4956.70","2974.02","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3836.49","77.4","","5214.50","5214.50","16415.28","1 through 10","576.46","3836.49","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.41","44.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","8.54","62.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.41","44.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","8.54","62.4","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.41","44.05","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","41.77","56.9","","812.12","238.65","1587.46","163","8.54","62.4","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.41","44.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","8.54","11.63","","112.68","112.68","146.99","38","8.54","62.4","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.41","44.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","56.82","77.4","","303.98","303.98","5854.79","1 through 10","8.54","62.4","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.41","44.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","8.54","11.63","","112.68","112.68","146.99","38","8.54","56.82","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.41","44.05","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","46.09","62.78","","780.86","208.94","10480.28","15","8.54","56.82","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.41","44.05","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","32.09","43.72","","179.76","179.76","179.76","1 through 10","8.54","56.82","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.41","44.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","53.38","72.72","","2355.45","298.99","3965.19","155","8.54","56.82","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.41","44.05","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","53.38","72.72","","3643.09","3643.09","3643.09","1 through 10","8.54","56.82","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.41","44.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","39.07","53.22","","554.28","554.28","554.28","16","8.54","56.82","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.41","44.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","46.17","62.9","","619.64","173.09","2370.64","150","8.54","56.82","percent of total billed charges",""
"TIP THREADED 1.25 150MM LG WIRE FIXATION REDUCTION PLATE SS STOP PK/10EA","SUP-ITM-10096782","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.41","44.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","56.82","77.4","","303.98","303.98","5854.79","1 through 10","8.54","56.82","percent of total billed charges",""
"TIP THREADED 1.25MMX150 SM WIRE PLATE REDUCTION SS STOP PK/10EA","SUP-ITM-10096781","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.88","68.33","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","13.24","96.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIP THREADED 1.25MMX150 SM WIRE PLATE REDUCTION SS STOP PK/10EA","SUP-ITM-10096781","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.88","68.33","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","13.24","96.8","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TIP THREADED 1.25MMX150 SM WIRE PLATE REDUCTION SS STOP PK/10EA","SUP-ITM-10096781","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.88","68.33","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","64.80","56.9","","812.12","238.65","1587.46","163","13.24","96.8","percent of total billed charges",""
"TIP THREADED 1.25MMX150 SM WIRE PLATE REDUCTION SS STOP PK/10EA","SUP-ITM-10096781","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.88","68.33","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","13.24","11.63","","112.68","112.68","146.99","38","13.24","96.8","percent of total billed charges",""
"TIP THREADED 1.25MMX150 SM WIRE PLATE REDUCTION SS STOP PK/10EA","SUP-ITM-10096781","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.88","68.33","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","88.14","77.4","","303.98","303.98","5854.79","1 through 10","13.24","96.8","percent of total billed charges",""
"TIP THREADED 1.25MMX150 SM WIRE PLATE REDUCTION SS STOP PK/10EA","SUP-ITM-10096781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.88","68.33","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","13.24","11.63","","112.68","112.68","146.99","38","13.24","88.14","percent of total billed charges",""
"TIP THREADED 1.25MMX150 SM WIRE PLATE REDUCTION SS STOP PK/10EA","SUP-ITM-10096781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.88","68.33","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","71.49","62.78","","780.86","208.94","10480.28","15","13.24","88.14","percent of total billed charges",""
"TIP THREADED 1.25MMX150 SM WIRE PLATE REDUCTION SS STOP PK/10EA","SUP-ITM-10096781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.88","68.33","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","49.79","43.72","","179.76","179.76","179.76","1 through 10","13.24","88.14","percent of total billed charges",""
"TIP THREADED 1.25MMX150 SM WIRE PLATE REDUCTION SS STOP PK/10EA","SUP-ITM-10096781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.88","68.33","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","82.81","72.72","","2355.45","298.99","3965.19","155","13.24","88.14","percent of total billed charges",""
"TIP THREADED 1.25MMX150 SM WIRE PLATE REDUCTION SS STOP PK/10EA","SUP-ITM-10096781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.88","68.33","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","82.81","72.72","","3643.09","3643.09","3643.09","1 through 10","13.24","88.14","percent of total billed charges",""
"TIP THREADED 1.25MMX150 SM WIRE PLATE REDUCTION SS STOP PK/10EA","SUP-ITM-10096781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.88","68.33","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","60.61","53.22","","554.28","554.28","554.28","16","13.24","88.14","percent of total billed charges",""
"TIP THREADED 1.25MMX150 SM WIRE PLATE REDUCTION SS STOP PK/10EA","SUP-ITM-10096781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.88","68.33","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","71.63","62.9","","619.64","173.09","2370.64","150","13.24","88.14","percent of total billed charges",""
"TIP THREADED 1.25MMX150 SM WIRE PLATE REDUCTION SS STOP PK/10EA","SUP-ITM-10096781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.88","68.33","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","88.14","77.4","","303.98","303.98","5854.79","1 through 10","13.24","88.14","percent of total billed charges",""
"TISSUE ALLOGRAFT RIGHT MEDIAL FEMORAL CONDYLE","SUP-ITM-10118282","CDM","C1889","HCPCS","0278","RC","","","","both","","","27857.44","16714.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","3239.82","23678.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TISSUE ALLOGRAFT RIGHT MEDIAL FEMORAL CONDYLE","SUP-ITM-10118282","CDM","C1889","HCPCS","0278","RC","","","","both","","","27857.44","16714.46","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","3239.82","23678.82","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TISSUE ALLOGRAFT RIGHT MEDIAL FEMORAL CONDYLE","SUP-ITM-10118282","CDM","C1889","HCPCS","0278","RC","","","","both","","","27857.44","16714.46","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","15850.88","56.9","","0.63","0.63","0.63","1 through 10","3239.82","23678.82","percent of total billed charges",""
"TISSUE ALLOGRAFT RIGHT MEDIAL FEMORAL CONDYLE","SUP-ITM-10118282","CDM","C1889","HCPCS","0278","RC","","","","both","","","27857.44","16714.46","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","4017.04","14.42","","317.14","317.14","317.14","1 through 10","3239.82","23678.82","percent of total billed charges",""
"TISSUE ALLOGRAFT RIGHT MEDIAL FEMORAL CONDYLE","SUP-ITM-10118282","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","27857.44","16714.46","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","4017.04","14.42","","317.14","317.14","317.14","1 through 10","3239.82","21561.66","percent of total billed charges",""
"TISSUE ALLOGRAFT RIGHT MEDIAL FEMORAL CONDYLE","SUP-ITM-10118282","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","27857.44","16714.46","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","17488.90","62.78","","1125.09","1125.09","1125.09","1 through 10","3239.82","21561.66","percent of total billed charges",""
"TISSUE ALLOGRAFT RIGHT MEDIAL FEMORAL CONDYLE","SUP-ITM-10118282","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","27857.44","16714.46","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","20257.93","72.72","","4732.50","1617.43","14180.40","1 through 10","3239.82","21561.66","percent of total billed charges",""
"TISSUE ALLOGRAFT RIGHT MEDIAL FEMORAL CONDYLE","SUP-ITM-10118282","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","27857.44","16714.46","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","17522.33","62.9","","3896.20","3341.38","3896.20","1 through 10","3239.82","21561.66","percent of total billed charges",""
"Tissue Culture Lymphocyte Analysi","PX-31000107","CDM","88230","CPT","0311","RC","","","","both","","","1376.00","825.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","960.45","69.8","","929.04","929.04","929.04","1 through 10","75.72","1169.6","percent of total billed charges",""
"Tissue Culture Lymphocyte Analysi","PX-31000107","CDM","88230","CPT","0311","RC","","","","both","","","1376.00","825.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","960.45","69.8","","929.04","929.04","929.04","1 through 10","75.72","1169.6","percent of total billed charges",""
"Tissue Culture Lymphocyte Analysi","PX-31000107","CDM","88230","CPT","0311","RC","","","","outpatient","","","1376.00","825.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1000.63","72.72","","967.90","967.90","967.90","1 through 10","32.26","1065.02","percent of total billed charges",""
"Tissue Culture Lymphocyte Analysi","PX-31000107","CDM","88230","CPT","0311","RC","","","","outpatient","","","1376.00","825.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","865.50","62.9","","838.53","838.53","2515.59","1 through 10","32.26","1065.02","percent of total billed charges",""
"Tissue Culture Lymphocyte Analysi","PX-31000107","CDM","88230","CPT","0311","RC","","","","outpatient","","","1376.00","825.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1065.02","77.4","","1031.53","1031.53","1031.53","1 through 10","32.26","1065.02","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","both","","","6924.01","4154.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","805.26","5885.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","both","","","6924.01","4154.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","805.26","5885.41","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","both","","","6924.01","4154.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3939.76","56.9","","0.63","0.63","0.63","1 through 10","805.26","5885.41","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","both","","","6924.01","4154.41","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","998.44","14.42","","317.14","317.14","317.14","1 through 10","805.26","5885.41","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6924.01","4154.41","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","998.44","14.42","","317.14","317.14","317.14","1 through 10","805.26","5359.18","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6924.01","4154.41","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4346.89","62.78","","1125.09","1125.09","1125.09","1 through 10","805.26","5359.18","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6924.01","4154.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5035.14","72.72","","4732.50","1617.43","14180.40","1 through 10","805.26","5359.18","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6924.01","4154.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4355.20","62.9","","3896.20","3341.38","3896.20","1 through 10","805.26","5359.18","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","both","","","6280.07","3768.04","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","730.37","5338.06","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","both","","","6280.07","3768.04","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","730.37","5338.06","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","both","","","6280.07","3768.04","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3573.36","56.9","","0.63","0.63","0.63","1 through 10","730.37","5338.06","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","both","","","6280.07","3768.04","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","905.59","14.42","","317.14","317.14","317.14","1 through 10","730.37","5338.06","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6280.07","3768.04","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","905.59","14.42","","317.14","317.14","317.14","1 through 10","730.37","4860.77","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6280.07","3768.04","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3942.63","62.78","","1125.09","1125.09","1125.09","1 through 10","730.37","4860.77","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6280.07","3768.04","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4566.87","72.72","","4732.50","1617.43","14180.40","1 through 10","730.37","4860.77","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6280.07","3768.04","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3950.16","62.9","","3896.20","3341.38","3896.20","1 through 10","730.37","4860.77","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","both","","","7568.67","4541.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","880.24","6433.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","both","","","7568.67","4541.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","880.24","6433.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","both","","","7568.67","4541.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4306.57","56.9","","0.63","0.63","0.63","1 through 10","880.24","6433.37","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","both","","","7568.67","4541.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1091.40","14.42","","317.14","317.14","317.14","1 through 10","880.24","6433.37","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7568.67","4541.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1091.40","14.42","","317.14","317.14","317.14","1 through 10","880.24","5858.15","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7568.67","4541.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4751.61","62.78","","1125.09","1125.09","1125.09","1 through 10","880.24","5858.15","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7568.67","4541.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5503.94","72.72","","4732.50","1617.43","14180.40","1 through 10","880.24","5858.15","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7568.67","4541.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4760.69","62.9","","3896.20","3341.38","3896.20","1 through 10","880.24","5858.15","percent of total billed charges",""
"TISSUE HUMAN 230MM+ LENGTH 4-8.5MM ALLOGRAFT TIBIALIS FLEXIGRAFT","SUP-ITM-10010304","CDM","C1889","HCPCS","0278","RC","","","","both","","","6280.07","3768.04","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","39000.00","39000.00","39000.00","1 through 10","730.37","5338.06","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TISSUE HUMAN 230MM+ LENGTH 4-8.5MM ALLOGRAFT TIBIALIS FLEXIGRAFT","SUP-ITM-10010304","CDM","C1889","HCPCS","0278","RC","","","","both","","","6280.07","3768.04","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","20937.50","3471.59","20937.50","1 through 10","730.37","5338.06","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TISSUE HUMAN 230MM+ LENGTH 4-8.5MM ALLOGRAFT TIBIALIS FLEXIGRAFT","SUP-ITM-10010304","CDM","C1889","HCPCS","0278","RC","","","","both","","","6280.07","3768.04","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3573.36","56.9","","0.63","0.63","0.63","1 through 10","730.37","5338.06","percent of total billed charges",""
"TISSUE HUMAN 230MM+ LENGTH 4-8.5MM ALLOGRAFT TIBIALIS FLEXIGRAFT","SUP-ITM-10010304","CDM","C1889","HCPCS","0278","RC","","","","both","","","6280.07","3768.04","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","905.59","14.42","","317.14","317.14","317.14","1 through 10","730.37","5338.06","percent of total billed charges",""
"TISSUE HUMAN 230MM+ LENGTH 4-8.5MM ALLOGRAFT TIBIALIS FLEXIGRAFT","SUP-ITM-10010304","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6280.07","3768.04","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","905.59","14.42","","317.14","317.14","317.14","1 through 10","730.37","4860.77","percent of total billed charges",""
"TISSUE HUMAN 230MM+ LENGTH 4-8.5MM ALLOGRAFT TIBIALIS FLEXIGRAFT","SUP-ITM-10010304","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6280.07","3768.04","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3942.63","62.78","","1125.09","1125.09","1125.09","1 through 10","730.37","4860.77","percent of total billed charges",""
"TISSUE HUMAN 230MM+ LENGTH 4-8.5MM ALLOGRAFT TIBIALIS FLEXIGRAFT","SUP-ITM-10010304","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6280.07","3768.04","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4566.87","72.72","","4732.50","1617.43","14180.40","1 through 10","730.37","4860.77","percent of total billed charges",""
"TISSUE HUMAN 230MM+ LENGTH 4-8.5MM ALLOGRAFT TIBIALIS FLEXIGRAFT","SUP-ITM-10010304","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6280.07","3768.04","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3950.16","62.9","","3896.20","3341.38","3896.20","1 through 10","730.37","4860.77","percent of total billed charges",""
"TOE IMPLANT MEDIUM PROSTHESIS JOINT PHALINX CANNULATED HAMMER","SUP-ITM-10194063","CDM","C1713","HCPCS","0278","RC","","","","both","","","5223.96","3134.38","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","607.55","4440.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TOE IMPLANT MEDIUM PROSTHESIS JOINT PHALINX CANNULATED HAMMER","SUP-ITM-10194063","CDM","C1713","HCPCS","0278","RC","","","","both","","","5223.96","3134.38","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","607.55","4440.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TOE IMPLANT MEDIUM PROSTHESIS JOINT PHALINX CANNULATED HAMMER","SUP-ITM-10194063","CDM","C1713","HCPCS","0278","RC","","","","both","","","5223.96","3134.38","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2972.43","56.9","","812.12","238.65","1587.46","163","607.55","4440.37","percent of total billed charges",""
"TOE IMPLANT MEDIUM PROSTHESIS JOINT PHALINX CANNULATED HAMMER","SUP-ITM-10194063","CDM","C1713","HCPCS","0278","RC","","","","both","","","5223.96","3134.38","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","607.55","11.63","","112.68","112.68","146.99","38","607.55","4440.37","percent of total billed charges",""
"TOE IMPLANT MEDIUM PROSTHESIS JOINT PHALINX CANNULATED HAMMER","SUP-ITM-10194063","CDM","C1713","HCPCS","0278","RC","","","","both","","","5223.96","3134.38","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4043.35","77.4","","303.98","303.98","5854.79","1 through 10","607.55","4440.37","percent of total billed charges",""
"TOE IMPLANT MEDIUM PROSTHESIS JOINT PHALINX CANNULATED HAMMER","SUP-ITM-10194063","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","607.55","11.63","","112.68","112.68","146.99","38","607.55","4043.35","percent of total billed charges",""
"TOE IMPLANT MEDIUM PROSTHESIS JOINT PHALINX CANNULATED HAMMER","SUP-ITM-10194063","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3279.60","62.78","","780.86","208.94","10480.28","15","607.55","4043.35","percent of total billed charges",""
"TOE IMPLANT MEDIUM PROSTHESIS JOINT PHALINX CANNULATED HAMMER","SUP-ITM-10194063","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2283.92","43.72","","179.76","179.76","179.76","1 through 10","607.55","4043.35","percent of total billed charges",""
"TOE IMPLANT MEDIUM PROSTHESIS JOINT PHALINX CANNULATED HAMMER","SUP-ITM-10194063","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3798.86","72.72","","2355.45","298.99","3965.19","155","607.55","4043.35","percent of total billed charges",""
"TOE IMPLANT MEDIUM PROSTHESIS JOINT PHALINX CANNULATED HAMMER","SUP-ITM-10194063","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3798.86","72.72","","3643.09","3643.09","3643.09","1 through 10","607.55","4043.35","percent of total billed charges",""
"TOE IMPLANT MEDIUM PROSTHESIS JOINT PHALINX CANNULATED HAMMER","SUP-ITM-10194063","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2780.19","53.22","","554.28","554.28","554.28","16","607.55","4043.35","percent of total billed charges",""
"TOE IMPLANT MEDIUM PROSTHESIS JOINT PHALINX CANNULATED HAMMER","SUP-ITM-10194063","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3285.87","62.9","","619.64","173.09","2370.64","150","607.55","4043.35","percent of total billed charges",""
"TOE IMPLANT MEDIUM PROSTHESIS JOINT PHALINX CANNULATED HAMMER","SUP-ITM-10194063","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4043.35","77.4","","303.98","303.98","5854.79","1 through 10","607.55","4043.35","percent of total billed charges",""
"TOE IMPLANT XSMALL 10DEG EXTRA CANNULATED PHALINX HAMMER NON CE","SUP-ITM-10194064","CDM","C1713","HCPCS","0278","RC","","","","both","","","5223.96","3134.38","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","607.55","4440.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TOE IMPLANT XSMALL 10DEG EXTRA CANNULATED PHALINX HAMMER NON CE","SUP-ITM-10194064","CDM","C1713","HCPCS","0278","RC","","","","both","","","5223.96","3134.38","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","607.55","4440.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TOE IMPLANT XSMALL 10DEG EXTRA CANNULATED PHALINX HAMMER NON CE","SUP-ITM-10194064","CDM","C1713","HCPCS","0278","RC","","","","both","","","5223.96","3134.38","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2972.43","56.9","","812.12","238.65","1587.46","163","607.55","4440.37","percent of total billed charges",""
"TOE IMPLANT XSMALL 10DEG EXTRA CANNULATED PHALINX HAMMER NON CE","SUP-ITM-10194064","CDM","C1713","HCPCS","0278","RC","","","","both","","","5223.96","3134.38","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","607.55","11.63","","112.68","112.68","146.99","38","607.55","4440.37","percent of total billed charges",""
"TOE IMPLANT XSMALL 10DEG EXTRA CANNULATED PHALINX HAMMER NON CE","SUP-ITM-10194064","CDM","C1713","HCPCS","0278","RC","","","","both","","","5223.96","3134.38","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4043.35","77.4","","303.98","303.98","5854.79","1 through 10","607.55","4440.37","percent of total billed charges",""
"TOE IMPLANT XSMALL 10DEG EXTRA CANNULATED PHALINX HAMMER NON CE","SUP-ITM-10194064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","607.55","11.63","","112.68","112.68","146.99","38","607.55","4043.35","percent of total billed charges",""
"TOE IMPLANT XSMALL 10DEG EXTRA CANNULATED PHALINX HAMMER NON CE","SUP-ITM-10194064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3279.60","62.78","","780.86","208.94","10480.28","15","607.55","4043.35","percent of total billed charges",""
"TOE IMPLANT XSMALL 10DEG EXTRA CANNULATED PHALINX HAMMER NON CE","SUP-ITM-10194064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2283.92","43.72","","179.76","179.76","179.76","1 through 10","607.55","4043.35","percent of total billed charges",""
"TOE IMPLANT XSMALL 10DEG EXTRA CANNULATED PHALINX HAMMER NON CE","SUP-ITM-10194064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3798.86","72.72","","2355.45","298.99","3965.19","155","607.55","4043.35","percent of total billed charges",""
"TOE IMPLANT XSMALL 10DEG EXTRA CANNULATED PHALINX HAMMER NON CE","SUP-ITM-10194064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3798.86","72.72","","3643.09","3643.09","3643.09","1 through 10","607.55","4043.35","percent of total billed charges",""
"TOE IMPLANT XSMALL 10DEG EXTRA CANNULATED PHALINX HAMMER NON CE","SUP-ITM-10194064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2780.19","53.22","","554.28","554.28","554.28","16","607.55","4043.35","percent of total billed charges",""
"TOE IMPLANT XSMALL 10DEG EXTRA CANNULATED PHALINX HAMMER NON CE","SUP-ITM-10194064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3285.87","62.9","","619.64","173.09","2370.64","150","607.55","4043.35","percent of total billed charges",""
"TOE IMPLANT XSMALL 10DEG EXTRA CANNULATED PHALINX HAMMER NON CE","SUP-ITM-10194064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5223.96","3134.38","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4043.35","77.4","","303.98","303.98","5854.79","1 through 10","607.55","4043.35","percent of total billed charges",""
"Total Abdominal Hysterect W/WO Rmvl Tube Ovary","PX-76001381","CDM","58150","CPT","0761","RC","","","","both","","","24473.00","14683.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","13925.14","56.9","","19493.98","19493.98","19493.98","1 through 10","995.01","20802.05","percent of total billed charges",""
"Total Iodine","PX-30002115","CDM","83789","CPT","0301","RC","","","","outpatient","","","105.00","63.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","76.36","72.72","","74.17","74.17","74.17","1 through 10","16.24","81.27","percent of total billed charges",""
"Total Iodine","PX-30002115","CDM","83789","CPT","0301","RC","","","","outpatient","","","105.00","63.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","81.27","77.4","","79.05","79.05","79.05","1 through 10","16.24","81.27","percent of total billed charges",""
"Toxoplasma Antibody","PX-30000999","CDM","86777","CPT","0302","RC","","","","both","","","77.00","46.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","53.75","69.8","","51.65","51.65","51.65","1 through 10","9.35","73.73","percent of total billed charges",""
"Toxoplasma Antibody","PX-30000999","CDM","86777","CPT","0302","RC","","","","outpatient","","","77.00","46.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","55.99","72.72","","53.81","53.81","53.81","1 through 10","13.41","59.6","percent of total billed charges",""
"Toxoplasma Antibody","PX-30000999","CDM","86777","CPT","0302","RC","","","","outpatient","","","77.00","46.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","59.60","77.4","","57.35","57.35","57.35","1 through 10","13.41","59.6","percent of total billed charges",""
"Toxoplasma Antibody Igm","PX-30001001","CDM","86778","CPT","0302","RC","","","","both","","","77.00","46.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","53.75","69.8","","51.65","51.65","51.65","1 through 10","9.37","73.73","percent of total billed charges",""
"Toxoplasma Antibody Igm","PX-30001001","CDM","86778","CPT","0302","RC","","","","outpatient","","","77.00","46.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","55.99","72.72","","53.81","53.81","53.81","1 through 10","13.42","59.6","percent of total billed charges",""
"Toxoplasma Antibody Igm","PX-30001001","CDM","86778","CPT","0302","RC","","","","outpatient","","","77.00","46.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","59.60","77.4","","57.35","57.35","57.35","1 through 10","13.42","59.6","percent of total billed charges",""
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R. Procedures","004","MS-DRG","","","","","","","","inpatient","","","265347.24","159208.34","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","108921.72","","Case rate ($105,749.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $97,639.64, add-ons for qualifying new technology services are included. If operating cost exceeds $101,557.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $55,500.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $97,609.32 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $97,194.78 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $7,695.06. The transfer capital threshold is the transfer adjustment factor * $7,695.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","183024.66","183024.66","183024.66","1 through 10","4637","526354.59","other","Inpatient DRG"
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R. Procedures","004","MS-DRG","","","","","","","","inpatient","","","265347.24","159208.34","MEDICARE [2001]","HB WDH MEDICARE","105749.24","","Case rate ($105,749.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $97,639.64, add-ons for qualifying new technology services are included. If operating cost exceeds $101,557.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $55,500.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $97,609.32 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $97,194.78 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $7,695.06. The transfer capital threshold is the transfer adjustment factor * $7,695.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","97624.48","97624.48","97624.48","1 through 10","4637","526354.59","other","Inpatient DRG"
"Transferrin","PX-30000707","CDM","84466","CPT","0301","RC","","","","outpatient","","","69.00","41.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","30.17","43.72","","29.29","29.29","29.29","1 through 10","11.89","53.41","percent of total billed charges",""
"Transferrin","PX-30000707","CDM","84466","CPT","0301","RC","","","","outpatient","","","69.00","41.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","50.18","72.72","","48.72","48.72","48.72","1 through 10","11.89","53.41","percent of total billed charges",""
"Transferrin","PX-30000707","CDM","84466","CPT","0301","RC","","","","outpatient","","","69.00","41.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","43.40","62.9","","42.21","42.21","42.21","1 through 10","11.89","53.41","percent of total billed charges",""
"Transferrin","PX-30000707","CDM","84466","CPT","0301","RC","","","","outpatient","","","69.00","41.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","53.41","77.4","","51.93","51.93","51.93","1 through 10","11.89","53.41","percent of total billed charges",""
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","1704.00","1022.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","1189.39","69.8","","1147.51","1147.51","1147.51","1 through 10","447.61","2919.03","percent of total billed charges",""
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","1704.00","1022.40","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","465.88","","APC Price ($456.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","422.97","422.97","422.97","1 through 10","447.61","2919.03","other","OPPS APC"
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","1704.00","1022.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2919.03","","Case rate ($2,919.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1586.41","1528.81","2847.84","11","447.61","2919.03","other","OPPS APC"
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","1704.00","1022.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1256.93","","Case rate ($1,256.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1226.29","1226.29","1226.29","11","447.61","2919.03","other","OPPS APC"
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","1704.00","1022.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","447.61","","APC Price ($456.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","456.80","447.66","456.80","16","447.61","2919.03","other","OPPS APC"
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","1704.00","1022.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","2359.42","","Case rate ($2,359.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2222.33","1643.07","2222.33","1 through 10","447.61","2919.03","other","OPPS APC"
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","1704.00","1022.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","969.58","56.9","","935.44","935.44","935.44","14","447.61","2919.03","percent of total billed charges",""
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","1704.00","1022.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","470.45","","APC Price ($456.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","461.09","461.09","461.09","1 through 10","447.61","2919.03","other","OPPS APC"
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","1704.00","1022.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","456.75","","APC Price ($456.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","447.66","447.66","447.66","21","447.61","2919.03","other","OPPS APC"
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","1704.00","1022.40","MEDICARE [2001]","HB WDH MEDICARE","456.75","","APC Price ($456.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","456.80","456.80","456.80","169","447.61","2919.03","other","OPPS APC"
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","1704.00","1022.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","456.75","","APC Price ($456.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","456.80","422.97","456.80","91","447.61","2919.03","other","OPPS APC"
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","outpatient","","","1704.00","1022.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","198.18","11.63","","226.38","194.19","415.20","31","198.18","1318.9","percent of total billed charges",""
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","outpatient","","","1704.00","1022.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1318.90","77.4","","1274.10","1274.10","1274.10","1 through 10","198.18","1318.9","percent of total billed charges",""
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","outpatient","","","1704.00","1022.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","198.18","11.63","","194.19","194.19","716.26","1 through 10","198.18","1318.9","percent of total billed charges",""
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0760","RC","","","","outpatient","","","1704.00","1022.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","245.72","14.42","","237.06","203.20","237.06","1 through 10","245.72","245.72","percent of total billed charges",""
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","","","","inpatient","","","40459.58","24275.75","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","6387.35","","Case rate ($6,517.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,050.02, add-ons for qualifying new technology services are included. If operating cost exceeds $9,968.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,248.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,629.06 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,605.15 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.77. The transfer capital threshold is the transfer adjustment factor * $443.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","6385.86","6385.86","6385.86","1 through 10","3975","30354.48","other","Inpatient DRG"
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","","","","inpatient","","","40459.58","24275.75","MEDICARE [2001]","HB WDH MEDICARE","6517.70","","Case rate ($6,517.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,050.02, add-ons for qualifying new technology services are included. If operating cost exceeds $9,968.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,248.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $5,629.06 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,605.15 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $443.77. The transfer capital threshold is the transfer adjustment factor * $443.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6497.71","0.05","6498.13","16","3975","30354.48","other","Inpatient DRG"
"Transurethral Procedures With Cc","669","MS-DRG","","","","","","","","inpatient","","","47880.15","28728.09","MEDICARE [2001]","HB WDH MEDICARE","12243.85","","Case rate ($12,243.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,335.20, add-ons for qualifying new technology services are included. If operating cost exceeds $15,253.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,667.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $10,936.78 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,890.33 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $862.20. The transfer capital threshold is the transfer adjustment factor * $862.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12151.96","12151.96","12152.77","1 through 10","3975","58976.16","other","Inpatient DRG"
"Transurethral Procedures With Cc","669","MS-DRG","","","","","","","","inpatient","","","47880.15","28728.09","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","12243.85","","Case rate ($12,243.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $11,335.20, add-ons for qualifying new technology services are included. If operating cost exceeds $15,253.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,667.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $10,936.78 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,890.33 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $862.20. The transfer capital threshold is the transfer adjustment factor * $862.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","12151.96","12151.96","12151.96","1 through 10","3975","58976.16","other","Inpatient DRG"
"Transurethral Prostatectomy With Cc/McC","713","MS-DRG","","","","","","","","inpatient","","","54857.29","32914.37","MEDICARE [2001]","HB WDH MEDICARE","11874.38","","Case rate ($11,874.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,994.18, add-ons for qualifying new technology services are included. If operating cost exceeds $14,912.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,640.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $10,594.30 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,549.30 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $835.20. The transfer capital threshold is the transfer adjustment factor * $835.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Includes an additional $800 of payment.","11355.66","11355.66","11384.09","1 through 10","3975","57129.35","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Trauma To The Skin, Subcutaneous Tissue And Breast With McC","604","MS-DRG","","","","","","","","inpatient","","","50349.84","30209.90","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","11403.68","","Case rate ($11,636.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,774.54, add-ons for qualifying new technology services are included. If operating cost exceeds $14,692.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,622.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,373.73 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,329.67 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.82. The transfer capital threshold is the transfer adjustment factor * $817.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","11424.13","11424.13","11424.13","1 through 10","3975","55939.95","other","Inpatient DRG"
"Trauma To The Skin, Subcutaneous Tissue And Breast With McC","604","MS-DRG","","","","","","","","inpatient","","","50349.84","30209.90","MEDICARE [2001]","HB WDH MEDICARE","11636.41","","Case rate ($11,636.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,774.54, add-ons for qualifying new technology services are included. If operating cost exceeds $14,692.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,622.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,373.73 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,329.67 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.82. The transfer capital threshold is the transfer adjustment factor * $817.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11655.23","11655.23","11655.23","1 through 10","3975","55939.95","other","Inpatient DRG"
"Trauma To The Skin, Subcutaneous Tissue And Breast With McC","604","MS-DRG","","","","","","","","inpatient","","","50349.84","30209.90","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","11636.41","","Case rate ($11,636.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,774.54, add-ons for qualifying new technology services are included. If operating cost exceeds $14,692.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,622.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $10,373.73 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,329.67 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $817.82. The transfer capital threshold is the transfer adjustment factor * $817.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11451.51","11451.51","11451.51","1 through 10","3975","55939.95","other","Inpatient DRG"
"Trauma To The Skin, Subcutaneous Tissue And Breast Without McC","605","MS-DRG","","","","","","","","inpatient","","","34557.90","20734.74","MEDICARE [2001]","HB WDH MEDICARE","7408.70","","Case rate ($7,408.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,872.41, add-ons for qualifying new technology services are included. If operating cost exceeds $10,790.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,313.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,454.95 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,427.54 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.88. The transfer capital threshold is the transfer adjustment factor * $508.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7414.62","0.05","7414.62","1 through 10","3975","34808.09","other","Inpatient DRG"
"Trauma To The Skin, Subcutaneous Tissue And Breast Without McC","605","MS-DRG","","","","","","","","inpatient","","","34557.90","20734.74","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7408.70","","Case rate ($7,408.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,872.41, add-ons for qualifying new technology services are included. If operating cost exceeds $10,790.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,313.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,454.95 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,427.54 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.88. The transfer capital threshold is the transfer adjustment factor * $508.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7432.78","7432.78","7432.78","1 through 10","3975","34808.09","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","","","","inpatient","","","62119.28","37271.57","MARTIN'S POINT [160007]","HB WDH MEDICARE","10348.57","","Case rate ($10,348.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,585.87, add-ons for qualifying new technology services are included. If operating cost exceeds $13,504.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,528.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,179.99 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,141.00 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $723.71. The transfer capital threshold is the transfer adjustment factor * $723.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10182.48","10182.48","10182.48","1 through 10","3975","49502.73","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","","","","inpatient","","","62119.28","37271.57","MEDICARE [2001]","HB WDH MEDICARE","10348.57","","Case rate ($10,348.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,585.87, add-ons for qualifying new technology services are included. If operating cost exceeds $13,504.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,528.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,179.99 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,141.00 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $723.71. The transfer capital threshold is the transfer adjustment factor * $723.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7132.45","7132.45","10341.54","1 through 10","3975","49502.73","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour With McC","085","MS-DRG","","","","","","","","inpatient","","","53657.93","32194.76","MEDICARE [2001]","HB WDH MEDICARE","17716.84","","Case rate ($17,716.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $16,386.71, add-ons for qualifying new technology services are included. If operating cost exceeds $20,304.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,067.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $16,009.83 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,941.84 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,262.14. The transfer capital threshold is the transfer adjustment factor * $1,262.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17587.58","17587.58","17587.58","1 through 10","3975","86332.43","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour With McC","085","MS-DRG","","","","","","","","inpatient","","","53657.93","32194.76","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","17716.84","","Case rate ($17,716.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $16,386.71, add-ons for qualifying new technology services are included. If operating cost exceeds $20,304.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,067.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $16,009.83 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $15,941.84 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,262.14. The transfer capital threshold is the transfer adjustment factor * $1,262.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","17228.17","17228.17","17228.17","1 through 10","3975","86332.43","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour Without Cc/McC","087","MS-DRG","","","","","","","","inpatient","","","29664.47","17798.68","MEDICARE [2001]","HB WDH MEDICARE","7398.82","","Case rate ($7,398.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,863.29, add-ons for qualifying new technology services are included. If operating cost exceeds $10,781.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,313.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,445.79 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,418.42 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.16. The transfer capital threshold is the transfer adjustment factor * $508.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7132.45","7132.45","7132.45","1 through 10","3975","34758.69","other","Inpatient DRG"
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","","","","inpatient","","","12721.42","7632.85","MARTIN'S POINT [160007]","HB WDH MEDICARE","11056.34","","Case rate ($11,056.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,239.15, add-ons for qualifying new technology services are included. If operating cost exceeds $14,157.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,580.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $9,836.05 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,794.28 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $775.43. The transfer capital threshold is the transfer adjustment factor * $775.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","6595.15","6595.15","6595.15","1 through 10","3975","53040.54","other","Inpatient DRG"
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","","","","inpatient","","","12721.42","7632.85","MEDICARE [2001]","HB WDH MEDICARE","11056.34","","Case rate ($11,056.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,239.15, add-ons for qualifying new technology services are included. If operating cost exceeds $14,157.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,580.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $9,836.05 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,794.28 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $775.43. The transfer capital threshold is the transfer adjustment factor * $775.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","834.67","834.67","10963.46","1 through 10","3975","53040.54","other","Inpatient DRG"
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","","","","inpatient","","","12721.42","7632.85","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","11056.34","","Case rate ($11,056.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,239.15, add-ons for qualifying new technology services are included. If operating cost exceeds $14,157.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,580.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $9,836.05 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,794.28 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $775.43. The transfer capital threshold is the transfer adjustment factor * $775.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10717.40","10717.40","10717.40","1 through 10","3975","53040.54","other","Inpatient DRG"
"Traumatic Stupor And Coma >1 Hour Without Cc/McC","084","MS-DRG","","","","","","","","inpatient","","","25717.80","15430.68","MEDICARE [2001]","HB WDH MEDICARE","7711.28","","Case rate ($7,711.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,151.68, add-ons for qualifying new technology services are included. If operating cost exceeds $11,069.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,336.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,735.42 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,706.81 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $530.99. The transfer capital threshold is the transfer adjustment factor * $530.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","0.05","0.05","0.05","1 through 10","4637","36320.5","other","Inpatient DRG"
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","6219.00","3731.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","723.27","5286.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","6219.00","3731.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3538.61","56.9","","2911.53","1863.86","5209.05","65","723.27","5286.15","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","6219.00","3731.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","723.27","11.63","","400.94","400.94","400.94","1 through 10","723.27","5286.15","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","6219.00","3731.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4813.51","77.4","","5214.50","5214.50","16415.28","1 through 10","723.27","5286.15","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","723.27","11.63","","400.94","400.94","400.94","1 through 10","723.27","4813.51","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2718.95","43.72","","1543.33","1543.33","1671.61","1 through 10","723.27","4813.51","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4522.46","72.72","","3700.21","2382.07","6427.18","53","723.27","4813.51","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4522.46","72.72","","12685.80","12685.80","12685.80","1 through 10","723.27","4813.51","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3911.75","62.9","","3408.87","2784.05","9859.40","46","723.27","4813.51","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4813.51","77.4","","5214.50","5214.50","16415.28","1 through 10","723.27","4813.51","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","6219.00","3731.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","723.27","5286.15","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","6219.00","3731.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3538.61","56.9","","2911.53","1863.86","5209.05","65","723.27","5286.15","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","6219.00","3731.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","723.27","11.63","","400.94","400.94","400.94","1 through 10","723.27","5286.15","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","6219.00","3731.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4813.51","77.4","","5214.50","5214.50","16415.28","1 through 10","723.27","5286.15","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","723.27","11.63","","400.94","400.94","400.94","1 through 10","723.27","4813.51","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2718.95","43.72","","1543.33","1543.33","1671.61","1 through 10","723.27","4813.51","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4522.46","72.72","","3700.21","2382.07","6427.18","53","723.27","4813.51","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4522.46","72.72","","12685.80","12685.80","12685.80","1 through 10","723.27","4813.51","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3911.75","62.9","","3408.87","2784.05","9859.40","46","723.27","4813.51","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6219.00","3731.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4813.51","77.4","","5214.50","5214.50","16415.28","1 through 10","723.27","4813.51","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","both","","","6062.50","3637.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","705.07","5153.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","both","","","6062.50","3637.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3449.56","56.9","","2911.53","1863.86","5209.05","65","705.07","5153.13","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","both","","","6062.50","3637.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","705.07","11.63","","400.94","400.94","400.94","1 through 10","705.07","5153.13","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","both","","","6062.50","3637.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4692.38","77.4","","5214.50","5214.50","16415.28","1 through 10","705.07","5153.13","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","705.07","11.63","","400.94","400.94","400.94","1 through 10","705.07","4692.38","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2650.53","43.72","","1543.33","1543.33","1671.61","1 through 10","705.07","4692.38","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4408.65","72.72","","3700.21","2382.07","6427.18","53","705.07","4692.38","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4408.65","72.72","","12685.80","12685.80","12685.80","1 through 10","705.07","4692.38","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3813.31","62.9","","3408.87","2784.05","9859.40","46","705.07","4692.38","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER EQUINOXE PLUS 0","SUP-ITM-10170082","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4692.38","77.4","","5214.50","5214.50","16415.28","1 through 10","705.07","4692.38","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","both","","","6062.50","3637.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","705.07","5153.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","both","","","6062.50","3637.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3449.56","56.9","","2911.53","1863.86","5209.05","65","705.07","5153.13","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","both","","","6062.50","3637.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","705.07","11.63","","400.94","400.94","400.94","1 through 10","705.07","5153.13","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","both","","","6062.50","3637.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4692.38","77.4","","5214.50","5214.50","16415.28","1 through 10","705.07","5153.13","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","705.07","11.63","","400.94","400.94","400.94","1 through 10","705.07","4692.38","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2650.53","43.72","","1543.33","1543.33","1671.61","1 through 10","705.07","4692.38","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4408.65","72.72","","3700.21","2382.07","6427.18","53","705.07","4692.38","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4408.65","72.72","","12685.80","12685.80","12685.80","1 through 10","705.07","4692.38","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3813.31","62.9","","3408.87","2784.05","9859.40","46","705.07","4692.38","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4692.38","77.4","","5214.50","5214.50","16415.28","1 through 10","705.07","4692.38","percent of total billed charges",""
"TRAY ADAPTER SHOULDER EQUINOXE PLATE +10","SUP-ITM-10195139","CDM","C1776","HCPCS","0278","RC","","","","both","","","6062.50","3637.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","705.07","5153.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TRAY ADAPTER SHOULDER EQUINOXE PLATE +10","SUP-ITM-10195139","CDM","C1776","HCPCS","0278","RC","","","","both","","","6062.50","3637.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3449.56","56.9","","2911.53","1863.86","5209.05","65","705.07","5153.13","percent of total billed charges",""
"TRAY ADAPTER SHOULDER EQUINOXE PLATE +10","SUP-ITM-10195139","CDM","C1776","HCPCS","0278","RC","","","","both","","","6062.50","3637.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","705.07","11.63","","400.94","400.94","400.94","1 through 10","705.07","5153.13","percent of total billed charges",""
"TRAY ADAPTER SHOULDER EQUINOXE PLATE +10","SUP-ITM-10195139","CDM","C1776","HCPCS","0278","RC","","","","both","","","6062.50","3637.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4692.38","77.4","","5214.50","5214.50","16415.28","1 through 10","705.07","5153.13","percent of total billed charges",""
"TRAY ADAPTER SHOULDER EQUINOXE PLATE +10","SUP-ITM-10195139","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","705.07","11.63","","400.94","400.94","400.94","1 through 10","705.07","4692.38","percent of total billed charges",""
"TRAY ADAPTER SHOULDER EQUINOXE PLATE +10","SUP-ITM-10195139","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2650.53","43.72","","1543.33","1543.33","1671.61","1 through 10","705.07","4692.38","percent of total billed charges",""
"TRAY ADAPTER SHOULDER EQUINOXE PLATE +10","SUP-ITM-10195139","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4408.65","72.72","","3700.21","2382.07","6427.18","53","705.07","4692.38","percent of total billed charges",""
"TRAY ADAPTER SHOULDER EQUINOXE PLATE +10","SUP-ITM-10195139","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4408.65","72.72","","12685.80","12685.80","12685.80","1 through 10","705.07","4692.38","percent of total billed charges",""
"TRAY ADAPTER SHOULDER EQUINOXE PLATE +10","SUP-ITM-10195139","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3813.31","62.9","","3408.87","2784.05","9859.40","46","705.07","4692.38","percent of total billed charges",""
"TRAY ADAPTER SHOULDER EQUINOXE PLATE +10","SUP-ITM-10195139","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6062.50","3637.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4692.38","77.4","","5214.50","5214.50","16415.28","1 through 10","705.07","4692.38","percent of total billed charges",""
"TRAY CATHETER 13.5FR 16CM IC HI FLO DUAL STRAIGHT EXT PK/5EA","SUP-ITM-10267426","CDM","C1750","HCPCS","0278","RC","","","","both","","","687.32","412.39","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","391.09","56.9","","986.49","974.06","986.49","1 through 10","79.94","584.22","percent of total billed charges",""
"TRAY CATHETER 13.5FR 16CM IC HI FLO DUAL STRAIGHT EXT PK/5EA","SUP-ITM-10267426","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","687.32","412.39","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","300.50","43.72","","951.63","951.63","951.63","1 through 10","79.94","531.99","percent of total billed charges",""
"TRAY CATHETER 13.5FR 16CM IC HI FLO DUAL STRAIGHT EXT PK/5EA","SUP-ITM-10267426","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","687.32","412.39","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","499.82","72.72","","1244.88","1244.88","1244.88","1 through 10","79.94","531.99","percent of total billed charges",""
"TRAY CATHETER 14FR 29CM PNEUMOTHORAX WAYNE WIRE GUIDED","SUP-ITM-10216588","CDM","C1729","HCPCS","0272","RC","","","","both","","","1772.42","1063.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","206.13","11.63","","19.51","17.34","54.47","21","206.13","1506.56","percent of total billed charges",""
"TRAY CATHETER 14FR 29CM PNEUMOTHORAX WAYNE WIRE GUIDED","SUP-ITM-10216588","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1772.42","1063.45","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","206.13","11.63","","19.51","17.34","54.47","21","206.13","1371.85","percent of total billed charges",""
"TRAY CATHETER 14FR 29CM PNEUMOTHORAX WAYNE WIRE GUIDED","SUP-ITM-10216588","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1772.42","1063.45","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","774.90","43.72","","61.93","61.93","61.93","1 through 10","206.13","1371.85","percent of total billed charges",""
"TRAY CATHETER 14FR 29CM PNEUMOTHORAX WAYNE WIRE GUIDED","SUP-ITM-10216588","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1772.42","1063.45","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1288.90","72.72","","330.75","267.63","330.75","1 through 10","206.13","1371.85","percent of total billed charges",""
"TRAY CATHETER 14FR 29CM PNEUMOTHORAX WAYNE WIRE GUIDED","SUP-ITM-10216588","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1772.42","1063.45","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1114.85","62.9","","89.25","87.07","231.86","1 through 10","206.13","1371.85","percent of total billed charges",""
"TRAY CATHETER 14FR 29CM PNEUMOTHORAX WAYNE WIRE GUIDED","SUP-ITM-10216588","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1772.42","1063.45","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","1288.90","72.72","","267.63","267.63","267.63","1 through 10","206.13","1371.85","percent of total billed charges",""
"TRAY COMPONENT 44MM HUMERAL COMPREHENSIVE REVERSE COBALT STANDARD","SUP-ITM-10121720","CDM","C1776","HCPCS","0278","RC","","","","both","","","5489.72","3293.83","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","638.45","4666.26","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TRAY COMPONENT 44MM HUMERAL COMPREHENSIVE REVERSE COBALT STANDARD","SUP-ITM-10121720","CDM","C1776","HCPCS","0278","RC","","","","both","","","5489.72","3293.83","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3123.65","56.9","","2911.53","1863.86","5209.05","65","638.45","4666.26","percent of total billed charges",""
"TRAY COMPONENT 44MM HUMERAL COMPREHENSIVE REVERSE COBALT STANDARD","SUP-ITM-10121720","CDM","C1776","HCPCS","0278","RC","","","","both","","","5489.72","3293.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","638.45","11.63","","400.94","400.94","400.94","1 through 10","638.45","4666.26","percent of total billed charges",""
"TRAY COMPONENT 44MM HUMERAL COMPREHENSIVE REVERSE COBALT STANDARD","SUP-ITM-10121720","CDM","C1776","HCPCS","0278","RC","","","","both","","","5489.72","3293.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4249.04","77.4","","5214.50","5214.50","16415.28","1 through 10","638.45","4666.26","percent of total billed charges",""
"TRAY COMPONENT 44MM HUMERAL COMPREHENSIVE REVERSE COBALT STANDARD","SUP-ITM-10121720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5489.72","3293.83","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","638.45","11.63","","400.94","400.94","400.94","1 through 10","638.45","4249.04","percent of total billed charges",""
"TRAY COMPONENT 44MM HUMERAL COMPREHENSIVE REVERSE COBALT STANDARD","SUP-ITM-10121720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5489.72","3293.83","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2400.11","43.72","","1543.33","1543.33","1671.61","1 through 10","638.45","4249.04","percent of total billed charges",""
"TRAY COMPONENT 44MM HUMERAL COMPREHENSIVE REVERSE COBALT STANDARD","SUP-ITM-10121720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5489.72","3293.83","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3992.12","72.72","","3700.21","2382.07","6427.18","53","638.45","4249.04","percent of total billed charges",""
"TRAY COMPONENT 44MM HUMERAL COMPREHENSIVE REVERSE COBALT STANDARD","SUP-ITM-10121720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5489.72","3293.83","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3992.12","72.72","","12685.80","12685.80","12685.80","1 through 10","638.45","4249.04","percent of total billed charges",""
"TRAY COMPONENT 44MM HUMERAL COMPREHENSIVE REVERSE COBALT STANDARD","SUP-ITM-10121720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5489.72","3293.83","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3453.03","62.9","","3408.87","2784.05","9859.40","46","638.45","4249.04","percent of total billed charges",""
"TRAY COMPONENT 44MM HUMERAL COMPREHENSIVE REVERSE COBALT STANDARD","SUP-ITM-10121720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5489.72","3293.83","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4249.04","77.4","","5214.50","5214.50","16415.28","1 through 10","638.45","4249.04","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE D TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL RT 13","SUP-ITM-10020263","CDM","C1776","HCPCS","0278","RC","","","","both","","","4570.97","2742.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","531.6","3885.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TRAY IMPLANT KNEE SIZE D TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL RT 13","SUP-ITM-10020263","CDM","C1776","HCPCS","0278","RC","","","","both","","","4570.97","2742.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2600.88","56.9","","2911.53","1863.86","5209.05","65","531.6","3885.32","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE D TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL RT 13","SUP-ITM-10020263","CDM","C1776","HCPCS","0278","RC","","","","both","","","4570.97","2742.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","531.60","11.63","","400.94","400.94","400.94","1 through 10","531.6","3885.32","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE D TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL RT 13","SUP-ITM-10020263","CDM","C1776","HCPCS","0278","RC","","","","both","","","4570.97","2742.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3537.93","77.4","","5214.50","5214.50","16415.28","1 through 10","531.6","3885.32","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE D TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL RT 13","SUP-ITM-10020263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4570.97","2742.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","531.60","11.63","","400.94","400.94","400.94","1 through 10","531.6","3537.93","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE D TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL RT 13","SUP-ITM-10020263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4570.97","2742.58","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1998.43","43.72","","1543.33","1543.33","1671.61","1 through 10","531.6","3537.93","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE D TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL RT 13","SUP-ITM-10020263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4570.97","2742.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3324.01","72.72","","3700.21","2382.07","6427.18","53","531.6","3537.93","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE D TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL RT 13","SUP-ITM-10020263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4570.97","2742.58","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3324.01","72.72","","12685.80","12685.80","12685.80","1 through 10","531.6","3537.93","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE D TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL RT 13","SUP-ITM-10020263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4570.97","2742.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2875.14","62.9","","3408.87","2784.05","9859.40","46","531.6","3537.93","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE D TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL RT 13","SUP-ITM-10020263","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4570.97","2742.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3537.93","77.4","","5214.50","5214.50","16415.28","1 through 10","531.6","3537.93","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT AOY LT MEDIAL SIZE D","SUP-ITM-10020387","CDM","C1776","HCPCS","0278","RC","","","","both","","","4570.97","2742.58","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","531.6","3885.32","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TRAY TIBIAL KNEE OXFORD COBALT AOY LT MEDIAL SIZE D","SUP-ITM-10020387","CDM","C1776","HCPCS","0278","RC","","","","both","","","4570.97","2742.58","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2600.88","56.9","","2911.53","1863.86","5209.05","65","531.6","3885.32","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT AOY LT MEDIAL SIZE D","SUP-ITM-10020387","CDM","C1776","HCPCS","0278","RC","","","","both","","","4570.97","2742.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","531.60","11.63","","400.94","400.94","400.94","1 through 10","531.6","3885.32","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT AOY LT MEDIAL SIZE D","SUP-ITM-10020387","CDM","C1776","HCPCS","0278","RC","","","","both","","","4570.97","2742.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3537.93","77.4","","5214.50","5214.50","16415.28","1 through 10","531.6","3885.32","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT AOY LT MEDIAL SIZE D","SUP-ITM-10020387","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4570.97","2742.58","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","531.60","11.63","","400.94","400.94","400.94","1 through 10","531.6","3537.93","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT AOY LT MEDIAL SIZE D","SUP-ITM-10020387","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4570.97","2742.58","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1998.43","43.72","","1543.33","1543.33","1671.61","1 through 10","531.6","3537.93","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT AOY LT MEDIAL SIZE D","SUP-ITM-10020387","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4570.97","2742.58","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3324.01","72.72","","3700.21","2382.07","6427.18","53","531.6","3537.93","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT AOY LT MEDIAL SIZE D","SUP-ITM-10020387","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4570.97","2742.58","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3324.01","72.72","","12685.80","12685.80","12685.80","1 through 10","531.6","3537.93","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT AOY LT MEDIAL SIZE D","SUP-ITM-10020387","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4570.97","2742.58","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2875.14","62.9","","3408.87","2784.05","9859.40","46","531.6","3537.93","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT AOY LT MEDIAL SIZE D","SUP-ITM-10020387","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4570.97","2742.58","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3537.93","77.4","","5214.50","5214.50","16415.28","1 through 10","531.6","3537.93","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2315.00","1389.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","1615.87","69.8","","4678.00","1559.33","6237.33","1 through 10","374.81","2444.27","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2315.00","1389.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2444.27","","Case rate ($2,444.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2234.00","2209.74","2384.67","73","374.81","2444.27","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2315.00","1389.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1052.50","","Case rate ($1,052.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1026.84","1007.71","1026.85","48","374.81","2444.27","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2315.00","1389.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","374.81","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","382.50","374.85","650.25","154","374.81","2444.27","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2315.00","1389.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1975.68","","Case rate ($1,975.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1734.74","1007.71","1927.49","68","374.81","2444.27","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2315.00","1389.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","393.93","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","387.67","387.67","387.68","48","374.81","2444.27","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2315.00","1389.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","376.38","374.85","382.50","121","374.81","2444.27","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2315.00","1389.00","MEDICARE [2001]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","382.50","360.01","382.50","518","374.81","2444.27","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2315.00","1389.00","TRICARE [160005]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","382.50","382.50","382.50","1 through 10","374.81","2444.27","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2315.00","1389.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","375.62","352.81","382.50","141","374.81","2444.27","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2315.00","1389.00","WELLPOINT [1015]","HB WDH ANTHEM PPO","1975.68","","Case rate ($1,975.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1927.49","1927.49","1927.49","1 through 10","374.81","2444.27","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","both","","","2315.00","1389.00","WELLSENSE NH [1050]","HB WDH MEDICARE","382.46","","APC Price ($382.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","395.20","395.20","395.20","1 through 10","374.81","2444.27","other","OPPS APC"
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","outpatient","","","2315.00","1389.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","333.82","14.42","","322.14","276.12","322.15","29","269.23","1791.81","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","outpatient","","","2315.00","1389.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","269.23","11.63","","273.44","263.87","307.62","23","269.23","1791.81","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","outpatient","","","2315.00","1389.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1453.36","62.78","","1402.51","1402.51","1402.51","1 through 10","269.23","1791.81","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","outpatient","","","2315.00","1389.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1683.47","72.72","","1624.56","1470.42","1624.57","47","269.23","1791.81","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","outpatient","","","2315.00","1389.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1456.14","62.9","","1407.42","1407.42","1407.42","52","269.23","1791.81","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","outpatient","","","2315.00","1389.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1791.81","77.4","","1624.57","1624.56","1624.57","1 through 10","269.23","1791.81","percent of total billed charges",""
"Treatment Device Cplx","PX-33000024","CDM","77334","CPT","0333","RC","","","","outpatient","","","2315.00","1389.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","269.23","11.63","","263.87","263.87","599.76","22","269.23","1791.81","percent of total billed charges",""
"Treatment Device Intermediate","PX-33000023","CDM","77333","CPT","0333","RC","","","","both","","","1191.00","714.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","138.73","138.73","138.73","1 through 10","135.94","1012.35","other","OPPS APC"
"Treatment Device Intermediate","PX-33000023","CDM","77333","CPT","0333","RC","","","","both","","","1191.00","714.60","MEDICARE [2001]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","138.73","132.20","138.73","1 through 10","135.94","1012.35","other","OPPS APC"
"Treatment Device Intermediate","PX-33000023","CDM","77333","CPT","0333","RC","","","","both","","","1191.00","714.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","136.52","136.52","136.52","1 through 10","135.94","1012.35","other","OPPS APC"
"Treatment Device Intermediate","PX-33000023","CDM","77333","CPT","0333","RC","","","","outpatient","","","1191.00","714.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","866.10","72.72","","6006.67","6006.67","6006.67","1 through 10","138.51","921.83","percent of total billed charges",""
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","489.00","293.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","341.32","69.8","","329.46","329.46","329.46","1 through 10","135.94","886.52","percent of total billed charges",""
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","489.00","293.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","886.52","","Case rate ($886.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","864.90","859.38","864.90","1 through 10","135.94","886.52","other","OPPS APC"
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","489.00","293.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","381.73","","Case rate ($381.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","372.43","372.43","372.43","1 through 10","135.94","886.52","other","OPPS APC"
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","489.00","293.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","135.94","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","138.73","132.20","235.84","1 through 10","135.94","886.52","other","OPPS APC"
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","489.00","293.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","716.57","","Case rate ($716.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","625.16","625.16","625.16","1 through 10","135.94","886.52","other","OPPS APC"
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","489.00","293.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","142.87","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","140.60","140.60","140.60","1 through 10","135.94","886.52","other","OPPS APC"
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","489.00","293.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","138.73","136.51","138.73","1 through 10","135.94","886.52","other","OPPS APC"
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","489.00","293.40","MEDICARE [2001]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","138.73","132.20","277.46","27","135.94","886.52","other","OPPS APC"
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","489.00","293.40","TRICARE [160005]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","138.73","138.73","138.73","1 through 10","135.94","886.52","other","OPPS APC"
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","both","","","489.00","293.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","138.71","","APC Price ($138.71). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","136.52","135.96","138.73","1 through 10","135.94","886.52","other","OPPS APC"
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","outpatient","","","489.00","293.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","70.51","14.42","","68.06","68.06","68.06","1 through 10","56.87","378.49","percent of total billed charges",""
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","outpatient","","","489.00","293.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","56.87","11.63","","55.75","55.75","55.75","1 through 10","56.87","378.49","percent of total billed charges",""
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","outpatient","","","489.00","293.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","355.60","72.72","","310.67","310.67","343.24","1 through 10","56.87","378.49","percent of total billed charges",""
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","outpatient","","","489.00","293.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","307.58","62.9","","297.36","297.36","297.36","1 through 10","56.87","378.49","percent of total billed charges",""
"Treatment Device Smp","PX-33000022","CDM","77332","CPT","0333","RC","","","","outpatient","","","489.00","293.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","56.87","11.63","","55.75","55.75","55.75","1 through 10","56.87","378.49","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","187.00","112.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","130.53","69.8","","126.34","113.85","126.34","119","8.61","158.95","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","187.00","112.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","130.53","69.8","","126.34","126.34","126.34","1 through 10","8.61","158.95","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","187.00","112.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","158.95","85","","126.34","11.91","126.34","1 through 10","8.61","158.95","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","outpatient","","","187.00","112.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","117.40","62.78","","113.63","113.63","227.26","1 through 10","12.33","144.74","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","outpatient","","","187.00","112.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","81.76","43.72","","79.13","79.13","79.14","13","12.33","144.74","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","outpatient","","","187.00","112.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","135.99","72.72","","131.62","131.62","131.62","151","12.33","144.74","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","outpatient","","","187.00","112.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","135.99","72.72","","131.62","131.62","131.62","1 through 10","12.33","144.74","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","outpatient","","","187.00","112.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","99.52","53.22","","96.49","96.49","289.47","18","12.33","144.74","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","outpatient","","","187.00","112.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","117.62","62.9","","114.03","114.03","114.03","193","12.33","144.74","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","outpatient","","","187.00","112.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","144.74","77.4","","140.28","140.28","140.28","98","12.33","144.74","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","outpatient","","","187.00","112.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","135.99","72.72","","131.62","131.62","131.62","1 through 10","12.33","144.74","percent of total billed charges",""
"Trichomonas Vaginalis Amplif","PX-30002753","CDM","87661","CPT","0300","RC","","","","both","","","273.00","163.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","190.55","69.8","","184.27","166.06","184.27","22","22.81","232.05","percent of total billed charges",""
"Trichomonas Vaginalis Amplif","PX-30002753","CDM","87661","CPT","0300","RC","","","","outpatient","","","273.00","163.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","171.39","62.78","","165.74","165.74","165.74","1 through 10","33.29","211.3","percent of total billed charges",""
"Trichomonas Vaginalis Amplif","PX-30002753","CDM","87661","CPT","0300","RC","","","","outpatient","","","273.00","163.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","198.53","72.72","","191.98","191.98","575.94","35","33.29","211.3","percent of total billed charges",""
"Trichomonas Vaginalis Amplif","PX-30002753","CDM","87661","CPT","0300","RC","","","","outpatient","","","273.00","163.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","198.53","72.72","","191.98","191.98","191.98","1 through 10","33.29","211.3","percent of total billed charges",""
"Trichomonas Vaginalis Amplif","PX-30002753","CDM","87661","CPT","0300","RC","","","","outpatient","","","273.00","163.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","145.29","53.22","","140.74","140.74","140.74","1 through 10","33.29","211.3","percent of total billed charges",""
"Trichomonas Vaginalis Amplif","PX-30002753","CDM","87661","CPT","0300","RC","","","","outpatient","","","273.00","163.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","171.72","62.9","","166.32","166.32","166.32","63","33.29","211.3","percent of total billed charges",""
"Trichomonas Vaginalis Amplif","PX-30002753","CDM","87661","CPT","0300","RC","","","","outpatient","","","273.00","163.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","211.30","77.4","","204.60","204.60","204.60","18","33.29","211.3","percent of total billed charges",""
"Trichomonas Vaginalis Amplif","PX-30002753","CDM","87661","CPT","0300","RC","","","","outpatient","","","273.00","163.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","198.53","72.72","","191.98","191.98","191.98","1 through 10","33.29","211.3","percent of total billed charges",""
"Triglycerides","PX-30000708","CDM","84478","CPT","0300","RC","","","","inpatient","","","81.00","48.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","62.26","76.86","","49.14","49.14","49.14","1 through 10","53.62","62.26","percent of total billed charges",""
"Triglycerides","PX-30000708","CDM","84478","CPT","0301","RC","","","","both","","","81.00","48.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","56.54","69.8","","54.44","54.44","54.44","1 through 10","3.73","68.85","percent of total billed charges",""
"Triglycerides","PX-30000708","CDM","84478","CPT","0301","RC","","","","outpatient","","","81.00","48.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","58.90","72.72","","56.72","56.72","56.72","23","5.36","62.69","percent of total billed charges",""
"Triglycerides","PX-30000708","CDM","84478","CPT","0301","RC","","","","outpatient","","","81.00","48.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","43.11","53.22","","41.58","41.58","41.58","1 through 10","5.36","62.69","percent of total billed charges",""
"Triglycerides","PX-30000708","CDM","84478","CPT","0301","RC","","","","outpatient","","","81.00","48.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","50.95","62.9","","49.14","49.14","49.14","1 through 10","5.36","62.69","percent of total billed charges",""
"Triglycerides","PX-30000708","CDM","84478","CPT","0301","RC","","","","outpatient","","","81.00","48.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","62.69","77.4","","60.45","60.45","60.45","1 through 10","5.36","62.69","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","both","","","92.00","55.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","64.22","69.8","","62.12","55.98","62.12","1 through 10","11.01","87.29","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","both","","","92.00","55.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","78.20","85","","87.29","87.29","87.29","1 through 10","11.01","87.29","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","outpatient","","","92.00","55.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","57.76","62.78","","55.87","38.91","55.87","1 through 10","15.79","71.21","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","outpatient","","","92.00","55.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","40.22","43.72","","38.91","38.91","38.91","1 through 10","15.79","71.21","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","outpatient","","","92.00","55.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","66.90","72.72","","64.72","64.72","64.72","23","15.79","71.21","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","outpatient","","","92.00","55.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","48.96","53.22","","47.45","47.45","47.45","1 through 10","15.79","71.21","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","outpatient","","","92.00","55.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","57.87","62.9","","56.07","56.07","56.07","41","15.79","71.21","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","outpatient","","","92.00","55.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","71.21","77.4","","68.98","68.98","68.98","1 through 10","15.79","71.21","percent of total billed charges",""
"Triiodothyronine (T-3) Reverse","PX-30000713","CDM","84482","CPT","0301","RC","","","","both","","","181.00","108.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","126.34","69.8","","122.15","110.08","122.15","1 through 10","10.24","153.85","percent of total billed charges",""
"Triiodothyronine (T-3) Reverse","PX-30000713","CDM","84482","CPT","0301","RC","","","","outpatient","","","181.00","108.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","113.63","62.78","","109.87","109.87","109.87","1 through 10","17.4","140.09","percent of total billed charges",""
"Triiodothyronine (T-3) Reverse","PX-30000713","CDM","84482","CPT","0301","RC","","","","outpatient","","","181.00","108.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","131.62","72.72","","127.26","127.26","127.26","1 through 10","17.4","140.09","percent of total billed charges",""
"Triiodothyronine (T-3) Reverse","PX-30000713","CDM","84482","CPT","0301","RC","","","","outpatient","","","181.00","108.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","113.85","62.9","","110.25","110.25","110.25","1 through 10","17.4","140.09","percent of total billed charges",""
"Triiodothyronine (T-3) Reverse","PX-30000713","CDM","84482","CPT","0301","RC","","","","outpatient","","","181.00","108.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","140.09","77.4","","135.63","135.63","135.63","1 through 10","17.4","140.09","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","both","","","77.00","46.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","53.75","69.8","","51.65","16.16","51.65","39","9.22","73.73","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","outpatient","","","77.00","46.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","33.66","43.72","","32.35","32.35","32.35","1 through 10","13.22","59.6","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","outpatient","","","77.00","46.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","55.99","72.72","","53.81","53.81","393.41","39","13.22","59.6","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","outpatient","","","77.00","46.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","55.99","72.72","","53.81","53.81","53.81","1 through 10","13.22","59.6","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","outpatient","","","77.00","46.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","40.98","53.22","","39.45","39.45","39.45","1 through 10","13.22","59.6","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","outpatient","","","77.00","46.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","48.43","62.9","","46.62","46.62","46.62","43","13.22","59.6","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","outpatient","","","77.00","46.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","59.60","77.4","","57.35","57.34","57.35","25","13.22","59.6","percent of total billed charges",""
"Trimming Nails Dystrophic","PX-51000111","CDM","G0127","HCPCS","0510","RC","","","","both","","","79.00","47.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","55.14","69.8","","53.05","53.05","53.05","1 through 10","55.14","396.58","percent of total billed charges",""
"Trimming Nails Dystrophic","PX-51000111","CDM","G0127","HCPCS","0510","RC","","","","both","","","79.00","47.40","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","63.30","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","62.07","62.07","62.07","1 through 10","55.14","396.58","other","OPPS APC"
"Trimming Nails Dystrophic","PX-51000111","CDM","G0127","HCPCS","0510","RC","","","","both","","","79.00","47.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","62.06","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","61.73","60.83","62.07","1 through 10","55.14","396.58","other","OPPS APC"
"Trimming Nails Dystrophic","PX-51000111","CDM","G0127","HCPCS","0510","RC","","","","both","","","79.00","47.40","MEDICARE [2001]","HB WDH MEDICARE","62.06","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.07","62.07","62.07","91","55.14","396.58","other","OPPS APC"
"Trimming Nails Dystrophic","PX-51000111","CDM","G0127","HCPCS","0510","RC","","","","both","","","79.00","47.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","62.06","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","60.83","60.83","60.83","70","55.14","396.58","other","OPPS APC"
"Trimming Nails Dystrophic","PX-51000111","CDM","G0127","HCPCS","0510","RC","","","","both","","","79.00","47.40","WELLSENSE NH [1050]","HB WDH MEDICARE","62.06","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","64.13","64.13","64.13","1 through 10","55.14","396.58","other","OPPS APC"
"Trimming Nails Dystrophic","PX-51000111","CDM","G0127","HCPCS","0510","RC","","","","outpatient","","","79.00","47.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","11.39","14.42","","10.96","10.96","10.96","1 through 10","9.19","61.15","percent of total billed charges",""
"Trimming Nails Dystrophic","PX-51000111","CDM","G0127","HCPCS","0510","RC","","","","outpatient","","","79.00","47.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","9.19","11.63","","10.47","9.30","19.20","11","9.19","61.15","percent of total billed charges",""
"Trimming Nails Dystrophic","PX-51000111","CDM","G0127","HCPCS","0510","RC","","","","outpatient","","","79.00","47.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","49.69","62.9","","47.88","47.88","47.88","1 through 10","9.19","61.15","percent of total billed charges",""
"Trimming Nails Dystrophic","PX-51000111","CDM","G0127","HCPCS","0510","RC","","","","outpatient","","","79.00","47.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","9.19","11.63","","8.98","8.98","99.31","1 through 10","9.19","61.15","percent of total billed charges",""
"Trimming Nails Nondystrophic","PX-76000086","CDM","11719","CPT","0761","RC","","","","both","","","79.00","47.40","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","63.30","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 102%.","62.07","62.07","62.07","1 through 10","44.95","396.58","other","OPPS APC"
"Trimming Nails Nondystrophic","PX-76000086","CDM","11719","CPT","0761","RC","","","","both","","","79.00","47.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","396.58","","Case rate ($396.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","79.00","79.00","79.00","1 through 10","44.95","396.58","other","OPPS APC"
"Trimming Nails Nondystrophic","PX-76000086","CDM","11719","CPT","0761","RC","","","","both","","","79.00","47.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","60.82","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","60.83","60.83","61.83","1 through 10","44.95","396.58","other","OPPS APC"
"Trimming Nails Nondystrophic","PX-76000086","CDM","11719","CPT","0761","RC","","","","both","","","79.00","47.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","63.92","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","63.93","63.93","63.93","1 through 10","44.95","396.58","other","OPPS APC"
"Trimming Nails Nondystrophic","PX-76000086","CDM","11719","CPT","0761","RC","","","","both","","","79.00","47.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","62.06","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","61.73","61.73","62.07","1 through 10","44.95","396.58","other","OPPS APC"
"Trimming Nails Nondystrophic","PX-76000086","CDM","11719","CPT","0761","RC","","","","both","","","79.00","47.40","MEDICARE [2001]","HB WDH MEDICARE","62.06","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.07","62.07","62.07","60","44.95","396.58","other","OPPS APC"
"Trimming Nails Nondystrophic","PX-76000086","CDM","11719","CPT","0761","RC","","","","both","","","79.00","47.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","62.06","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","60.83","60.83","60.83","35","44.95","396.58","other","OPPS APC"
"Trimming Nails Nondystrophic","PX-76000086","CDM","11719","CPT","0761","RC","","","","both","","","79.00","47.40","WELLSENSE NH [1050]","HB WDH MEDICARE","62.06","","APC Price ($62.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","220.51","64.47","220.51","1 through 10","44.95","396.58","other","OPPS APC"
"Trimming Nails Nondystrophic","PX-76000086","CDM","11719","CPT","0761","RC","","","","outpatient","","","79.00","47.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","11.39","14.42","","11.39","11.39","11.39","1 through 10","9.19","61.15","percent of total billed charges",""
"Trimming Nails Nondystrophic","PX-76000086","CDM","11719","CPT","0761","RC","","","","outpatient","","","79.00","47.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","9.19","11.63","","10.88","9.67","10.88","1 through 10","9.19","61.15","percent of total billed charges",""
"Trimming Nails Nondystrophic","PX-76000086","CDM","11719","CPT","0761","RC","","","","outpatient","","","79.00","47.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","57.45","57.45","57.45","1 through 10","9.19","61.15","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Trimming Nails Nondystrophic","PX-76000086","CDM","11719","CPT","0761","RC","","","","outpatient","","","79.00","47.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","9.19","11.63","","79.00","79.00","79.00","1 through 10","9.19","61.15","percent of total billed charges",""
"TROCAR NONTHREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095295","CDM","C1769","HCPCS","0272","RC","","","","both","","","161.42","96.85","AETNA [1001]","HB WDH AETNA COMMERCIAL","112.67","69.8","","279.80","225.71","279.80","16","18.77","137.21","percent of total billed charges",""
"TROCAR NONTHREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095295","CDM","C1769","HCPCS","0272","RC","","","","both","","","161.42","96.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","18.77","137.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TROCAR NONTHREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095295","CDM","C1769","HCPCS","0272","RC","","","","both","","","161.42","96.85","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","91.85","56.9","","18.95","9.41","1260.18","1 through 10","18.77","137.21","percent of total billed charges",""
"TROCAR NONTHREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095295","CDM","C1769","HCPCS","0272","RC","","","","both","","","161.42","96.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","18.77","11.63","","37.78","11.63","183.64","21","18.77","137.21","percent of total billed charges",""
"TROCAR NONTHREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095295","CDM","C1769","HCPCS","0272","RC","","","","both","","","161.42","96.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","124.94","77.4","","225.79","68.39","1154.35","11","18.77","137.21","percent of total billed charges",""
"TROCAR NONTHREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095295","CDM","C1769","HCPCS","0272","RC","","","","both","","","161.42","96.85","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","18.77","137.21","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TROCAR NONTHREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095295","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","161.42","96.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","18.77","11.63","","37.78","11.63","183.64","21","18.77","124.94","percent of total billed charges",""
"TROCAR NONTHREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095295","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","161.42","96.85","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","101.34","62.78","","123.83","114.55","572.63","1 through 10","18.77","124.94","percent of total billed charges",""
"TROCAR NONTHREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095295","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","161.42","96.85","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","70.57","43.72","","127.38","127.38","148.03","1 through 10","18.77","124.94","percent of total billed charges",""
"TROCAR NONTHREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095295","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","161.42","96.85","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","117.38","72.72","","196.34","62.16","1727.00","33","18.77","124.94","percent of total billed charges",""
"TROCAR NONTHREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095295","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","161.42","96.85","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","117.38","72.72","","173.00","173.00","173.00","1 through 10","18.77","124.94","percent of total billed charges",""
"TROCAR NONTHREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095295","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","161.42","96.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","85.91","53.22","","205.24","190.08","205.24","1 through 10","18.77","124.94","percent of total billed charges",""
"TROCAR NONTHREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095295","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","161.42","96.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","101.53","62.9","","305.08","81.02","4529.24","103","18.77","124.94","percent of total billed charges",""
"TROCAR NONTHREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095295","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","161.42","96.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","124.94","77.4","","225.79","68.39","1154.35","11","18.77","124.94","percent of total billed charges",""
"TROCAR THREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095294","CDM","C1769","HCPCS","0272","RC","","","","both","","","165.84","99.50","AETNA [1001]","HB WDH AETNA COMMERCIAL","115.76","69.8","","279.80","225.71","279.80","16","19.29","140.96","percent of total billed charges",""
"TROCAR THREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095294","CDM","C1769","HCPCS","0272","RC","","","","both","","","165.84","99.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","291.34","291.34","291.34","1 through 10","19.29","140.96","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TROCAR THREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095294","CDM","C1769","HCPCS","0272","RC","","","","both","","","165.84","99.50","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","94.36","56.9","","18.95","9.41","1260.18","1 through 10","19.29","140.96","percent of total billed charges",""
"TROCAR THREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095294","CDM","C1769","HCPCS","0272","RC","","","","both","","","165.84","99.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","19.29","11.63","","37.78","11.63","183.64","21","19.29","140.96","percent of total billed charges",""
"TROCAR THREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095294","CDM","C1769","HCPCS","0272","RC","","","","both","","","165.84","99.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","128.36","77.4","","225.79","68.39","1154.35","11","19.29","140.96","percent of total billed charges",""
"TROCAR THREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095294","CDM","C1769","HCPCS","0272","RC","","","","both","","","165.84","99.50","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","90.12","90.12","90.12","1 through 10","19.29","140.96","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TROCAR THREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095294","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","165.84","99.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","19.29","11.63","","37.78","11.63","183.64","21","19.29","128.36","percent of total billed charges",""
"TROCAR THREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095294","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","165.84","99.50","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","104.11","62.78","","123.83","114.55","572.63","1 through 10","19.29","128.36","percent of total billed charges",""
"TROCAR THREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095294","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","165.84","99.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","72.51","43.72","","127.38","127.38","148.03","1 through 10","19.29","128.36","percent of total billed charges",""
"TROCAR THREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095294","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","165.84","99.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","120.60","72.72","","196.34","62.16","1727.00","33","19.29","128.36","percent of total billed charges",""
"TROCAR THREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095294","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","165.84","99.50","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","120.60","72.72","","173.00","173.00","173.00","1 through 10","19.29","128.36","percent of total billed charges",""
"TROCAR THREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095294","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","165.84","99.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","88.26","53.22","","205.24","190.08","205.24","1 through 10","19.29","128.36","percent of total billed charges",""
"TROCAR THREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095294","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","165.84","99.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","104.31","62.9","","305.08","81.02","4529.24","103","19.29","128.36","percent of total billed charges",""
"TROCAR THREADED 1.6MM 220 GUIDEWIRE ORTHOPEDIC SS POINT","SUP-ITM-10095294","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","165.84","99.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","128.36","77.4","","225.79","68.39","1154.35","11","19.29","128.36","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0300","RC","","","","inpatient","","","144.00","86.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","110.68","76.86","","87.57","87.57","87.57","1 through 10","95.33","110.68","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","both","","","144.00","86.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","100.51","69.8","","97.02","87.43","97.02","98","8.11","122.4","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","both","","","144.00","86.40","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","100.51","69.8","","97.02","97.02","97.02","1 through 10","8.11","122.4","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","both","","","144.00","86.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","122.40","85","","73.94","73.94","73.94","1 through 10","8.11","122.4","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","outpatient","","","144.00","86.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","90.40","62.78","","174.53","87.26","174.53","1 through 10","9.17","111.46","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","outpatient","","","144.00","86.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","62.96","43.72","","60.77","60.77","182.31","1 through 10","9.17","111.46","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","outpatient","","","144.00","86.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","104.72","72.72","","101.08","101.08","202.16","107","9.17","111.46","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","outpatient","","","144.00","86.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","104.72","72.72","","404.32","202.16","404.32","1 through 10","9.17","111.46","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","outpatient","","","144.00","86.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","76.64","53.22","","222.30","222.30","222.30","1 through 10","9.17","111.46","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","outpatient","","","144.00","86.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","90.58","62.9","","87.57","87.57","326.62","189","9.17","111.46","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","outpatient","","","144.00","86.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","111.46","77.4","","107.73","107.73","215.45","51","9.17","111.46","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","outpatient","","","144.00","86.40","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","104.72","72.72","","101.08","101.08","101.08","1 through 10","9.17","111.46","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0300","RC","","","","inpatient","","","200.00","120.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","153.72","76.86","","121.59","121.59","121.59","1 through 10","132.4","153.72","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","both","","","200.00","120.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","139.60","69.8","","134.71","14.76","134.71","17","11.23","170","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","145.44","72.72","","140.35","140.35","140.35","16","12.06","154.8","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","145.44","72.72","","140.35","140.35","140.35","1 through 10","12.06","154.8","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","106.44","53.22","","102.89","102.89","102.89","1 through 10","12.06","154.8","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","125.80","62.9","","243.18","121.59","364.77","19","12.06","154.8","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","outpatient","","","200.00","120.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","154.80","77.4","","149.58","138.91","149.58","12","12.06","154.8","percent of total billed charges",""
"TUBE EUSTACHIAN 6X16MM AERA BALLOON DILATION PK/5EA","SUP-ITM-10185058","CDM","C1726","HCPCS","0272","RC","","","","both","","","8002.50","4801.50","AETNA [1001]","HB WDH AETNA COMMERCIAL","5585.75","69.8","","166.96","137.81","825.49","1 through 10","930.69","6802.13","percent of total billed charges",""
"TUBE EUSTACHIAN 6X16MM AERA BALLOON DILATION PK/5EA","SUP-ITM-10185058","CDM","C1726","HCPCS","0272","RC","","","","both","","","8002.50","4801.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1716.86","1716.86","1716.86","1 through 10","930.69","6802.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TUBE EUSTACHIAN 6X16MM AERA BALLOON DILATION PK/5EA","SUP-ITM-10185058","CDM","C1726","HCPCS","0272","RC","","","","both","","","8002.50","4801.50","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","4281.09","1182.65","4281.09","1 through 10","930.69","6802.13","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TUBE EUSTACHIAN 6X16MM AERA BALLOON DILATION PK/5EA","SUP-ITM-10185058","CDM","C1726","HCPCS","0272","RC","","","","both","","","8002.50","4801.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","930.69","11.63","","262.01","27.19","426.66","1 through 10","930.69","6802.13","percent of total billed charges",""
"TUBE EUSTACHIAN 6X16MM AERA BALLOON DILATION PK/5EA","SUP-ITM-10185058","CDM","C1726","HCPCS","0272","RC","","","","both","","","8002.50","4801.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6193.94","77.4","","1411.46","916.55","1411.46","1 through 10","930.69","6802.13","percent of total billed charges",""
"TUBE EUSTACHIAN 6X16MM AERA BALLOON DILATION PK/5EA","SUP-ITM-10185058","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","8002.50","4801.50","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","930.69","11.63","","262.01","27.19","426.66","1 through 10","930.69","6193.94","percent of total billed charges",""
"TUBE EUSTACHIAN 6X16MM AERA BALLOON DILATION PK/5EA","SUP-ITM-10185058","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","8002.50","4801.50","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3498.69","43.72","","517.05","517.05","517.05","1 through 10","930.69","6193.94","percent of total billed charges",""
"TUBE EUSTACHIAN 6X16MM AERA BALLOON DILATION PK/5EA","SUP-ITM-10185058","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","8002.50","4801.50","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5819.42","72.72","","1556.61","860.02","1914.17","1 through 10","930.69","6193.94","percent of total billed charges",""
"TUBE EUSTACHIAN 6X16MM AERA BALLOON DILATION PK/5EA","SUP-ITM-10185058","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","8002.50","4801.50","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","5033.57","62.9","","1348.55","745.07","1348.55","19","930.69","6193.94","percent of total billed charges",""
"TUBE EUSTACHIAN 6X16MM AERA BALLOON DILATION PK/5EA","SUP-ITM-10185058","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","8002.50","4801.50","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","6193.94","77.4","","1411.46","916.55","1411.46","1 through 10","930.69","6193.94","percent of total billed charges",""
"TUBE EUSTACHIAN 6X16MM AERA BALLOON DILATION PK/5EA","SUP-ITM-10185058","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","8002.50","4801.50","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","5819.42","72.72","","860.02","860.02","860.02","1 through 10","930.69","6193.94","percent of total billed charges",""
"TUBE SUCTION 10FRX4.25IN 90DEG FRAZIER ANGLED FINGER CUT OFF STYLET THUMB PC CURVED PC/1EA","SUP-ITM-10049214","CDM","C1776","HCPCS","0278","RC","","","","both","","","135.30","81.18","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","3537.05","3537.05","3537.05","1 through 10","15.74","115.01","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"TUBE SUCTION 10FRX4.25IN 90DEG FRAZIER ANGLED FINGER CUT OFF STYLET THUMB PC CURVED PC/1EA","SUP-ITM-10049214","CDM","C1776","HCPCS","0278","RC","","","","both","","","135.30","81.18","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","76.99","56.9","","2911.53","1863.86","5209.05","65","15.74","115.01","percent of total billed charges",""
"TUBE SUCTION 10FRX4.25IN 90DEG FRAZIER ANGLED FINGER CUT OFF STYLET THUMB PC CURVED PC/1EA","SUP-ITM-10049214","CDM","C1776","HCPCS","0278","RC","","","","both","","","135.30","81.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","15.74","11.63","","400.94","400.94","400.94","1 through 10","15.74","115.01","percent of total billed charges",""
"TUBE SUCTION 10FRX4.25IN 90DEG FRAZIER ANGLED FINGER CUT OFF STYLET THUMB PC CURVED PC/1EA","SUP-ITM-10049214","CDM","C1776","HCPCS","0278","RC","","","","both","","","135.30","81.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","104.72","77.4","","5214.50","5214.50","16415.28","1 through 10","15.74","115.01","percent of total billed charges",""
"TUBE SUCTION 10FRX4.25IN 90DEG FRAZIER ANGLED FINGER CUT OFF STYLET THUMB PC CURVED PC/1EA","SUP-ITM-10049214","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","135.30","81.18","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","15.74","11.63","","400.94","400.94","400.94","1 through 10","15.74","104.72","percent of total billed charges",""
"TUBE SUCTION 10FRX4.25IN 90DEG FRAZIER ANGLED FINGER CUT OFF STYLET THUMB PC CURVED PC/1EA","SUP-ITM-10049214","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","135.30","81.18","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","59.15","43.72","","1543.33","1543.33","1671.61","1 through 10","15.74","104.72","percent of total billed charges",""
"TUBE SUCTION 10FRX4.25IN 90DEG FRAZIER ANGLED FINGER CUT OFF STYLET THUMB PC CURVED PC/1EA","SUP-ITM-10049214","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","135.30","81.18","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","98.39","72.72","","3700.21","2382.07","6427.18","53","15.74","104.72","percent of total billed charges",""
"TUBE SUCTION 10FRX4.25IN 90DEG FRAZIER ANGLED FINGER CUT OFF STYLET THUMB PC CURVED PC/1EA","SUP-ITM-10049214","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","135.30","81.18","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","98.39","72.72","","12685.80","12685.80","12685.80","1 through 10","15.74","104.72","percent of total billed charges",""
"TUBE SUCTION 10FRX4.25IN 90DEG FRAZIER ANGLED FINGER CUT OFF STYLET THUMB PC CURVED PC/1EA","SUP-ITM-10049214","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","135.30","81.18","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","85.10","62.9","","3408.87","2784.05","9859.40","46","15.74","104.72","percent of total billed charges",""
"TUBE SUCTION 10FRX4.25IN 90DEG FRAZIER ANGLED FINGER CUT OFF STYLET THUMB PC CURVED PC/1EA","SUP-ITM-10049214","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","135.30","81.18","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","104.72","77.4","","5214.50","5214.50","16415.28","1 through 10","15.74","104.72","percent of total billed charges",""
"TUBE VENTILATION 8.5CMX1.27MM EAR BEVELED CURVED PK/5EA","SUP-ITM-10230130","CDM","L8699","HCPCS","0278","RC","","","","both","","","292.76","175.66","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","292.76","292.76","292.76","1 through 10","34.05","248.85","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","both","","","4400.08","2640.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","511.73","3740.07","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","both","","","4400.08","2640.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","511.73","3740.07","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","both","","","4400.08","2640.05","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2503.65","56.9","","812.12","238.65","1587.46","163","511.73","3740.07","percent of total billed charges",""
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","both","","","4400.08","2640.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","511.73","11.63","","112.68","112.68","146.99","38","511.73","3740.07","percent of total billed charges",""
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","both","","","4400.08","2640.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3405.66","77.4","","303.98","303.98","5854.79","1 through 10","511.73","3740.07","percent of total billed charges",""
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4400.08","2640.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","511.73","11.63","","112.68","112.68","146.99","38","511.73","3405.66","percent of total billed charges",""
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4400.08","2640.05","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2762.37","62.78","","780.86","208.94","10480.28","15","511.73","3405.66","percent of total billed charges",""
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4400.08","2640.05","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1923.71","43.72","","179.76","179.76","179.76","1 through 10","511.73","3405.66","percent of total billed charges",""
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4400.08","2640.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3199.74","72.72","","2355.45","298.99","3965.19","155","511.73","3405.66","percent of total billed charges",""
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4400.08","2640.05","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3199.74","72.72","","3643.09","3643.09","3643.09","1 through 10","511.73","3405.66","percent of total billed charges",""
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4400.08","2640.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2341.72","53.22","","554.28","554.28","554.28","16","511.73","3405.66","percent of total billed charges",""
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4400.08","2640.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2767.65","62.9","","619.64","173.09","2370.64","150","511.73","3405.66","percent of total billed charges",""
"ULNA PLATE 2.0MM 7 HOLE BONE LCP SS DISTAL","SUP-ITM-10079679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4400.08","2640.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","3405.66","77.4","","303.98","303.98","5854.79","1 through 10","511.73","3405.66","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","6668.15","4000.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","775.51","5667.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","6668.15","4000.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","775.51","5667.93","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","6668.15","4000.89","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","3794.18","56.9","","812.12","238.65","1587.46","163","775.51","5667.93","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","6668.15","4000.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","775.51","11.63","","112.68","112.68","146.99","38","775.51","5667.93","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","6668.15","4000.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5161.15","77.4","","303.98","303.98","5854.79","1 through 10","775.51","5667.93","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6668.15","4000.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","775.51","11.63","","112.68","112.68","146.99","38","775.51","5161.15","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6668.15","4000.89","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4186.26","62.78","","780.86","208.94","10480.28","15","775.51","5161.15","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6668.15","4000.89","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2915.32","43.72","","179.76","179.76","179.76","1 through 10","775.51","5161.15","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6668.15","4000.89","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","4849.08","72.72","","2355.45","298.99","3965.19","155","775.51","5161.15","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6668.15","4000.89","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","4849.08","72.72","","3643.09","3643.09","3643.09","1 through 10","775.51","5161.15","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6668.15","4000.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","3548.79","53.22","","554.28","554.28","554.28","16","775.51","5161.15","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6668.15","4000.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","4194.27","62.9","","619.64","173.09","2370.64","150","775.51","5161.15","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6668.15","4000.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5161.15","77.4","","303.98","303.98","5854.79","1 through 10","775.51","5161.15","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","5262.25","3157.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","612","4472.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","5262.25","3157.35","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","612","4472.91","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","5262.25","3157.35","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2994.22","56.9","","812.12","238.65","1587.46","163","612","4472.91","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","5262.25","3157.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","612.00","11.63","","112.68","112.68","146.99","38","612","4472.91","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","5262.25","3157.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4072.98","77.4","","303.98","303.98","5854.79","1 through 10","612","4472.91","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5262.25","3157.35","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","612.00","11.63","","112.68","112.68","146.99","38","612","4072.98","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5262.25","3157.35","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","3303.64","62.78","","780.86","208.94","10480.28","15","612","4072.98","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5262.25","3157.35","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","2300.66","43.72","","179.76","179.76","179.76","1 through 10","612","4072.98","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5262.25","3157.35","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3826.71","72.72","","2355.45","298.99","3965.19","155","612","4072.98","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5262.25","3157.35","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","3826.71","72.72","","3643.09","3643.09","3643.09","1 through 10","612","4072.98","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5262.25","3157.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","2800.57","53.22","","554.28","554.28","554.28","16","612","4072.98","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5262.25","3157.35","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","3309.96","62.9","","619.64","173.09","2370.64","150","612","4072.98","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5262.25","3157.35","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","4072.98","77.4","","303.98","303.98","5854.79","1 through 10","612","4072.98","percent of total billed charges",""
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With McC","278","MS-DRG","","","","","","","","inpatient","","","235464.00","141278.40","MEDICARE [2001]","HB WDH MEDICARE","42761.55","","Case rate ($42,761.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $39,502.70, add-ons for qualifying new technology services are included. If operating cost exceeds $43,420.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $50,897.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. The base transfer operating payment is the transfer adjustment factor * $39,224.41 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $39,057.83 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,092.27. The transfer capital threshold is the transfer adjustment factor * $3,092.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","38295.87","38295.87","38295.87","1 through 10","3975","211516.16","other","Inpatient DRG"
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","","","","inpatient","","","178305.07","106983.04","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","23764.93","","Case rate ($23,072.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $21,330.16, add-ons for qualifying new technology services are included. If operating cost exceeds $25,248.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,458.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $20,974.37 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $20,885.29 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,653.52. The transfer capital threshold is the transfer adjustment factor * $1,653.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","23249.73","23249.73","23249.73","1 through 10","4637","113103.5","other","Inpatient DRG"
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","","","","inpatient","","","178305.07","106983.04","MEDICARE [2001]","HB WDH MEDICARE","23072.75","","Case rate ($23,072.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $21,330.16, add-ons for qualifying new technology services are included. If operating cost exceeds $25,248.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,458.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $20,974.37 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $20,885.29 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,653.52. The transfer capital threshold is the transfer adjustment factor * $1,653.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","23659.42","23659.42","23659.42","1 through 10","4637","113103.5","other","Inpatient DRG"
"Uncomplicated Peptic Ulcer Without McC","384","MS-DRG","","","","","","","","inpatient","","","36974.78","22184.87","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","17514.85","","Fee schedule rate ($17,514.85). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($145,269), then multiplying the difference by the percent of outlier that is reimbursed (74.6%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","17818.10","17818.10","17818.10","1 through 10","4637","32482.49","case rate",""
"Upgradeable Lens Iol Posterior Chamber","PX-27002286","CDM","V2632","HCPCS","0276","RC","","","","outpatient","","","446.00","267.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","280.53","62.9","","648.64","518.04","648.64","1 through 10","51.87","345.2","percent of total billed charges",""
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","","","","inpatient","","","53835.51","32301.31","MEDICARE [2001]","HB WDH MEDICARE","13353.04","","Case rate ($13,353.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $12,358.97, add-ons for qualifying new technology services are included. If operating cost exceeds $16,277.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,748.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $11,964.92 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $11,914.10 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $943.26. The transfer capital threshold is the transfer adjustment factor * $943.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","13258.00","13258.00","13258.00","1 through 10","3975","64520.37","other","Inpatient DRG"
"Upper Limb And Toe Amputation For Circulatory System Disorders With McC","255","MS-DRG","","","","","","","","inpatient","","","74347.83","44608.70","MEDICARE [2001]","HB WDH MEDICARE","20951.67","","Case rate ($20,951.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $19,372.43, add-ons for qualifying new technology services are included. If operating cost exceeds $23,290.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,303.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $19,008.29 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $18,927.56 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,498.52. The transfer capital threshold is the transfer adjustment factor * $1,498.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20239.19","20239.19","20239.19","1 through 10","3975","102501.47","other","Inpatient DRG"
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","both","","","57.00","34.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","39.79","69.8","","38.39","34.60","38.39","19","2.57","48.45","percent of total billed charges",""
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","outpatient","","","57.00","34.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","41.45","72.72","","40.00","40.00","40.00","14","3.68","44.12","percent of total billed charges",""
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","outpatient","","","57.00","34.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","30.34","53.22","","29.32","29.32","29.32","1 through 10","3.68","44.12","percent of total billed charges",""
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","outpatient","","","57.00","34.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","35.85","62.9","","34.65","34.65","138.60","19","3.68","44.12","percent of total billed charges",""
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","outpatient","","","57.00","34.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","44.12","77.4","","42.63","42.63","42.63","1 through 10","3.68","44.12","percent of total billed charges",""
"Urea Nitrogen Urine","PX-30000723","CDM","84540","CPT","0301","RC","","","","outpatient","","","68.00","40.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","52.63","77.4","","51.15","51.15","51.15","1 through 10","4.43","52.63","percent of total billed charges",""
"URETEROSCOPE LITHOVUE DIGITAL FLEX STD DEFLECTION","SUP-ITM-10165176","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","5077.95","69.8","","5077.95","5077.95","5077.95","1 through 10","846.08","6183.75","percent of total billed charges",""
"URETEROSCOPE LITHOVUE DIGITAL FLEX STD DEFLECTION","SUP-ITM-10165176","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","","27.90","27.9% of billed. Final payment is multiplied by 102%.","2017.24","1433.22","2017.24","1 through 10","846.08","6183.75","other","OPPS APC"
"URETEROSCOPE LITHOVUE DIGITAL FLEX STD DEFLECTION","SUP-ITM-10165176","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1613.60","1613.60","3131.77","1 through 10","846.08","6183.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"URETEROSCOPE LITHOVUE DIGITAL FLEX STD DEFLECTION","SUP-ITM-10165176","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1613.60","1613.60","1613.60","1 through 10","846.08","6183.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"URETEROSCOPE LITHOVUE DIGITAL FLEX STD DEFLECTION","SUP-ITM-10165176","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","","27.90","27.9% of billed. Final payment is multiplied by 98%.","1440.49","1404.56","10725.54","11","846.08","6183.75","other","OPPS APC"
"URETEROSCOPE LITHOVUE DIGITAL FLEX STD DEFLECTION","SUP-ITM-10165176","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","1613.60","1613.60","3131.78","14","846.08","6183.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"URETEROSCOPE LITHOVUE DIGITAL FLEX STD DEFLECTION","SUP-ITM-10165176","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4139.48","56.9","","4139.48","4139.47","5651.63","1 through 10","846.08","6183.75","percent of total billed charges",""
"URETEROSCOPE LITHOVUE DIGITAL FLEX STD DEFLECTION","SUP-ITM-10165176","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1049.06","14.42","","899.19","899.19","1049.06","1 through 10","846.08","6183.75","percent of total billed charges",""
"URETEROSCOPE LITHOVUE DIGITAL FLEX STD DEFLECTION","SUP-ITM-10165176","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","846.08","11.63","","1001.77","1001.77","1001.77","1 through 10","846.08","6183.75","percent of total billed charges",""
"URETEROSCOPE LITHOVUE DIGITAL FLEX STD DEFLECTION","SUP-ITM-10165176","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","","27.90","27.9% of billed. Final payment is multiplied by 103%.","14119.80","1552.69","14119.80","1 through 10","846.08","6183.75","other","OPPS APC"
"URETEROSCOPE LITHOVUE DIGITAL FLEX STD DEFLECTION","SUP-ITM-10165176","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","MEDICARE [2001]","HB WDH MEDICARE","","27.90","27.9% of billed.","1828.04","1433.22","4511.67","49","846.08","6183.75","other","OPPS APC"
"URETEROSCOPE LITHOVUE DIGITAL FLEX STD DEFLECTION","SUP-ITM-10165176","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","","27.90","27.9% of billed.","1458.84","1404.56","1816.58","20","846.08","6183.75","other","OPPS APC"
"URETEROSCOPE LITHOVUE DIGITAL FLEX STD DEFLECTION","SUP-ITM-10165176","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5630.85","77.4","","10942.85","10942.85","10942.85","1 through 10","846.08","6183.75","percent of total billed charges",""
"URETEROSCOPE LITHOVUE DIGITAL FLEX STD DEFLECTION","SUP-ITM-10165176","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","WELLSENSE NH [1050]","HB WDH MEDICARE","","27.90","27.9% of billed.","6226.53","6226.53","6226.53","1 through 10","846.08","6183.75","other","OPPS APC"
"URETEROSCOPE LITHOVUE DIGITAL FLEX STD DEFLECTION","SUP-ITM-10165176","CDM","C1747","HCPCS","0272","RC","","","","outpatient","","","7275.00","4365.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1049.06","14.42","","899.19","899.19","1049.06","1 through 10","846.08","5630.85","percent of total billed charges",""
"URETEROSCOPE LITHOVUE DIGITAL FLEX STD DEFLECTION","SUP-ITM-10165176","CDM","C1747","HCPCS","0272","RC","","","","outpatient","","","7275.00","4365.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","846.08","11.63","","1001.77","1001.77","1001.77","1 through 10","846.08","5630.85","percent of total billed charges",""
"URETEROSCOPE LITHOVUE DIGITAL FLEX STD DEFLECTION","SUP-ITM-10165176","CDM","C1747","HCPCS","0272","RC","","","","outpatient","","","7275.00","4365.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4567.25","62.78","","4567.25","4567.25","4567.25","1 through 10","846.08","5630.85","percent of total billed charges",""
"URETEROSCOPE LITHOVUE DIGITAL FLEX STD DEFLECTION","SUP-ITM-10165176","CDM","C1747","HCPCS","0272","RC","","","","outpatient","","","7275.00","4365.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3180.63","43.72","","3180.63","3180.63","3180.63","1 through 10","846.08","5630.85","percent of total billed charges",""
"URETEROSCOPE LITHOVUE DIGITAL FLEX STD DEFLECTION","SUP-ITM-10165176","CDM","C1747","HCPCS","0272","RC","","","","outpatient","","","7275.00","4365.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5290.38","72.72","","5290.38","5290.38","5290.38","1 through 10","846.08","5630.85","percent of total billed charges",""
"URETEROSCOPE LITHOVUE DIGITAL FLEX STD DEFLECTION","SUP-ITM-10165176","CDM","C1747","HCPCS","0272","RC","","","","outpatient","","","7275.00","4365.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5630.85","77.4","","10942.85","10942.85","10942.85","1 through 10","846.08","5630.85","percent of total billed charges",""
"URETEROSCOPE LITHOVUE EMPOWER BUNDLE FLEXIBLE","SUP-ITM-10281687","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","5077.95","69.8","","5077.95","5077.95","5077.95","1 through 10","846.08","6183.75","percent of total billed charges",""
"URETEROSCOPE LITHOVUE EMPOWER BUNDLE FLEXIBLE","SUP-ITM-10281687","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","AETNA [1001]","HB WDH AETNA MEDICARE REPLACEMENT","","27.90","27.9% of billed. Final payment is multiplied by 102%.","2017.24","1433.22","2017.24","1 through 10","846.08","6183.75","other","OPPS APC"
"URETEROSCOPE LITHOVUE EMPOWER BUNDLE FLEXIBLE","SUP-ITM-10281687","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1613.60","1613.60","3131.77","1 through 10","846.08","6183.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"URETEROSCOPE LITHOVUE EMPOWER BUNDLE FLEXIBLE","SUP-ITM-10281687","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","1613.60","1613.60","1613.60","1 through 10","846.08","6183.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"URETEROSCOPE LITHOVUE EMPOWER BUNDLE FLEXIBLE","SUP-ITM-10281687","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","","27.90","27.9% of billed. Final payment is multiplied by 98%.","1440.49","1404.56","10725.54","11","846.08","6183.75","other","OPPS APC"
"URETEROSCOPE LITHOVUE EMPOWER BUNDLE FLEXIBLE","SUP-ITM-10281687","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","1613.60","1613.60","3131.78","14","846.08","6183.75","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"URETEROSCOPE LITHOVUE EMPOWER BUNDLE FLEXIBLE","SUP-ITM-10281687","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","4139.48","56.9","","4139.48","4139.47","5651.63","1 through 10","846.08","6183.75","percent of total billed charges",""
"URETEROSCOPE LITHOVUE EMPOWER BUNDLE FLEXIBLE","SUP-ITM-10281687","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1049.06","14.42","","899.19","899.19","1049.06","1 through 10","846.08","6183.75","percent of total billed charges",""
"URETEROSCOPE LITHOVUE EMPOWER BUNDLE FLEXIBLE","SUP-ITM-10281687","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","846.08","11.63","","1001.77","1001.77","1001.77","1 through 10","846.08","6183.75","percent of total billed charges",""
"URETEROSCOPE LITHOVUE EMPOWER BUNDLE FLEXIBLE","SUP-ITM-10281687","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","","27.90","27.9% of billed. Final payment is multiplied by 103%.","14119.80","1552.69","14119.80","1 through 10","846.08","6183.75","other","OPPS APC"
"URETEROSCOPE LITHOVUE EMPOWER BUNDLE FLEXIBLE","SUP-ITM-10281687","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","MEDICARE [2001]","HB WDH MEDICARE","","27.90","27.9% of billed.","1828.04","1433.22","4511.67","49","846.08","6183.75","other","OPPS APC"
"URETEROSCOPE LITHOVUE EMPOWER BUNDLE FLEXIBLE","SUP-ITM-10281687","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","","27.90","27.9% of billed.","1458.84","1404.56","1816.58","20","846.08","6183.75","other","OPPS APC"
"URETEROSCOPE LITHOVUE EMPOWER BUNDLE FLEXIBLE","SUP-ITM-10281687","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5630.85","77.4","","10942.85","10942.85","10942.85","1 through 10","846.08","6183.75","percent of total billed charges",""
"URETEROSCOPE LITHOVUE EMPOWER BUNDLE FLEXIBLE","SUP-ITM-10281687","CDM","C1747","HCPCS","0272","RC","","","","both","","","7275.00","4365.00","WELLSENSE NH [1050]","HB WDH MEDICARE","","27.90","27.9% of billed.","6226.53","6226.53","6226.53","1 through 10","846.08","6183.75","other","OPPS APC"
"URETEROSCOPE LITHOVUE EMPOWER BUNDLE FLEXIBLE","SUP-ITM-10281687","CDM","C1747","HCPCS","0272","RC","","","","outpatient","","","7275.00","4365.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","1049.06","14.42","","899.19","899.19","1049.06","1 through 10","846.08","5630.85","percent of total billed charges",""
"URETEROSCOPE LITHOVUE EMPOWER BUNDLE FLEXIBLE","SUP-ITM-10281687","CDM","C1747","HCPCS","0272","RC","","","","outpatient","","","7275.00","4365.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","846.08","11.63","","1001.77","1001.77","1001.77","1 through 10","846.08","5630.85","percent of total billed charges",""
"URETEROSCOPE LITHOVUE EMPOWER BUNDLE FLEXIBLE","SUP-ITM-10281687","CDM","C1747","HCPCS","0272","RC","","","","outpatient","","","7275.00","4365.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","4567.25","62.78","","4567.25","4567.25","4567.25","1 through 10","846.08","5630.85","percent of total billed charges",""
"URETEROSCOPE LITHOVUE EMPOWER BUNDLE FLEXIBLE","SUP-ITM-10281687","CDM","C1747","HCPCS","0272","RC","","","","outpatient","","","7275.00","4365.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","3180.63","43.72","","3180.63","3180.63","3180.63","1 through 10","846.08","5630.85","percent of total billed charges",""
"URETEROSCOPE LITHOVUE EMPOWER BUNDLE FLEXIBLE","SUP-ITM-10281687","CDM","C1747","HCPCS","0272","RC","","","","outpatient","","","7275.00","4365.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","5290.38","72.72","","5290.38","5290.38","5290.38","1 through 10","846.08","5630.85","percent of total billed charges",""
"URETEROSCOPE LITHOVUE EMPOWER BUNDLE FLEXIBLE","SUP-ITM-10281687","CDM","C1747","HCPCS","0272","RC","","","","outpatient","","","7275.00","4365.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","5630.85","77.4","","10942.85","10942.85","10942.85","1 through 10","846.08","5630.85","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","65.00","39.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","45.37","69.8","","43.97","39.63","43.97","56","2.94","55.25","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","65.00","39.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","45.37","69.8","","5.83","5.83","5.83","1 through 10","2.94","55.25","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","65.00","39.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","55.25","85","","6.33","6.33","6.33","1 through 10","2.94","55.25","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","outpatient","","","65.00","39.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","40.81","62.78","","39.55","39.55","39.55","1 through 10","4.2","50.31","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","outpatient","","","65.00","39.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","47.27","72.72","","45.81","45.81","45.81","75","4.2","50.31","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","outpatient","","","65.00","39.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","47.27","72.72","","45.81","43.78","45.81","1 through 10","4.2","50.31","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","outpatient","","","65.00","39.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","34.59","53.22","","33.59","33.59","33.59","1 through 10","4.2","50.31","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","outpatient","","","65.00","39.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","40.89","62.9","","39.69","39.69","119.07","79","4.2","50.31","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","outpatient","","","65.00","39.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","50.31","77.4","","48.83","48.83","48.83","38","4.2","50.31","percent of total billed charges",""
"Uric Acid Other Source","PX-30000726","CDM","84560","CPT","0301","RC","","","","outpatient","","","68.00","40.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","42.77","62.9","","41.58","41.58","41.58","1 through 10","4.43","52.63","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0300","RC","","","","inpatient","","","47.00","28.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","36.12","76.86","","28.35","27.12","54.24","1 through 10","31.11","36.12","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","47.00","28.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","32.81","69.8","","31.41","28.31","31.41","240","2.06","39.95","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","47.00","28.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","39.95","85","","71.61","3.80","71.61","1 through 10","2.06","39.95","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","47.00","28.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","29.51","62.78","","28.25","28.25","84.75","13","2.95","36.38","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","47.00","28.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","20.55","43.72","","19.67","19.67","19.67","40","2.95","36.38","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","47.00","28.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","34.18","72.72","","32.72","32.72","78.81","377","2.95","36.38","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","47.00","28.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","34.18","72.72","","32.72","32.72","32.72","24","2.95","36.38","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","47.00","28.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","25.01","53.22","","23.99","23.99","23.99","27","2.95","36.38","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","47.00","28.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","29.56","62.9","","28.35","28.35","85.05","489","2.95","36.38","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","47.00","28.20","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","34.18","72.72","","32.72","32.72","32.72","1 through 10","2.95","36.38","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","47.00","28.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","36.38","77.4","","34.88","34.87","34.88","146","2.95","36.38","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","47.00","28.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","34.18","72.72","","32.72","32.72","32.72","1 through 10","2.95","36.38","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","33.00","19.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","23.03","69.8","","22.34","20.13","22.34","68","1.46","28.05","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","33.00","19.80","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","23.03","69.8","","22.34","22.34","22.34","1 through 10","1.46","28.05","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","33.00","19.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","28.05","85","","32.00","3.15","151.24","1 through 10","1.46","28.05","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","outpatient","","","33.00","19.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","20.72","62.78","","20.09","20.09","60.27","13","1.66","25.54","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","outpatient","","","33.00","19.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","14.43","43.72","","13.99","13.99","13.99","1 through 10","1.66","25.54","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","outpatient","","","33.00","19.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","24.00","72.72","","23.27","23.27","32.00","185","1.66","25.54","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","outpatient","","","33.00","19.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","24.00","72.72","","23.27","23.27","23.27","1 through 10","1.66","25.54","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","outpatient","","","33.00","19.80","INTERNATIONAL COMMERCIAL [140001]","HB WDH UNITED HMO / PPO / INDEM","25.54","77.4","","24.80","24.80","24.80","1 through 10","1.66","25.54","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","outpatient","","","33.00","19.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","17.56","53.22","","17.06","17.06","34.12","1 through 10","1.66","25.54","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","outpatient","","","33.00","19.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","20.76","62.9","","20.16","20.16","20.16","243","1.66","25.54","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","outpatient","","","33.00","19.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","25.54","77.4","","24.80","24.79","24.80","93","1.66","25.54","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","outpatient","","","33.00","19.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","24.00","72.72","","23.27","23.27","23.27","1 through 10","1.66","25.54","percent of total billed charges",""
"Urinalysis Micro Only","PX-30001379","CDM","81015","CPT","0307","RC","","","","both","","","41.00","24.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","28.62","69.8","","27.92","27.92","27.92","1 through 10","1.98","34.85","percent of total billed charges",""
"Urinalysis Micro Only","PX-30001379","CDM","81015","CPT","0307","RC","","","","outpatient","","","41.00","24.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","25.79","62.9","","25.20","25.20","25.20","1 through 10","2.83","31.73","percent of total billed charges",""
"Urinary Stones With McC","693","MS-DRG","","","","","","","","inpatient","","","22929.10","13757.46","MEDICARE [2001]","HB WDH MEDICARE","10666.35","","Case rate ($10,666.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,879.18, add-ons for qualifying new technology services are included. If operating cost exceeds $13,797.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,551.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $9,474.55 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $9,434.31 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $746.93. The transfer capital threshold is the transfer adjustment factor * $746.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11539.78","11539.78","11539.78","1 through 10","3975","51091.13","other","Inpatient DRG"
"Urinary Stones Without McC","694","MS-DRG","","","","","","","","inpatient","","","30970.18","18582.11","MEDICARE [2001]","HB WDH MEDICARE","6387.69","","Case rate ($6,387.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,930.03, add-ons for qualifying new technology services are included. If operating cost exceeds $9,848.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,239.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,508.56 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,485.16 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $434.27. The transfer capital threshold is the transfer adjustment factor * $434.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Includes an additional $800 of payment.","6356.25","6356.25","6356.25","1 through 10","3975","29704.68","other","Inpatient DRG - Martin's Point USFHP/Tricare/Champva"
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0300","RC","","","","inpatient","","","99.00","59.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","76.09","76.86","","60.48","60.48","60.48","1 through 10","65.54","76.09","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","99.00","59.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","69.10","69.8","","67.01","67.01","67.01","36","8.61","84.15","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","outpatient","","","99.00","59.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","62.15","62.78","","60.27","60.27","180.81","1 through 10","5.9","76.63","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","outpatient","","","99.00","59.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","43.28","43.72","","41.97","41.97","41.97","1 through 10","5.9","76.63","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","outpatient","","","99.00","59.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","71.99","72.72","","69.81","69.81","69.81","48","5.9","76.63","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","outpatient","","","99.00","59.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","71.99","72.72","","69.81","69.81","69.81","1 through 10","5.9","76.63","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","outpatient","","","99.00","59.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","52.69","53.22","","51.18","51.18","51.18","1 through 10","5.9","76.63","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","outpatient","","","99.00","59.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","62.27","62.9","","60.48","60.48","181.44","87","5.9","76.63","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","outpatient","","","99.00","59.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","76.63","77.4","","74.40","74.40","74.40","23","5.9","76.63","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","outpatient","","","99.00","59.40","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","71.99","72.72","","69.81","69.81","69.81","1 through 10","5.9","76.63","percent of total billed charges",""
"Urine Volume Measure","PX-30001382","CDM","81050","CPT","0307","RC","","","","both","","","42.00","25.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","29.32","69.8","","28.62","25.79","28.62","11","2.37","35.7","percent of total billed charges",""
"Urine Volume Measure","PX-30001382","CDM","81050","CPT","0307","RC","","","","both","","","42.00","25.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","35.70","85","","9.83","3.28","9.83","1 through 10","2.37","35.7","percent of total billed charges",""
"Urine Volume Measure","PX-30001382","CDM","81050","CPT","0307","RC","","","","outpatient","","","42.00","25.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","18.36","43.72","","17.93","17.93","17.93","1 through 10","3.59","32.51","percent of total billed charges",""
"Urine Volume Measure","PX-30001382","CDM","81050","CPT","0307","RC","","","","outpatient","","","42.00","25.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","30.54","72.72","","29.82","29.82","29.82","13","3.59","32.51","percent of total billed charges",""
"Urine Volume Measure","PX-30001382","CDM","81050","CPT","0307","RC","","","","outpatient","","","42.00","25.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","26.42","62.9","","25.83","25.83","25.83","25","3.59","32.51","percent of total billed charges",""
"Urine Volume Measure","PX-30001382","CDM","81050","CPT","0307","RC","","","","outpatient","","","42.00","25.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","32.51","77.4","","31.78","31.77","31.78","1 through 10","3.59","32.51","percent of total billed charges",""
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0400","RC","","","","inpatient","","","1119.00","671.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","860.06","76.86","","680.40","680.40","680.40","1 through 10","740.78","860.06","percent of total billed charges",""
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","1119.00","671.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","753.84","753.84","753.84","1 through 10","108.88","951.15","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","1119.00","671.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","692.73","696.33","29","108.88","951.15","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","1119.00","671.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","299.84","34","108.88","951.15","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","1119.00","671.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","111.11","107.12","111.11","26","108.88","951.15","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","1119.00","671.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","559.93","562.84","22","108.88","951.15","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","1119.00","671.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","114.44","112.15","114.44","1 through 10","108.88","951.15","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","1119.00","671.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.33","109.22","111.11","41","108.88","951.15","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","1119.00","671.40","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","55","108.88","951.15","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","1119.00","671.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","951.15","85","","661.40","661.40","661.40","1 through 10","108.88","951.15","percent of total billed charges",""
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","1119.00","671.40","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","951.15","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","1119.00","671.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","108.89","111.11","36","108.88","951.15","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","1119.00","671.40","WELLSENSE NH [1050]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","114.34","114.34","114.34","1 through 10","108.88","951.15","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","1119.00","671.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","161.36","14.42","","155.74","149.39","155.74","11","130.14","866.11","percent of total billed charges",""
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","1119.00","671.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","130.14","11.63","","148.72","127.56","272.75","56","130.14","866.11","percent of total billed charges",""
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","1119.00","671.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","472.18","472.18","472.18","1 through 10","130.14","866.11","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","1119.00","671.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","785.38","785.38","785.38","24","130.14","866.11","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","1119.00","671.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","785.38","785.38","785.38","1 through 10","130.14","866.11","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","1119.00","671.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","703.85","62.9","","680.40","680.40","1306.60","31","130.14","866.11","percent of total billed charges",""
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","1119.00","671.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","866.11","77.4","","837.00","837.00","837.00","1 through 10","130.14","866.11","percent of total billed charges",""
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","1119.00","671.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","130.14","11.63","","127.56","127.56","382.68","28","130.14","866.11","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","919.00","551.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","692.73","696.33","40","108.88","781.15","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","919.00","551.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","299.84","96","108.88","781.15","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","919.00","551.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","111.11","107.12","111.11","77","108.88","781.15","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","919.00","551.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","298.29","562.84","53","108.88","781.15","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","919.00","551.40","CHAMPVA [160001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","107.12","111.11","1 through 10","108.88","781.15","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","919.00","551.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","114.44","112.15","114.44","29","108.88","781.15","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","919.00","551.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.22","109.00","111.11","57","108.88","781.15","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","919.00","551.40","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","189","108.88","781.15","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","919.00","551.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","781.15","85","","138.89","138.89","138.89","1 through 10","108.88","781.15","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","919.00","551.40","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","15","108.88","781.15","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","919.00","551.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","108.89","111.11","96","108.88","781.15","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","919.00","551.40","WELLPOINT [1015]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","559.93","559.93","1 through 10","108.88","781.15","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","919.00","551.40","WELLSENSE NH [1050]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","114.34","114.34","116.67","17","108.88","781.15","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","919.00","551.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","132.52","14.42","","127.91","109.63","127.91","28","106.88","711.31","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","919.00","551.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","106.88","11.63","","122.14","104.76","224.01","79","106.88","711.31","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","919.00","551.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","387.80","387.80","387.80","1 through 10","106.88","711.31","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","919.00","551.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","645.03","322.51","645.03","61","106.88","711.31","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","919.00","551.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","645.03","645.03","645.03","1 through 10","106.88","711.31","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","919.00","551.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","578.05","62.9","","558.81","558.81","1676.43","90","106.88","711.31","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","919.00","551.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","711.31","77.4","","687.43","645.03","687.43","25","106.88","711.31","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","919.00","551.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","106.88","11.63","","104.76","104.76","177.78","43","106.88","711.31","percent of total billed charges",""
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","1191.00","714.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","623.47","623.47","692.73","1 through 10","108.88","1012.35","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","1191.00","714.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","268.47","299.84","1 through 10","108.88","1012.35","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","1191.00","714.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","111.11","108.89","111.11","1 through 10","108.88","1012.35","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","1191.00","714.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","298.29","559.93","1 through 10","108.88","1012.35","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","1191.00","714.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","112.15","112.15","112.15","1 through 10","108.88","1012.35","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","1191.00","714.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","108.89","108.89","108.89","26","108.88","1012.35","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","1191.00","714.60","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","59","108.88","1012.35","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","1191.00","714.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","108.89","108.89","111.11","35","108.88","1012.35","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","1191.00","714.60","WELLSENSE NH [1050]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","114.34","114.34","114.34","1 through 10","108.88","1012.35","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","outpatient","","","1191.00","714.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","171.74","14.42","","142.02","142.02","142.02","1 through 10","138.51","921.83","percent of total billed charges",""
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","outpatient","","","1191.00","714.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","835.55","721.34","835.55","1 through 10","138.51","921.83","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","outpatient","","","1191.00","714.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","835.55","835.55","835.55","1 through 10","138.51","921.83","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","outpatient","","","1191.00","714.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","749.14","62.9","","723.87","723.87","723.87","1 through 10","138.51","921.83","percent of total billed charges",""
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","outpatient","","","1191.00","714.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","921.83","77.4","","890.48","890.48","890.48","1 through 10","138.51","921.83","percent of total billed charges",""
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","both","","","707.00","424.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","493.49","69.8","","476.04","476.04","952.07","1 through 10","90.15","600.95","percent of total billed charges",""
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","both","","","707.00","424.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","493.49","69.8","","476.04","476.04","476.04","1 through 10","90.15","600.95","percent of total billed charges",""
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","both","","","707.00","424.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","600.95","85","","600.67","123.96","1452.65","1 through 10","90.15","600.95","percent of total billed charges",""
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","both","","","707.00","424.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.16","90.16","90.16","87","90.15","600.95","other","OPPS APC"
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","outpatient","","","707.00","424.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","495.95","495.95","2039.79","1 through 10","82.22","547.22","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","outpatient","","","707.00","424.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","547.22","77.4","","1057.10","1057.10","1057.10","1 through 10","82.22","547.22","percent of total billed charges",""
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","both","","","925.00","555.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","692.73","692.73","1 through 10","108.88","786.25","other","OPPS APC"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","both","","","925.00","555.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","299.84","1 through 10","108.88","786.25","other","OPPS APC"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","both","","","925.00","555.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","298.29","559.93","1 through 10","108.88","786.25","other","OPPS APC"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","both","","","925.00","555.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","114.44","114.44","114.44","1 through 10","108.88","786.25","other","OPPS APC"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","both","","","925.00","555.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","786.25","other","OPPS APC"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","both","","","925.00","555.00","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","786.25","other","OPPS APC"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","both","","","925.00","555.00","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","786.25","other","OPPS APC"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","both","","","925.00","555.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.34","55.56","111.11","1 through 10","108.88","786.25","other","OPPS APC"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","outpatient","","","925.00","555.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","107.58","11.63","","109.30","109.30","109.30","1 through 10","107.58","715.95","percent of total billed charges",""
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","outpatient","","","925.00","555.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","649.39","649.39","649.39","1 through 10","107.58","715.95","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","outpatient","","","925.00","555.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","581.83","62.9","","562.59","562.59","562.59","1 through 10","107.58","715.95","percent of total billed charges",""
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","outpatient","","","925.00","555.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","715.95","77.4","","692.08","692.08","692.08","1 through 10","107.58","715.95","percent of total billed charges",""
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","outpatient","","","925.00","555.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","107.58","11.63","","105.48","105.48","105.48","1 through 10","107.58","715.95","percent of total billed charges",""
"US Chest|REDUCED SERVICES","PX-40000030","CDM","76604","CPT","0402","RC","","","52","both","","","925.00","555.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","55.56","55.56","55.56","1 through 10","108.88","114.43","other","OPPS APC"
"US Chest|REDUCED SERVICES","PX-40000030","CDM","76604","CPT","0402","RC","","","52","both","","","925.00","555.00","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","55.56","55.56","55.56","1 through 10","108.88","114.43","other","OPPS APC"
"US Chest|REDUCED SERVICES","PX-40000030","CDM","76604","CPT","0402","RC","","","52","both","","","925.00","555.00","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","55.56","55.56","55.56","1 through 10","108.88","114.43","other","OPPS APC"
"US Chest|REDUCED SERVICES","PX-40000030","CDM","76604","CPT","0402","RC","","","52","both","","","925.00","555.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","55.56","55.56","55.56","1 through 10","108.88","114.43","other","OPPS APC"
"US Encephalogram","PX-40000014","CDM","76506","CPT","0402","RC","","","","both","","","1154.00","692.40","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","980.9","other","OPPS APC"
"US Encephalogram","PX-40000014","CDM","76506","CPT","0402","RC","","","","outpatient","","","1154.00","692.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","166.41","14.42","","160.64","160.64","160.64","1 through 10","134.21","893.2","percent of total billed charges",""
"US Extremity Non Vascular Complete","PX-40000062","CDM","76881","CPT","0402","RC","","","","both","","","793.00","475.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","710.05","other","OPPS APC"
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","both","","","687.00","412.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","692.73","692.73","1 through 10","108.88","710.05","other","OPPS APC"
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","both","","","687.00","412.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","299.84","1 through 10","108.88","710.05","other","OPPS APC"
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","both","","","687.00","412.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","111.11","111.11","111.11","1 through 10","108.88","710.05","other","OPPS APC"
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","both","","","687.00","412.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","559.93","559.93","1 through 10","108.88","710.05","other","OPPS APC"
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","both","","","687.00","412.20","CHAMPVA [160001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","663.00","663.00","663.00","1 through 10","108.88","710.05","other","OPPS APC"
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","outpatient","","","687.00","412.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","99.07","14.42","","95.60","95.60","95.60","1 through 10","79.9","531.74","percent of total billed charges",""
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","outpatient","","","687.00","412.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","79.90","11.63","","91.30","81.15","91.30","17","79.9","531.74","percent of total billed charges",""
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","outpatient","","","687.00","412.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","499.59","72.72","","482.13","482.13","482.13","1 through 10","79.9","531.74","percent of total billed charges",""
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","outpatient","","","687.00","412.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","432.12","62.9","","417.69","417.69","417.69","1 through 10","79.9","531.74","percent of total billed charges",""
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","outpatient","","","687.00","412.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","531.74","77.4","","513.83","513.83","513.83","1 through 10","79.9","531.74","percent of total billed charges",""
"US Fetal Doppler Velocimerty Cereb","PX-40000052","CDM","76821","CPT","0402","RC","","","","both","","","581.00","348.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","561.00","379.72","561.00","1 through 10","108.88","710.05","other","OPPS APC"
"US Fetal Doppler Velocimerty Cereb","PX-40000052","CDM","76821","CPT","0402","RC","","","","both","","","581.00","348.60","WELLPOINT [1015]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","561.00","561.00","561.00","1 through 10","108.88","710.05","other","OPPS APC"
"US Fetal Doppler Velocimerty Cereb","PX-40000052","CDM","76821","CPT","0402","RC","","","","outpatient","","","581.00","348.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","83.78","14.42","","69.34","69.34","80.90","1 through 10","67.57","449.69","percent of total billed charges",""
"US Fetal Doppler Velocimerty Cereb","PX-40000052","CDM","76821","CPT","0402","RC","","","","outpatient","","","581.00","348.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","67.57","11.63","","77.25","68.67","77.25","1 through 10","67.57","449.69","percent of total billed charges",""
"US Fetal Doppler Velocimerty Cereb","PX-40000052","CDM","76821","CPT","0402","RC","","","","outpatient","","","581.00","348.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","422.50","72.72","","407.96","407.96","407.96","20","67.57","449.69","percent of total billed charges",""
"US Fetal Doppler Velocimerty Cereb","PX-40000052","CDM","76821","CPT","0402","RC","","","","outpatient","","","581.00","348.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","365.45","62.9","","353.43","353.43","1060.29","12","67.57","449.69","percent of total billed charges",""
"US Fetal Doppler Velocimerty Cereb","PX-40000052","CDM","76821","CPT","0402","RC","","","","outpatient","","","581.00","348.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","449.69","77.4","","434.78","434.78","434.78","1 through 10","67.57","449.69","percent of total billed charges",""
"US Fetal Doppler Velocimerty Cereb","PX-40000052","CDM","76821","CPT","0402","RC","","","","outpatient","","","581.00","348.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","67.57","11.63","","331.30","66.26","331.30","1 through 10","67.57","449.69","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","both","","","227.00","136.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","219.00","148.22","219.00","1 through 10","108.88","710.05","other","OPPS APC"
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","both","","","227.00","136.20","WELLPOINT [1015]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","219.00","219.00","219.00","1 through 10","108.88","710.05","other","OPPS APC"
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","outpatient","","","227.00","136.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","32.73","14.42","","27.07","27.07","31.58","1 through 10","26.4","175.7","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","outpatient","","","227.00","136.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","26.40","11.63","","30.16","26.81","30.16","1 through 10","26.4","175.7","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","outpatient","","","227.00","136.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","165.07","72.72","","159.26","159.26","159.26","19","26.4","175.7","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","outpatient","","","227.00","136.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","142.78","62.9","","137.97","137.97","413.91","13","26.4","175.7","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","outpatient","","","227.00","136.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","175.70","77.4","","169.73","169.73","169.73","1 through 10","26.4","175.7","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","outpatient","","","227.00","136.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","26.40","11.63","","129.35","25.87","129.35","1 through 10","26.4","175.7","percent of total billed charges",""
"US Guidance Intraoperative","PX-40000085","CDM","76998","CPT","0402","RC","","","","both","","","1921.00","1152.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","1340.86","69.8","","1294.09","1294.09","1294.09","1 through 10","1093.05","1632.85","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","both","","","486.00","291.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","469.00","469.00","469.00","1 through 10","276.53","413.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","both","","","486.00","291.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","276.53","56.9","","266.86","266.86","266.86","1 through 10","276.53","413.1","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","both","","","486.00","291.60","WELLPOINT [1015]","HB WDH ANTHEM PPO","","","Case rate ($0).","469.00","469.00","469.00","1 through 10","276.53","413.1","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","outpatient","","","486.00","291.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","70.08","14.42","","67.63","57.97","536.63","1 through 10","56.52","376.16","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","outpatient","","","486.00","291.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","56.52","11.63","","64.58","57.41","118.45","1 through 10","56.52","376.16","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","outpatient","","","486.00","291.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","353.42","72.72","","341.06","341.06","341.06","1 through 10","56.52","376.16","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","outpatient","","","486.00","291.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","305.69","62.9","","295.47","295.47","295.47","13","56.52","376.16","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","outpatient","","","486.00","291.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","376.16","77.4","","363.48","363.48","363.48","1 through 10","56.52","376.16","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","outpatient","","","486.00","291.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","56.52","11.63","","55.40","55.40","55.40","1 through 10","56.52","376.16","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","both","","","341.00","204.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","194.03","56.9","","187.20","187.20","187.21","1 through 10","194.03","289.85","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","outpatient","","","341.00","204.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","49.17","14.42","","47.44","40.66","47.44","1 through 10","39.66","263.93","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","outpatient","","","341.00","204.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","39.66","11.63","","83.09","45.30","83.09","1 through 10","39.66","263.93","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","outpatient","","","341.00","204.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","214.08","62.78","","206.55","206.55","206.55","1 through 10","39.66","263.93","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","outpatient","","","341.00","204.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","247.98","72.72","","239.25","239.25","239.25","1 through 10","39.66","263.93","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","outpatient","","","341.00","204.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","214.49","62.9","","207.27","207.27","207.27","1 through 10","39.66","263.93","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","outpatient","","","341.00","204.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","263.93","77.4","","254.98","254.98","254.98","1 through 10","39.66","263.93","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","outpatient","","","341.00","204.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","39.66","11.63","","38.86","38.86","38.86","1 through 10","39.66","263.93","percent of total billed charges",""
"US Hips Infant Static","PX-40000067","CDM","76886","CPT","0402","RC","","","","both","","","1022.00","613.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","587.88","","Case rate ($587.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","573.54","573.54","575.52","1 through 10","90.15","868.7","other","OPPS APC"
"US Hips Infant Static","PX-40000067","CDM","76886","CPT","0402","RC","","","","both","","","1022.00","613.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","253.14","","Case rate ($253.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","246.97","246.97","246.97","15","90.15","868.7","other","OPPS APC"
"US Hips Infant Static","PX-40000067","CDM","76886","CPT","0402","RC","","","","both","","","1022.00","613.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","90.15","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","92.00","88.54","92.00","1 through 10","90.15","868.7","other","OPPS APC"
"US Hips Infant Static","PX-40000067","CDM","76886","CPT","0402","RC","","","","both","","","1022.00","613.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","475.18","","Case rate ($475.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","463.58","463.58","465.18","12","90.15","868.7","other","OPPS APC"
"US Hips Infant Static","PX-40000067","CDM","76886","CPT","0402","RC","","","","both","","","1022.00","613.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","92.00","92.00","92.00","1 through 10","90.15","868.7","other","OPPS APC"
"US Hips Infant Static","PX-40000067","CDM","76886","CPT","0402","RC","","","","both","","","1022.00","613.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","868.70","85","","838.10","838.10","838.10","1 through 10","90.15","868.7","percent of total billed charges",""
"US Hips Infant Static","PX-40000067","CDM","76886","CPT","0402","RC","","","","both","","","1022.00","613.20","TRICARE [160005]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","92.00","92.00","92.00","1 through 10","90.15","868.7","other","OPPS APC"
"US Hips Infant Static","PX-40000067","CDM","76886","CPT","0402","RC","","","","both","","","1022.00","613.20","WELLPOINT [1015]","HB WDH ANTHEM PPO","475.18","","Case rate ($475.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","463.58","463.58","463.58","1 through 10","90.15","868.7","other","OPPS APC"
"US Hips Infant Static","PX-40000067","CDM","76886","CPT","0402","RC","","","","outpatient","","","1022.00","613.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","147.37","14.42","","142.18","142.18","1072.67","1 through 10","118.86","791.03","percent of total billed charges",""
"US Hips Infant Static","PX-40000067","CDM","76886","CPT","0402","RC","","","","outpatient","","","1022.00","613.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","118.86","11.63","","135.77","116.46","249.01","15","118.86","791.03","percent of total billed charges",""
"US Hips Infant Static","PX-40000067","CDM","76886","CPT","0402","RC","","","","outpatient","","","1022.00","613.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","641.61","62.78","","619.01","619.01","619.01","1 through 10","118.86","791.03","percent of total billed charges",""
"US Hips Infant Static","PX-40000067","CDM","76886","CPT","0402","RC","","","","outpatient","","","1022.00","613.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","743.20","72.72","","717.02","717.02","717.02","14","118.86","791.03","percent of total billed charges",""
"US Hips Infant Static","PX-40000067","CDM","76886","CPT","0402","RC","","","","outpatient","","","1022.00","613.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","642.84","62.9","","621.18","621.18","621.18","11","118.86","791.03","percent of total billed charges",""
"US Hips Infant Static","PX-40000067","CDM","76886","CPT","0402","RC","","","","outpatient","","","1022.00","613.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","791.03","77.4","","764.15","764.15","764.15","1 through 10","118.86","791.03","percent of total billed charges",""
"US Hips Infant Static","PX-40000067","CDM","76886","CPT","0402","RC","","","","outpatient","","","1022.00","613.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","118.86","11.63","","116.46","116.46","116.46","1 through 10","118.86","791.03","percent of total billed charges",""
"US Intravascular Initial Vessel","PX-48000107","CDM","92978","CPT","0481","RC","","","","outpatient","","","4551.00","2730.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","3309.49","72.72","","3193.86","3193.86","3193.86","1 through 10","529.28","3522.47","percent of total billed charges",""
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-40000065","CDM","76882","CPT","0402","RC","","","","both","","","872.00","523.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.22","109.22","109.22","1 through 10","108.88","741.2","other","OPPS APC"
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-40000065","CDM","76882","CPT","0402","RC","","","","both","","","872.00","523.20","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","741.2","other","OPPS APC"
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-40000065","CDM","76882","CPT","0402","RC","","","","both","","","872.00","523.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","741.20","85","","2469.82","714.85","2469.82","1 through 10","108.88","741.2","percent of total billed charges",""
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-40000065","CDM","76882","CPT","0402","RC","","","","both","","","872.00","523.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","107.12","111.11","25","108.88","741.2","other","OPPS APC"
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-40000065","CDM","76882","CPT","0402","RC","","","","outpatient","","","872.00","523.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","634.12","72.72","","611.58","527.98","611.58","1 through 10","101.41","674.93","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","1037.00","622.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","692.73","696.33","11","108.88","881.45","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","1037.00","622.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","299.84","30","108.88","881.45","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","1037.00","622.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","111.11","108.89","188.89","28","108.88","881.45","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","1037.00","622.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","298.29","1371.98","16","108.88","881.45","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","1037.00","622.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","114.44","112.46","114.44","1 through 10","108.88","881.45","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","1037.00","622.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","109.22","111.11","14","108.88","881.45","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","1037.00","622.20","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","107.12","111.11","36","108.88","881.45","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","1037.00","622.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","881.45","85","","649.75","143.98","1404.00","1 through 10","108.88","881.45","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","1037.00","622.20","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","91.11","111.11","1 through 10","108.88","881.45","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","1037.00","622.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","110.37","108.89","111.11","23","108.88","881.45","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","1037.00","622.20","WELLSENSE NH [1050]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","116.67","116.67","116.67","1 through 10","108.88","881.45","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","1037.00","622.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","149.54","14.42","","144.34","123.72","144.34","1 through 10","120.6","802.64","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","1037.00","622.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","120.60","11.63","","118.24","68.92","252.81","22","120.6","802.64","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","1037.00","622.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","651.03","62.78","","628.43","628.43","628.43","1 through 10","120.6","802.64","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","1037.00","622.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","754.11","72.72","","363.97","363.97","1208.97","14","120.6","802.64","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","1037.00","622.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","754.11","72.72","","363.97","363.97","363.97","1 through 10","120.6","802.64","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","1037.00","622.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","652.27","62.9","","630.63","630.63","630.63","36","120.6","802.64","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","1037.00","622.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","802.64","77.4","","775.78","775.78","775.78","1 through 10","120.6","802.64","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","1037.00","622.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","120.60","11.63","","118.24","118.24","354.72","18","120.6","802.64","percent of total billed charges",""
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","969.00","581.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","692.73","692.73","1 through 10","108.88","823.65","other","OPPS APC"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","969.00","581.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","108.89","108.89","108.89","1 through 10","108.88","823.65","other","OPPS APC"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","969.00","581.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","298.29","1 through 10","108.88","823.65","other","OPPS APC"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","969.00","581.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","823.65","other","OPPS APC"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","969.00","581.40","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","823.65","other","OPPS APC"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","969.00","581.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","109.34","111.11","1 through 10","108.88","823.65","other","OPPS APC"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","outpatient","","","969.00","581.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","139.73","14.42","","134.83","134.83","134.83","1 through 10","112.69","750.01","percent of total billed charges",""
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","outpatient","","","969.00","581.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","609.50","62.9","","589.05","589.05","589.05","1 through 10","112.69","750.01","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","1002.00","601.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","298.29","1 through 10","108.88","851.7","other","OPPS APC"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","both","","","1248.00","748.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","692.73","692.73","1 through 10","108.88","1060.8","other","OPPS APC"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","both","","","1248.00","748.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","298.29","1 through 10","108.88","1060.8","other","OPPS APC"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","both","","","1248.00","748.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","1060.8","other","OPPS APC"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","1248.00","748.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","179.96","14.42","","173.62","148.81","173.62","1 through 10","145.14","965.95","percent of total billed charges",""
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","1248.00","748.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","145.14","11.63","","165.79","142.21","304.07","25","145.14","965.95","percent of total billed charges",""
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","1248.00","748.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","145.14","11.63","","142.21","142.21","142.21","1 through 10","145.14","965.95","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1549.00","929.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","180.15","11.63","","205.86","182.99","205.86","1 through 10","180.15","1198.93","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1549.00","929.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","974.32","62.9","","941.85","941.85","941.85","1 through 10","180.15","1198.93","percent of total billed charges",""
"US Pregnancy Detailed Single","PX-40000042","CDM","76811","CPT","0402","RC","","","","outpatient","","","1549.00","929.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","180.15","11.63","","176.58","176.58","396.03","1 through 10","180.15","1198.93","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","976.00","585.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","692.73","692.73","1 through 10","108.88","829.6","other","OPPS APC"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","976.00","585.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","111.11","111.11","111.11","1 through 10","108.88","829.6","other","OPPS APC"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","976.00","585.60","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","829.6","other","OPPS APC"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","976.00","585.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","140.74","14.42","","135.84","130.36","135.84","22","113.51","755.42","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","976.00","585.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","113.51","11.63","","129.71","115.30","237.90","45","113.51","755.42","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","976.00","585.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","613.90","62.9","","593.46","593.46","593.46","1 through 10","113.51","755.42","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","976.00","585.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","113.51","11.63","","111.26","111.26","111.26","1 through 10","113.51","755.42","percent of total billed charges",""
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","both","","","713.00","427.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","688.00","688.00","688.00","1 through 10","108.88","710.05","other","OPPS APC"
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","both","","","713.00","427.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","298.29","1 through 10","108.88","710.05","other","OPPS APC"
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","both","","","713.00","427.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","111.11","111.11","111.11","1 through 10","108.88","710.05","other","OPPS APC"
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","both","","","713.00","427.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","688.00","298.29","688.00","1 through 10","108.88","710.05","other","OPPS APC"
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","outpatient","","","713.00","427.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","102.81","14.42","","99.21","85.04","99.21","14","82.92","551.86","percent of total billed charges",""
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","outpatient","","","713.00","427.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","82.92","11.63","","94.74","84.21","243.78","30","82.92","551.86","percent of total billed charges",""
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","outpatient","","","713.00","427.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","500.31","500.31","500.31","1 through 10","82.92","551.86","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","outpatient","","","713.00","427.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","379.46","53.22","","447.20","447.20","447.20","1 through 10","82.92","551.86","percent of total billed charges",""
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","outpatient","","","713.00","427.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","448.48","62.9","","433.44","433.44","433.44","1 through 10","82.92","551.86","percent of total billed charges",""
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","outpatient","","","713.00","427.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","82.92","11.63","","81.26","81.26","177.78","1 through 10","82.92","551.86","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","811.00","486.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","116.95","14.42","","112.91","112.91","112.91","1 through 10","94.32","627.71","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","811.00","486.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","94.32","11.63","","95.84","95.84","95.84","1 through 10","94.32","627.71","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","811.00","486.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","569.40","569.40","569.40","1 through 10","94.32","627.71","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0400","RC","","","","inpatient","","","1046.00","627.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","803.96","76.86","","610.42","610.42","610.42","1 through 10","692.45","803.96","percent of total billed charges",""
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","1046.00","627.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 69.8% of billed. Procedures 2 - 9999, 34.9% of billed.","704.28","704.28","704.28","1 through 10","108.88","889.1","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","1046.00","627.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","692.73","696.33","48","108.88","889.1","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","1046.00","627.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","299.84","100","108.88","889.1","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","1046.00","627.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","109.33","108.89","111.11","74","108.88","889.1","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","1046.00","627.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","298.29","562.84","53","108.88","889.1","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","1046.00","627.60","CHAMPVA [160001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","889.1","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","1046.00","627.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","114.44","113.95","114.44","26","108.88","889.1","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","1046.00","627.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.22","109.22","111.11","105","108.88","889.1","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","1046.00","627.60","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","287","108.88","889.1","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","1046.00","627.60","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","15","108.88","889.1","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","1046.00","627.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","108.89","111.11","136","108.88","889.1","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","1046.00","627.60","WELLPOINT [1015]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","559.93","559.93","1 through 10","108.88","889.1","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","1046.00","627.60","WELLSENSE NH [1050]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","114.34","114.34","116.67","13","108.88","889.1","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","1046.00","627.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","150.83","14.42","","145.50","124.71","145.50","28","121.65","809.6","percent of total billed charges",""
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","1046.00","627.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","121.65","11.63","","138.94","119.18","254.83","63","121.65","809.6","percent of total billed charges",""
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","1046.00","627.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","","","Payment is accumulated by procedure count. Procedure 1, 62.78% of billed. Procedures 2 - 9999, 31.39% of billed.","633.45","633.45","633.45","1 through 10","121.65","809.6","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","1046.00","627.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","441.13","441.13","441.13","1 through 10","121.65","809.6","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","1046.00","627.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","733.74","733.74","733.74","59","121.65","809.6","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","1046.00","627.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","733.74","733.74","733.74","1 through 10","121.65","809.6","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","1046.00","627.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","556.68","53.22","","537.90","537.90","537.90","1 through 10","121.65","809.6","percent of total billed charges",""
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","1046.00","627.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","657.93","62.9","","635.67","635.67","635.67","50","121.65","809.6","percent of total billed charges",""
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","1046.00","627.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","809.60","77.4","","781.98","781.98","781.98","26","121.65","809.6","percent of total billed charges",""
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","1046.00","627.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","121.65","11.63","","119.18","119.18","176.00","24","121.65","809.6","percent of total billed charges",""
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","1012.00","607.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","692.73","692.73","1 through 10","108.88","860.2","other","OPPS APC"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","1012.00","607.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","299.84","15","108.88","860.2","other","OPPS APC"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","1012.00","607.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","111.11","107.12","188.89","1 through 10","108.88","860.2","other","OPPS APC"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","1012.00","607.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","562.84","562.84","562.84","1 through 10","108.88","860.2","other","OPPS APC"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","1012.00","607.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.22","109.22","111.11","1 through 10","108.88","860.2","other","OPPS APC"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","1012.00","607.20","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","17","108.88","860.2","other","OPPS APC"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","1012.00","607.20","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","111.11","252.57","1 through 10","108.88","860.2","other","OPPS APC"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","1012.00","607.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","109.34","111.11","1 through 10","108.88","860.2","other","OPPS APC"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","1012.00","607.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","145.93","14.42","","140.88","140.88","140.88","1 through 10","117.7","783.29","percent of total billed charges",""
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","1012.00","607.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","117.70","11.63","","134.53","115.40","246.75","1 through 10","117.7","783.29","percent of total billed charges",""
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","1012.00","607.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","710.47","710.47","710.47","18","117.7","783.29","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","1012.00","607.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","710.47","710.47","710.47","1 through 10","117.7","783.29","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","1012.00","607.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","636.55","62.9","","615.51","615.51","615.51","15","117.7","783.29","percent of total billed charges",""
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","1012.00","607.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","783.29","77.4","","757.18","757.18","757.18","11","117.7","783.29","percent of total billed charges",""
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","1012.00","607.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","117.70","11.63","","115.40","115.40","346.20","11","117.7","783.29","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","1151.00","690.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","803.40","69.8","","775.48","761.37","775.48","1 through 10","108.88","978.35","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","1151.00","690.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","692.73","696.33","43","108.88","978.35","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","1151.00","690.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","299.84","92","108.88","978.35","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","1151.00","690.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","109.33","107.12","111.11","88","108.88","978.35","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","1151.00","690.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","298.29","562.84","39","108.88","978.35","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","1151.00","690.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","114.44","113.95","114.44","35","108.88","978.35","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","1151.00","690.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.22","109.22","111.11","93","108.88","978.35","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","1151.00","690.60","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","238","108.88","978.35","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","1151.00","690.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","978.35","85","","869.35","191.83","944.35","1 through 10","108.88","978.35","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","1151.00","690.60","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","1222.11","1 through 10","108.88","978.35","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","1151.00","690.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","108.89","111.11","101","108.88","978.35","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","1151.00","690.60","WELLSENSE NH [1050]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","114.80","114.34","116.67","1 through 10","108.88","978.35","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","1151.00","690.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","165.97","14.42","","160.21","137.32","1208.74","14","133.86","890.87","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","1151.00","690.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","133.86","11.63","","152.98","131.22","280.58","34","133.86","890.87","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","1151.00","690.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","","","Payment is accumulated by procedure count. Procedure 1, 43.72% of billed. Procedures 2 - 9999, 21.86% of billed.","485.73","485.73","485.73","1 through 10","133.86","890.87","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","1151.00","690.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","807.92","807.92","807.92","58","133.86","890.87","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","1151.00","690.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","612.56","53.22","","1776.81","592.27","1776.81","1 through 10","133.86","890.87","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","1151.00","690.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","723.98","62.9","","699.93","699.93","699.93","90","133.86","890.87","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","1151.00","690.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","890.87","77.4","","861.03","861.03","861.03","35","133.86","890.87","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","1151.00","690.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","807.92","807.92","807.92","1 through 10","133.86","890.87","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","1151.00","690.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","133.86","11.63","","131.22","131.22","393.66","30","133.86","890.87","percent of total billed charges",""
"US Spinal Canal","PX-40000037","CDM","76800","CPT","0402","RC","","","","both","","","1160.00","696.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","809.68","69.8","","781.06","781.06","781.06","1 through 10","108.88","986","percent of total billed charges",""
"US Spinal Canal","PX-40000037","CDM","76800","CPT","0402","RC","","","","both","","","1160.00","696.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","298.29","1 through 10","108.88","986","other","OPPS APC"
"US Spinal Canal","PX-40000037","CDM","76800","CPT","0402","RC","","","","outpatient","","","1160.00","696.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","134.91","11.63","","136.97","136.97","136.97","1 through 10","134.91","897.84","percent of total billed charges",""
"US Spinal Canal","PX-40000037","CDM","76800","CPT","0402","RC","","","","outpatient","","","1160.00","696.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","843.55","72.72","","813.74","813.74","813.74","1 through 10","134.91","897.84","percent of total billed charges",""
"US Spinal Canal","PX-40000037","CDM","76800","CPT","0402","RC","","","","outpatient","","","1160.00","696.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","729.64","62.9","","704.97","704.97","704.97","1 through 10","134.91","897.84","percent of total billed charges",""
"US Spinal Canal","PX-40000037","CDM","76800","CPT","0402","RC","","","","outpatient","","","1160.00","696.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","897.84","77.4","","867.23","867.23","867.23","1 through 10","134.91","897.84","percent of total billed charges",""
"US Spinal Canal","PX-40000037","CDM","76800","CPT","0402","RC","","","","outpatient","","","1160.00","696.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","134.91","11.63","","132.17","132.17","132.17","1 through 10","134.91","897.84","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","1204.00","722.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","692.73","696.33","13","108.88","1023.4","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","1204.00","722.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","299.84","29","108.88","1023.4","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","1204.00","722.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","111.11","108.89","111.11","24","108.88","1023.4","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","1204.00","722.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","298.29","562.84","15","108.88","1023.4","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","1204.00","722.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","114.44","114.44","114.44","1 through 10","108.88","1023.4","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","1204.00","722.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","109.22","111.11","1 through 10","108.88","1023.4","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","1204.00","722.40","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","107.12","111.11","23","108.88","1023.4","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","1204.00","722.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","757.32","62.9","","732.06","732.06","732.06","36","108.88","1023.4","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","1204.00","722.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","1023.40","85","","167.13","167.13","167.13","1 through 10","108.88","1023.4","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","1204.00","722.40","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","91.11","111.11","1 through 10","108.88","1023.4","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","1204.00","722.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","105.41","111.11","19","108.88","1023.4","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","1204.00","722.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","931.90","77.4","","900.55","900.55","900.55","1 through 10","108.88","1023.4","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","1204.00","722.40","WELLSENSE NH [1050]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","116.67","116.67","116.67","1 through 10","108.88","1023.4","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","1204.00","722.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","173.62","14.42","","167.56","143.62","167.56","1 through 10","140.03","173.62","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","1204.00","722.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","140.03","11.63","","142.23","137.25","293.46","18","140.03","173.62","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","1204.00","722.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","","","Payment is accumulated by procedure count. Procedure 1, 62.78% of billed. Procedures 2 - 9999, 31.39% of billed.","729.50","729.50","729.50","1 through 10","140.03","173.62","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","1204.00","722.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","845.01","845.01","845.01","13","140.03","173.62","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","1204.00","722.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","845.01","845.01","845.01","1 through 10","140.03","173.62","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","1204.00","722.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","140.03","11.63","","137.25","137.25","411.75","13","140.03","173.62","percent of total billed charges",""
"USERS KIT","SUP-ITM-10294683","CDM","C1787","HCPCS","0270","RC","","","","both","","","9675.75","5805.45","AETNA [1001]","HB WDH AETNA COMMERCIAL","6753.67","69.8","","1412.58","1412.58","1412.58","1 through 10","1125.29","8224.39","percent of total billed charges",""
"USERS KIT","SUP-ITM-10294683","CDM","C1787","HCPCS","0270","RC","","","","both","","","9675.75","5805.45","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","18158.40","2245.75","18158.40","1 through 10","1125.29","8224.39","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"USERS KIT","SUP-ITM-10294683","CDM","C1787","HCPCS","0270","RC","","","","both","","","9675.75","5805.45","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","5505.50","56.9","","15498.18","15498.18","15498.18","1 through 10","1125.29","8224.39","percent of total billed charges",""
"USERS KIT","SUP-ITM-10294683","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","9675.75","5805.45","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","7036.21","72.72","","4236.03","4236.03","4236.03","1 through 10","1125.29","7489.03","percent of total billed charges",""
"Ustekinumab Drug Level","PX-30003524","CDM","80299","CPT","0301","RC","","","","both","","","213.00","127.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","148.67","69.8","","69.80","62.90","69.80","1 through 10","12.12","181.05","percent of total billed charges",""
"Ustekinumab Drug Level","PX-30003524","CDM","80299","CPT","0301","RC","","","","outpatient","","","213.00","127.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","93.12","43.72","","43.72","43.72","43.72","1 through 10","12.76","164.86","percent of total billed charges",""
"Ustekinumab Drug Level","PX-30003524","CDM","80299","CPT","0301","RC","","","","outpatient","","","213.00","127.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","154.89","72.72","","72.72","72.72","72.72","1 through 10","12.76","164.86","percent of total billed charges",""
"Ustekinumab Drug Level","PX-30003524","CDM","80299","CPT","0301","RC","","","","outpatient","","","213.00","127.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","154.89","72.72","","190.53","190.53","190.53","1 through 10","12.76","164.86","percent of total billed charges",""
"Ustekinumab Drug Level","PX-30003524","CDM","80299","CPT","0301","RC","","","","outpatient","","","213.00","127.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","113.36","53.22","","53.31","53.31","53.31","1 through 10","12.76","164.86","percent of total billed charges",""
"Ustekinumab Drug Level","PX-30003524","CDM","80299","CPT","0301","RC","","","","outpatient","","","213.00","127.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","133.98","62.9","","63.00","63.00","189.00","13","12.76","164.86","percent of total billed charges",""
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC","742","MS-DRG","","","","","","","","inpatient","","","94736.09","56841.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","27453.89","","Fee schedule rate ($27,453.89). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","62309.94","62309.94","62309.94","1 through 10","3975","69722.58","case rate",""
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC","742","MS-DRG","","","","","","","","inpatient","","","94736.09","56841.65","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","55530.74","","Fee schedule rate ($55,530.74). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","53937.15","53937.15","53937.15","1 through 10","3975","69722.58","case rate",""
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC","742","MS-DRG","","","","","","","","inpatient","","","94736.09","56841.65","MEDICARE [2001]","HB WDH MEDICARE","14393.82","","Case rate ($14,393.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $13,319.59, add-ons for qualifying new technology services are included. If operating cost exceeds $17,237.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,824.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $12,929.64 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $12,874.73 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,019.31. The transfer capital threshold is the transfer adjustment factor * $1,019.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","14264.18","14264.18","14264.18","1 through 10","3975","69722.58","other","Inpatient DRG"
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC","743","MS-DRG","","","","","","","","inpatient","","","67418.75","40451.25","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","37550.13","","Fee schedule rate ($37,550.13). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","35394.13","35394.13","35394.13","1 through 10","3975","47146.72","case rate",""
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC","743","MS-DRG","","","","","","","","inpatient","","","67418.75","40451.25","MEDICARE [2001]","HB WDH MEDICARE","9877.21","","Case rate ($9,877.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $9,150.81, add-ons for qualifying new technology services are included. If operating cost exceeds $13,068.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,494.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $8,743.08 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $8,705.95 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.26. The transfer capital threshold is the transfer adjustment factor * $689.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10879.48","10879.48","10879.48","1 through 10","3975","47146.72","other","Inpatient DRG"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/McC","741","MS-DRG","","","","","","","","inpatient","","","52525.37","31515.22","MEDICARE [2001]","HB WDH MEDICARE","11286.70","","Case rate ($11,286.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,451.76, add-ons for qualifying new technology services are included. If operating cost exceeds $14,369.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,597.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $10,049.57 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,006.89 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.26. The transfer capital threshold is the transfer adjustment factor * $792.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","10836.37","10836.37","10836.37","1 through 10","3975","54191.94","other","Inpatient DRG"
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","","","","inpatient","","","13907.27","8344.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","40720.91","","Fee schedule rate ($40,720.91). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","11167.28","11167.28","15288.92","1 through 10","3506","40720.91","case rate",""
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","","","","inpatient","","","13907.27","8344.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","16034.22","","Fee schedule rate ($16,034.22). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","13907.14","12620.31","14884.11","1 through 10","3506","40720.91","case rate",""
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","","","","inpatient","","","13907.27","8344.36","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","32432.27","","Fee schedule rate ($32,432.27). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","11954.71","8616.64","17152.67","14","3506","40720.91","case rate",""
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","","","","inpatient","","","13907.27","8344.36","TRICARE [160005]","HB WDH MEDICARE","8591.63","","Case rate ($8,591.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $7,964.24, add-ons for qualifying new technology services are included. If operating cost exceeds $11,882.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,400.34, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,551.45 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,519.38 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.32. The transfer capital threshold is the transfer adjustment factor * $595.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5010.41","507.68","5562.51","1 through 10","3506","40720.91","other","Inpatient DRG"
"Vaginal Delivery With Sterilization And/Or D&C With McC","796","MS-DRG","","","","","","","","inpatient","","","15655.10","9393.06","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","44346.12","","Fee schedule rate ($44,346.12). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","14738.48","14738.48","14738.48","1 through 10","3506","44346.12","case rate",""
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/McC","798","MS-DRG","","","","","","","","inpatient","","","28964.61","17378.77","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","28966.90","","Fee schedule rate ($28,966.90). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","28588.13","28588.13","28588.13","1 through 10","3506","36369.9","case rate",""
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","","","","inpatient","","","12706.71","7624.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","28652.08","","Fee schedule rate ($28,652.08). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","13556.02","10004.16","16930.84","1 through 10","3506","28652.08","case rate",""
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","","","","inpatient","","","12706.71","7624.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","11282.01","","Fee schedule rate ($11,282.01). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","10563.06","8849.78","10563.06","33","3506","28652.08","case rate",""
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","","","","inpatient","","","12706.71","7624.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","6053.57","","Case rate ($6,177.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,735.66, add-ons for qualifying new technology services are included. If operating cost exceeds $9,653.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,223.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,313.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,290.79 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $418.88. The transfer capital threshold is the transfer adjustment factor * $418.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5904.75","5904.75","6706.30","1 through 10","3506","28652.08","other","Inpatient DRG"
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","","","","inpatient","","","12706.71","7624.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","22820.02","","Fee schedule rate ($22,820.02). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","12349.16","10009.34","20616.02","25","3506","28652.08","case rate",""
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","","","","inpatient","","","12706.71","7624.03","MARTIN'S POINT [160007]","HB WDH MEDICARE","6177.11","","Case rate ($6,177.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,735.66, add-ons for qualifying new technology services are included. If operating cost exceeds $9,653.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,223.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,313.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,290.79 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $418.88. The transfer capital threshold is the transfer adjustment factor * $418.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5446.07","5446.07","5446.07","1 through 10","3506","28652.08","other","Inpatient DRG"
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","","","","inpatient","","","12706.71","7624.03","MEDICARE [2001]","HB WDH MEDICARE","6177.11","","Case rate ($6,177.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,735.66, add-ons for qualifying new technology services are included. If operating cost exceeds $9,653.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,223.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,313.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,290.79 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $418.88. The transfer capital threshold is the transfer adjustment factor * $418.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5904.75","5904.75","5904.75","1 through 10","3506","28652.08","other","Inpatient DRG"
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","","","","inpatient","","","12706.71","7624.03","TRICARE [160005]","HB WDH MEDICARE","6177.11","","Case rate ($6,177.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,735.66, add-ons for qualifying new technology services are included. If operating cost exceeds $9,653.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,223.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,313.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,290.79 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $418.88. The transfer capital threshold is the transfer adjustment factor * $418.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","4184.92","4184.92","4334.11","1 through 10","3506","28652.08","other","Inpatient DRG"
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","","","","inpatient","","","12706.71","7624.03","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","6177.11","","Case rate ($6,177.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,735.66, add-ons for qualifying new technology services are included. If operating cost exceeds $9,653.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,223.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,313.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $5,290.79 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $418.88. The transfer capital threshold is the transfer adjustment factor * $418.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5918.98","5918.98","5918.98","1 through 10","3506","28652.08","other","Inpatient DRG"
"Vaginal Delivery Without Sterilization Or D&C With McC","805","MS-DRG","","","","","","","","inpatient","","","13994.53","8396.72","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","41009.71","","Fee schedule rate ($41,009.71). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","7620.00","7620.00","7620.00","1 through 10","3506","41009.71","case rate",""
"Vaginal Delivery Without Sterilization Or D&C With McC","805","MS-DRG","","","","","","","","inpatient","","","13994.53","8396.72","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","16147.94","","Fee schedule rate ($16,147.94). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","14300.29","11608.61","14568.73","1 through 10","3506","41009.71","case rate",""
"Vaginal Delivery Without Sterilization Or D&C With McC","805","MS-DRG","","","","","","","","inpatient","","","13994.53","8396.72","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","8476.43","","Case rate ($8,649.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,017.58, add-ons for qualifying new technology services are included. If operating cost exceeds $11,935.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,404.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,605.01 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,572.71 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $599.54. The transfer capital threshold is the transfer adjustment factor * $599.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","7975.25","7975.25","7975.25","1 through 10","3506","41009.71","other","Inpatient DRG"
"Vaginal Delivery Without Sterilization Or D&C With McC","805","MS-DRG","","","","","","","","inpatient","","","13994.53","8396.72","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","32662.29","","Fee schedule rate ($32,662.29). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","12482.24","10268.78","14568.73","12","3506","41009.71","case rate",""
"Vaginal Delivery Without Sterilization Or D&C With McC","805","MS-DRG","","","","","","","","inpatient","","","13994.53","8396.72","MEDICARE [2001]","HB WDH MEDICARE","8649.42","","Case rate ($8,649.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $8,017.58, add-ons for qualifying new technology services are included. If operating cost exceeds $11,935.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,404.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,605.01 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $7,572.71 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $599.54. The transfer capital threshold is the transfer adjustment factor * $599.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7975.25","7975.25","7975.25","1 through 10","3506","41009.71","other","Inpatient DRG"
"Vaginal Delivery Without Sterilization Or D&C Without Cc/McC","807","MS-DRG","","","","","","","","inpatient","","","11099.53","6659.72","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","25619.67","","Fee schedule rate ($25,619.67). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","12694.49","6877.92","15363.15","36","3506","25619.67","case rate",""
"Vaginal Delivery Without Sterilization Or D&C Without Cc/McC","807","MS-DRG","","","","","","","","inpatient","","","11099.53","6659.72","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","10087.97","","Fee schedule rate ($10,087.97). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","9303.26","7863.04","9303.26","74","3506","25619.67","case rate",""
"Vaginal Delivery Without Sterilization Or D&C Without Cc/McC","807","MS-DRG","","","","","","","","inpatient","","","11099.53","6659.72","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","5459.03","","Case rate ($5,570.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,175.71, add-ons for qualifying new technology services are included. If operating cost exceeds $9,093.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,179.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,751.01 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,730.84 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.55. The transfer capital threshold is the transfer adjustment factor * $374.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 98%.","5253.56","5253.56","8931.05","25","3506","25619.67","other","Inpatient DRG"
"Vaginal Delivery Without Sterilization Or D&C Without Cc/McC","807","MS-DRG","","","","","","","","inpatient","","","11099.53","6659.72","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","20404.85","","Fee schedule rate ($20,404.85). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","10333.74","8094.27","14652.72","105","3506","25619.67","case rate",""
"Vaginal Delivery Without Sterilization Or D&C Without Cc/McC","807","MS-DRG","","","","","","","","inpatient","","","11099.53","6659.72","CHAMPVA [160001]","HB WDH MEDICARE","5570.44","","Case rate ($5,570.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,175.71, add-ons for qualifying new technology services are included. If operating cost exceeds $9,093.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,179.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,751.01 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,730.84 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.55. The transfer capital threshold is the transfer adjustment factor * $374.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","4152.55","4152.55","4152.55","1 through 10","3506","25619.67","other","Inpatient DRG"
"Vaginal Delivery Without Sterilization Or D&C Without Cc/McC","807","MS-DRG","","","","","","","","inpatient","","","11099.53","6659.72","MARTIN'S POINT [160007]","HB WDH MEDICARE","5570.44","","Case rate ($5,570.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,175.71, add-ons for qualifying new technology services are included. If operating cost exceeds $9,093.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,179.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,751.01 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,730.84 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.55. The transfer capital threshold is the transfer adjustment factor * $374.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","4864.46","4864.46","8525.51","1 through 10","3506","25619.67","other","Inpatient DRG"
"Vaginal Delivery Without Sterilization Or D&C Without Cc/McC","807","MS-DRG","","","","","","","","inpatient","","","11099.53","6659.72","MEDICARE [2001]","HB WDH MEDICARE","5570.44","","Case rate ($5,570.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,175.71, add-ons for qualifying new technology services are included. If operating cost exceeds $9,093.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,179.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,751.01 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,730.84 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.55. The transfer capital threshold is the transfer adjustment factor * $374.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5266.42","5266.42","5266.42","1 through 10","3506","25619.67","other","Inpatient DRG"
"Vaginal Delivery Without Sterilization Or D&C Without Cc/McC","807","MS-DRG","","","","","","","","inpatient","","","11099.53","6659.72","TRICARE [160005]","HB WDH MEDICARE","5570.44","","Case rate ($5,570.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,175.71, add-ons for qualifying new technology services are included. If operating cost exceeds $9,093.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,179.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,751.01 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,730.84 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.55. The transfer capital threshold is the transfer adjustment factor * $374.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","4034.13","134.65","5678.10","38","3506","25619.67","other","Inpatient DRG"
"Vaginal Delivery Without Sterilization Or D&C Without Cc/McC","807","MS-DRG","","","","","","","","inpatient","","","11099.53","6659.72","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","5570.44","","Case rate ($5,570.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $5,175.71, add-ons for qualifying new technology services are included. If operating cost exceeds $9,093.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,179.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $4,751.01 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $4,730.84 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $374.55. The transfer capital threshold is the transfer adjustment factor * $374.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","5253.56","5253.56","5266.09","1 through 10","3506","25619.67","other","Inpatient DRG"
"Vaginal Delivery Without Sterilization Or D&C Without Cc/McC","807","MS-DRG","","","","","","","","inpatient","","","11099.53","6659.72","WELLPOINT [1015]","HB WDH ANTHEM PPO","20404.85","","Fee schedule rate ($20,404.85). The outlier payment amount is calculated by taking the estimated cost amount, subtracting the threshold amount ($211,072), then multiplying the difference by the percent of outlier that is reimbursed (42.03%). If the calculated outlier amount is greater than $0, it is added to the reimbursement total. The estimated cost amount is the billed amount multiplied by the cost-to-charge ratio (1).","10000.14","10000.14","10000.14","1 through 10","3506","25619.67","case rate",""
"Vancomycin","PX-30000192","CDM","80202","CPT","0301","RC","","","","both","","","192.00","115.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","134.02","69.8","","116.99","115.54","116.99","1 through 10","8.8","163.2","percent of total billed charges",""
"Vancomycin","PX-30000192","CDM","80202","CPT","0301","RC","","","","outpatient","","","192.00","115.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","139.62","72.72","","135.26","115.34","135.26","1 through 10","12.62","148.61","percent of total billed charges",""
"Vancomycin","PX-30000192","CDM","80202","CPT","0301","RC","","","","outpatient","","","192.00","115.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","139.62","72.72","","135.26","135.26","135.26","1 through 10","12.62","148.61","percent of total billed charges",""
"Vancomycin","PX-30000192","CDM","80202","CPT","0301","RC","","","","outpatient","","","192.00","115.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","120.77","62.9","","351.54","217.76","468.72","11","12.62","148.61","percent of total billed charges",""
"Vancomycin","PX-30000192","CDM","80202","CPT","0301","RC","","","","outpatient","","","192.00","115.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","148.61","77.4","","288.30","288.30","288.30","1 through 10","12.62","148.61","percent of total billed charges",""
"Vancomycin","PX-30000192","CDM","80202","CPT","0301","RC","","","","outpatient","","","192.00","115.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","139.62","72.72","","405.78","405.78","405.78","1 through 10","12.62","148.61","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0300","RC","","","","inpatient","","","182.00","109.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","139.89","76.86","","110.88","110.88","110.88","1 through 10","120.48","139.89","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","both","","","182.00","109.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","127.04","69.8","","122.85","110.70","122.85","73","8.37","154.7","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","both","","","182.00","109.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","127.04","69.8","","122.85","122.85","122.85","1 through 10","8.37","154.7","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","both","","","182.00","109.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","154.70","85","","122.85","122.85","122.85","1 through 10","8.37","154.7","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","outpatient","","","182.00","109.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","114.26","62.78","","110.49","110.49","110.49","1 through 10","12.01","140.87","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","outpatient","","","182.00","109.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","79.57","43.72","","76.95","76.95","153.89","1 through 10","12.01","140.87","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","outpatient","","","182.00","109.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","132.35","72.72","","127.99","127.99","127.99","90","12.01","140.87","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","outpatient","","","182.00","109.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","96.86","53.22","","93.83","93.83","93.83","1 through 10","12.01","140.87","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","outpatient","","","182.00","109.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","114.48","62.9","","110.88","110.88","110.88","113","12.01","140.87","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","outpatient","","","182.00","109.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","140.87","77.4","","136.40","136.40","136.40","63","12.01","140.87","percent of total billed charges",""
"Vasc Embolize/Occlude Artery","PX-76001943","CDM","37242","CPT","0761","RC","","","","both","","","46827.00","28096.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","51627.41","","Case rate ($51,627.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","47822.57","47822.57","47822.57","1 through 10","18385.25","119896.73","other","OPPS APC"
"Vasc Embolize/Occlude Bleed","PX-76001945","CDM","37244","CPT","0761","RC","","","","outpatient","","","20634.00","12380.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","12978.79","62.9","","12543.93","12543.93","12543.93","1 through 10","2399.73","15970.72","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","both","","","200.00","120.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","139.60","69.8","","134.71","14.76","134.71","17","11.23","170","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","inpatient","","","200.00","120.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","153.72","76.86","","121.59","121.59","121.59","1 through 10","132.4","153.72","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","outpatient","","","200.00","120.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","145.44","72.72","","140.35","140.35","140.35","16","12.06","154.8","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","outpatient","","","200.00","120.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","145.44","72.72","","140.35","140.35","140.35","1 through 10","12.06","154.8","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","outpatient","","","200.00","120.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","106.44","53.22","","102.89","102.89","102.89","1 through 10","12.06","154.8","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","outpatient","","","200.00","120.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","125.80","62.9","","243.18","121.59","364.77","19","12.06","154.8","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","outpatient","","","200.00","120.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","154.80","77.4","","149.58","138.91","149.58","12","12.06","154.8","percent of total billed charges",""
"Vasopressin (Adh)","PX-30000733","CDM","84588","CPT","0301","RC","","","","outpatient","","","182.00","109.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","132.35","72.72","","127.99","127.99","127.99","1 through 10","31.62","140.87","percent of total billed charges",""
"Veeg by Tech 2-12 Hours Unmonitored","PX-74000064","CDM","95711","CPT","0740","RC","","","","both","","","3665.00","2199.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","895.30","","Case rate ($895.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","873.47","873.47","873.47","1 through 10","318.83","3115.25","other","OPPS APC"
"Veeg by Tech 2-12 Hours Unmonitored","PX-74000064","CDM","95711","CPT","0740","RC","","","","both","","","3665.00","2199.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2085.39","56.9","","2012.55","2012.55","2012.55","1 through 10","318.83","3115.25","percent of total billed charges",""
"Veeg by Tech 2-12 Hours Unmonitored","PX-74000064","CDM","95711","CPT","0740","RC","","","","outpatient","","","3665.00","2199.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","528.49","14.42","","510.04","510.04","510.04","1 through 10","426.24","2836.71","percent of total billed charges",""
"Veeg by Tech 2-12 Hours Unmonitored","PX-74000064","CDM","95711","CPT","0740","RC","","","","outpatient","","","3665.00","2199.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","426.24","11.63","","487.04","487.04","487.04","1 through 10","426.24","2836.71","percent of total billed charges",""
"Veeg by Tech 2-12 Hours Unmonitored","PX-74000064","CDM","95711","CPT","0740","RC","","","","outpatient","","","3665.00","2199.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","2300.89","62.78","","2220.53","2220.53","2220.53","1 through 10","426.24","2836.71","percent of total billed charges",""
"Veeg by Tech 2-12 Hours Unmonitored","PX-74000064","CDM","95711","CPT","0740","RC","","","","outpatient","","","3665.00","2199.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2665.19","72.72","","2741.17","2741.17","2741.17","1 through 10","426.24","2836.71","percent of total billed charges",""
"Veeg by Tech 2-12 Hours Unmonitored","PX-74000064","CDM","95711","CPT","0740","RC","","","","outpatient","","","3665.00","2199.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2305.29","62.9","","2228.31","2228.31","2228.31","1 through 10","426.24","2836.71","percent of total billed charges",""
"Veeg by Tech 2-12 Hr Continuous R-T Monitoring","PX-74000066","CDM","95713","CPT","0740","RC","","","","both","","","4581.00","2748.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","3197.54","69.8","","3085.86","3085.86","3085.86","1 through 10","543.26","3893.85","percent of total billed charges",""
"Veeg by Tech 2-12 Hr Continuous R-T Monitoring","PX-74000066","CDM","95713","CPT","0740","RC","","","","both","","","4581.00","2748.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","543.26","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","545.54","545.54","545.54","1 through 10","543.26","3893.85","other","OPPS APC"
"Veeg by Tech 2-12 Hr Intermittent Monitoring","PX-74000065","CDM","95712","CPT","0740","RC","","","","both","","","4123.00","2473.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","2079.19","","Case rate ($2,079.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2028.48","2028.48","2028.48","1 through 10","318.83","3504.55","other","OPPS APC"
"Veeg by Tech 2-12 Hr Intermittent Monitoring","PX-74000065","CDM","95712","CPT","0740","RC","","","","both","","","4123.00","2473.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","895.30","","Case rate ($895.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4852.47","4852.47","4852.47","1 through 10","318.83","3504.55","other","OPPS APC"
"Veeg by Tech 2-12 Hr Intermittent Monitoring","PX-74000065","CDM","95712","CPT","0740","RC","","","","both","","","4123.00","2473.80","MEDICARE [2001]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","305.82","305.82","305.82","1 through 10","318.83","3504.55","other","OPPS APC"
"Veeg by Tech 2-12 Hr Intermittent Monitoring","PX-74000065","CDM","95712","CPT","0740","RC","","","","both","","","4123.00","2473.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","325.34","","APC Price ($325.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","318.88","318.88","318.88","1 through 10","318.83","3504.55","other","OPPS APC"
"Veeg by Tech Ea Incr 12-26 Hr Unmonitored","PX-74000067","CDM","95714","CPT","0740","RC","","","","both","","","4123.00","2473.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","2877.85","69.8","","2777.34","2777.34","2777.34","1 through 10","543.26","3542.81","percent of total billed charges",""
"Veeg by Tech Ea Incr 12-26 Hr Unmonitored","PX-74000067","CDM","95714","CPT","0740","RC","","","","both","","","4123.00","2473.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","3542.81","","Case rate ($3,542.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3456.41","3456.41","3456.41","1 through 10","543.26","3542.81","other","OPPS APC"
"Veeg by Tech Ea Incr 12-26 Hr Unmonitored","PX-74000067","CDM","95714","CPT","0740","RC","","","","both","","","4123.00","2473.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1525.53","","Case rate ($1,525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1488.34","1488.34","1488.34","1 through 10","543.26","3542.81","other","OPPS APC"
"Veeg by Tech Ea Incr 12-26 Hr Unmonitored","PX-74000067","CDM","95714","CPT","0740","RC","","","","both","","","4123.00","2473.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","543.26","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","554.41","522.23","554.41","1 through 10","543.26","3542.81","other","OPPS APC"
"Veeg by Tech Ea Incr 12-26 Hr Unmonitored","PX-74000067","CDM","95714","CPT","0740","RC","","","","both","","","4123.00","2473.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","2345.99","56.9","","2264.05","2264.05","2264.05","1 through 10","543.26","3542.81","percent of total billed charges",""
"Veeg by Tech Ea Incr 12-26 Hr Unmonitored","PX-74000067","CDM","95714","CPT","0740","RC","","","","both","","","4123.00","2473.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","570.98","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","560.95","560.95","560.95","1 through 10","543.26","3542.81","other","OPPS APC"
"Veeg by Tech Ea Incr 12-26 Hr Unmonitored","PX-74000067","CDM","95714","CPT","0740","RC","","","","both","","","4123.00","2473.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","554.35","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","544.99","544.99","544.99","1 through 10","543.26","3542.81","other","OPPS APC"
"Veeg by Tech Ea Incr 12-26 Hr Unmonitored","PX-74000067","CDM","95714","CPT","0740","RC","","","","both","","","4123.00","2473.80","MEDICARE [2001]","HB WDH MEDICARE","554.35","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","554.42","554.41","554.42","12","543.26","3542.81","other","OPPS APC"
"Veeg by Tech Ea Incr 12-26 Hr Unmonitored","PX-74000067","CDM","95714","CPT","0740","RC","","","","both","","","4123.00","2473.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","3504.55","85","","1209.67","1209.67","1209.67","1 through 10","543.26","3542.81","percent of total billed charges",""
"Veeg by Tech Ea Incr 12-26 Hr Unmonitored","PX-74000067","CDM","95714","CPT","0740","RC","","","","both","","","4123.00","2473.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","554.35","","APC Price ($554.35). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","545.54","545.54","554.41","1 through 10","543.26","3542.81","other","OPPS APC"
"Veeg by Tech Ea Incr 12-26 Hr Unmonitored","PX-74000067","CDM","95714","CPT","0740","RC","","","","outpatient","","","4123.00","2473.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","479.50","11.63","","469.99","469.98","1004.91","1 through 10","479.5","3191.2","percent of total billed charges",""
"Veeg by Tech Ea Incr 12-26 Hr Unmonitored","PX-74000067","CDM","95714","CPT","0740","RC","","","","outpatient","","","4123.00","2473.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1802.58","43.72","","1739.62","1739.62","1739.62","1 through 10","479.5","3191.2","percent of total billed charges",""
"Veeg by Tech Ea Incr 12-26 Hr Unmonitored","PX-74000067","CDM","95714","CPT","0740","RC","","","","outpatient","","","4123.00","2473.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2998.25","72.72","","2893.53","2893.53","2893.53","1 through 10","479.5","3191.2","percent of total billed charges",""
"Veeg by Tech Ea Incr 12-26 Hr Unmonitored","PX-74000067","CDM","95714","CPT","0740","RC","","","","outpatient","","","4123.00","2473.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","2593.37","62.9","","2506.77","2506.77","2506.77","1 through 10","479.5","3191.2","percent of total billed charges",""
"Vein Ligation And Stripping","263","MS-DRG","","","","","","","","inpatient","","","69063.32","41437.99","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","23688.56","","Case rate ($23,688.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $21,898.54, add-ons for qualifying new technology services are included. If operating cost exceeds $25,816.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,503.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $21,545.17 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $21,453.67 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,698.52. The transfer capital threshold is the transfer adjustment factor * $1,698.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20336.56","20336.56","20336.56","1 through 10","3975","116181.51","other","Inpatient DRG"
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","9.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","11.17","69.8","","11.17","7.00","11.17","357","6","13.6","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","9.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","11.17","69.8","","11.17","11.17","11.39","13","6","13.6","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","9.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","13.60","85","","12.36","2.84","13.60","48","6","13.6","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","outpatient","","","16.00","9.60","INTERNATIONAL COMMERCIAL [140001]","HB WDH UNITED HMO / PPO / INDEM","12.38","77.4","","12.40","12.40","12.40","1 through 10","8.52","12.38","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","outpatient","","","16.00","9.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","10.06","62.9","","10.08","10.08","20.16","13","8.52","12.38","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","outpatient","","","16.00","9.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","12.38","77.4","","12.40","12.40","12.40","1362","8.52","12.38","percent of total billed charges",""
"Vent Mngmnt Inpat/Obs Init Day","PX-41000001","CDM","94002","CPT","0410","RC","","","","both","","","1026.00","615.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","690.69","","APC Price ($690.69). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","684.66","684.66","684.66","1 through 10","583.79","4414.15","other","OPPS APC"
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","both","","","424.00","254.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","9141.46","","Case rate ($9,141.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1938.18","957.60","2183.36","1 through 10","241.26","21229.64","other","OPPS APC"
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","both","","","424.00","254.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","3255.41","","APC Price ($3,321.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","950.00","950.00","950.00","1 through 10","241.26","21229.64","other","OPPS APC"
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","both","","","424.00","254.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","17159.72","","Case rate ($17,159.72). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3137.11","2144.12","3137.11","1 through 10","241.26","21229.64","other","OPPS APC"
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","both","","","424.00","254.40","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","241.26","56.9","","232.72","232.72","232.72","1 through 10","241.26","21229.64","percent of total billed charges",""
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","outpatient","","","424.00","254.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","49.31","11.63","","56.32","56.32","56.32","1 through 10","49.31","328.18","percent of total billed charges",""
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","outpatient","","","424.00","254.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","","","Payment is accumulated by procedure count. Procedure 1, 62.78% of billed. Procedures 2 - 9999, 31.39% of billed.","256.77","256.77","256.77","1 through 10","49.31","328.18","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","outpatient","","","424.00","254.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","","","Payment is accumulated by procedure count. Procedure 1, 72.72% of billed. Procedures 2 - 9999, 36.36% of billed.","297.42","297.42","297.42","1 through 10","49.31","328.18","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Version Cephalic External","PX-72000018","CDM","59412","CPT","0720","RC","","","","outpatient","","","424.00","254.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","266.70","62.9","","257.67","257.67","257.67","1 through 10","49.31","328.18","percent of total billed charges",""
"Viral Illness With McC","865","MS-DRG","","","","","","","","inpatient","","","26541.46","15924.88","MEDICARE [2001]","HB WDH MEDICARE","11835.59","","Case rate ($11,835.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $10,958.38, add-ons for qualifying new technology services are included. If operating cost exceeds $14,876.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,637.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $10,558.36 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $10,513.52 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $832.37. The transfer capital threshold is the transfer adjustment factor * $832.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","11581.28","11581.28","11581.28","1 through 10","3975","56935.55","other","Inpatient DRG"
"Viral Illness Without McC","866","MS-DRG","","","","","","","","inpatient","","","14357.06","8614.24","MEDICARE [2001]","HB WDH MEDICARE","7055.94","","Case rate ($7,055.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,546.82, add-ons for qualifying new technology services are included. If operating cost exceeds $10,465.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,288.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,127.98 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,101.95 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.10. The transfer capital threshold is the transfer adjustment factor * $483.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7138.49","7138.49","7138.49","1 through 10","3975","33044.89","other","Inpatient DRG"
"Viral Illness Without McC","866","MS-DRG","","","","","","","","inpatient","","","14357.06","8614.24","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","7055.94","","Case rate ($7,055.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $6,546.82, add-ons for qualifying new technology services are included. If operating cost exceeds $10,465.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $48,288.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,127.98 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $6,101.95 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.10. The transfer capital threshold is the transfer adjustment factor * $483.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","7121.10","7121.10","7121.10","1 through 10","3975","33044.89","other","Inpatient DRG"
"Virus Isolate & ID Non-Immunologic","PX-30001205","CDM","87255","CPT","0306","RC","","","","both","","","351.00","210.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","245.00","69.8","","236.62","236.62","236.62","1 through 10","22.01","298.35","percent of total billed charges",""
"Virus Isolate & ID Non-Immunologic","PX-30001205","CDM","87255","CPT","0306","RC","","","","both","","","351.00","210.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","298.35","85","","236.62","236.62","236.62","1 through 10","22.01","298.35","percent of total billed charges",""
"Virus Isolate & ID Non-Immunologic","PX-30001205","CDM","87255","CPT","0306","RC","","","","outpatient","","","351.00","210.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","255.25","72.72","","246.52","246.52","246.52","1 through 10","31.55","271.67","percent of total billed charges",""
"Virus Isolate & ID Non-Immunologic","PX-30001205","CDM","87255","CPT","0306","RC","","","","outpatient","","","351.00","210.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","186.80","53.22","","180.72","180.72","180.72","1 through 10","31.55","271.67","percent of total billed charges",""
"Virus Isolate & ID Non-Immunologic","PX-30001205","CDM","87255","CPT","0306","RC","","","","outpatient","","","351.00","210.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","220.78","62.9","","213.57","213.57","213.57","1 through 10","31.55","271.67","percent of total billed charges",""
"Virus Isolate & ID Non-Immunologic","PX-30001205","CDM","87255","CPT","0306","RC","","","","outpatient","","","351.00","210.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","271.67","77.4","","262.73","262.73","262.73","1 through 10","31.55","271.67","percent of total billed charges",""
"Virus Isolate Shell ID","PX-30001204","CDM","87254","CPT","0306","RC","","","","outpatient","","","143.00","85.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","76.10","53.22","","147.14","147.14","147.14","1 through 10","5.87","110.68","percent of total billed charges",""
"Virus Not Elsewhere Specified","PX-30001009","CDM","86790","CPT","0302","RC","","","","both","","","69.00","41.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","48.16","69.8","","46.77","46.77","46.77","1 through 10","8.37","66.21","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","both","","","64.00","38.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","44.67","69.8","","43.28","13.22","43.28","21","7.55","60.21","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","outpatient","","","64.00","38.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","40.18","62.78","","38.92","38.92","38.92","1 through 10","10.81","49.54","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","outpatient","","","64.00","38.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","27.98","43.72","","27.11","27.11","27.11","1 through 10","10.81","49.54","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","outpatient","","","64.00","38.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","46.54","72.72","","45.09","45.09","45.09","22","10.81","49.54","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","outpatient","","","64.00","38.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","46.54","72.72","","45.09","45.09","45.09","1 through 10","10.81","49.54","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","outpatient","","","64.00","38.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","34.06","53.22","","33.05","33.05","33.05","1 through 10","10.81","49.54","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","outpatient","","","64.00","38.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","40.26","62.9","","39.06","39.06","39.06","49","10.81","49.54","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","outpatient","","","64.00","38.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","49.54","77.4","","48.05","48.05","48.05","12","10.81","49.54","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","81.00","48.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","56.54","69.8","","54.44","49.06","54.44","218","9.8","78.25","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","81.00","48.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","56.54","69.8","","54.44","54.44","54.44","1 through 10","9.8","78.25","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","81.00","48.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","68.85","85","","54.44","9.59","78.26","1 through 10","9.8","78.25","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","outpatient","","","81.00","48.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","50.85","62.78","","48.97","48.97","48.97","1 through 10","11.18","62.69","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","outpatient","","","81.00","48.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","35.41","43.72","","34.10","34.10","34.10","11","11.18","62.69","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","outpatient","","","81.00","48.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","58.90","72.72","","56.72","56.72","56.72","271","11.18","62.69","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","outpatient","","","81.00","48.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","58.90","72.72","","56.72","56.72","113.44","15","11.18","62.69","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","outpatient","","","81.00","48.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","43.11","53.22","","41.58","41.58","41.58","25","11.18","62.69","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","outpatient","","","81.00","48.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","50.95","62.9","","49.14","49.14","49.14","451","11.18","62.69","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","outpatient","","","81.00","48.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","62.69","77.4","","60.45","60.45","60.45","141","11.18","62.69","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","outpatient","","","81.00","48.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","58.90","72.72","","56.72","56.72","56.72","1 through 10","11.18","62.69","percent of total billed charges",""
"Vitamin B-2 (Riboflavin)","PX-30000668","CDM","84252","CPT","0301","RC","","","","outpatient","","","259.00","155.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","162.91","62.9","","157.50","157.50","157.50","1 through 10","24.25","200.47","percent of total billed charges",""
"Vitamin B-2 (Riboflavin)","PX-30000668","CDM","84252","CPT","0301","RC","","","","outpatient","","","259.00","155.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","200.47","77.4","","193.75","193.75","193.75","1 through 10","24.25","200.47","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","both","","","152.00","91.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","106.10","69.8","","102.61","28.10","102.61","1 through 10","18.27","144.46","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","both","","","152.00","91.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","129.20","85","","144.48","144.48","144.48","1 through 10","18.27","144.46","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","outpatient","","","152.00","91.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","66.45","43.72","","64.27","64.27","64.27","1 through 10","26.17","117.65","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","outpatient","","","152.00","91.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","110.53","72.72","","106.90","106.90","106.90","1 through 10","26.17","117.65","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","outpatient","","","152.00","91.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","110.53","72.72","","106.90","106.90","106.90","1 through 10","26.17","117.65","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","outpatient","","","152.00","91.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","95.61","62.9","","277.83","92.61","370.44","13","26.17","117.65","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","outpatient","","","152.00","91.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","117.65","77.4","","113.93","113.93","113.93","1 through 10","26.17","117.65","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","both","","","115.00","69.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","80.27","69.8","","77.48","24.20","77.48","38","13.8","109.86","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","outpatient","","","115.00","69.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","72.20","62.78","","69.69","69.69","69.69","1 through 10","19.79","89.01","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","outpatient","","","115.00","69.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","50.28","43.72","","48.53","48.53","48.53","1 through 10","19.79","89.01","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","outpatient","","","115.00","69.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","83.63","72.72","","80.72","80.72","80.72","44","19.79","89.01","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","outpatient","","","115.00","69.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","61.20","53.22","","59.17","59.17","59.17","1 through 10","19.79","89.01","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","outpatient","","","115.00","69.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","72.34","62.9","","69.93","69.93","69.93","87","19.79","89.01","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","outpatient","","","115.00","69.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","89.01","77.4","","86.03","86.03","86.03","22","19.79","89.01","percent of total billed charges",""
"Vitamin C (Ascorbic Acid)","PX-30000318","CDM","82180","CPT","0301","RC","","","","both","","","113.00","67.80","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","96.05","85","","92.65","92.65","92.65","1 through 10","6.43","96.05","percent of total billed charges",""
"Vitamin C (Ascorbic Acid)","PX-30000318","CDM","82180","CPT","0301","RC","","","","outpatient","","","113.00","67.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","71.08","62.9","","68.67","68.67","68.67","1 through 10","11.85","87.46","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","422.00","253.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","294.56","69.8","","284.78","256.63","284.78","248","19.24","358.7","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","422.00","253.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","358.70","85","","153.51","39.10","346.80","1 through 10","19.24","358.7","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","outpatient","","","422.00","253.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","264.93","62.78","","256.14","256.14","256.14","11","27.58","326.63","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","outpatient","","","422.00","253.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","184.50","43.72","","178.38","178.38","178.38","1 through 10","27.58","326.63","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","outpatient","","","422.00","253.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","306.88","72.72","","296.70","296.70","296.70","331","27.58","326.63","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","outpatient","","","422.00","253.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","306.88","72.72","","296.70","296.70","296.70","19","27.58","326.63","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","outpatient","","","422.00","253.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","224.59","53.22","","217.50","217.50","652.50","27","27.58","326.63","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","outpatient","","","422.00","253.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","265.44","62.9","","257.04","257.04","257.04","485","27.58","326.63","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","outpatient","","","422.00","253.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","326.63","77.4","","316.20","316.20","316.20","193","27.58","326.63","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","outpatient","","","422.00","253.20","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","306.88","72.72","","296.70","296.70","296.70","1 through 10","27.58","326.63","percent of total billed charges",""
"Vitamin E","PX-30000703","CDM","84446","CPT","0301","RC","","","","both","","","163.00","97.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","113.77","69.8","","110.28","14.18","110.28","1 through 10","9.22","138.55","percent of total billed charges",""
"Vitamin E","PX-30000703","CDM","84446","CPT","0301","RC","","","","outpatient","","","163.00","97.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","118.53","72.72","","114.90","114.90","114.90","1 through 10","13.22","126.16","percent of total billed charges",""
"Vitamin E","PX-30000703","CDM","84446","CPT","0301","RC","","","","outpatient","","","163.00","97.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","102.53","62.9","","99.54","99.54","99.54","1 through 10","13.22","126.16","percent of total billed charges",""
"Vitamin E","PX-30000703","CDM","84446","CPT","0301","RC","","","","outpatient","","","163.00","97.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","126.16","77.4","","122.45","122.45","122.45","1 through 10","13.22","126.16","percent of total billed charges",""
"Vitamin K","PX-30000736","CDM","84597","CPT","0301","RC","","","","outpatient","","","157.00","94.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","114.17","72.72","","110.53","110.53","110.53","1 through 10","12.78","121.52","percent of total billed charges",""
"Vitamin K","PX-30000736","CDM","84597","CPT","0301","RC","","","","outpatient","","","157.00","94.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","98.75","62.9","","95.76","95.76","95.76","1 through 10","12.78","121.52","percent of total billed charges",""
"Vitamin K","PX-30000736","CDM","84597","CPT","0301","RC","","","","outpatient","","","157.00","94.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","121.52","77.4","","117.80","117.80","117.80","1 through 10","12.78","121.52","percent of total billed charges",""
"Voltage-Gated Calcium Channel Antibody Each","PX-30003773","CDM","86596","CPT","0302","RC","","","","outpatient","","","211.00","126.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","153.44","72.72","","148.35","148.35","148.35","1 through 10","24.54","163.31","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","608.08","364.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","70.72","516.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","608.08","364.85","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","70.72","516.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","608.08","364.85","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","346.00","56.9","","812.12","238.65","1587.46","163","70.72","516.87","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","608.08","364.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","70.72","11.63","","112.68","112.68","146.99","38","70.72","516.87","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","608.08","364.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","470.65","77.4","","303.98","303.98","5854.79","1 through 10","70.72","516.87","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","608.08","364.85","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","70.72","11.63","","112.68","112.68","146.99","38","70.72","470.65","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","608.08","364.85","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","381.75","62.78","","780.86","208.94","10480.28","15","70.72","470.65","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","608.08","364.85","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","265.85","43.72","","179.76","179.76","179.76","1 through 10","70.72","470.65","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","608.08","364.85","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","442.20","72.72","","2355.45","298.99","3965.19","155","70.72","470.65","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","608.08","364.85","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","442.20","72.72","","3643.09","3643.09","3643.09","1 through 10","70.72","470.65","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","608.08","364.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","323.62","53.22","","554.28","554.28","554.28","16","70.72","470.65","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","608.08","364.85","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","382.48","62.9","","619.64","173.09","2370.64","150","70.72","470.65","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","608.08","364.85","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","470.65","77.4","","303.98","303.98","5854.79","1 through 10","70.72","470.65","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.62","84.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","16.35","119.53","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.62","84.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","16.35","119.53","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.62","84.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","80.01","56.9","","812.12","238.65","1587.46","163","16.35","119.53","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.62","84.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16.35","11.63","","112.68","112.68","146.99","38","16.35","119.53","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.62","84.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","108.84","77.4","","303.98","303.98","5854.79","1 through 10","16.35","119.53","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.62","84.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","16.35","11.63","","112.68","112.68","146.99","38","16.35","108.84","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.62","84.37","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","88.28","62.78","","780.86","208.94","10480.28","15","16.35","108.84","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.62","84.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","61.48","43.72","","179.76","179.76","179.76","1 through 10","16.35","108.84","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.62","84.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","102.26","72.72","","2355.45","298.99","3965.19","155","16.35","108.84","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.62","84.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","102.26","72.72","","3643.09","3643.09","3643.09","1 through 10","16.35","108.84","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.62","84.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","74.84","53.22","","554.28","554.28","554.28","16","16.35","108.84","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.62","84.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","88.45","62.9","","619.64","173.09","2370.64","150","16.35","108.84","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.62","84.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","108.84","77.4","","303.98","303.98","5854.79","1 through 10","16.35","108.84","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.85","90.51","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","17.54","128.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.85","90.51","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","17.54","128.22","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.85","90.51","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","85.83","56.9","","812.12","238.65","1587.46","163","17.54","128.22","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.85","90.51","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","17.54","11.63","","112.68","112.68","146.99","38","17.54","128.22","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.85","90.51","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","116.76","77.4","","303.98","303.98","5854.79","1 through 10","17.54","128.22","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.85","90.51","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","17.54","11.63","","112.68","112.68","146.99","38","17.54","116.76","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.85","90.51","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","94.70","62.78","","780.86","208.94","10480.28","15","17.54","116.76","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.85","90.51","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","65.95","43.72","","179.76","179.76","179.76","1 through 10","17.54","116.76","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.85","90.51","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","109.70","72.72","","2355.45","298.99","3965.19","155","17.54","116.76","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.85","90.51","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","109.70","72.72","","3643.09","3643.09","3643.09","1 through 10","17.54","116.76","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.85","90.51","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","80.28","53.22","","554.28","554.28","554.28","16","17.54","116.76","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.85","90.51","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","94.88","62.9","","619.64","173.09","2370.64","150","17.54","116.76","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.85","90.51","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","116.76","77.4","","303.98","303.98","5854.79","1 through 10","17.54","116.76","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","125.28","75.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","14.57","106.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","125.28","75.17","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","14.57","106.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","125.28","75.17","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","71.28","56.9","","812.12","238.65","1587.46","163","14.57","106.49","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","125.28","75.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","14.57","11.63","","112.68","112.68","146.99","38","14.57","106.49","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","125.28","75.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","96.97","77.4","","303.98","303.98","5854.79","1 through 10","14.57","106.49","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","125.28","75.17","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","14.57","11.63","","112.68","112.68","146.99","38","14.57","96.97","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","125.28","75.17","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","78.65","62.78","","780.86","208.94","10480.28","15","14.57","96.97","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","125.28","75.17","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","54.77","43.72","","179.76","179.76","179.76","1 through 10","14.57","96.97","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","125.28","75.17","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","91.10","72.72","","2355.45","298.99","3965.19","155","14.57","96.97","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","125.28","75.17","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","91.10","72.72","","3643.09","3643.09","3643.09","1 through 10","14.57","96.97","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","125.28","75.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","66.67","53.22","","554.28","554.28","554.28","16","14.57","96.97","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","125.28","75.17","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","78.80","62.9","","619.64","173.09","2370.64","150","14.57","96.97","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","125.28","75.17","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","96.97","77.4","","303.98","303.98","5854.79","1 through 10","14.57","96.97","percent of total billed charges",""
"WASHER BONE 8MM 4 SCREW SS BX/6EA","SUP-ITM-10063070","CDM","C1713","HCPCS","0278","RC","","","","both","","","580.44","348.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","67.51","493.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER BONE 8MM 4 SCREW SS BX/6EA","SUP-ITM-10063070","CDM","C1713","HCPCS","0278","RC","","","","both","","","580.44","348.26","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","67.51","493.37","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER BONE 8MM 4 SCREW SS BX/6EA","SUP-ITM-10063070","CDM","C1713","HCPCS","0278","RC","","","","both","","","580.44","348.26","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","330.27","56.9","","812.12","238.65","1587.46","163","67.51","493.37","percent of total billed charges",""
"WASHER BONE 8MM 4 SCREW SS BX/6EA","SUP-ITM-10063070","CDM","C1713","HCPCS","0278","RC","","","","both","","","580.44","348.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","67.51","11.63","","112.68","112.68","146.99","38","67.51","493.37","percent of total billed charges",""
"WASHER BONE 8MM 4 SCREW SS BX/6EA","SUP-ITM-10063070","CDM","C1713","HCPCS","0278","RC","","","","both","","","580.44","348.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","449.26","77.4","","303.98","303.98","5854.79","1 through 10","67.51","493.37","percent of total billed charges",""
"WASHER BONE 8MM 4 SCREW SS BX/6EA","SUP-ITM-10063070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","580.44","348.26","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","67.51","11.63","","112.68","112.68","146.99","38","67.51","449.26","percent of total billed charges",""
"WASHER BONE 8MM 4 SCREW SS BX/6EA","SUP-ITM-10063070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","580.44","348.26","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","364.40","62.78","","780.86","208.94","10480.28","15","67.51","449.26","percent of total billed charges",""
"WASHER BONE 8MM 4 SCREW SS BX/6EA","SUP-ITM-10063070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","580.44","348.26","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","253.77","43.72","","179.76","179.76","179.76","1 through 10","67.51","449.26","percent of total billed charges",""
"WASHER BONE 8MM 4 SCREW SS BX/6EA","SUP-ITM-10063070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","580.44","348.26","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","422.10","72.72","","2355.45","298.99","3965.19","155","67.51","449.26","percent of total billed charges",""
"WASHER BONE 8MM 4 SCREW SS BX/6EA","SUP-ITM-10063070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","580.44","348.26","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","422.10","72.72","","3643.09","3643.09","3643.09","1 through 10","67.51","449.26","percent of total billed charges",""
"WASHER BONE 8MM 4 SCREW SS BX/6EA","SUP-ITM-10063070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","580.44","348.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","308.91","53.22","","554.28","554.28","554.28","16","67.51","449.26","percent of total billed charges",""
"WASHER BONE 8MM 4 SCREW SS BX/6EA","SUP-ITM-10063070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","580.44","348.26","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","365.10","62.9","","619.64","173.09","2370.64","150","67.51","449.26","percent of total billed charges",""
"WASHER BONE 8MM 4 SCREW SS BX/6EA","SUP-ITM-10063070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","580.44","348.26","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","449.26","77.4","","303.98","303.98","5854.79","1 through 10","67.51","449.26","percent of total billed charges",""
"WASHER SCREW 13.5MM 4 BONE SPIKED","SUP-ITM-10037539","CDM","C1713","HCPCS","0278","RC","","","","both","","","603.38","362.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","70.17","512.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER SCREW 13.5MM 4 BONE SPIKED","SUP-ITM-10037539","CDM","C1713","HCPCS","0278","RC","","","","both","","","603.38","362.03","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","70.17","512.87","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER SCREW 13.5MM 4 BONE SPIKED","SUP-ITM-10037539","CDM","C1713","HCPCS","0278","RC","","","","both","","","603.38","362.03","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","343.32","56.9","","812.12","238.65","1587.46","163","70.17","512.87","percent of total billed charges",""
"WASHER SCREW 13.5MM 4 BONE SPIKED","SUP-ITM-10037539","CDM","C1713","HCPCS","0278","RC","","","","both","","","603.38","362.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","70.17","11.63","","112.68","112.68","146.99","38","70.17","512.87","percent of total billed charges",""
"WASHER SCREW 13.5MM 4 BONE SPIKED","SUP-ITM-10037539","CDM","C1713","HCPCS","0278","RC","","","","both","","","603.38","362.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","467.02","77.4","","303.98","303.98","5854.79","1 through 10","70.17","512.87","percent of total billed charges",""
"WASHER SCREW 13.5MM 4 BONE SPIKED","SUP-ITM-10037539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","603.38","362.03","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","70.17","11.63","","112.68","112.68","146.99","38","70.17","467.02","percent of total billed charges",""
"WASHER SCREW 13.5MM 4 BONE SPIKED","SUP-ITM-10037539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","603.38","362.03","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","378.80","62.78","","780.86","208.94","10480.28","15","70.17","467.02","percent of total billed charges",""
"WASHER SCREW 13.5MM 4 BONE SPIKED","SUP-ITM-10037539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","603.38","362.03","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","263.80","43.72","","179.76","179.76","179.76","1 through 10","70.17","467.02","percent of total billed charges",""
"WASHER SCREW 13.5MM 4 BONE SPIKED","SUP-ITM-10037539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","603.38","362.03","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","438.78","72.72","","2355.45","298.99","3965.19","155","70.17","467.02","percent of total billed charges",""
"WASHER SCREW 13.5MM 4 BONE SPIKED","SUP-ITM-10037539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","603.38","362.03","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","438.78","72.72","","3643.09","3643.09","3643.09","1 through 10","70.17","467.02","percent of total billed charges",""
"WASHER SCREW 13.5MM 4 BONE SPIKED","SUP-ITM-10037539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","603.38","362.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","321.12","53.22","","554.28","554.28","554.28","16","70.17","467.02","percent of total billed charges",""
"WASHER SCREW 13.5MM 4 BONE SPIKED","SUP-ITM-10037539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","603.38","362.03","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","379.53","62.9","","619.64","173.09","2370.64","150","70.17","467.02","percent of total billed charges",""
"WASHER SCREW 13.5MM 4 BONE SPIKED","SUP-ITM-10037539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","603.38","362.03","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","467.02","77.4","","303.98","303.98","5854.79","1 through 10","70.17","467.02","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.71","357.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","69.28","506.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.71","357.43","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","69.28","506.35","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.71","357.43","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","338.96","56.9","","812.12","238.65","1587.46","163","69.28","506.35","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.71","357.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","69.28","11.63","","112.68","112.68","146.99","38","69.28","506.35","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.71","357.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","461.08","77.4","","303.98","303.98","5854.79","1 through 10","69.28","506.35","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.71","357.43","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","69.28","11.63","","112.68","112.68","146.99","38","69.28","461.08","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.71","357.43","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","373.99","62.78","","780.86","208.94","10480.28","15","69.28","461.08","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.71","357.43","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","260.44","43.72","","179.76","179.76","179.76","1 through 10","69.28","461.08","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.71","357.43","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","433.20","72.72","","2355.45","298.99","3965.19","155","69.28","461.08","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.71","357.43","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","433.20","72.72","","3643.09","3643.09","3643.09","1 through 10","69.28","461.08","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.71","357.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","317.04","53.22","","554.28","554.28","554.28","16","69.28","461.08","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.71","357.43","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","374.70","62.9","","619.64","173.09","2370.64","150","69.28","461.08","percent of total billed charges",""
"WASHER SCREW 13.5X5.5MM BONE SPIKED","SUP-ITM-10019128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.71","357.43","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","461.08","77.4","","303.98","303.98","5854.79","1 through 10","69.28","461.08","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.49","216.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","41.92","306.42","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.49","216.29","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","41.92","306.42","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.49","216.29","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","205.12","56.9","","812.12","238.65","1587.46","163","41.92","306.42","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.49","216.29","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","41.92","11.63","","112.68","112.68","146.99","38","41.92","306.42","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.49","216.29","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","279.02","77.4","","303.98","303.98","5854.79","1 through 10","41.92","306.42","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","360.49","216.29","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","41.92","11.63","","112.68","112.68","146.99","38","41.92","279.02","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","360.49","216.29","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","226.32","62.78","","780.86","208.94","10480.28","15","41.92","279.02","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","360.49","216.29","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","157.61","43.72","","179.76","179.76","179.76","1 through 10","41.92","279.02","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","360.49","216.29","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","262.15","72.72","","2355.45","298.99","3965.19","155","41.92","279.02","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","360.49","216.29","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","262.15","72.72","","3643.09","3643.09","3643.09","1 through 10","41.92","279.02","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","360.49","216.29","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","191.85","53.22","","554.28","554.28","554.28","16","41.92","279.02","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","360.49","216.29","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","226.75","62.9","","619.64","173.09","2370.64","150","41.92","279.02","percent of total billed charges",""
"WASHER SCREW 3.2X8MM BONE SS SPIKED","SUP-ITM-10017069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","360.49","216.29","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","279.02","77.4","","303.98","303.98","5854.79","1 through 10","41.92","279.02","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.40","71.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","13.89","101.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.40","71.64","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","13.89","101.49","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.40","71.64","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","67.94","56.9","","812.12","238.65","1587.46","163","13.89","101.49","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.40","71.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","13.89","11.63","","112.68","112.68","146.99","38","13.89","101.49","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.40","71.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","92.42","77.4","","303.98","303.98","5854.79","1 through 10","13.89","101.49","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.40","71.64","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","13.89","11.63","","112.68","112.68","146.99","38","13.89","92.42","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.40","71.64","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","74.96","62.78","","780.86","208.94","10480.28","15","13.89","92.42","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.40","71.64","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","52.20","43.72","","179.76","179.76","179.76","1 through 10","13.89","92.42","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.40","71.64","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","86.83","72.72","","2355.45","298.99","3965.19","155","13.89","92.42","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.40","71.64","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","86.83","72.72","","3643.09","3643.09","3643.09","1 through 10","13.89","92.42","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.40","71.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","63.54","53.22","","554.28","554.28","554.28","16","13.89","92.42","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.40","71.64","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","75.10","62.9","","619.64","173.09","2370.64","150","13.89","92.42","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.40","71.64","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","92.42","77.4","","303.98","303.98","5854.79","1 through 10","13.89","92.42","percent of total billed charges",""
"WASHER SCREW 7.0MM CANCELLOUS PERILOC LOCKING PLATES BX/6EA","SUP-ITM-10063264","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.61","294.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","57.06","417.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER SCREW 7.0MM CANCELLOUS PERILOC LOCKING PLATES BX/6EA","SUP-ITM-10063264","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.61","294.37","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","57.06","417.02","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER SCREW 7.0MM CANCELLOUS PERILOC LOCKING PLATES BX/6EA","SUP-ITM-10063264","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.61","294.37","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","279.16","56.9","","812.12","238.65","1587.46","163","57.06","417.02","percent of total billed charges",""
"WASHER SCREW 7.0MM CANCELLOUS PERILOC LOCKING PLATES BX/6EA","SUP-ITM-10063264","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.61","294.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","57.06","11.63","","112.68","112.68","146.99","38","57.06","417.02","percent of total billed charges",""
"WASHER SCREW 7.0MM CANCELLOUS PERILOC LOCKING PLATES BX/6EA","SUP-ITM-10063264","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.61","294.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","379.73","77.4","","303.98","303.98","5854.79","1 through 10","57.06","417.02","percent of total billed charges",""
"WASHER SCREW 7.0MM CANCELLOUS PERILOC LOCKING PLATES BX/6EA","SUP-ITM-10063264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.61","294.37","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","57.06","11.63","","112.68","112.68","146.99","38","57.06","379.73","percent of total billed charges",""
"WASHER SCREW 7.0MM CANCELLOUS PERILOC LOCKING PLATES BX/6EA","SUP-ITM-10063264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.61","294.37","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","308.00","62.78","","780.86","208.94","10480.28","15","57.06","379.73","percent of total billed charges",""
"WASHER SCREW 7.0MM CANCELLOUS PERILOC LOCKING PLATES BX/6EA","SUP-ITM-10063264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.61","294.37","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","214.49","43.72","","179.76","179.76","179.76","1 through 10","57.06","379.73","percent of total billed charges",""
"WASHER SCREW 7.0MM CANCELLOUS PERILOC LOCKING PLATES BX/6EA","SUP-ITM-10063264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.61","294.37","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","356.77","72.72","","2355.45","298.99","3965.19","155","57.06","379.73","percent of total billed charges",""
"WASHER SCREW 7.0MM CANCELLOUS PERILOC LOCKING PLATES BX/6EA","SUP-ITM-10063264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.61","294.37","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","356.77","72.72","","3643.09","3643.09","3643.09","1 through 10","57.06","379.73","percent of total billed charges",""
"WASHER SCREW 7.0MM CANCELLOUS PERILOC LOCKING PLATES BX/6EA","SUP-ITM-10063264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.61","294.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","261.10","53.22","","554.28","554.28","554.28","16","57.06","379.73","percent of total billed charges",""
"WASHER SCREW 7.0MM CANCELLOUS PERILOC LOCKING PLATES BX/6EA","SUP-ITM-10063264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.61","294.37","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","308.59","62.9","","619.64","173.09","2370.64","150","57.06","379.73","percent of total billed charges",""
"WASHER SCREW 7.0MM CANCELLOUS PERILOC LOCKING PLATES BX/6EA","SUP-ITM-10063264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.61","294.37","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","379.73","77.4","","303.98","303.98","5854.79","1 through 10","57.06","379.73","percent of total billed charges",""
"WASHER SCREW 9MM 1MM THICK CORTICAL STAINLESS STEEL","SUP-ITM-10241055","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.50","207.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","40.18","293.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER SCREW 9MM 1MM THICK CORTICAL STAINLESS STEEL","SUP-ITM-10241055","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.50","207.30","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","40.18","293.68","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER SCREW 9MM 1MM THICK CORTICAL STAINLESS STEEL","SUP-ITM-10241055","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.50","207.30","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","196.59","56.9","","812.12","238.65","1587.46","163","40.18","293.68","percent of total billed charges",""
"WASHER SCREW 9MM 1MM THICK CORTICAL STAINLESS STEEL","SUP-ITM-10241055","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.50","207.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.18","11.63","","112.68","112.68","146.99","38","40.18","293.68","percent of total billed charges",""
"WASHER SCREW 9MM 1MM THICK CORTICAL STAINLESS STEEL","SUP-ITM-10241055","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.50","207.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","267.42","77.4","","303.98","303.98","5854.79","1 through 10","40.18","293.68","percent of total billed charges",""
"WASHER SCREW 9MM 1MM THICK CORTICAL STAINLESS STEEL","SUP-ITM-10241055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.18","11.63","","112.68","112.68","146.99","38","40.18","267.42","percent of total billed charges",""
"WASHER SCREW 9MM 1MM THICK CORTICAL STAINLESS STEEL","SUP-ITM-10241055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","216.90","62.78","","780.86","208.94","10480.28","15","40.18","267.42","percent of total billed charges",""
"WASHER SCREW 9MM 1MM THICK CORTICAL STAINLESS STEEL","SUP-ITM-10241055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","151.05","43.72","","179.76","179.76","179.76","1 through 10","40.18","267.42","percent of total billed charges",""
"WASHER SCREW 9MM 1MM THICK CORTICAL STAINLESS STEEL","SUP-ITM-10241055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","251.25","72.72","","2355.45","298.99","3965.19","155","40.18","267.42","percent of total billed charges",""
"WASHER SCREW 9MM 1MM THICK CORTICAL STAINLESS STEEL","SUP-ITM-10241055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","251.25","72.72","","3643.09","3643.09","3643.09","1 through 10","40.18","267.42","percent of total billed charges",""
"WASHER SCREW 9MM 1MM THICK CORTICAL STAINLESS STEEL","SUP-ITM-10241055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","183.88","53.22","","554.28","554.28","554.28","16","40.18","267.42","percent of total billed charges",""
"WASHER SCREW 9MM 1MM THICK CORTICAL STAINLESS STEEL","SUP-ITM-10241055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","217.32","62.9","","619.64","173.09","2370.64","150","40.18","267.42","percent of total billed charges",""
"WASHER SCREW 9MM 1MM THICK CORTICAL STAINLESS STEEL","SUP-ITM-10241055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.50","207.30","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","267.42","77.4","","303.98","303.98","5854.79","1 through 10","40.18","267.42","percent of total billed charges",""
"WASHER SPHERICAL 6.5/ 7.3MM SM OVAL FOR CANNULATED SCREW","SUP-ITM-10037540","CDM","C1713","HCPCS","0278","RC","","","","both","","","826.99","496.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","96.18","702.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER SPHERICAL 6.5/ 7.3MM SM OVAL FOR CANNULATED SCREW","SUP-ITM-10037540","CDM","C1713","HCPCS","0278","RC","","","","both","","","826.99","496.19","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","96.18","702.94","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WASHER SPHERICAL 6.5/ 7.3MM SM OVAL FOR CANNULATED SCREW","SUP-ITM-10037540","CDM","C1713","HCPCS","0278","RC","","","","both","","","826.99","496.19","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","470.56","56.9","","812.12","238.65","1587.46","163","96.18","702.94","percent of total billed charges",""
"WASHER SPHERICAL 6.5/ 7.3MM SM OVAL FOR CANNULATED SCREW","SUP-ITM-10037540","CDM","C1713","HCPCS","0278","RC","","","","both","","","826.99","496.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","96.18","11.63","","112.68","112.68","146.99","38","96.18","702.94","percent of total billed charges",""
"WASHER SPHERICAL 6.5/ 7.3MM SM OVAL FOR CANNULATED SCREW","SUP-ITM-10037540","CDM","C1713","HCPCS","0278","RC","","","","both","","","826.99","496.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","640.09","77.4","","303.98","303.98","5854.79","1 through 10","96.18","702.94","percent of total billed charges",""
"WASHER SPHERICAL 6.5/ 7.3MM SM OVAL FOR CANNULATED SCREW","SUP-ITM-10037540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","96.18","11.63","","112.68","112.68","146.99","38","96.18","640.09","percent of total billed charges",""
"WASHER SPHERICAL 6.5/ 7.3MM SM OVAL FOR CANNULATED SCREW","SUP-ITM-10037540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","519.18","62.78","","780.86","208.94","10480.28","15","96.18","640.09","percent of total billed charges",""
"WASHER SPHERICAL 6.5/ 7.3MM SM OVAL FOR CANNULATED SCREW","SUP-ITM-10037540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","361.56","43.72","","179.76","179.76","179.76","1 through 10","96.18","640.09","percent of total billed charges",""
"WASHER SPHERICAL 6.5/ 7.3MM SM OVAL FOR CANNULATED SCREW","SUP-ITM-10037540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","601.39","72.72","","2355.45","298.99","3965.19","155","96.18","640.09","percent of total billed charges",""
"WASHER SPHERICAL 6.5/ 7.3MM SM OVAL FOR CANNULATED SCREW","SUP-ITM-10037540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","601.39","72.72","","3643.09","3643.09","3643.09","1 through 10","96.18","640.09","percent of total billed charges",""
"WASHER SPHERICAL 6.5/ 7.3MM SM OVAL FOR CANNULATED SCREW","SUP-ITM-10037540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","440.12","53.22","","554.28","554.28","554.28","16","96.18","640.09","percent of total billed charges",""
"WASHER SPHERICAL 6.5/ 7.3MM SM OVAL FOR CANNULATED SCREW","SUP-ITM-10037540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","520.18","62.9","","619.64","173.09","2370.64","150","96.18","640.09","percent of total billed charges",""
"WASHER SPHERICAL 6.5/ 7.3MM SM OVAL FOR CANNULATED SCREW","SUP-ITM-10037540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","826.99","496.19","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","640.09","77.4","","303.98","303.98","5854.79","1 through 10","96.18","640.09","percent of total billed charges",""
"Wdh 7- Dehydrocholesterol","PX-30003588","CDM","82542","CPT","0300","RC","","","","outpatient","","","168.00","100.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","122.17","72.72","","117.81","117.81","117.81","1 through 10","16.24","130.03","percent of total billed charges",""
"Wdh 7- Dehydrocholesterol","PX-30003588","CDM","82542","CPT","0300","RC","","","","outpatient","","","168.00","100.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","105.67","62.9","","102.06","102.06","102.06","1 through 10","16.24","130.03","percent of total billed charges",""
"Wdh 7- Dehydrocholesterol","PX-30003588","CDM","82542","CPT","0300","RC","","","","outpatient","","","168.00","100.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","130.03","77.4","","125.55","125.55","125.55","1 through 10","16.24","130.03","percent of total billed charges",""
"Wdh Anaplasma Phago (Accutix)","PX-30003599","CDM","87798","CPT","0300","RC","","","","both","","","188.00","112.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","131.22","69.8","","127.04","114.48","508.14","20","22.81","180.59","percent of total billed charges",""
"Wdh Anaplasma Phago (Accutix)","PX-30003599","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","118.03","62.78","","114.26","114.26","114.26","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Anaplasma Phago (Accutix)","PX-30003599","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","82.19","43.72","","79.57","79.57","79.57","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Anaplasma Phago (Accutix)","PX-30003599","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","529.40","79","24.28","145.51","percent of total billed charges",""
"Wdh Anaplasma Phago (Accutix)","PX-30003599","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Anaplasma Phago (Accutix)","PX-30003599","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","118.25","62.9","","114.66","114.66","114.66","231","24.28","145.51","percent of total billed charges",""
"Wdh Anaplasma Phago (Accutix)","PX-30003599","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","145.51","77.4","","141.05","141.05","564.20","57","24.28","145.51","percent of total billed charges",""
"Wdh Anaplasma Phago (Accutix)","PX-30003599","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Anaplasma Phago Pcr (Accutix)","PX-30003601","CDM","87798","CPT","0300","RC","","","","both","","","188.00","112.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","131.22","69.8","","127.04","114.48","508.14","20","22.81","180.59","percent of total billed charges",""
"Wdh Anaplasma Phago Pcr (Accutix)","PX-30003601","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","118.03","62.78","","114.26","114.26","114.26","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Anaplasma Phago Pcr (Accutix)","PX-30003601","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","82.19","43.72","","79.57","79.57","79.57","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Anaplasma Phago Pcr (Accutix)","PX-30003601","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","529.40","79","24.28","145.51","percent of total billed charges",""
"Wdh Anaplasma Phago Pcr (Accutix)","PX-30003601","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Anaplasma Phago Pcr (Accutix)","PX-30003601","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","118.25","62.9","","114.66","114.66","114.66","231","24.28","145.51","percent of total billed charges",""
"Wdh Anaplasma Phago Pcr (Accutix)","PX-30003601","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","145.51","77.4","","141.05","141.05","564.20","57","24.28","145.51","percent of total billed charges",""
"Wdh Anaplasma Phago Pcr (Accutix)","PX-30003601","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Anti-Myeloperoxidase","PX-30003579","CDM","86317","CPT","0302","RC","","","","both","","","80.00","48.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","55.84","69.8","","53.75","53.75","53.75","1 through 10","9.74","76.77","percent of total billed charges",""
"Wdh Anti-Myeloperoxidase","PX-30003579","CDM","86317","CPT","0302","RC","","","","outpatient","","","80.00","48.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","58.18","72.72","","55.99","55.99","55.99","1 through 10","13.96","61.92","percent of total billed charges",""
"Wdh Anti-Myeloperoxidase","PX-30003579","CDM","86317","CPT","0302","RC","","","","outpatient","","","80.00","48.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","50.32","62.9","","145.53","48.51","182.32","11","13.96","61.92","percent of total billed charges",""
"Wdh Anti-Myeloperoxidase","PX-30003579","CDM","86317","CPT","0302","RC","","","","outpatient","","","80.00","48.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","61.92","77.4","","59.68","59.68","59.68","1 through 10","13.96","61.92","percent of total billed charges",""
"Wdh Bordetella Pertusis/ Parapertusis","PX-30003592","CDM","87798","CPT","0300","RC","","","","both","","","188.00","112.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","131.22","69.8","","127.04","114.48","508.14","20","22.81","180.59","percent of total billed charges",""
"Wdh Bordetella Pertusis/ Parapertusis","PX-30003592","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","118.03","62.78","","114.26","114.26","114.26","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Bordetella Pertusis/ Parapertusis","PX-30003592","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","82.19","43.72","","79.57","79.57","79.57","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Bordetella Pertusis/ Parapertusis","PX-30003592","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","529.40","79","24.28","145.51","percent of total billed charges",""
"Wdh Bordetella Pertusis/ Parapertusis","PX-30003592","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Bordetella Pertusis/ Parapertusis","PX-30003592","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","118.25","62.9","","114.66","114.66","114.66","231","24.28","145.51","percent of total billed charges",""
"Wdh Bordetella Pertusis/ Parapertusis","PX-30003592","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","145.51","77.4","","141.05","141.05","564.20","57","24.28","145.51","percent of total billed charges",""
"Wdh Bordetella Pertusis/ Parapertusis","PX-30003592","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Bordetella Pertussis, Pcr","PX-30003581","CDM","87798","CPT","0300","RC","","","","both","","","188.00","112.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","131.22","69.8","","127.04","114.48","508.14","20","22.81","180.59","percent of total billed charges",""
"Wdh Bordetella Pertussis, Pcr","PX-30003581","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","118.03","62.78","","114.26","114.26","114.26","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Bordetella Pertussis, Pcr","PX-30003581","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","82.19","43.72","","79.57","79.57","79.57","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Bordetella Pertussis, Pcr","PX-30003581","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","529.40","79","24.28","145.51","percent of total billed charges",""
"Wdh Bordetella Pertussis, Pcr","PX-30003581","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Bordetella Pertussis, Pcr","PX-30003581","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","118.25","62.9","","114.66","114.66","114.66","231","24.28","145.51","percent of total billed charges",""
"Wdh Bordetella Pertussis, Pcr","PX-30003581","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","145.51","77.4","","141.05","141.05","564.20","57","24.28","145.51","percent of total billed charges",""
"Wdh Bordetella Pertussis, Pcr","PX-30003581","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Ehrlichia Chaff (Accutix)","PX-30003600","CDM","87798","CPT","0300","RC","","","","both","","","188.00","112.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","131.22","69.8","","127.04","114.48","508.14","20","22.81","180.59","percent of total billed charges",""
"Wdh Ehrlichia Chaff (Accutix)","PX-30003600","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","118.03","62.78","","114.26","114.26","114.26","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Ehrlichia Chaff (Accutix)","PX-30003600","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","82.19","43.72","","79.57","79.57","79.57","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Ehrlichia Chaff (Accutix)","PX-30003600","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","529.40","79","24.28","145.51","percent of total billed charges",""
"Wdh Ehrlichia Chaff (Accutix)","PX-30003600","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Ehrlichia Chaff (Accutix)","PX-30003600","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","118.25","62.9","","114.66","114.66","114.66","231","24.28","145.51","percent of total billed charges",""
"Wdh Ehrlichia Chaff (Accutix)","PX-30003600","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","145.51","77.4","","141.05","141.05","564.20","57","24.28","145.51","percent of total billed charges",""
"Wdh Ehrlichia Chaff (Accutix)","PX-30003600","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Ehrlichia Chaffeensis Pcr (Accutix)","PX-30003602","CDM","87798","CPT","0300","RC","","","","both","","","188.00","112.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","131.22","69.8","","127.04","114.48","508.14","20","22.81","180.59","percent of total billed charges",""
"Wdh Ehrlichia Chaffeensis Pcr (Accutix)","PX-30003602","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","118.03","62.78","","114.26","114.26","114.26","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Ehrlichia Chaffeensis Pcr (Accutix)","PX-30003602","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","82.19","43.72","","79.57","79.57","79.57","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Ehrlichia Chaffeensis Pcr (Accutix)","PX-30003602","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","529.40","79","24.28","145.51","percent of total billed charges",""
"Wdh Ehrlichia Chaffeensis Pcr (Accutix)","PX-30003602","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Ehrlichia Chaffeensis Pcr (Accutix)","PX-30003602","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","118.25","62.9","","114.66","114.66","114.66","231","24.28","145.51","percent of total billed charges",""
"Wdh Ehrlichia Chaffeensis Pcr (Accutix)","PX-30003602","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","145.51","77.4","","141.05","141.05","564.20","57","24.28","145.51","percent of total billed charges",""
"Wdh Ehrlichia Chaffeensis Pcr (Accutix)","PX-30003602","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Ehrlichia/Anap Lasm Pcr","PX-30003595","CDM","87798","CPT","0300","RC","","","","both","","","188.00","112.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","131.22","69.8","","127.04","114.48","508.14","20","22.81","180.59","percent of total billed charges",""
"Wdh Ehrlichia/Anap Lasm Pcr","PX-30003595","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","118.03","62.78","","114.26","114.26","114.26","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Ehrlichia/Anap Lasm Pcr","PX-30003595","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","82.19","43.72","","79.57","79.57","79.57","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Ehrlichia/Anap Lasm Pcr","PX-30003595","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","529.40","79","24.28","145.51","percent of total billed charges",""
"Wdh Ehrlichia/Anap Lasm Pcr","PX-30003595","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Ehrlichia/Anap Lasm Pcr","PX-30003595","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","118.25","62.9","","114.66","114.66","114.66","231","24.28","145.51","percent of total billed charges",""
"Wdh Ehrlichia/Anap Lasm Pcr","PX-30003595","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","145.51","77.4","","141.05","141.05","564.20","57","24.28","145.51","percent of total billed charges",""
"Wdh Ehrlichia/Anap Lasm Pcr","PX-30003595","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Epstein Barr by Pcr","PX-30003593","CDM","87798","CPT","0300","RC","","","","both","","","188.00","112.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","131.22","69.8","","127.04","114.48","508.14","20","22.81","180.59","percent of total billed charges",""
"Wdh Epstein Barr by Pcr","PX-30003593","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","118.03","62.78","","114.26","114.26","114.26","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Epstein Barr by Pcr","PX-30003593","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","82.19","43.72","","79.57","79.57","79.57","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Epstein Barr by Pcr","PX-30003593","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","529.40","79","24.28","145.51","percent of total billed charges",""
"Wdh Epstein Barr by Pcr","PX-30003593","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Epstein Barr by Pcr","PX-30003593","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","118.25","62.9","","114.66","114.66","114.66","231","24.28","145.51","percent of total billed charges",""
"Wdh Epstein Barr by Pcr","PX-30003593","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","145.51","77.4","","141.05","141.05","564.20","57","24.28","145.51","percent of total billed charges",""
"Wdh Epstein Barr by Pcr","PX-30003593","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Legionella Ag, Urine","PX-30003585","CDM","87449","CPT","0300","RC","","","","both","","","103.00","61.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","71.89","69.8","","62.90","62.90","64.92","1 through 10","7.79","87.55","percent of total billed charges",""
"Wdh Legionella Ag, Urine","PX-30003585","CDM","87449","CPT","0300","RC","","","","inpatient","","","103.00","61.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","79.17","76.86","","63.00","63.00","63.00","1 through 10","68.19","79.17","percent of total billed charges",""
"Wdh Legionella Ag, Urine","PX-30003585","CDM","87449","CPT","0300","RC","","","","outpatient","","","103.00","61.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","74.90","72.72","","72.72","72.72","72.72","1 through 10","10.68","79.72","percent of total billed charges",""
"Wdh Legionella Ag, Urine","PX-30003585","CDM","87449","CPT","0300","RC","","","","outpatient","","","103.00","61.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","64.79","62.9","","63.00","63.00","63.00","1 through 10","10.68","79.72","percent of total billed charges",""
"Wdh Legionella Ag, Urine","PX-30003585","CDM","87449","CPT","0300","RC","","","","outpatient","","","103.00","61.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","79.72","77.4","","77.50","77.50","77.50","1 through 10","10.68","79.72","percent of total billed charges",""
"Wdh Mass Spec, Tandem Mass Spec","PX-30003582","CDM","83789","CPT","0300","RC","","","","outpatient","","","105.00","63.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","76.36","72.72","","74.17","74.17","74.17","1 through 10","16.24","81.27","percent of total billed charges",""
"Wdh Mass Spec, Tandem Mass Spec","PX-30003582","CDM","83789","CPT","0300","RC","","","","outpatient","","","105.00","63.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","81.27","77.4","","79.05","79.05","79.05","1 through 10","16.24","81.27","percent of total billed charges",""
"Wdh Norwalk-Like Virus, Ag","PX-30003597","CDM","87449","CPT","0300","RC","","","","both","","","103.00","61.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","71.89","69.8","","62.90","62.90","64.92","1 through 10","7.79","87.55","percent of total billed charges",""
"Wdh Norwalk-Like Virus, Ag","PX-30003597","CDM","87449","CPT","0300","RC","","","","inpatient","","","103.00","61.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","79.17","76.86","","63.00","63.00","63.00","1 through 10","68.19","79.17","percent of total billed charges",""
"Wdh Norwalk-Like Virus, Ag","PX-30003597","CDM","87449","CPT","0300","RC","","","","outpatient","","","103.00","61.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","74.90","72.72","","72.72","72.72","72.72","1 through 10","10.68","79.72","percent of total billed charges",""
"Wdh Norwalk-Like Virus, Ag","PX-30003597","CDM","87449","CPT","0300","RC","","","","outpatient","","","103.00","61.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","64.79","62.9","","63.00","63.00","63.00","1 through 10","10.68","79.72","percent of total billed charges",""
"Wdh Norwalk-Like Virus, Ag","PX-30003597","CDM","87449","CPT","0300","RC","","","","outpatient","","","103.00","61.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","79.72","77.4","","77.50","77.50","77.50","1 through 10","10.68","79.72","percent of total billed charges",""
"Wdh Occ Blood Draw","PX-99900495","CDM","36415","CPT","0999","RC","","","","both","","","30.00","18.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","20.94","69.8","","11.17","7.00","11.17","357","6","25.5","percent of total billed charges",""
"Wdh Occ Blood Draw","PX-99900495","CDM","36415","CPT","0999","RC","","","","both","","","30.00","18.00","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","20.94","69.8","","11.17","11.17","11.39","13","6","25.5","percent of total billed charges",""
"Wdh Occ Blood Draw","PX-99900495","CDM","36415","CPT","0999","RC","","","","both","","","30.00","18.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","25.50","85","","12.36","2.84","13.60","48","6","25.5","percent of total billed charges",""
"Wdh Occ Blood Draw","PX-99900495","CDM","36415","CPT","0999","RC","","","","outpatient","","","30.00","18.00","INTERNATIONAL COMMERCIAL [140001]","HB WDH UNITED HMO / PPO / INDEM","23.22","77.4","","12.40","12.40","12.40","1 through 10","15.97","23.22","percent of total billed charges",""
"Wdh Occ Blood Draw","PX-99900495","CDM","36415","CPT","0999","RC","","","","outpatient","","","30.00","18.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","18.87","62.9","","10.08","10.08","20.16","13","15.97","23.22","percent of total billed charges",""
"Wdh Occ Blood Draw","PX-99900495","CDM","36415","CPT","0999","RC","","","","outpatient","","","30.00","18.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","23.22","77.4","","12.40","12.40","12.40","1362","15.97","23.22","percent of total billed charges",""
"Wdh Pbg Deaminase, RBC","PX-30003589","CDM","82657","CPT","0300","RC","","","","both","","","255.00","153.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","177.99","69.8","","172.41","172.41","172.41","1 through 10","14.41","216.75","percent of total billed charges",""
"Wdh Pbg Deaminase, RBC","PX-30003589","CDM","82657","CPT","0300","RC","","","","outpatient","","","255.00","153.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","160.40","62.9","","155.61","155.61","155.61","1 through 10","16.24","197.37","percent of total billed charges",""
"Wdh Pneumocystis Jirov Detect Pcr","PX-30003584","CDM","87798","CPT","0306","RC","","","","both","","","188.00","112.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","131.22","69.8","","127.04","114.48","508.14","20","22.81","180.59","percent of total billed charges",""
"Wdh Pneumocystis Jirov Detect Pcr","PX-30003584","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","118.03","62.78","","114.26","114.26","114.26","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Pneumocystis Jirov Detect Pcr","PX-30003584","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","82.19","43.72","","79.57","79.57","79.57","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Pneumocystis Jirov Detect Pcr","PX-30003584","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","529.40","79","24.28","145.51","percent of total billed charges",""
"Wdh Pneumocystis Jirov Detect Pcr","PX-30003584","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Pneumocystis Jirov Detect Pcr","PX-30003584","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","118.25","62.9","","114.66","114.66","114.66","231","24.28","145.51","percent of total billed charges",""
"Wdh Pneumocystis Jirov Detect Pcr","PX-30003584","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","145.51","77.4","","141.05","141.05","564.20","57","24.28","145.51","percent of total billed charges",""
"Wdh Pneumocystis Jirov Detect Pcr","PX-30003584","CDM","87798","CPT","0306","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Pneumocystis Jiroveci Dfa, Bal","PX-30003598","CDM","87798","CPT","0300","RC","","","","both","","","188.00","112.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","131.22","69.8","","127.04","114.48","508.14","20","22.81","180.59","percent of total billed charges",""
"Wdh Pneumocystis Jiroveci Dfa, Bal","PX-30003598","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","118.03","62.78","","114.26","114.26","114.26","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Pneumocystis Jiroveci Dfa, Bal","PX-30003598","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","82.19","43.72","","79.57","79.57","79.57","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Pneumocystis Jiroveci Dfa, Bal","PX-30003598","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","529.40","79","24.28","145.51","percent of total billed charges",""
"Wdh Pneumocystis Jiroveci Dfa, Bal","PX-30003598","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Pneumocystis Jiroveci Dfa, Bal","PX-30003598","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","118.25","62.9","","114.66","114.66","114.66","231","24.28","145.51","percent of total billed charges",""
"Wdh Pneumocystis Jiroveci Dfa, Bal","PX-30003598","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","145.51","77.4","","141.05","141.05","564.20","57","24.28","145.51","percent of total billed charges",""
"Wdh Pneumocystis Jiroveci Dfa, Bal","PX-30003598","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Trichomonas Vaginalis by Tma","PX-30003594","CDM","87798","CPT","0300","RC","","","","both","","","188.00","112.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","131.22","69.8","","127.04","114.48","508.14","20","22.81","180.59","percent of total billed charges",""
"Wdh Trichomonas Vaginalis by Tma","PX-30003594","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","118.03","62.78","","114.26","114.26","114.26","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Trichomonas Vaginalis by Tma","PX-30003594","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","82.19","43.72","","79.57","79.57","79.57","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Trichomonas Vaginalis by Tma","PX-30003594","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","529.40","79","24.28","145.51","percent of total billed charges",""
"Wdh Trichomonas Vaginalis by Tma","PX-30003594","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Trichomonas Vaginalis by Tma","PX-30003594","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","118.25","62.9","","114.66","114.66","114.66","231","24.28","145.51","percent of total billed charges",""
"Wdh Trichomonas Vaginalis by Tma","PX-30003594","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","145.51","77.4","","141.05","141.05","564.20","57","24.28","145.51","percent of total billed charges",""
"Wdh Trichomonas Vaginalis by Tma","PX-30003594","CDM","87798","CPT","0300","RC","","","","outpatient","","","188.00","112.80","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","136.71","72.72","","132.35","132.35","132.35","1 through 10","24.28","145.51","percent of total billed charges",""
"Wdh Voriconazole, Lc-Ms","PX-30003590","CDM","80299","CPT","0300","RC","","","","both","","","213.00","127.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","148.67","69.8","","69.80","62.90","69.80","1 through 10","12.12","181.05","percent of total billed charges",""
"Wdh Voriconazole, Lc-Ms","PX-30003590","CDM","80299","CPT","0300","RC","","","","outpatient","","","213.00","127.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","93.12","43.72","","43.72","43.72","43.72","1 through 10","12.76","164.86","percent of total billed charges",""
"Wdh Voriconazole, Lc-Ms","PX-30003590","CDM","80299","CPT","0300","RC","","","","outpatient","","","213.00","127.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","154.89","72.72","","72.72","72.72","72.72","1 through 10","12.76","164.86","percent of total billed charges",""
"Wdh Voriconazole, Lc-Ms","PX-30003590","CDM","80299","CPT","0300","RC","","","","outpatient","","","213.00","127.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","154.89","72.72","","190.53","190.53","190.53","1 through 10","12.76","164.86","percent of total billed charges",""
"Wdh Voriconazole, Lc-Ms","PX-30003590","CDM","80299","CPT","0300","RC","","","","outpatient","","","213.00","127.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","113.36","53.22","","53.31","53.31","53.31","1 through 10","12.76","164.86","percent of total billed charges",""
"Wdh Voriconazole, Lc-Ms","PX-30003590","CDM","80299","CPT","0300","RC","","","","outpatient","","","213.00","127.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","133.98","62.9","","63.00","63.00","189.00","13","12.76","164.86","percent of total billed charges",""
"West Nile Virus Antibody","PX-30001008","CDM","86789","CPT","0300","RC","","","","inpatient","","","77.00","46.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","59.18","76.86","","46.62","46.62","46.62","1 through 10","50.97","59.18","percent of total billed charges",""
"West Nile Virus Antibody","PX-30001008","CDM","86789","CPT","0302","RC","","","","outpatient","","","77.00","46.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","55.99","72.72","","53.81","53.81","53.81","1 through 10","13.41","59.6","percent of total billed charges",""
"West Nile Virus Antibody","PX-30001008","CDM","86789","CPT","0302","RC","","","","outpatient","","","77.00","46.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","48.43","62.9","","89.54","89.54","89.54","1 through 10","13.41","59.6","percent of total billed charges",""
"West Nile Virus Antibody Igm","PX-30001007","CDM","86788","CPT","0300","RC","","","","inpatient","","","92.00","55.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","70.71","76.86","","56.07","56.07","56.07","1 through 10","60.9","70.71","percent of total billed charges",""
"West Nile Virus Antibody Igm","PX-30001007","CDM","86788","CPT","0302","RC","","","","outpatient","","","92.00","55.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","66.90","72.72","","64.72","64.72","64.72","1 through 10","13.31","71.21","percent of total billed charges",""
"West Nile Virus Antibody Igm","PX-30001007","CDM","86788","CPT","0302","RC","","","","outpatient","","","92.00","55.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","57.87","62.9","","107.20","107.20","107.20","1 through 10","13.31","71.21","percent of total billed charges",""
"Whfo, Rigid W/O Joints","PX-27000491","CDM","L3808","HCPCS","0274","RC","","","","both","","","371.00","222.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","258.96","69.8","","258.96","258.96","258.96","1 through 10","211.1","465.69","percent of total billed charges",""
"Whfo, Rigid W/O Joints","PX-27000491","CDM","L3808","HCPCS","0274","RC","","","","both","","","371.00","222.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","211.10","56.9","","53.28","53.28","53.28","1 through 10","211.1","465.69","percent of total billed charges",""
"Whfo, Rigid W/O Joints","PX-27000491","CDM","L3808","HCPCS","0274","RC","","","","outpatient","","","371.00","222.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","269.79","72.72","","269.79","269.79","269.79","1 through 10","162.2","287.15","percent of total billed charges",""
"Whfo, Rigid W/O Joints","PX-27000491","CDM","L3808","HCPCS","0274","RC","","","","outpatient","","","371.00","222.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","233.36","62.9","","233.73","233.73","233.73","1 through 10","162.2","287.15","percent of total billed charges",""
"Whole Body CT Myeloma Survey","PX-35000100","CDM","76497","CPT","0352","RC","","","","both","","","7800.00","4680.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","86.77","86.77","86.77","1 through 10","90.15","6630","other","OPPS APC"
"WIRE BONE 2X150MM KIRSCHNER FIXATION PERI-LOC STAINLESS STEEL THREADED TROCAR POINT LG FRAGMENT STERILE DISPOSABLE BX/6","SUP-ITM-10261544","CDM","C1713","HCPCS","0278","RC","","","","both","","","587.35","352.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","68.31","499.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WIRE BONE 2X150MM KIRSCHNER FIXATION PERI-LOC STAINLESS STEEL THREADED TROCAR POINT LG FRAGMENT STERILE DISPOSABLE BX/6","SUP-ITM-10261544","CDM","C1713","HCPCS","0278","RC","","","","both","","","587.35","352.41","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","68.31","499.25","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WIRE BONE 2X150MM KIRSCHNER FIXATION PERI-LOC STAINLESS STEEL THREADED TROCAR POINT LG FRAGMENT STERILE DISPOSABLE BX/6","SUP-ITM-10261544","CDM","C1713","HCPCS","0278","RC","","","","both","","","587.35","352.41","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","334.20","56.9","","812.12","238.65","1587.46","163","68.31","499.25","percent of total billed charges",""
"WIRE BONE 2X150MM KIRSCHNER FIXATION PERI-LOC STAINLESS STEEL THREADED TROCAR POINT LG FRAGMENT STERILE DISPOSABLE BX/6","SUP-ITM-10261544","CDM","C1713","HCPCS","0278","RC","","","","both","","","587.35","352.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","68.31","11.63","","112.68","112.68","146.99","38","68.31","499.25","percent of total billed charges",""
"WIRE BONE 2X150MM KIRSCHNER FIXATION PERI-LOC STAINLESS STEEL THREADED TROCAR POINT LG FRAGMENT STERILE DISPOSABLE BX/6","SUP-ITM-10261544","CDM","C1713","HCPCS","0278","RC","","","","both","","","587.35","352.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","454.61","77.4","","303.98","303.98","5854.79","1 through 10","68.31","499.25","percent of total billed charges",""
"WIRE BONE 2X150MM KIRSCHNER FIXATION PERI-LOC STAINLESS STEEL THREADED TROCAR POINT LG FRAGMENT STERILE DISPOSABLE BX/6","SUP-ITM-10261544","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","587.35","352.41","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","68.31","11.63","","112.68","112.68","146.99","38","68.31","454.61","percent of total billed charges",""
"WIRE BONE 2X150MM KIRSCHNER FIXATION PERI-LOC STAINLESS STEEL THREADED TROCAR POINT LG FRAGMENT STERILE DISPOSABLE BX/6","SUP-ITM-10261544","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","587.35","352.41","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","368.74","62.78","","780.86","208.94","10480.28","15","68.31","454.61","percent of total billed charges",""
"WIRE BONE 2X150MM KIRSCHNER FIXATION PERI-LOC STAINLESS STEEL THREADED TROCAR POINT LG FRAGMENT STERILE DISPOSABLE BX/6","SUP-ITM-10261544","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","587.35","352.41","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","256.79","43.72","","179.76","179.76","179.76","1 through 10","68.31","454.61","percent of total billed charges",""
"WIRE BONE 2X150MM KIRSCHNER FIXATION PERI-LOC STAINLESS STEEL THREADED TROCAR POINT LG FRAGMENT STERILE DISPOSABLE BX/6","SUP-ITM-10261544","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","587.35","352.41","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","427.12","72.72","","2355.45","298.99","3965.19","155","68.31","454.61","percent of total billed charges",""
"WIRE BONE 2X150MM KIRSCHNER FIXATION PERI-LOC STAINLESS STEEL THREADED TROCAR POINT LG FRAGMENT STERILE DISPOSABLE BX/6","SUP-ITM-10261544","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","587.35","352.41","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","427.12","72.72","","3643.09","3643.09","3643.09","1 through 10","68.31","454.61","percent of total billed charges",""
"WIRE BONE 2X150MM KIRSCHNER FIXATION PERI-LOC STAINLESS STEEL THREADED TROCAR POINT LG FRAGMENT STERILE DISPOSABLE BX/6","SUP-ITM-10261544","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","587.35","352.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","312.59","53.22","","554.28","554.28","554.28","16","68.31","454.61","percent of total billed charges",""
"WIRE BONE 2X150MM KIRSCHNER FIXATION PERI-LOC STAINLESS STEEL THREADED TROCAR POINT LG FRAGMENT STERILE DISPOSABLE BX/6","SUP-ITM-10261544","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","587.35","352.41","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","369.44","62.9","","619.64","173.09","2370.64","150","68.31","454.61","percent of total billed charges",""
"WIRE BONE 2X150MM KIRSCHNER FIXATION PERI-LOC STAINLESS STEEL THREADED TROCAR POINT LG FRAGMENT STERILE DISPOSABLE BX/6","SUP-ITM-10261544","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","587.35","352.41","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","454.61","77.4","","303.98","303.98","5854.79","1 through 10","68.31","454.61","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.67","206.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","40.09","292.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.67","206.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","40.09","292.97","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.67","206.80","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","196.12","56.9","","812.12","238.65","1587.46","163","40.09","292.97","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.67","206.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.09","11.63","","112.68","112.68","146.99","38","40.09","292.97","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","both","","","344.67","206.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","266.77","77.4","","303.98","303.98","5854.79","1 through 10","40.09","292.97","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","344.67","206.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","40.09","11.63","","112.68","112.68","146.99","38","40.09","266.77","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","344.67","206.80","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","216.38","62.78","","780.86","208.94","10480.28","15","40.09","266.77","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","344.67","206.80","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","150.69","43.72","","179.76","179.76","179.76","1 through 10","40.09","266.77","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","344.67","206.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","250.64","72.72","","2355.45","298.99","3965.19","155","40.09","266.77","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","344.67","206.80","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","250.64","72.72","","3643.09","3643.09","3643.09","1 through 10","40.09","266.77","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","344.67","206.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","183.43","53.22","","554.28","554.28","554.28","16","40.09","266.77","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","344.67","206.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","216.80","62.9","","619.64","173.09","2370.64","150","40.09","266.77","percent of total billed charges",""
"WIRE COMPRESSION 2.8MM 10 THREAD 200 SCREW BONE THREAD","SUP-ITM-10125400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","344.67","206.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","266.77","77.4","","303.98","303.98","5854.79","1 through 10","40.09","266.77","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","both","","","466.49","279.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","54.25","396.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","both","","","466.49","279.89","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","54.25","396.52","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","both","","","466.49","279.89","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","265.43","56.9","","812.12","238.65","1587.46","163","54.25","396.52","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","both","","","466.49","279.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","54.25","11.63","","112.68","112.68","146.99","38","54.25","396.52","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","both","","","466.49","279.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","361.06","77.4","","303.98","303.98","5854.79","1 through 10","54.25","396.52","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","466.49","279.89","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","54.25","11.63","","112.68","112.68","146.99","38","54.25","361.06","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","466.49","279.89","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","292.86","62.78","","780.86","208.94","10480.28","15","54.25","361.06","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","466.49","279.89","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","203.95","43.72","","179.76","179.76","179.76","1 through 10","54.25","361.06","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","466.49","279.89","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","339.23","72.72","","2355.45","298.99","3965.19","155","54.25","361.06","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","466.49","279.89","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","339.23","72.72","","3643.09","3643.09","3643.09","1 through 10","54.25","361.06","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","466.49","279.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","248.27","53.22","","554.28","554.28","554.28","16","54.25","361.06","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","466.49","279.89","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","293.42","62.9","","619.64","173.09","2370.64","150","54.25","361.06","percent of total billed charges",""
"WIRE FIXATION 1.8X400MM SMOOTH MR CONDITIONAL","SUP-ITM-10039190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","466.49","279.89","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","361.06","77.4","","303.98","303.98","5854.79","1 through 10","54.25","361.06","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.66","268.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","51.95","379.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.66","268.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","51.95","379.66","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.66","268.00","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","254.15","56.9","","812.12","238.65","1587.46","163","51.95","379.66","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.66","268.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","51.95","11.63","","112.68","112.68","146.99","38","51.95","379.66","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.66","268.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","345.71","77.4","","303.98","303.98","5854.79","1 through 10","51.95","379.66","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.66","268.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","51.95","11.63","","112.68","112.68","146.99","38","51.95","345.71","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.66","268.00","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","280.41","62.78","","780.86","208.94","10480.28","15","51.95","345.71","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.66","268.00","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","195.28","43.72","","179.76","179.76","179.76","1 through 10","51.95","345.71","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.66","268.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","324.81","72.72","","2355.45","298.99","3965.19","155","51.95","345.71","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.66","268.00","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","324.81","72.72","","3643.09","3643.09","3643.09","1 through 10","51.95","345.71","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.66","268.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","237.71","53.22","","554.28","554.28","554.28","16","51.95","345.71","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.66","268.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","280.95","62.9","","619.64","173.09","2370.64","150","51.95","345.71","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.66","268.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","345.71","77.4","","303.98","303.98","5854.79","1 through 10","51.95","345.71","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","2936.75","1762.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","341.54","2496.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","2936.75","1762.05","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","341.54","2496.24","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","2936.75","1762.05","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","1671.01","56.9","","812.12","238.65","1587.46","163","341.54","2496.24","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","2936.75","1762.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","341.54","11.63","","112.68","112.68","146.99","38","341.54","2496.24","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","2936.75","1762.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2273.04","77.4","","303.98","303.98","5854.79","1 through 10","341.54","2496.24","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","341.54","11.63","","112.68","112.68","146.99","38","341.54","2273.04","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","1843.69","62.78","","780.86","208.94","10480.28","15","341.54","2273.04","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","1283.95","43.72","","179.76","179.76","179.76","1 through 10","341.54","2273.04","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2135.60","72.72","","2355.45","298.99","3965.19","155","341.54","2273.04","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2135.60","72.72","","3643.09","3643.09","3643.09","1 through 10","341.54","2273.04","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","1562.94","53.22","","554.28","554.28","554.28","16","341.54","2273.04","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1847.22","62.9","","619.64","173.09","2370.64","150","341.54","2273.04","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2936.75","1762.05","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2273.04","77.4","","303.98","303.98","5854.79","1 through 10","341.54","2273.04","percent of total billed charges",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc","464","MS-DRG","","","","","","","","inpatient","","","51398.29","30838.97","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","24847.91","","Case rate ($24,124.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $22,300.61, add-ons for qualifying new technology services are included. If operating cost exceeds $26,218.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,535.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $21,948.95 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $21,855.74 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,730.35. The transfer capital threshold is the transfer adjustment factor * $1,730.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Final payment is multiplied by 103%.","7725.00","7725.00","7725.00","1 through 10","3975","118358.91","other","Inpatient DRG"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc","464","MS-DRG","","","","","","","","inpatient","","","51398.29","30838.97","MARTIN'S POINT [160007]","HB WDH MEDICARE","24124.18","","Case rate ($24,124.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.025, exceeds $22,300.61, add-ons for qualifying new technology services are included. If operating cost exceeds $26,218.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.305, exceeds $49,535.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $21,948.95 + an uncompensated DSH payment of $444.87. The transfer operating threshold is the transfer adjustment factor * $21,855.74 + an uncompensated DSH payment of $444.87. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,730.35. The transfer capital threshold is the transfer adjustment factor * $1,730.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount.","20319.17","20319.17","20319.17","1 through 10","3975","118358.91","other","Inpatient DRG"
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","both","","","19181.92","11509.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","","","Case rate ($0).","1061.04","1061.04","1061.04","1 through 10","2230.86","16304.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","both","","","19181.92","11509.15","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","2671.87","22.68","3073.42","11","2230.86","16304.63","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","both","","","19181.92","11509.15","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","10914.51","56.9","","812.12","238.65","1587.46","163","2230.86","16304.63","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","both","","","19181.92","11509.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2230.86","11.63","","112.68","112.68","146.99","38","2230.86","16304.63","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","both","","","19181.92","11509.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","14846.81","77.4","","303.98","303.98","5854.79","1 through 10","2230.86","16304.63","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19181.92","11509.15","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","2230.86","11.63","","112.68","112.68","146.99","38","2230.86","14846.81","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19181.92","11509.15","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","12042.41","62.78","","780.86","208.94","10480.28","15","2230.86","14846.81","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19181.92","11509.15","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","8386.34","43.72","","179.76","179.76","179.76","1 through 10","2230.86","14846.81","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19181.92","11509.15","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","13949.09","72.72","","2355.45","298.99","3965.19","155","2230.86","14846.81","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19181.92","11509.15","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","13949.09","72.72","","3643.09","3643.09","3643.09","1 through 10","2230.86","14846.81","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19181.92","11509.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","10208.62","53.22","","554.28","554.28","554.28","16","2230.86","14846.81","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19181.92","11509.15","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","12065.43","62.9","","619.64","173.09","2370.64","150","2230.86","14846.81","percent of total billed charges",""
"WRIST PLATE 2.4X170MM SPANNING LCP STRAIGHT","SUP-ITM-10297322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19181.92","11509.15","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","14846.81","77.4","","303.98","303.98","5854.79","1 through 10","2230.86","14846.81","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","both","","","196.00","117.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","136.81","69.8","","18.52","18.52","18.52","1 through 10","111.52","166.6","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","both","","","196.00","117.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","","","Case rate ($0).","189.00","189.00","189.00","1 through 10","111.52","166.6","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","outpatient","","","196.00","117.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","28.26","14.42","","27.25","27.25","27.25","1 through 10","22.79","151.7","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","outpatient","","","196.00","117.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","22.79","11.63","","26.03","22.33","50.26","1 through 10","22.79","151.7","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","outpatient","","","196.00","117.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","142.53","72.72","","137.44","137.44","137.44","1 through 10","22.79","151.7","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","outpatient","","","196.00","117.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","123.28","62.9","","119.07","119.07","228.28","11","22.79","151.7","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","outpatient","","","196.00","117.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","151.70","77.4","","146.48","146.47","146.48","1 through 10","22.79","151.7","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","outpatient","","","196.00","117.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","22.79","11.63","","22.33","22.33","22.33","1 through 10","22.79","151.7","percent of total billed charges",""
"Xr Abdomen Ap/Decub/Erct/Cxr","PX-32000196","CDM","74022","CPT","0320","RC","","","","both","","","853.00","511.80","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","725.05","other","OPPS APC"
"Xr Abdomen Ap/Decub/Erct/Cxr","PX-32000196","CDM","74022","CPT","0320","RC","","","","outpatient","","","853.00","511.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","620.30","72.72","","598.49","598.49","598.49","1 through 10","99.2","660.22","percent of total billed charges",""
"Xr Abdomen Ap/Decub/Erct/Cxr","PX-32000196","CDM","74022","CPT","0320","RC","","","","outpatient","","","853.00","511.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","536.54","62.9","","518.49","518.49","518.49","1 through 10","99.2","660.22","percent of total billed charges",""
"Xr Abscess Sinus/Fistula Study","PX-32000249","CDM","76080","CPT","0320","RC","","","","both","","","909.00","545.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","3660.99","","Case rate ($3,660.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3571.71","3571.71","3571.71","1 through 10","228.93","3660.99","other","OPPS APC"
"Xr Abscess Sinus/Fistula Study","PX-32000249","CDM","76080","CPT","0320","RC","","","","both","","","909.00","545.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","561.39","","APC Price ($572.84). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","572.91","561.45","973.95","1 through 10","228.93","3660.99","other","OPPS APC"
"Xr Abscess Sinus/Fistula Study","PX-32000249","CDM","76080","CPT","0320","RC","","","","both","","","909.00","545.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","2959.14","","Case rate ($2,959.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1537.99","1537.99","1537.99","1 through 10","228.93","3660.99","other","OPPS APC"
"Xr Abscess Sinus/Fistula Study","PX-32000249","CDM","76080","CPT","0320","RC","","","","both","","","909.00","545.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","572.84","","APC Price ($572.84). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","572.91","567.95","572.91","1 through 10","228.93","3660.99","other","OPPS APC"
"Xr Abscess Sinus/Fistula Study","PX-32000249","CDM","76080","CPT","0320","RC","","","","both","","","909.00","545.40","MEDICARE [2001]","HB WDH MEDICARE","572.84","","APC Price ($572.84). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","572.91","572.91","572.91","11","228.93","3660.99","other","OPPS APC"
"Xr Abscess Sinus/Fistula Study","PX-32000249","CDM","76080","CPT","0320","RC","","","","both","","","909.00","545.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","572.84","","APC Price ($572.84). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","561.76","280.73","572.91","1 through 10","228.93","3660.99","other","OPPS APC"
"Xr Abscess Sinus/Fistula Study","PX-32000249","CDM","76080","CPT","0320","RC","","","","outpatient","","","909.00","545.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","131.08","14.42","","126.46","126.46","126.46","1 through 10","105.72","703.57","percent of total billed charges",""
"Xr Abscess Sinus/Fistula Study","PX-32000249","CDM","76080","CPT","0320","RC","","","","outpatient","","","909.00","545.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","661.02","72.72","","637.75","637.75","637.75","1 through 10","105.72","703.57","percent of total billed charges",""
"Xr Abscess Sinus/Fistula Study","PX-32000249","CDM","76080","CPT","0320","RC","","","","outpatient","","","909.00","545.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","105.72","11.63","","2713.32","103.59","2713.32","1 through 10","105.72","703.57","percent of total billed charges",""
"Xr Ac Joints Bilat W/W/O Weights","PX-32000094","CDM","73050","CPT","0320","RC","","","","both","","","751.00","450.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","253.14","","Case rate ($253.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","247.82","247.82","247.82","1 through 10","90.15","638.35","other","OPPS APC"
"Xr Ac Joints Bilat W/W/O Weights|REDUCED SERVICES","PX-32000094","CDM","73050","CPT","0320","RC","","","52","both","","","751.00","450.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","94.75","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","47.38","47.38","47.38","1 through 10","90.15","94.75","other","OPPS APC"
"Xr Ankle 2 Views","PX-32000174","CDM","73600","CPT","0320","RC","","","","both","","","632.00","379.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.66","90.66","90.66","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Ankle 3+ Views","PX-32000177","CDM","73610","CPT","0320","RC","","","","both","","","692.00","415.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.66","90.53","92.00","1 through 10","90.15","588.2","other","OPPS APC"
"Xr Ankle 3+ Views","PX-32000177","CDM","73610","CPT","0320","RC","","","","outpatient","","","692.00","415.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","503.22","72.72","","485.77","485.77","485.77","1 through 10","80.48","535.61","percent of total billed charges",""
"Xr Ankle 3+ Views","PX-32000177","CDM","73610","CPT","0320","RC","","","","outpatient","","","692.00","415.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","535.61","77.4","","1035.40","1035.40","1035.40","1 through 10","80.48","535.61","percent of total billed charges",""
"Xr Aortogram Abdomen W/Ser","PX-32000328","CDM","75625","CPT","0323","RC","","","","both","","","10270.00","6162.00","MEDICARE [2001]","HB WDH MEDICARE","3288.38","","APC Price ($3,288.38). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3288.76","3288.76","3288.76","1 through 10","647.26","21015.78","other","OPPS APC"
"Xr Bone Age","PX-32000272","CDM","77072","CPT","0320","RC","","","","both","","","410.00","246.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","286.18","69.8","","276.41","265.24","276.41","1 through 10","107.44","710.05","percent of total billed charges",""
"Xr Bone Age","PX-32000272","CDM","77072","CPT","0320","RC","","","","both","","","410.00","246.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","396.00","396.00","396.00","1 through 10","107.44","710.05","other","OPPS APC"
"Xr Bone Age","PX-32000272","CDM","77072","CPT","0320","RC","","","","both","","","410.00","246.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","299.84","1 through 10","107.44","710.05","other","OPPS APC"
"Xr Bone Age","PX-32000272","CDM","77072","CPT","0320","RC","","","","both","","","410.00","246.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","111.11","111.11","111.11","1 through 10","107.44","710.05","other","OPPS APC"
"Xr Bone Age","PX-32000272","CDM","77072","CPT","0320","RC","","","","both","","","410.00","246.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","559.93","1 through 10","107.44","710.05","other","OPPS APC"
"Xr Bone Age","PX-32000272","CDM","77072","CPT","0320","RC","","","","both","","","410.00","246.00","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","107.44","710.05","other","OPPS APC"
"Xr Bone Age","PX-32000272","CDM","77072","CPT","0320","RC","","","","outpatient","","","410.00","246.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","59.12","14.42","","48.95","48.95","57.10","1 through 10","47.68","317.34","percent of total billed charges",""
"Xr Bone Age","PX-32000272","CDM","77072","CPT","0320","RC","","","","outpatient","","","410.00","246.00","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","47.68","11.63","","54.53","46.78","100.01","1 through 10","47.68","317.34","percent of total billed charges",""
"Xr Bone Age","PX-32000272","CDM","77072","CPT","0320","RC","","","","outpatient","","","410.00","246.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","298.15","72.72","","287.97","259.17","287.97","1 through 10","47.68","317.34","percent of total billed charges",""
"Xr Bone Age","PX-32000272","CDM","77072","CPT","0320","RC","","","","outpatient","","","410.00","246.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","257.89","62.9","","249.48","249.48","249.48","1 through 10","47.68","317.34","percent of total billed charges",""
"Xr Bone Age","PX-32000272","CDM","77072","CPT","0320","RC","","","","outpatient","","","410.00","246.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","47.68","11.63","","46.78","46.78","46.78","1 through 10","47.68","317.34","percent of total billed charges",""
"Xr Bone Density Appendicular","PX-32000279","CDM","77081","CPT","0320","RC","","","","both","","","618.00","370.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","94.75","","APC Price ($91.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","92.86","92.86","92.86","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Bone Density Appendicular","PX-32000279","CDM","77081","CPT","0320","RC","","","","both","","","618.00","370.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","91.99","","APC Price ($91.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.16","90.16","90.16","29","90.15","587.88","other","OPPS APC"
"Xr Bone Density Appendicular","PX-32000279","CDM","77081","CPT","0320","RC","","","","both","","","618.00","370.80","MEDICARE [2001]","HB WDH MEDICARE","91.99","","APC Price ($91.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","92.00","92.00","92.00","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Bone Density Appendicular","PX-32000279","CDM","77081","CPT","0320","RC","","","","both","","","618.00","370.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.16","86.77","90.16","58","90.15","587.88","other","OPPS APC"
"Xr Bone Density Appendicular","PX-32000279","CDM","77081","CPT","0320","RC","","","","both","","","618.00","370.80","WELLSENSE NH [1050]","HB WDH MEDICARE","91.99","","APC Price ($91.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","94.67","94.67","94.67","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","829.00","497.40","AETNA [1001]","HB WDH AETNA COMMERCIAL","578.64","69.8","","558.40","558.40","558.40","1 through 10","108.88","710.05","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","829.00","497.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","503.93","503.93","503.93","1 through 10","108.88","710.05","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","829.00","497.40","HARVARD PILGRIM [120001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","105.28","105.28","105.28","1 through 10","108.88","710.05","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","829.00","497.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","112.15","112.15","112.15","78","108.88","710.05","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","829.00","497.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","108.89","108.89","111.11","328","108.88","710.05","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","829.00","497.40","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","710.05","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","829.00","497.40","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","704.65","85","","215.98","128.54","680.00","1 through 10","108.88","710.05","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","829.00","497.40","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","710.05","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","829.00","497.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","108.89","104.98","108.89","368","108.88","710.05","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","829.00","497.40","WELLSENSE NH [1050]","HB WDH MEDICARE","111.10","","APC Price ($111.10). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","114.34","114.34","114.34","34","108.88","710.05","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","outpatient","","","829.00","497.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","119.54","14.42","","115.36","98.88","115.36","16","96.41","641.65","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","outpatient","","","829.00","497.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","96.41","11.63","","110.16","94.49","202.04","32","96.41","641.65","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","outpatient","","","829.00","497.40","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","520.45","62.78","","502.24","502.24","502.24","1 through 10","96.41","641.65","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","outpatient","","","829.00","497.40","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","362.44","43.72","","349.76","349.76","349.76","1 through 10","96.41","641.65","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","outpatient","","","829.00","497.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","602.85","72.72","","581.76","581.76","581.76","49","96.41","641.65","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","outpatient","","","829.00","497.40","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","602.85","72.72","","581.76","581.76","581.76","1 through 10","96.41","641.65","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","outpatient","","","829.00","497.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","521.44","62.9","","504.00","504.00","504.00","81","96.41","641.65","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","outpatient","","","829.00","497.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","641.65","77.4","","620.00","620.00","620.00","36","96.41","641.65","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","outpatient","","","829.00","497.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","96.41","11.63","","174.22","94.49","177.78","23","96.41","641.65","percent of total billed charges",""
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","652.00","391.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","298.29","1 through 10","108.88","710.05","other","OPPS APC"
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","652.00","391.20","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","710.05","other","OPPS APC"
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","outpatient","","","652.00","391.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","75.83","11.63","","74.30","74.30","74.30","1 through 10","75.83","504.65","percent of total billed charges",""
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","outpatient","","","652.00","391.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","285.05","43.72","","275.00","275.00","275.00","1 through 10","75.83","504.65","percent of total billed charges",""
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","outpatient","","","652.00","391.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","474.13","72.72","","457.41","457.41","457.41","1 through 10","75.83","504.65","percent of total billed charges",""
"Xr Bone Survey Cmpl","PX-32000275","CDM","77075","CPT","0320","RC","","","","both","","","1835.00","1101.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","114.44","114.44","114.44","1 through 10","108.88","1559.75","other","OPPS APC"
"Xr Bone Survey Cmpl","PX-32000275","CDM","77075","CPT","0320","RC","","","","both","","","1835.00","1101.00","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","1559.75","other","OPPS APC"
"Xr Bone Survey Cmpl","PX-32000275","CDM","77075","CPT","0320","RC","","","","both","","","1835.00","1101.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.39","105.28","109.39","1 through 10","108.88","1559.75","other","OPPS APC"
"Xr Bone Survey Cmpl","PX-32000275","CDM","77075","CPT","0320","RC","","","","outpatient","","","1835.00","1101.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","264.61","14.42","","218.90","218.90","218.90","1 through 10","213.41","1420.29","percent of total billed charges",""
"Xr Bone Survey Cmpl","PX-32000275","CDM","77075","CPT","0320","RC","","","","outpatient","","","1835.00","1101.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1420.29","77.4","","1372.53","1372.53","1372.53","1 through 10","213.41","1420.29","percent of total billed charges",""
"Xr Bone Survey Infant","PX-32000276","CDM","77076","CPT","0320","RC","","","","outpatient","","","1854.00","1112.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","267.35","14.42","","257.97","257.97","257.97","1 through 10","215.62","1435","percent of total billed charges",""
"Xr Bone Survey Infant","PX-32000276","CDM","77076","CPT","0320","RC","","","","outpatient","","","1854.00","1112.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","215.62","11.63","","246.35","246.35","246.35","1 through 10","215.62","1435","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","712.00","427.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","587.88","","Case rate ($587.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","573.54","573.54","575.52","1 through 10","90.15","605.2","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","712.00","427.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","253.14","","Case rate ($253.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","246.97","246.97","247.82","1 through 10","90.15","605.2","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","712.00","427.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","90.15","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","92.00","90.16","92.00","15","90.15","605.2","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","712.00","427.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","475.18","","Case rate ($475.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","463.58","463.58","465.18","1 through 10","90.15","605.2","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","712.00","427.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","94.75","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","94.76","94.76","94.76","1 through 10","90.15","605.2","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","712.00","427.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.44","90.25","92.00","19","90.15","605.2","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","712.00","427.20","MEDICARE [2001]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","92.00","92.00","92.00","53","90.15","605.2","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","712.00","427.20","TRICARE [160005]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","92.00","92.00","92.00","1 through 10","90.15","605.2","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","712.00","427.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.66","90.16","90.86","12","90.15","605.2","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","712.00","427.20","WELLSENSE NH [1050]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","94.67","94.67","96.60","1 through 10","90.15","605.2","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","outpatient","","","712.00","427.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","102.67","14.42","","99.07","84.91","99.07","14","82.81","551.09","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","outpatient","","","712.00","427.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","82.81","11.63","","94.60","81.14","173.50","21","82.81","551.09","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","outpatient","","","712.00","427.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","446.99","62.78","","431.30","431.30","431.30","1 through 10","82.81","551.09","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","outpatient","","","712.00","427.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","311.29","43.72","","300.36","300.36","300.36","1 through 10","82.81","551.09","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","outpatient","","","712.00","427.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","517.77","72.72","","499.59","499.59","499.59","26","82.81","551.09","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","outpatient","","","712.00","427.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","447.85","62.9","","432.81","432.81","432.81","23","82.81","551.09","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","outpatient","","","712.00","427.20","UNITED HEALTHCARE [1016]","HB WDH HPHC HMO POS PPO","517.77","72.72","","532.43","532.43","532.43","1 through 10","82.81","551.09","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","outpatient","","","712.00","427.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","551.09","77.4","","532.43","532.42","532.43","1 through 10","82.81","551.09","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","outpatient","","","712.00","427.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","82.81","11.63","","81.14","81.14","243.42","12","82.81","551.09","percent of total billed charges",""
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","972.00","583.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","678.46","69.8","","654.72","654.72","654.72","1 through 10","108.88","826.2","percent of total billed charges",""
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","972.00","583.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","692.73","696.33","1 through 10","108.88","826.2","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","972.00","583.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","299.84","1 through 10","108.88","826.2","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","972.00","583.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","111.11","107.12","188.89","11","108.88","826.2","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","972.00","583.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","298.29","559.93","1 through 10","108.88","826.2","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","972.00","583.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","114.44","113.85","114.44","1 through 10","108.88","826.2","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","972.00","583.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.22","109.00","111.11","1 through 10","108.88","826.2","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","972.00","583.20","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","21","108.88","826.2","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","972.00","583.20","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","826.2","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","972.00","583.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.39","108.89","111.11","1 through 10","108.88","826.2","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","972.00","583.20","WELLSENSE NH [1050]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","114.34","114.34","114.34","1 through 10","108.88","826.2","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","outpatient","","","972.00","583.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","140.16","14.42","","135.26","115.94","135.26","1 through 10","113.04","752.33","percent of total billed charges",""
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","outpatient","","","972.00","583.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","113.04","11.63","","129.16","114.81","129.16","1 through 10","113.04","752.33","percent of total billed charges",""
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","outpatient","","","972.00","583.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","424.96","43.72","","410.09","410.09","410.09","1 through 10","113.04","752.33","percent of total billed charges",""
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","outpatient","","","972.00","583.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","706.84","72.72","","682.11","682.11","682.11","1 through 10","113.04","752.33","percent of total billed charges",""
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","outpatient","","","972.00","583.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","611.39","62.9","","590.94","590.94","590.94","12","113.04","752.33","percent of total billed charges",""
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","outpatient","","","972.00","583.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","752.33","77.4","","726.95","726.95","726.95","1 through 10","113.04","752.33","percent of total billed charges",""
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","outpatient","","","972.00","583.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","113.04","11.63","","110.79","110.79","332.37","1 through 10","113.04","752.33","percent of total billed charges",""
"Xr C-Spine 6 or More Views","PX-32000058","CDM","72052","CPT","0320","RC","","","","both","","","1173.00","703.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","692.73","692.73","1 through 10","108.88","997.05","other","OPPS APC"
"Xr C-Spine 6 or More Views","PX-32000058","CDM","72052","CPT","0320","RC","","","","both","","","1173.00","703.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","298.29","1 through 10","108.88","997.05","other","OPPS APC"
"Xr C-Spine 6 or More Views","PX-32000058","CDM","72052","CPT","0320","RC","","","","both","","","1173.00","703.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","111.11","110.59","111.11","1 through 10","108.88","997.05","other","OPPS APC"
"Xr C-Spine 6 or More Views","PX-32000058","CDM","72052","CPT","0320","RC","","","","both","","","1173.00","703.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","108.99","108.99","108.99","1 through 10","108.88","997.05","other","OPPS APC"
"Xr C-Spine 6 or More Views","PX-32000058","CDM","72052","CPT","0320","RC","","","","outpatient","","","1173.00","703.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","169.15","14.42","","163.23","163.23","163.23","1 through 10","136.42","907.9","percent of total billed charges",""
"Xr C-Spine 6 or More Views","PX-32000058","CDM","72052","CPT","0320","RC","","","","outpatient","","","1173.00","703.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","136.42","11.63","","155.88","155.88","155.88","1 through 10","136.42","907.9","percent of total billed charges",""
"Xr Calcaneus 2+ Views","PX-32000189","CDM","73650","CPT","0320","RC","","","","both","","","532.00","319.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.66","90.53","90.66","1 through 10","29.42","587.88","other","OPPS APC"
"Xr Catheter Biliary Only","PX-32000217","CDM","74328","CPT","0320","RC","","","","both","","","826.00","495.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","576.55","69.8","","78.09","78.09","78.09","1 through 10","469.99","702.1","percent of total billed charges",""
"Xr Catheter Biliary Only","PX-32000217","CDM","74328","CPT","0320","RC","","","","both","","","826.00","495.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","469.99","56.9","","453.49","453.49","453.49","1 through 10","469.99","702.1","percent of total billed charges",""
"Xr Catheter Biliary Only","PX-32000217","CDM","74328","CPT","0320","RC","","","","outpatient","","","826.00","495.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","96.06","11.63","","109.75","109.75","109.75","1 through 10","96.06","639.32","percent of total billed charges",""
"Xr Catheter Biliary Only","PX-32000217","CDM","74328","CPT","0320","RC","","","","outpatient","","","826.00","495.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","439.60","53.22","","424.88","424.88","424.88","1 through 10","96.06","639.32","percent of total billed charges",""
"Xr Catheter Biliary Only","PX-32000217","CDM","74328","CPT","0320","RC","","","","outpatient","","","826.00","495.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","519.55","62.9","","502.11","502.11","502.11","1 through 10","96.06","639.32","percent of total billed charges",""
"Xr Catheter Biliary Only","PX-32000217","CDM","74328","CPT","0320","RC","","","","outpatient","","","826.00","495.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","96.06","11.63","","94.14","94.14","94.14","1 through 10","96.06","639.32","percent of total billed charges",""
"Xr Change Tube/Drainage Catheter","PX-32000317","CDM","75984","CPT","0320","RC","","","","outpatient","","","1079.00","647.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","125.49","11.63","","122.96","122.96","122.96","1 through 10","125.49","835.15","percent of total billed charges",""
"Xr Clavicle Cmpl","PX-32000084","CDM","73000","CPT","0320","RC","","","","outpatient","","","581.00","348.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","422.50","72.72","","407.96","407.96","407.96","1 through 10","67.57","422.5","percent of total billed charges",""
"Xr Cystogram 3+ Views","PX-32000229","CDM","74430","CPT","0320","RC","","","","both","","","629.00","377.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1026.79","","Case rate ($1,026.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1048.83","1048.83","1048.83","1 through 10","175.28","2384.56","other","OPPS APC"
"Xr Cystogram 3+ Views","PX-32000229","CDM","74430","CPT","0320","RC","","","","both","","","629.00","377.40","MEDICARE [2001]","HB WDH MEDICARE","373.12","","APC Price ($373.12). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","373.16","373.16","373.16","1 through 10","175.28","2384.56","other","OPPS APC"
"Xr Cystogram 3+ Views","PX-32000229","CDM","74430","CPT","0320","RC","","","","outpatient","","","629.00","377.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","90.70","14.42","","87.53","87.53","87.53","1 through 10","73.15","486.85","percent of total billed charges",""
"Xr Cystogram 3+ Views","PX-32000229","CDM","74430","CPT","0320","RC","","","","outpatient","","","629.00","377.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","457.41","72.72","","441.41","441.41","441.41","1 through 10","73.15","486.85","percent of total billed charges",""
"Xr Cystourethrogram Voiding","PX-32000232","CDM","74455","CPT","0320","RC","","","","both","","","2007.00","1204.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","247.49","","APC Price ($252.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","233.97","233.97","233.97","1 through 10","247.49","1705.95","other","OPPS APC"
"Xr Elbow 2 Views","PX-32000100","CDM","73070","CPT","0320","RC","","","","both","","","532.00","319.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","371.34","69.8","","358.07","358.07","358.07","1 through 10","90.15","587.88","percent of total billed charges",""
"Xr Elbow 2 Views","PX-32000100","CDM","73070","CPT","0320","RC","","","","both","","","532.00","319.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.66","90.16","90.66","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Elbow 2 Views","PX-32000100","CDM","73070","CPT","0320","RC","","","","outpatient","","","532.00","319.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","386.87","72.72","","373.05","373.05","373.05","1 through 10","61.87","411.77","percent of total billed charges",""
"Xr Elbow Cmpl 3+ Views","PX-32000103","CDM","73080","CPT","0320","RC","","","","both","","","592.00","355.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.53","90.53","90.53","1 through 10","32.42","587.88","other","OPPS APC"
"Xr Enema Barium W/W/O Kub","PX-32000208","CDM","74270","CPT","0320","RC","","","","both","","","3568.00","2140.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","960.75","","Case rate ($960.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","937.31","937.31","937.31","1 through 10","182.27","3032.8","other","OPPS APC"
"Xr Enema Barium W/W/O Kub","PX-32000208","CDM","74270","CPT","0320","RC","","","","both","","","3568.00","2140.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.85","182.85","182.85","1 through 10","182.27","3032.8","other","OPPS APC"
"Xr Enema Barium W/W/O Kub","PX-32000208","CDM","74270","CPT","0320","RC","","","","outpatient","","","3568.00","2140.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","514.51","14.42","","425.55","425.55","425.55","1 through 10","414.96","2761.63","percent of total billed charges",""
"Xr Ercp Catheter Biliary&Pancreas","PX-32000219","CDM","74330","CPT","0320","RC","","","","outpatient","","","1109.00","665.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","128.98","11.63","","280.62","280.62","280.62","1 through 10","128.98","858.37","percent of total billed charges",""
"Xr Ercp Catheter Biliary&Pancreas","PX-32000219","CDM","74330","CPT","0320","RC","","","","outpatient","","","1109.00","665.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","806.46","72.72","","778.10","778.10","778.10","1 through 10","128.98","858.37","percent of total billed charges",""
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","both","","","1775.00","1065.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1188.62","","Case rate ($1,188.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1159.63","1159.63","1159.63","1 through 10","182.27","1508.75","other","OPPS APC"
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","both","","","1775.00","1065.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","182.27","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","186.01","186.01","186.01","1 through 10","182.27","1508.75","other","OPPS APC"
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","both","","","1775.00","1065.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","960.75","","Case rate ($960.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","937.31","937.31","937.31","1 through 10","182.27","1508.75","other","OPPS APC"
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","both","","","1775.00","1065.00","MEDICARE [2001]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","186.01","186.01","17","182.27","1508.75","other","OPPS APC"
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","both","","","1775.00","1065.00","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","1508.75","85","","260.41","260.41","260.41","1 through 10","182.27","1508.75","percent of total billed charges",""
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","both","","","1775.00","1065.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.05","182.79","185.05","1 through 10","182.27","1508.75","other","OPPS APC"
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","outpatient","","","1775.00","1065.00","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","255.96","14.42","","211.73","211.73","211.73","1 through 10","206.43","1373.85","percent of total billed charges",""
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","outpatient","","","1775.00","1065.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1290.78","72.72","","1245.69","1245.69","1245.69","1 through 10","206.43","1373.85","percent of total billed charges",""
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","outpatient","","","1775.00","1065.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1116.48","62.9","","1079.19","1079.19","1079.19","1 through 10","206.43","1373.85","percent of total billed charges",""
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","outpatient","","","1775.00","1065.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1373.85","77.4","","1327.58","1327.58","1327.58","1 through 10","206.43","1373.85","percent of total billed charges",""
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","outpatient","","","1775.00","1065.00","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","206.43","11.63","","202.34","202.34","297.62","1 through 10","206.43","1373.85","percent of total billed charges",""
"Xr Eye Foreign Body","PX-32000003","CDM","70030","CPT","0320","RC","","","","both","","","592.00","355.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","503.20","85","","797.12","797.12","797.12","1 through 10","90.15","587.88","percent of total billed charges",""
"Xr Eye Foreign Body","PX-32000003","CDM","70030","CPT","0320","RC","","","","both","","","592.00","355.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.66","90.46","90.66","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Eye Foreign Body","PX-32000003","CDM","70030","CPT","0320","RC","","","","outpatient","","","592.00","355.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","430.50","72.72","","830.46","830.46","830.46","1 through 10","68.85","458.21","percent of total billed charges",""
"Xr Eye Foreign Body","PX-32000003","CDM","70030","CPT","0320","RC","","","","outpatient","","","592.00","355.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","458.21","77.4","","885.06","885.06","885.06","1 through 10","68.85","458.21","percent of total billed charges",""
"Xr Facial Bones 3+ Views","PX-32000012","CDM","70150","CPT","0320","RC","","","","both","","","853.00","511.80","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","725.05","other","OPPS APC"
"Xr Facial Bones 3+ Views","PX-32000012","CDM","70150","CPT","0320","RC","","","","both","","","853.00","511.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.34","109.34","109.34","1 through 10","108.88","725.05","other","OPPS APC"
"Xr Facial Bones 3+ Views","PX-32000012","CDM","70150","CPT","0320","RC","","","","outpatient","","","853.00","511.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","536.54","62.9","","518.49","518.49","518.49","1 through 10","99.2","660.22","percent of total billed charges",""
"Xr Facial Bones 3+ Views","PX-32000012","CDM","70150","CPT","0320","RC","","","","outpatient","","","853.00","511.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","660.22","77.4","","637.83","637.83","637.83","1 through 10","99.2","660.22","percent of total billed charges",""
"Xr Facial Bones Less Than 3 Views","PX-32000011","CDM","70140","CPT","0320","RC","","","","outpatient","","","573.00","343.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","66.64","11.63","","65.32","65.32","65.32","1 through 10","66.64","443.5","percent of total billed charges",""
"Xr Finger(S) 2+ Views","PX-32000131","CDM","73140","CPT","0320","RC","","","","both","","","751.00","450.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","524.20","69.8","","506.05","506.05","506.05","1 through 10","90.15","638.35","percent of total billed charges",""
"Xr Finger(S) 2+ Views","PX-32000131","CDM","73140","CPT","0320","RC","","","","both","","","751.00","450.60","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","524.20","69.8","","1012.10","1012.10","1012.10","1 through 10","90.15","638.35","percent of total billed charges",""
"Xr Finger(S) 2+ Views","PX-32000131","CDM","73140","CPT","0320","RC","","","","both","","","751.00","450.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.66","90.66","90.66","1 through 10","90.15","638.35","other","OPPS APC"
"Xr Finger(S) 2+ Views","PX-32000131","CDM","73140","CPT","0320","RC","","","","outpatient","","","751.00","450.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","546.13","72.72","","527.22","527.22","527.22","1 through 10","87.34","581.27","percent of total billed charges",""
"Xr Finger(S) 2+ Views","PX-32000131","CDM","73140","CPT","0320","RC","","","","outpatient","","","751.00","450.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","581.27","77.4","","527.22","527.22","527.22","1 through 10","87.34","581.27","percent of total billed charges",""
"Xr Fluoro <1hr","PX-32000359","CDM","76000","CPT","0320","RC","","","","both","","","930.00","558.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","649.14","69.8","","626.11","626.11","626.11","1 through 10","247.49","1613.96","percent of total billed charges",""
"Xr Fluoro <1hr","PX-32000359","CDM","76000","CPT","0320","RC","","","","both","","","930.00","558.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1613.96","","Case rate ($1,613.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","897.00","897.00","897.00","1 through 10","247.49","1613.96","other","OPPS APC"
"Xr Fluoro <1hr","PX-32000359","CDM","76000","CPT","0320","RC","","","","both","","","930.00","558.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","694.97","","Case rate ($694.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","897.00","678.03","897.00","1 through 10","247.49","1613.96","other","OPPS APC"
"Xr Fluoro <1hr","PX-32000359","CDM","76000","CPT","0320","RC","","","","both","","","930.00","558.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","247.49","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","248.53","234.93","248.53","1 through 10","247.49","1613.96","other","OPPS APC"
"Xr Fluoro <1hr","PX-32000359","CDM","76000","CPT","0320","RC","","","","both","","","930.00","558.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1304.55","","Case rate ($1,304.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","897.00","897.00","897.00","1 through 10","247.49","1613.96","other","OPPS APC"
"Xr Fluoro <1hr","PX-32000359","CDM","76000","CPT","0320","RC","","","","both","","","930.00","558.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","260.12","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","260.15","260.15","260.15","1 through 10","247.49","1613.96","other","OPPS APC"
"Xr Fluoro <1hr","PX-32000359","CDM","76000","CPT","0320","RC","","","","both","","","930.00","558.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","248.28","248.28","248.28","1 through 10","247.49","1613.96","other","OPPS APC"
"Xr Fluoro <1hr","PX-32000359","CDM","76000","CPT","0320","RC","","","","both","","","930.00","558.00","MEDICARE [2001]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","238.75","252.57","1 through 10","247.49","1613.96","other","OPPS APC"
"Xr Fluoro <1hr","PX-32000359","CDM","76000","CPT","0320","RC","","","","both","","","930.00","558.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","248.53","247.82","252.57","1 through 10","247.49","1613.96","other","OPPS APC"
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","both","","","1141.00","684.60","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","649.23","56.9","","626.47","626.47","626.47","1 through 10","649.23","969.85","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","outpatient","","","1141.00","684.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","164.53","14.42","","158.76","136.08","158.76","1 through 10","132.7","883.13","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","outpatient","","","1141.00","684.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","132.70","11.63","","278.06","151.61","278.06","1 through 10","132.7","883.13","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","outpatient","","","1141.00","684.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","716.32","62.78","","691.21","691.21","691.21","1 through 10","132.7","883.13","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","outpatient","","","1141.00","684.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","498.85","43.72","","481.36","481.36","481.36","1 through 10","132.7","883.13","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","outpatient","","","1141.00","684.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","829.74","72.72","","800.65","800.65","800.65","1 through 10","132.7","883.13","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","outpatient","","","1141.00","684.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","717.69","62.9","","693.63","693.63","693.63","1 through 10","132.7","883.13","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","outpatient","","","1141.00","684.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","883.13","77.4","","853.28","853.28","853.28","1 through 10","132.7","883.13","percent of total billed charges",""
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","outpatient","","","1141.00","684.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","132.70","11.63","","130.05","130.05","130.05","1 through 10","132.7","883.13","percent of total billed charges",""
"Xr Fluoro Needle Localization","PX-32000365","CDM","77003","CPT","0320","RC","","","","both","","","1012.00","607.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","575.83","56.9","","555.91","555.91","555.91","1 through 10","575.83","860.2","percent of total billed charges",""
"Xr Fluoro Needle Localization","PX-32000365","CDM","77003","CPT","0320","RC","","","","outpatient","","","1012.00","607.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","117.70","11.63","","115.40","115.40","115.40","1 through 10","117.7","783.29","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","both","","","1097.00","658.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","","","Case rate ($0).","1059.00","1059.00","1059.00","1 through 10","624.19","932.45","other","OPPS APC standard_charge|negotiated_dollar calculated as 0;"
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","both","","","1097.00","658.20","CIGNA [1006]","HB WDH CIGNA HMO / PPO / INDEM","624.19","56.9","","602.57","602.57","602.57","1 through 10","624.19","932.45","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","outpatient","","","1097.00","658.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","127.58","11.63","","145.82","125.08","267.45","1 through 10","127.58","849.08","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","outpatient","","","1097.00","658.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","479.61","43.72","","462.99","462.99","462.99","1 through 10","127.58","849.08","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","outpatient","","","1097.00","658.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","797.74","72.72","","770.10","734.15","770.10","1 through 10","127.58","849.08","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","outpatient","","","1097.00","658.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","690.01","62.9","","667.17","667.17","667.17","1 through 10","127.58","849.08","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","outpatient","","","1097.00","658.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","849.08","77.4","","820.73","820.73","820.73","1 through 10","127.58","849.08","percent of total billed charges",""
"Xr Foot Cmpl 3+ Views","PX-32000186","CDM","73630","CPT","0320","RC","","","","both","","","641.00","384.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","447.42","69.8","","432.06","432.06","432.06","1 through 10","90.15","587.88","percent of total billed charges",""
"Xr Foot Cmpl 3+ Views","PX-32000186","CDM","73630","CPT","0320","RC","","","","both","","","641.00","384.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","475.18","","Case rate ($475.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","463.58","463.58","463.58","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Foot Cmpl 3+ Views","PX-32000186","CDM","73630","CPT","0320","RC","","","","both","","","641.00","384.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.66","90.16","90.76","29","90.15","587.88","other","OPPS APC"
"Xr Foot Cmpl 3+ Views","PX-32000186","CDM","73630","CPT","0320","RC","","","","outpatient","","","641.00","384.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","466.14","72.72","","450.14","450.14","2498.66","1 through 10","74.55","496.13","percent of total billed charges",""
"Xr Foot Cmpl 3+ Views","PX-32000186","CDM","73630","CPT","0320","RC","","","","outpatient","","","641.00","384.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","496.13","77.4","","959.46","959.46","959.46","1 through 10","74.55","496.13","percent of total billed charges",""
"Xr Forearm 2 Views","PX-32000109","CDM","73090","CPT","0320","RC","","","","both","","","551.00","330.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.56","90.16","90.66","1 through 10","30.18","587.88","other","OPPS APC"
"Xr Hand Cmp 3+V","PX-32000128","CDM","73130","CPT","0320","RC","","","","both","","","692.00","415.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","483.02","69.8","","466.26","466.26","466.26","1 through 10","90.15","588.2","percent of total billed charges",""
"Xr Hand Cmp 3+V","PX-32000128","CDM","73130","CPT","0320","RC","","","","both","","","692.00","415.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","588.20","85","","221.66","221.66","221.66","1 through 10","90.15","588.2","percent of total billed charges",""
"Xr Hand Cmp 3+V","PX-32000128","CDM","73130","CPT","0320","RC","","","","both","","","692.00","415.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.66","90.46","90.66","21","90.15","588.2","other","OPPS APC"
"Xr Hand Cmp 3+V","PX-32000128","CDM","73130","CPT","0320","RC","","","","outpatient","","","692.00","415.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","503.22","72.72","","485.77","485.77","971.54","1 through 10","80.48","535.61","percent of total billed charges",""
"Xr Hand Cmp 3+V","PX-32000128","CDM","73130","CPT","0320","RC","","","","outpatient","","","692.00","415.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","535.61","77.4","","1035.40","1035.40","1035.40","1 through 10","80.48","535.61","percent of total billed charges",""
"Xr Humerus 2+ Views","PX-32000097","CDM","73060","CPT","0320","RC","","","","both","","","611.00","366.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.16","90.16","90.16","1 through 10","32.81","587.88","other","OPPS APC"
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","both","","","1715.00","1029.00","AETNA [1001]","HB WDH AETNA COMMERCIAL","1197.07","69.8","","1155.19","1155.19","1155.19","1 through 10","247.49","1613.96","percent of total billed charges",""
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","both","","","1715.00","1029.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1613.96","","Case rate ($1,613.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1574.60","1574.60","1574.60","1 through 10","247.49","1613.96","other","OPPS APC"
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","both","","","1715.00","1029.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","694.97","","Case rate ($694.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","678.03","678.03","2333.03","1 through 10","247.49","1613.96","other","OPPS APC"
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","both","","","1715.00","1029.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","247.49","","APC Price ($252.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","238.75","238.75","238.75","1 through 10","247.49","1613.96","other","OPPS APC"
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","both","","","1715.00","1029.00","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","1304.55","","Case rate ($1,304.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","378.86","378.86","378.86","1 through 10","247.49","1613.96","other","OPPS APC"
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","both","","","1715.00","1029.00","TRICARE [160005]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","252.57","252.57","252.57","1 through 10","247.49","1613.96","other","OPPS APC"
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","both","","","1715.00","1029.00","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","252.54","","APC Price ($252.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","248.02","248.02","248.02","1 through 10","247.49","1613.96","other","OPPS APC"
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","outpatient","","","1715.00","1029.00","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","1247.15","72.72","","1203.52","1203.52","1203.52","1 through 10","199.45","1327.41","percent of total billed charges",""
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","outpatient","","","1715.00","1029.00","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1078.74","62.9","","1042.65","1042.65","1042.65","1 through 10","199.45","1327.41","percent of total billed charges",""
"Xr Hysterosalpingogram","PX-32000239","CDM","74740","CPT","0320","RC","","","","outpatient","","","1715.00","1029.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1327.41","77.4","","1282.63","1282.63","1282.63","1 through 10","199.45","1327.41","percent of total billed charges",""
"Xr Knee 1-2 Views","PX-32000154","CDM","73560","CPT","0320","RC","","","","both","","","672.00","403.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.46","90.46","92.00","1 through 10","35.06","587.88","other","OPPS APC"
"Xr Knee 3 Views","PX-32000157","CDM","73562","CPT","0320","RC","","","","both","","","782.00","469.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.66","90.46","90.66","1 through 10","90.15","664.7","other","OPPS APC"
"Xr Knee 3 Views","PX-32000157","CDM","73562","CPT","0320","RC","","","","outpatient","","","782.00","469.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","568.67","72.72","","549.04","549.04","549.04","1 through 10","90.95","605.27","percent of total billed charges",""
"Xr Knee Cmpl 4+ Views","PX-32000160","CDM","73564","CPT","0320","RC","","","","both","","","853.00","511.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","595.39","69.8","","1148.91","574.45","1148.91","1 through 10","108.88","725.05","percent of total billed charges",""
"Xr Knee Cmpl 4+ Views","PX-32000160","CDM","73564","CPT","0320","RC","","","","both","","","853.00","511.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.39","105.48","109.39","35","108.88","725.05","other","OPPS APC"
"Xr Knee Cmpl 4+ Views","PX-32000160","CDM","73564","CPT","0320","RC","","","","outpatient","","","853.00","511.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","620.30","72.72","","1196.97","598.49","1196.98","15","99.2","660.22","percent of total billed charges",""
"Xr Knee Cmpl 4+ Views","PX-32000160","CDM","73564","CPT","0320","RC","","","","outpatient","","","853.00","511.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","660.22","77.4","","1275.66","1275.66","1275.66","1 through 10","99.2","660.22","percent of total billed charges",""
"Xr Knee Stand Both Knees","PX-32000161","CDM","73565","CPT","0320","RC","","","","both","","","802.00","481.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","94.75","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","94.76","94.76","94.76","1 through 10","90.15","681.7","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","712.00","427.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","687.00","687.00","692.73","27","108.88","710.05","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","712.00","427.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","299.84","58","108.88","710.05","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","712.00","427.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","109.33","108.89","111.11","47","108.88","710.05","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","712.00","427.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","298.29","559.93","12","108.88","710.05","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","712.00","427.20","CHAMPVA [160001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","107.12","107.12","107.12","1 through 10","108.88","710.05","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","712.00","427.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","496.98","69.8","","479.53","479.53","479.53","1 through 10","108.88","710.05","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","712.00","427.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","114.44","114.35","114.44","18","108.88","710.05","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","712.00","427.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.22","109.00","111.11","48","108.88","710.05","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","712.00","427.20","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","132","108.88","710.05","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","712.00","427.20","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","605.20","85","","445.93","445.93","445.93","1 through 10","108.88","710.05","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","712.00","427.20","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","710.05","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","712.00","427.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.39","108.89","111.11","52","108.88","710.05","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","712.00","427.20","WELLSENSE NH [1050]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","114.34","114.34","116.67","1 through 10","108.88","710.05","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","outpatient","","","712.00","427.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","102.67","14.42","","99.07","84.91","99.07","25","82.81","551.09","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","outpatient","","","712.00","427.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","82.81","11.63","","94.60","81.14","173.50","62","82.81","551.09","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","outpatient","","","712.00","427.20","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","446.99","62.78","","431.30","431.30","431.30","1 through 10","82.81","551.09","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","outpatient","","","712.00","427.20","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","311.29","43.72","","901.08","300.36","901.08","1 through 10","82.81","551.09","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","outpatient","","","712.00","427.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","517.77","72.72","","499.59","499.59","499.59","43","82.81","551.09","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","outpatient","","","712.00","427.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","447.85","62.9","","432.81","432.81","432.81","32","82.81","551.09","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","outpatient","","","712.00","427.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","551.09","77.4","","532.43","532.43","532.43","20","82.81","551.09","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","outpatient","","","712.00","427.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","82.81","11.63","","81.14","81.14","243.42","30","82.81","551.09","percent of total billed charges",""
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","994.00","596.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","692.73","696.33","1 through 10","108.88","844.9","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","994.00","596.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","299.84","1 through 10","108.88","844.9","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","994.00","596.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","108.89","105.41","111.11","1 through 10","108.88","844.9","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","994.00","596.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","559.93","559.93","1 through 10","108.88","844.9","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","994.00","596.40","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","114.44","114.44","114.44","1 through 10","108.88","844.9","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","994.00","596.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.22","105.30","111.11","1 through 10","108.88","844.9","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","994.00","596.40","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","11","108.88","844.9","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","994.00","596.40","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","844.9","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","994.00","596.40","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.39","108.89","109.39","12","108.88","844.9","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","994.00","596.40","WELLSENSE NH [1050]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","114.34","114.34","114.34","1 through 10","108.88","844.9","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","outpatient","","","994.00","596.40","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","143.33","14.42","","118.53","118.53","118.53","1 through 10","115.6","769.36","percent of total billed charges",""
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","outpatient","","","994.00","596.40","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","115.60","11.63","","242.20","117.38","242.20","1 through 10","115.6","769.36","percent of total billed charges",""
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","outpatient","","","994.00","596.40","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","722.84","72.72","","697.38","697.38","697.38","1 through 10","115.6","769.36","percent of total billed charges",""
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","outpatient","","","994.00","596.40","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","625.23","62.9","","604.17","604.17","604.17","1 through 10","115.6","769.36","percent of total billed charges",""
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","outpatient","","","994.00","596.40","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","769.36","77.4","","743.23","743.23","743.23","1 through 10","115.6","769.36","percent of total billed charges",""
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","outpatient","","","994.00","596.40","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","115.60","11.63","","113.27","113.27","113.27","1 through 10","115.6","769.36","percent of total billed charges",""
"Xr L-Spine Bending Only 2/3 Views","PX-32000068","CDM","72120","CPT","0320","RC","","","","both","","","893.00","535.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","299.84","299.84","299.84","1 through 10","108.88","759.05","other","OPPS APC"
"Xr L-Spine Bending Only 2/3 Views","PX-32000068","CDM","72120","CPT","0320","RC","","","","both","","","893.00","535.80","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","759.05","other","OPPS APC"
"Xr L-Spine Bending Only 2/3 Views","PX-32000068","CDM","72120","CPT","0320","RC","","","","outpatient","","","893.00","535.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","561.70","62.9","","543.06","543.06","543.06","1 through 10","103.86","691.18","percent of total billed charges",""
"Xr L-Spine W/Bending Views, Min 6","PX-32000067","CDM","72114","CPT","0320","RC","","","","both","","","1173.00","703.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","299.84","1 through 10","108.88","997.05","other","OPPS APC"
"Xr L-Spine W/Bending Views, Min 6","PX-32000067","CDM","72114","CPT","0320","RC","","","","both","","","1173.00","703.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1132.00","1132.00","1132.00","1 through 10","108.88","997.05","other","OPPS APC"
"Xr L-Spine W/Bending Views, Min 6","PX-32000067","CDM","72114","CPT","0320","RC","","","","both","","","1173.00","703.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","114.44","114.44","114.44","1 through 10","108.88","997.05","other","OPPS APC"
"Xr L-Spine W/Bending Views, Min 6","PX-32000067","CDM","72114","CPT","0320","RC","","","","both","","","1173.00","703.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","105.30","111.11","1 through 10","108.88","997.05","other","OPPS APC"
"Xr L-Spine W/Bending Views, Min 6","PX-32000067","CDM","72114","CPT","0320","RC","","","","both","","","1173.00","703.80","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","997.05","other","OPPS APC"
"Xr L-Spine W/Bending Views, Min 6","PX-32000067","CDM","72114","CPT","0320","RC","","","","both","","","1173.00","703.80","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","997.05","other","OPPS APC"
"Xr L-Spine W/Bending Views, Min 6","PX-32000067","CDM","72114","CPT","0320","RC","","","","both","","","1173.00","703.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.34","109.19","109.39","1 through 10","108.88","997.05","other","OPPS APC"
"Xr L-Spine W/Bending Views, Min 6","PX-32000067","CDM","72114","CPT","0320","RC","","","","outpatient","","","1173.00","703.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","169.15","14.42","","163.23","163.23","163.23","1 through 10","136.42","907.9","percent of total billed charges",""
"Xr L-Spine W/Bending Views, Min 6","PX-32000067","CDM","72114","CPT","0320","RC","","","","outpatient","","","1173.00","703.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","136.42","11.63","","285.89","155.88","285.89","1 through 10","136.42","907.9","percent of total billed charges",""
"Xr L-Spine W/Bending Views, Min 6","PX-32000067","CDM","72114","CPT","0320","RC","","","","outpatient","","","1173.00","703.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","853.01","72.72","","823.19","823.19","823.19","1 through 10","136.42","907.9","percent of total billed charges",""
"Xr L-Spine W/Bending Views, Min 6","PX-32000067","CDM","72114","CPT","0320","RC","","","","outpatient","","","1173.00","703.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","737.82","62.9","","713.16","713.16","713.16","1 through 10","136.42","907.9","percent of total billed charges",""
"Xr L-Spine W/Bending Views, Min 6","PX-32000067","CDM","72114","CPT","0320","RC","","","","outpatient","","","1173.00","703.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","907.90","77.4","","877.30","877.30","877.30","1 through 10","136.42","907.9","percent of total billed charges",""
"Xr Mandible Cmpl 4+ Views","PX-32000005","CDM","70110","CPT","0320","RC","","","","both","","","773.00","463.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.22","109.22","109.22","1 through 10","108.88","710.05","other","OPPS APC"
"Xr Mandible Cmpl 4+ Views","PX-32000005","CDM","70110","CPT","0320","RC","","","","outpatient","","","773.00","463.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","89.90","11.63","","102.72","102.72","102.72","1 through 10","89.9","598.3","percent of total billed charges",""
"Xr Mandible Cmpl 4+ Views","PX-32000005","CDM","70110","CPT","0320","RC","","","","outpatient","","","773.00","463.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","89.90","11.63","","88.12","88.12","88.12","1 through 10","89.9","598.3","percent of total billed charges",""
"Xr Nasal Cmpl 3+ Views","PX-32000013","CDM","70160","CPT","0320","RC","","","","both","","","721.00","432.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","503.26","69.8","","485.81","485.81","485.81","1 through 10","38.06","612.85","percent of total billed charges",""
"Xr Nasal Cmpl 3+ Views","PX-32000013","CDM","70160","CPT","0320","RC","","","","both","","","721.00","432.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","253.14","","Case rate ($253.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","247.82","247.82","247.82","1 through 10","38.06","612.85","other","OPPS APC"
"Xr Nasal Cmpl 3+ Views","PX-32000013","CDM","70160","CPT","0320","RC","","","","both","","","721.00","432.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","475.18","","Case rate ($475.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","463.58","463.58","463.58","1 through 10","38.06","612.85","other","OPPS APC"
"Xr Nasal Cmpl 3+ Views","PX-32000013","CDM","70160","CPT","0320","RC","","","","both","","","721.00","432.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.44","90.44","90.44","1 through 10","38.06","612.85","other","OPPS APC"
"Xr Nasal Cmpl 3+ Views","PX-32000013","CDM","70160","CPT","0320","RC","","","","outpatient","","","721.00","432.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","103.97","14.42","","100.36","100.36","100.36","1 through 10","83.85","558.05","percent of total billed charges",""
"Xr Nasal Cmpl 3+ Views","PX-32000013","CDM","70160","CPT","0320","RC","","","","outpatient","","","721.00","432.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","83.85","11.63","","95.84","85.19","95.84","1 through 10","83.85","558.05","percent of total billed charges",""
"Xr Nasal Cmpl 3+ Views","PX-32000013","CDM","70160","CPT","0320","RC","","","","outpatient","","","721.00","432.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","524.31","72.72","","506.13","506.13","506.13","1 through 10","83.85","558.05","percent of total billed charges",""
"Xr Nasal Cmpl 3+ Views","PX-32000013","CDM","70160","CPT","0320","RC","","","","outpatient","","","721.00","432.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","453.51","62.9","","438.48","438.48","438.48","1 through 10","83.85","558.05","percent of total billed charges",""
"Xr Nasal Cmpl 3+ Views","PX-32000013","CDM","70160","CPT","0320","RC","","","","outpatient","","","721.00","432.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","558.05","77.4","","539.40","539.40","539.40","1 through 10","83.85","558.05","percent of total billed charges",""
"Xr Nasal Cmpl 3+ Views","PX-32000013","CDM","70160","CPT","0320","RC","","","","outpatient","","","721.00","432.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","83.85","11.63","","82.21","82.21","82.21","1 through 10","83.85","558.05","percent of total billed charges",""
"Xr Neck Soft Tissue","PX-32000039","CDM","70360","CPT","0320","RC","","","","both","","","611.00","366.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","587.88","","Case rate ($587.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","573.54","573.54","573.54","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Neck Soft Tissue","PX-32000039","CDM","70360","CPT","0320","RC","","","","both","","","611.00","366.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","253.14","","Case rate ($253.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","246.97","246.97","246.97","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Neck Soft Tissue","PX-32000039","CDM","70360","CPT","0320","RC","","","","both","","","611.00","366.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","90.15","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","590.00","590.00","590.00","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Neck Soft Tissue","PX-32000039","CDM","70360","CPT","0320","RC","","","","both","","","611.00","366.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.44","90.44","90.44","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Neck Soft Tissue","PX-32000039","CDM","70360","CPT","0320","RC","","","","both","","","611.00","366.60","MEDICARE [2001]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","92.00","92.00","92.00","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Neck Soft Tissue","PX-32000039","CDM","70360","CPT","0320","RC","","","","both","","","611.00","366.60","PHCS MULTIPLAN [1022]","HB WDH PHCS MULTIPLAN","519.35","85","","411.82","411.82","411.82","1 through 10","90.15","587.88","percent of total billed charges",""
"Xr Neck Soft Tissue","PX-32000039","CDM","70360","CPT","0320","RC","","","","outpatient","","","611.00","366.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","88.11","14.42","","85.08","85.08","85.08","1 through 10","71.06","472.91","percent of total billed charges",""
"Xr Neck Soft Tissue","PX-32000039","CDM","70360","CPT","0320","RC","","","","outpatient","","","611.00","366.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.06","11.63","","149.01","69.69","149.01","1 through 10","71.06","472.91","percent of total billed charges",""
"Xr Neck Soft Tissue","PX-32000039","CDM","70360","CPT","0320","RC","","","","outpatient","","","611.00","366.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","444.32","72.72","","429.05","429.05","429.05","1 through 10","71.06","472.91","percent of total billed charges",""
"Xr Neck Soft Tissue","PX-32000039","CDM","70360","CPT","0320","RC","","","","outpatient","","","611.00","366.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","384.32","62.9","","371.70","371.70","371.70","1 through 10","71.06","472.91","percent of total billed charges",""
"Xr Neck Soft Tissue","PX-32000039","CDM","70360","CPT","0320","RC","","","","outpatient","","","611.00","366.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","472.91","77.4","","457.25","457.25","457.25","1 through 10","71.06","472.91","percent of total billed charges",""
"Xr Neck Soft Tissue","PX-32000039","CDM","70360","CPT","0320","RC","","","","outpatient","","","611.00","366.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.06","11.63","","69.69","69.69","69.69","1 through 10","71.06","472.91","percent of total billed charges",""
"Xr Orbits Cmp 4+ Views","PX-32000022","CDM","70200","CPT","0320","RC","","","","both","","","843.00","505.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.39","109.39","109.39","1 through 10","108.88","716.55","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","682.00","409.20","AETNA [1001]","HB WDH AETNA COMMERCIAL","476.04","69.8","","459.28","459.28","459.28","1 through 10","108.88","710.05","percent of total billed charges",""
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","682.00","409.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","680.55","658.00","680.55","1 through 10","108.88","710.05","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","682.00","409.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","299.84","1 through 10","108.88","710.05","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","682.00","409.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","107.12","62.07","107.12","1 through 10","108.88","710.05","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","682.00","409.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","298.29","956.29","1 through 10","108.88","710.05","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","682.00","409.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.22","109.22","109.22","1 through 10","108.88","710.05","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","682.00","409.20","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","710.05","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","682.00","409.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.34","109.09","109.39","1 through 10","108.88","710.05","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","682.00","409.20","WELLSENSE NH [1050]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","114.34","114.34","114.34","1 through 10","108.88","710.05","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","outpatient","","","682.00","409.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","98.34","14.42","","94.88","81.33","94.88","1 through 10","79.32","527.87","percent of total billed charges",""
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","outpatient","","","682.00","409.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","79.32","11.63","","166.17","90.61","175.50","13","79.32","527.87","percent of total billed charges",""
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","outpatient","","","682.00","409.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","495.95","72.72","","478.50","478.50","957.00","13","79.32","527.87","percent of total billed charges",""
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","outpatient","","","682.00","409.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","428.98","62.9","","414.54","414.54","414.54","1 through 10","79.32","527.87","percent of total billed charges",""
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","outpatient","","","682.00","409.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","527.87","77.4","","509.95","509.95","509.95","1 through 10","79.32","527.87","percent of total billed charges",""
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","outpatient","","","682.00","409.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","79.32","11.63","","77.72","77.72","77.72","1 through 10","79.32","527.87","percent of total billed charges",""
"Xr Ribs 2 Views Uni","PX-32000048","CDM","71100","CPT","0324","RC","","","","both","","","652.00","391.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.66","90.66","90.66","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Ribs 3 Views Bilat","PX-32000050","CDM","71110","CPT","0320","RC","","","","both","","","742.00","445.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","710.05","other","OPPS APC"
"Xr Ribs 3 Views Bilat","PX-32000050","CDM","71110","CPT","0320","RC","","","","both","","","742.00","445.20","WELLSENSE NH [1050]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","114.34","114.34","114.34","1 through 10","108.88","710.05","other","OPPS APC"
"Xr Ribs 3 Views Bilat","PX-32000050","CDM","71110","CPT","0320","RC","","","","outpatient","","","742.00","445.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","86.29","11.63","","98.59","98.59","98.59","1 through 10","86.29","574.31","percent of total billed charges",""
"Xr Ribs 3 Views Bilat","PX-32000050","CDM","71110","CPT","0320","RC","","","","outpatient","","","742.00","445.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","539.58","72.72","","520.68","520.68","520.68","1 through 10","86.29","574.31","percent of total billed charges",""
"Xr Ribs W/Cxr 3+ Views Uni","PX-32000049","CDM","71101","CPT","0324","RC","","","","both","","","721.00","432.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.39","108.89","109.39","1 through 10","108.88","710.05","other","OPPS APC"
"Xr Ribs W/Cxr 4+ Views Bilat","PX-32000051","CDM","71111","CPT","0324","RC","","","","both","","","913.00","547.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","111.11","111.11","111.11","1 through 10","108.88","776.05","other","OPPS APC"
"Xr Ribs W/Cxr 4+ Views Bilat","PX-32000051","CDM","71111","CPT","0324","RC","","","","both","","","913.00","547.80","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","776.05","other","OPPS APC"
"Xr Ribs W/Cxr 4+ Views Bilat","PX-32000051","CDM","71111","CPT","0324","RC","","","","both","","","913.00","547.80","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","107.12","111.11","1 through 10","108.88","776.05","other","OPPS APC"
"Xr Ribs W/Cxr 4+ Views Bilat","PX-32000051","CDM","71111","CPT","0324","RC","","","","outpatient","","","913.00","547.80","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","131.65","14.42","","127.04","127.04","127.04","1 through 10","106.18","706.66","percent of total billed charges",""
"Xr Ribs W/Cxr 4+ Views Bilat","PX-32000051","CDM","71111","CPT","0324","RC","","","","outpatient","","","913.00","547.80","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","106.18","11.63","","121.31","121.31","121.31","1 through 10","106.18","706.66","percent of total billed charges",""
"Xr Ribs W/Cxr 4+ Views Bilat","PX-32000051","CDM","71111","CPT","0324","RC","","","","outpatient","","","913.00","547.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","663.93","72.72","","640.66","640.66","640.66","1 through 10","106.18","706.66","percent of total billed charges",""
"Xr Ribs W/Cxr 4+ Views Bilat","PX-32000051","CDM","71111","CPT","0324","RC","","","","outpatient","","","913.00","547.80","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","106.18","11.63","","104.06","104.06","104.06","1 through 10","106.18","706.66","percent of total billed charges",""
"Xr Sacroili Jt 3+ Views","PX-32000072","CDM","72202","CPT","0320","RC","","","","both","","","712.00","427.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.22","109.22","109.22","1 through 10","108.88","710.05","other","OPPS APC"
"Xr Sacroili Jt 3+ Views","PX-32000072","CDM","72202","CPT","0320","RC","","","","both","","","712.00","427.20","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","710.05","other","OPPS APC"
"Xr Sacroili Jt 3+ Views","PX-32000072","CDM","72202","CPT","0320","RC","","","","both","","","712.00","427.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.39","109.39","109.39","1 through 10","108.88","710.05","other","OPPS APC"
"Xr Sacroili Jt 3+ Views","PX-32000072","CDM","72202","CPT","0320","RC","","","","outpatient","","","712.00","427.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","102.67","14.42","","99.07","84.91","99.07","1 through 10","82.81","551.09","percent of total billed charges",""
"Xr Sacroili Jt 3+ Views","PX-32000072","CDM","72202","CPT","0320","RC","","","","outpatient","","","712.00","427.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","82.81","11.63","","173.50","81.14","173.50","1 through 10","82.81","551.09","percent of total billed charges",""
"Xr Sacroili Jt 3+ Views","PX-32000072","CDM","72202","CPT","0320","RC","","","","outpatient","","","712.00","427.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","517.77","72.72","","499.59","499.59","499.59","1 through 10","82.81","551.09","percent of total billed charges",""
"Xr Sacroili Jt 3+ Views","PX-32000072","CDM","72202","CPT","0320","RC","","","","outpatient","","","712.00","427.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","447.85","62.9","","432.81","432.81","432.81","1 through 10","82.81","551.09","percent of total billed charges",""
"Xr Sacroili Jt 3+ Views","PX-32000072","CDM","72202","CPT","0320","RC","","","","outpatient","","","712.00","427.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","551.09","77.4","","532.43","532.43","532.43","1 through 10","82.81","551.09","percent of total billed charges",""
"Xr Sacroili Jt 3+ Views","PX-32000072","CDM","72202","CPT","0320","RC","","","","outpatient","","","712.00","427.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","82.81","11.63","","81.14","81.14","81.14","1 through 10","82.81","551.09","percent of total billed charges",""
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","611.00","366.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","253.14","","Case rate ($253.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","246.97","246.97","246.97","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","611.00","366.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","90.15","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","92.00","90.53","156.40","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","611.00","366.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","475.18","","Case rate ($475.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","463.58","463.58","463.58","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","611.00","366.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","94.75","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","94.56","94.56","94.56","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","611.00","366.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","92.00","90.44","92.00","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","611.00","366.60","MEDICARE [2001]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","92.00","92.00","92.00","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","611.00","366.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.66","90.66","90.66","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","outpatient","","","611.00","366.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","88.11","14.42","","72.92","72.92","72.92","1 through 10","71.06","472.91","percent of total billed charges",""
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","outpatient","","","611.00","366.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.06","11.63","","149.01","69.69","149.01","1 through 10","71.06","472.91","percent of total billed charges",""
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","outpatient","","","611.00","366.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","444.32","72.72","","429.05","429.05","429.05","1 through 10","71.06","472.91","percent of total billed charges",""
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","outpatient","","","611.00","366.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","384.32","62.9","","371.70","371.70","371.70","1 through 10","71.06","472.91","percent of total billed charges",""
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","outpatient","","","611.00","366.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","472.91","77.4","","457.25","457.25","457.25","1 through 10","71.06","472.91","percent of total billed charges",""
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","outpatient","","","611.00","366.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","71.06","11.63","","69.69","69.69","69.69","1 through 10","71.06","472.91","percent of total billed charges",""
"Xr Shoulder Cmp 2+ Views","PX-32000090","CDM","73030","CPT","0320","RC","","","","both","","","581.00","348.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.66","90.16","90.66","30","90.15","587.88","other","OPPS APC"
"Xr Shoulder Cmp 2+ Views","PX-32000090","CDM","73030","CPT","0320","RC","","","","outpatient","","","581.00","348.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","422.50","72.72","","815.92","407.96","815.92","1 through 10","67.57","449.69","percent of total billed charges",""
"Xr Sinuses 3+ Views","PX-32000028","CDM","70220","CPT","0320","RC","","","","both","","","742.00","445.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","587.88","","Case rate ($587.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","573.54","573.54","573.54","1 through 10","90.15","630.7","other","OPPS APC"
"Xr Sinuses 3+ Views","PX-32000028","CDM","70220","CPT","0320","RC","","","","both","","","742.00","445.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","253.14","","Case rate ($253.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","247.82","247.82","247.82","1 through 10","90.15","630.7","other","OPPS APC"
"Xr Sinuses 3+ Views","PX-32000028","CDM","70220","CPT","0320","RC","","","","both","","","742.00","445.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.46","90.44","90.46","1 through 10","90.15","630.7","other","OPPS APC"
"Xr Sinuses 3+ Views","PX-32000028","CDM","70220","CPT","0320","RC","","","","both","","","742.00","445.20","MEDICARE [2001]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","92.00","92.00","92.00","1 through 10","90.15","630.7","other","OPPS APC"
"Xr Sinuses 3+ Views","PX-32000028","CDM","70220","CPT","0320","RC","","","","outpatient","","","742.00","445.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","574.31","77.4","","554.90","554.90","554.90","1 through 10","86.29","574.31","percent of total billed charges",""
"Xr Skull Cmpl 4+ Views","PX-32000031","CDM","70260","CPT","0320","RC","","","","both","","","843.00","505.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","692.73","692.73","1 through 10","108.88","716.55","other","OPPS APC"
"Xr Skull Cmpl 4+ Views","PX-32000031","CDM","70260","CPT","0320","RC","","","","both","","","843.00","505.80","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","110.33","110.33","110.33","1 through 10","108.88","716.55","other","OPPS APC"
"Xr Skull Cmpl 4+ Views","PX-32000031","CDM","70260","CPT","0320","RC","","","","outpatient","","","843.00","505.80","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","613.03","72.72","","591.21","591.21","591.21","1 through 10","98.04","652.48","percent of total billed charges",""
"Xr Skull Cmpl 4+ Views","PX-32000031","CDM","70260","CPT","0320","RC","","","","outpatient","","","843.00","505.80","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","530.25","62.9","","512.19","512.19","512.19","1 through 10","98.04","652.48","percent of total billed charges",""
"Xr Skull Ltd <4 Views","PX-32000030","CDM","70250","CPT","0320","RC","","","","outpatient","","","712.00","427.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","82.81","11.63","","173.50","81.14","173.50","1 through 10","82.81","551.09","percent of total billed charges",""
"Xr Small Intestine","PX-32000206","CDM","74250","CPT","0320","RC","","","","both","","","2515.00","1509.00","MEDICARE [2001]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","186.01","186.01","1 through 10","182.27","2137.75","other","OPPS APC"
"Xr Spine 1 View Any Level","PX-32000055","CDM","72020","CPT","0320","RC","","","","both","","","431.00","258.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.44","90.44","90.44","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Spine 1 View Any Level","PX-32000055","CDM","72020","CPT","0320","RC","","","","both","","","431.00","258.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.46","90.46","90.46","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Spine 1 View Any Level","PX-32000055","CDM","72020","CPT","0320","RC","","","","outpatient","","","431.00","258.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","270.58","62.78","","261.16","261.16","261.16","1 through 10","50.13","333.59","percent of total billed charges",""
"Xr Spine 1 View Any Level","PX-32000055","CDM","72020","CPT","0320","RC","","","","outpatient","","","431.00","258.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","313.42","72.72","","302.52","302.52","302.52","1 through 10","50.13","333.59","percent of total billed charges",""
"Xr Spine 1 View Any Level","PX-32000055","CDM","72020","CPT","0320","RC","","","","outpatient","","","431.00","258.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","50.13","11.63","","49.13","49.13","49.13","1 through 10","50.13","333.59","percent of total billed charges",""
"Xr Sternoclavicular Jt 3+ Views","PX-32000053","CDM","71130","CPT","0324","RC","","","","outpatient","","","742.00","445.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","574.31","77.4","","554.90","554.90","554.90","1 through 10","86.29","574.31","percent of total billed charges",""
"Xr Sternum 2+ Views","PX-32000052","CDM","71120","CPT","0324","RC","","","","both","","","592.00","355.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","253.14","","Case rate ($253.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","247.82","247.82","247.82","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Sternum 2+ Views","PX-32000052","CDM","71120","CPT","0324","RC","","","","both","","","592.00","355.20","MEDICARE [2001]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","92.00","88.54","92.00","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Sternum 2+ Views","PX-32000052","CDM","71120","CPT","0324","RC","","","","both","","","592.00","355.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.70","90.70","90.70","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Sternum 2+ Views","PX-32000052","CDM","71120","CPT","0324","RC","","","","outpatient","","","592.00","355.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","85.37","14.42","","571.00","571.00","571.00","1 through 10","68.85","458.21","percent of total billed charges",""
"Xr Sternum 2+ Views","PX-32000052","CDM","71120","CPT","0324","RC","","","","outpatient","","","592.00","355.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","430.50","72.72","","823.19","823.19","823.19","1 through 10","68.85","458.21","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","both","","","231.00","138.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","161.24","69.8","","311.30","311.30","311.30","1 through 10","70.7","3660.99","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","both","","","231.00","138.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","1576.42","","Case rate ($1,576.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","223.00","223.00","223.00","1 through 10","70.7","3660.99","other","OPPS APC"
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","both","","","231.00","138.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","2959.14","","Case rate ($2,959.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","446.00","223.00","446.00","1 through 10","70.7","3660.99","other","OPPS APC"
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","both","","","231.00","138.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","572.84","","APC Price ($572.84). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","223.00","223.00","223.00","1 through 10","70.7","3660.99","other","OPPS APC"
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","outpatient","","","231.00","138.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","33.31","14.42","","32.16","27.56","32.16","1 through 10","26.87","178.79","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","outpatient","","","231.00","138.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","26.87","11.63","","28.77","26.34","28.77","1 through 10","26.87","178.79","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","outpatient","","","231.00","138.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","145.02","62.78","","420.00","420.00","420.00","1 through 10","26.87","178.79","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","outpatient","","","231.00","138.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","100.99","43.72","","292.50","292.50","292.50","1 through 10","26.87","178.79","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","outpatient","","","231.00","138.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","167.98","72.72","","486.50","162.17","486.51","15","26.87","178.79","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","outpatient","","","231.00","138.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","145.30","62.9","","280.98","134.95","421.47","15","26.87","178.79","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","outpatient","","","231.00","138.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","178.79","77.4","","160.63","160.63","160.63","1 through 10","26.87","178.79","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","outpatient","","","231.00","138.60","UNITED HEALTHCARE ALTERNATE [1020]","HB WDH HPHC HMO POS PPO","167.98","72.72","","136.31","136.31","136.31","1 through 10","26.87","178.79","percent of total billed charges",""
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","641.00","384.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","692.73","619.00","692.73","1 through 10","108.88","710.05","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","641.00","384.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","299.84","13","108.88","710.05","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","641.00","384.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","109.33","108.89","111.11","13","108.88","710.05","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","641.00","384.60","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","299.84","562.84","1 through 10","108.88","710.05","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","641.00","384.60","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","114.44","110.33","114.44","1 through 10","108.88","710.05","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","641.00","384.60","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.22","105.30","109.22","12","108.88","710.05","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","641.00","384.60","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","35","108.88","710.05","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","641.00","384.60","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","710.05","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","641.00","384.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.39","108.89","111.11","1 through 10","108.88","710.05","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","641.00","384.60","WELLPOINT [1015]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","559.93","559.93","1 through 10","108.88","710.05","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","641.00","384.60","WELLSENSE NH [1050]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","116.67","114.34","116.67","1 through 10","108.88","710.05","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","outpatient","","","641.00","384.60","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","92.43","14.42","","89.26","76.51","89.26","1 through 10","74.55","496.13","percent of total billed charges",""
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","outpatient","","","641.00","384.60","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","74.55","11.63","","85.24","75.77","156.32","13","74.55","496.13","percent of total billed charges",""
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","outpatient","","","641.00","384.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","402.42","62.78","","388.61","388.61","388.61","1 through 10","74.55","496.13","percent of total billed charges",""
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","outpatient","","","641.00","384.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","280.25","43.72","","270.63","270.63","270.63","1 through 10","74.55","496.13","percent of total billed charges",""
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","outpatient","","","641.00","384.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","466.14","72.72","","450.14","450.14","450.14","1 through 10","74.55","496.13","percent of total billed charges",""
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","outpatient","","","641.00","384.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","403.19","62.9","","389.97","389.97","389.97","1 through 10","74.55","496.13","percent of total billed charges",""
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","outpatient","","","641.00","384.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","496.13","77.4","","479.73","479.73","479.73","1 through 10","74.55","496.13","percent of total billed charges",""
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","outpatient","","","641.00","384.60","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","74.55","11.63","","73.11","73.11","177.78","1 through 10","74.55","496.13","percent of total billed charges",""
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","712.00","427.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","710.05","","Case rate ($710.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","687.00","687.00","692.73","1 through 10","108.88","710.05","other","OPPS APC"
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","712.00","427.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","305.75","","Case rate ($305.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","298.29","298.29","299.84","1 through 10","108.88","710.05","other","OPPS APC"
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","712.00","427.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","108.88","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","111.11","108.89","188.89","1 through 10","108.88","710.05","other","OPPS APC"
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","712.00","427.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","573.93","","Case rate ($573.93). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","559.93","299.84","559.93","1 through 10","108.88","710.05","other","OPPS APC"
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","712.00","427.20","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","114.43","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","114.44","114.44","114.44","1 through 10","108.88","710.05","other","OPPS APC"
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","712.00","427.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.22","109.22","111.11","1 through 10","108.88","710.05","other","OPPS APC"
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","712.00","427.20","MEDICARE [2001]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","107.12","111.11","15","108.88","710.05","other","OPPS APC"
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","712.00","427.20","TRICARE [160005]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","111.11","111.11","111.11","1 through 10","108.88","710.05","other","OPPS APC"
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","712.00","427.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","111.10","","APC Price ($111.10). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","109.39","105.28","111.11","1 through 10","108.88","710.05","other","OPPS APC"
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","outpatient","","","712.00","427.20","GENERIC COMMERCIAL [1009]","HB WDH AMERIHEALTH CARITAS","102.67","14.42","","99.07","99.07","99.07","1 through 10","82.81","551.09","percent of total billed charges",""
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","outpatient","","","712.00","427.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","82.81","11.63","","173.50","94.60","173.50","1 through 10","82.81","551.09","percent of total billed charges",""
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","outpatient","","","712.00","427.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","517.77","72.72","","499.59","499.59","499.59","1 through 10","82.81","551.09","percent of total billed charges",""
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","outpatient","","","712.00","427.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","447.85","62.9","","432.81","432.81","432.81","1 through 10","82.81","551.09","percent of total billed charges",""
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","outpatient","","","712.00","427.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","551.09","77.4","","532.43","532.43","532.43","1 through 10","82.81","551.09","percent of total billed charges",""
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","outpatient","","","712.00","427.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","82.81","11.63","","81.14","81.14","81.14","1 through 10","82.81","551.09","percent of total billed charges",""
"Xr T-Spine 4+ Views","PX-32000062","CDM","72074","CPT","0320","RC","","","","outpatient","","","812.00","487.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","510.75","62.9","","493.92","493.92","493.92","1 through 10","94.44","628.49","percent of total billed charges",""
"Xr Tibia/Fibula 2 Views","PX-32000167","CDM","73590","CPT","0320","RC","","","","both","","","603.00","361.80","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.46","90.16","90.53","1 through 10","86.95","587.88","other","OPPS APC"
"Xr Tibia/Fibula 2 Views","PX-32000167","CDM","73590","CPT","0320","RC","","","","both","","","603.00","361.80","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","466.72","77.4","","902.10","902.10","902.10","1 through 10","86.95","587.88","percent of total billed charges",""
"Xr Tmj Open & Closed Bilat","PX-32000036","CDM","70330","CPT","0320","RC","","","","both","","","1043.00","625.80","AETNA [1001]","HB WDH AETNA COMMERCIAL","728.01","69.8","","702.19","702.19","702.19","1 through 10","90.15","886.55","percent of total billed charges",""
"Xr Tmj Open & Closed Bilat","PX-32000036","CDM","70330","CPT","0320","RC","","","","both","","","1043.00","625.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","253.14","","Case rate ($253.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","247.82","247.82","247.82","1 through 10","90.15","886.55","other","OPPS APC"
"Xr Tmj Open & Closed Bilat","PX-32000036","CDM","70330","CPT","0320","RC","","","","both","","","1043.00","625.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","90.15","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","87.12","87.12","87.12","1 through 10","90.15","886.55","other","OPPS APC"
"Xr Tmj Open & Closed Bilat","PX-32000036","CDM","70330","CPT","0320","RC","","","","both","","","1043.00","625.80","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","475.18","","Case rate ($475.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","463.58","463.58","463.58","1 through 10","90.15","886.55","other","OPPS APC"
"Xr Tmj Open & Closed Bilat","PX-32000036","CDM","70330","CPT","0320","RC","","","","both","","","1043.00","625.80","MEDICARE [2001]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","92.00","92.00","92.00","1 through 10","90.15","886.55","other","OPPS APC"
"Xr Toe(S) 2+ Views","PX-32000192","CDM","73660","CPT","0320","RC","","","","both","","","621.00","372.60","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.66","90.16","90.66","1 through 10","90.15","587.88","other","OPPS APC"
"Xr Toe(S) 2+ Views","PX-32000192","CDM","73660","CPT","0320","RC","","","","outpatient","","","621.00","372.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","451.59","72.72","","435.59","435.59","435.59","1 through 10","72.22","480.65","percent of total billed charges",""
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","2867.00","1720.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM FEDERAL","1188.62","","Case rate ($1,188.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1159.63","1159.63","1163.69","1 through 10","182.27","2436.95","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","2867.00","1720.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM HMO","511.82","","Case rate ($511.82). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","499.34","499.34","501.09","1 through 10","182.27","2436.95","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","2867.00","1720.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","182.27","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.29","179.02","316.22","1 through 10","182.27","2436.95","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","2867.00","1720.20","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM PPO","960.75","","Case rate ($960.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($0) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","940.60","937.31","940.60","1 through 10","182.27","2436.95","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","2867.00","1720.20","MARTIN'S POINT [160007]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.85","182.85","182.85","1 through 10","182.27","2436.95","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","2867.00","1720.20","MEDICARE [2001]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","186.01","186.01","21","182.27","2436.95","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","2867.00","1720.20","TRICARE [160005]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","156.36","156.36","156.36","1 through 10","182.27","2436.95","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","2867.00","1720.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.79","91.65","182.79","1 through 10","182.27","2436.95","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","outpatient","","","2867.00","1720.20","GENERIC COMMERCIAL [1009]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","333.43","11.63","","381.02","338.68","381.02","1 through 10","333.43","2219.06","percent of total billed charges",""
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","outpatient","","","2867.00","1720.20","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","2084.88","72.72","","2012.16","2012.16","2012.16","1 through 10","333.43","2219.06","percent of total billed charges",""
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","outpatient","","","2867.00","1720.20","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","2084.88","72.72","","2012.16","2012.16","2012.16","1 through 10","333.43","2219.06","percent of total billed charges",""
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","outpatient","","","2867.00","1720.20","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","1803.34","62.9","","1743.21","1743.21","1743.21","1 through 10","333.43","2219.06","percent of total billed charges",""
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","outpatient","","","2867.00","1720.20","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","2219.06","77.4","","2144.43","2144.43","2144.43","1 through 10","333.43","2219.06","percent of total billed charges",""
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","outpatient","","","2867.00","1720.20","WELLSENSE NH [1050]","HB WDH NH HEALTHY FAMILIES + WELLSENSE","333.43","11.63","","326.83","326.83","326.83","1 through 10","333.43","2219.06","percent of total billed charges",""
"Xr Ugi W/O Kub","PX-32000200","CDM","74240","CPT","0320","RC","","","","both","","","2465.00","1479.00","HUMANA [1012]","HB WDH HUMANA MEDICARE REPLACEMENT","191.57","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","191.59","191.59","191.59","1 through 10","182.27","2095.25","other","OPPS APC"
"Xr Ugi W/O Kub","PX-32000200","CDM","74240","CPT","0320","RC","","","","both","","","2465.00","1479.00","MARTIN'S POINT [160007]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","186.01","186.01","1 through 10","182.27","2095.25","other","OPPS APC"
"Xr Ugi W/O Kub","PX-32000200","CDM","74240","CPT","0320","RC","","","","both","","","2465.00","1479.00","MEDICARE [2001]","HB WDH MEDICARE","185.99","","APC Price ($185.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","186.01","186.01","186.01","1 through 10","182.27","2095.25","other","OPPS APC"
"Xr Ugi W/O Kub","PX-32000200","CDM","74240","CPT","0320","RC","","","","outpatient","","","2465.00","1479.00","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","1907.91","77.4","","1843.73","1843.73","1843.73","1 through 10","286.68","1907.91","percent of total billed charges",""
"Xr Venogram Extremity Uni","PX-32000283","CDM","75820","CPT","0320","RC","","","","both","","","2279.00","1367.40","BLUE CROSS BLUE SHIELD [110001]","HB WDH ANTHEM MEDICARE REPLACEMENT + PATHWAYS","1590.51","","APC Price ($1,622.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1590.70","1590.70","1590.70","1 through 10","644.41","10372.29","other","OPPS APC"
"Xr Venogram Extremity Uni","PX-32000283","CDM","75820","CPT","0320","RC","","","","both","","","2279.00","1367.40","MARTIN'S POINT [160007]","HB WDH MEDICARE","1622.97","","APC Price ($1,622.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1623.16","1623.16","1623.16","1 through 10","644.41","10372.29","other","OPPS APC"
"Xr Venogram Extremity Uni","PX-32000283","CDM","75820","CPT","0320","RC","","","","both","","","2279.00","1367.40","MEDICARE [2001]","HB WDH MEDICARE","1622.97","","APC Price ($1,622.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1623.16","1623.16","1623.16","1 through 10","644.41","10372.29","other","OPPS APC"
"Xr Wrist Cmpl 3+ Views","PX-32000119","CDM","73110","CPT","0320","RC","","","","both","","","782.00","469.20","COVENTRY FIRST HEALTH [1021]","HB WDH AETNA COMMERCIAL","545.84","69.8","","526.99","526.99","526.99","1 through 10","40.69","664.7","percent of total billed charges",""
"Xr Wrist Cmpl 3+ Views","PX-32000119","CDM","73110","CPT","0320","RC","","","","both","","","782.00","469.20","UNITED HEALTHCARE [1016]","HB WDH MEDICARE","91.99","","APC Price ($91.99). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.204). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.66","90.16","90.66","1 through 10","40.69","664.7","other","OPPS APC"
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","both","","","61.00","36.60","AETNA [1001]","HB WDH AETNA COMMERCIAL","42.58","69.8","","41.18","12.98","41.18","30","7.4","58.69","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","outpatient","","","61.00","36.60","HARVARD PILGRIM [120001]","HB WDH HPHC ELEVATE","38.30","62.78","","37.04","37.04","37.04","1 through 10","10.61","47.21","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","outpatient","","","61.00","36.60","HARVARD PILGRIM [120001]","HB WDH HPHC EXCHANGE","26.67","43.72","","25.79","25.79","25.79","1 through 10","10.61","47.21","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","outpatient","","","61.00","36.60","HARVARD PILGRIM [120001]","HB WDH HPHC HMO POS PPO","44.36","72.72","","42.90","42.90","42.90","31","10.61","47.21","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","outpatient","","","61.00","36.60","HARVARD PILGRIM ALTERNATE [120002]","HB WDH HPHC HMO POS PPO","44.36","72.72","","42.90","42.90","42.90","1 through 10","10.61","47.21","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","outpatient","","","61.00","36.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP HMO","32.46","53.22","","31.45","31.45","31.45","1 through 10","10.61","47.21","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","outpatient","","","61.00","36.60","MGB HEALTH PLAN [150001]","HB WDH MGBHP PPO","38.37","62.9","","37.17","37.17","37.17","56","10.61","47.21","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","outpatient","","","61.00","36.60","UNITED HEALTHCARE [1016]","HB WDH UNITED HMO / PPO / INDEM","47.21","77.4","","45.73","45.73","45.73","14","10.61","47.21","percent of total billed charges",""